An Asia Society and South Asian Lesbian and Gay Association Panel Discussion on

Sex, Lies and AIDS:
India and the Coming AIDS Explosion

with Siddharth Dube, Development expert and author of the best-selling
Sex, Lies and AIDS
Dr. Ruth Hayward, Author of Breaking the Earthenware Jar: Lessons from South Asia to End Violence Against Women and Girls
Dr. Marty Markowitz, Staff Investigator, Aaron Diamond AIDS Research Center,
Associate Professor and Physician, Rockefeller University
Anil Purohit, Director, HIV/AIDS Programs, François-Xavier Bagnoud Foundation, Rajasthan Society
moderated by Dr. Robert W. Radtke, Vice President, Business & Policy Programs, Asia Society

New York, September 28, 2000

Siddharth Dube: In half a dozen cities and towns in India, between 3-5 % of all adults are infected, which are dangerously high levels that are rarely seen outside of Sub-Saharan Africa. So, clearly the explosion began years ago, it's not coming. Next, apart from these national level figures, the other important thing to know about the epidemic is that it is a patchwork at this point in India, which is not very surprising, given India's continental size population. So, the situation varies from being severe in some states to the emergence of problems in other states.

The two worst hit states are Maharashtra and Andhra Pradesh-to the West of India and to the South of India. In these two states, well over 2% of the entire adult population are infected. These are levels that put these states on par with Thailand, which is amongst the worst hit countries in the whole of Asia. In the second rank of states, where between 1-2% of all adults are infected, come the two Southern states of Tamil Nadu and Karnataka, and the two northeastern Indian states of Manipur and Nagaland. In the third rank of states you have a larger number. And these are states where infection levels amongst the adults are approaching 1%. These states include Gujarat, Delhi, Punjab, West Bengal, Kerala. Then in the remaining parts of India, you have soaring infection rates within groups at higher risks or who have higher risk behavior, as well as in areas from which large numbers of men migrate to work from urban areas.

Turning to the second issue, why are so many Indians clearly vulnerable to contracting AIDS/HIV-and who are these Indians? The sad and terrible truth is that most developing countries, including India, are bone-dry forest for the spread of HIV. India, for instance, has been transformed and continues to be transformed over the past fifty years by enormous increases in population in urbanization and by somewhat wider prosperity. Given all this change, it is not surprising that the realities of sexual behavior in India are very different to the modern day myths that Indians are asexual or strictly monogamous within marriage.

The truth is there is tons of sex happening before and outside marriage and add to this, several other combustible elements. One is the very powerful taboo on discussions of sex, particularly public discussion of sex. This serves to leave the vast majority of Indians entirely ignorant of more sexual matters, whether it is the how to of having sex or the how to of preventing sexually transmitted diseases. Yet another very combustible element is the abysmal state of India's health care services and they are worse for the treatment of sexually transmitted diseases and the prevention of sexually transmitted diseases. You put all this together and various elements that I can't talk about because of time constraints. And the upshot is 1 in 10 of all Indian adults, men and women alike are estimated to suffer from one or more sexually transmitted diseases, which as you know greatly enhances the risks of contracting HIV.

Consequently, because of one disadvantage or another or because of multiple disadvantages that compound each other powerfully, the vast majority of Indians are susceptible to contracting HIV and earlier other STDS at some point in their adult life. In terms of class, I would say that poorer and low income Indians bear the greatest number of disadvantages. But upper income, middle income and wealthy Indians also do bear substantial disadvantages, particularly and most widespread the taboo on discussion of sex and the multiple disadvantages that all Indian women face.

In terms of gender, currently in India, there are nearly twice as many men infected as women. This is not surprising in the earlier stages of generalized epidemics. And in time, it is likely that as the epidemic matures or deepens, that there will be parity in the number or even there might be more women infected than men.

In terms of age, the vast proportion, about 90% of all infected, are in the age group between 15 to about 50-55. And then very quickly in terms of broad sexual behaviors, in the worst affected urban areas, in the worst affected states of India, only a minority of new infections can be traced back to people or groups with high risk drug taking or sexual behavior. In other words, the vast majority of new infections, in the worst affected areas of India are now taking place amongst people with average risk sexual behavior.

I'll move very quickly to the third thing that I wanted to talk about, which is: why is India's epidemic virtually unchecked, given fairly significant public and government awareness of the severity of the problem and also a fairly substantial amount of money being spent on prevention. In 1992, faced with very clear evidence that middle class men and women and upper income men and women were being infected and had been infected and not just the poor and so called sexual degenerates, the government of India put an end to its reliance on penal and punitive methods of trying to control the epidemic, which had included such things as forcible testing and quarantine.

Since then-between 1992 and now-it has borrowed nearly 300 million dollars from the World Bank for AIDS prevention, making India's prevention efforts enviably well funded at least by the standards of developing countries. Borrowing such sums is clear evidence of serious official concern and now even top-level political concern is evident. Since 1998, Prime Minister Vajpayee has called AIDS "India's greatest health threat." And he made it a point repeating this at this year's Independence Day address. Despite all this, the brutal reality is that India's epidemic is running and galloping far ahead of the government's response. The programs in place today would perhaps have been sufficient to control the epidemic a decade ago. Today all this activity around AIDS, in my view, only adds up to masking or disguising the fact that the epidemic is virtually unchecked. And the inadequacy of the government's response is particularly evident in the worst hit areas. In these areas for instance, in most of them, sex workers lack the information and support they would need to begin to protect themselves and their clients. STD treatment services are still abysmal. There are virtually no prevention programs for men who have sex with men which is an enormously dangerous error in India given the vast extent of male bisexuality. And because the public information campaigns evade sexual issues, they have spawned dangerous new myths, such as the myth that HIV only spreads through vaginal sex and through anal sex. And very worrisomely, there are virtually no sex education programs for young people in schools and colleges. Tamil Nadu is perhaps the only state perhaps which has such programs, which leaves young people very vulnerable to contracting HIV.

If all this were not enough to doom the chances of prevention, civil rights abuses linked to HIV/AIDS are still legion. Nowadays, most of the vast majority of these abuses are the consequence of private actions. For instance, by doctors or health care providers, employers, relatives, neighbors. But a significant number are still caused by the actions and the policies of the state governments. Though not, I would point out, by the federal government. So, just to give you very two quick examples, the police, politicians and even judges, routinely order the arrest and forcible testing of sex workers. In the badly affected states of Maharashtra and Karnataka, legislatures are still pushing for laws that will allow the branding of sex workers.

So, to end, my reluctant and very depressing conclusion is that in the near future, we can only expect more of the same. At the federal government level, we can expect visionary and well-funded plans that are then gutted by very weak political commitment and at the very critical state government level, we can expect very shoddy implementation, frequent recourse to punitive methods, and a persisting climate of terror. All of which will serve to make prevention an impossibility. Consequently, in the near future I believe we face an absolute calamity with AIDS in India. Thank you.

Ruth: I'm going to talk about the risk to women and girls, particularly in the family, rather than outside the family, in the course of just regular, mundane, ongoing life, as a factor for the spread of HIV/AIDS. I think it was about 10 years ago that I heard Jonathan Mann who was the first director of WHO's HIV/AIDS program and later went to Harvard for program there and unfortunately was killed in the Swiss Air crash with his wife not too long ago, that I heard him talking about the importance of empowerment of women as a prevention measure for the spread of HIV/AIDS. What did he mean? He meant in particular that the women do not, and certainly married girls, do not have much control over when and how sexual relations take place. And that they if they did, they might be able to choose for there to be protection in sex acts, which would benefit them. He may also have had in mind double standards about expected fidelity for women versus men and the tendency for women to be blamed if STDs or HIV/AIDS pops up in the family context. He wasn't talking about incest as a factor in the spread of HIV/AIDS within the home and the context of double standards where men may have multiple sex partners. But in fact, if we stop to think about it, incest and rape within the family of children is a factor, a risk factor for this spread of HIV/AIDS which is not likely to be addressed at all because of the very sensitive nature of the subject. Of course, this year, those of you who keep up with UNAIDS, you'll be pleased to know that the responsibility of men and working with and through men to take more responsible behaviors is a theme-the theme- for UNAIDS, so addressing concepts of masculinity, men's roles, trying to work towards more equal gender relationships in home-are all seen as part of the prevention of HIV/AIDS.

I want to talk a little bit about violence, family violence and how that also makes it even more likely when men are infected that wives and daughters will become infected. Obviously marital rape-along with incest and the beating and the psychological abuse, and the economical abuse that often accompanies it- sets an atmosphere in which it is very difficult for women and girls, particularly when their education is low, andwhen they are not employed, to assert their rights and preferences within the family and in the sexual arena. What does this have to do with India? There may be an impression that within South Asia, family violence is actually low but that does not prove to be the case. UNICEF South Asia has just published a book of mine, "Breaking the Earthenware Jar: Lessons from South Asia to end Violence against Women and Girls," based on research in the region including India and trying to bring out what people are doing to stop domestic violence and its effects, not only the extent of it. But although there are no national studies yet, isolated individual studies indicate that violence in the family ranges from some 22% for physical assault, to some 75% for repeated beatings. And this is also in the context where people really don't necessarily think of beating as a problem or they underreport. And there's one study-this isn't much, but it gives you some idea-where 22% of the men interviewed admitted that they forced sex in the family upon their wives. As for the physical abuse of children, the figure would be in the millions for children so abused in the family if one takes the 15-20% range for likely sexual abuse in the family and applies it to India and I will come to in a moment to what Shekhar Sheshadri of the NIMHANS, the National Institute of Mental Health and Neurological Sciences, has projected accordingly.

Let me go to a few specific studies about HIV/AIDS and violence in India and I think most of you are very familiar with the subcontinent. But for those of you who are not, generally speaking the girls are considered of lesser values than boys, they receive less education, they're less well-nourished, it's primarily patrilineal, patrilocal, marriage is outside into a patriarchal context. Daughters may be told, "And don't come home here without the permission of your new family unless you are dead." Why do I mention that? Because it sets a little bit of glimpse of the atmosphere for the powerlessness of many women in India today. And particularly because there's a lot of young marriage, young age of marriage in India which is coupled with less education, it's the younger girls, girl women-we tend to think them not as girls anymore once they're married, but they are, who have less influence over decision-making about sex in their lives within the family.

A study in Uttar Pradesh in 1999 illustrates the problem. It notes that sexual abuse of wives is more common among men who have extra-marital affairs and that the abuse could be the reason for the increase of HIV infection among monogamous Indian women. That's only of course, if the men are positive. And according to the UNFPA, only 11% percent of currently married girls ages 15-19 were using contraceptives in any country within the SAARC region other than Bangladesh and Sri Lanka where it was 33%. And in one study in Pune, Maharashtra, of some 400 women attending STD clinics there, 93% were married, 91% had never had sex with anyone outside marriage but all had STDs. And an outstanding 13.6% were HIV positive. And that's in rural Maharashtra. And while HIV/AIDS is associated with truckers and prostitutes, as well as drug users and the fast-life in the big city, there is evidence that it is already entrenched in rural India. For example, UNAIDS and WHO reported in 1998, that in Tamil Nadu, 2.1% of the adult population living in the countryside was HIV positive compared to the 0.7% in urban areas.

Trafficking, now this is not to say that we are not concerned with risk factors to women and girls outside of the home which is also linked with unequal gender relationships and violence. Trafficking, rape and sexual slavery also in situation of armed conflict are all examples of situations into which women and girls are forced with high-risk of HIV/AIDS. Unfortunately, younger and younger girls are being drawn into trafficking. Sometimes with the involvement of family members who sell them to traffickers. For example, some 5,000 - 7,000 Nepali girls are trafficked across border from Nepal to India every year and most become sex workers in Delhi or Bombay. The average age, it is noted, has fallen over the years from the 14-16 range to the 10-14 range. And there's also trafficking of course from Bangladesh to Calcutta and young women may come there themselves in search of work as domestics and then are drawn into sex-work. And when girls are rescued and this touches on a point you made, "rescued" for repatriation and sometimes are tested for HIV/AIDS, they often are not even told about their health status. Figures on rape and situations of armed conflict are not available but that is also obvious risk.

What to do about this area? Well, breaking the silence about violence in the family as a risk factor and overcoming denial of the pandemic and its impact on the family as well as outside of it is an important place to begin. So we need better statistics on domestic violence, marital rape, incest, stronger laws and services accordingly and that the laws are enforced. I don't believe now that there is a law against incest. Prevention messages to girls and women, as well as to men and boys are needed; girls should be kept in school; the delay of age of marriage should go ahead; and they should be given more responsibility to the responsibility of men for equal gender and sexual relations. And government attention to the risk of HIV/AIDS from violence in the home, and unequal gender relations for groups outside the home is very much needed with the concerted effort also to stop trafficking and sexual slavery. And this should really be addressed also as human and child rights problem, not left aside with the idea that discussion of rights for women and girls stop at the door of the house.

Kimura could you just come down. I want to close with some cartoons from a young Indian cartoonist, Pawan, which he did to try and dramatize some of the excuses for not really looking at domestic violence and its effects on women.

So, AFTER ALL, SHE'S MY WIFE. An excuse giving men the right to do as they wish with women and their bodies.

And women may also guard the privacy of the home at the expense of their health and that of their children. "DON'T YOU TRY TO SAVE ME, THIS IS OUR FAMILY MATTER"

And you can see this one "HOW CAN YOU BEAT YOUR WIFE SO MUCH?" "WHAT DO YOU EXPECT US TO DO, GO OUTSIDE AND FIGHT?" Again, this is what goes on inside the house as a regular pattern.

Then, there's the regular question of extra-marital affairs and their acceptance and the use of violence to chastise the wife but go out and do one wishes.

Two more…

And the whole idea of masculinity sometimes related to men's right to have sex whenever they want it. Mabel Aroli, who's unfortunately dead now worked with us in Kathmandu and has a famous John K Project said that in her work, many women she interviewed said the first time when they had sex was on their wedding night and that they were raped and beaten.

And the very last one, the idea that the domestic problems should indeed be seen as human rights issues and that this would also be a factor in limiting the spread of HIV/AIDS. Thank you.

Rob Radtke: We are delighted that our next speaker made it in from the airport from Geneva to be with us, Anil Purohit. Anil is the AIDS program Director for the FXB Foundation which means among his many responsibilities, he is also overseeing the FXB Society Rajasthan. Rajasthan Society is taking a community health center approach to educating people about HIV/AIDS and promoting voluntary testing and treatment options.

Anil Purohit: Thank you. Good evening. I am sorry I am late and I am glad I made it. In fact, I am coming from Rajasthan and I'd introduce FXB and the Countess who founded this organization. FXB is François-Xavier Bagnoud, a young helicopter pilot who died in helicopter crash in 1986. He was flying in Africa to rescue people dying of famine. His mother, Countess Albina, who's based in Paris, France, founded this organization in 1990 and we run programs in seventeen different countries. India is one of the few countries. We have programs in Rajasthan, Goa, Mizoram, and Calcutta and today my topic is Rajasthan. We're going to focus on Rajasthan. In 1998 November, we started a voluntary counseling and testing center at Bhagwan Mahavir Hospital in Samirpur in partnership with that hospital in the rural setting and interestingly the data we're getting from testing is 9.55%. And, in my meeting with the house Secretary of the Government of Rajasthan last week, this was a point of discussion and I brought up this issue in front of him, saying that we have 9.55% and this migrant population is a small sample size and could you please get a check whether if we're following your guidelines or not. And if we're not, you need to help us. And if our figures right, you need to tighten up because this is the migrant population going to Mumbai, bringing the disease to Rajasthan and infecting the families and we're already seeing orphans. So, the title of the program today is "India and the Coming AIDS Explosion," but I already feel that the explosion right there in Rajasthan. And the problem with most of these studies done by the foreign agencies or the Indian government is that they are in urban settings when 70 % of the population lives in rural settings. So, this is our first project; we started in 1998 and this is the situation; we are getting 9-10% positive rate.

The way we function in this particular setting is that in a week, three times we go to villages and talk to the community leaders, lay population, on HIV/AIDS in local languages and that promotes them to come for testing. And recently, we also got funded from Bill and Melinda Gates Foundation for $300,000 for three years to continue this project and expand five folds. And, then we have a program in Jodhpur, Rajasthan which we are doing in partnership with the Government of Rajasthan, Government of India, it's a medical college hospital where the government provided testing and we provide counseling. It took us almost a year to fight with the government to start this partnership but it was a very successful idea, I guess because we didn't hope to get the permission. But it was the first project in the country which is being, you know, approved by the Government of the India's National AIDS Control Organization and Government of Rajasthan. And we see close to 2-3 patients per day who are HIV positive and we're kind of asked by the medical school to run this 24 hours now. It used to be 8 hrs. a day, but now it's 12 hrs.; from Oct. 1st it's going to be for 24 hrs. And the reason being, a lot of people who get involved in risky behaviors because of social stigma, they don't want to come for testing during day, and they'd rather prefer coming after hours. So, we are extending this service 24 hrs. a day, beginning Oct. 1st.

In Jodhpur, we also have a pediatrician who goes to middle schools, high schools and talks to children about HIV/AIDS. We have poster competition, essay competition; it's going on for a year and we are trying to measure these programs, how successful they could be and we are in the initial stage and it seems we're getting a very good response. In Jodhpur, we also got involved in tourism industry. Most of you in this room know that Rajasthan is a very big tourism center; it's bordering a lot of states-Gujarat, Maharashtra, M. P., Haryana, Punjab and of course, Pakistan, where you've got a big military force. And HIV because of tourism and military, it's spreading widely in Rajasthan. Unfortunately, no studies have been done. And we're expanding our studies in that particular area. Then, we have a program in Jaipur which is the capital city of Rajasthan, 220 miles away from New Delhi. We are continuing medical education program for counselors, doctors, health care workers, and mostly focusing on counseling. We are also starting on October 1st, counseling center at SMS Medical College in Jaipur where we'll be seeing three to four hundred women for pre-test counseling and we don't know what the positive rate is going to be. It seems it's very high as per some studies done in Jaipur. So, these are the programs we have right now and we are expanding very soon in Jaisalmer, Pushkar, mostly all the tourist parts.

We also have a plan to start a public health school in Rajasthan and we're working with Medical Council of India, and various other organizations, so we hope to start this in a rural setting which will be the first rural public health school in the country. It's unfortunate that with a population of a billion, we only have one public health institute in India. So, this will be probably the second public health institute if we succeed and it'll be in a rural setting. And, I want to apologize again, I don't have any slides or my power point presentation because I flew from Rajasthan and Geneva and I am glad that I made it. So, I'll be more than happy to answer your questions. I have brought some brochures which I will be handing out to you so you know what we do and what programs we are getting involved which is mostly focusing on India and besides, with more responsibilities, I am also handling the FXB US Foundation since last week, so that also gives you an access to my phone number in Boston. So, the brochure has all the information. Thank you very much.

Marty: I am used to giving talks this way, so bear with me please. If I am in the way of the slides, just let me know. I was asked to sort of talk about a potpourri of issues. I just wanted to put this up here, this is from the World AIDS Report, June 2000. You can get it on the internet-www.UNAIDS.org. It's sobering to read, having been in Durban this summer, and meeting people from all over Africa who are HIV infected, it really opened my eyes because it's one thing to hear the numbers. It's another thing to see the teachers, the doctors, the nurses, the mothers, the fathers, the kids, it's amazing. In just 1999 alone, 5.4 million people were infected. There were 33.4 people living worldwide with HIV; 2.8 million people died in 1999 and 18.8 million have died since the beginning of the epidemic or the pandemic, making it the greatest killer of man. It has surpassed the bubonic plague, not percentage-wise but numbers wise. And the total numbers of AIDS orphans, defined as the number of children who have lost either a mother, or both parents now numbers 13.2 million. And when you hear the stories from places like Botswana where there aren't enough teachers anymore to staff the schools, where the kids can't go to school even if there are teachers, because everyone else has died and somebody has to work the fields to provide food, you just basically start to cry. And this is where it's all happening: basically, you can see sub-Saharan Africa and to use a quote "AFRICA is BURNING" but if you look at South and Southeast Asia, 5.6 million and rapidly expanding. So, this is a global perspective. You actually look around the world-approximately 30 million people have no access to therapy and are scheduled to die within the next five to seven years, unless something dramatic happens.

What I am first going to talk about is to sort of try to help you understand what are the factors that are associated with the HIV infection and this is some data presented by a woman named Ann Buve at last year's retrovirus conference in San Francisco. And what they did basically is look at areas, four areas in Africa-two in the Benin and Cameroon, cities in Benin and Cameroon where there's very relatively low prevalence of HIV infection compared to Kenya and Zambia where you can see that the prevalence in both women and men is dramatically higher. And they looked at variety of factors including sexual behavior, ages of first sexual encounter, number of sex partners, etc. And I won't bore you with those details but what I will show you is rather striking. In the areas of low prevalence, there's a relatively low incidence of all sorts of STDs, and the presence of all sorts of STDs increases the risk of HIV transmission anywhere from two fold to 32 fold depending on the study.

Notice also that in Benin and Cameroon where religious practices promote circumcision, there's a relatively low, very low incidence of HIV infection in men as opposed to areas in Kenya and Zambia where there's essentially a very very rare incidence of circumcision. And circumcision has been shown in numerous studies to be quite protective for men to contract HIV infection. And not surprisingly you can see that also STDs-Herpes Simplex II virus, again is more common in women in Kenya and Zambia than in Benin and Cameroon though the differences are not as marked as they are in men.

Now another very interesting theory that was published this year in New England Journal of Medicine also talks about why certain people get infected and others don't and basically, what they observed were 415 sera discordant couples, meaning one person is infected and one person is not infected. And they basically counselled the couples, etc. as well as they could and observe over time and this took place in Uganda. And what they looked at was basically were behavioral demographics, the presence of STDs and the amount of virus circulating in the blood of these people. It's called HIV/RNA in plasma; it's something you can measure in laboratory.

Now, a baseline of about 55% of the cohort were infected men with uninfected wives and 45% were infected wives with uninfected husbands. Now a total about of 20% o(or 90) sera-converted, meaning became infected during the course of observation. And very interestingly in this cohort, the male-to-female transmission and female-to-male transmission was equal. Now this is a somewhat surprising finding; it's been assumed that women are more easily infected than men but not in this particular cohort. Whether this is due to circumcision practices or the presence of other STDs, we don't know. And, there are no studies being done; these kinds of studies are very difficult to do here in the US and other western cultures. And of course, as most of you wouldn't be surprised to know that people at most risk are the young people, the highest transmission occurred in the 15-19 year old age group. In this study, actually, no circumcised men actually became infected. And most importantly, the people who transmitted had significantly higher viral loads than people who did not transmit. And quite interestingly, at viral loads less than 1,500 copies per ml of plasma, there was no transmission.

Now, if you go to third world countries where no treatment is available, the average viral loads are well in excess of 1,500 copies per ml. And the inability for people in the third world to get access to effective therapies promotes the transmission of HIV. It's further exacerbated by the problem of co-infections; if you go to India, what's killing people is tuberculosis. I have been told by friends-I have never been to India- that the hospitals in Bombay are filled and that there are people in the hallways everywhere and they are all co-infected with tuberculosis and HIV. And tuberculosis is a very pathogenic organism so it does not require the kind of immuno-deficiency that Pneumocystis pneumonia requires or some of the other infections that kill Americans, so the people tend to get much sicker, much quicker and die much faster because of their HIV infection. And as you can see that for people who have high viral loads which is generally the rule, and for people who have concomitant diseases, their transmission was much higher. And for every order of magnitude increase in the amount of virus circulating in the blood, there was a 2.45 fold increase in transmission. So, it is pretty clear that if we wanted to really do effective control of HIV transmission in the Third World, not only we have to do counseling, not only do we have to develop effective vaccines, but treatment is really one of the cornerstones of effective control of this epidemic.

I am going to shift now because I was asked to talk a little bit about preventative strategies. Let me just tell you why there's no vaccine yet available for HIV. Almost all vaccines that have been developed first of all have been emperic-the mumps vaccine, the measles vaccines, etc. All vaccines that are available, that are available and effective today rely on the development of anti-bodies that are able to neutralize viruses. HIV, unfortunately, is a virus that has a very very thick dense sugar coating and that sugar coating protects the virus from anti-body neutralization. And it's quite clear from many many studies that in order to control HIV, one has to develop what are called cytotoxic T-cells. And we are all able to mount cytotoxic T-cell responses, but they are genetically fixed. So, if the virus is replicating in the presence of that immune response, it can very easily escape. So that's why despite the presence of very very robust immune responses to HIV in infected people, the virus always wins. Because it has an uncanny ability when it makes copies of itself to escape the effects of the immune system. And because of that, we basically have been stuck trying to develop different scientific strategies, different vaccine strategies that go beyond what we've had to do with other viral diseases.

I don't know if people have heard of a vaccine called Remune, or HIV immunogen. It is basically a dead virus particle. Unfortunately, in the process of killing it, it loses its envelope and loses its immunogenicity, meaning that it is not able to really create a robust immune response. Particularly, it does not seem to be able to mount a CTL response and has proven rather disappointing. Recombinant proteins, despite the objections of many scientists, are being tested in Thailand and the United States. Recombinant proteins basically are proteins that mimic or are basically HIV proteins and what they are basically testing now are envelopes that look like HIV virus. The problem with recombinant proteins is that they are very good at stimulating an antibody response, but very bad at stimulating a CTL response, or cellular immune response. So, despite the fact that this vaccine will not work for political and economic reasons, it has gone ahead into testing. Now perhaps one of the more promising vaccine strategies is basically a DNA vaccine and you can take naked DNA and inject it into an animal, or a human, and the DNA basically can get to the right place, make protein on a consistent basis, get expressed and cause an immune response., Especially if it is combined with recombinant viral vector. What a recombinant viral vector is is you take a virus and you genetically engineer it. So, you can take a virus like, say a canary pox virus, or a Venezuelan Aquinas encephalitis virus, which is not pathogenic in man, and put HIV DNA into that virus, and then have it expressed. This is a very promising area. Whether or not it will translate into an effective virus is probably going to take a very very long time. But I am going to tell you about some of the more promising vectors that are available. There's also an interesting approach, as you know there are bacteria that cause typhoid fever and para-typhoid fever and they are very immunogenic. And they can also be genetically engineered. You can take attenuated salmonella that doesn't cause disease in human beings, put HIV genetic material into it and deliver that orally. When delivered orally, it goes into the lymphoid system and the GI tract has more lymph tissue than any other system in your body basically. And can generate an immune response such that the body basically thinks it's seeing HIV and that immune response might be enough to prevent infection. We are not talking about therapeutic vaccine, we are talking about preventing infection.

The attenuated virus is really a very controversial area. I think many of you might have heard that if you take HIV virus and remove some pieces out of its genetic material, the virus doesn't grow as well. However, and there were people that were infected with attenuated virus in Sydney, the famous Sydney blood bank cohort and these people did not progress for many years. So, the concept was, well, can you use the attenuated virus to vaccinate? In the animal models, in the monkey model, this virus is protective. However, it is shown that the attenuated virus is not attenuated in all hosts. And when given to baby monkeys, this virus caused death. And the patients who were infected with this attenuated virus, started to progress. So, we really don't know how to attenuate HIV. Just for point of reference, there are some attenuated vaccines, for example, the yellow fever vaccine is an attenuated virus. The typhoid fever vaccine is also an attenuated bacteria.

I'm just going to mention the alpha virus vector because of all the viral vectors, it's probably the most promising. And it's really the prototype is the Venezuelan Equine Encephalitis virus which sounds frightening except it affects horses, not people. It's very amenable to genetic manipulation. In studies outside the body, it appears to be able to be extremely immunogenic and it's highly immunogenic in animals such as mice. And the thing about this vector that's so fantastic is that, as I said it's very amenable to genetic manipulation and it also has a very heavy sugar-coating. So, when it gets into the body, it almost immediately goes into a draining lymph node and gets processed. This really, I think of all the possibilities right now, is really the most hopeful. What's really slowing it down, are the regulatory agencies that are forcing this company to make a monovalent vaccine meaning just put one HIV portion in it as opposed to putting multiple. And there's a very very aggressive program to design a vaccine toward Clade C viruses which is the dominant virus in Africa as well as Asia.

I think I do have a couple more slides. I wanted to just show you something from the International AIDS Vaccine Initiative. These are really what are considered the barriers to an effective vaccine, even if scientific issues are answered: the economics, the ability to scale up regulatory bodies. I can tell you from my own personal experience that they are the most conservative people on earth and today if we had to develop a smallpox vaccine, I doubt it would happen. You know, most vaccine development was empiric. And the fear of doing more harm than good is overwhelming and when one thinks about the enormity of this pandemic, one really has to step back and wonder why. It'll be very hard to look at efficacy, we need a lot of money to support these efforts and then again, when all is said and done, how are we going to get an effective vaccine into resource poor areas. Well, that is why IAVI basically exists: because they support research, and when they support research, they get the rights to the vaccine, and by getting the rights to the vaccine, they will make sure that it gets where they are going, it'll be reasonably priced; they are partnering with World Bank and other organizations, including government and other private agencies like the Gates Foundation, to make sure that if the scientific breakthroughs happen just like treatment, they are not confined to the US, Western Europe, and Canada but are more broadly distributed. So I am going to stop there and I hope there are some other questions about HIV pathogenesis and immunology. Thank you.

Rob: Great, thank you very much. If you would like to just stand up or raise your hands, I'll call on you. Could people please identify themselves when …well, just raise their hands and go ahead and have the questions.

Shyama: What is the role of the pharmaceutical companies in providing disincentives for scientific advances in AIDS research to be made available in developing countries?

Marty: Well, this is an area that I am very familiar with because I deal with pharmaceutical industry to a large degree. The pharmaceutical industry is unfortunately in business here in America to make money. And, they answer to stockholders and it is clear to me that probably more recently they have been willing to compromise enormously. However, when one thinks about it, it's not just the pharmaceutical industry that needs to bear the responsibility of drug distribution. The barriers are enormous. For example, if I decided to tomorrow to buy, to get, ten million dollars from the Bill and Melinda Gates Foundation, and I wanted to send drugs to South Africa, they would not let me do it. They would impose import taxes, they would confiscate the drug at the border and they'd not let the drugs get into the hands of the people that need them. The other problem is that, the pharmaceutical industry, in my dealings with them, for example, say we'd love to give you drug for a year or two. But you have to have a long-term solution. What is the long-term solution, because you can't just give drug for a year and stop it. This is continuous therapy or even if it is intermittent therapy, it still require a long-term plans, government cooperation, local employers, local industries and one also has to ask what about Coca Cola, what about Pepsi Cola, what about Nike. What about the other industries that make huge profits, not only here in America but all over the world. I mean you travel anywhere, there's always a Coca Cola, there's always a Coca Cola machine in almost any small town in Africa. People say that you can't use drugs that aren't refrigerated, hell that's untrue. There is always a refrigerator for Coke there. And I think that it's just a reflection of a fact that people are pretty much willing to write-off in the short-term, I mean they look at Africa as, well we'll write-off Africa, we've got China with a billion people. Hey, but you know the same thing's going to happen in China eventually, as well.

It's a very complex issue, but I agree with you that the pharmaceutical industry has been problematic but they are willing Glaxo Wellcome has announced that they'd provide Combivere for $2 a day. You can't make it for $2 a day so they are losing money on it. So, it's a very complicated issue. I don't want to sound like I am you know, making an argument that they are totally good because remember they have a lot of other issues, but I don't think that they are not the bad guys here. And there are other large problems, that are looming in trying to get effective therapies to the Third World.

Ruth: May I add a point? In San Francisco, I don't remember the year of the AIDS Conference there but my husband is a physician, and I went with the idea of devoting our lives to the prevention of HIV/AIDS. And one thing that deterred us was the performance by ACT-Up and other activist groups. And what they were really calling for was that all money and all testing be done with a cure for "me in my lifetime" rather than being concerned with using you know whatever is available for prevention or for work in developing countries. So I think one also has to look at the inner play with activists group and their priorities, as well as the pharmaceuticals and the governments and the international organizations

Smita Narula (Human Rights Watch): My question is for Mr. Dube. You touched upon some of the civil rights issues that are that are dealing with prevention and spreading of sexually transmission. We've been receiving reports of attacks on NGOs who have been working to spread information about sexual transmission. Most glaringly and recently the attack on Sahyog in Uttar Pradesh. Many of its members were arrested, charged with, some charged as threats to national security-although those charges were dropped- and others charged with hurting public sentiment and others for just basically distributing a pamphlet which described sexual transmission and a particular sexual practice in the area. How much of the problem do you think is the fact that there isn't freedom for these NGOs to effectively do their work? And as an adjunct to that, there is also an increasingly… this is what people are calling an imposition of a moral code by the Hindutva groups which are related to the BJP in the center but most particularly in the states. Is that also having a chilling effect on talking about sexual transmission?

Dube: I'd agree with both your points. In terms of NGOs, that's only part of the much bigger problem, which is the lack of public discussion or concern about sexuality, about AIDS, how to have safe sex and it's within that larger ban, that the ban on or the constraints on NGOs operate. And I'm not really sure, I mean I very much push for NGOs to have freedoms and other bits of civil society to have greater freedoms but it is not going to happen in isolation. If there are government policies which still allow forcible testing of sex workers, there is no way in that mind set that they are going to agree that NGOs should just go forward with their own programs, so it's part of a much bigger problem.

In terms of your second question, this sort of fundamentalist mind set, and does that affect HIV prevention work? Yes it does. Having said that, I would also say that even in states where you don't have the fundamentalist Hindu parties or the right wing Hindu parties, even those states are a disaster in terms of HIV prevention. Even in Kerala for instance is doing fairly badly on prevention. Andhra Pradesh doesn't have a fundamentalist party in power, and it's a disaster, Tamil Nadu doesn't have but it is doing really well in terms of prevention are doing fairly well. Perhaps one model I can think of which is where there is great respect or grudging but great respect for human rights and civil liberties is West Bengal, where there's been humanization allowed of sex workers. The fundamentalist shift in mind set and thinking is a problem, at the national level in particular. For instance, since the BJP government came to power, one hand, you've had Prime Minister Vajpayee taking a strong leadership position on HIV which one doesn't know if any other Indian leader would have done that, an Indian leader even given the size of the problem till today. On the other hand, you have people like the former Communications Minister, Sushma Swaraj who banned one of the most popular and influential radio programs on discussion of sex, HIV and STDs. So, the matters are not helped by this shift.

Audience 1(for Anil): You said some of your prevalence data shows 9.6 %. What is the comparable data for NACO because NACO has their own survey in Rajasthan? Second, what is the objective of situating your program and institute rural area to you? Are you going to train, what kind of people are you training, what kind of degrees with you give, and how is that helping the prevention of HIV.

Anil: NACO is labeling Rajasthan with low prevalence and which I do not agree with Mr. Rao and Anil Kapoor. We had a meeting for six hours where they invited us, the only NGO to address our issues and to discuss our projects. Twenty of our employees were invited and we had a six hour meeting in New Delhi and they label Rajasthan as low prevalence and nobody is doing studies in rural Rajasthan and I think I am comfortable saying, I think we are the only ones doing studies in rural Rajasthan. We are focusing on migrant workers and the rate I said was 9.6 to 10. It's alarming definitely.

Audience 1: You're saying NACO doesn't have figures.

Anil: Not for rural setting, it doesn't have figures. NACO does not have figures. Your second question, Public Health Institute, we are planning to offer, I don't know how plans are that we should have this institute in place by 2001 fall which is July, the academic year in India. We will be offering diplomas, like certificates and also MPH and we are trying to get affiliated with Australian University and Rajasthan University. It looks very promising so far. We also have plans to start a med school by 2002, we don't know how far we will go but public health is our priority.

Audience 2: My name is David and I am a grad student. There are many people living in India with HIV/AIDS. What about their rights, career opportunities and what's happening to them?

Dube: I think in short, the answer is that it is an absolute nightmare for people who have HIV and as Marty pointed out, people with HIV infection progress to AIDS much faster in developing countries and then die very shortly after progressing to severe HIV infection. In fact in India, the best estimates suggest that people who develop severe HIV infection die between six months to four years. Fours years with good treatment but often enough within six months and many people die of course of TB even before they get severe HIV infection, which was why I was stressing how abysmal India's health care system is. And there is nothing more depressing and heartbreaking to watch than to see how people are floundering trying to get treatment. And if you are poor, if you are low income, even if you are middle class, it's an absolute nightmare to try and get treatment for opportunistic infections caused by HIV. Let alone ever trying to get hold of cocktails or AZT to prevent mother to child transmission. So, one has to see it within the larger picture that health care services are under funded by the government in India, that they are badly run, that they are spotty on the ground and that people with HIV, once health care providers realize, typically that people have HIV, they'll typically turn them away, which is not a commentary on all health care providers but that's the norm. So, people with HIV/AIDS get very little care in India and they can generally not even afford the price of medicines for the more complicated opportunistic infections.

Ruth: There is also the question of who is likely to be blamed and the stigma that goes with that and in a situation where a married women has HIV/AIDS and the man has HIV/AIDS. It is often the woman who is blamed for behavior that allegedly happened outside the home, even if it didn't. So she can kind of be socially sacrificed for the benefit of the status of others in the family. You can also imagine for a woman, with high rates of mother to child transmission of HIV/AIDS, there is the extra pain of having the children infected and not necessarily being able to have care. In Nepal at least, I've seen sex workers who come home and if it is known that they have HIV/AIDS, their communities will turn them away. And if there is no programs for them outside of their communities what are they to do? So, I don't know exactly how that is in India, whether people are risking to even have it known that they have HIV/AIDS, which may be a step that has to be taken before you can get treatment, even if it were available, but there are so many social as well as medical costs.

Marty: You know the issue is not only therapy but effective therapy. I've not been to India. I have been to Malaysia, which is a relatively rich country in that part of the world. And I went to a clinic, where vast majority of the patients looked like my clinic back in 1984. Basically, everybody was dying. And the reality of the situation is that in order to treat HIV effectively, you have to use a minimum of three drugs, perhaps four and even in some people five. And this is beyond the means of even middle class, upper middle class, even at reduced rates. And so effective therapy does not exist more or less.

Audience 3: In the absence of vaccines for HIV/AIDS, (not clear/decipherable)

Dube: I'll be happy to have the first crack at the question. I think one can do a lot in terms of prevention, in terms of reducing the final size of an epidemic in any country. The first step is to have the political will and then to have the resources. And very often poorer developing countries, particularly in Africa don't have the resources, even at a national level. In a country like India, the financial resources do exist to a certain degree and the government of India, both at the federal level and at the state level could increase spending for health care and for STD treatment and for prevention of HIV. So governments have to be committed to doing all this. Then you do have larger questions like the one you brought up-where there is poverty, where there is illiteracy, can you have information campaigns that do work? You can. Again, it just needs commitment and it also needs recognition that AIDS prevention is not money wasted. The treatment of STDs or information on the prevention of STDs should be done anyway. They reduce suffering and death and certainly a great deal of illness anyway. So, I think it first requires a change in mindsets about the issues of health and poverty and it requires public and government commitment in these societies and worldwide to reducing poverty and ill health. And there are many things that can be done after that. They're difficult things because, particularly with STDs and HIV/AIDS, it's a discussion on sexuality that is rife with all kinds of sensitivity. But I don't think one should be hopeless, I'm sort of hopeless about governments doing things on time but I'm not hopeless in terms of "nothing can be done"; it's not inevitable. If governments take resolute and firm action-and it really is incumbent on governments to do so-then they can prevent large scale epidemics. And in India we've seen with Tamil Nadu a model, again with qualifications, of fairly successful government action and managing to quell a very severe epidemic. Infections rate in Tamil Nadu would have been higher than Andhra Pradesh; instead they are about slightly less than 2% rather than being 4% in the entire Tamil Nadu adult population. So, there are things that can be done and Tamil Nadu is not a success story on every level but even small things can make a big difference.

Ruth: I'd like to give an example from a global meeting around 1988 that the Division for the Advancement of Women sponsored in Vienna on rural women. I was asked to give a paper on the impact of the HIV/AIDS pandemic, the environmental crisis and the debt crisis on rural women. What was interesting was that some governments there didn't like the word pandemic being used and they complained that anything about HIV/AIDS had to be struck from the record, that it wasn't even discussed on the grounds that given the religion predominant in their countries, it would be impossible for people to have extra-marital sex. That this was insulting and therefore there couldn't be any discussion on the HIV/AIDS pandemic. And believe it or not at a UN meeting , that this was a setting for this, it was struck from the record that the paper was ever given, that the topic was even discussed because of the forcefulness of the government arguments on the basis of offense to religion. Now the positive side is, I won't mention the governments concerned, but the positive side is that the particular government that led that trashing, whatever you want to call it, now has a very good prevention program for HIV/AIDS. So, part of the answer to the question about "are we doomed to seeing increasing incidence in developing countries in particular?" is how willing are people and governments and religious groups going to be to discuss matter of sexuality and see discussing them as in the interest of the public rather than the against the interest of the public.

Rob: Okay, we have time for one more question.

Audience 4: Question not decipherable.

Anil: I learned in India working for last five or six years, although trained in Boston but it is very easy to work with the central governments and the state governments if you go to them and seek advice about how we could work together? And things really work because I know through my collaborators, friends who've been very active against the government, yelling at them, screaming at them, we need this, we that. But I have been very successful with all of my training programs funded by (indecipherable), World AIDS Foundation, now with FXB people , now we are local chapter registered, we are FXB India now. It's very easy to go and discuss with them issues of how can we work together…that's how we are trying to do partnerships. And I think in a country like India, it might be helpful to work in this kind of style, in my experience. So, I would rather not go into what we can do in this country.

Dube: I think the bottom line is that it is very difficult to make the Indian government, whether at the federal level or particularly at the state level to do anything on time. So, you know you are caught in a cleft stick. If you are aggressive and antagonistic, they are going to not let you do anything and they are going to react to it and get the hackles up. Perhaps, which isn't to say that the right tack is only to be accommodating and to join because what then happens is that the slant given on HIV is a very moderate one and the sexuality is taken out of it. So, they do the easy programs. Like let's give health care at hospitals or we'll have testing and counseling and those are people who are already infected or are very worried about being infected. And so matters run on just the way they are. So, to change things, for instance, to make the government in India realize that sex workers have a right to be uninfected, that sex workers have a right to live and have medicines if they are infected, all that homosexuality, that bisexuality is a huge issue in India, that homosexual men or women have a right not to get infected. Those are things we need to battle the government one way or the other. But it's really a losing battle because even if we put it into their reports and now the government of India does recognize that MSM (men who have sex with men) is a significant cause of many people getting infected and of larger transmission. They don't do the programs. They just say show us the data even if their own reports are saying yes we are going to spend money on it. So, that is why I am so pessimistic about the whole situation, which is you need action to happen yesterday and that action is not even going to happen tomorrow.

Robert Radtke: Thank you everyone for being with us tonight for this enlightening and sobering discussion. We have a few copies of Siddharth's book for sale outside the auditorium and it is also available for sale at the Asia Society. I put an emphasis on a very few. We have 15 copies, the rest of the books are tied up customs at JFK but if more them 15 of you want to have copies of the book, we have order forms or there should be order forms and we will be able to send you the book after the program when they are released from customs. I'd also like to take a moment to thank Alyssa Ayres who did a great job putting this program together. And her colleague Sanjeev Sherchan who just recently joined the Asia Society and has also done a terrific job tonight. Finally, I'd like to thank each of our panelists for really doing a terrific job tonight and helping us understand this awful problem we all face together. Thank you very much!