Sheetal Doshi stories from The Center for Public Integrity

India

India — 2012-02-27T13:06:38-05:00

Background

The Indian subcontinent is bordered on the west and south by the Indian Ocean and the Arabian Sea, on the east by the Bay of Bengal, and on the north by Pakistan, Nepal, China and Bangladesh. Just over 1 million square miles are home to 1.1 billion people — one-sixth of the world's population, with more than 60 percent living in rural areas.

Once a colony of the British Empire, the country gained independence in 1947. Now a federal union, the Republic of India has 28 states and seven union territories that are self-governing and a prime minister who is the elected head of the country.

The country is characterized by its diversity in language, culture, landscape and heritage. Fertile lands and river valleys support agriculture, which employs about 60 percent of the labor force.

The face of HIV

Migrant laborers and truck drivers, who spend days to months on the road, are among the most vulnerable groups for HIV/AIDS infection. According to the National AIDS Control Organization (NACO), India's central HIV/AIDS agency, there have been 124,995 officially reported cases of AIDS from 1986 to August 2006, though that number may be grossly underestimated because many people do not report their cases. Of those who have reported being infected, 58 percent live in rural areas and about 39 percent are women.

Just over half of all reported cases of HIV/AIDS are in two southern states: 52,036 in Tamil Nadu and 15,099 in Andhra Pradesh. In fact, those two states, along with the southern state of Karnataka and the western state of Maharashtra, which together make up 30 percent of India's population, account for about 75 percent of HIV cases.

Migrant workers and truck drivers who reside in southern India and engage in sex with commercial sex workers or with other men account for the high prevalence rate there.

In the northern states, HIV is often transferred by intravenous drug users; AIDS prevention programs targeting that population have made inroads.

However, according to the most recent report from UNAIDS, the Joint United Nations Program on HIV/AIDS, 5.7 million Indians were living with HIV/AIDS by the end of 2005. The disparity between cases reported and official figures by UNAIDS highlights one of the difficulties facing those working to stop the spread of AIDS in India. Heterosexual behavior is the leading cause driving the epidemic in India.

Among other challenges in fighting HIV/AIDS is the government's ability to provide health care especially in states considered vulnerable to the epidemic and the guiding social framework found in rural north and central India.

Challenges to fighting the HIV epidemic

Poverty proves to be a major hurdle in combating the spread of HIV/AIDS in India. About 350 million people, or more than 34 percent, live below the international $1 a day poverty level, and nearly 80 percent live on less than $2 a day. HIV/AIDS services are poor in rural areas, where most of the infected Indians live. Outreach is difficult. And many patients are unable to access services and medicine at the municipal hospitals because there is no funding for bus fare.

Social practices and taboos are serious challenges facing India as well. Stigma about those with the disease and discrimination force many who have AIDS to remain quiet about their status.

Another roadblock to delivering AIDS services is a law on the books dating from British colonial rule that says conviction for a homosexual sex act can carry a penalty of a fine and up to 10 years in jail. Because of that 1860 law, homosexuals are less likely to seek medical attention.

Those working to combat AIDS consider the law to be one of the greatest obstacles in combating the spread of the infection. Men who have sex with men (MSM), as they are commonly referred to, are a marginalized and vulnerable group at high risk of contracting the HIV virus. The law pushes the community underground, making medical outreach more difficult, according to AIDS prevention activists.

Workers for several organizations, such as the Naz Foundation (India) Trust, devoted to reducing the spread of HIV and other sexually transmitted infections in India, have faced police harassment, extortion and even jail time while attempting to reach MSM and other vulnerable communities. Naz attempted to repeal the law in Indian courts, but its petition was dismissed in November 2004.

As of August 2006, however, the government, with the support of Sujatha Rao, the current director of NACO, has been reviewing the law again. "Laws and regulations that target commercial sex workers, men who have sex with men or intravenous drug users only result in making these groups invisible and push the infection underground," Rao said, "making it virtually impossible for NACO to intervene effectively in ensuring primary prevention or access to treatment."

Indian government response

In 1992, the Indian government, with financial help from the World Bank, began Phase I of the National Aids Control Project (NACP), a public health program to implement a national HIV/AIDS prevention program. The first phase, which ended in 1999, coordinated the states and territories in monitoring the epidemic, developing effective prevention programs and reducing the rate of infection. The second phase, which runs through 2006, involves regional workshops bringing together state government leaders, nongovernmental organization leaders, health care professionals and others to create plans to implement prevention and treatment programs. Monitoring the programs and focusing on prevention and care are also major components of the second phase. In addition to NACP, the Indian government provides free medicine to AIDS patients such as new mothers, infected children and those who receive treatment at government hospitals.

U.S. government response

Since 2004 India has received nearly $77 million from the President's Emergency Plan for AIDS Relief, the five-year, $15 billion U.S. initiative to combat HIV/AIDS. That is the highest amount allocated to a country that is not among PEPFAR's 15 "focus countries", which together account for more than half of the world's HIV infections. PEPFAR funds are used to support programs implemented by NACO, such as one program that creates social centers for truck drivers who travel along the Chennai-Bangalore highway. In two of India's states hardest hit by the epidemic, the U.S. Agency for International Development helps fund programs such as the AIDS Prevention and Control Project in Tamil Nadu and the Avert Society in Maharashtra.

The U.S. has provided technical assistance through the Centers for Disease Control and Prevention to upgrade the ART [antiretroviral treatment] Centre and Laboratory in Chennai, which treats more than 3,000 patients a year; antiretroviral treatment has transformed HIV/AIDS from a fatal condition to a manageable illness The U.S. National Institutes of Health also is involved with operational research into HIV/AIDS in India by helping to fund clinical trials of vaccines and evaluation of using antiretroviral treatments to lower the risk of transmission between couples where one person is HIV-positive.

Thailand

Thailand — 2012-02-27T13:05:02-05:00

Background

Thailand lies between the Andaman Sea and the Gulf of Thailand just south of Myanmar and Laos and north/northwest of Cambodia. Since unified as the kingdom of Siam in the mid-14th century, Thailand remains the only Southeast Asian country never ruled by a European power. After a bloodless revolution in 1932, Thailand became a constitutional monarchy guided by a written constitution that outlines the monarch's responsibilities and duties. In September 2006, a military coup removed Prime Minister Thaksin Shinawatra and his government from power. Thailand is currently being ruled by an interim government, which has promised to deliver a new constitution by October 2007.

The economy is heavily driven by tourism, with the services industry accounting for 46 percent of Thailand's gross domestic product. Although most visitors come to see the natural beauty of the fertile lands and beaches, a small portion visit Thailand as "sex tourists" who frequent the brothels in Bangkok, Chiang Mai and other major cities. Said Sudarat Sereewat, director of the Coalition to Fight Against Child Exploitation: "A lot of people want to come for the weather, the culture, the cheap prices. ... But the big problem is that there are many factors that made Thailand a paradise for these sex tourists: weak law enforcement, technology and things like that."

The face of HIV

The sex industry played a major role in the spread of the HIV/AIDS epidemic in Thailand, which recorded its first case of AIDS in 1984. Men who have sex with men (MSM), sex workers and intravenous drug users fueled the epidemic, which peaked at 143,000 new cases in 1991. In 1988 the government spent only the equivalent of $180,000 on prevention because of a belief that it was a foreigner's disease. In 1991, Anand Panyarachun became prime minister and made AIDS prevention and control a national priority. Thailand spent $44 million in 1993 on efforts to curb the spread.

Alongside this new government policy, a massive media campaign was launched by cabinet member Mechai Viravaidya in which AIDS awareness messages were aired on the hour on all radio stations and the six television stations. A "100 percent condom" program was also initiated, enforcing correct and consistent condom use and providing free condoms for all commercial sex workers and their clients. The combination of programs produced the necessary results, with the annual number of new cases falling dramatically to about 19,000 by 2003.

Challenges to fighting the HIV epidemic

Thailand's government received accolades from governments and nongovernmental agencies (NGOs) around the world for its quick response and early containment of the disease. However, several NGOs and activists warn that Thailand needs to reevaluate the communities it has targeted and recognize that the face of AIDS is changing in the country. Thailand's prevention efforts and campaigns have dwindled noticeably in the past decade, and some fear that high-risk groups, which now include young people, are going to suffer the consequences.

Rapeepun Jommaroeng of Rainbow Sky Association, an NGO working with MSM in Thailand, said that because of tradition and custom, sex is still a taboo subject, leaving the younger population in the dark about the consequences of unsafe sex. "If you can't bring sex to the table, you can't talk about a prevention campaign."

Overall prevention campaigns are less prominent than they were in the 1990s, and as the United Nations Development Program HIV report on Thailand found, prevention services for young people are adequately reaching only 5 percent of the population. According to the report, only 20 to 30 percent of youth who are engaging in sexual activity are consistently using a condom. Youth today are too young to remember the messages that were so prevalent nearly a decade ago, and without an adequate reinforcement of the message, they are at risk of giving rise to a new wave of the disease, the report warns.

Thai government response

After the coup d'etat in Thailand in September 2006, an interim government has been set in place. In an effort to deal with a marked deficit and overspending by the former government, the budget was substantially changed and Thailand is struggling to keep funding for prevention efforts.It is likely that the new government will try to make positive changes to the HIV/AIDS programs, although it remains unknown at this time.

One of Thailand's major accomplishments in HIV/AIDS treatment is being able to supply 20,000 HIV-positive people with free antiretroviral drugs, which have been credited with transforming HIV/AIDS from a fatal condition to a manageable illness. Thailand produces generic drugs that cost only $300 annually per patient, which is far less than the $8,000 that the Kaiser Family Foundation says that brand-name drugs would cost in the U.S. and European countries. The government announced in June 2006 that it hopes to continue reaching out in this way to more HIV-positive people this year. In collaboration with the Joint United Nations Program on HIV/AIDS and the World Health Organization, the Thai government has come up with a National Plan for HIV/AID Vaccine Development, a program designed to foster research and development of a safe and affordable vaccine for HIV through strategic planning, research and clinical trials.

U.S. government response

Although Thailand is not among the 15 "focus countries" receiving special emphasis from the President's Emergency Plan for AIDS Relief, it has received $22.4 million under PEPFAR, the five-year, $15 billion U.S. initiative to combat HIV/AIDS. A program PEPFAR sponsors is the Human Development Foundation's Mercy Center located in Bangkok. People who are HIV-positive can obtain antiretroviral treatment from the center, as well as hospice care and outreach education. The facility reaches out to people living in the slums surrounding Bangkok.

Under the Global AIDS Program, two U.S. agencies, the Department of Health and Human Services and the Centers for Disease Control and Prevention, also work in Thailand; they provided $5.7 million in 2004. Their work there has provided help in coordinating and educating volunteer staff in counseling services. The program also funded technical services to implement a monitoring system for prevention of mother-to-child transmission of HIV.

Condoms' reliability disputed

2012-02-27T14:59:58-05:00

The major U.S. government program engaged in the worldwide war on the HIV/AIDS epidemic requires those in the field to tell at-risk communities that latex condoms aren't very reliable in preventing transmission of the disease, and instead to emphasize abstinence and fidelity programs.

But several key government agencies and the condom industry disagree with that approach, saying the message is wrong. They maintain that condoms are a vital weapon in fighting the spread of the disease and that they are more effective than the government program acknowledges.

The report, summarizing a workshop in 2000 co-sponsored by the U.S. Agency for International Development (USAID), the Federal Drug Administration, the National Institutes of Health and the Centers for Disease Control and Prevention, found that condoms are "essentially impermeable to particles the size of [sexually transmitted disease] pathogens."

In 2004, the Joint United Nations Program on HIV/AIDS (UNAIDS), the World Health Organization and the United Nations Population Fund released a joint position statement supporting the availability of condoms universally, not only to the parts of the population that are at high risk for contracting HIV, as the President's Emergency Plan for AIDS Relief (PEPFAR) provides, but also to the general population.

Despite those findings, the $15 billion PEPFAR program has been saying that condoms are only 80 to 90 percent effective. The study cited by PEPFAR giving this low range of effectiveness was not exclusively a latex condom study and could have included natural membrane or lambskin condoms which are not recommended by the CDC for disease prevention.

According to the CDC, "only latex or polyurethane condoms provide a highly effective mechanical barrier." USAID refused to comment on this issue but did confirm that it distributes only 100 percent natural latex condoms.

Also, studies show that youth being taught about HIV prevention using PEPFAR's so-called ABC approach, for "Abstinence," "Be Faithful" and "correct and consistent Condom use," don't have a clear understanding of the condom component.

In a 2006 survey of 1,365 Kenyan youths released by the Population Council, only 13 percent of those who had received ABC training defined consistent condom use correctly and many viewed condom use as negative. The survey found that a significant percentage "indicated that condoms were ineffective for HIV prevention because they leaked or burst. …"

Family Health International's Julie Pulerwitz, research director of the Population Council's Horizons Program, conducted the surveys in Kenya and said it was clear that the youths were receiving positive messages about the Abstinence and Be Faithful components and had received negative messages about correct and consistent Condom use. "If you're trying to have a balanced approach and all three of those behaviors are vital to HIV prevention, then you need to address directly the negative views," she said.

One participant of the survey said, "We are told [that condoms have] small holes that can allow the virus to go through." An adult in another group surveyed explained how they were taught about condoms' ineffectiveness: "They bring condoms and put in water, then they dry. After about five minutes the bottoms start becoming wet, implying that it is passing water through."

Every condom distributed through USAID is made of natural latex and subject to a battery of tests and standards. Unless incorrectly used, there is no reason for a hole to develop in a condom once it has left the factory, according to Suren Solanki, head of innovation and development for SSL International, the world's leading condom manufacturer, which uses the brand name Durex.

According to Solanki, stringent testing is conducted at every stage of manufacturing, from checking the raw latex batches to electronic testing of every condom to ensure product integrity. In addition, various national bodies — Durex condoms are sold in more than 160 countries — "audit our manufacturing sites and test our products in their own laboratories," he said

In those labs, randomly selected condoms are measured for thickness, length, strength and elasticity. They are also tested for leakage. If one condom fails any of the tests, the entire batch is thrown away.

International standards require that 99.7 percent of condoms be free from holes. Condoms distributed through the PEPFAR program meet these standards. According to Solanki, the odds of finding a hole in a Durex condom are less than 0.1 percent.

To help ensure correct use of the product and reduce the possibility of breakage, all U.S.-manufactured and FDA-approved latex condoms are required to include a "Directions for Use" and "Precautions" insert or labeling.

U.S. studies and the report by the four U.S. agencies estimate breakage rates to be between 0.4 percent and 2.3 percent.

To those questioning the effectiveness of condoms, Solanki said, "There is no technical debate about the value of condoms in preventing transmission of various STIs and HIV on a global scale — they work and are our only real ammunition to curb the spread of these infections."

Norman Hearst, a professor of medicine at the University of California, San Francisco, has spent 20 years researching HIV/AIDS in developing countries. In a 2003 report funded by UNAIDS, he concluded that condoms were effective 90 percent of the time based on an aggregate study of all studies done on condom effectiveness.

Hearst does not criticize PEPFAR for using the 80 to 90 percent figure, but he believes that condom effectiveness is more in the range of 85 to 90 percent. "You could argue whether it is the top or bottom of that range. … The bottom line is we won't ever have an exact number."

But worrying that a condom might be permeable, he maintains, is focusing on the wrong risk. "Condoms, when they fail, it's very seldom or almost never due to holes in the latex or things going through, somehow passing through the latex. It's exceedingly rare and it much more happens because they break, or they slip or people don't use them correctly," Hearst said. "Those things are a hundred or thousand times more common than holes in a condom."