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World AIDS Day: Prevention and Policy

Panelists: Donna Futterman, M.D., Associate Professor of Pediatrics, Albert Einstein College of Medicine in the Bronx, New York; Director, Adolescent AIDS Program at Montefiore Medical Center, Pete Lamptey, M.D., Dr.P.H., Director, Implementing AIDS Prevention and Care (IMPACT) Project; IMPACT manages HIV/AIDS prevention and care programs in Africa, Asia, Latin America, Caribbean, Eastern Europe, Anne Macharia, Founding Board Member, Sourcenet Development Organization, a Nairobi-based non-governmental organization that focuses on the needs of marginalized women and girls, Josiah Rich, M.D., M.P.H., Associate Professor of Medicine and Community Health, Brown Medical School; Attending Physician, the Miriam Hospital in Providence, Rhode Island. An expert on harm reduction, including prevention, treatment and care for injecting drug users, and Holly J. Burkhalter, U.S. Policy Director, Physicians for Human Rights and its Health Action AIDS campaign
Presider: Princeton N. Lyman, Ralph Bunche Senior Fellow in Africa Policy Studies, Council on Foreign Relations
December 1, 2003
Council on Foreign Relations

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Council on Foreign Relations
New York, New York


PRINCETON LYMAN: (In progress) -- in the struggle against the pandemic of AIDS. We just have the report of the WHO [World Health Organization] and UNAIDS [the Joint United Nations Programme on HIV/AIDS] that shows that this pandemic continues to be one of the most serious challenges to the world community, that the number of infections continues to rise, but also that the concern of the international community is also gradually stepping up. Much remains to be done, and we have an opportunity today to look at this situation very closely and to have some new insights into how the international community together should address this problem.

It's my pleasure now to introduce Len Rubenstein, the director of Physicians for Human Rights.

LEONARD RUBENSTEIN: Good morning, and thank you, Princeton. And we're delighted to share this event with the council, which has been incredibly supportive of the work we're doing. And we look forward to further collaboration on addressing the pandemic with the Council on Foreign Relations.

Physicians for Human Rights is an organization that promotes health by protecting human rights. Last year Physicians for Human Rights began the Health Action AIDS Campaign, which is designed to mobilize members of the medical, public health and nursing communities to promote AIDS policies around the world that are consistent with best public health practice and the protection of human rights.

Thousands of people die every day from HIV/AIDS. At the same time, this World AIDS Day provides many sources of hope. The World Health Organization has just released its plan for treating 3 million people by 2005, and if the plan is implemented and the resources are available, we can begin to turn the corner on treatment -- treatment that a couple of years ago was considered impossible for the vast majority of people with HIV/AIDS.

At the same time, prevention policy is at a crossroads. So we're here today to talk about the need for public health practices as the driver of AIDS prevention policy and to prevent ideological concerns from undermining those public health policies.

The panel today consists of:

Holly Burkhalter, who is the U.S. policy director for Physicians for Human Rights and an expert on human rights and HIV/AIDS, particularly the rights of women and the impact on women and girls of discrimination in AIDS-affected countries.

We also have with us Dr. Peter Lamptey, who is president of the Family Health International AIDS Institute. Dr. Lamptey manages AIDS prevention and care programs in Africa, Asia, Latin America and the Caribbean, and Eastern Europe, and is a public health physician who is internationally recognized as an expert in HIV/AIDS and STDs generally, with particular emphasis on infectious disease transmission in developing countries. He's an adviser to the Physicians for Human Rights Health Action AIDS Campaign.

Josiah Rich is associate professor of medicine and community health at Brown Medical School. And his expertise is in treatment and prevention of infectious disease, with an emphasis on HIV and hepatitis viruses, particularly among persons who have addiction and in incarcerated populations. He is the principal investigator for the Ryan White Title III grant to provide early-intervention services with respect to HIV/AIDS, and has worked with the U.S. Conference of Mayors on syringe and care access.

Anne Macharia is a founding board member and former program director of Sourcenet Development Organization, a Nairobi-based organization that focuses on the needs of marginalized women and girls. Sourcenet has facilitated sex-worker peer education and theater programs on safer sex practices, condom use negotiation, signs and symptoms of common sexually transmitted diseases, method of HIV/AIDS transmission prevention and control, and home-based care for those living with HIV/AIDS.

So without further ado, I turn it over to Holly, who will give us an overview of U.S. policy on prevention and where we need to go from here.

HOLLY BURKHALTER: Thank you very much. And thank you for coming.

Before turning the panel over to the experts in prevention who work in the field, I'd like to just by way of background say a few words about the state of play on HIV/AIDS prevention policies here in the United States. As you know, there is a large increase in HIV/AIDS funding available in the course of the past year as a consequence of the president's announcement of a major new program, and there have been an enormous amount of effort and energy put into the development of HIV/AIDS policy by members of Congress and senators from both sides of the aisle.

It's vitally important that the money that the United Sates provides be spent well, for two reasons. One, even with these increases, international funding to confront the pandemic falls very far short of need, and the United States currently provides about half the funding. Thus, if we waste money here in the United States on programs that don't work or are even counterproductive, it not only deprives people who otherwise might be provided services -- deprives them of that, but it also could sort of create a "race to the bottom" in terms of the way money is spent and AIDS prevention policies from other donors as well. So the United States needs to be a leader not just in providing funds but also in leading on promoting best prevention practices.

There are some restrictions in laws that were passed, and so the Bush administration does not have carte blanche to spend this money any way it pleases. One of the most controversial features of the new AIDS legislation that will govern the use of money set aside for prevention is a requirement that one-third of AIDS prevention funds be used to promote abstinence in overseas programs. But even given some of the restrictions in law, there's a great deal of discretion, and that's the reason why we brought these experts together today to speak to the Bush administration and urge it to use its discretion and work with Congress in implementing programs.

We are releasing today a letter to Randall Tobias. Ambassador Tobias is the AIDS czar, as it were. Our letter urging him to support best practice in a whole variety of prevention strategies to confront the pandemic was signed by 145 American doctors and nurses. They are the leading figures in fighting the AIDS pandemic here at home and abroad.

And again in keeping with our approach, which is to fund and support and nourish and nurture not only best practices in health but best practices in human rights are reflected in that letter, which the press has in the packets before them.

But back to the notion about the discretion that the administration will have in funding and supporting best practice. Even given the legislation that specifically designates that one-third of AIDS prevention funds be used for abstinence, there's a great deal that can be done within that rubric and to support appropriates polices.

One would be, there should be no gag rule. The administration should not withhold funds from nongovernmental organizations, either international ones or domestic, local organizations, which are involved with and integrated with others who do provide non-abstinence, or rather, condoms and some of the other elements of best practice in prevention.

Two, they should not support any false advertising about condoms. Some of the abstinence promoters -- not all, but some -- have worked at home and abroad to try to denigrate or discourage condom use on the grounds that condoms don't work. And in fact condoms are the only physical barrier to AIDS transmission, and discouraging people who are sexually active from using them is a disservice to those people and to the greatest pandemic in human history. And there's no reason the administration has to fund such programs. They should avoid them and make sure that they aren't soaking up some of these resources.

Third, some of this abstinence money could be used to work on programs that protect women and girls from rape and sexual violence. Just as some conservatives are promoting the notion that people should not be sexually active until marriage, there are many, many, many victims of rape and sexual violence who would have loved to have the right not to be sexually active until marriage for whom that right has been taken away from them.

And I hope that the concept of abstinence for women and girls, for example, who have been trafficked into the sex industry, not just in Africa, but in Thailand and in India, are also seen to be part of the focus of abstinence in prevention.

I would also say that it's very important that we not neglect in our AIDS prevention programs those populations who are often neglected and despised and marginalized within their own countries. And here today to talk about some of those people who are particularly at risk are Dr. Peter Lamptey, Anne Macharia and Dr. Rich.

With that, I think I'll turn the microphone over to Peter to say something about AIDS prevention strategies in Africa.

Thank you.

PETER LAMPTEY: Thanks, Holly.

The UNAID's World AIDS Report has just been released today, and the report confirms that the HIV epidemic continues to spread and the impact is more devastating than ever. And I'd like to briefly quote one of the paragraphs from this report.

It says, "In several countries in sub-Saharan Africa, high levels of AIDS mortality now match the high rate of new infections, creating a cycle of illness and death, due in great part to the almost complete absence of large-scale HIV prevention or antiretroviral treatment programs."

It has been mentioned that there is now an urgent push by WHO, by the Bush administration and Tobias, to provide treatment for those in need in Africa and other places, but the greatest needs in prevention are yet to be met. Most of our prevention programs are small-scale, so-called "boutique" approaches that are limited in scale, and that is the reason why we have yet to have a major impact on slowing down the epidemic.

There are several success stories, both at the national level as well as the regional and district levels in countries, and the most notable is Uganda. But there are others beyond Uganda. There is Senegal, there's Thailand, there's Cambodia, where large-scale prevention efforts, comprehensive in nature, comprise a variety of different approaches, including abstinence, be faithful, condoms, treatment of sexually transmitted diseases, programs directed at high- risk groups as well as the general population.

We admit that ABC is a critical component of prevention programs, and it certainly was a major contributor to the success of the Uganda program. But again, to emphasize what Holly said, it is not the only approach that needs to be adopted. We need to be responsive to the needs of the countries' epidemics and to -- and the need to scale-up to control the epidemics at the country level.

I'd like to just give you some examples from our personal experience in some of the programs we have in Africa and Asia.

One of the programs that are urgently needed is for people to be able to determine their HIV status and be able to plan their future and be able to access care services -- and this is voluntary -- and counseling programs.

And two programs that I saw recently in Kenya, Rwanda -- in Kenya, the government has an ambitious plan to have 350 VCT centers, voluntary counseling centers, for the whole country by next year. We've already provided about 60 of them. We intend to build -- start up another hundred. That will provide about 50 percent of the government's expansion program.

The second program that I saw was in Rwanda, smaller country. We've created 22 centers that are now providing access to 7,000 people every month for counseling and testing.

And so these programs are very quickly being scaled up in a number of countries, but we need to do more. We need to do it in a lot more countries and make sure that not only 10 percent of people who are infected get to know their status, but a much larger proportion.

The second is prevention of mother-to-child transmission. We've had the technology, the availability of nevirapine and other drugs to prevent mother-to-child transmission. But less than 1 percent of mothers -- infected mothers have access to these technologies at this point in time. And again, we have programs. The best examples are Kenya, Rwanda and Guyana, where programs are expanding to cover most of -- most women who are in need of programs to prevent them -- the spread of HIV from them to their children.

And the last example is the reduction of stigma and discrimination. This is an important problem that only prevents or limits our prevention efforts, but also limits access to care. And we need to not only address this more systematically, but also expand our approaches to reducing the denial, the stigma and discrimination.

To conclude, my most important point is that prevention should continue to be a major focus of all our efforts, the global efforts, especially of the Bush administration.

And it is the only way we know now to control the epidemic. Treatment is essential, is urgent. The needs are great. But prevention is the only way to prevent new people from getting affected, therefore needing treatment in the long run.

And the second is that even with the commitment for more resources for 14 countries, there are even more urgent need for commitment to other countries that have an expanding epidemic and also the need for extensive prevention programs.

And lastly, even when we think of prevention and treatment, we shouldn't forget that all these programs can only be successful when we develop the infrastructure and the capacity within these countries to institute good prevention and care programs.

JOSIAH RICH: I want to expand on what Peter mentioned about stigma and discrimination, in the next five minutes. Now during these five minutes, approximately 30 people are going to die from HIV and AIDS, and about 50 people are going to be infected. So there are more people getting infected than are dying, and that underscores the tremendous need for prevention.

I'm especially honored to be speaking here today on World AIDS Day wearing the -- under the banner of Physicians for Human Rights, because to me, as a clinician, having cared for hundreds if not thousands of patients over the last 15 years, with this disease, it's quite obvious that this is a human rights issue.

The stigma of having this disease itself is a tremendous burden to bear. I'm going to focus a little bit on an additional stigma that people with -- that inject drugs bear as well.

Now when somebody injects a drug, they take a sharp object that has -- a needle/syringe, and they put it into their arm. And they may draw -- pull back to get blood into it and then flush the drug in, to get it into the vein, and then oftentimes will pull back and flush back and forth. And when they've completed that process, they have a syringe that not only has had blood on it, because it went into a vein, but blood has gone in and out of that syringe, along with any viruses that are there.

Now if somebody does that, just that image of somebody injecting and flushing blood back and forth is just -- is something that really turns our stomach, that most people are repulsed by. And it's something that we don't want to see, we don't want to hear about, we don't want to know about, and we've had the ostrich approach. We've stuck our head in the sand and avoided that population and avoided that behavior.

And the net result is that people that participate in this behavior are stigmatized. They're discriminated against, even in the health care setting. They're often told things -- many patients have told me the countless horror stories of how they've been treated and mistreated when they're coming to seek medical care.

So when you turn people away from the medical system and turn them away from public health system, you end up getting people that hide this condition, hide their disease, and very mistrustful of the health care setting, and ultimately having their human rights discriminated against. That leads to further spread of the epidemic.

Now, how do you approach this? What works, and what can you do about it? Certainly, preventing drug use to begin with is very beneficial, so any programs that can do that. But once people are hooked and inject drugs, a lot of people are very concerned there is nothing that really works; and that's not true. Clearly, the components of successful programs are access to drug treatment. If people get into drug treatment, it clearly works. No matter what the drug, no matter what the treatment, almost, more treatment works better. That doesn't mean it works any individual time, but our treatment for addiction is far superior than our treatment for most cancers, and far more cost-effective. So drug treatment works.

How do you get people into drug treatment? You really need community-based programs. You really need them locally tailored to get people into treatment. Now, that's for drug treatment

Medical treatment, it's quite clear -- not just for injection- drug users, anybody -- medical treatment is a critical linkage for HIV prevention. If I'm in a place where, if I get tested and find I have HIV and all I get is negative things -- I get discriminated against, I get run out of my village, I get my family beaten up, I lose my employment -- if that's the only consequence of finding out that I have HIV, why would I possibly get tested for HIV? Now if I've seen my neighbors and relatives and friends get sick and die from this horrible disease, and then I see that there's treatment and people that I would expect to die turn around and get better -- put on weight, be healthy, be productive, be active -- that's a powerful incentive to go out and get tested and to encourage everyone to get tested. So the linkage with treatment and prevention is crucial.

And I can't overemphasize enough: The stigma associated with HIV, associated with different sexual practices, associated with drug use, is really fanning the flames of this epidemic. And the sooner we can aggressively deal with them in culturally sensitive and locally targeted ways, the sooner we'll prevent further spread of this disease.

Much of our approach to addiction in this country, unfortunately, involves the criminal justice system, and that's really been a -- that's another human rights issue. Incarceration does not work for addiction. It does not reduce addiction. It does not reduce demand for drug use. And when people leave from an incarcerated setting, they resume their drug use. And that's very different than drug treatment. So in this country and in many others, a focus on drug treatment is going to be critically important.

You know, this is a lesson that we've learned -- or maybe we haven't learned -- that can be translated to Eastern Europe and Asia and many areas where injection-drug use is really driving the epidemic.

So I'll look forward to entertaining further questions.

ANNE MACHARIA: Maybe if I can follow what Josiah just said about discrimination, what I'm going to talk about or to give a brief is on a group that we work with called the marginalized, or that falls within the marginalized communities. And these are the sex workers. We have been working with the sex workers as partners, really, not working for them, but working hand in hand, like two programs, with the sex workers.

And by working with them, we have learned so much which we had not known about sex workers. As we all know that the sex work is something that nobody can really give statistics about, we don't know so much about it, because that group [inaudible] in -- have been excluded for a long time, and we don't know much about them.

And one of the things that we learned from them is most of the women and girls who are in prostitution are gone there or they have been driven there by poverty. And their other category that have gone to prostitution is forced early marriages, because, you know, some of the cultures in my country force girls to get married when you are like 9 years. You're married to a 60-year-old person, and in an effort to run away from that set-up, then you end up in prostitution.

Another one is peer pressure from the families. When the family is so poor and people cannot make it or cannot make ends meet, sometimes women or girls become the target. They're the ones who are used to go and bridge the gap for the economic gain of the family. That means women are even [inaudible] to force their girls to go for prostitution, so that they can bring money home. And especially those who are sex workers -- sometimes when the girl is like 14 years old, they tell them, "You go and make your money. I make my money. We bring it in the evening." Because sometimes -- you know, most of the times is when they go, they don't get clients, especially when they are old. The older they get, they don't get clients. So they think their girls are competitive enough and they can bring money home.

So those are the main reasons that make people go to prostitution. And some of these pressures from the families have even led to trafficking, because some of the women, when we brought them to a group in a meeting, they said, "Sometimes we tell our girls to go out there and get white men, go with them, even if they have to travel to their country, with the hope that we will make them -- you know, it'll make them live a better living." And they don't know what is on the other side, where the girls are going, and with no education and whatever. What can somebody do in America when you are not educated?

You are coming here, so you end up in prostitution, and not even prostitution that will give them money because you are kept somewhere, you are working with a pimp, and somebody else who takes the money on your behalf, and you never even have money to take home.

So, what the sex workers have said as their main problems in that industry is discrimination and stigma. They can never access the medical services because some of -- most of the clinics in Kenya -- Dr. Lamptey will correct me -- have been privatized. They are all -- if you go there, you have to pay some money, and these women, if they are not making their [inaudible], they do not get money to go to the doctor. Under the private government clinics, when they go there, so long as they are prostitutes, they are given like -- like they are the last in the queue, and sometimes they are not treated; they are told if you're a prostitute, we know you'll get the disease again, so you just go and prostitute with your disease. And I know – [inaudible] -- in that case they don't even get treatment.

And what happens in those government clinics, according to the sex workers? Whatever I'm giving here is what we heard as their problems when we brought them to our national, and again in the regional meeting. They say that when they go to the government clinics they are forced to be tested for HIV/AIDS, and when they are found positive, they are taken to the prison. They are arrested, they are taken to the police as a way of taking them away not to spread the HIV/AIDS. And what happens after that is the women goes to the prison, she has no money to pay for the fine. And again, the girl who was left in the house that was prostituting maybe gets HIV positive, goes to the prison, and the vicious cycle continues.

And then they say that when they go to the -- if they have money and they go to the private clinics, if they are checked and they are found they are HIV positive, they have no money to accept the drugs that are required. So in that way, they live with their HIV status and they continue passing it to the men who go to prostitute with them.

So, with all these problems that affect all that sex workers, our organization came up with a strategy how we could help them to get out of this. And one of the things that we did is we made partnerships with some of the private clinics so that the doctors could see them or could give them the drugs that are not very expensive, and then if the problem is bigger than that, that's where you cannot manage, but there is a doctor who sees them a regular basis without discrimination, he knows they are prostitutes, and he can give them the advice or the medicines that are not very expensive.

Another thing we have done -- because these sex workers, they have more problems than just HIV. Considering that you are told that we have trained them on condom use and how to protect themselves and all that, the problem is the client. We have been dealing with the women; we have not dealt with the client. And the client is the problem because some of the clients believe that actually there is no HIV/AIDS. Most of them believe that. And they don't want to pay money to just go there and have sex inside a pocket or a paper or something like that, so they are willing to pay more to the sex worker so that they can have sex without condom.

And a sex worker who has gone three days -- I'm sure most of us have gone three days without eating? I have gone four days without eating, so I know what it means. Somehow I have -- other than hearing from the sex workers, I have come up from a [inaudible] that is sex- work based, so I know what it is to go four days without eating. They'll not even care about condom. The disease can come later. I feed today. By the time I get sick, maybe there will be drugs, the [inaudible] will come with the drugs to cure the disease. So I know what it means.

So what happens is if a client comes up with an idea that they want to have sex without condom, the sex worker will not care. Whether she knows she is positive or not, she'll just go with a man, get the money, feed the kids, and that's it. So the man gets infected and he also passes it to somebody else.

So something else we have done is we have tried to -- because these sex workers have no way they can have bank accounts, they have no health insurances, what we have done is we have talked to the banks and we have opened, like -- the account is like a group account where they can be saving their money which they earned from prostitution, and after three months we give them money and they have started small businesses. And by the time I left the country, which is, like, two and a half, two and three-quarter years ago, about five of them had quit sex work and they had started small businesses with the money that we had given them.

And then health insurance is -- we have talked to the insurance company, and we've become a grantor. Those who want to have insurance covers for their families and themselves using the money that they prostitute with, we have helped them to do that.

And other than that, I think there are so many things that we have done for sex workers. The thing is, I don't think I have time to -- if you ask me questions, I will answer, but --

BURKHALTER: Okay. Thank you very much, Anne and Peter and Jody.

We have some time to entertain questions from the news people in the room. If you would be so kind as to direct your question at one or the other or any of the panelists and identify yourself, we'd be glad to hear from you.

Yes, sir?

AUDIENCE: Yeah. Hi. Richard Finney with Radio Free Asia. Do you expect -- yeah, hi. Do you expect U.S. funding for AIDS prevention, you know, focused internationally, to impact the situation in Asia at all? And could somebody speak to what the trends are now in the Asian countries?

BURKHALTER: Well, just a quick word, and then Dr. Lamptey will probably want to speak to that.

The -- there are significant existing programs on HIV/AIDS prevention and -- though not much in the area of treatment in Asia. And the new program does focus on 14 African countries, but it's not the entirety of American funding available to confront the pandemic.

I've heard that they're going to add one Asian country to the list of 14 target countries. It may be India, though I don't know that that's been set yet. But other, preexisting programs will certainly continue to deal with the pandemic, which, as most of you know, is considered to be the next wave of the global AIDS pandemic. India and China alone will account for a very large number of the new infections in the global pandemic.

Peter, did you want to speak to that?

LAMPTEY: Yes. The first part of the question -- currently, the U.S. government spends roughly about $1 billion a year on programs, and the programs -- we are working in about 65 countries. We spend roughly about maybe 50 percent of our funding in Africa, another 35, 40 percent in Asia, and the rest in Latin America and the Caribbean, Eastern Europe.

The additional $2 billion a year that is expected to come from the Bush administration is supposed to be earmarked for those 14 countries. So there will still continue to be funding for the rest of the [inaudible] countries, as they are called, and actually I believe that Mr. Tobias has even said that funding will increase in the non-focus countries. So there will continue to be funding to those countries. And also we expect that the funding that goes through the global funds from the U.S. government will also be available for all other countries.

The second part of your question, the epidemic in Asia -- the epidemic, yes, continues to expand. The worst-affected countries are India; Vietnam, especially because of IV drug use; China -- in some parts of China, 70 to 80 percent of drug users are infected -- Nepal, also primarily due to drug use. There are several countries where the epidemic is at the beginning stages, but it's expanding very quickly. And as Holly said, within the next few years, there will be more HIV infections in Asia than the rest of the world together.

AUDIENCE: If I could just follow up. Is Vietnam cooperating with the United States in education programs or cooperation along other lines?

LAMPTEY: Yes. We have actually quite a number of programs in Vietnam, some of them targeted at sex workers, some targeted at drug users, and some targeted to the general population. And those programs are relatively small-scale, but yes, the government has been a key partner, as well as other nongovernmental organizations in the country. And we've had programs there for about seven years now.

BURKHALTER: If I could just say a word about Vietnam and other Asian countries, there's an aspect to HIV/AIDS prevention that is not commonly thought of in the context of health and disease transmission, and that is the issue of trafficking, both the forcing or tricking or coercing of women and girls into the sex industry.

And in Thailand, for example, the vast majority of sex workers are not Thais; they are Burmese women and girls. For example, Nepal has a terrible problem with very large numbers of women and girls going to Thailand and India. Vietnam is a source country for many trafficking victims in Cambodia. And some of the youngest trafficking victims in the world are Vietnamese -- little Vietnamese girls aged five to 15 who have been trafficked from Vietnam to Cambodia, but many trafficking victims are actually coerced into the commercial sex industry within their own countries. It's not just across a border -- you don't have to just cross a border to be a victim of sex trafficking.

And the rights of women and girls who have been forced into prostitution, or tricked, or any girl under the age of majority should not -- there is no such thing as consent for a child in prostitution. Their rights are not to have access to condoms. Their rights are not to be in the sex industry at all.

And that is something that governments can and must control, because it is a crime. It is a crime to be commercially exploiting sexually women and girls. Thus, if it's happening on a daily and hourly basis in full view of the public, where customers can find these women and girls who have been forced into the sex industry, if their customers can find them, then the police can find them. And it must be attended to, and it is not being attended to in any country of the world.

So a part of our human rights agenda in the context of the pandemic is the right of women and girls who have been forced, by violence or by coercion or trickery, promised a job in a noodle shop, and end up in prostitution and debt, bonded to a pimp and not able to leave. And after the first couple hundred clients, then your possibility of returning to your home or to your home village are finished, and you never do leave sex trafficking.

And as Anne Macharia knows, women who grow old in the -- no woman does grow old in the sex industry. When they're too old to attract clients, then they're out on the street.

So the degradation of women and girls through sex trafficking, through child prostitution and sexual exploitation is an aspect of the AIDS pandemic -- they are very vulnerable to disease, and particularly because of the violence associated with forced sex and because of their very young age -- in many circumstances is a kind of unnoticed aspect to the pandemic that just be considered and dealt with both as a health problem but also as a human rights violation and a crime.

Anne, did you want to speak to that?

MACHARIA: What I wanted to add about that is I think we are neglecting a very big number that is out there that we don't know, because according to a study that was done by the University of Nairobi in 1999, they estimated that the number of prostitutes in the city by itself was 250,000. And according to sex workers, each sex worker sleeps with four men a day; if you have to make ends meet, you have to sleep with four men a day. So, if we assume like half of the prostitutes are HIV positive, which could be possible, which is 125,000, if they sleep with four men in a day, you can see why the spread is so high.

So, if we don't really work out some programs to target that group -- I'm not saying they are the ones who are increasing the number, but there is a possibility because nobody is giving them access to prevention, they don't know about -- how to use condoms.

And we may think that people know about HIV/AIDS. I just attended -- we had a booth at the ICASA [International Conference on AIDS and Sexually transmitted Diseases in Africa] meeting, this international conference on AIDS and STIs in Nairobi in September. We had a booth there trying to educate people about HIV/AIDS, especially the people from the rural areas. And I was surprised that so many told me, when you bring these things in Nairobi and you don't bring them to the rural areas, you don't know the number that is out there. They don't even know what we are talking about, HIV/AIDS. They don't know what it is. They still believe that people are dying of natural causes, they are dying of curses, and they are dying of many other things, but not HIV/AIDS.

So, we may think because we are either urban or we are in big cities, that everybody knows about HIV/AIDS. They don't know. That's what I came to realize. I didn't know about that. I was thinking because of the radio media and all this, that people know about HIV/AIDS, only to learn that they don't know. And I can agree that. I grew up in the rural areas, and I hardly saw a newspaper. My father used to go to the market, read the newspaper, comes back home. He does not tell us about the newspaper. So my mother, and many other women who were out there who never go to the markets because maybe they have no time to go to the market, they don't ever know what is happening out there, they never know what diseases are coming up.

So, I was thinking, other than even going to the programs of empowering them, I think the programs of educating them about HIV/AIDS still needs to be done. Let's forget about empowering them or giving them money or what, because maybe they are thinking sex workers are out there wanting money. The thing is, let them be educated. Let us educate everybody.

I think the coming World AIDS Conference is talking about access to all. Who is "all"? If you are leaving such a big number out there, without targeting them, I'm wondering who is "all." But maybe the experts can tell me!

BURKHALTER: Other questions or comments? Yes, sir?

AUDIENCE: If you all could give your opinions about just the overall direction of the Bush efforts on the global AIDS front, I mean, if you had to grade what's been done so far, what needs to be done, how's he doing in terms of leading this effort?

BURKHALTER: Well, I can start with that. The president's commitment of $15 billion over five years in his State of the Union address in late January last year and his setting a numerical goal for numbers of people that he wants to have on treatment and numbers of AIDS infections that he wants his program to avert -- he wants to have 2 million people on treatment and 7 million infections averted -- that gave an inestimable boost to the global effort to confront the campaign (sic), and it really accelerated the efforts in the United States and enhanced the possibilities very greatly. And I really can't say strongly enough how significant that commitment of both resources and of political energy associated with confronting the pandemic -- how helpful that was in sort of changing the whole playing field in the United States. That's the positive part of the message.

On the negative side, I am worried and distressed at the increasing pressure, both within the administration, from people within the administration, and outside the administration, to spend the money on programs and activities that are not science-based and are not proven winners in terms of particularly prevention.

There is pressure against funding research, for example, at the CDC [Centers for Disease Control and Prevention] and NIH [National Institutes of Health]. And it's increasingly controversial, for example, to fund programs that disseminate condoms, distribute condoms. Research for IV drug users and for prostitutes and others of the marginalized communities that are vulnerable to AIDS are really under fire, both within the administration and from very conservative groups outside the administration. And that worries me. And the administration did not fight those efforts particularly hard during the consideration of the AIDS legislation.

So I think it's too -- I'm certainly not prepared to say that, you know, they've done a bad job. The program is only now just getting off the ground. You know, Randall Tobias was confirmed in October. You know, two months into the job is too early to do anything except wish him very well and offer best advice for those programs. But I think there are some danger signs that the administration needs to be alert to.

I yield to my panelists.

Josiah?

RICH: I guess I would expand on that, the concern about effects on science-based prevention and treatment programs. There's been a list of -- I don't know if it's 100 or 200 National Institutes of Health-funded grants that have -- that are currently receiving extra scrutiny. These are grants that are studying things like sexual behavior and drug use. And as I mentioned before, there are people that are uncomfortable, fundamentally uncomfortable with people's drug use or sexuality, and to really -- what's going on now is an attack on the National Institutes of Health, the NIH's scientific review process and it's injecting conservative political ideology into that process. And this is really very unfortunate and very potentially devastating. If you allow a political group to say we are not -- if researchers are going to study, for example, drug use or certain sexual behaviors and how that contributes to the spread of HIV, that those researchers are going to be somehow scrutinized additionally and harassed, that has a very chilling effect on what researchers want to do. I recently heard of a colleague who was on an NIH review panel of a grant who expressed concern that, "I don't really want to vote on that particular grant because I'm concerned somebody's going to find out that I voted in favor of this and come back and attack my research and attack the --"

So that is unprecedented, to allow politics to enter into the NIH's scientific review process, and it's really unacceptable because the logical conclusion is going to be the ostrich sticking the head in the sand approach. And if you don't address these behaviors that you may or may not like, and how they spread HIV and how to prevent HIV, you're going to have a much worse problem than you ever had.

And, you know, I guess I would say that not only this administration, but the previous administration, has really come up short on HIV prevention in drug users. The whole debate over needle exchange and it's -- you know, I would put "debate" in quotes. The scientific and public health evidence is quite clear these programs are highly effective at outreaching to drug users and getting them into care and getting them into prevention and reducing the spread of disease without encouraging drug use. But yet, there is an ongoing ban on the funding of syringes for drug users.

So I'm perhaps a little less optimistic.

LAMPTEY: Just an addition to what Holly and Josh have said. I think what is remarkable about the Bush effort is, one, the level of resources for the 14 countries. This is remarkable, to have that much resources for those countries.

Second, the emphasis on treatment. Of the 6 million people who need treatment, we estimate that less than 300,000 people all over the world have access to treatment, and most of those people are in Latin America and Eastern Europe.

Q What were those figures, again?

LAMPTEY: Six million people need treatment, access to treatment, and only 300,000 people currently; and of these, only 50,000 are in Africa. So to have that level of resources that is available for treatment is also remarkable.

The third factor is the fact that both prevention and treatment are going to be on a large scale, something that hasn't happened in most countries, and to have this happen in 14 countries. But as Holly said, some of the unknown is how well is this going to be operationalized and how well will it respond to the needs of the epidemic or different types of epidemic in a country, making sure that resources are spent on programs that will actually change the epidemic, and not necessarily the programs based on either ideology or some congressional emphasis.

But I believe that I'm a little more -- I'm more optimistic. I believe that eventually the resources are going to be used to scale up both prevention and treatment programs that will eventually control the epidemic and also treat those who need -- provide access to those who need treatment as well as mitigate the impact especially on orphans and vulnerable children.

BURKHALTER: If I could just add one remark, if you permit me. There's one area where I would give the administration a C-minus with regard to its program, and that is the issue of infrastructure. And the reason I give them a poor grade in that area is that the president announced this whacking big $15 billion amount and brought immense political support for that, and created, then, the expectation there would be, if it's a five-year program, $3 billion a year, a huge scale-up -- and a terribly necessary scale-up because, quite frankly, the actual needs globally are more probably like $10 billion a year. But there was this notion, because 15 divided by 5 is 3, that at least $3 billion would be available in year one of the plan.

And then the administration and his highest-ranking people in the administration and the leaders of the president's party in the United States Senate who are most looked to for leadership and expertise on the pandemic, then fought the Congress tooth and nail to keep them from actually appropriating $3 billion for the first year of the program.

And I found myself thinking, when President Kennedy announced that there was going to be a space program to put a man on the Moon, he then didn't turn around and fight the Congress when they tried to pay for it. You know, if you're really serious about getting the work done, you would actually be trying to front-load those resources because you want to get the job done, not because you're playing games with the budget.

And if the money cannot be used in the first year, which I actually don't think is the case, then for goodness sakes, spend extra billions the first year to build those medical and nursing schools; to, you know, create the labs and buy the supplies and train the docs and the nurses and the health workers and the educators on an urgent basis because, you know, this is the moment now.

And I think that was a grave disappointment to AIDS activists everywhere in the world that the president, having created a political moment, then didn't seize that moment and secure the maximum amount of funding while he is president and while he has the world's attention directed to his program and enormous bipartisan support for it.

Are there other questions or comments from the audience? (No response.) I think with that, Princeton, do you want to wrap up for us? Thank you very much.

LYMAN: Thank you, Holly. Thank the whole panel for what is an extraordinarily important discussion.

We are engaged in a process on HIV/AIDS that goes beyond, I think, anything the world has seen. And even as we now gear up for a major international effort and a much more aggressive U.S. effort, it's clear that we have a long way to go.

I want to congratulate the Physicians for Human Rights for putting together this panel, for the letter that they are sending today to Ambassador Tobias.

I want to mention that the Council on Foreign Relations, in conjunction with the Milbank Memorial Fund and the Open Society Institute, is conducting a roundtable study on the president's new initiative. Our report will be out early in the next year. I think the issues raised here are an important part of it, and two I want to focus on in particular that, it seems to me, comes out of the panel and are very relevant to this.

The first is that while we talk about this, our response is in terms of, understandably, prevention, treatment and care, et cetera, underlying that approach are the issues of vulnerability, of gender, of stigma and discrimination. And those can't be addressed in a kind of formulaic way that deals simply with setting up health centers, et cetera, but goes at some very fundamental ways in which one reaches into the social issues that impact on the spread of HIV/AIDS. And I think the panel has brought that out and I think it's an important challenge.

The second is the importance of science-based, evidence-based approaches to dealing with this problem. If we go down the wrong path, if we spend the money on things which go against what we can learn and have learned and what we can learn in the future on what works, we will waste precious time and, above all, waste precious lives.

So I think the panel has been extraordinarily valuable in bringing out those issues, and I want to thank them.

And I want to urge that you continue the work, and we at the council certainly welcome your participation and help with us on our study. Thank you all very much.

Let me turn it over to Len Rubenstein.

RUBENSTEIN: Thank you, Princeton, and thank you, members of the panel. Princeton, of course, you stole my thunder.

But I would like to return to what Dr. Lamptey said at the beginning: that the greatest advances in treatment have yet to be made and that wonderful new initiatives on prevention need to be made and that the initiatives on treatment should not impede comprehensive, scaled-up approaches to prevention. And they must be driven by public health and human rights principles.

There's been a lot of reference this morning to the letter that we're sending to Ambassador Tobias today, which embodies a lot of the principles we believe should be followed by the administration. That letter is available on our website at phrusa.org and healthactionaids.org. And I urge all of you to review it and continue the discussion of how prevention can be comprehensive and can save lives of many, many people who remain at risk for this terrible disease.

Thank you all. (Applause.)

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