Fourth International Congress on AIDS in Asia and the Pacific
Many Asian and Pacific nations find that their AIDS epidemics have little in common with those of their neighbors. HIV is spread primarily by heterosexual sex in some countries, by drug use, male-to-
male sex, or via blood products in others. A nation's wealth, or lack of it, largely determines both its ability to execute prevention programs and patients' access to therapy.
Like Africa, Asia and the Pacific have a regional AIDS meeting every two years. The Fourth International Congress on AIDS and Asia in the Pacific (ICAAP) was held in Manila on October 25-29, 1997, in conjunction with the Second Philippine National Convention on AIDS. The Congress gathered approximately 3000 scientists, people working in the communities, and people living with HIV/AIDS. The number of attendees was rather impressive in view of the recent economic turmoil in the region.
The theme of the Congress was "Partnerships across Borders against HIV/AIDS." Under this main theme, the four days of the conference were each assigned their own theme: "Why is HIV spreading in Asia and the Pacific?," "How are we dealing with the problem?," "What should be done?," and "What do we expect in the future?" Thus, the conference had the opportunity to cover a wide range of topics, from HIV subtypes to HIV in prisons. The meeting was one of the best forums among all the international AIDS conferences for people with greatly divergent interests to participate and share ideas and experiences.
In his opening address to the conference, Philippine President Fidel V. Ramos described recently proposed legislation that would establish a comprehensive legal framework for halting HIV infection and protecting the rights of people with HIV in the Philippines. "Once enacted," Ramos said, "the proposed law will advance AIDS education and information dissemination in schools, work places, and communities. It shall prohibit mandatory testing and protect privileged communication with regard to people with HIV." Many Asian delegates felt that President Ramos's declaration was one of the strongest anti-AIDS remarks ever made by an Asian head of state. It is hoped that other heads of states will show a similar degree of commitment.
The HIV epidemic in Asia and the Pacific
At the opening plenary session, Peter Piot, MD, PhD, executive director of UNAIDS, reported, "UNAIDS estimates that 5 to 7 million people are now living with HIV in Asia and the Pacific, and in India alone 3 to 5 million." Dr. Piot also warned that Asia and the Pacific were showing the steepest infection curve and would fast become the region with the most HIV infections in the world. The reporting and surveillance of HIV/AIDS in Asia and the Pacific is far from exhaustive. Australia is one of the few countries in the region in which reporting of AIDS cases is relatively thorough. Researchers have noted a steady decline in AIDS incidence since 1987. However, Sydney epidemiologist John Kaldor cautioned, "Even though the rate of transmission has gone down, people should never be complacent."
With one of the world's best HIV surveillance systems, Thailand has enjoyed its reputation for having curbed the epidemic. Among the various groups surveyed, HIV incidence has been stable in intravenous drug users and blood donors (95 percent of Thailand's blood donors are male) for several years. HIV incidence has already decreased in conscripts and pregnant women.
The single most important factor that has contributed to the success of the HIV control program in Thailand is the mass campaign for condom use. The 100 percent condom use campaign can be implemented in the sex industry in many provinces in Thailand. The program requires the collaboration of the owners, workers, and clients of the sex establishments, as well as that of local health and law enforcement authorities.
According to Werasit Sittitrai, PhD, a Thai social scientist who is now working for UNAIDS in Geneva, "Researchers were able to demonstrate the temporal relationship between the increase in condom use and the decrease in the incidences of sexually transmitted diseases and HIV infection."
In contrast to the stabilizing situation in Thailand, the HIV epidemic has worsened rapidly in many countries in Asia. Although only 4980 AIDS cases had been reported in India as of September 1997, the World Health Organization (WHO) estimated that India could have 3 to 5 million people living with HIV infection by the end of 1997. In view of India's population, its prevalence rate of HIV infection is still lower than that of Thailand, where 800,000 people are infected. It is estimated that Myanmar has 350,000 HIV/AIDS cases, most of which are located along the borders with China, Laos, and Thailand (the so-called "Golden Triangle"). China just released an official estimate of 400,000 HIV/AIDS cases at the end of 1997. The figure could reach 1.2 million by the year 2000. Cambodia, another country in the region hardest hit by HIV, estimated that it has 100,000 HIV-infected persons, or a prevalence of 2 percent in the adult population.
It is also interesting to note that the number of HIV-infected persons in many countries in the region is still quite low, despite the long-standing epidemic in these countries. Philippines, Indonesia, Bangladesh, Japan, and Korea are among the countries with low HIV prevalence. Whether this slow epidemic is due to lower risk behaviors among the populace or whether it is just a matter of time before these epidemics worsen remains to be seen. Presentations at the Congress outlined rapidly developing HIV epidemics in countries such as Vietnam, Malaysia, and Papua New Guinea. Therefore, no country should feel complacent about this pandemic.
Risk behaviors in Asia and the Pacific
The majority of known HIV/AIDS cases in Japan are related to blood and blood products, whereas male homosexual activity is the major risk behavior for HIV infection in Australia, New Zealand, and Singapore. Intravenous drug use contributes significantly to HIV infection in Myanmar, Malaysia, China, and Vietnam. Overall, heterosexual transmission causes the majority of HIV infections in Asia and the Pacific, as exemplified by the situation in India and Thailand.
Sexually transmitted diseases (STD) are undoubtedly linked to HIV infection. The prevalence of STD has been increasing in many countries in Asia and the Pacific, even in countries where the prevalence of HIV is still low. Therefore, there is an urgent need to control STD before HIV becomes widespread.
Megan Passey, MD, of the Papua New Guinea Institute of Medical Research, pointed out several factors that led to the high prevalence of STD in the Pacific islands. Urbanization and modernization separate people from their families when individuals seek work in large cities. This results in increased sexual activity with commercial sex workers. Many traditional social and cultural restraints are no longer in place, and premarital and extramarital sex have become more frequent.
"Low levels of formal education combined with religious and cultural beliefs create barriers to health awareness and health promotion programs," Passey explained. In addition, the low status of women, inadequate health services, and limited access to condoms also play a part in the spread of STD in the Pacific islands.
Chlamydia is the most prevalent STD in the Western Pacific region, reported George Poumerol, MD, of the Western Pacific Regional Office of WHO in Manila. Chlamydia infection was present in 5 percent of general population in Japan and China and 20 percent in Papua New Guinea. Up to 55 percent of commercial sex workers in Japan harbor chlamydia. The prevalence of syphilis among the general population in the Western Pacific region was less than 2 percent in most countries, however there was a prevalence of 4 percent in Cambodia and 8 percent in the South Pacific. The prevalence of syphilis among commercial sex workers averaged 15 to 20 percent, but was as high as 40 percent in Vietnam and 50 percent in Malaysia. Gonorrhea is the only STD that has been found to be decreasing in prevalence in almost every country. For example, the prevalence of gonorrhea among female sex workers in Cebu City, Philippines, decreased from 8 percent in 1991 to 3 percent in 1996, Poumerol reported. The decrease of gonococcal prevalence worldwide is thought to be a result of increased accessibility to antibiotics and treatment. However, incomplete treatment and poor compliance accounted for the increased presence of antibiotic-
Women and HIV in the Asia-Pacific region
About 42 percent of the 30 million people with HIV/AIDS in the world are women. The lower social status of women, poverty, and illiteracy are contributing factors to the high rate of HIV infection in women. Women constitute about 60 percent of world's 1 billion poor, and two-thirds of poor women are also illiterate, said Marina Mahathir, president of the Malaysian AIDS Council and daughter of the Prime Minister of Malaysia. Mahathir also warned that "high economic status does not guarantee protection from women when social and cultural barriers exist."
According to Mahathir, the lack of sex education in Malaysian schools and difficulties in legally safeguarding women's rights were some of the main obstacles to preventing HIV infection in Malaysian women. "Greater affluence allows men to have more legal and illegal partners," she said. "Women thus feel insecure and afraid to assert their rights, including the right to protect themselves from infection." The issue of marital rape is not recognized in many societies, she added. Women also have to be caregivers and are usually unpaid, untrained, and unrecognized. Infected and affected women frequently face isolation because of stigma and discrimination.
Clinical manifestations of HIV infection in Asia and the Pacific
Janak K. Maniar, MD, of the Godulkas Tejpal Hospital and STD Clinic, Bombay, India, presented an impressive clinical picture of 7200 HIV-infected patients who were studied from March 1991 to March 1997. Thirty percent of the patients were women, and 90.5 percent of the infections were sexually acquired. HIV-2 infection was seen in 7.5 percent of the cases, and 17.0 percent had dual infection with HIV-1 and HIV-2. The most commonly found constitutional symptoms were fever of unknown origin (81 percent), wasting (63 percent), and darkening of skin (60 percent). Tuberculosis was the most common opportunistic infection (90 percent), followed by oral candidiasis (76 percent), scabies (23 percent), pneumonia (22 percent), cerebral toxoplasmosis (21 percent), and meningitis (21 percent), the majority of which was cryptococcal. Maniar also noted that fewer than 40 percent of patients taking antituberculous drugs were compliant, a statistic that was particularly worrisome given the implications for multidrug resistance.
Antiretroviral therapy in Asia
Many sessions at the Congress were devoted to antiretroviral therapy and the optimal use of immunologic and virologic parameters in assessing treatment outcomes. It is obvious that most patients in Asia do not have access to antiviral treatment due to financial constraints. Most patients in Asia have to pay for the medications themselves.
Praphan Phanuphak, MD, PhD, of the Thai Red Cross Society, reported a Thai Ministry of Public Health statistic -- only about 5 percent of Thais would be able to pay the price of double nucleosides. By doing so, they would have hardly any money left for nonfood expenditures. As a result, since 1992 the Ministry of Public Health of Thailand has had to allocate a considerable amount of its annual budget to procure nucleoside analogs for the poor. Initially, the recommended therapy was ZDV monotherapy. Later, as new information arrived, the recommendation changed to double nucleosides. Large volume government purchases drove the price of antiretrovirals down considerably, particularly zidovudine, for which there was a competing generic compound. However, the free antiretroviral program had to be halted in early 1997 due to the financial burden and the need for program revision. It is felt that it might be more efficient and realistic to have each hospital integrate the cost of care of HIV patients with the cost of routine hospital operations and have the government pour more resources into the hospitals.
"Although 400 mg per day of zidovudine is commonly used in Thailand," said Phanuphak, "we do not know whether it is as effective as the standard dose of 500 to 600 mg." There are several other unsolved questions regarding antiretroviral use in countries with moderate resources. First, if triple therapy will never be affordable, should one use single or double nucleosides at all? If so, should the treatment be initiated late in the disease process in order to maximize the short-term benefit of the drugs? Another question is whether one should still continue using single or double nucleosides in patients who are clinically stable, but whose CD4+ counts indicate that they are no longer responding to the drugs. "Clinical trials are another way to bring treatment to patients who will otherwise never have access to the treatment," Phanuphak said. In general, internationally based pharmaceutical companies are reluctant to invest in clinical trials in developing countries due to uncertainty about the quality of the data being generated. "The HIV-Netherlands Australia Thailand Research Collaboration (HIV-NAT) is one of the international joint efforts intended to demonstrate to the pharmaceutical industry that clinical trials at the good clinical practice (GCP) level can be achieved in developing countries," he explained.
HIV-NAT is a joint collaboration between the National AIDS Therapy Evaluation Centre (NATEC) in Amsterdam headed by Joep Lange, MD, PhD; the National Centre in HIV Epidemiology and Clinical Research (NCHECR) in Sydney headed by David Cooper, MD, DSc; and the Program on AIDS of the Thai Red Cross Society headed by Phanuphak. HIV-NAT is conducting clinical trials that serve the local interest but at the same time have scientific merit. Examples are trials of full dose vs half-dose double nucloesides or double vs triple nucleosides. Patient recruitment was fast, drop-out rate was low, and the quality of data was high. The set-up of HIV-NAT provides a practical example for other developing countries in Asia to follow.
Perinatal HIV transmission in Asia and the Pacific
Since over 90 percent of HIV infection in Asia and the Pacific islands is heterosexually acquired and almost equal numbers of women and men are being infected, vertical transmission of HIV poses a real threat in the region. The prevalence of HIV infection in the antenatal care clinics in several towns in Thailand and India is already over 10 percent. The mother-to-
Although ZDV has been proven effective in preventing mother-to-
The Thai Red Cross Society has started a campaign to obtain donations in order to procure ZDV for poor pregnant women throughout Thailand. The slogan of the campaign is "10,000 Bahts (US$400) Could Save a Child's Life from AIDS." The campaign is under the patronage of Princess Soamsawalee. Over a 14-month period, donations increased steadily, and over 1000 pregnant women from 57 hospitals throughout Thailand have received free ZDV from the project. The Thai Ministry of Public Health also donated ZDV to the project. The success of this project was cited by Peter Piot as being one of the positive examples of public-private collaboration in the fight against AIDS.
This conference offered the best type of forum for experts in all fields and people affected by HIV/AIDS to come together and learn from each other. They had a chance to express their concerns and expectations. It is probably the first time that the rights of HIV-infected people were discussed openly in Asia. Asian people with HIV infection have started to have a voice. It is hoped that the message will be brought to the attention of the policy makers in individual countries.
Complacency is the number one enemy in the fight against AIDS. It is hoped that the more technologically advanced countries in Asia and the Pacific, such as Japan, Singapore, Korea, and New Zealand will demonstrate stronger leadership and commitment in the fight against AIDS in the region at the next congress in Malaysia two years from now.
Praphan Phanuphak, MD, PhD, is professor of medicine and microbiology at Chulalongkorn University and director of the Program on AIDS of the Thai Red Cross Society, Bangkok, Thailand.