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| Home » Interview » Dr. Chris Beyrer |
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INTERVIEW - Dr. Chris Beyrer, |
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Director, Johns Hopkins
Fogarty AIDS International Training and Research Program |
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| “Regional efforts are going
to be important in Asia.” |
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| What have you observed as
general trends in the spread of AIDS in Asia? In which countries
have the cases been rising? |
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| It might be useful to frame it to some extent
by the perspective of decades. During the first decade of AIDS,
about half of it is from 1980 to 1985, nobody knew what was
happening. HIV tests were licensed in 1985. So the virus was
spreading for a considerable amount of time and with considerable
speed in much of the world before we knew anything about it.
At that time when we finally had a test to look for the HIV
virus, it was very clear that what we saw basically was sub-populations
in the United States and Western Europe which would be men who
have sex with men, drug users, haemophiliacs and heterosexuals
in Africa. That really was the principle picture. In the next
decade unfortunately, despite a lot of effort on behalf of an
awful lot of people, what we've seen is a worsening and, in
some cases, an acceleration of the epidemic in Africa. |
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| Then there is unfortunately this rapid spread
of HIV in Asia, which began fairly consistently sometime around
the late 80s. Thailand, for example, had very little HIV despite
a lot of risk behaviour in 1987 and 1988 and really had its
explosive takeoff in 1989. |
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| Most of the cases in China were scattered, sporadic, and very
unusual until about the early 1990s when there was an outbreak
in Yunnan on the border with Burma. Then after 1996 for the
first time it spread outside of Yunnan among drug users. Now
it's a very rapidly rising epidemic. |
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| Probably nowhere has the epidemic spread more quickly and
more explosively than in India, which is to some extent a function
of how dense the population is and how many people there are
with lack of education. It is also a function of what is going
on with their medical system because they have not succeeded
in cleaning up the blood supply. This is, I think, a very important
point that people often neglect. Once we had the test in most
developed countries, there was a very rapid drop in HIV associated
with blood products: haemophilia, surgery. But in poor parts
of the world, this has continued to be a problem. In India,
at least about two or three years ago, it was still the case
that a third of the infections are thought to be associated
with blood transfusions. This is because there are so many private
blood banks, unregulated blood banks, inadequate testing, and
of course other kinds of spread through unsterile equipment
and unsterile procedures. There is also people's preference
for injectable drugs. People love getting bags of Dextrose where
they could just as easily get the same value out of drinking
a Coca Cola. But there is a demand to be hooked up to an IV
and then you get not only HIV but Hepatitis B, Hepatitis C,
tetanus, syphilis, malaria. It's very common. This certainly
is also a factor in some of the other really resource poor countries
like Cambodia. |
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| What populations are most effected? Reports
usually point to drug users, sex workers, and migrants as vulnerable
populations? |
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| The focus has often been on vulnerable groups.
That is an unfortunate outcome of the way the epidemic looked
in the west. For example, in central southern Africa –
who is vulnerable? Young women of childbearing age and all heterosexual
men, and we put those two pools together and you have a tremendous
percentage of the population. Are they vulnerable? Yes! They
don't have to be sex workers or to have had a blood transfusion.
That is a function of the fact that once this virus gets out
of vulnerable populations, and begins to spread in general populations,
the risk for everybody who is sexually active goes up. |
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| At this point, for example, China does not have
much evidence of heterosexual spread; and we really are talking
about drug users overwhelmingly. But there are a number of countries
that have moved beyond this, and India certainly would be one
where the rate in married, monogamous women has reached the
level that you see in sex workers. There are tremendous rates
of HIV in monogamous married heterosexual women whose risks
are the fact that they're married and that their husbands are
engaging in risk behaviour that they have no say in, which,
unfortunately, is the Asian model in general. Women across Asia,
particularly in the lower end of the socio-economic strata have
very little power or negotiating ability over their husband's
sexual behaviours. |
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| That is the case all over India. It's certainly
the case in Bangladesh, Burma, Cambodia, Thailand, Vietnam,
and China. So male sexual behaviour has really driven this epidemic
in Asia in a big way. The other countries that have now reached
the point where general population heterosexual spread is significant
would be Burma, Cambodia, increasingly Vietnam and certainly
India. This is also happening in Papua New Guinea which has
the worst epidemic among the Pacific countries. |
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| What are the latest treatments?
Are they reaching Asia? |
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| Unfortunately we have this paradox, and it's
a very painful paradox, and that is in general that the countries
that can afford these drugs are not the countries that have
significant epidemics. So for example if you were a person with
AIDS and have a good health insurance in Taiwan, you probably
would get a fair and reasonable access to treatments. The same
would probably be true in Hong Kong, Japan and probably in South
Korea. These are not countries that have significant epidemics.
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| The places where the largest number of people with HIV infection
anywhere in the world are in India, and the overwhelming majority
of those people, somewhere now in the range of 6-8 million people,
don't know they have HIV and have not been tested. The consequences
of testing are not without problems, particularly if HIV status
is revealed. Almost none of these people are getting any access
to treatment. |
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| Certainly in Burma there is absolutely no treatment, and there
isn't going to be. Cambodia, also, cannot afford this. Cambodia
and Burma are the only two countries where the population prevalence,
in other words the rate in the population, is approaching African
levels where you would have as many as say 1 in 25 or even 1
in 20 adults with HIV infection. Those are the two highest rates
in the region. They, of course, are two of the poorest countries
in the region. |
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| Now, there has been more effort to try and get antiviral drugs
out there is in the case of perinatal transmission. We do know
that in the case of a short course of AZT, one drug alone, can
have a huge impact on preventing infection. Thailand and Malaysia
have really tried to implement AZT for pregnant women. Of course,
that is a very short course, and it's a very different thing
than trying to implement antiviral therapy for a large population.
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| One drug treatment like AZT alone is no longer standard for
AIDS care. This method isn't used because the virus gets resistant
to one drug, so combination drugs are now used. The new class
of agents, which we call HART, (highly active antiretroviral
therapy) includes the protease inhibitors, the nucleoside analogs,
and the non-nucleoside reverse transcriptase inhibitors. Basically
you need multiple drugs, at least three. The majority of the
people on the best care are on more like four or five from different
classes of antiviral drugs. Plus drugs to treat the other opportunistic
infections or prevent opportunistic infections. |
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| How has AIDS affected women
and children in Asia? |
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| It's abundantly clear, particularly in the Asian
context, that there is going to have to be empowerment of women
to respond to this epidemic. That is one of the places where
Africa, sadly, has really stumbled and been unable to move ahead.
If women don't have some sexual power, negotiating power and
can't protect themselves, and we can't get some new technologies
that are under female control such as the condom (strictly the
male condom anyway is so much under male control) then we're
really going to have a problem dealing with these heterosexual
epidemics. Our research is trying to come up with vaginal products
that women can use with or without male consent that would be
under their control that would give them some protection. |
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| It extends, of course, to children. We have a huge number
of orphans, more than 80,000 now. Even if they are HIV negative,
which the majority of children born to infected mothers are
negative (more than two-thirds even without treatment) and are
going to survive, they still get the same kinds of stigma. They
can't go to school, nobody wants to eat with them, they are
socially ostracised, and face discrimination in marriage. You
know the likelihood is that this kind of denial of opportunity
and possibility is actually going to make these children vulnerable
to HIV when they come of age. |
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| How has AIDS affected activism in Asia?
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| One of the things that's been very heartening
is that HIV/AIDS activism, because it's regional and international
and because there's been this kind of support from UNAIDS and
other agencies, has really jump started activism of some other
kinds. So, for example, a number of countries where there hasn't
been much of a Men having Sex with Men (MSM) movement, AIDS
activism has really helped get a movement going. The same thing
has happened with sex workers. The first real attempt for sex
workers in India to unionise has come out of a response to HIV.
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| What stage do you see efforts in developing
an AIDS vaccine for developing countries? A World Bank report
said that most research has been on the sub-type B virus that
is the predominant sub-type in North America and Europe, but
there has been little testing on sub-types prevalent in developing
countries. Is this still the case? |
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| Well, this is a rapidly changing field. There
is no question that in general that is unfortunately the case.
Where it's most painfully the case is in Africa where you have
multiple subtypes and a number of unique subtypes; and where,
I think it's fair to say, that there is almost no research that
as far as we know would work against all these African subtypes.
Perhaps more than anywhere else, all things being equal, in
about by 2010 Asia will have outstripped Africa in terms of
HIV; and that's because the epidemic is very rapid, but also
because the AIDS populations are so huge. I mean India itself
is larger than the whole of Africa. That's an epidemic totally
out of control. |
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| But the exception in terms of HIV vaccines to this rule is
Thailand. Early on in 1993, Thailand was the first developing
country to approve a national plan for HIV vaccine development
and began working with pharmaceutical companies. Our research
group and other groups provided isolates from newly infected
Thai subjects and patients in our trials and hospitals such
that the manufacturers had access to the Thai viruses. So now
there are at least three HIV vaccine candidates, probably four
that have been developed that fit the picture of the subtypes
in Thailand. There are two viruses: subtype B and subtype E
which are the predominant ones. Right now the first clinical
trial to test an HIV vaccine for efficacy in the world has started,
and that is a joint U.S./Thai collaborative trial. In Thailand,
trials are being held among IV drug users. |
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| There is a very important lesson for developing countries
here, which is they are going to have to follow the Thai model
- engage international researchers, engage the pharmaceutical
industry, make it clear that they're willing to be partners
in vaccine research. Unfortunately, there are always these issues
with first-world/third-world research about the use of human
subjects and anxieties that governments have about drugs being
tested in their country that will subsequently be unaffordable
in their country. |
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| If a country chooses to follow the Thai lead, then the pharmaceutical
industry is willing to invest. If they feel that all they're
getting is heat for not developing a vaccine for countries that
aren't interested in working with them it's not going to get
us anywhere. India has been somewhat resistant but is really
beginning to come around. It's very heartening because there's
been a kind of political paralysis in India in terms of dealing
with HIV that hopefully is really turning. |
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| China is very actively taking a lead in HIV vaccines. They
want to do their own vaccine development, are eager to collaborate
with foreigners and scientists, and are also investing in Chinese
science, people, and infrastructure to move this forward. So
I'm actually very optimistic that Asia is going to play a huge
role in this. |
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| How have culture and religion
played a role in the battle against AIDS in Asia? |
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| These barriers have been so strong. I've been
involved in this for a number of years. It's as though each
and every country is unable to learn the lessons for their neighbours
or from the west and has to go through this whole process all
over again starting out with a very recognisable phase of denial.
The Indian Minister of Health stood up in 1995 and said India
will be protected by Indian family values, to which one wants
to point out – Which Indian family values? Husbands and
wives can't talk about sex; husbands go to sex workers when
their wives are pregnant; wives get STDs and come in with discharges;
and their doctors don't tell them that they have gonorrhoea.
Those family values? Unfortunately, this has had catastrophic
effects. |
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| In Burma, which is a country I'm very involved
with, the Minister of Health just reiterated that there are
no more than 12,000 or 13,000 infections and that there is no
sex work in Burma because it's illegal, and the problem of drug
users has been overstated. Well the UN, which uses very conservative
estimates that were developed in collaboration with the Ministry
of Health in Burma and that I helped analyse, estimated that
there were 440,000. That was in 1995, and we think it's doubled.
Just to give you an idea of how off the mark this can be. Then
when a country finally does start to respond, and usually it's
not because of science or political pressure, it's usually because
people start dying and hospitals get full of people living with
AIDS that people begin to realise that this is not just an obsession
of the west. cbcvbcvbcvb |
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| How has AIDS become a human
rights issue in the region? |
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| I think the prison situation definitely involves
fundamental denials of human rights. One of the early studies
done in drug users on Thailand found consistently, and we're
still seeing this in our studies, that incarceration is associated
with HIV infection. It's a major risk for infection. You know
there are several reasons why that would be the case. Certainly
one is that drugs are available in many countries. Prisons,
needles, and syringes are extremely rare and hard to get. So
prison is a bad place in terms of drug exposure. Secondly, prison
hospitals are almost uniformly across Asia horrendous places
where you do not want to be sick in. So there may be AIDS spreading
there. |
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| Third, is that at least among male prisoners,
there's a lot of sex in prison; and it's totally denied in most
of these countries. Even Thailand which has no law against MSM
doesn't allow distribution of condoms in prison. The United
States is just as bad. We have 48 prisons, state and federal
prisons, in New York State and four of them allow condoms. This
is a major issue in Asia, and it's a major unresolved issue.
The head of India's prison system resigned over the demand from
the UN that India supply condoms in prison. Her argument was
that MSM is a western problem and denied the existence in Indian
prisons. If you talk to anyone who has been in an Indian prison,
that's not the case. |
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| But for the majority population human rights
is a fundamental issue. Very few countries in the developing
world have adequate protection on confidentiality. The right
to know is a major problem, and there are still many places
where counselling is inadequate and people do not really have
the right to know. Family members get told first. Husbands get
told, not wives, and that's a big problem. Discrimination and
social stigma is probably the single most important human rights
issue. It's absolutely vast, and it has really created an incredible
amount of suffering throughout the region. |
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| So it's a huge problem for Asia, and it's very
under addressed. There is discrimination at work. For those
countries that actually are at the level where they have insurance,
there is discrimination of insurance. There are also human rights
issues with travel that are very important. The U.S. remains
one of the countries that have this ridiculous visa ban. That's
why we never have the International AIDS Meeting in the U.S.
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| How have Asian governments and NGOs been
responding to the spread of AIDS? Is their regional cooperation?
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| I think there are a lot of regional efforts in AIDS that are
really going to be important. Certainly the Thais, again, have
been very active in this in terms of Thai Ministry of Health
involved in Vietnam, involved in Laos, involved in Cambodia;
and more of that kind of work is going to have to happen. The
local and regional NGO activity around this epidemic in Asia
and the connections between NGOs is extraordinary. A good one,
for example, is the Asian Harm Reduction Network, which is a
kind of umbrella organisation of NGOs that works with harm reduction
for IDU. It is stated with Australian money, but it is based
in Northern Thailand; and it involves people from India, Nepal,
Thailand, Cambodia, Vietnam, and China. They do workshops, training,
outreach and policy that are really trying to push governments
to move forward on policy. I think UNAIDS has played a tremendous
role in the region in supporting NGOs and then helping them
get linked up together. Southeast Asia AIDS Network allows NGOs
even in very remote places, as long as they get on E-mail, to
get updates, to communicate, to ask for things like "anybody
have a workshop training on gynaecological manifestations of
AIDS?" Then you see this information. So those networks
have been very important. |
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| Dr. Chris Beyrer, Director of the Johns Hopkins Fogarty
AIDS International Training and Research Program, talked with
AsiaSource about the issues surrounding the rapid spread of
AIDS in Asia. Dr. Beyrer works mainly on HIV prevention research,
trials of prevention strategies, and the efforts to develop
an HIV vaccine. With a specific focus on AIDS in Burma and Cambodia,
he has published several articles on political, social, and
medical problems surrounding the spread of HIV in Asia. |
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