CNS: Articles of Ishdeep Kohli

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Growing call for collaboration between NCDs and HIV programmes

This Podcast features conversation on people living with HIV but dying of non-communicable diseases (NCDs). This dialogue took place at the 10th International Conference on HIV Science (IAS 2019) in Mexico.
Panelists included:

Dr Rishi Sethi, Professor, Cardiology Department, King George’s Medical University (KGMU), India and Executive Council member, Cardiological Society of India (CSI) and Member Scientific Committee, Asia Pacific Society of Interventional Cardiology (APSIC);

Ishdeep Kohli, CNS Correspondent
“While public health officials call sex workers and drug users ‘hard-to-reach populations,’ police have little trouble finding them,” said Daniel Wolfe, Director of the Open Society International Harm Reduction Development Programme.

Ishdeep Kohli – CNS

A number of countries in the Asia and the Pacific are showing commitment and leadership by increasing domestic investments for HIV. Malaysia currently funds 97% of its own AIDS response, China 88% and Thailand 85%; India too has committed to increase domestic funding to more than 90% in its next phase of the AIDS response.

Ishdeep Kohli - CNS
Many developed countries in Asia and the Middle East rely on migrant workers to keep their economies functioning. Migrants send back valuable economic resources to their origin countries and contribute to the economies of the destination countries. Migrant populations are vulnerable to violence, discriminations and lack of social and healthcare services. In some countries the policy and practice of mandatory HIV testing for migrant workers is discriminatory and violates the migrant’s human rights.

Ishdeep Kohli - CNS
In the race for a cure for HIV, we have the Berlin Patient, the Mississippi Baby, the Visconti Cohort - 14 patients in France - and most recently, two men in Boston who were declared to be HIV- free. Through a variety of mechanisms and treatments including bone marrow stem-cell transplants and gene therapy, all of these people were able to shake the virus and stop taking the drugs that HIV-infected patients ordinarily need to survive. They represent possibility - that modern science is capable of curing a deadly infection.

Ishdeep Kohli - CNS
In line with the UNAIDS campaign to achieve the 'Three Zeroes' -- Zero new infections, Zero new deaths and Zero discrimination, the Community Programme Committee for ICAAP11 came up with the 'Community Three Zeroes' -- Zero funding, Zero political will and Zero legal reform.

Women are more likely to be infected with HIV than men due to a combination of socio-cultural factors, physiology and biology. And yet women have had little control over most prevention methods. Condom use, abstinence, fidelity and male circumcision are all effective methods for HIV prevention, but they rely on a male partner's cooperation or action, which is not always possible. Unfortunately, current methods have not done enough to stem the epidemic among women. Women already make up half of the 34.2 million people worldwide living with HIV. According to UNAIDS figures, 1.3 million women and girls became HIV positive last year and 63% of those are young women between 15-24 living with the virus. In Sub-Saharan Africa, 60% of those with HIV are women and girls.

Nineteen years after female condoms were approved by the US FDA in 1993, they are not yet available as widely as one would have wished. What could have delayed their optimal utilization to meet the unmet prevention needs: was it because female condoms were not rolled out under a robust enough and well resourced comprehensive programme and strategy, or potential users didn't prefer using it? The delegates of the XIX International AIDS Conference (AIDS 2012) vote for female condoms sending a clear message that female condom introduction must be supported by strong, well resourced and strategic scale up programmes in countries and communities where unmet need is acute. Carol Nawina Nyirenda, from Zambia CITAM Plus, has been living with HIV for several years. She shared her perspective about using the female condom. It makes her "feel sexy" and she can wear it even five hours before sex, she said.

In communities where sharing of injecting equipment drives the HIV epidemic, a parallel epidemic of hepatitis C virus (HCV) often lurks quietly. A couple of days before the World Hepatitis Day, 28 July, Dr Victor Lo Re, an infectious disease researcher at the University of Pennsylvania, presented data on the impact of HIV and HCV co-infection at the XIX International AIDS Conference (AIDS 2012). His work shows that, despite effective antiretroviral therapy, people co-infected with HIV and HCV remain at higher risk of liver deterioration and other liver-related complications than those with HCV alone.

At the XIX International AIDS Conference (AIDS 2012) the message is clear: it will be the task of the activists, implementers, policy makers, scientists, and each one of us to work together to turn the tide so that everyone who needs high-quality treatment and prevention interventions for the global HIV, hepatitis C virus (HCV), and tuberculosis (TB) pandemics receive them. "The 2012 Pipeline Report: HIV, HCV, and TB Drugs, Diagnostics, Vaccines, and Preventive Technologies in Development" which was released at AIDS 2012 by HIV i-Base and Treatment Action Group (TAG) reveals the deepening gulf between new scientific advances that make it possible to prevent, treat, and in some cases cure people living with HIV, HCV, and TB; and access to these where they are most needed.

The XIX International AIDS Conference (AIDS 2012) opened in Washington DC on 22nd July 2012, twenty two years after the 6th International AIDS Conference had taken place on the US soil in 1990 (San Francisco, USA). The US had imposed a travel ban on people living with HIV (PLHIV) in 1987, when the US Department of Health and Human Services added HIV to a list of communicable diseases prohibiting PLHIV from entering the country. When Barack Obama became President he lifted the travel restrictions on PLHIV in January 2010, allowing the conference to take place on US soil after twenty two years.

The fight against HIV/AIDS is currently viewed with considerable more optimism than in the past years because powerful interventions have been developed, proven effective and refined. If these tools are made widely available to those who need them, an AIDS-free generation may be possible. Speaking on an AIDS free generation before the opening of XIX International AIDS Conference (AIDS 2012), Dr Anthony S Fauci, Director, National Institute of Allergy and Infectious Diseases (NIAID), said ending the global HIV pandemic may be possible.

Expanding Access to the Female Condom

Women represent over 47 percent of those infected with HIV worldwide, and will soon make up the majority. Each day, millions of women around the world are put at risk of HIV infection from unprotected sexual intercourse. Greater focus is urgently needed on strategies that address women's disproportionate risk of infection, enable them to negotiate safe sex, and provide tools, such as female condoms, to protect themselves from infection. Women and girls remain at risk because they are economically and socially dependent on husbands or partners, are at risk of sexual coercion and violence, and have little power to negotiate safe sex.

In sub-Saharan Africa, the hardest hit region, women account for more than 55 percent of all infections. "In India, where HIV is spreading rapidly, current data from UNAIDS and India's National AIDS Control Organization reveal that women make up at least one quarter of all HIV infections," states Avni Amin, Senior Program Associate at CHANGE. The female condom is the only existing method of STI and HIV prevention that can be initiated and controlled by women. Data show that the female condom is a highly effective barrier against transmission of HIV and many other sexually transmitted infections. Consistent and correct use of the female condom reduces the risk of sexually transmitted infection (including HIV) by between 94% and 97% per act of intercourse. In addition, the female condom allows women to simultaneously protect themselves from unwanted pregnancy.

Studies from several countries indicate that with appropriate levels of education, training, and support, women find the female condom both effective and empowering, allowing them to negotiate safe sex. In Ghana, observes Alice Lamptey, National Coordinator of the Society for Women and AIDS in Africa (SWAA)-Ghana, "it is accepted that men can do what they like with their wives and girlfriends. We had to find a way to protect women, and we found the female condom." Ghana's female condom program is currently one of the most successful in the world.

Cost, lack of knowledge of the method, and provider biases are the most important impediments to increased access to the female condom worldwide. The female condom sells for roughly U.S. 55 cents per unit, which is clearly too high for sustained use in many settings. This is partly related to the lack of public sector investment in this method by governments or international donor agencies. The United States and other donor countries could dramatically reduce HIV transmission by investing in expanded access to the female condom and the programs needed to support sustained use worldwide. By investing in strategies to support expanded use of the female condom, we can start saving lives right now!

Ishdeep Kohli-CNS

President and princess on plenary podium

"There is so much more we could do with resources", said Ugandan President Yoweri Museveni, addressing the first plenary session at the XV International AIDS Conference on "Access to resources: commitment and accountability".

Summarising Uganda's achievements in combating HIV/AIDS, President Museveni stressed the reduction in prevalence of HIV there has been the result of a broad-based national effort backed by firm political commitment, including his own involvement.

Uganda, one of the first countries in sub-Saharan Africa to experience and take action against HIV/AIDS, is a rare success in a region ravaged by the epidemic. While the rate of new infections continues to increase in most of sub-Saharan Africa, Uganda has succeeded in lowering very high infection rates.

Since 1993, HIV infections in pregnant women - a key indicator of the progress of the epidemic - have more than halved in some areas, and infection rates among men seeking treatment for sexually transmitted infections have dropped by over a third. Uganda is the first African country to have reversed the spread of the disease, giving hope that the tide can at last be turned.

The political commitment President Museveni identifies has meant the involvement of a wide range of partners, including religious and traditional leaders, community groups, NGOs and many other sectors of society. Key was the forging of a consensus on the need to contain the spread of HIV, and to provide care and support for those affected.

The president used political rallies and public broadcast messages, especially by radio, to educate the Ugandan people.

President Museveni added that through additional funding from the Global Fund and the US President's Emergency Plan For AIDS Relief, supplies and infrastructure are in place to begin treating HIV-positive people with antiretroviral drugs.

Jean-Francois Rischard, vice-president of the World Bank, made an address on the subject "Global problem-solving in the 21st Century: desperate times deserve innovative approaches". He discussed the urgent need for new global problem-solving approaches; the clock is ticking inexorably towards "high noon" - also the title of his book - before time runs out to resolve the world's 20 most urgent problems, ranging from global warming and water shortages to communicable diseases such as HIV/AIDS.

These problems are all interlinked, Mr Rischard said, and there is an urgent need to discuss appropriate responses.

He dismisses the idea of global governance, citing the European Union, which has been trying to become a regional government for the last 50 years. Instead, he proposes "Global Issues Networks", comprising government experts in the relevant fields, international civil society organisations and businesses. Different networks deal with each of the 20 big issues. He suggests that such networks are a real possibility for better and faster global problem-solving. They would be able, he argues, to reach a rough consensus towards the necessary action.

A striking example of effective collective action was the "Montreal Protocol" on ozone-depleting substances, which had seen a rapid reduction in the production of ozone-depleting gases. But this is the exception, Mr Rischard warns. For networks to work, he said, India and China must participate, since these nations represent about one-third of the world's population.

Critical review of funding mechanisms was discussed by HRH Princess Mabel of Orange-Nassau, currently with the Open Society Institute (OSI). The challenges, she said, are to increase available funding for HIV/AIDS in low- and middle-income countries, to improve donor co-operation in support of national plans and frameworks, to develop comprehensive programmes and to make necessary policy changes.

Princess Mabel argued that these objectives can achieved by involving civil society and other stakeholders in program design and implementation, and by streamlining and harmonising donor procedures. Comprehensive programmes should prioritise needs and not be based on ideology. They should also address controversial aspects of HIV/AIDS, and look at tackling structural, political and legal barriers. Underlying health structures should be strengthened, she added.

The "three ones" principles also received endorsement from Princess Mabel, who sees them as a means to achieve the most effective and efficient use of resources, and to ensure rapid action and results-based management. As she explained, the principles are:

    * One agreed HIV/AIDS action framework that provides the basis for co-ordinating the work of all partners.
    * One national AIDS co-ordinating authority with a broad-based multi-sectoral mandate
    * One agreed country-level monitoring and evaluation system.

Princess Mabel went on to mention the new funding initiative from the US: the President's Emergency Plan for AIDS Relief (PEPFAR), which favours a bilateral approach. Canada, France, Germany, Italy, Japan and the UK have also increased their funding, and the increasing contributions of Ireland, the Netherlands, Norway and Sweden are impressive, she said.

She continued by praising the Global Fund for being participatory, and addressing the problems it is experiencing. But, she said, it is at a critical juncture, and will need at least $3.5 billion in 2005, of which only $880 million has been pledged so far. She noted that French President Jacques Chirac and others have suggested that the Fund's needs should be provided on the following basis: one-third from the US, one-third from the EU, and one-third from other countries and private sources. While recipients need to use AIDS funds effectively, international donors must also increase the impact of their efforts, she said.

"The business response to HIV/AIDS" was presented by Tsetsele Fantan, project leader of the African Comprehensive HIV/AIDS Partnership. Since the XIV International AIDS Conference in Barcelona, international focus has increasingly shifted towards addressing HIV as part of a continuum between the workplace and the community. Indeed, a growing number of national business coalitions and industry associations are supporting national responses, and the Global Business Coalition on HIV/AIDS has doubled its membership since 2002.

Speaking about the Debswana mining workplace programme, Ms Fantan added that HIV/AIDS is a business issue requiring effective leadership, adequate resources and a commitment to manage its impact. The programme extends productive lives through the provision of antiretroviral therapy. Debswana encourages voluntary counselling and testing, and employees and spouses who test HIV positive receive treatment. In 2003, Debswana agreed to introduce the government's antiretroviral scheme at their mine hospitals.

A company should not operate in isolation, said Ms Fantan; it is important to engage other stakeholders from the business area and community. She continued by saying that effective monitoring of impacts requires good information management, and this will help inform better decisions.

Ms Debswana concluded by stressing how, in developing countries, sustainable access to healthcare can be provided through public-private partnerships, where the government delivers the minimum standard of care, the private sector brings skills and core competencies and the donors bring funding and other resources. The public and private sectors are complementary, she insisted, and effective public-private partnership is about structured co-operation and collaboration.

Given the examples presented , it appears that such partnership, combined with innovative approaches to funding, can help increase access to essential services based on structures already in place.

Ishdeep Kohli-CNS

Drug use and its impact on women

A number of speakers noted the particular problems associated with injecting drug use among women and the increased vulnerability to HIV/AIDS that comes with it

"This is the time to seize the opportunity, this is the time to scale up services", emphasised Pakistan's federal minister for health, Muhammad Nasir Khan, demonstrating strong political commitment during the First Asia-Pacific Women, Girls and HIV/AIDS Best Practices conference.

He was referring to the issue of drug use and its impact on women, which were discussed by delegates from India, Pakistan and Bangladesh during a conference working group session specifically on the subject. The session examined how the behaviour of drug users (IDU) increases women's vulnerability to HIV/AIDS and other health issues, and looked at best practices in harm reduction and prevention.

IDUs are one of the highest risk groups for HIV/AIDS transmission due to needle sharing and unprotected sex. The opportunity to confront the drug epidemic in Asia-Pacific is gone according to Tariq Zafar of Nai Zindagi, Pakistan. In Asia, 65% of injection drug users share needles. Unfortunately, drug-related harm reduction and health services only reach a small percentage of those who need them.

Women are often forced into the sex trade to finance their own (or their spouse's) drug addiction, which further increases their chance of HIV infection. The psycho-social effects of this on women drug users and their families can be devastating, undermining the fabric of the family. The healthcare difficulties posed by a lack of HIV prevention information and education, and the stark social inequalities and prejudices related to gender, sexuality and criminality, are further compounded when women are taking drugs.

The complex problems associated with drug use by women need to be highlighted and understood, and special measures adopted to counter them and reduce related harm. Many women who use drugs are forced to sell sex to sustain their habit. Where opiate drugs, such as heroin, are involved there is a further complication of the desperation of withdrawal that affects both brothel-based and 'informal' sex workers.

Such circumstances make condom negotiation difficult, and greatly increase HIV/AIDS vulnerability. Women in sex work who also have HIV are doubly stigmatised, made even worse if they are also drug users. Such women are by and large not in control of their own circumstances. To help them requires cross-cutting services that address these multiple issues holistically.

Key are harm reduction strategies, which are policies and programmes that attempt primarily to reduce the adverse health, social and economic consequences of mood altering substances to individuals, drug users, their families and their communities.
Appropriate drug treatment and rehabilitation not only help to reduce drug use, but also diminishes associated HIV risk. Harm reduction, care and prevention programmes are more successful when laws and government agencies facilitate outreach and service provision aimed at drug users and which actively involve the community.

A basic ethical principle of effective intervention should be that drug control policies must reduce and not augment the HIV risk faced by drug users. A special strategy aimed at reducing drug-related harm among women should be incorporated into all existing or new harm reduction programmes.

Ishdeep Kohli-CNS

Gender and HIV/AIDS

Women's rights have never been at the top of the political gender in Asia-Pacific; one conference session discussed what this has meant for the spread of HIV.

What contributes to women and girls' increased vulnerability to HIV/AIDS, and what solutions exist? These were the questions examined by speakers from Pakistan, India, Cambodia, Iran and the UK during one working group session at the first Asia/Pacific Women, Girls and HIV/AIDS Best Practices Conference.

Gender discrimination is often entrenched in law and government policy in the developing countries of Asia and the Pacific, the session heard. This contributes to poverty and undermines women's position in society, ultimately exposing them to greater risk of HIV/AIDS.

Women in Asia and the Pacific are often unable to decide the nature and circumstances of their own sexual behaviour, and while sex outside marriage is widely practiced by men, women often do not have the latitude even to refuse or discuss sex, or insist on condom use by their partners.

During the session, Dr Suman Mehta from UNAIDS said women rarely have the right to decide who, or at what age, they will marry and have children. Women should be given "the chance to develop physically, [and] the chance to educate themselves and to empower themselves," said Dr Mehta.

Moreover, women in the region have few property rights and poor education levels, making them highly dependent on the male population. High incidences of poverty and minimal financial independence prevent women from seeking the sexual healthcare and support they need, while illiteracy makes educating them about HIV/AIDS highly problematic.

Some of the most effective approaches to assisting women were brought out in the discussion. One of the most effective in terms of independence was to provide women with skills in income generation, helping improve their decision making power in the household.

Working with significant "gatekeepers" to women's empowerment such as brothel owners, parents and so on, is another proven means of reducing women's vulnerability to HIV/AIDS. And, involving HIV positive women in advocacy ensures female voices and needs are heard at all levels.

Other suggestions included addressing poverty as an important cause of HIV vulnerability, provision of sexual health education in schools, co-operation with religious leaders and groups, reduction of discrimination and raising awareness of HIV-related health issues among sex workers.

Ken Bluestone, senior policy advisor for Voluntary Services Overseas - part of the UK government's development assistance programme - emphasised the role of men in creating and responding to the vulnerabilities of women and girls. Greater attention must be paid to men's motivations and attitudes when designing policies, he said. One means is to identify and publicise positive male role models, and to promote traditional male values to enhance men's understanding of the impact of their behaviour on others as well their sense of self-worth. He added that pre-emptive and supportive work with violent men can also be effective.

Despite institutionalised disempowerment of women in the region, examples of positive efforts to decrease their vulnerability to HIV/AIDS exist. Men are clearly as much a part of the solution as the problem. And provided HIV/AIDS programmes do not increase the burden on women in Asia-Pacific, continued efforts can help ensure they have a healthier future.

Ishdeep Kohli-CNS

Interview with Nafis Sadiq

Dr Nafis Sadiq was appointed by the UN Secretary General in May 2002 to serve as his special envoy for HIV/AIDS in Asia and the Pacific. Dr Sadiq, a national of Pakistan, has raised awareness about the vulnerability of women to AIDS, the plight of children orphaned by AIDS and other key issues. Dr Sadiq joined the United Nations Population Fund (UNFPA) in 1971, and was appointed Assistant Executive Director and then Executive Director from April 1987 until her retirement in 2000. Immediately following her retirement from UNFPA, Dr Sadiq was appointed as Special Envoy to the UN Secretary General. For her efforts to raise awareness of these issues and developing or effecting policies, Dr Nafis Sadiq has received awards from governments and organizations in many countries including Pakistan, China, Indonesia, Egypt and the United States.

HDN: It is almost two-and-a-half years since you were appointed by the UN Secretary-General [In May 2002] to serve as his Special Envoy for HIV/AIDS in Asia and the Pacific - what has been your greatest single challenge and achievement in that time?

Dr Sadiq: The greatest challenge in this region was that at the first instance all the countries were in denial, the message you got from the ministers and leaders was that there are so many other priorities, and having just a few cases of HIV did not put it on the priority list. It took a while to convince the heads of states and the ministers that HIV is not like any other disease, prevalence levels today are not an indication of what could happen in the near future.

At least since last year, HIV/AIDS has been gaining lot more attention. Most of the governments have been responding, some more rapidly than others but I think all are getting the message. That has been a good achievement, getting them from denial to awareness. Now we have to get them to be more active; the main problem is to articulate, how to talk about some very sensitive issues. The leadership in this region finds it difficult to articulate about this subject, since it deals with issues that are not talked about in Asia in general; these are very taboo subjects in the sub-continent. So what goes on in their minds is that this deals with deviant behaviour - and the dilemma is how to reconcile condemnation of behaviour and yet be pragmatic and accepting.

HDN: Last year (also in Pakistan), you said "my job is to pursue Pakistan's leadership and its people not to hesitate from discussing and taking preventive measures against HIV." That presumably also applies to the entire Asia Pacific region, so how well have leaders and the people of this region responded to your appeals?

Dr Sadiq: It was then that I met with Mr Jamali the Prime minister of Pakistan at that time. It was agreed to have a press release [about HIV/AIDS] and the government was open about drafting and endorsing it, but he did not come out and be open about it, the President has also mentioned it. But the leaders here mention about HIV/AIDS issues only during HIV/AIDS meetings. Mr Shaukat Aziz, the present Prime Minister was the finance minister then and he had launched the National AIDS Control Program where he spoke well about HIV/AIDS issues. But now the leaders are getting the connection between poverty reduction, gender equality and HIV/AIDS. In the beginning it was difficult to understand what the connections were, now the ministers have begun to understand many of these are so interlinked and feel the need to do more on gender equality and empowerment. If you want to address the HIV/AIDS problem, you have to face the facts that even in your own society there are sex workers and IDU [injection drug users]. It is a big thing that now NGOs are allowed to work with sex workers and IDUs with the agreement of the governments.

We have moved to a more pragmatic stage in this region, but what we need now is more action, more leadership more articulation. It is vital that leaders speak and it is important to speak on different occasions - not only during an HIV conference. For example whenever they make a speech about the future of the country, economy etc? they should say that there are some threats in our society like HIV, they don't have to go into sexual and reproductive behaviour and discussions, that is going to take a while. Just use every occasion to talk about HIV and raise awareness.

For the region, China has made huge decisions, when they were reviewing the MDG [Millennium Development Goals] earlier in the year, all the experts that came including myself said you may achieve all your goals but you will not achieve the HIV/AIDS goals unless you really step up. Even the goal of gender equality which they are very proud about will be very much affected. Because you see many of the connections on gender - equality and inequality and lack of power of women translates itself in increased vulnerability of women to HIV/AIDS, so they have taken that advice very seriously, so I was quite pleased with the China programme. India is also making progress; their parliamentarians are a very strong group. The new government has come out with the social minimum programme, which has HIV/AIDS as a component but it is not very strong. Recently, Mr Manmohan Singh, the Prime Minister of India, did make a statement about strengthening the HIV/AIDS programme, but we need to get all this moving and in all the Indian states.

HDN: How would you describe leadership by civil society and the role of people living with HIV/AIDS in this region?

Dr Sadiq: Leadership of the civil society is there but they are not getting a voice in the planning and policy-making. That is common to many of the countries in the region. The civil society voices are there; they are also listed in the coordinating groups but the voices are not heard as much as they should be. Also there is the whole issue of people living with HIV/AIDS and how they should be involved. Every one of the countries has a token representation; we need to get their voices to the policy-makers. Here the media can play a significant role - if they talk to women who got infected as many of them have not got it [HIV] because of their behaviour. There are stories that can be told in a nice way without accusing anyone. Even the man needs to know without any accusations; as that is not productive. I think just to hear what happens to the women - what happens to them when they disclose that they are infected and they come forward. What problems do they face; the stigma they deal with - from their families and the husband's family. I think those stories can have a very powerful effect in the removal of stigma and discrimination.

In India many people are now saying that marriage is hazardous to a women's health because according to a study in the state of Karnataka - the infection rate among young married women is twice as high compared to other women. Marriage is a risk factor - some of the states wanted to have compulsory [HIV] testing, which was discouraged. Many parents are now asking for voluntary testing and if the prospective suitor refuses then they can refuse the marriage. But of course many parents still think that he is a good catch. The fact is that all these factors highlight the basics, which show that women's security and safety is seen in marriage, rather than in themselves. We need to get that changed. I tell the women groups - this brings home that how dependent the women are. We need to get going that everyone needs to be empowered to look after themselves.

HDN: Just over a year ago, you said of regional leaders that (paraphrased): They can't have harm reduction programmes for drug users because that might appear to be recognizing drug use and "These kinds of ways of thinking or attitudes, they just have to change" (quote). From what we are seeing of the 'war on drugs' in countries like Thailand, and speeches 'blaming gays' for AIDS from a senior minister of state in Singapore (last week) and the attitude of leaders towards sex workers, your message does not seem to be getting through. What can be done if leaders simply refuse to adopt evidence-based HIV/AIDS strategies that organisations like the UN propose?

Dr Sadiq: This is one of the problems, attitudes need to change. We hear about religion, about Asian values, we hear about our culture. I mean they make out that - all of them somehow are so pure, none of these issues exist. And if it exists it is deviant and only in some small groups. But even then though, I am not sure that it is that small, if it exists we have to do something about. This is coming out more. In India there has been a dialogue in the media now about sex workers, MSMs [men who have sex with men] and IDUs. Even in the parliament there has been a discussion about sex workers. For other countries in the region - in Bangladesh there was a discussion about sex workers. The government before this one by Ms Khaleeda Zia had closed down the brothels. So now the sex workers are dispersed in the whole population and we don't know how to have programmes for them. This is a huge problem, but as she was saying to me, we can't say that now the brothels should be re-opened, the public won't accept it. There is a real dilemma, the NGOs that were working with the sex workers are complaining that it is very difficult now for the sex workers to come to their centres, they are harassed on the way and are singled out. These are problems in the society that have to be faced.

What is interesting to note is - these were not things that we could talk about just a year ago. So there is a huge change, we can make public speeches; even discuss it with ministers and leaders. Many NGOs are working here quite courageously and fearlessly. There are needle exchange programmes in the region. There are others like the Sonagachi sex workers programme in Kolkata, India. These practices should be looked at by other countries. In Cambodia, they have done a good job of educating the sex workers and the hundred percent condom use programme in Thailand are all practices that have to be shared in the region. In China I saw an excellent injection drug users' needle exchange programme, done by former reformed drug users who find it easier to identify the drug users.

Though a year ago when I went to Nepal - the workers in the needle exchange programme spoke out that as soon as you gave the needle to the drug user, the drug user and sometimes the NGO person was hauled off to jail and locked up. I talked to the human rights groups there. You don't have to consider the drug users as criminals; of course it is against the law but then so many things are against the law. But in this case you are protecting the rest of the population also. In the parliamentary group meeting I said, that we need to protect the rights of everyone, including sex workers and IDUs. They were surprised and commented - how can they have human rights; but when they started to think about it, they came to a different conclusion. In India I am very pleased in the human rights commission. The group - Lawyers Collective have drafted a whole book of suggested legislations, these include all kinds of changes in legislation that could be considered. Human rights groups should also consider it. I am hopeful; I am suggesting to India that they convene a meeting of all the human rights commissions all over the Asia Pacific and think together what they can do collectively. It could be the SAARC [South Asian Association for Regional Cooperation] region where most of the laws are similar. They can do a lot with the support of each other

HDN: On the issue of care services - do you think '3 by 5' and similar ARV [anti-retroviral drugs] initiatives will deliver on their promise in the Asia Pacific region?

Dr Sadiq: The '3 by 5' is an important initiative, what we need is to have a complete programme which should include treatment and care. We have to introduce treatment very responsibly. First of all you need to prepare the health system and the health workers. The health system must have ways to protect the health workers - they don't have disposable gloves or disposable needles; this is true in all our hospitals. The countries must first designate which health centres or hospitals are the treatment centres. Then they must carefully prepare all the health care workers. There are ways to select who should be eligible for ARVs, not everyone needs ARVs. Once you start them on ARVs they have to be maintained, there are all kinds of problems, some have side effects and give it up, some feel better and give it up because they feel now we are getting better. But I was saying that one observes all kinds of issues including a continued supply of medicines, which have not been addressed.

HDN: '3 by 5' and other initiatives are only trying to reach 50% of the people who need ARVs today. If the majority of people living with HIV in the AP region will not receive ARVs in the foreseeable future (especially in the large population countries such as India and China): How can we avoid the imminent situation where large numbers of people die while they wait for ARV programmes such as '3 by 5' to deliver on their promises? Are there other ways that people currently living with HIV can be kept alive without ARVs?

Dr Sadiq: It is not going to reach even the 50% of the people who need ARVs. You can give them treatment and care for other infections. For the treatment of opportunistic infections also, the health systems need to be prepared. The health system is also a big obstacle, when someone who is HIV positive comes for treatment they don't treat them very well. They put labels, red crosses on the patients chart in countries like Pakistan and in India. You cannot single them out; when you do they don't want to come to the hospitals for treatment.

We need to treat them quickly and aggressively for other infections. That also needs public education and education within the health systems. How we must treat and how to manage, how to prevent the infections and how not to discriminate against them. You don't have to have separate hospitals for people living with HIV/AIDS. Nutrition support is also needed; you have to have supplemental feeding and vitamin programmes. All these especially for the poor are very important. There are some lessons to be learnt from Thailand - where they have introduced micro-credit schemes. The credit is given to two people, one who is positive and one partner who is not positive. This also shows that partnership in a business association removes stigma. All of us have some micro-credit schemes of some kind which could be based on the sharing of cost of care and some effort to reduce stigma.

HDN: You are well known for your work promoting contraception and population control (even the Pope has publicly spoken out against your attitudes to birth control) - ten years on from ICPD and over twenty years into the HIV epidemic, currently there seems to be another struggle - between those who wish to preach to young people about their sexual behaviour (i.e., the US government and its abstinence-only HIV prevention strategy) and institutions such as the UN and what it sees as the evidence base for inclusion of condoms in HIV prevention programmes for youth. What is your personal opinion about this?

Dr Sadiq: I think the US is changing; President Bush made some statement recently that condoms are okay. They know that 'abstinence only' programmes leads to a lot of babies. They also need to change their attitude towards sex workers - [they seem to believe] that if you make sex work safe it will increase sex work and increase trafficking, they have this logic of some kind. Mr Tobias, the US government's global AIDS coordinator, made a statement in Bangkok [at the 2004 International AIDS Conference], where there was a lot of agitation against the 'abstinence only' approach and the restriction of condom supply. He said, "we do not mean abstinence only we mean A (abstinence), B (be faithful), and C (use condoms)." How much of this is going to happen or not I don't know. World Health Organization, Joint United Nations Programme on HIV/AIDS and all other organizations are promoting access to condoms. We have to not only promote male condoms but also female condoms. In many places they don't even know that there is such a thing [as the female condom].

We have to test how it can be used effectively and ways to bring down the costs. I was talking to a supplier of the female condom in the United States and they said we are the only ones producing it, if the demand increases than the costs of supply will go down. They are supplying them in some countries at a very low cost. Some of the African countries are really using the female condom. I went to a Pacific island conference, where the people were very interested in the female condom and what did it look like. Some of the women there were very irate that how come we were never told about it. Besides the male condom we need to talk about the female condom and promote it

HDN: The theme of this year's World AIDS Day is Women, Girls, HIV and AIDS - given your former position as Executive Director of the United Nations Population Fund (UNFPA), your personal track record of advocacy on the importance of addressing the needs of women, and now your role as Special Envoy for HIV/AIDS in Asia and the Pacific, you would be well-placed to write several volumes on the WAD theme. If pressed, what is the single most important and significant issue facing women in relation to HIV in this region?

Dr Sadiq: It is really empowerment of women and balance in gender relationships. Violence etc? all comes as part of it. I will not single out violence; it is not just violence, there exist many non-violent relationships where the woman thinks she has to act whatever is asked of her. The fact that she has no knowledge, she really doesn't know and is totally ignorant, that adds to her problems. The stigma in Asia, particularly in South Asia, is associated with women being HIV positive; this is many times higher than men who are HIV positive. It is double discrimination against women considering most of them - over 90% get it from the one partner they have. I hope that the theme of this year's World AIDS Day - Women, Girls, HIV and AIDS, will help empowerment of women, and push for gender equality and a need for women to have more power over their own decisions.

HDN: The 'slogan' of World AIDS Day is: Have you heard me today? How do you interpret that slogan, and who would you personally most like to hear from in relation to women and HIV/AIDS.

Dr Sadiq: I would like to hear all the young women who are HIV positive, I would like to hear their voices; their stories are really poignant. I want to understand how their marriages were arranged and what was told to them, what did they think their future was going to be and what do they find is left with the present and future. I think those voices need to be heard. And I hope other women will start to listen, and hopefully policy-makers and partners also become part of this listening - hope to find something that really touches them and can make a difference in the lives of these young women who are HIV positive.

Ishdeep Kohli-CNS

Orphans and vulnerable children: Communities in need of support

The Regional Psychosocial Support Initiative for Children Affected by HIV/AIDS (REPSSI) provided the regional perspective for East and Southern Africa during the Technical Consultation on Children and HIV/AIDS in London, 7-8 February, 2006. The initiative is a psychosocial support (PSS) network for children affected by HIV and AIDS. REPSSI operates in 13 countries and has a partner base of nearly 60 organisations in the region working to mainstream PSS into their activities and policies. Ms Noreen M Huni, speaking for the region told participants that the family system has not collapsed, but is very overstretched. Communities are committed to caring for and supporting the children themselves; extended families, communities, faith-based and non-governmental organisations provide the majority of care and support for orphans and vulnerable children (OVC) in the HIV/AIDS context.

In this region OVC programming has recognised that cultural systems, practices and beliefs are a valuable entry point for successful and sustainable interventions. For example, Malawian initiation ceremonies have included HIV/AIDS prevention messages in their curriculum. The elderly are increasingly taking up this responsibility, yet their own material, physical, social, spiritual and emotional needs remain unmet. The overall capacity to responding is extremely inadequate. Knowledge, skills and resources are far from sufficient. Communities need resources and technical capacity enhancement to manage these resources.

The comprehensive care and support packages provided so far are physical, spiritual and material in nature, ignoring the psychosocial wellbeing of the children. Thus, there is a huge gap requiring unique interventions to strengthen the existing responses. Access to essential services has been agreed upon but tremendous barriers hinder access to these basics. Access to ARVs remains limited based on affordability, accessibility and treatment literacy. Children are still not accessing ARVs, as priority is given to adults and appropriate dosages and formulations for children are unavailable.

National Plans of Action are in place and most governments are attempting to address OVC needs with the necessary policies, for example 'Free Education for All', although other barriers continue to hinder children from attending school. But there is no legislative review to support the Convention on the Rights of the Child; these rights remain inaccessible to most OVCs. Many OVC have no legal existence at national level due to lack of birth registration - therefore no resources are allocated for OVC. Most countries have no National Social Policy on OVC - leaving the non-governmental and faith based organisations to take the lead in responding.

Government officials have begun to include the plight of orphans in their campaign and advocacy strategies. Schools are becoming centres of care and support. Hospitals are also being used as meeting places for support groups, counselling centres and provide information on the well-being of orphans. Certain print and broadcast media are taking a positive responsibility to educate and create awareness of issues pertaining to children within an HIV/AIDS context. There has also been a major increase in the number of NGOs focusing on OVC issues. But challenges remain - there are too many soldiers and no generals in this fight. It is not clear which ministries are mandated for OVC and what status these ministries have. The OVC challenge has a very low profile among the national governments. Noting that children constitute 50% of the population in most countries, isn't it time to create a special ministry for them?

International funding partners, UN agencies, regional and national political structures have all emphasised the seriousness of the problem. But the funding duration is usually less than 5 years, which ignores the fundamentals of child rights programming. Donors often arrive with pre-planned interventions, rather than supporting existing multi-sectoral responses - searching for 'quick results'. Some interventions are unrealistic, and do not take into account succession plans, such as exit strategies. A lack of coordinated donor activities is reported in most African countries and information-sharing is limited between funding partners and recipients. FBOs and CBOs often do not have the technical capacity to access available funds. An additional problem is that regional political structures (Pan African Parliamentarians, AU, SADC and NEPAD) have failed to mainstream OVC in regional HIV/AIDS, poverty reduction and budgeting and planning frameworks.

UNICEF in collaboration with REPSSI and some African universities have started working on a 'Children at Risk' certificate level programme for child care and support service providers in response to the knowledge and skills gap. Children, families, communities, non-governmental and faith-based organisations are providing the majority of OVC with care and support. But there is an urgent need to make these interventions more visible and respected by the communities themselves, before trying out 'new' interventions. The programme for orphans and vulnerable children should be high on the international, regional and national agendas. The nature and duration of intervention should ensure there is no additional trauma by placing the child and family at the centre of the interventions.

Ishdeep Kohli-CNS

Social Welfare: A Core Response to Child Poverty

The Technical Consultation preceding the Global Partners Forum on Children Affected by HIV and AIDS, February, 2006, highlighted the importance of improving outcomes for children through integrated national systems of social welfare which guarantee basic living standards to the most vulnerable.

All children in highly impacted communities are negatively affected by the social and economic impact of HIV and AIDS. Recent evidence suggests that the impact on children is worsening as households and communities become less able to cope with the burdens of care associated with the disease. Current responses to children affected by HIV and AIDS are inadequate. Tackling child poverty and enabling households to meet the needs of children in their care necessitates a coherent policy mix of direct and indirect instruments.

Mexico, Brazil and India are examples of nations that are developing their social welfare systems and enhancing state capacity to deliver social outcomes. Certain countries in Africa are also adapting social policy frameworks and institutions to meet the challenges of poverty and HIV and AIDS.

Successful direct instruments which have demonstrated positive impacts on child poverty and on children affected by HIV and AIDS include the cash grant system of social transfers in South Africa, Namibia, Botswana and Lesotho, including child support grants and non-contributory old age pensions.

Those countries which have moved towards strengthened national capacity in social welfare have adopted strong coherent social policy frameworks and have invested in state capacity to deliver policy and benefits. Direct instruments will assist families affected by HIV and AIDS to support children in their care. Such instruments need to be part of a national response situated within a national social policy framework ensuring best policy coherence for social outcomes for the most vulnerable children.

Mr Stephen Kidd, of DFID's Social Protection Division, called attention to social welfare as being a core human right, specifically quoting from the Convention on the Rights of the Child, Article 26: "for every child the right to benefit from social security" and Article 27: "the right of every child to a standard of living adequate for the child's physical, mental, spiritual, moral and social development". These rights have attracted little attention in poor countries, yet they should be a core response to tackling child poverty, especially in the context of AIDS.

Social transfers can improve household food security, increase rates of participation in education and the uptake of health services. A study commissioned by UNICEF in Southern and Eastern Africa found that cash transfers in the form of child care grants and social pensions were effective in helping families support children in their care. The study concluded that transfers had the potential to strengthen the capacities of families and individuals to support children affected by HIV and AIDS; that predictable ongoing support was most effective and that cash payments afforded flexibility in utilisation which allowed recipients to maximise multiplier effects.

Social protection can promote growth by allowing people to take up higher return - but also more risky - economic activities. It is also an investment in people, generating a healthier workforce and gives children the opportunity to break the poverty cycle; especially important in the context of HIV and AIDS. This increases the number of people contributing to the economy, as those receiving transfers are more likely to be in work than non-beneficiaries.

Social welfare should complement other interventions though and should not replace interventions in health, education and tackling HIV and AIDS. Social welfare is essential to improving impact on child poverty outcomes, including in health and education.

Fee waivers, for example, are not sufficient for many of the poorest to access school and health as they face other barriers. Even ARVs are less effective when recipients have poor nutrition. Other interventions can build on the platform provided by social welfare.

National governments should develop a strategic framework for social welfare provision, integrate social welfare and child poverty outcomes into national Poverty Reduction Strategies, revise National OVC Action Plans to incorporate social protection and embed them within national social policy frameworks.

It is essential that governments take forward national planning on social welfare and increase budget allocations. The international community also needs to invest in building coherent institutions to deliver social welfare for the most vulnerable.

Ishdeep Kohli-CNS

Peter McDermott, Opening Session: Global Situation and Response for Children Affected by HIV/AIDS

Unite for Children, Unite Against AIDS.

The Technical Consultation on Children Affected by HIV AIDS bought together around 100 representatives of civil society, governments, bilateral and multilateral donors, UN agencies and academics. This was the first time that the Global Partners Forum on Children Affected by HIV and AIDS was preceded by a 'Technical Consultation' that provided an opportunity for discussions on the key actions required to eliminate barriers to scaling up effective services for children affected by HIV and AIDS.

Recommendations from the Technical Consultation were to be presented at the Global Partners Forum, 9-10 February, 2006.

Peter McDermott, chief, HIV/AIDS section, UNICEF speaking on the global situation and the response to children affected by HIV and AIDS, said that though children and AIDS have become the subject of growing local, national and international attention over recent years, significant momentum is needed to make a real difference. While there has been a paradigm shift, children are still missing from the global response.

There were 700,000 new HIV infections among children in 2005 and 2.3 million children are estimated to be living with HIV as of the end of the year. 15 million children have so far been orphaned by AIDS, but the worst is yet to come - the number of orphans will rise even after the number of adults infected stagnates or declines.

Children are affected by HIV/AIDS for many reasons, but the majority of children affected by AIDS are made vulnerable because the adults around them are sick, dying or have recently died. Orphans are not always the most vulnerable, though they are often at higher risk of becoming infected themselves and are less likely to receive a proper education.

Peter Mc Dermott explained the global campaign 'Unite for Children, Unite Against AIDS', which aims to unite the efforts of all those fighting AIDS to meet children's needs in four key areas. This provides a child-focused framework for nationally owned programmes around the 'Four Ps' - urgent imperatives that will make a real difference in the lives and life chances of children affected by AIDS. These are:

    * Prevent mother-to-child transmission of HIV
    * Provide paediatric treatment
    * Prevent infection among adolescents and young people
    * Protect and support children affected by HIV/AIDS

To prevent mother-to-child transmission of HIV, the campaign seeks to expand services to 80 percent of women in need by 2010, up from the current 10 percent.

By providing pediatric drug treatment, the campaign seeks to cut in half the number of children who are infected at birth and die each year before reaching the age of one year -currently about 500,000. The target is to provide either antiretroviral treatment or cotrimoxazole, or both to 80 percent of the children in need by 2010.

By preventing new infections among adolescents and young people, the campaign hopes to reduce by 25 percent the number of children between the ages of 4 and 15 infected annually by 2010.

The 'Unite for Children, Unite against AIDS' campaign advocates for improved birth and death registration systems - at present it is often difficult for children and extended family members to obtain official records proving that they are orphans, which can make them ineligible for such benefits as food aid or free medical care.

The campaign also advocates for education and health services to be strengthened, and for governments and agencies to work towards the elimination of user fees for primary education and, where appropriate health-care services. Thus, the campaign provides a platform for continued action and advocacy to promote the implementation of the Convention on the Rights of the Child and other international conventions.

The global momentum to fight HIV/AIDS now includes the US President's Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, and the World Bank Multi-Country HIV/AIDS Program for Africa, as well as a significant increase in responses from civil society and faith-based organisations. Coordinating the contributions of all these actors is a daunting but essential task. But unless it is successful, there is a danger that isolated interventions will lead to the proliferation of small projects that are not linked to wider and longer-term programmatic, sectoral or national interventions.

The number of international contributions to the fight against HIV/AIDS often strains the capacity of national coordinating bodies, leaves gaps in national responses and increases the risk of duplication. The Unite for Children, Unite against AIDS Campaign provides a platform for all agencies involved in halting and reversing the spread of HIV/AIDS among children, adolescents and young people. It helps ensure that the children's face of HIV/AIDS is represented at every level of the 'Three Ones'.

Ishdeep Kohli-CNS