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