Transcript

Host: This is “On The Line,” and I'm Eric Felten. First Lady Laura Bush traveled to Africa to visit health clinics and other organizations that are being funded by the President's Emergency Plan for AIDS Relief. President George W. Bush has proposed increasing the amount of money the U-S spends to treat H-I-V/AIDS in Africa:

President Bush: “To date, the Emergency Plan has supported treatment for 1.1 million people infected with H-I-V. This is a promising start. Yet, without further action, the legislation that funded this Emergency Plan is set to expire in 2008. Today I asked Congress to demonstrate America's continuing commitment to fighting the scourge of H-I-V/AIDS by reauthorizing this legislation now. I asked Congress to double our initial commitment and approve an addition thirty billion dollars for H-I-V/AIDS prevention, for care, and for treatment over the next five years.”

Host: H-I-V, the virus that causes AIDS, continues to spread in Africa at alarming and devastating rates. The epidemic has grown, even though there has been much greater access to the antiretroviral drugs that can effectively treat those with H-I-V. For every African who began treatment last year, there were five others who became infected with the virus.

Why is H-I-V/AIDS spreading so aggressively in Africa? And can it be stopped? I'll ask my guests -- Patricio Rojas, head of the H-I-V/AIDS program for Latin America and the Caribbean at the World Health Organization, and Jennifer Cooke, codirector of the Africa Program at the Center for Strategic & International Studies, a Washington-based think tank. Welcome. Thanks for joining us today. Appreciate it.

So, Patricio Rojas, why does AIDS continue to spread so aggressively in Africa?

Rojas: Because it is a question of behaviors, you know -- social behaviors -- and it's very difficult to change behaviors. So, although we all are very happy because with the introduction of antiretrovirals and the results of some prevention interventions, nevertheless, unless the communities understand that a major change in the perception of sexuality and the change of sexual behavior get anyone to control.

Host: Jennifer Cooke, an issue of sexual attitudes and sexual behavior?

Cooke: I think very much so. I would add to that the important role of women and the empowerment of women. I think that's gonna be a major stumbling block to halting the spread of the disease. Until women -- and, increasingly, women are more quickly affected than men, and the proportion of women affected are rising more quickly than those of men -- unless women are able or empowered to kind of negotiate the terms of their sexuality, empowered economically, socially, legally, they are gonna continue to be vulnerable to the disease, and I think that goes fundamentally to that cultural and behavioral attitude that it will take some time to shift.

Host: Well, there are three things that you bring up there -- economic, social, and legal issues. Which are -- Which is the most difficult of those to change, and which is the most important to change?

Rojas: I think altogether, really, you can singularize one simple determinant, you know, and, in fact, the mistake of some countries, trying to address one issue only, has been exactly that -- to end up with a partial solution. Those who thought for a moment that the antiretrovirals were the solution was a mistake, because, of course, it helps a lot the people who are sick but doesn't control the number of new infections. You yourself said in your introduction that for every person accessing to treatment, five more get infected -- new infections. Well, that was last year's information. This year, it's one every six, you know? So, on the one hand, you are expanding the pool of people who will need more medicine for long periods of time, but, on the other hand, you haven't cut the tap which controls the new infections. So, I think that, unless you have a comprehensive approach to all the terminals of the disease, it will be very difficult to control it -- economic, social, and especially educational, by far.

Host: What's your sense on this, Jennifer Cooke -- these issues of social attitudes, legal issues, but then also economic issues? Are they things that can be addressed individually, all together?

Cooke: As Professor Rojas says, I think it has to be a comprehensive approach. There is a tendency, particularly to address this from a medical perspective, and we've seen that with the President's Emergency Plan, PEPFAR, which has brought an incredible boon to people suffering from H-I-V -- the ability to live many more years of a productive life. But you need those fundamental developmental aspects -- the education system, the economic system that allows, for example, women to make choices in terms of leaving a husband who may be unfaithful, not resorting, for example, to commercial sex work, and the education to be able to sustain themselves through jobs and so forth. There are so many fundamental development issues that play into this that it's a very complex -- It'll be a very complex solution, and you can't address it simply from the medical, from the economic, from the political. It really has to be this broad-based approach.

Host: What has been going on with prevention efforts? What's been tried at this point? Francois Venter, who's the president of the Southern African H-I-V Clinicians Society, told a reporter recently that South Africa has had huge money poured into it for prevention and has done diddly-squat. That's the way he put it. What prevention efforts have been tried at this point?

Rojas: Yeah. I think there is one issue there which is the main problem with prevention -- that many interventions, valid interventions, haven't been measured -- the impact of them. So, you have good ideas, you have good interventions, but we haven't measured how much impact they have on the populations. For instance, the condom promotion, you know -- Monies are spent -- millions, in fact -- but the actual measurement of the change of behavior in the use of condoms -- we cannot tell, actually. Of course, we know it's a powerful preventive tool, but unless you have a base line to check with, it's difficult to measure the impact of it, you know? Abstinence and faithfulness, which is an essential issue as well -- Again, the same thing happens, you know? So, what we need is more evidence-based intervention promoted. Now we have measured concession, which is another great advance. But the impact of measured concession in the health systems already overburdened, you know, by AIDS patients and other patients, you know. It's very difficult to assess.

Host: Let's talk about that just a little bit. What is this issue that seems to be fairly new that's being discussed of male circumcision as being a part of this package of preventing AIDS? Jennifer Cooke.

Cooke: Well, I think there's an increasing body of studies that show that male circumcision can help prevent the transmission from an infected male to another and for the male to become infected. I won't go into the biology of it, but it's actually a remarkable measure of prevention -- almost, I think, as effective as some -- As a vaccine, as currently contemplated, might be. The problem is you don't want to sell it as a vaccine because you don't want to disinhibit people from practicing safe sex, thinking, "I've been circumcised. Therefore, I'm safe.” So, there's a lot of issues with that. But I think the studies are -- It is a remarkable new development as a prevention measure.

Host: Now, are there cultural norms and attitudes toward circumcision in southern African countries that will have to be overcome if that's to become a central part of this strategy?

Rojas: Yes, yes, but at only that, you know? First of all, these are the results -- spectacular results, in a way -- which prove that we have here a very powerful prevention tool. However, moving from a result of a study to a public-health policy is a different thing. You have to necessarily have proof that this is going to work. You can imagine the burden, you know, that would be on the health systems in Africa -- in other countries, as well, in the developing world -- to add, you know, these colossal numbers of male queuing to be circumcised, you know, by the thousands. And this is not, by the way, minor surgery, you know. We're talking about a surgical procedure with complications as well, so we have to be very careful before we move into the -- How could I say? -- expectations created around a very positive development to formulate a public policy, you know, to recommend this as a major event. This is on the one hand. On the other hand, the costs involved are also staggering, you know, because you have to think in terms of actually millions of men, you know, to be circumcised. Now, are you going to circumcise at birth or later on? And, finally, coming to your point, the cultural issues, you know -- In some societies, like in Latin America, for instance, circumcision is not an issue, you know? I mean, it's not something that you normally accept as part of your social and cultural upbringing, as it is in the north -- in the northern hemisphere. So, before we recommend this, we have to assess the situation and the cultural acceptance in every country, you know, 'cause that will be the determinant in this respect.

Host: Jennifer Cooke, one other thing that seems to be a big effect in the effort to change behaviors is that you have at the same time that you have so many people dying from AIDS and has been going on now for a decade or more, an increase in the number of orphans, and so you have people who have been growing up without family institutions and an upbringing that might facilitate learning sexual mores that might be protective of them. How much more complicated is it to try to deal with these preventive issues when you have large populations of orphans growing up?

Cooke: Well, it is a huge complicating factor. Already in these countries, a number of countries in Africa have large youth populations. The majority of the population are young. When that population is not educated, has not grown up in a family setting, does not have a means of livelihood, there is the much higher potential to engage in high-risk behaviors. For girls, that often may mean engaging in commercial sex work. For boys, a kind of -- It's similarly kind of asocial behaviors and so forth. It is a big problem. The numbers are bit overwhelming. To date, a lot of those orphans have been kind of absorbed into kind of village or extended-family structures, but those structures are being completely overwhelmed, and I think dealing with the orphans of this disease is gonna be a major challenge in the coming years that's gonna grow as well.

Host: Patricio Rojas, how does that affect the ability to push prevention efforts?

Rojas: Dramatically in the sense that you have more and more people in need of services, you know -- of care. And, of course, in an environment of limited resources, you have to choose, and with the attraction of medicines and drugs, you know, the bulk of the resources go to the acquisition of antiretrovirals and prevention interventions, and the whole study of the complex situation generated by the epidemic -- social, economic, cultural, you know -- are a little bit left behind. So, very few countries have done the separation of research that Jennifer was talking about, and this research is essential towards intake-policy decisions, you know? In the absence of that, anybody coming can go to whatever, you know -- buying drugs or buying condoms or promoting interventions which are not evidence-based, as we say, and satisfy a donor because you use the money, use it effectively -- I mean, efficiently. But you don't address the main issue, which is the control of the epidemic. So, to us as well, you know, the question of operational research is essential in the sense that this is the only way you have to orientate not only governments but also donors where to put the money.

Host: Well, Jennifer Cooke, this issue of money -- We've had this significant effort coming from the U-S and now a proposal to step that up again, and yet we see it lagging far behind the actual pace of the epidemic. Is there, at this point, any amount of money that is going to make a big difference?

Cooke: Well, there's always gonna be a need, and I have to say the money to date has actually made a big difference in terms of getting people on treatment -- Preventing someone from leaving an orphan at 10 years old versus at 20 years old, for example. So, the money, to date, has made an enormous impact. In the future, though, I think we have to go from this kind of emergency approach, which is getting treatment, getting money as quickly as we can to the ground, to thinking out more on some of the sustainability issues -- getting prevention right. Prevention is hard because it involves sexuality. It involves condoms and abstinence, and there's some debate here in the United States as well as elsewhere in the world on that. It involves difficult questions of sexuality. It also is very difficult to measure, so you can't come back and say, "We prevented 20,000 infections today.” Getting prevention right has to be at the core of that. And, to a certain extent, other obstacles to sustainability are the systems, the health systems, that we're relying increasingly on. They're weak in Africa. There's a huge shortage of health professionals, of nurses, technicians, and so forth, and no amount of money, if you have this very fragile system, is going to be able to fix the problem. So, there will always be a need for resources, but resources need to be focused on kind of getting over those sustainability obstacles -- the prevention, the systems, the gender issues.

Host: Well, Patricio Rojas, what's the sense of -- In this question of sustainability and infrastructure, when you have treatment with antiretroviral drugs -- This is something that has to go on indefinitely and requires treatment every day, medications to be taken multiple times a day -- What's the sense, at this point, of the effectiveness not only of getting these drugs into the countries where they're needed but the ability to actually distribute them and get people to take them on a regular regime?

Rojas: That's the main challenge, really, you know? One thing is to get the money, another thing is to buy the drugs, and the third thing is make the drugs available to people where they are. In some countries, you have the drugs in the Ministries of Health, you know, and they're there. So the patients have to come and pick them up from the provinces and faraway places.

Host: Which countries are those, where that's been -- yeah.

Rojas: Almost everywhere. In the Third World, when you have -- The majority of countries don't have these solid health-system infrastructures to support a massive effort as it is to provide people every day, as you say, with drugs for the rest of their lives. So, you have to necessarily consider the strengthening of the health systems as well, you know -- Not only the procurement of drugs but also the whole managerial chain to secure that the drugs eventually become available, you know, to the peoples in need. If you think for a moment, the number of people receiving drugs, in spite of all the efforts and the money spent, is still, you know, low in comparison to those who actually need it. Only four percent of children in need of treatment receive treatment today. Very few drugs have formulas -- pediatric formulas -- to make things easier for the mothers, so you take the big pill and you have to cut it up and give it to the children because, of course, since the numbers are small, for laboratories, it's not that productive to produce big numbers of formulas, so you just rely on the adults' formula, which is a burden, you know, and complicates things for a lot of treatment. So, the whole process, you know, is -- And I think that Jennifer took that issue as well -- is more than simply money, you know? Of course, it's essential -- the money -- but where you put it in the future will be, to me, the key issue -- Strategically, to define areas which are in need of a strengthening together with the provision of the drugs.

Host: Well, Jennifer Cooke, where should the money be going at this point that it isn't going already?

Cooke: Well, as I say, I think prevention has been overlooked, again, because treatment is more politically attractive to save lives rather than prevent something that hasn't happened.

Host: It's also something that a government can actually go and do. It can provide drugs, but it can't not have someone have sex.

Cooke: Right. And it's very hard to measure prevention, and so you can't come back and say, "We got good results.” So, it's hard for governments to invest big money because it doesn't have the immediate tangible benefit of saving lives. So, prevention is one of those neglected areas. The health system generally and health professionals is another area. The other area -- Much of the international effort has kind of created these parallel systems in some ways in these countries -- an H-I-V distribution that is often separate from the regular health system so that a lot of other diseases in these countries get neglected -- child mortality, maternal problems. And I think one of the key areas to invest in is integrating H-I-V with other components of the health system -- with reproductive health, with T-B and so forth.

Host: Well, Patricio Rojas, these new efforts to try to also fund efforts against T-B, tuberculosis, and against malaria -- And is there an opportunity to get more effect on all of these efforts by combining how they get distributed, how the medicines are organized?

Rojas: Certainly. Besides, you know, together with the question of medicine is the laboratories attach that, because to make the follow-up of the impact of the drug in the person, the patient, you need to check with blood tests and other tests, which means you have to have a laboratory behind you to support you, which also is a major weakness in many of the countries we have with these high prevalency rates. So, certainly, we are addressing major diseases -- malaria, tuberculosis, and then H-I-V/AIDS. There are other diseases as well, and this brings a very interesting issue here. It's a very serious issue, actually -- the ethical responsibility of those working in AIDS, you know, because we are receiving for AIDS a colossal amount of money in comparative terms, you know? Never, ever before in the history of public health a public-health public has gathered so much resources -- never before, you know? And, as Jennifer said, it's not the only disease in the world killing people. So, there is an ethical responsibility there, you know, to provide results and to put the money where it can work.

Host: All right. Well, I'm afraid that's gonna have to be the last word for today. We're out of time. But I'd like to thank my guests for joining me today -- Patricio Rojas of the World Health Organization and Jennifer Cooke of CSIS. Before we go, I'd like to invite you to send us your questions or comments. You can reach us through our website at www.voanews.com/ontheline. For “On The Line,” I'm Eric Felten.