December 2003 VOL. 9, NO.

12

M O N T H L Y

National leadership,
international cooperation
keys to effective
AIDS response
 IAPAC, with its broad mission
to improve the healthcare of
all who have been affected by
the AIDS pandemic, is working
to ease suffering and to
ensure that persons living
with HIV/AIDS are able to live
productive lives. Though the
battle ahead is one requiring
the greatest of global commit-
ments, even small donations
from concerned world citizens
with the means to provide a
small amount of financial
assistance can make a notable
impact.
The same poverty that
engenders higher infection
rates in the developing world
also means an inadequacy of
healthcare infrastructure and,
often, the inability of physicians
and allied health professionals
to access the training and
information that they require
to effectively treat those in
their care.

SPONSOR A With your donation of US$60 (or more), you can help IAPAC in its mission as an agent of
change. For only US$60, IAPAC can sustain the cost of an annual membership for a physician in the
developing world, thus enabling physicians in the regions most heavily burdened by HIV disease to
DEVELOPING gain greater access to critical clinical and policy information and to more
fully partake of specialized HIV/AIDS medical training provided in the coun-
tries where it is most needed.
WORLD For additional information on how you can make a difference, contact
Joey Atwell, Director of Membership, at (312) 795-4941 or jatwell@iapac.org,
PHYSICIAN or complete and submit an on-line application at www.iapac.org.
 December 2003 Volume 9, Number 12

M O N T H L Y

320 battling complacency

advancing commitment

INTERNATIONAL ASSOCIATION
OF PHYSICIANS IN AIDS CARE
Headquarters Office
Chicago, Illinois, USA

PRESIDENT/CEO José M. Zuniga

VICE PRESIDENT/CFO Harry J. Snyder
VICE PRESIDENT/CMO Mulamba Diese
VICE PRESIDENT/Membership Joey Atwell

INTERNATIONAL ASSOCIATION
OF PHYSICIANS IN AIDS CARE
African Regional Office
National leadership, international cooperation Johannesburg, South Africa
keys to effective AIDS response
EXECUTIVE DIRECTOR Mulamba Diese
Mark D. Wagner DEPUTY DIRECTOR Tania Adendorff

Experts from 24 countries gathered at the 6th International Conference on Healthcare

IAPAC MONTHLY
Resource Allocation for HIV/AIDS to dissect their national responses to HIV/AIDS.
Their consensus was that political will and resources cannot alone stem the tide EDITOR-IN-CHIEF José M. Zuniga
of the AIDS pandemic—leadership and cooperation are as essential to mounting MANAGING EDITOR Lisa McKamy
a concerted national and international effort against HIV disease. POLITICAL EDITOR Scott A. Wolfe
CREATIVE/DESIGN DIRECTOR Holly J. Emanuelson
ADVERTISING DIRECTOR Cathy Supina

D E P A R T M E N T S WRITER-AT-LARGE Mark Mascolini

CONTRIBUTING WRITERS Michael Carter,

R E P O R T F R O M T H E P R E S I D E N T 312 Carrie Scharrer, Mark D. Wagner

A R V U P D AT E 314 IAPAC Monthly (ISSN 1545-1089) is published monthly by the

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R E P O R T
What a difference a year makes
José M. Zuniga
T
he history of the AIDS pandemic
recommends proceeding cautiously
with declarations of progress; the
virus and its consequences always
seem to be one step ahead of us. In
2003, for example, there were new warnings
of entrenched and growing epidemics in
countries such as China, Ethiopia, India,
and Russia. In Africa, there were fresh signs
that HIV/AIDS is exacerbating famine. In
even the wealthiest countries, such as the
United States, political support for treatment
coverage wavered, and growing incidence
rates may reflect complacency vis-à-vis
prevention messages. Finally, 2003 marked
the first time that as many women as men
were infected worldwide, an epidemiological
trend that speaks to widespread gender
inequality and reminds us of another way in
which real control of HIV/AIDS may require
long-term cultural and systemic changes.
Without ignoring these sobering realities,
however, any review of the world’s response
to HIV/AIDS in 2003 must also include a
measure of genuine, if necessarily cautious,
optimism. Several national and interna-
tional developments are now unfolding,
and if they live up to their potential, 2003
may be marked as a turning point.
As demonstrated recently in presentations
delivered at the 6th International Conference
on Healthcare Resource Allocation for
HIV/AIDS, which the International
Association of Physicians in AIDS Care
(IAPAC) co-hosted two months ago in
Washington, DC, scaling up treatment for
HIV/AIDS requires both international and
national commitment. It was heartening,
then, to see the governments of South
Africa and China commit within the last
month to universal treatment, including
antiretroviral therapy. Both governments
had long wavered on the problem of HIV
312 IAPAC Monthly
battling complacency
advancing commitment
F R O M T H E P R E S I D E N T
disease in their respective countries, with
South Africa’s leadership questioning for
some time established medical knowledge
about the link between HIV and AIDS,
and China turning a blind eye to vastly
increasing prevalence rates. In changing
course from ambivalence to action, South
Africa’s strategy is the better conceived,
committing millions not only to buying
drugs, but also to improving the health sys-
tem to ensure that they are used effectively.
Plans to address China’s severe deficiencies
in treatment capacity are not yet in line
with the need. Nonetheless, both of these
developments bespeak the importance of
individual countries prioritizing the fight
against HIV/AIDS within their borders and
the leaders of these two nations should be
commended for these bold steps forward
in the face of daunting challenges.
The foregoing, however, should not
serve to diminish the importance of inter-
national partnerships, several of which,
along with the increasingly bright global
spotlight on HIV/AIDS that they represent,
worked to move China, South Africa, and
other countries to fight their epidemics
more aggressively.
The first development on this front in
2003 was US President George W. Bush’s
Emergency Plan for AIDS Relief. Despite
a somewhat slow start, this US$15 billion
initiative remains an historic development.
Never before has the global fight against
AIDS received this type of pledge from
the world’s most powerful country, and
the good that can be done with this money
directly in the 12 African and two Caribbean
nations soon to derive benefit, in addition
to the example it sets and the opportunities
for leveraging further commitments from
wealthy nations that it represents, is a
great cause for hope.
Even as the current US president has
demonstrated leadership this year in
addressing the AIDS pandemic, his prede-
cessor is making notable strides in that
direction as well. Former US President
Bill Clinton, through his foundation and the
international team of experts it assembled,
has been instrumental in working with
manufacturers of generic antiretroviral
drugs to reduce the cost of a year’s worth
of pills to roughly US$140—a price that
would have seemed beyond reach several
years ago, when the least expensive regimens
available globally cost over US$10,000
per year. As important, Clinton, in a pro-
tracted process to which I was party sev-
eral years ago, also worked with South
African President Thabo Mbeki to present
evidence that changed his mind about the
cause of AIDS and the wisdom of making
effective treatment widely available. The
William J. Clinton Foundation is also
working with the governments of several
African and Caribbean countries to help
them address healthcare infrastructure
issues relating to HIV/AIDS treatment.
December 2003
 Among international groups, the World
Health Organization (WHO) has shown
renewed leadership since Director-General
J.W. Lee took office in July 2003, and the
WHO’s decision to declare HIV/AIDS a
global health emergency was as important as
it was overdue. If this promising leadership
stance being taken by the WHO does not
ultimately amount to “new clothes on a
dirty body,” as one notable figure recently
challenged, and if the world is indeed suc-
cessful in placing 3 million citizens in
developing world countries on antiretrovi-
ral therapy by 2005, then the urgency with
which Lee and his staff are mobilizing
disparate groups and stakeholders to
cooperatively reach this goal will share a
good portion of the credit.
That said, I confess some concern that
the rush to distribute medication that is
part of the “3 x 5” Initiative may result in
some cases of antiretroviral drugs being
used outside the realm of any real medical
care. This is precisely what is happening
in China, and already data show that
one in five people who began taking anti-
retroviral drugs has now stopped. As I
communicated in a statement lauding
South Africa’s new HIV treatment plan,
sound national and global responses to
HIV/AIDS require a mixture of radical
reform and careful forethought. The AIDS
pandemic is truly an emergency, and the
world must act with all speed to confront
it; but we must always do more good
WHO “3 x 5” partners meeting
Jack Chow, WHO Assistant Director-General for HIV/AIDS, Tuberculosis, and Malaria, addresses a gathering of “3 x 5”
Initiative partner organizations held November 5, 2003, in Geneva. In the background are IAPAC President/CEO
José M. Zuniga and IAPAC Vice President/CMO Mulamba Diese.
December 2003
than harm, and rash decisions are never
warranted.
Fortunately, I think that the various
developments of 2003 are testament to a
new spirit of partnership that could help
us to avoid these pitfalls. I have been
tremendously frustrated that this esprit de
corps has often been lacking in the past,
but it makes for excellent opportunities
to do good work in the present. IAPAC
is working closely with several groups,
including the WHO, William J. Clinton
Foundation, Pangaea Global AIDS
Foundation, AHF Global Immunity,
American International Health Alliance,
and other like-minded organizations to
identify and act on strategic institutional
strengths and areas of cooperation neces-
sary to mount the response signaled by
the “3 x 5” Initiative. Negotiations to
greatly expand our healthcare professional
training activities, and to directly provide
care and treatment in numerous countries,
are in final stages. Among the areas of
expanded activity that IAPAC anticipates
in 2004 through these and other partner-
ships, a few key examples include plans to:
• offer direct HIV care and treatment,
including antiretroviral therapy, through
an IAPAC Center of Excellence in
Sharpeville, South Africa;
• expand partnerships in South Africa to
execute that country’s newly announced
antiretroviral treatment access plan;
• provide technical assistance to care centers
worldwide engaged in twinning projects
geared at preventing mother-to-child
transmission of HIV;
• supply HIV care tools (eg, GRIP Guides)
to countries in which access to antiretro-
viral therapy is being expanded via the
“3 x 5” and other initiatives; and
• accelerate implementation and expand
the geographic reach of the Global
AIDS Learning & Evaluation Network
(GALEN).
With these ambitious and meaningful
plans close at hand, at no other time has
IAPAC’s active membership in over 100
countries assumed such importance to the
mission of the association and to the global
community’s ability to turn the tides of
the AIDS pandemic. In the very near
term, I am certain that the host of skills
and energies necessary to fulfill these
commitments will require the very active
participation of IAPAC’s physician and
allied health professional members. In this
respect, I sincerely trust that we will be
able to count on the dedication of our
members to carry the torch forward on
many projects. Toward this end, IAPAC
will soon initiate a focused outreach cam-
paign meant to identify areas of volunteer
interest through which to best marshal the
respective knowledge and skills of the
12,000-plus individuals who make up our
association.
Does all of the above mean that 2003
will be remembered as a turning point in
the fight against the AIDS pandemic?
That remains to be seen. Or, more precisely,
it remains to be determined. We all have a
stake in determining said outcome. Thus,
my parting words for this eventful year
are a sincere expression of hope that we
will all work together in 2004 and beyond
to realize the unprecedented opportunities
that have presented themselves to us —
opportunities to alleviate pain and suffer-
ing that remained an unfortunate norm in
2003. To do any less would be to turn our
back on our common humanity. For, in
the words of American aviator Charles
Lindbergh, “When the value of life and
the dignity of death are removed, what is
left?” ■
José M. Zuniga is President/CEO of the
International Association of Physicians in
AIDS Care, and Editor-in-Chief of the
IAPAC Monthly.
IAPAC Monthly 313

HAART patients at greater risk of severe side effects than AIDS
Michael Carter
H
IV-positive patients on highly active
antiretroviral therapy (HAART) are
more likely to experience a serious
or life-threatening treatment side
effect than develop an AIDS-
defining condition, according to a US
study published in the December 1, 2003,
issue of the Journal of Acquired Immune
Deficiency Syndromes. The study investiga-
tors suggest that physicians should carefully
assess their patients’ medical history and
circumstances before prescribing HAART
and, thus, avoid the use of antiretroviral
drugs that could aggravate existing health
conditions.
Investigators analyzed the results from
five US multi-center HAART trials that had
a common system of reporting adverse
events, AIDS events, and deaths between
1996 and 2001. Partial findings from the
study were presented at the 9th Conference
on Retroviruses and Opportunistic Infections
in 2002.
The investigators wished to establish
the incidence and determinants of serious
or life-threatening treatment side effects,
AIDS-defining illnesses, and death.
Data were analyzed from 2,947 patients
who were followed for a median of 20.7
months, contributing 5,940 person-years
of follow-up. At the time of enrollment to
the studies, 53 percent of patients were
antiretroviral-naive, average age was a little
over 39 years, 83 percent were male, 55
percent were gay men, 16 percent had a
history of injecting drug use, the median
CD4 count was 211 cells/mm3, and 40
percent had a previous AIDS diagnosis.
All the patients were prescribed anti-
retroviral therapy, and at month 12 of
follow-up 89 percent were receiving
HAART (70 percent a protease inhibitor-
314 IAPAC Monthly
A R V U P D A T E
and 19 percent a non-nucleoside reverse
transcriptase inhibitor-based regimen),
3 percent mono- or dual-nucleoside reverse
transcriptase inhibitor treatment, and 8
percent had stopped antiretroviral therapy
on either a permanent or temporary basis.
Following are some highlights from
the study:
• 675 patients (11.4 cases per 100 person-
years) experienced a severe or life-
threatening side effect (grade 4 adverse
event); 332 developed an AIDS-defining
condition (5.6 cases per 100 person-years);
and 272 patients died (4.6 cases per 100
person-years).
• The cumulative percentage of patients
with a severe or life-threatening side
effect at month 12 was 15.6 percent; at
month 24, 23.7 percent; and at month
36, 30.8 percent. The corresponding
percentages for AIDS events were 7.3
percent, 10.8 percent, and 16.5 percent;
and the percentages for deaths were 3.9
percent, 7.9 percent, and 13.1 percent.
• Liver-related side effects were the most
frequently reported adverse events (148
patients, 2.6 per 100 person-years).
• When the investigators looked at the
risk factors for the experience of severe
or life-threatening side effects, they
found that the risk was lower in
younger patients (hazard ratio [HR]
0.83 for every decade in years,
p = 0.0001), and patients who had never
taken antiretroviral drugs (HR = 0.59,
p = 0.0001). The risks were increased
for patients with a history of injecting
drug use (HR = 1.41, p = 0.0006), lower
baseline CD4 count (for every 100
cells/mm3, HR = 1.06, p = 0.04), and a
prior AIDS-defining illness (HR = 1.22,
p = 0.03).
• The investigators also found that women
were at increased risk of experiencing
severe or life-threatening neutropenia
(HR = 1.76, p = 0.03), while African
Americans were at increased risk of
neutropenia (HR = 3.78, p = 0.0001),
anemia (HR = 2.46, p = 0.008), and kidney-
related events (HR = 22.41, p = 0.00250).
Latinos had an increased risk of
neutropenia (HR = 2.75, p = 0.01).
• Of the 272 patients who died, 159 expe-
rienced both a grade 4 adverse reaction
and an AIDS-defining illness.
• Coinfection with hepatitis B (HR = 5.97,
p = 0.0001) and hepatitis C (HR = 2.74,
p = 0.009) were significantly associated
with the risk of experiencing a severe
liver-related side effect.
The investigators noted that their “prin-
cipal finding is that the rate of grade 4
events is greater than the rate of AIDS
events, and that the risk of death associated
with these grade 4 events was very high
for many events.”
Two important implications were noted:
First, the procedure for collecting data of
adverse events during clinical trials needs
to be improved. Second, physicians need
to carefully assess their patients for the
existence of other medical problems, taking
into account social and economic status
and drug and alcohol use. “For example,
patients at increased risk of cardiovascular
events might benefit from being placed on
a protease inhibitor-sparing HAART regi-
men. Similarly, patients with a history of
severe depression may be better off with an
efavirenz-sparing HAART regimen.” ■
Editor’s Note: Reprinted with permission
from www.aidsmap.com (first e-published
December 2, 2003).
December 2003
 French investigators warn of LPV/TDF/ddI interaction
Michael Carter
P
rotease inhibitors, particularly
lopinavir (LPV) and ritonavir
(RTV) can interact with the
nucleotide analogue tenofovir
(TDF) resulting in kidney toxicity,
warn French investigators writing in the
December 15, 2003, issue of Clinical
Infectious Diseases.
The French physicians report the
case of a 34-year-old gay man who was
admitted to the hospital in May 2003 with
a five week history of fatigue, dehydra-
tion, weight loss, painful neuropathy in
the lower limbs, polyuria, and polydipsia.
The man had high blood pressure and a
rapid heart rate. No evidence of infectious
disease was found. His CD4 count at
hospitalization was 87 cells/mm3 and his
viral load 13,000 copies/mL.
At the time of admission, the patient
was taking an anti-HIV treatment regi-
men consisting of lamivudine (3TC),
didanosine (ddI), LPV, and TDF.
The physicians diagnosed Fanconi
syndrome, a kidney condition that has
been previously reported in patients
treated with TDF. All antiretroviral therapy
ART and liver-related mortality in HIV/HCV
Michael Carter
ntiretroviral therapy is associated
A
with a lower rate of mortality
from liver-related causes in
patients co-infected with HIV
and hepatitis C virus (HCV),
according to a German study
published in the November, 22, 2003,
issue of The Lancet.
Investigators from Bonn examined
liver-related deaths in a cohort of 285
HIV/HCV-coinfected patients as part
of an observational study, which ran
from 1990 to 2002. The investigators
stratified patients into one of three
groups according to HIV treatment his-
tory: antiretroviral treatment; dual- or
mono-nucleoside reverse transcriptase
inhibitor (NRTI) treatment; and no
antiretroviral treatment. Data were also
December 2003
was stopped, and the patient’s condition
improved after 17 days of hydration therapy,
multivitamins, and amlodipine. He was
then discharged from the hospital, but was
not restarted on antiretroviral therapy.
Therapeutic drug monitoring performed
two weeks before the man’s admission to
hospital showed plasma concentrations of
TDF of 0.412 mg/L (expected value,
0.12 mg/L) and a plasma concentration of
ddI of 0.444 mg/L (expected value,
0.12 mg/L). Before the patient had started
taking TDF, his ddI plasma level had been
0.05 mg/L, increasing to 0.23 mg/L after
eight months of TDF therapy. Plasma
levels of LPV remained ~9 mg/L.
The investigators comment that their
patient’s clinical and biological character-
istics were consistent with Fanconi syn-
drome and nephrogenic diabetes insipidus.
Patients in all six cases used RTV and
the investigators suggest that RTV can
increase proximal tubular concentrations
of TDF in the kidneys, leading to toxicity.
Investigators note that their patient,
and two of the others in whom Fanconi
syndrome has been reported in association
with TDF, was also taking ddI. Plasma
concentrations of ddI can be increased by
gathered on HIV and HCV viral load and
CD4 count to determine whether any
independent predictors of liver-related
mortality could be identified.
In total, 93 patients were treated with
HAART, 55 individuals received dual- or
mono-NRTI therapy, and 137 patients
took no antiretroviral drugs. None of the
patients were treated with interferon either
alone or with ribavirin as HCV therapy.
Investigators established that the rate of
liver-related mortality was significantly
lower in patients who received HAART
(two patient deaths, 0.45 per 100 person-
years, p < 0.001), than in patients who
were given dual- or mono-NRTI therapy
(five patient deaths, 0.69 per 100 person
years, p < 0.001), and in patients who
received no antiretroviral treatment (18
patient deaths, 1.70 per 100 person years).
CD4 cell gain after the initiation of
between 30 percent and 60 percent
when the drug is used with TDF,
explaining this patient’s neuropathy.
The extraordinary increase in TDF
levels in this patient may be connected
with RTV, the researchers suggest.
Tenofovir is taken up into the proximal
tubular cells of the kidneys by human
organic anion transporter-1 (OAT-1), and
is removed and secreted into the urine
by multidrug resistance protein MRP-2.
Ritonavir is a potent inhibitor of
p-glycoprotein and of MRP-2-mediated
transport, both of which might lead to
increased proximal tubular concentra-
tions of TDF by reducing its efflux
from the kidneys. Substances that
might increase OAT-1 activity should
be treated with suspicion whenever
combined with TDF and/or ddI, the
authors suggest, highlighting another
case report of ddI-associated proximal
tubulopathy in which aciclovir was dosed
alongside ddI (aciclovir is a substrate
for OAT-1) ■
Editor’s Note: Reprinted with permission
from www.aidsmap.com (first e-pub-
lished November 24, 2003).
HAART was associated with a significant
decrease in the risk of dying from liver
related causes (p < 0.001), while each
one year increase in age (p = 0.001)
and increase in bilirubin (p < 0.001)
were both significantly associated with an
increased risk of liver-related mortality.
The investigators noted that HCV
viral loads increased significantly in all
three groups of patients, regardless of
their HIV treatment histories
(p < 0.001), but that the increase was
particularly marked in patients who
received HAART. Severe drug-related
liver toxicity occurred in 13.8 percent
of patients taking HAART, and result-
ed in no patient deaths. ■
Editor’s Note: Reprinted with permission
from www.aidsmap.com (first e-published
November 28, 2003).
IAPAC Monthly 315
 N E W S F R O M T H E C D C

CDC announces increases in US HIV diagnoses

Editor’s Note: The following is excerpted
from Hall HI, Song R, and McKenna MT. Table 1. Estimated number and percentage of persons with
Increases in HIV Diagnoses — 29 States, new diagnosis of HIV infection, by sex and selected
1999-2002. MMWR 2003;52(47);1145- characteristics—29 states* with HIV reporting, 1992-2002
1148. Male Female Total
Characteristic No. (%) No. (%) No. (%)

S
ince the advent of highly active
antiretroviral therapy in 1996, pro- Age group (years)
gression from receiving diagnosis <13 315 (0.4) 398 (1.3) 713 (0.7)
of HIV infection to having AIDS 13-24 6,337 (8.8) 5,074 (16.8) 11,411 (11.1)
has slowed substantially, making 25-34 20,378 (28.2) 9,330 (30.8) 29,708 (29.0)
HIV transmission patterns less predictable
35-44 27,518 (38.0) 9,383 (31.0) 36,901 (36.0)
through AIDS surveillance alone.
Consequently, the US Centers for Disease 45-54 12,776 (17.7) 4,365 (14.4) 17,142 (16.7)
Control and Prevention (CDC) has 55-64 3,811 (5.3) 1,278 (4.2) 5,089 (5.0)
recommended that states report diagnoses ≥65 1,189 (1.6) 436 (1.4) 1,625 (1.6)
of HIV infections in addition to cases Total† 72,323 (100.0) 30,264 (100.0) 102,590 (100.0)
of AIDS. 1 Recent estimates of HIV
Race/ethnicity
diagnoses suggested a leveling of the
downward trend in HIV infections White, non-Hispanic 26,602 (36.8) 5,474 (18.1) 32,077 (31.3)
nationally and increases in HIV infec- Black, non-Hispanic 35,127 (48.6) 21,744 (71.8) 56,872 (55.4)
tions among certain populations.2 Reports Hispanic ‡ 9,266 (12.8) 2,563 (8.5) 11,829 (11.5)
of syphilis outbreaks and increased Asian/Pacific Islander 432 (0.6) 129 (0.4) 562 (0.5)
unprotected sex raised concerns regarding
American Indian/Alaska Native 435 (0.6) 174 (0.6) 609 (0.6)
increases in HIV transmission among
men who have sex with men (MSM).3-5 Unknown 461 (0.6) 179 (0.6) 641 (0.6)
In response to these developments, Exposure category
the CDC analyzed trends in HIV diag- Men who have sex with men (MSM) 43,144 (59.7) — — 43,144 (42.1)
noses in 29 states that conducted name-
Injection-drug use 11,419 (15.8) 6,133 (20.3) 17,553 (17.1)
based HIV/AIDS surveillance during
1999-2002 (see listing in footnotes to MSM who inject drugs 3,917 (5.4) — — 3,917 (3.8)
Table 1). This report summarizes the Heterosexual contact 12,879 (17.8) 23,205 (76.7) 36,084 (35.2)
results of that study, which indicated Other 963 (1.3) 926 (3.1) 1,891 (1.8)
that HIV diagnoses increased among Year of diagnosis
men, particularly MSM, and also among
1999 17,556 (24.3) 7,575 (25.0) 25,133 (24.5)
non-Hispanic whites and Hispanics. The
findings emphasize the need for new 2000 17,872 (24.7) 7,588 (25.1) 25,461 (24.8)
prevention strategies to reverse potential 2001 18,050 (25.0) 7,542 (24.9) 25,592 (24.9)
increases in HIV transmission among 2002 18,843 (26.1) 7,559 (25.0) 26,403 (25.7)
these populations.
* Alabama, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Louisiana, Michigan, Minnesota, Mississippi, Missouri,
In 1994, the CDC began supporting a Nebraska, Nevada, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota,
uniform system for national, integrated Tennessee, Utah, Virginia, West Virginia, Wisconsin, and Wyoming.
HIV and AIDS surveillance. At that time, † Includes persons for whom data on sex, age, or race/ethnicity are missing. Columns might not add to total because of rounding.
25 states required confidential reporting ‡ Hispanics might be of any race.

of persons with HIV infection whether or

316 IAPAC Monthly December 2003
 derived from variances based on monthly
Figure 1. Estimated number of persons with HIV diagnosis,* by data submissions to the CDC.7 Year-to-
exposure category and year — 29 states,† 1999-2002 year differences in the numbers of new
diagnoses were considered statistically
14,000 – Men who have sex with men (MSM) significant when 95 percent confidence
Heterosexual contact
Injection drug use
intervals (CIs) based on calculated standard
12,000 –
MSM who inject drugs deviations did not overlap for those years.
10,000 – During 1999-2002, HIV infection was
diagnosed in 102,590 persons in the 29
8,000 –
Number

HIV-reporting states. Of these persons,

72,323 (70.5 percent) were male, and
6,000 –
30,264 (29.5 percent) were female. (Table 1)
4,000 – Among racial/ethnic populations, the
majority (56,872 [55.4 percent]) of HIV
2,000 –
diagnoses were among non-Hispanic
0– blacks, accounting for 71.8 percent of all
1999 2000 2001 2002 diagnoses in females and 48.6 percent of
Year all diagnoses in males. The remainder of
the HIV diagnoses occurred primarily
* Adjusted for reporting delays and redistribution of cases reported without exposure category. among non-Hispanic whites (32,077 [31.3
† Alabama, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, percent]), followed by Hispanics (11,829
Nevada, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Utah,
Virginia, West Virginia, Wisconsin, and Wyoming. [11.5 percent]). Among males, the most
prevalent mode of exposure was MSM
(59.7 percent), followed by heterosexual
Figure 2. Estimated number of persons with HIV diagnosis,* with contact (17.8 percent), and injection drug use
and without AIDS, by year — 29 states,† 1999-2002 (15.8 percent). Among females, the most
prevalent exposure category was hetero-
HIV diagnosis without AIDS sexual contact (76.7 percent), followed by
25,000 –
HIV diagnosis with AIDS injection drug use (20.3 percent).
During 1999-2002, the number of
20,000 – males with new HIV diagnoses increased
7.3 percent, from 17,556 (95 percent
15,000 – CI = 17,412-17,701) to 18,843 (95 percent
Number

CI = 18,360-19,326). Among MSM, the

10,000 –
5,000 –
0–
1999
* Adjusted for reporting delays.
† Alabama, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska,
Nevada, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Utah,
Virginia, West Virginia, Wisconsin, and Wyoming.
not their infection had progressed to
AIDS. Four additional states included in
this analysis have had confidential HIV
reporting since at least 1999, the year the
lowest number of HIV diagnoses was
reported among the original 25 states. In
this analysis, persons with HIV were
defined as those who received a diagnosis
of HIV with or without a diagnosis of
AIDS. Annual numbers of HIV diagnoses
during 1999-2002 were based on the
earliest reported dates of diagnosis.
December 2003
2000 2001
Year
All analyses were adjusted for delays in
reporting. Reports with no identified
mode of HIV exposure were later reclas-
sified to an exposure category (eg, MSM,
injection drug use, MSM who inject
drugs, and heterosexual contact). 6
Variance estimates and standard
deviations for the annual number of HIV
diagnoses were calculated, taking
into account adjustments for reporting
delay and reclassification to exposure
categories. Variance estimates were
number with new HIV diagnoses increased
17 percent, from 9,988 (95 percent
CI = 9,733-10,243) to 11,686 (95 percent
CI = 11,239-12,132). (Figure 1) The number
of new HIV diagnoses did not change signif-
icantly during 1999-2002 among females,
2002
persons exposed through heterosexual
contact, injection drug users, or MSM who
inject drugs. (Figure 1)
Trends varied among racial/ethnic
populations. During 1999-2002, the number
of HIV diagnoses increased 26.2 percent
among Hispanics, from 2,622 (95 percent
CI = 2,566-2,678) to 3,308 (95 percent
CI = 3,106-3,510) and 8.1 percent among
non-Hispanic whites, from 7,716 (95 percent
CI = 7,618-7,814) to 8,341 (95 percent
CI = 8,016-8,665). No significant changes
were observed for non-Hispanic blacks or
Asians/Pacific Islanders.
During 1999 –2002, the number of per-
sons in whom AIDS was diagnosed along
with HIV did not change significantly
(Figure 2); however, the number of persons
Continued on page 331
IAPAC Monthly 317

Censoring research on AIDS
Nancy S. Padian
I
was in Bangalore, with a team of inter-
national researchers who are working
to prevent the spread of AIDS on the
Indian subcontinent, when I learned
that my name and my research were
on a “hit list” of researchers and projects
apparently targeted for additional scrutiny
and possible loss of funding by the US
National Institutes of Health (NIH).
The targeted projects mainly deal with
sexual behavior and risk of infection from
sexually transmitted diseases, including
HIV/AIDS. The assault on NIH-sponsored
projects was particularly chilling because
my research, like that of my colleagues at the
University of California at San Francisco
who were also targeted, had gone through
extensive scientific and ethical peer
review before receiving NIH funding.
Why were the red flags being thrown at
this point in the game?
It soon emerged that the “hit list” was
prepared by the Traditional Values Coalition
(TVC), a conservative advocacy group.
The TVC objects to homosexuality, all
forms of abortion, and all contraceptive
interventions. In fact, the TVC objects to
all sex outside marriage—hence its effort
to withdraw funding from any project that
attempts to mitigate health problems asso-
ciated with sex outside of marriage by
using any means other than abstinence.
The TVC’s unprecedented scare tactic
sent a wave of anger and resentment through
the entire international community of public
health and medical researchers. Even more
alarming, although the TVC has acknowl-
edged authorship of the list, NIH is still
preparing a report for the US Congress
about the research projects listed.
One may ask how a lobbying organiza-
tion with such a strong sectarian political
and religious viewpoint could initiate an
318 IAPAC Monthly
P U B L I C P O L I C Y
investigation of approved research projects.
Evidently the TVC feels that it enjoys an
open invitation to change the priorities and
goals of government-approved scientific
research, outside all established procedural
channels.
To understand why this tactic is so
insidious, the public needs to understand
how scientists win federal funding for
NIH-sponsored scientific research pro-
jects, and what is at stake if this system is
eroded for ideological reasons.
All the projects targeted by the TVC—
indeed, all government-funded science
projects — go through rigorous academic
peer review. That is, as proposals compete
for funding, they are judged by teams of
accomplished, unbiased, and internationally
respected scientists in related fields. The
results of these investigations are continually
reported in international, peer-reviewed
medical journals.
The integrity and independence of this
peer-review process is essential for the
continued vitality and quality of American
medical and public health research. It cannot
be subjected to an extremist litmus test.
Disease does not respect political or
religious affiliations, nor does it observe
any international boundaries. Medical
research is bound by the strictest ethical
standards. It must have the freedom to
find answers to how diseases are caused
and spread, and how to develop ethical
and effective treatments for them.
Infectious diseases attack whole popula-
tions, not just individuals. Thus, controlling
infectious diseases means focusing on all of
the populations affected. It is neither morally
nor medically defensible to withhold research
or treatment just because the behavior of one
segment of society is distasteful to another.
The ever-present risk of the spread of
infection from any segment to the larger
community — including people who fear
and dislike those affected by disease —
requires understanding how disease
spreads and how to develop appropriate,
effective interventions for everyone.
Rigorous scientific research makes suc-
cessful interventions possible.
All of the research targeted by the TVC
witch-hunt promotes the improvement of
public health. No outcomes are prejudiced
in advance by the research; lack of bias is a
hallmark of quality scientific investigation.
The overarching goal of all of the research
in question is to change behavior in order to
save lives, a long-term goal of American
and international public health policy and
practice. The targeted programs have
included thousands of vulnerable individuals
at risk for sexually transmitted infections,
including HIV. We have already seen benefits
of much of this work at national and inter-
national levels. It is amazing that these
values, which are truly traditional and
durable, even need explanation, let alone
defense.
It is time for the Bush Administration
to distance itself firmly and explicitly
from any kind of scientific McCarthyism.
The unthinkable alternative is the erosion
of this country’s high standards for public
health and medical research, and higher
rates of infection from diseases that need
to be cured and controlled. There is too
much at stake to play politics. ■
Nancy S. Padian is a Professor of Obstetrics,
Gynecology, and Reproductive Sciences
at the University of California at San
Francisco, and Director of International
Research at the UCSF AIDS Research
Institute.
Editor’s Note: This commentary, which first
appeared in the November 6, 2003, edition
of the San Francisco Chronicle, is reprinted
here with permission from its author.
December 2003

World AIDS Day 2003
Anthony S. Fauci
T
he annual observance of World AIDS
Day reminds us of the immense
challenges facing the global commu-
nity as we work to slow the trajectory
of — and ultimately terminate — the
global HIV/AIDS pandemic. World AIDS
Day also provides an opportunity to express
our appreciation to the many scientists,
healthcare workers, policymakers, political
leaders, philanthropists, activists, religious
leaders, volunteers in clinical trials, and
others who have worked tirelessly to curb
this global plague.
New estimates on the scope of the
HIV/AIDS pandemic are profoundly
sobering. An estimated 40 million people
worldwide are living with HIV/AIDS,
according to a newly released report from
the Joint United Nations Program on
HIV/AIDS (UNAIDS). In 2003 alone, 5
million people worldwide were newly
infected with HIV — about 14,000 each
day, more than 95 percent of whom live in
low- and middle-income countries. In
2003, 3 million people worldwide with
HIV/AIDS died. In the United States,
nearly 1 million people are living with
HIV/AIDS, and by the end of 2002, more
than 500,000 people with HIV/AIDS had
died, according to estimates of the US
Centers for Disease Control and Prevention
(CDC).
As shocking as these numbers are, they
do not begin to adequately reflect the
physical and emotional devastation to
individuals, families, and communities
coping with HIV/AIDS, nor do they
capture the huge deleterious impact of
HIV/AIDS on the economies and security
of nations, and indeed entire regions.
Even as the burden of HIV/AIDS
continues to grow, recent developments
December 2003
N I A I D N E W S
provide some measure of optimism. Four
new antiretroviral drugs were licensed
in 2003 by the US Food and Drug
Administration (FDA), bringing the total of
FDA-approved antiretroviral formulations
to 23 and providing new hope to individuals
who may have exhausted other treatment
options. Novel approaches to HIV preven-
tion are being studied and validated, and
the pipeline of HIV vaccines is larger than
it has ever been.
To help turn the tide of the global
HIV/AIDS pandemic, the National Institute
of Allergy and Infectious Diseases
(NIAID) has established research collabo-
rations with international colleagues
in more than 50 countries to develop
comprehensive approaches to the HIV
pandemic, encompassing vaccine devel-
opment and other prevention activities,
therapeutics, and care of the HIV-infected
person. These collaborations already
have yielded important results, notably
in developing methods to reduce mother-
to-child transmission of HIV.
A rate-limiting factor in providing
treatment for HIV/AIDS in developing
countries has been a lack of funds for the
purchase of antiretroviral drugs and for
improving existing healthcare infrastructure.
[President George W. Bush’s] Emergency
Plan for AIDS Relief will help change
this situation. The plan commits US$15
billion over five years for HIV/AIDS
prevention, treatment, and care in 14
countries in sub-Saharan Africa and the
Caribbean. This life-saving effort will not
only reduce the suffering caused by
HIV/AIDS in countries that account for
about half of the world’s HIV infections,
but also will provide a framework for
research efforts to develop new and
improved tools for treatment and preven-
tion. The president’s plan complements
(and will contribute to) another significant
effort: the Global Fund to Fight AIDS,
Tuberculosis, and Malaria.
I am further encouraged by the
substantial reductions in the prices of
anti-HIV medications recently announced,
and by new national plans to fight
HIV/AIDS, developed by countries seri-
ously impacted by HIV/AIDS, notably
South Africa, which has the most HIV-
infected citizens of any country in the
world. In addition to robust international
HIV/AIDS research efforts conducted by
NIAID and many other organizations, we
now can point to numerous examples
of community programs in developing
countries — generally modest in scale —
that clearly demonstrate that HIV care and
prevention services can successfully
be delivered in resource-poor settings.
The momentum provided by increased
funding, political will, and the sustained
commitment of AIDS fighters across the
globe suggest that we can “scale up”
such programs so that the availability of
HIV treatment and prevention becomes
the rule, not the exception, for all the
citizens of the world, rich and poor alike.
At the same time, it is critical that we
accelerate efforts to develop the next
generation of therapies and prevention
tools that will improve upon our current
armamentarium.
Let us not expend our energies in concern
for reasons why these efforts might fail;
rather, on the occasion of World AIDS
Day, let us apply ourselves as a global
team to assuring that such efforts do
indeed succeed. ■
Anthony S. Fauci is the Director of the
National Institute of Allergy and
Infectious Diseases at the US National
Institutes of Health in Bethesda.
IAPAC Monthly 319
National leadership,
international cooperation
keys to effective
AIDS response

320 IAPAC Monthly December 2003

 6 T H I N T E R N A T I O N A L C O N F E R E N C E O N
H E A L T H C A R E R E S O U R C E A L L O C A T I O N F O R H I V / A I D S
O C T O B E R 1 3 - 1 5 , 2 0 0 3
Mark D. Wagner
t is now almost universally
I acknowledged, in rhetoric
and word, if not always by
appropriate action, that HIV/
AIDS is among the most dangerous forces
that humanity has ever faced. It is our
shared global burden; we speak most
often of international responses because
bringing together the money, expertise, and
technology that it will take to alleviate this
threat can only be accomplished through
international cooperation.
There is a way, however, in which this
emphasis on things global can mask the
fact that prevention and treatment of
HIV/AIDS, and the success or failure
thereof, are deeply enmeshed in regional,
national, and local realities. It may be
generally understood that access to life-
prolonging medicines is much greater in
wealthy countries than it is in the so-
called global South. But outside that lin-
ear model, which runs from privilege to
poverty, there are myriad factors at work
that impact on the efficacy of HIV prevention
and the availability of effective treatment.
With the foregoing in mind, represen-
tatives from around the globe gathered
October 13-15, 2003, in Washington, DC,
for the 6th International Conference on
Healthcare Resource Allocation for
HIV/AIDS (6th ICHRA). In the words of
organizers from the International Association
of Physicians in AIDS Care (IAPAC),
which acted as conference host; the
London School of Hygiene and Tropical
Medicine; McGill University (Montreal);
and the University of Natal (South Africa);
delegates were to examine how the “response
to a common global threat is shaped by
the history, culture, and institutions of
each country, [and] particularly how the
health system response to HIV reflects the
arrangements for healthcare existing prior
to the onset of the AIDS pandemic and
how these are, in turn, influenced by the
demands of the pandemic.”
Among the key outcomes of the 6th
December 2003
• W A S H I N G T O N , D C
ICHRA is to be a unique policy book—
scheduled for publication by Oxford
University Press in 2004—comprising the
contributions of experts from 24 countries
represented at the conference and six who
were unable to attend, as well as thematic
overviews of key issues in the battle
against the AIDS pandemic.
This small sampling of Earth’s nearly
200 countries must necessarily miss some of
the complexity of the international picture
that delegates hoped to render in sharper
definition. Important patterns were evident,
however, and provided noteworthy addi-
tions to our collective knowledge of the
now 20-plus year fight against HIV/AIDS.
Delegates, plenary speakers, and attendees
pointed repeatedly, for example, to the
protection of human and civil rights as an
over-arching factor that in a variety of
ways influences treatment and prevention of
HIV/AIDS. These protections are manifest
in laws and judicial rulings mandating
universal healthcare and access to anti-
retroviral therapy (ART), and in the right
of patients and their advocates to organize
and demand such legal changes. It can
also be conspicuous in its absence, as with
countries where such organization would be
illegal or ineffectual. Rate of transmission
is exacerbated by a failure to protect the
rights of women and other minorities, and
prevention is made difficult — because
voluntary testing will be resisted—when
the rights and dignity of people living
with HIV are not protected.
Protecting healthcare as a human right
is also reflected in the value a government
places, and has placed in the past, on such
things as building adequate facilities and
training, recruiting, and retaining medical
personnel. These clinical infrastructure
issues are also influenced by national
poverty, of course, as well as the quality
of national healthcare planning, and
negative historical legacies of colonialism,
dictatorship, racism, and poorly planned
international development schemes.
Whatever the reasons for infrastructure
inadequacies, speakers referred repeatedly
to questions that had bearing on a national
health system’s ability to provide HIV
treatment, including ART. Are there enough
physicians and allied healthcare profes-
sionals with training in HIV medicine?
Are there counselors and other support
personnel? Are there adequate facilities,
including access to testing laboratories?
Are all of the above accessible to people
who lack the ability to pay?
The expense of antiretroviral (ARV)
drugs also greatly deters treatment, in
some countries far more than in others,
and delegates were largely in agreement
that drug costs in resource-constrained
settings must be brought down. They
rejected the argument that reducing the
prices of ARV drugs should not be a priority
until after infrastructure improvements
have been made (the “it’s not patents, it’s
poverty” excuse), and their reasons were
clear. First, it was reinforced in the various
country presentations that the so-called
“developing world” is no uniform place;
many middle-income countries have
relatively good health systems and could
create or better maintain national ART
programs if the cost of drugs was further
reduced. Second, even in countries with
very poorly developed health systems,
lives can be saved through international
efforts that bring in healthcare staff, facilities,
and funding. In the words of Eric van Praag
of Family Health International (Arlington,
Virginia, USA), who spoke during a panel
session on the conference’s final day, this
“fast and foreign” approach can parallel
the “slow but steady” improvement of
national health services and systems and
make ART available immediately.
However, van Praag argued and conferees
agreed that national health systems are
ultimately the best and most sustainable
method for providing ART, and indeed all
healthcare. Their fitness to do so must be
addressed and improved. To borrow a
metaphor from South African presenter
David McCoy (London School of Hygiene
and Tropical Medicine, and Health Systems
Trust, Durban, South Africa), “If health
IAPAC Monthly 321
Regional panelists discuss perspectives on health system responses to HIV/AIDS in the Caribbean
From left to right: Robert Carr (Executive Director, Jamaica AIDS Support), Leslie Ramsammy (Minister of Health, Guyana), José M. Zuniga (panel chair and President/CEO, International
Association of Physicians in AIDS Care), Timothy Roach (Director, AIDS Management Team, Queen Elizabeth Hospital, St. Michael, Barbados), Luis Emilio Montalvo Arzeno (Executive
Director, Presidential Council on AIDS of the Dominican Republic), and Antoine Augustin (President/CEO, The MARCH Foundation & Centre d’Analyse des Politiques de la Santé, Haiti).

systems are to be considered the vehicle for
the delivery of services and interventions
to deal with HIV/AIDS, [the public health
community] has over the last few years
tended to neglect the vehicle,” McCoy said.
“Much more attention has been paid to get-
ting the passengers into the vehicle and
determining where the vehicle is supposed
to go, as opposed to trying to address the
deficiencies of the vehicle itself.”
Latin America
A characteristic common to the health
system “vehicles” of the four Latin
American countries represented at the 6th
ICHRA is a constitutional commitment to
healthcare as a human right and, more
specifically, guaranteed access to ART.
Methods for providing and financing
healthcare differ in various respects between
Argentina, Brazil, Costa Rica, and Mexico,
as does their success in preventing and
treating HIV/AIDS. But prioritizing equity
of access to healthcare and effective HIV
treatment was evident in every case, and
results, on the whole, have been relatively
good, noted José Carvalho de Noronha
(Federal University of Rio de Janeiro),
who presented on Brazil’s response to its
HIV epidemic and summarized Latin
American regional presentations for the
conference as a whole.
According to presenter Carlos Falistocco
322 IAPAC Monthly
(National Program on Human Retroviruses,
Argentine Ministry of Health), Argentina
has managed to place 26,000 of its citizens
on ART. Selection of drugs is relatively
good, largely because the Argentine
government has managed to secure prices
for ARV drugs that are among the lowest
in Latin America. The Ministry of Health
dictates a minimum standard of care to
include triple combination therapy with
two nucleoside reverse transcriptase
inhibitors (NRTI) and either a nonnucleoside
reverse transcriptase inhibitor (NNRTI) or a
protease inhibitor (PI) as well as HIV RNA
and CD4 tests. Incidence of AIDS has
decreased significantly, with a greater
than 50 percent drop from 1996, when
there were 2,750 new cases of AIDS, to
2002, when there were 1,070.
Argentina’s national AIDS treatment
program has its origins in a 1990 law that
commits the Ministry of Health to diagnosis,
care, and treatment for all people living
with HIV/AIDS. This commitment has
been maintained, Falistocco said, despite
a plan of economic restructuring in
the 1990s that included privatization
of many state-run programs and the intro-
duction of profit incentives in public health-
care institutions. The health system is now
enduring the most severe recession in the
country’s history, an economic disaster
that began in 2001 and which has prompted
the state to declare a health emergency.
The economic crisis has led to an overbur-
dening of the cost-free public healthcare
sector, where 70 percent of patients on
ART are treated. The country’s economic
problems may be hampering prevention
and testing efforts as well, as estimates
hold that 130,000 Argentines are living
with HIV/AIDS but are unaware of their
HIV infection.
Costa Rica, the smallest country repre-
senting the Latin American region at the
conference, is also the country with the
longest tradition of guaranteed healthcare
for its citizens, which was officially codified
in 1973. Furthermore, the Constitutional
Court ruled in 1997 that in order to meet
this legal guarantee, the government needed
to cover the costs of triple combination
ART. Manuel Ignacio Salom Echeverria
(HIV/AIDS Clinic at Mexico Hospital,
San Jose, Costa Rica) attributed the middle-
income country’s dedication to its health
system — represented in its spending 7.4
percent of gross domestic product (GDP)
on health expenditures — to “containing
an epidemic that otherwise would have
behaved as the catastrophe” that it is in
other countries.
In a population of 3.8 million, 4,307
cases of HIV or AIDS have been diagnosed
since 1983. Annual incidence rates have
held steady over the last few years at 400 to
December 2003
500 diagnoses, a situation that Echeverria
described as a steady-state epidemic.
Though he credited early and aggressive
public awareness campaigns with slowing
the virus’s spread, he also said that some
government-communicated prevention
messages may have contributed to a
stigmatization of people living with HIV/
AIDS. The messages have been altered,
but the stigma remains, and has been
heightened in recent years by relatively high
prevalence rates among poor immigrants
from neighboring countries, particularly
Nicaragua, a group of people who are
already subject to prejudices.
Brazil is a country whose health system
response to HIV/AIDS has been held up as a
model for the rest of the world. Antiretroviral
drugs for the country’s treatment program
are procured at very low expense (US$250
to US$500 per patient year) due to domestic
manufacture of generic drugs and differential
pricing agreements with brand name
international producers. And as Maya L.
Peterson (Oswaldo Cruz Foundation, Rio de
Janeiro) said in her half of the Brazilian
presentation, “Brazil has succeeded in
providing very high coverage with ART,
including laboratory monitoring, in a
setting of extreme income disparity, vast
geographical distances, and large regional
differences in healthcare infrastructure.”
Of an estimated 600,000 people living
with HIV/AIDS, 170,000 were on ART
by 2001, significantly more than in any
other developing country. AIDS mortality
has decreased markedly and viral resistance
levels are no higher than in resource-rich
countries.
As with any country, Brazil’s health
system is certainly not perfect, and problems
of unequal access persist. Nonetheless,
the successes thus far are impressive, and
as in Costa Rica and Argentina, they
speak to the good if not fully modernized
healthcare infrastructures of these middle-
income countries and to guarantees of
healthcare protected in national law. In
Brazil’s case, a new constitution that
mandated universal healthcare was drafted
in 1988 after decades of military rule. In
the mid-1990s, activists lobbied success-
fully for the inclusion of ART as standard
care. Peterson and Noronha reported that
a relatively liberal attitude toward sexual
matters in Brazilian society allows for
frank discussions of HIV prevention and
the widespread use of harm reduction-
style interventions.
December 2003
The last country from the Latin American
region represented at the 6th ICHRA,
Mexico, is the one that has most recently
made a commitment to providing full health-
care coverage for its citizens. A government-
backed insurance scheme was signed into
law in May 2003 and will go into effect in
2004, reported Carlos Avila-Figueroa
“If health systems are
to be considered the
vehicle for the delivery
of services and
interventions to
deal with
HIV/AIDS,
[the public
health community]
has over the last
few years tended to
neglect the vehicle.”
(Mexican Ministry of Health). As with
Brazil’s earlier reform, it comes in con-
junction with recent governmental upheaval
and, Figueroa said, a newly revived commit-
ment to human rights. (Mexican President
Vicente Fox’s election in 2000 marked the
first peaceful transition of power to the polit-
ical opposition in the 179 years since inde-
pendence, and the first time in 71 years that
a president took power who was not a mem-
ber of the Institutional Revolutionary Party.)
Until recently, ARV drugs were only
available to those who could not afford
them through participation in research
programs, but full coverage is to be imple-
mented through the new “National System
for Social Protection in Health.” Though
prevention programs are in some cases
inadequate, as with prevention of mother-
to-child transmission of HIV, Mexico’s
overall prevalence rate, as with all of Latin
America, is relatively low: less than 0.5
percent.
Asia
Six countries represented Asia at the 6th
ICHRA, and as they were generally a more
heterogeneous group — with one of the
world’s poorest countries (Cambodia), the
world’s two most populous countries
(India and China), a constitutional monarchy
(Thailand), and one of the world’s last
communist countries (China), as well as
an archipelago nation comprising a mind-
boggling 17,000 islands (Indonesia) —
there is less of a common theme to their
national responses to HIV/AIDS than is
the case with Latin America.
It is interesting, however, as conference
co-chair and moderator of the Asian
sessions Eduard J. Beck (McGill University)
pointed out, that Thailand’s experience
bears remarkable similarities to that of
Brazil, and the Latin American region as a
whole. The Southeast Asian country went
through “major political reform” in 1997,
in the words of presenter Chutima
Suraratdecha (International AIDS Vaccine
Initiative, New York), and the resulting
new constitution provides broad guarantees
for healthcare.
The healthcare infrastructure was being
built up for years before the new constitu-
tional commitment to universal coverage,
and that fact, combined with the domestic
manufacture of inexpensive ARV drugs,
has allowed relatively rapid scale-up of
ART. In 2002, 13,000 were on ART out of
an estimated 50,000 to 60,000 who
required it immediately and 600,000 who
were infected with HIV. The Thai Ministry
of Public Health committed to providing
ART to all who need it by 2004, but Wiput
Phoolchareon, Suraratdecha’s co-presenter
and an official from the Ministry of
Health, admitted in his presentation that
this goal may not be wholly met. The
results are nonetheless impressive.
Thailand’s HIV prevention program is
widely seen as a success story. Incidence
rates have fallen since the mid-1990s,
particularly among the country’s large
population of sex workers. Phoolchareon
attributed the success to a high level of
political commitment; good cooperation
between local health authorities and com-
mercial sex establishment owners; high
accessibility of quality condoms; the
availability of treatment for sexually trans-
mitted infections; and a comprehensive
program of sex and life-skills education in
public schools.
The situation in Cambodia is in many
IAPAC Monthly 323
Welcoming delegates to Washington, DC
Her Excellency Barbara Masekela, Ambassador of the Republic of South Africa to the United States of America, graciously hosted a welcome reception at her residence for 6th ICHRA dele-
gates. Pictured from left to right are Robin Wood (University of Cape Town, South Africa), Her Excellency Barbara Masekela, José M. Zuniga (President/CEO, International Association of
Physicians in AIDS Care), and Veronica Moss (Chief Executive, Mildmay International, London).
ways similar to that in Thailand, yet in
others very different. While both countries
have been through recent upheaval,
Cambodia was “thoroughly destroyed”
over the last three decades, to use the
words of presenter Maurits van Pelt (UK
Department for International Development,
Phnom Penh), a disaster that did not befall
Thailand. Thailand is a middle-income
country with a serviceable healthcare system,
while Cambodia is among the poorest
countries in the world and access to
healthcare is extremely limited. Van Pelt’s
fellow presenter, Peter Godwin (Community
Action for Preventing HIV/AIDS Project,
Phnom Penh), explained that the similarity
comes in the fact that both countries saw
their national incidence rates increase
exponentially shortly after they exploded
among sex workers and their clients. In
Cambodia, incidence declined precipitously
in the aftermath of an aggressive prevention
strategy that strives for 100 percent condom
use. With virtually no national spending
on healthcare, Cambodia’s interventions
have been financed by global partners,
primarily the World Bank. Antiretroviral
therapy is not provided through any
national plan and remains, Godwin said, a
challenge for the future.
Indonesia differs from Thailand and
Cambodia in many respects, but it has the
324 IAPAC Monthly
potential to follow a similar pattern of
increased incidence. On the positive side,
Indonesia’s HIV/AIDS prevalence rate
remains, by comparison, quite low. A group
of Indonesian and international experts
estimated that 130,000 people are living
with HIV/AIDS in a total population of
215 million. The bad news, according to
presenter Suriadi Gunawan (Indonesian
National Institute of Health Research and
Development, Jakarta), is that the country
may be on the verge of a large-scale HIV
outbreak and is faced with several diffi-
culties in responding effectively.
Greatly increased prevalence rates
since 2000 among populations at high risk
for infection (most prominently intra-
venous drug users, and commercial
sex workers and their clients) portend
increased overall infection rates. Chronic
underfunding of the healthcare system
and a damaged social safety net, along
with resistance to condoms, governmental
prohibition of harm reduction-style preven-
tion interventions, and widespread discrim-
ination are hampering otherwise robust
plans to stem the problem of HIV/AIDS
before it reaches its disastrous potential.
The other island nation among the
Asian representatives at the 6th ICHRA, the
Philippines, bears similarities to Indonesia
in its national HIV epidemic and health
system response. The Philippines is also a
low-prevalence country, with an even
smaller number of infections relative
to the total population than Indonesia:
approximately 2,000 people are living
with HIV/AIDS out of a total population of
82 million, according to figures presented
by Roderick Poblete (Philippine National
AIDS Council, Manila). As with Indonesia,
however, there are signs indicating the
potential for increased incidence. Poblete
cited a mobile population, high prevalence
of STIs, low levels of condom use, and
sharing of syringes among intravenous
drug users.
In many ways, the Philippines is failing
to deal with this threat, Poblete said, as
evidenced by inadequate funding for the
health system generally, and prevention,
treatment, and care of HIV/AIDS in partic-
ular. The health system as a whole does not
adequately meet the needs of citizens, and
there are only two public hospitals that
treat HIV/AIDS, both on the same island
and geographically isolated from patients in
other parts of the country. The government’s
budget for 2003 included US$300,000
for HIV/AIDS programs, a number that
represents 0.16 percent of Department of
Health spending. Most interventions
are financed and implemented by foreign
organizations.
December 2003
 The social safety net is also failing
people with HIV/AIDS in India, creating
the bitterly ironic situation of a country that
produces very inexpensive generic anti-
retroviral drugs but fails to provide them
to its dying citizens. Nagalingeswaran
Kumarasamy (YRG Centre for AIDS,
Chennai) told delegates that although the
cost of safe, effective, triple-combination
therapy is as low as US$360 per year, and
monitoring costs add US$600, these
expenses are beyond the reach of most
citizens in a country where many subsist
on US$1 per day.
Even if assistance to offset the costs of
drugs and treatment were available, however,
barriers to treatment would remain. Ritu
Priya (Jawaharlal Nehru University, New
Delhi) spoke to the erosion of a once
robust public health sector due to an
overemphasis on both providing family
planning services, and the prevention of
particular diseases, to the exclusion of
offering a broad range of care. In light of
the deficiencies of the health system,
Priya said, “the cost of drugs is the least
of the issues… The point is, how are you
going to get it there with the whole range
of services that is required along with the
ARVs?” Improvements to the health sys-
tem that would make scale-up of ART a
viable choice are attainable and should not
be ignored. Kumarasamy agreed, saying
that training programs to educate physi-
cians and allied healthcare professionals
on ART addressed a serious infrastructure
problem and were now being scaled up. Such
preparations should be prioritized because,
as Kumarasamy stated, an estimated 4
million Indians are infected with HIV and
the epidemic is growing.
The decreasing quality of healthcare in
India is mirrored in its fellow population
giant to the north. Sheila Hillier (Barts &
the London School of Medicine and
Dentistry) stated that, “Over the last 20
years, the people of China have become
richer and unhealthier.” The rolling back
of communist social and economic policies
has increased personal wealth, at least for
some. But, in destroying the cooperative
medical system, reform has left millions
with no access to medical care. Attempts
to address the problem have thus far met
with little success.
With respect to HIV/AIDS, the govern-
ment’s response has not been completely
lacking, with a program for generic ARV
manufacture and delivery springing up
December 2003
seemingly overnight in the last year, said
presenter Zhang Kong-Lai (Peking Union
Medical College and the China AIDS
Network). But, Kong-Lai stated, far more
will be needed to stem the destruction of an
epidemic that has already infected at least
1 million people (millions more, by other
estimates), primarily in rural areas where
healthcare delivery is least developed.
Alarmingly, the healthcare system as a
whole has less than 50 physicians with
real experience treating HIV disease, he
said, and most of these reside in Beijing
and a few other large cities. In addition
to building treatment capacity for ART
scale-up, Kong-Lai argued that China
needed policies to enshrine the legal
rights of people living with HIV/AIDS
and alleviate stigma and discrimination.
Caribbean
It goes almost without saying that the
Caribbean region is vastly different from
the Asian in terms of geographical and
population size. The island region’s entire
population would not equal that of large
provinces in China and India. And, in
sheer numbers, the epidemic is also smaller
in the Caribbean. According to data from
the Joint United Nations Programme on
HIV/AIDS (UNAIDS), presented at the
conference by Leslie Ramsammy (Ministry
of Health, Guyana), there were about
600,000 people living with HIV/AIDS in
the Caribbean at the end of 2002—about
the same number as the estimate for
Thailand alone, and many times less than
the millions that are estimated for India or
China. Yet, as a proportion of its population,
the Caribbean epidemic is the second largest
in the world, with approximately 2 percent
of all Caribbean people infected with HIV.
The Jamaican experience is characterized
by early successes in limiting HIV trans-
mission followed by more recent setbacks
that have led to increasing incidence,
reported presenters Robert R. Carr (Jamaica
AIDS Support, Kingston) and Peter Carr
(independent public health consultant,
Kingston). A commitment to free healthcare
to all is hampered by staff shortages and
limited resources in four regional health
authorities that follow the guidelines and
policies of a national Ministry of Health.
The Carrs credited the World Health
Organization’s (WHO) Accelerating Access
Initiative with reducing ARV drug costs
by as much as 80 percent. However, since
the expense of treatment is still beyond
the means of many Jamaicans, and,
because the national health system does not
cover the full costs of ARV drugs, ART
remains somewhat limited. Prevention of
mother-to-child HIV transmission has
been aggressive and successful, with the
government providing a short course of
treatment for each infected mother and
newborn, but ART costs are not covered for
the mother after she has given birth. The
presenters stated that all prevention, care,
and treatment efforts were made difficult
by “high levels of stigma and discrimination
that permeate society, including govern-
ment workplaces.”
Located on the continent of South
America, but usually grouped by virtue of
cultural similarities within the Caribbean
region, Guyana is an economically con-
strained country that has nonetheless
managed to begin manufacture of five
different generic ARV drugs and two
fixed-dose combination pills, reported
Ramsammy. It began a cost-free, govern-
ment-run, ART program in April 2002
that has thus far managed to place just
over 200 patients on treatment. CD4 count
testing is not generally available in Guyana,
so patients are admitted to the treatment
program based on WHO guidelines for
clinical assessment of disease progres-
sion. Ramsammy cited data showing good
adherence, minimal side effects, and positive
clinical results; he predicted an increase in
the number of patients treated as word of
successful ART spread throughout the
population and more people sought out
treatment. Guyana’s prevention efforts
have yielded a 52 percent increase in condom
sales from 1995 to 1996, and there are
plans to bring the ARV-based prevention of
mother-to-child HIV transmission program
from 11 sites to nationwide operation.
In a region with broad differences in
national wealth, as well as wide gaps in
income between the most and least privileged
citizens in any one country, Barbados was
the nation representing the Caribbean
region at the 6th ICHRA with the highest
per capita gross national product (GNP):
approximately US$6,000, or more than
twice that of Jamaica, the country with the
second highest per capita GNP among
Caribbean countries represented. Timothy
Roach (University of the West Indies,
Barbados), reported that the country has one
of the most advanced healthcare systems
in the region, and had managed several
successes in preventing and treating
IAPAC Monthly 325
Examining corporate, donor agency, UN, and NGO responses to HIV/AIDS
Ambassador Stephen Lewis (United Nations Special Envoy for HIV/AIDS in Africa) addresses a delegate question at the end of his plenary address on the broad role of the United Nations in
stemming the tide of the pandemic. Also presenting plenary addresses October 14, 2003, were (from left to right) Mamadou Seck (AfriCASO, Dakar, Senegal), Linda Distlerath (Merck & Co.),
David Stanton (US Agency for International Development, Washington, DC), and panel chair Timothy Quinlan (University of Natal, South Africa).

HIV/AIDS, but faced difficulties due to
both the expense of the drugs and high
levels of stigma and discrimination that
work in several insidious ways to hamper
prevention, care, and treatment.
The private healthcare sector in
Barbados is limited in its ability to provide
HIV care by the fact that insurers exclude
coverage of people living with HIV/AIDS.
Roach reported that Barbados’s public
sector facilities — where treatment is
provided without cost to the patient—have
technology, treatment capacity, personnel,
and expertise that is actually better than
that found in private sector facilities in
any case. But state-run hospitals and clinics
are stigmatized in the eyes of Barbados’s
citizens and, as a result, they are underuti-
lized. A 2002 World Bank loan for HIV
treatment greatly reduced the cost of ART
in the public sector, and the resulting
treatment program shows good clinical
results among an as-yet small patient group.
Roach suggested that the government
would have to change public attitudes
about its facilities in order to maximize
the impact of this positive development.
He stated that generalized prejudice
against people living with HIV/AIDS as
well as the most vulnerable populations,
such as sex workers, prisoners, and, in par-
ticular, men who have sex with men, are
visible in government officials and the
326 IAPAC Monthly
small community of nongovernmental
organizations that have sought to deal with
the HIV epidemic. He cited such attitudes
as a major barrier to prevention but felt
that improved access to treatment might
be one factor in reducing stigma.
While Barbados, as is the case with
most Caribbean nations, shrugged off
colonial rule in the second half of the 20th
century, Haiti is the oldest Republic in the
Western Hemisphere after the United
States. Unfortunately, its nearly 200-year
history of independence is coupled with a
multi-decade span of economic stagnation
that has left it the poorest country in that
hemisphere, reported Antoine Augustin
(Centre d’Analyse des Politiques de
Santé, Port-au-Prince, Haiti). With an esti-
mated 4.5 percent of the population living
with HIV/AIDS, it is also the country
with the highest prevalence rate in the
region. The very real difficulty of fighting
HIV/AIDS in a country that is extremely
poor in economic terms, however, was only
one of the lessons to be drawn from
Augustin’s presentation. He said Haiti
proved that a country’s healthcare delivery
system “does not have to be stellar,” with
“fancy hospitals” and infrastructure on a
par with that found in wealthy developed
nations “in order to have an impact.”
Of factors working in Haiti’s favor,
Augustin emphasized the well-coordinated
public-private partnerships that characterize
Haiti’s health system and its response to
HIV/AIDS. A remarkable 35 percent of
total medical service delivery is handled
by private, non-profit organizations, com-
pared with 40 percent by the public sector,
and 25 percent by for-profit enterprises.
Among these are the Partners in Health
program run by Paul Farmer and the
Centres GHESKIO, led by Jean W. Pape,
both of which have provided unique models
for care and treatment of HIV in resource-
constrained settings. As important, the
Ministry of Health has been able to har-
monize these efforts, from early detection
and prevention interventions to current
scale-up of ART. The success of prevention
programs is shown in the epidemic’s
stability over the course of the last decade
when many experts were predicting a dou-
bling of HIV/AIDS prevalence, Augustin
said. Private partners have been involved
in both the receipt and utilization of
financing from the Global Fund to Fight
AIDS, Tuberculosis, and Malaria for
scale-up of ART, and with Ministry of
Health plans to strengthen the healthcare
infrastructure.
Africa
Recent UNAIDS estimates hold that more
than 36 million of the world’s 40 million
people living with HIV/AIDS live in
December 2003
Africa. Though there is variability from
one country to the next, access to any type
of HIV treatment, let alone ART, ranges
from limited to non-existent.
Like Haiti, Ethiopia is a country that is
rich in the vibrancy of its people and culture
but heartbreakingly poor in terms of
economic and industrial development.
Though its estimated 6.6 percent prevalence
rate means a lower proportion of the total
population is HIV-infected in Ethiopia
than in the southern African countries
with which it shared regional representation
at the 6th ICHRA, that number represents
2.2 million people and is higher than that
of any country outside Africa.
The Ethiopian health system’s current
ability to prevent and treat HIV/AIDS, or
any medical condition, is severely limited.
Yayehyirad Kitaw (Health Development,
Addis Ababa) reported that most
Ethiopians, and particularly those living
in rural areas, still rely on traditional
practitioners and have no access to modern
medicine. Kitaw cited some bleak statistics:
there is only one physician for every
59,000 people in the country as a whole, and
one physician for every 110,000 people
in rural areas. Total healthcare expendi-
ture for the current year is estimated at
US$2.64 per person, and, as with many
developing countries, this healthcare
staffing shortage is largely attributable to
a “brain drain” problem of professionals
leaving for countries where they are
better paid.
Predictably, HIV/AIDS is heavily taxing
Ethiopia’s very limited capacity to
provide healthcare. Kitaw stated that HIV-
related medical conditions, particularly
tuberculosis, account for 50 percent of
all hospital beds. Seventy percent of all
mortality in adults aged 20 to 54 is related
to HIV infection. The government estab-
lished a National Task Force for HIV in
1985, but Kitaw reported minimal successes
for its efforts to promote testing, surveillance,
prevention, and care. In 2000, Ethiopia
established its National AIDS Prevention
and Control Council, under the leadership
of the country’s president and involving
broad representation from governmental
ministries, nongovernmental organizations,
people living with HIV/AIDS, religious
groups, and civil society. Kitaw reported
that social marketing of condoms has
been greatly increased; HIV testing is now
available in “most hospitals;” and ART
guidelines for treatment and prevention of
December 2003
mother-to-child HIV transmission have
been drafted.
There has been very limited implementa-
tion of ART thus far. Planning is nonetheless
ambitious, and the government has com-
mitted to annual spending of US$140 mil-
lion for prevention and US$30 million for
treatment with the goal of reducing preva-
lence to 5 percent by 2010 and 3.6 percent
by 2020, Kitaw said. Recent funding for
national HIV prevention, care, and treat-
ment efforts by the Global Fund to
Fight AIDS, Tuberculosis, and Malaria
are expected to expedite such efforts.
In contrast to Ethiopia, South Africa is
one of the most developed countries on the
African continent. Though not really an
economically wealthy country, South
Africa can be said to be in the middle-
income category. According to David
McCoy and Robin Wood (University of
Cape Town), the country’s response to the
need to prevent and treat HIV/AIDS has
been inadequate due largely to failures of
political will and racial apartheid’s legacy
of inequality. In McCoy’s words, “Not
only did apartheid lead to the oppression
of the country’s majority population, and
consequently their under-development and
impoverishment, but it also created a health
system that was fragmented, segmented by
race and geography, over-bureaucratized,
inefficient, and inequitable.” Public aware-
ness campaigns to educate the population
on HIV transmission and safer sex have
been relatively robust, but Wood stated
these efforts have been undermined by
President Thabo Mbeki’s publicly asserting
denialist theories that HIV does not cause
AIDS. Whatever the reasons, it is clear
that prevention efforts have been largely
ineffective. Wood claimed that the number
of people living with HIV is expected to
climb from 5.4 million today to 8 million
by 2008, by which point there will have
been 6.5 million AIDS-related deaths.
Mbeki’s doubts about established medical
facts are largely responsible for South
Africa’s failure to prepare its health system
for treatment of HIV/AIDS to go beyond
the limited, if nonetheless successful,
ART pilot programs that have existed thus
far, Wood said. He reported that civil
organizations such as the well-known
Treatment Access Campaign (TAC) have
used activism and the courts to force the
South African government to adhere to its
constitutional mandate of guaranteed
healthcare and provide HIV treatment,
including ART. A new plan for government-
funded provision of ART in the public
sector was scheduled for public release
within a few weeks of this writing.
According to Wood, the limited medical
infrastructure, and its above mentioned
inequities, along with the sheer numbers
of people needing treatment, means that a
“concerted national effort on an unprece-
dented scale” will be required to make
widespread access to ART in South Africa
a reality.
If South Africa is to be successful in
this endeavor, it might look to the lessons
learned by its neighbor to the north,
Botswana, during the roll-out of its 2001
commitment to universal HIV treatment.
According to Louisiana Lush (London
School of Hygiene and Tropical Medicine),
factors that have allowed Botswana to
implement this ambitious plan among a
population that leads the world with an
adult prevalence rate near 40 percent
include a relatively good healthcare
infrastructure, the commitment of political
leaders, and a high level of national
financing that is enhanced by donations
from global partners, including Merck
& Co. and the Bill and Melinda Gates
Foundation.
Botswana launched its cost-free ART
program in January 2002. By September
2003, 12,000 people were recruited into
the program and 8,000 were placed
on treatment, Lush stated. This means
Botswana has more people on clinically
managed ART than any other African
country. Nonetheless, the number of
patients on treatment is not in line with
the original goal. Lush cited a variety of
reasons for the shortfall, including a need
for more medical personnel with training
in HIV treatment; a somewhat mysterious
failure of people to volunteer for HIV
testing, despite the availability of treat-
ment; a tendency of people to not present
for treatment until they are very sick
resulting in higher care costs than if treat-
ment had been started earlier; and the frag-
mented quality of program implementation,
resulting from difficulty in coordinating
all the various government ministries,
foreign partners, and district authorities
involved.
Botswana has also committed to an
aggressive program of HIV prevention
through public awareness campaigns,
education for young people, and preven-
tion of mother-to-child HIV transmission.
IAPAC Monthly 327
The conceptual model for behavioral
change programs is the much-touted
“ABC” approach, in which citizens are
encouraged to “Abstain, Be Faithful,
Condomize.” The impact has been negli-
gible to date, however, and Lush theorized
that radical changes in the attitudes and
sexual behavior of young men, and redress-
ing the imbalance of sexual power between
men and women, would be required
before real reductions in HIV transmis-
sion rates are realized.
Famously, Uganda has had better
results in preventing HIV transmission.
As Justin O. Parkhurst (London School of
Hygiene and Tropical Medicine) reported,
a variety of data indicate that prevalence
and incidence rates fell dramatically in
Uganda during the 1990s. The country is
now often thought of as “the African
success story” with 5 percent of adults, or
less, now infected with HIV. As with
Botswana, political commitment from the
highest levels in the Ugandan government
has contributed to these positive results,
Parkhurst said. He also argued that there
is an interesting way in which the frag-
mentation of public health efforts in
Uganda — with a variety of non-profit
organizations, church groups, and civil
society groups involving themselves —
may have aided the success of HIV pre-
vention programs. He said this situation
encouraged the creation of prevention
messages and strategies “tailored to small
local communities.” Widespread social
marketing of condoms and a largely
unexplained tendency for people to have
personal conversations about HIV infec-
tion were other keys, he noted. Use of the
ABC prevention model was not the single
explanation for Uganda’s prevention suc-
cess, Parkhurst said, despite what has
sometimes been implied.
If by encouraging a diversity of
responses Uganda’s underdeveloped and
largely uncoordinated healthcare system was
a serendipitous benefit to HIV prevention
efforts, it is a detriment, Parkhurst explained,
to most medical treatment, including
ART. Reductions in the prices of ARV
drugs, through the availability of generics,
have already improved ART access to
some extent, he stated, and efforts should
continue in that direction. Parkhurst also
argued, however, that Uganda will have to
address such issues as human resource
shortages and local treatment capacity as
ART is scaled up.
328 IAPAC Monthly
Europe
In contrast to Botswana and Uganda,
where there is a high level of political
commitment to fighting HIV/AIDS, and
to doing so by encouraging open and
frank dialogue on the subject and reducing
stigma, Russia might represent the opposite
extreme. Julie Stachowiak (AIDS Infoshare,
Moscow, and Johns Hopkins University,
Baltimore, USA) argued that the Russian
response to HIV/AIDS is in many ways
an artifact of disease control methods in
the Soviet era, with involuntary testing of
vulnerable populations and punitive
prevention methods that violate human
rights and are ineffective at preventing
transmission.
In light of increasing incidence and a
prevalence rate that some estimates place
at 2 percent of the population, government
spending is paltry. Of approximately
US$17 million in the federal AIDS
budget, the lion’s share, Stachowiak said,
goes to testing. Those found to be HIV
positive are banned from working in
several professions but have little hope of
accessing treatment. Stachowiak adamantly
rejected official UNAIDS data that show
half of all people in need of ART are getting
it; rather, she said, fewer than 500 people
receive ARV drugs at all and most are not
getting a combination regimen or a
consistent supply of medicine. Intravenous
drug users represent more than 80 percent
of new cases, but the government
excludes them from access to ART. Illicit
drug laws were made harsher to discourage
their use and prevent transmission from
the sharing of syringes, Stachowiak said, but
the drug laws have not reduced incidence,
and may actually increase it by growing
the populations of the already overcrowded
prisons where rates of HIV and tuberculosis
incidence are very high. Harm reduction
interventions, such as condom disbursal
and needle exchange, are unheard of in
prisons and not a part of the government’s
prevention strategy elsewhere, Stachowiak
said.
The presenter from the other former
Soviet state representing Europe at the
6th ICHRA, the Ukraine, reported a
different type of national response. Lydia
Andrushchak (UNAIDS, Kiev) said that
her country had managed to create pre-
vention programs working with infectious
drug users, prisoners, and sex workers.
Peer education programs on HIV preven-
tion have been started for youth. Through
partnership efforts with the United Nations
Children’s Fund (UNICEF) and Médecins
Sans Frontières (MSF), an aggressive pro-
gram for prophylaxis of mother-to-child
HIV transmission has resulted in an 18
percent drop in children being born with
HIV. Working with the UN Accelerating
Access Initiative, the Ukraine has begun
placing patients on ART. Sixty patients
are on combination therapy so far,
Andrushchak said, citing insufficient gov-
ernment funding for the impending failure
to reach the original goal of 4,000 patients
on ART by the end of 2003.
This treatment funding shortfall
notwithstanding, the difference between
the Ukrainian response and the Russian
one, Stachowiak said in reply to an audience
question, can be partially accounted for
by the Ukrainian government’s taking the
threat more seriously. It accepted help
earlier, and has been willing to work with
international organizations, such as the
Accelerating Access Initiative and the
Global Fund to Fight AIDS, Tuberculosis,
and Malaria.
Western European countries, by virtue of
economic wealth, strong healthcare infra-
structures, and constitutional commitments
to universal healthcare, represent a very
different story from their neighbors on the
other side of the continent. Presenters from
France and the United Kingdom at the 6th
ICHRA stated that their respective countries
have been able to reduce incidence, provide
ART to nearly every patient who needs
it, and as a result, greatly reduce AIDS
diagnoses and mortality rates from the
period before the introduction of combination
therapy in the mid-1990s.
Despite these positive reports, there are
nonetheless difficulties in providing
medical care and ART in France and the
United Kingdom. In both countries, the
increasing costs of all medications,
including ARV drugs, is coupled with
growing HIV incidence rates among
medically indigent populations, specifically
African immigrants, that rely very heavily
on the public health sector.
United States and Canada
Presenters from the United States and
Canada, the two other high-income countries
represented at the 6th ICHRA, were more
critical of their countries’ healthcare sys-
tems than were the European presenters.
As Bruce Fetter (University of Wisconsin,
Milwaukee, USA) and Douglas Morgan
December 2003
(US Health Resources and Services
Administration, Maryland, USA) both
pointed out, the United States is the only
Western country that does not guarantee
universal access to health insurance or
health services. A patchwork of federal
and state programs that provide govern-
mental insurance coverage for senior
citizens, people with long-term disabilities,
and people with low incomes (Medicare
and Medicaid) is riddled with holes that
leave millions with little coverage of med-
ical expenses. Care for people living with
HIV/AIDS, including ART, is specifically
funded through the federal Ryan White
CARE Act and coupled with funds dedi-
cated for that purpose by individual states.
A combination of increasing costs and
depleted governmental coffers, however,
mean that many states now have waiting
lists for ART and some benefits have
been cut.
Budget constraints have also ham-
pered delivery of medical services in
Canada, where universal healthcare is
obtained through provincial insurance
schemes, also called Medicare, that pay
for treatment at private hospitals, reported
Michael O’Shaughnessy (St. Paul’s
Hospital, Vancouver, British Columbia).
There are waiting lists for various surgi-
cal procedures and to see specialists, and
Canadians have largely lost faith in the
system, he said. As in the United States,
recent increases in HIV incidence rates,
particularly among economically disen-
franchised and otherwise marginal popu-
lations, pose new challenges. In both
countries, O’Shaughnessy said, whether
governmental leaders will remain com-
mitted to paying the high and increasing
cost of treatment for HIV/AIDS is a
continual question of political will.
Despite these several concerns, however,
it remains true that access to ART, clinically
managed by trained healthcare professionals
in state-of-the-art facilities, and comple-
mented with continuum of care support
such as social work case management,
behavioral health services, and housing, is
the standard of care in these two privileged
countries, as in Western Europe, and it is
available to almost everyone living with
HIV/AIDS.
Conclusion
What will it take to stop the spread of
HIV and provide appropriate treatment
and care for all people living with
December 2003
HIV/AIDS, instead of just those who live
in the very wealthy nations of the world?
In an opening presentation on the state
of the pandemic, Catherine Hankins
(UNAIDS, Geneva) discussed the concept
of “public health plus.” Traditional public
health strategies are not enough to stop
this insidious pandemic, she said. Instead,
public health plus has as much to do with
power as it does with science; it means
“the power to legislate, the power to
shape the global economy, and the power
to lead.”
Indeed, the 24 countries represented at
the 6th ICHRA provide evidence that the
power to set both national and international
agendas can have a tremendous impact on
prevention and treatment of HIV/AIDS.
Legal protection for human rights helps
lay the groundwork for appropriate and
effective prevention and treatment. A
country’s ability to generate funding to secure
medications, as well as its government’s
political will to do so, are factors—as are
its economic fitness and determination to
build up the healthcare system for treatment
with ARV drugs. On the international
level, plenary speaker Stephen Lewis (UN
Special Envoy for HIV/AIDS in Africa)
noted in his October 14, 2003, address to
6th ICHRA conferees that the myriad
agencies of the United Nations should, for
example, be counted on to provide techni-
cal guidance and assistance in this
respect. Similar commitments were
echoed in other plenary presentations
delivered by David Stanton (US Agency
for International Development, Washington,
DC) and Linda Distlerath (Merck & Co.)
who spoke to the efforts and lessons
learned by the donor agency community
and pharmaceutical industry, respectively.
It is clear that firm commitment to
mounting an appropriate response to the
pandemic exists on the part of most actors
from each of the government, nongovern-
mental, private sector, and international
agency groups which comprise the loosely
termed “global AIDS community.” The
challenge is translating this medley of
voices and perspectives into a coordinated
response which is then delivered with due
regard for the realities faced at national
and local levels. Cooperation with and
between international organizations and
industries is imperative, and as Conference
Co-Chair and IAPAC President/CEO José
M. Zuniga noted in opening the confer-
ence, “it is only through such cooperation,
harnessing strategic advantages and orga-
nizational strengths, that we will truly live
up to the ethical call that is presented to us
in the form of this disease.”
The task before us is clearly huge, but
the stakes are even larger. Guyana’s
Minister of Health, Leslie Ramsammy,
closed the conference with words that
bear repeating, for they capture the
essence of the collective dilemma with which
we currently contend. He challenged:
It is unacceptable, even unforgivable,
and some will even say criminal,
that we are unwilling or unable to
make full use of the tools at our
disposal. We have been appalled
before by holocausts—Nazi Germany,
Idi Amin’s war of genocide in
Uganda, Pol Pot in Cambodia, etc.
This particular holocaust is entirely
within our capacity to stop. The var-
ious presentations at this conference
confirm this.
As we grapple with the dilemma of
knowing the tools, of having the
tools, but the uneven distribution of
these tools has become yet another
equity issue in the North-South divide,
let us remember the path we take
will define the moral character of our
societies and of the world we live in.
Are we willing to accept a world in
which the haves can afford to use tools
to stop HIV and the have-nots must
face the possibility of extinction?
The obvious answer to this question, one
clearly shared by 6th ICHRA delegates, is
no. The difficulty remains convincing
those nay-sayers among us that by action
or inaction against this disease we all
stand to benefit or suffer. And, the more
focused challenge for those of us who are
dedicated to the daily fight against this
disease is to ensure that we are doing the
right things for the right reasons, placing
national, organizational, and institutional
ego to the side in order to ensure that
our efforts are coordinated, cooperative,
and efficient. We owe it to the world, and
to the generations to come, to meet this
challenge. ■
Mark D. Wagner is Director of
Communications at the International
Association of Physicians in AIDS Care.
IAPAC Monthly 329

Journal of Acquired Immune
Deficiency Syndromes
Characteristics of HIV-infected women who
do not receive preventive antiretroviral
therapy in the French Perinatal Cohort
Mayaux MJ et al.
OBJECTIVE: To determine the percentage and the
profile of women with known HIV-1 seropositivity
who do not receive the prepartum phase of preventive
treatment for maternofetal transmission. METHODS:
An observational study was conducted as part of the
French Perinatal Cohort, an ongoing nationwide
cohort of HIV-infected women and their children
(followed from birth). This analysis was restricted
to women who were delivered between 1996 and
1999. RESULTS: Among the 2,167 women studied,
92 (4.3 percent) did not receive the prepartum phase
of preventive treatment. This proportion fell below
10 percent in 1996 and subsequently stabilized at
3 to 4 percent. The reasons for nontreatment were the
woman's refusal (34 percent), premature delivery
(8 percent, before initiation of planned treatment),
late diagnosis of maternal HIV infection (3 percent,
at the time of delivery), or unmonitored pregnancy
(54 percent). One third of the women in this latter
category were aware of their seropositivity before
becoming pregnant. Treated and untreated women
did not differ in terms of the usual parameters of
HIV infection, geographic origin (sub-Saharan
Africa vs Europe), or HIV transmission category
(sexual vs intravenous [IV] drug use). Untreated
women were also less likely than treated women to
receive other preventive measures such as intrapartum
IV zidovudine infusion, treatment of the newborn,
and formula feeding. Indirect evidence strongly
suggested that the untreated women were socially
marginalized. CONCLUSIONS: The prepartum
phase of preventive treatment for maternofetal
transmission is well accepted by HIV-seropositive
women in France. The proportion of women who do
not receive this treatment could be further reduced
by earlier screening (before or at the beginning of
pregnancy) and by focusing on a small subgroup of
socially marginalized women.
J Acquir Immune Defic Syndr 2003;34(3):338-43.
AIDS
Tuberculosis epidemics driven by HIV:
Is prevention better than cure?
Currie CS et al.
OBJECTIVE: To compare the benefits of tuberculosis
(TB) treatment with TB and HIV prevention for the
control of TB in regions with high HIV prevalence.
DESIGN/METHODS: A compartmental difference
equation model of TB and HIV has been developed
and fitted to time series and other published data
using Bayesian methods. The model is used to compare
the effectiveness of TB chemotherapy with three
330 IAPAC Monthly
A B S T R A C T S
strategies for prevention: highly active antiretroviral
therapy (HAART), the treatment of latent TB infection
(TLTI) and the reduction of HIV transmission.
RESULTS: Even where the prevalence of HIV infection
is high, finding and curing active TB is the most
effective way to minimize the number of TB cases
and deaths over the next 10 years. HAART can be as
effective, but only with very high levels of coverage
and compliance. TLTI is comparatively ineffective
over all time scales. Reducing HIV incidence is
relatively ineffective in preventing TB and TB
deaths over 10 years but is much more effective over
20 years. CONCLUSIONS: In countries where the
spread of HIV has led to a substantial increase in
the incidence of TB, TB control programs should
maintain a strong emphasis on the treatment of
active TB. To ensure effective control of TB in the
longer term, methods of TB prevention should be
carried out in addition to, but not as a substitute for,
treating active cases.
AIDS 2003;17(17):2501-8.
British Medical Journal
Decline in mortality, AIDS, and hospital
admissions in perinatally HIV-1 infected
children in the United Kingdom and Ireland
Gibb DM et al.
OBJECTIVE: To describe changes in demographic
factors, disease progression, hospital admissions,
and use of antiretroviral therapy in children with
HIV. DESIGN: Active surveillance through the
national study of HIV in pregnancy and childhood
(NSHPC) and additional data from a subset of
children in the collaborative HIV pediatric study
(CHIPS). SETTING: United Kingdom and Ireland.
PARTICIPANTS: 944 children with perinatally
acquired HIV-1 under clinical care. MAIN OUTCOME
MEASURES: Changes over time in progression to
AIDS and death, hospital admission rates, and use of
antiretroviral therapy. RESULTS: 944 children with
perinatally acquired HIV were reported in the United
Kingdom and Ireland by October 2002; 628 (67 percent)
were black African, 205 (22 percent) were aged ≥10
years at last follow up, 193 (20 percent) are known
to have died. The proportion of children presenting
who were born abroad increased from 20 percent in
1994 to 1995 to 60 percent during 2000 to 2002.
Mortality was stable before 1997 at 9.3 per 100 child
years at risk but fell to 2.0 in 2001 to 2002 (trend
P < 0.001). Progression to AIDS also declined
(P < 0.001). From 1997 onwards the proportion of
children on three- or four-drug antiretroviral therapy
increased. Hospital admission rates declined by 80
percent, but with more children in follow-up the
absolute number of admissions fell by only 26 percent.
CONCLUSION: In children with HIV infection,
mortality, AIDS, and hospital admission rates have
declined substantially since the introduction of three-
or four-drug antiretroviral therapy in 1997. As
infected children in the United Kingdom and Ireland
are living longer, there is an increasing need to
address their medical, social, and psychological
needs as they enter adolescence and adult life.
BMJ 2003;327(7422):1019.
HIV Clinical Trials
Relationship between low bone mineral
density and highly active antiretroviral
therapy including protease inhibitors
in HIV-infected patients
Fernandez-Rivera J et al.
PURPOSE: The objectives of this study were to
determine the prevalence of osteopenia and the factors
associated with its presence in HIV-infected patients
under highly active antiretroviral therapy (HAART)
and to assess the changes of bone mineral density
(BMD) in a population followed prospectively.
METHOD: BMD was assessed by dual-energy
X-ray absorptiometry (DEXA) scans at the lumbar
spine and at the femoral neck in 78 HIV-infected
patients who had previously received HAART as the
first antiretroviral regimen and in 11 antiretroviral-
naive HIV-infected patients. BMD measurements
were repeated in 70 treated patients who had completed
one year of follow-up. RESULTS: Thirty-seven (42
percent) patients showed osteopenia at any localization.
The prevalence of osteopenia in PI-naive patients
was 23 percent versus 49 percent in individuals who
had received PI at any moment [p = 0.001; adjusted
odds ratio (95 percent CI) = 0.11 (0.02-0.48)]. The
frequency of osteopenia was significantly higher
among men than among women [50 percent vs 17
percent; p = 0.016; adjusted OR (95 percent CI) =
12.1 (2.22 - 66.20)]. The level of plasma albumin
was independently associated with osteopenia
[adjusted OR (95 percent CI) per each g/dL of plasma
albumin decrease 2.55 (1.18-10)]. In patients in
whom a second DEXA was done, no significant
changes in BMD were found. CONCLUSION: The
prevalence of osteopenia in HIV-infected patients
on HAART is high. Loss of BMD is associated
with PI therapy, low plasma albumin level, and male
sex. Osteopenia does not progress after one year of
continued HAART.
HIV Clin Trials 2003;4(5):337-46.
AIDS
Six-year follow-up of HIV-1-infected adults
in a clinical trial of antiretroviral therapy
with indinavir, zidovudine, and lamivudine
Gulick RM et al.
OBJECTIVE: To assess virological and immunological
responses and toxicity in subjects receiving combination
antiretroviral therapy. DESIGN: Six-year follow-up
of a single arm of a randomized study of combination
antiretroviral therapy. METHODS: HIV-infected,
December 2003
zidovudine-experienced patients originally randomized
to receive indinavir, zidovudine, and lamivudine
had HIV RNA levels and CD4 cell counts assessed
over six years. Information was collected by ques-
tionnaire from subjects who discontinued the study
regimen before six years. Both on-study and post-
study responses were assessed. RESULTS: Of 33
subjects, 16 (48 percent) discontinued before 6
years of follow-up. After six years, 16 (53 percent)
and 14 (47 percent) of 30 contributing subjects had
HIV RNA levels < 500 and < 50 copies/ml, respectively,
and the median increase in CD4 cell count from
baseline for 28 contributing subjects was 268 x 106
cells/ml. Treatment-limiting nephrolithiasis
occurred in four subjects. Of the 16 subjects who
discontinued the study, 12 had post-study question-
naire data available and seven had HIV RNA < 500
copies/ml on a post-study regimen. In an exploratory
analysis combining both on-study and post-study
data at approximately six years, 26 (79 percent) and
19 (58 percent) of 33 had HIV RNA levels < 500
and < 50 copies/ml, respectively, and the median
increase in CD4 cell count from baseline was 344 x
106 cells/ml. CONCLUSIONS: Antiretroviral therapy
with indinavir, zidovudine, and lamivudine sup-
pressed HIV viremia and produced continued CD4
cell increases in a majority of subjects for six years.
Most subjects who discontinued study medications
had HIV RNA levels suppressed on post-study therapy.
Though based on a small group, this study demon-
strates the durable effects of antiretroviral therapy.
AIDS 2003;17(16):2345-2349.
Quarterly Journal of Medicine
Endothelial function in HIV-infected
patients receiving protease inhibitor
therapy: Does immune competence
affect cardiovascular risk?
Nolan D et al.
BACKGROUND: The use of HIV protease inhibitors
(PIs) as a component of combination antiretroviral
therapy in HIV-infected patients has been associated
with dyslipidemia, but its significance as a risk factor
for cardiovascular disease is unclear. Endothelial
dysfunction is an early phase of atherogenesis that
may be assessed non-invasively with ultrasonogra-
phy in vivo. AIM: To evaluate vascular function and
investigate potential determinants of endothelial
dysfunction of the peripheral circulation in PI-treated,
HIV-infected men with dyslipidemia. DESIGN:
Observational, case-control study. METHODS: We
studied 24 HIV-infected, PI-treated men with
dyslipidemia and 24 normolipidemic, healthy male
controls matched for age and body mass index.
Brachial artery endothelial function was studied
using high-resolution ultrasound and computerized
edge-detection software. This non-invasive technique
measured post-ischemic flow-mediated dilatation
(FMD), and the endothelium-independent vasodilatory
response to glyceryl trinitrate (GTN). RESULTS:
Within the HIV patient group, FMD was significantly
associated with percentage of “naive” CD4 + 45RA
+ T cells (p = 0.03), while plasma lipid/lipoprotein
and insulin levels, body mass, and smoking status
did not correlate with endothelial function. FMD
was not significantly different between the study
group and the controls. CONCLUSIONS: The
atherogenic potential of PI-associated dyslipidemia
may be attenuated in HIV-infected patients with
decreased immune competence, reflecting a possible
contribution of cell-mediated immune responses to
the pathogenesis of atherosclerosis.
QJM 2003;96(11):825-832.
December 2003
CDC announces increases...
Continued from page 317
with HIV diagnosis and no AIDS diagnosis
during the same calendar month increased
by 9.3 percent, from 18,712 (95 percent
CI = 18,554-18,870) to 20,443 (95 percent
CI = 19,925-20,961).
Editorial note
The increase in total HIV diagnoses during
1999-2002 reflects increases primarily
among males, particularly MSM, and
among non-Hispanic whites and Hispanics.
The 29 states participating in these analyses
did not include certain states (eg, California,
Illinois, New York, and Washington) that
have reported increases among MSM in
other sexually transmitted diseases.3,4 In
addition, among states not participating,
certain states (eg, New York and Texas)
have recently implemented confidential
HIV reporting that will enable monitoring of
HIV diagnoses; other states (eg, California,
Illinois, and Maryland) are implementing
alternative forms of surveillance such as
coded patient identifiers. Standard protocols
are being developed to evaluate the per-
formance of these alternative surveillance
procedures. Nationwide reporting of HIV
diagnoses would improve estimates of the
size of the HIV-infected population.
The findings in this report are subject
to at least three limitations. First, delays in
reporting were assumed to be ≤ 5 years,
and reporting delays were assumed
consistent within the preceding five years.
When implemented fully, electronic
laboratory reporting should decrease the
time between HIV diagnosis and reporting
to the surveillance system. Second, classi-
fication of cases with no identified mode
of exposure into exposure categories was
based on follow-up investigations. Cases
with follow-up information were assumed
to constitute a representative sample of all
cases initially reported with no identified
exposure, and the distribution among
exposure categories was assumed consistent
during the preceding 10 years. The validity
of these estimates is being evaluated by
sampling and intensive follow-up. Finally,
completeness of reporting and potential
duplicate reporting by different states is
being evaluated in accordance with the
CDC’s performance standards for
HIV/AIDS surveillance.1
Changes in the annual number of HIV
diagnoses might be affected by changes in
testing patterns for HIV infection. Additional
data on testing patterns are needed; new
testing technologies that distinguish
between recent and long-term infections
will allow for better characterization of
recent HIV-transmission patterns and more
rapid and targeted preventive measures.8
However, population surveys suggest stable
trends in testing in recent years, with
approximately 45 percent of US adults
reporting they ever had an HIV test.9 In
addition, because the number of simulta-
neous diagnoses of HIV and AIDS did not
increase, the increase in HIV diagnoses
more likely reflects an increase in newly
infected persons rather than more intensive
testing efforts.
Hispanic and non-Hispanic black popu-
lations, with historically less access to
treatment and prevention services, are
affected disproportionately by HIV. New
strategies are needed to remove access
barriers to those populations and address
the HIV epidemic among MSM. Advances
in treatment for HIV infection can lower
concern regarding AIDS and perhaps lead to
an increase in high-risk sexual behaviors.5
To address these concerns, the CDC’s new
initiative, Advancing HIV Prevention:
New Strategies for a Changing Epidemic,
promotes access to testing, medical care,
and prevention services for all persons
with HIV infection.10 The CDC also is
funding a series of projects regarding the
prevention needs of MSM, both HIV-positive
and -negative, and MSM who belong to
racial/ethnic minority populations. ■
References
1. CDC. Guidelines for national human immunodeficiency virus case
surveillance, including monitoring of human immunodeficiency virus
infection and acquired immunodeficiency syndrome. MMWR
1999;48(No. RR-13).
2. CDC. Diagnosis and reporting of HIV and AIDS in states with
HIV/AIDS surveillance — United States, 1994-2000. MMWR
2002;51:595-598.
3. CDC. Primary and secondary syphilis—United States, 1999. MMWR
2001;50:113-116.
4. CDC. Primary and secondary syphilis among men who have sex with
men—New York City, 2001. MMWR 2002;51:853-856.
5. Chen SY, Gibson S, Katz MH, et al. Continuing increases in sexual
risk behavior and sexually transmitted diseases among men who have
sex with men: San Francisco, California, 1999-2001. Am J Public
Health 2002;92:1387-1388.
6. Green T. Using surveillance data to monitor trends in the AIDS epidemic.
Stat Med 1998;17:143-154.
7. Brookmeyer R, Liao J. The analysis of delays in disease reporting:
methods and results for the acquired immunodeficiency syndrome.
Am J Epidemiol 1990;132:355-365.
8. Rutherford GW, Schwarcz SK, McFarland W. Surveillance for incident
HIV infection: New technology and new opportunities. J Acquir
Immune Defic Syndr 2000;25(suppl 2):S115-S119.
9. CDC. HIV testing—United States, 2001. MMWR 2003;52:540-545.
10. CDC. Advancing HIV prevention: New strategies for a changing
epidemic—United States, 2003. MMWR 2003;52:329-332.
IAPAC Monthly 331
 I N T H E
Silver Sisneros
Vanity Fair readers have every month since 1993
enjoyed The Proust Questionnaire, a series
of questions posed to celebrities and other
famous subjects. In June 2002, IAPAC Monthly
introduced “In the Life,” through which IAPAC
members are asked to bare their souls.
This month, IAPAC Monthly is proud to feature
Silver Sisneros, who is Chief of HIV/AIDS Medicine
and Medical Director of the Adult Immunology
Clinic at Alameda County Medical Center/Highland
General Hospital in Oakland, California.
What proverb, colloquial expression, or quote best
describes how you view the world and yourself in it?
Any good that we can do, let us do it now, for we shall
not pass this way again.
What activities, avocations, or hobbies interest you?
Do you have a hidden talent?
Reading, gardening, and camping are my hobbies. Hidden
talent would be drawing/art.
332 IAPAC Monthly
L I F E
If you could live anywhere in the world, where would
it be?
The California coast—San Luis Obispo area—on a farm
with lots of animals and open space.
Who are your mentors or real life heroes?
My real life hero and mentor would have to be my mother.
She was not college educated, but she made sure her
children were. She exemplified compassion, responsibility,
and dignity.
With what historical figure do you most identify?
Crazy Horse—Native American hero—because his tenacity
of purpose, his modest life, unfailing courage, and tragic
death are examples of his selfless dedication and service
to others.
Who are your favorite authors, painters, and/or com-
posers?
Author: J.K. Rowling and Rudolfo A. Anaya. Painter: Crew
Mixer.
If you could have chosen to live during any time period
in human history, which would it be?
I am glad to be living today, because I am hopeful
that the past’s triumphs and failures will allow us
to know ourselves better and not duplicate any major
mistakes.
If you did not have the option of becoming a physi-
cian, what would you have likely become given the
opportunity?
An architect or painter.
In your opinion, what are the greatest achievements
and failures of humanity?
Achievements are many—too many to list.
Failures: Our ability to dismiss the importance of all
living creatures and our inability to recognize that
their uniqueness is essential to our survival as a
planet.
What is your prediction as to the future of our planet
one full decade from present day?
I envision a world in which technology exercises authority
and control. I am just hopeful that there will still be a
time to enjoy the smaller things in life. ■
December 2003
 [In Memoriam]

IAPAC mourns Gary DeSimone The International Association of Physicians in AIDS

Care (IAPAC) mourns the loss of longtime physician
member Gary DeSimone, who died September 29,
2003, after a 10-month battle against non-Hodgkin’s
lymphoma. Since 1998, DeSimone served as a Staff
Physician at the Whitman-Walker Clinic in Washington,
DC, and also as Clinical Director of the Whitman-Walker
Men’s Health & Wellness Clinic.

DeSimone attended Thomas Jefferson Medical College

and served his residency in internal medicine at the
Washington Hospital Center. He also served an elective
rotation at the Community Health Project at Bellevue
Hospital in New York. In addition to his IAPAC member-
ship, DeSimone was a member of the American College
of Physicians, the American Medical Association, the
District of Columbia Medical Society, the Gay and
Lesbian Medical Association, and the National Health
Service Corps.

DeSimone was a graduate of the American University,

where he majored in international relations; and he
completed his post-baccalaureate pre-med studies at the
University of Pennsylvania. He spent two semesters
with Semester at Sea, where he traveled the world
studying international affairs and global cultures.

In addition to his partner of 21 years, Gregg Stull,

DeSimone is survived by his parents, Clara and
Pasquale DeSimone; his siblings Tom, Mike, and John
DeSimone, Patti Rainey, and Lisa Cohn; his nieces and
nephews Alicia, Stephen, Todd, Jared, and Kelsey;
and many other relatives, friends, co-workers, and
patients.

A scholarship has been established in DeSimone’s

name with Semester at Sea. Contributions may be
made to the Institute for Shipboard Education — Gary
DeSimone, MD, Memorial Scholarship, and mailed to
Semester at Sea, 811 William Pitt Union, University
of Pittsburgh, Pittsburgh, PA 15260. ■

December 2003 IAPAC Monthly 333

 José M. Zuniga M O N T H L Y Lisa McKamy
Editor-in-Chief Managing Editor

Index to Volume 9
January — December 2003

January 2003 VOL. 9, NO. 1 February 2003 VOL. 9, NO. 2 March 2003 VOL. 9, NO. 3 April 2003 VOL. 9, NO. 4

M O N T H L Y M O N T H L Y M O N T H L Y M O N T H L Y

Heavy lifting
in Glasgow
(wherein HIV
researchers
uncrate some
Clydeside
surprises)

Retro Part 1:
A suite of
new therapies
Will AIDS finally (or, my funny
teach us the meaning valentine)
of sustainable human
development (for all)?
How human
immunodeficiency
virus voluntary testing
can contribute to
tuberculosis control

January 2003 February 2003 March 2003 April 2003

Pages 1-28 Pages 29-48 Pages 49-68 Pages 69-92

May 2003 VOL. 9, NO. 5 June 2003 VOL. 9, NO. 6 July 2003 VOL. 9, NO. 7 August 2003 VOL. 9, NO. 8

M O N T H L Y M O N T H L Y M O N T H L Y M O N T H L Y

Keeping an eye
on HIV treatment:
From substance
abuse to side
effects

Antiretroviral
The Western Hemisphere
treatment in
treatment in
tentatively faces
developing countries:
developing countries:
its AIDS problem
The peril of neglecting

Heartbreaks and STIs (or, remembering Dolly) private providers

May 2003 June 2003 July 2003 August 2003

Pages 93-116 Pages 117-136 Pages 137-172 Pages 173-196

September 2003 VOL. 9, NO. 9 October 2003 VOL. 9, NO. 10 November 2003 VOL. 9, NO. 11 December 2003 VOL. 9, NO. 12

M O N T H L Y M O N T H L Y M O N T H L Y M O N T H L Y

Sublime versus
20 years of simple side (or, forget the
HIV science: effect stories adiponectin,

Setbacks just stop smoking)

and activism

National leadership,
international cooperation
keys to effective
AIDS response

September 2003 October 2003 November 2003 December 2003

Pages 197-232 Pages 233-268 Pages 269-304 Pages 305-336
334 IAPAC Monthly December 2003

At the beginning of the program, we lost our
skilled health and other workers to the cooperating
partners, including NGOs, all of whom pay better
than the government… This is a dilemma we face.
Festus Mogae, President of Botswana, on one
of the difficulties his country has experienced
in enrolling and accommodating patients
in its cost-free antiretroviral therapy
program. According to an Associated Press
report, Mogae, who was speaking November
12, 2003, at a one-day conference in
Washington, DC, said Botswana’s public
health sector has had to resort to recruit-
ing healthcare professionals from other,
often poorer, countries that face their own
HIV epidemics.
We are already late. We cannot go on waiting
for social and economic change in developing
countries to tackle this problem.
Paulo Teixiera, mastermind of Brazil’s
antiretroviral access campaign, now Director
of the World Health Organization (WHO)
Department of HIV/AIDS, quoted in a
November 6, 2003, Reuters report about a
major drive to secure US$9 billion in support
of a plan to bring antiretroviral therapy to
3 million people in the developing world
by 2005. WHO Director-General J.W. Lee
and UNAIDS Executive Director Peter
Piot unveiled the “3 x 5” Initiative during a
press conference held December 1, 2003.
My body became cold after I was raped. My
husband tried to take care of me, but later on
he got sick, too.
A 21-year-old woman from the Democratic
Republic of the Congo who was kid-
napped in September 2003 and sexually
assaulted by rebel soldiers; physicians at the
clinic she attends are certain she is infected
with HIV but have not told her because they
cannot offer effective treatment. The quote
and story appeared in a November 13,
December 2003
S A Y A N Y T H I N G
2003, Washington Post article that reported
on the tendency of African wars to exacer-
bate the spread of HIV through widespread
prostitution and rape.
I am glad that we will now be able to look
people with HIV in the developing world in
the eye and say, “Britain is doing something
about treatment.”
Derek Bodell, Chief Executive of the United
Kingdom’s National AIDS Trust, responding
to remarks made by UK Secretary of State
for International Development Hilary
Benn about his government’s intention to
place AIDS at the center of its presidency
of the G-8 group of wealthy nations and the
European Union in 2005. Benn, speaking
at a November 25, 2003, London press
conference to launch the UNAIDS 2003
AIDS Epidemic Update, indicated that
previous reluctance on the part of the
British government to support HIV treat-
ment in the developing world has receded.
I knew it needed to be done.
Former US President Bill Clinton in a
November 3, 2003, Time Europe interview
in which he explained the impetus for his
namesake foundation’s efforts to lower the
price of antiretroviral drugs and develop
the ability of national healthcare systems
in Africa and the Caribbean to provide
antiretroviral therapy. In addition to
successfully negotiating with generic
antiretroviral drug manufacturers to
reduce their prices to about 37 cents
per patient per day in four African and
nine Caribbean countries, the William
J. Clinton Foundation facilitated a U-
turn in South African policy around the
wide-scale provision of antiretroviral
therapy (see next quote).
If the government wants to buy, they must let
us know for how many, when, and do they
have the money.
Yusuf K. Hamied, Chair and Managing
Director of generic antiretroviral drug
manufacturer Cipla, as quoted in a
December 1, 2003, New York Times article
entitled, “India Plans Free AIDS Therapy,
But Effort Hinges on Price Accord With
Drug Makers.” According to the article, by
April 2004 India plans to begin providing
free antiretroviral therapy to HIV-positive
new parents and children under 15 in
the six states most affected by AIDS. The
decision is a shift for the government,
which has not previously tried to offer
antiretroviral therapy on a major scale.
To do so, the government must reach an
agreement with the country’s generic
pharmaceutical manufacturers, including
Cipla, to reduce the price of their anti-
retroviral drugs. India’s generic drug
companies have said that past efforts to
work with their own government have
been frustrating.
If you’re sitting with an unaffordable pro-
gram, I don’t know how you look people in
the eye and say, “Sorry, we can no longer
afford to give you these drugs.”
South African Finance Minister Trevor
Manuel in a November 19, 2003,
Wall Street Journal article about
that country’s plan to undertake the
world’s largest AIDS treatment
program by providing antiretroviral
therapy free of charge in the public
sector. The plan recommends that
South Africa pay for the biggest slice
of the program out of its own treasury
rather than with donor funding to
ensure that funding is in place for
patients to take antiretroviral drugs
uninterrupted for life.
IAPAC Monthly 335
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