MALE SPEAKER: -- the AMFAR global director since 1998. I sat as the director of the vaccines and biological department of WHO and also as a senior policy advisor to the director general.

Asia and the Pacific soon had more of new HIV infections than any other part of the world. The regions of (MS?) are the epicenters of the global AIDS pandemic.

They need a (MS?) for a comprehensive response to the global problem of HIV/AIDS in Asia and the Pacific -- a response that includes treatment and prevention, care, research, education and training, and that cooperation and partnership between the public and private sectors.

As an important component of this much needed response, AMFAR is launching a (MS?) initiative known as Therapeutics Research, Education in AIDS Training in Asia, know also as TREAT -- TREAT Asia.

TREAT Asia is another (MS?), but critical element of this comprehensive response. Its approach is to help build capacity for therapeutics research, education, and training in Asia and the Pacific.

In building this capacity, Treat Asia will increase the availability of high quality HIV/AIDS treatment and care by expending a crew of physicians, all health care professionals, who are well qualified in the safe and effective delivery of therapeutics and the management of HIV infection and AIDS.

It will also advance a clinical research agenda that is responsive to the needs of HIV-infected populations in the region. Over time, it will expand access to antiretroviral therapy and experimental therapeutics, and identify and address the policy obstacles that hinder the expansion of access to drug treatments for HIV/AIDS across Asia and the Pacific region.

Given the vast size of this region, the scope of the problem, Treat Asia represents one strategy among the constellation of approaches to addressing HIV/AIDS in Asia.

In developing the network, AMFAR has worked with over 14 countries in the region, as well as vital organizations, including the International AIDS Society, the HIV Netherlands Australia Thailand Research Collaboration, known as HIVNAT, the Fogerty International Center, the U.S. National Institutes of Health and IID, and with the private and public sectors, as well as with communities.

Responding to HIV/AIDS in Asia and the Pacific requires an understanding of the unique opportunities and challenges of this region. Tonight, you will hear from leading experts, who will discuss the epidemiology of HIV/AIDS in Asia, the micro and macro impact of AIDS in the continent, the need for effective infrastructure, and the importance of international collaborations in the areas of education, care and treatment.

I have to relay to you apologies from Dr. Che-Jong (MS?), who is a person living with HIV. And he was due to join us on this panel today. She’s from the Philippines. Unfortunately, she had a death in her family just a few days ago, and was not able to join us and join you today. So to you, members of the audience, I express (MS?) for Natasha’s absence. And to Natasha, on my and your behalf, our heartfelt condolences.

Our first speaker tonight is Dr. Anedia (MS?) Chatterjee. Dr. Anedia Chatterjee will speak on behalf of Dr. Peter Piot, executive director of UNAIDS, and assistant secretary general of the United Nations. Dr. Peter Piot had to change his schedule at the last minute. He apologizes for not being with us today, but he’s an old partner of AMFAR, an old friend, and a supporter of the foundation. So Peter will be with us in spirit, if not in person.

Dr. Chatterjee is a colleague. And I’m looking for my notes on Dr. Chatterjee, but I can tell you that he’s a psychiatrist. And he has done wonderful work in Asia on mental health, developing mental health programs, networks, community-based outreach programs, particularly reaching out to injecting drug users.

Dr. Chatterjee is the UNAIDS regional person for Asia. He is with us today. We are grateful for him to share with us his vision of what HIV/AIDS is about in Asia and the Pacific.

Dr. Chatterjee, please, the floor is yours.

[applause]

DR. CHATTERJEE: Thank you, Dr. Janentoma (MS?). Good evening, ladies and gentlemen.

I’m here to speak on behalf of Dr. Peter Piot, executive director of the joint United Nations program on HIV/AIDS. He has sent his sincere apologies and regrets for not being able to be here today. The conference has completely overtaken his schedule and there’s nothing he can do about it.

And I’m afraid I’m not -– I cannot give inspiring speeches like Peter. So I decided that I’d be very brief. I’m used to more boring, technical speeches. So I‘ve decided to be very brief.

Now as you have all seen in reports, including the Barcelona conference report that came out, that HIV/AIDS is spreading very rapidly in Asia. We already have 6.6 million people living in the region. And among those 6.6 million, we have a million new infections just last year.

So you can imagine this is relatively new epidemic, compared to other parts of the world, particularly Africa. And so, there are scopes, still scopes in many countries of Asia to have a global stress points.

Secondly, you know, many new epidemics are emerging every day. You can look at Indonesia, how quickly the situation changed, where you have concentrated epidemics among the injecting drug users and sex workers over the last two years’ time.

And secondly, we also have rather high prevalence rates in some countries. Several countries have infection rates over 1% in the general population – that includes Thailand, Cambodia, possibly Myanmar, at least five states in India.

So the scenario is rapidly marching. And we have a very diverse and complex epidemic with all kinds of transmission groups. You have drug injecting related transmission. You have, of course, sexual transmission -- predominant in most parts. You also have tens of thousands of possibly even more people infected through contaminated blood products.

So this is a very complex situation of which we are dealing with in Asia. Several vulnerability factors, such as political turmoil, instability, economic meltdowns, huge migration of populations, changing drug trafficking routes, all expose Asian populations to the risk of HIV.

So you can imagine the challenge. Prevention, of course, is critically important, but it is also important in Asia to have our comprehensive response. Countries can no more refuse to respond to the care needs.

It’s already a serious issue in pockets of Asia. It is gathering political momentum. And if the countries don’t address care issues along with prevention issues strategically, they will be forced to respond to it (MS?), because they cannot refuse to address it any more. And it should a part of our comprehensive response.

And faced with mounting evidence of infection – rising infection rates, governments in many countries in Asia (MS?) reacting, responding to the need of comprehensive programs of prevention and treatment.

And the international community is also showing signs of a coherent and committed response to Asia. There’s a huge press coverage on the epidemic in Asia in the last week, which is very encouraging.

The primary aim of initiatives like TREAT Asia is to go to capacity for safe and effective and administration of HIV/AIDS therapeutics as access to these drugs gradually expand across the region.

And developing capacities in the countries, helping countries to develop their own infrastructure, to deliver complex regimes of treatment, developing networks of professionals across Asia are all key elements, as I understand of this program, which is very, very important.

And incidentally, I like the name TREAT Asia. It’s good, actually. And at UNAIDS, it is extremely important for us to see these partnerships across multiple sectors and countries and regions grow because UNAIDS sells only one product, and that’s partnership.

And so, we very much welcome this initiative. And we’re also pleased to see that, in researching the needs of the region and developing a blueprint for the TREAT Asia initiative, AMFAR has worked in collaboration with other HIV/AIDS groups and our organizations in Asia and the Pacific. And we look forward to working with AMFAR as this initiative moves forward in the same spirit of cooperation. Thanks you, ladies and gentlemen.

[applause]

MALE SPEAKER: Okay, my thanks to you -- some of the issues you have raised on the scope and need for an enhanced and coordinated response to HIV/AIDS in the region.

I am pleased to introduce that David Bloom (MS?), who will now discuss the micro, macroeconomics in parts of AIDS in Asia. Dr. Bloom is the acting chair of the Department of Population and International Health at the Harvard University School of Public Health. He’s also research associate at the National Bureau of Economic Research in Cambridge, Massachusetts, and has served on the faculties of Carnegie Mellon University, Harvard University, and Columbia University.

Ladies and gentlemen, Dr. David Bloom. Where are you, David? Please.

(applause)

DR. DAVID BLOOM: Thank you, Daniel. And also thanks to AMFAR for organizing this session.

The focus of my remarks this evening is on the impact, the economic impacts of HIV/AIDS in Asia. I’d like to make a couple of quick points before I proceed. First, in the interest of full disclosure, let me state at the outset, as Daniel alluded to, that I am a card-carrying economist. In other words, unlike ethicists who are taught that virtue is its own reward, I’ve been trained to regard reward as its own virtue.

But for those of us here who subscribe to John Kenneth Galbraith’s amusingly cynical view of modern economics, I want to assure you that I recognize that HIV/AIDS is first and foremost a health problem, and a matter of enormous humanitarian concern.

Still, policymakers dealing with AIDS, are faced with a multitude of demands that competes strenuously for their attention. And economic reasoning and evidence provide a practical approach to deciding among alternative claims for public resources.

In addition, the inherent complexity of the causes and consequences of HIV and AIDS extends beyond the areas of medicine and public health and calls for multidisciplinary analytical frameworks and evidence that embrace economic thinking and take advantage of economic forces.

Let me also add that I’d be happy to provide to anyone who wants the full text of my remarks, the accompanying slides, and back-up references, calculations, etcetera, that support the statements I make.

My intention this evening, I keep saying this evening. It really doesn’t feel like evening, but anyway, my intention is to make three points. The first point is that the HIV/AIDS epidemic will wreak macro economic havoc in Asia over the next two decades if it’s allowed to expand with the same intensity as it has in sub Saharan Africa.

The second point is that, even under the more likely scenario, in which HIV/AIDS spreads at a more modest pace than it has in Africa, the epidemic will impede Asia’s economic development. But it will do so, namely through its impact on vulnerable occupational and industrial sectors of the economy, and on vulnerable subgroups of the population, especially the poor and less educated.

And the third point is that spending on HIV prevention and AIDS treatment and care is powerfully justified, not only on humanitarian grounds, but also by the high economic returns that can reasonably be expected to flow from such spending.

For economists of all breeds and persuasions, this represents an unmistakable call to action. Economists have been studying the macro economic consequences of HIV and AIDS for about 15 years now. In purely academic terms, this is quite novel, as economists have conventionally believed that causality runs from wealth to health, and not the other way around.

The AIDS epidemic has highlighted population health as a cornerstone of a strong macro economy. And it helps stimulate a fairly significant breakthrough in economic thinking on this subject. For those of you who are interested, much of this new thinking is set forth in the recent report of the WHO commission on macroeconomics and health.

Now there are four key channels through which health affects economic performance at the macro economic level. All of these are pertinent to understanding the economic implications of AIDS. The key features of which, as we all know, are large numbers of cases, costly treatments, and an age pattern of mortality that’s heavily concentrated among prime AIDS workers.

I’d like to go through these channels very briefly with you. Okay. The first channel involves the effect of health on labor productivity. We all know that people tend to work longer, harder and more efficiently when they’re healthier. So I don’t think I need to say that much more about the first of these channels, other than the fact that all of these comments that I’m making have quite a bit of empirical evidence to back them up.

The second channel involves the effect of health on education. Healthy children are better able to learn and have more to gain by attending school, because they can expect to live and work longer. And healthy families impose fewer burdens on children of having to care for sick relatives.

The third channel involves the effect of health on savings and capital accumulation. Healthy populations are like a powerful magnet that attracts foreign investment.

In addition, longer-lived individuals tend to save more in anticipation of retirement. And their savings gets transformed into the infrastructure and the factories that are the usual prerequisites for economic prosperity.

And the final of these channels involves the effective health on the AIDS structure of the population, whereby improvements in health result in declines in the dependency burden, which can be quite favorable for economic growth.

These four channels roll up into a large overall effect of health on economic growth. For example, a 10-year gain in life expectancy will provide up to a 1-percentage point boost to the growth rate of per capita income.

Now conversely, a ten-year drop in life expectancy, due for example, to HIV and AIDS, will consume up to 1 percentage point of economic growth.

These are very disturbing magnitudes. Certainly, in light of Karen Stemeke’s (MS?) report earlier this week indicating that HIV/AIDS has caused life expectancy to drop by over 30 years in some African countries. And also because average growth rates of per capita income typically range in the 0% to 6% category.

Now I’d like to share – to draw these points out a little bit more, I’d like to share two sets of calculations I’ve prepared, concerning the potential economic impacts of AIDS in Asia.

The first calculation refers to the economic impact in a worse case scenario in Asia. Okay? And by worse case scenario, I mean a Botswana-style epidemic.

The result of such an epidemic in an Asia country would be a reduction of about 3 percentage points in the average growth rate of income per capita over the next 25 years. AIDS could best halve the growth rate of an East Asian miracle economy. It could result in economic stagnation in an up-and-coming Southeast Asian economy. Or it could lead to an absolute decline in living standards in the slower-growing economy of South Asia.

And I would add here that these economic shocks would not be confined to Asia because of the fact that most Asian economies are deeply integrated into the world economy through trade, capital mobility, and labor mobility.

In other words, the economic impact of AIDS in Asia will also be felt throughout, for example, Europe and North America. And much more so than the impact of AIDS in Africa.

The second calculation I’d like to share with you refers to the economic impact of AIDS in Thailand. And it’s based on data that come from Thailand at the point of 1990. Okay. Those data, if we just basically turn the clock back to 1990 and put those data in front of us, those data suggest an epidemic that would have resulted in 10 million deaths, one sixth of Thailand’s population, by the year 2015.

My calculation suggests that income per capita in Thailand would have fallen by 15% or roughly $1,300, had this scenario been realized. This result supports the view that AIDS has the potential to severely undermine living standards in Asia.

The current example actually provides a very natural link between my first message about the potential impacts, the potential economic impacts of the AIDS epidemic and my second message about the likely economic impacts.

It provides this link because the Thai epidemic was substantially controlled, and has developed with only a fraction of the fury implicit in those 1990 numbers. As a result, the epidemic appears to have had only a small negative effect on per capita income in Thailand.

Calculations based on reported AIDS cases for Cambodia, Myanmar and India suggest similarly small effects thus far. In addition, calculations based on projected cases for those countries suggest somewhat larger effects of AIDS on economic growth, but even those effects, I would have to say, are relatively modest in size.

However, even if the macro economic implications of AIDS in Asia prove to be relatively mild, the economic consequences are likely to be quite severe for particular groups.

For example, the poor are likely to be especially hard-hit by the economic impact of AIDS. Survey data from Cambodia and Vietnam show that poor and less educated people are at much higher risk of contracting HIV than richer and better-educated people. The poor are more likely to be sexually active at an early age. They have less knowledge of the benefits of condoms. And they use them less often. They are less likely to have been tested for AIDS. And their knowledge of causes of HIV infection and prevention methods is much weaker as well.

In addition, labor is the main asset that poor people have to generate income. And this is precisely the asset that is attacked and diminished by AIDS.

There’s also evidence that the poor pay more by being misled and abused in terms of the drugs and treatments they need and how much they have to pay.

So the AIDS epidemic threatens the poor with a triple blow. The first blow comes from higher infection rates. The second blow comes from a proportionately bigger loss of income. And the final blow comes when the poor get fleeced by cracks, charlatans and other opportunists.

Thus, the AIDS epidemic is working in the direction of enlarging the problem of poverty reduction. It also makes this problem, not just bigger, but also more complex, because poverty reduction programs commonly promote mobility and migration. And those two dynamics are strongly connected as we know to HIV transmission.

Let me now turn to the -– my final point, which is that there are huge economic benefits from early intervention to combat AIDS. And I’d like to start by taking Thailand’s successful efforts to reduce the spread of the virus.

As we know, Thailand’s AIDS campaign or anti-AIDS campaign, was headed by the prime minister, which was a vital symbol of the importance given to the campaign. It targeted both vulnerable and mainstream populations. An extensive media and education effort was backed by a 100% condom campaign, which has successfully promoted near 100% condom use in brothels.

In addition, public spending on HIV and AIDS increased more than 100 fold in Thailand between 1988 and 1997. Private spending has also proceeded at considerable levels.

The result of the campaign is that Thailand is on track to prevent, in large measure, the raging epidemic that was forecast in the early 1990s. As this chart shows, and this chart was prepared by the Thai working group on HIV/AIDS projection, and basically what it shows is as of 1990, it – the purple line that goes up shows what was forecast, based on the 1990 epidemiological data. And the hatched red line below shows what’s actually – what actually took place up to 2000 and what’s projected going forward, out to 2020.

And you see that there is a huge difference between what was projected in 1990 and what actually took place or is currently projected as of today. And as I say, I think the belief is that that difference is substantially due to the HIV prevention campaign in Thailand.

(MS?) had behavioral change not taken place. Okay, in other words, Thailand’s investments in AIDS prevention and treatment achieved a huge reduction in the burden of HIV infections, AIDS cases, and AIDS deaths.

Now my colleague, R.J. Mahall and I, have estimated the rate of return to HIV spending in Thailand. And I’d like to describe the calculation and the results. Okay. We did the calculation basically in three steps. Okay. First, we estimated the dollar value of public, private, and international donor spending on HIV prevention from 1990 to 2020.

Okay, that’s the cost side of the equation. Second, we estimated the dollar value of AIDS cases averted between 1990 and 2020. Okay, and we did this by taking account of medical care costs that were averted and also income losses that were averted.

That represents the benefit side of the equation. And third, under the assumption that just half of the averted AIDS cases were due to the spending, we used a standard economic formula to compare the costs and the benefits, and to generate estimates of the rate of return to spending on HIV prevention in Thailand.

Now as you can imagine, many assumptions were necessary to implement those calculations. And so in fairness, we also analyzed, we spend a great deal of time analyzing the sensitivity of our results to a wide range of alternative, plausible assumptions.

Now also, I would note at this point that these calculations pertain to the overall portfolio prevention activities in Thailand, and not to any particular component of those activities.

The exercise, this rate of return calculation exercise, yields in fact, and as described here, some rather remarkable results. Okay, first of all, every combination of assumptions we explored resulted in estimated rates of return above 10%.

That’s extremely significant, because 10% is a conventional threshold that international development agencies, such as the World Bank, regard as acceptable for undertaking a project.

Second, I would note that the rate of return exceeds 10% even if we limit the benefits to averted medical care costs. In other words, even if we completely ignore averted income losses.

And third, the rate of return reaches the range of 37% to 55% if we account for both averted medical care costs and averted income losses in our estimation of the benefits of HIV spending in Thailand.

That range, 37% to 55%, is well above the 10% threshold. And I would say comfortably elevates AIDS spending into the category of what we sometimes call a no-brainer.

In somewhat less colloquial terms, these calculations provide evidence of a powerful economic rationale, above and beyond the humanitarian rationale, for spending on HIV prevention. And also, on AIDS treatment and care insofar as that promotes prevention.

It means that the time to start spending is now, because as our old friend, Senor Miguel Di Cervantes once wrote, “delay always breeds danger.” And I would say especially so when it comes to safeguarding Asian economic promise. Thank you.

(applause)

MALE SPEAKER: Thank you, David. If you don’t mind, perhaps take a couple of questions now. There will be more time for questions at the end of the session when all have presented. A couple of questions for David. And I ask –- I would like to ask Dr. Chatterjee to join us here. There may be some questions directed to him as well.

Dr. Popan (MS?)?

DR. POPAN: Thank you for your calculations and your interest in the Thai situation. What I would like to ask is, you know, if you are checking to the calculations for the cost of treatment, antiretrovirals for example, to see how much cost return of whether our investment return might be very interesting for our government and for our country. That’s number one. So I would like you to give recent calculations.

Number two, although it looks like, you know, to outside very good, you know, Thailand is working very well. However, you know, the bucket for HIV has been stabilized for the last six years, okay, never increased, okay in spite of the medication is cheaper and so on and so forth.

So I just wondered, I just would like to ask Professor Bloom’s advice in terms of what would be the strategy, to make the economies in the countries, to make the politicians in the country understand these kind of issues, and then you know, work on it.

For example, is it necessary to have some economists in the country in Thailand or in other countries, to work along with you all to do calculations. And if we send them to the policymakers, what would be the best way to approach, you know, this kind of people in our country?

DR. DAVID BLOOM: Thank you, Dr. Popan, for your observations and question. First of all, let me stress that the calculations that I reported refer only to HIV spending that was on prevention. So we tried to separate out of total spending the amount that was on prevention and just looking at averted cases.

I think it would be useful probably, as you say, to go to the next step and to begin to look at treatment as well from this point of view, to see if it provides further reinforcement for the moral, the ethical and the humanitarian case for spending on treatment and care, as well. So I agree with that.

Also, it’s absolutely correct, as you say, that there was a big run-up from let’s say 1988 through 1991. Spending on HIV prevention increased by maybe 15 during those years. And then again, another run up by a factor of maybe 8 though 1997. After which, as you say, HIV spending publicly did stabilize.

And I think these are, in fact, the kinds of calculations that often can get the attention of people who control budgets in countries. So I think that they’re useful. But again, only as reinforcement for the fundamental case, which I think always has to be made on moral and ethical grounds.

KEN MAYER (MS?): David, it was an excellent and elegant talk, as usual.

MALE SPEAKER: Could you introduce yourself?

KEN MAYER: Sure, Ken Mayer from Brown University. It was an excellent and elegant talk. I’m curious if your analysis has looked at the issues of the secondary spread of tuberculosis, which -– the reason I’m thinking of this is that –- to try to get international funders, particularly in the U.S., to think beyond self interests, productive life lost may be within the country may be less salient. I think you made an excellent point, talking about the impact on developed world economies.

But I wonder also about the secondary spread of other infectious diseases, as another issue that one might factor in the costs of that to the developed world, as well as the developing world.

DAVID BLOOM: Right, Ken, I think it’s an excellent point. These calculations only look at the – sort of the benefits of averted HIV infections in country.

So in that sense, you can interpret them as a lower bound on the true benefits of averting HIV infections, because of these spillovers, the fact that there’s more TB in the human reservoir and what have you.

So insofar as the numbers here are above the threshold, they’re probably even much more above the threshold, if you took account of that, which I think would be quite useful to do as well.

KEN MAYER: And the reason I ask that though is thinking about the partition to make the argument to the funders, not just because some other countries may not have the resources to respond, even though the arguments you’re making are extremely cogent.

[AUDIO GAP]

MALE SPEAKER: -- with existing programs and initiatives in the region, it can complement their efforts, avoid duplicating what has already been done, and help to fill gaps where they exist.

Now our next speaker is David Cooper. Dr. David Cooper will address the issue of the importance of collaboration in Asia. David is professor of medicine at the University of New South Wales and the director of the National Center in HIV Epidemiology and Clinical Research in Sydney, Australia, which conducts research on the epidemic in Australia.

He is recognized as a leading HIV clinician and clinical investigator. David, we all recall, was also once the chair and a very effective chair of International AIDS Society.

Ladies and gentlemen, Dr. David Cooper.

[applause]

DR. DAVID COOPER: Thank you very much, Daniel. And thanks to AMFAR for inviting me.

I want to particularly focus on HIV/AIDS research collaboration in Asia and the Pacific, and particularly some of the things that we have done in Thailand.

So these are the five issues I want to cover. A little bit about clinical research in the developing world and its priorities. Some observations from our next speaker, Professor Popan about the priorities in Thailand. To tell you a little bit about our research collaboration, HIPNAT. To talk a little bit about the role of the developed country partner in such research collaborations and how these research collaborations can be made to happen.

So why should we be doing clinical research in the developing world? I think there’s a number of reasons. Clearly, there’s a large HIV/AIDS infected population. There is sadly at the present time minimal treatment available.

I’ve always felt that the research agenda to some degree drives treatment policy. It certainly provides academic education and training. It enables relevant research to be done.

Although not the vast majority patients, but some patients do get access to treatment. But despite all that, there are a number of obstacles to the clinical research in the developing world. It’s traditionally had a very low priority amongst physicians and other healthcare professionals.

There’s negligible career structure for it. There is very poor pay in the public sector, which necessitates after hours work for physicians and other healthcare professionals making the amount of extra time you can spend on all the details of research very limited.

It’s a lack of resources. There’s generally, in many settings, a lack of experience of research ethics committees, which is a fundamental support for doing the right work.

And there’s also been a very poor track record so far as sustainability in many research areas. Not always, but often that’s the case.

And there’s a very poor perception of these collaborations, sometimes, because of the very negative image of the developed country partners. And Professor Popan has always called this parachute research, where the developed country partner just parachutes in, takes out all the samples and see you later. And that’s a very important think to obviously to avoid.

What do we need? We need infrastructure to do this. You need dedicated and adequate space for all staff. You need conference rooms. One of the issues of working in Asia or Africa is the power is not always there all the time. You know, sometimes, it doesn’t happen in California either. But you do, if you got precious samples, need back up generators for power failures.

If you’re doing clinical research with patients, patients have to have comfortable space to be seen. And drugs have to be very well stored, proper temperature conditions and locked up safely and accounted for.

There are human resources that you need to do clinical research. M.D.’s, nurses, laboratory personnel, pharmacists, data managers. You need administration staff, security. And you need the involvement of the community and people living with HIV and AIDS.

Education and training in clinical research is critical if we’re going to make it a success. And this involves having good clinical practice, according to internationally recognized guidelines of regulatory agencies and also good laboratory practice for this to be done.

And these things are not easy to set up in the absence of any track record in there.

What about Thailand? We have already heard some very elegant economic aspects. What’s happening a little bit there right now. And this is some of Professor Popan’s thoughts. And I acknowledge him for this, about the AIDS war in Thailand as a sort of continuous struggle between government policy, how the public perceives HIV/AIDS and its stigmatization, and individual acceptance of infected people and their families.

There’s political commitment. And it’s related to how much you get in the AIDS budget versus the defense budget versus the other competing interests above a healthcare budget.

In the AIDS budget itself, how much do you put in to prevention? How much do you put into care? And that’s a very active debate, which is often very polarized, unfortunately.

And for care, how much do you put into opportunistic infections, such as tuberculosis, which is a very important public health issue versus antiretroviral therapies.

And the antiretrovirals themselves, what type do you use? What are the prices? Should you be using generic? Should you be using brand names? And who pays for all of this?

What’s happening right now in Thailand, generally access is by self-payment. In hospitals, there is partial subsidy for the poor, but that is very limited. And there are third party payments for government and corporate employees in some sectors, like the very uncommon Social Security funds for people, and never by private insurance.

There are some access through donations, such as the Thai Red Cross Society or Medicine St. Fontiere and similar. Clinical trials are very small component of that. And for example, sort of HIVNAT and other industry sponsored studies or the Ministry of Public Health Clinical Trial network.

In 2002, there has been some extraordinary progress in Thailand regarding access. There’s the availability of GPOvir (MS?). You know, GPOvir (MS?) is produced by the government pharmaceutical office. It’s a fixed dose combination of stavudine, lamivudine and Nova rapine (MS?).

And for 60 tablets, the cost is 1320 Thai baht, which is about $33 a month. And that’s approximately $1.00 a day. And if – that makes triple combination therapy for many Thai people who can afford it, $1.00 a day, which is getting in the right range, affordable for many.

And the uptake has really been quite extraordinary over the last year.

What about HIVNAT? This is us in downtown Bangkok on the Chilolongkong (MS?) campus. The collaborating organizations have been the Thai Red Cross AIDS Research Center, the National Center, which I direct in Sydney. And Professor Yublang (MS?) is INARTIC (MS?), which he directs in Amsterdam.

Our mission and objectives are to conduct multi center HIV related clinical studies, according to GCP and GLP, to provide access to antiretroviral therapy for infected people in Thailand, to educate healthcare workers in Thailand, and the region on GCP, GLP and HIV medicine.

Now structuring governments is fairly simple. We try to have decision-making by consensus if possible. We have oversight by the stakeholders, which includes academia, hospital and university administration, the ministry of health, drug regulators.

We have a core group for day-to-day management of this research initiative. And senior academics decide priorities in specific projects.

And the main thing is to keep it flexible. Don’t impose too many rules.

What are our milestones? We have the concept. The three of us in 1995. And we started operations just after Vancouver with one Dutch physician in 1996, who went out to Bangkok.

In 1997, we were very fortunate to have our first presentations at international meetings. In 1998, we started the Bangkok Symposium in HIV Medicine, which is a very important symposium for education and training in HIV medicine in Thailand and the region, which has occurred annually since we became a UNAIDS collaborating center.

In 1999, Professor Popan was able to persuade the Thai Red Cross to, as we were expanding, to give use a new building and facilities. Our first peer review publications came out in 2000. There’s always quite a lag between the start of clinical trials and getting the publications out.

And in 2001, we have approximately 1200 patients on studies. And this year, we have finally started applying to the public sector finally.

Our clinical research priorities are a number of forms. Firstly, what are the public health implications for transmission in people with undetectable HIV viral load? Two, begin to try and assemble cohorts for prevention, vaccine, evaluation, and chemoprophylaxis.

To try to expand the scope of mother to child studies to include the mother and the immediate family and the Thai Red Cross is one of the applicants for MTC plus.

To try and integrate tuberculosis treatment with heart, and to look at heart sparing strategies in view of the long term toxicities and the cost of antiretroviral therapies, such as treatment, interruption, or immuno therapies.

This is a conceptual slide, rather than specifics, looking at the timelines of our studies from 1996 onwards. And one of the points that I want to make is that what we’ve done is that all our studies only last about 48 weeks, what the principle we try to do is to continue the patients on studies by adding – asking another relevant research question.

And because the number of patients who stay on study, and their adherence is excellent, we don’t lose patients. So for example, this study here, we originally randomized 100 patients. And now in 2001, they’re moving into a structured treatment interruption study, we have 80. And that is quite amazing in terms of the – any – it would be the envy of any clinical research organization in the developed world to retain patients over that period of time in studies.

It hasn’t always been possible to continue drug supply. And so very creatively, under Professor Popan’s leadership, we have set up the HIVNAT drug fund, which is overseen by Dr. Jinjanou (MS?), which often pays sometimes for the third drug, you know, in a patient who’s finished a study and who can afford to pay a certain amount assessed by social workers independently.

So what’s HIVNAT achieved? 1200 patients on antiretroviral therapy for as long as five years. Exceptional adherence. The stimulation of interest in HIV trials to GCP standards in Thailand and the region. And international recognition is a model for clinical research in the developing world. And were invited to do one of the UNAID’s best practice series.

Ongoing drug supply is a problem. We try to have to rollover study design, as I showed you. We request from the pharmaceutical industry, two years of drug supply following the end of the study period. And we won’t do a study unless this is fulfilled.

We try to make the ongoing drug supply this responsibility of all stakeholders, not just farmer. We are not inflexible with the duration of a type of regimen. And we don’t allow the ongoing drug supply to become the patient’s responsibility.

And we don’t waste the opportunity because the drug supply isn’t guaranteed. The situation changes. And look at 2002 with GPOvir.

What about sustainability? We kept the research question simple and practical. We provide the majority of education and training on site. And we make sure the developed country partner in this case Australia and the Netherlands make absolutely sure that the work is carried out on site.

We encourage support by the ministry of health, abstract publications and community involvement, as well as ongoing drug supplies.

DAVID COOPER: What about us, the developed country partner in all of this? What do we do? I think our role is our expertise and our contacts, our experience in education and training, and our support and commitment over a long period of time. It’s been a pleasure to work with this organization over a period of six years now. It’s one of the most exciting things I do. I think it promotes cultural sensitivity and awareness, but, at the end of the day, it ain’t your project -– it’s not you, it doesn’t belong to you, and you have to be able to let go.

How can we make all of this happen? We need to work with the pharmaceutical industry. It’s preferable to do research in partnership with industry because of their knowledge base and product support. You don’t make them responsible for everything; you show public sector leadership; and you preserve future drug development. We need their drugs. That’s not going to happen by generic manufacturers. There aren’t any drugs without them. Who’s going to fund all of this? Hopefully, international donor organizations, foreign aid agencies of developed country governments, research grants given by public sector agencies in developed countries, charitable foundations, PhRMA, ministries of health in the country. And there have been examples of all of those over the last couple of years, and they’re growing, particularly in the area of antiretroviral therapy.

So, that was about HIVNAT opening, whenever it was – 1998, 99, something like that – lovely day. I’d like to acknowledge our key supporters, particularly the Faculty of Medicine at Chulalongkorn University, NIAID, the AIDS Division in the Ministry of Public Health in Thailand, government pharmaceutical organization, and many PhRMA companies who’ve helped us. And to acknowledge many of the people in HIVNAT, particularly in Bangkok, but also our colleagues in Amsterdam and Sydney, who’ve also put some time and effort into this. So, that’s our website. And I’d like to acknowledge my wife, who does my presentations. [laughter] Thank you very much. [applause]

MALE SPEAKER 1: We could take a couple of questions now. Please walk to the microphone if you wish to ask a question.

MALE SPEAKER 2: Thanks very much. Tim Flanagan from Brown University in Rhode Island in the U.S. A comment -- one, it strikes one how many studies have to be done in partnership with the developing world, because so many questions we haven’t been able to answer in the U.S., and examples include, as you mentioned, integrating HIV and TB treatment together; looking at strategies to monitor therapy cheaply, and doing equivalency studies to see what’s cheapest. When you think about the U.S., our patients are fortunate, largely, not to have to worry about cost. So those studies aren’t being done, so we design studies that those issues are largely ignored. In that regard, you mentioned working with the pharmaceutical companies, that generic manufacturing cannot do it alone. But it strikes me that generics can actually do it better in many ways. And a good example is using fixed combination dosages, such as is done with TB, to prevent the emergence of resistance. We’ve got great drugs that could be used in combinations together – in the U.S., Europe, and Australia – but because of the pharmaceutical barriers we can’t combine them. The issue of emergence of resistance is so enormous and adherence is so important – should we put DDI together with 3TC and nevirapine (MS?)? Should we throw (MS?) in there? The possibilities are endless.

And if Thailand can produce D4T3CC and nevirapine so cheaply, then the next step is for them to sell it regionally. And not just for their own country, but sell it -– create a market, and then you develop a whole alternative industry that can grow and develop, so -– why?

DAVID COOPER: I absolutely agree with you. But the whole issue is that we don’t get the public sector funding to move our organization forward for five years to do this kind of work. We’ve shown some leadership, to show what antiretroviral therapy can do, to show our Thai colleagues how to do clinical research, and if people want to come on the back of that and ask those critical questions – absolutely. We hope that there’s the infrastructure there to do that sort of thing. The only people who believed in us in 1996 after Vancouver was PhRMA.

MALE SPEAKER 2: There are two persons there – we’ll take two questions, and then we’ll have more questions at the end.

FEMALE SPEAKER 1: Gretchen Schmell (MS?) from AMFAR. Thank you very much, Dr. Cooper. My question is about the ethics guidelines that you use, and how do these compare to ethics guidelines in other developing countries, and are they a model for other countries? I’m speaking in particular for the mother to child transmission studies, where there are no placebos allowed, etcetera.

DAVID COOPER: HIVNAT, per se, has not done (MS?) studies, it’s not our expertise. Our expertise is in adult HIV medicine, so I really can’t – Professor Praphan (MS?) may want to comment on that. Let me say, however, about ethics committees – it’s a very, very hard standard in Thailand. All our protocols have to go through, firstly, the Chulalongkorn University Hospital ethics committee, and then on to the MOPH ethics committee. So they require two ethical clearances before we can do any studies.

MALE SPEAKER 1: Thank you.

FEMALE SPEAKER 2: Hi, my name’s Debbie Hosely (MS?) from Tufts University, U.S.A. I just wanted to ask you – you were talking about the structure and oversight in your organization, and I was wondering if you have a community advisory board or something similar to what we use in the U.S. for our clinical trials and other prevention projects.

DAVID COOPER: We do have a – I guess it’s an informal community advisory board. Professor Praphan has – one of the community organizations he’s encouraged is the “Wednesday Friends Club.” This group of people provide informal advice to HIVNAT. It’s not as formalized as in developed countries, and I think we could be doing better in that, I do accept that.

MALE SPEAKER 1: Thank you, David. Will you join us? [applause] In many parts of Asia and the Pacific there is a pressing need for greater experiments in the management and treatment of HIV infections and AIDS, among physicians and health care professionals. An expanded pool of experienced and highly trained health care providers, with knowledge of delivering therapeutics effectively and safely, is a necessary component of a comprehensive health care infrastructure that will be needed in the region. It is a pleasure to introduce Dr. Praphan Phanuphak, who will address education and training in therapeutics in Asia. Dr. Phanuphak – also known worldwide as Praphan – is Director of the Thai Red Cross Program on AIDS and the former president of the Virology and Immunology Association of Thailand. He is also Professor of Medicine and Microbiology and Head of the Department of Medicine at Chulalongkorn University, Thailand, where he conducts clinical trials of HIV vaccine and develops models of AIDS medication and counseling. Ladies and gentlemen, Dr. Praphan Phanuphak.

[applause]

PRAPHAN PHANUPHAK: Thank you very much, Daniel, and I would like to thank amfAR. As an Asian, I’d like to thank amfAR for their interest in Asia, of HIV/AIDS prevention and treatment in Asia. Of course nowadays (MS?) people talk about Africa, and even the Global Trust Fund, a big chunk goes to Africa, so it’s very gratifying to know that (MS?) agency is interested in Asia. I also would like to thank David Cooper for telling the nice story about HIVNAT, about Thailand. Before I start, I will just answer the question about the quality of the ethics committee. Nowadays it’s much better. They don’t let the protocols go out very easily; they ask lots of questions, which is good, rather than to say “no, everything’s fine.” As you mentioned about the mother to child transmission projects, (MS?) control, that one is really political issue, so I will not touch on that one. But, fortunately, there has been a result.

My talk today will just talk about education and training issues, especially for Asia. I think HIV and AIDS is a relatively new epidemic. Therefore, it’s a new medical field. Not very many people know about HIV and AIDS from medical school, at least (MS?). Most countries have (MS?). So we can do treatment a little bit better than African countries. (MS?)

[speaker moved away from microphone – not enough volume to hear him]

[speaker moved back to microphone]

PRAPHAN PHANUPHAK: We need this kind of pressure push from the patients, from the families, from community-based organizations, from the media, from the doctors. So we, as the doctors, we are pushers for care if we want to do it. Besides that, (MS?) policies. Okay? Not just policy, you need to give them some resources, some power, some weapons to do it. So don’t say “we will treat”; give them the medication that they will treat. (MS?) works. I think this is something very important. (MS?) works – that means give them a plaque, give them some good words, nice words (MS?) “you’re doing so well.” To all of them, not just to doctors, to patients, (MS?) people. So, this to me is very important.

Okay, let’s talk about forms of education. What are the forms of education? It can be extended course. Extended course may be three months up to two years. Course may not be degree, may not be diploma, may be Master’s degree, maybe infectious disease (MS?), whatever. Short course. Maybe one week, maybe four weeks. Even Asians, they like to have a certificate. Certificate can be hung in a clinic, and they say “ah ha, we have to get this.” So give them a certificate. Conference. It can be a national conference; it can even be an international major conference like this. It may be three days; it may be six days. Education can be done within a few hours – by symposium, by seminar, by special lecture – which can be organized by a national organization; it can be organized by international organizations in the country; or it can be a training program. Or it can be organized through the pharmaceutical industry. Education can sometimes be by textbook, journal, by Internet. You know, we talk about (MS?) –- the global learning network, something like that. We could use that facility. (MS?) CME, continuous medical education is increasingly demanded by various medical societies, including Thailand. This is the reason for more education activities. You want to gain some marks, some points, huh? Otherwise, you cannot renew your license.

Forms of training -– we’re talking about education, and now it’s forms of training. Training, it can be medical training, it can be nursing, it can counseling, psychosocial, clinical psychology. So don’t forget about other forms of training, rather than just talking about medical trainings.

Our medical technologist needs to have some training, as well. Psychosocial workers needs some psychosocial training. In the medical training, it can be (MS?), it can be service on (MS?), or in the clinic.

Who should provide training and education? Who should provide education? Certainly, but more importantly, I think people living with HIV and AIDS and this NGO/CEO, were an important part of providers of education training about HIV and AIDS. Don’t forget about them. Hospital University, certainly they are –- the (MS?) do it. Professional organizations, infectious disease organizations, in society (MS?). International organization or institution.

Then you offer education and training. In country, training to me is most cost-effective. It could by done by local experts. Local experts shouldn’t take a leading role. However, if you have some foreign experts like David Cooper, (MS), you know big time people, (MS?) – people love that. They will attract more people to them. It’s true. It’s true. So, you need to use a local expert, but you need to get not too many. Huh? It’s too expensive? Training abroad is very effective – many people want to (MS?). But, it’s expensive, okay? They may not have investment return.

Some have gone and they have training and they come back and they don’t see HIV patients anywhere. Don’t forget that, (MS) cooperation is cheaper and enough to give some incentive to certain people. For example, we cooperate Cambodia with China, okay? So that the doctor’s coming to Thailand –- from China from Cambodia, it’s not bad, huh? Maybe a little bit –- not as good as going to Australia or to America, but these two can enjoy something in Thailand.

So, you know, it’s a good enough incentive. (MS?), can be used for in country training and training abroad. Okay? So I’m saying here, if you get a grant, getting all the people back to U.S., for the training, you know, these kind of people can be trained in their own countries, or in (MS?) countries, or in maybe a few months in USA or something like that. Don’t just say, “oh, this kind of people have to work institution.” Don’t think about that.

(MS?), I just give you some example of what we are doing. In 1894-’87, self-learning. You know, just looking at it by textbook and some journals. We also have some trained i.d. expert coming back from the states. Now, I came back from the states in 1978. I didn’t know anything about HIV and AIDS. 1988 to 1992, it’s many by training abroad. Chart course, conference, and field trip.

1992 to 1996, we had Scott Hammer (MS?), courting a grant from (MS?) foundation. And he came to Thailand twice that year and have training in Bangkok and in certain parts of Thailand. In 1997, up to now, as David Cooper said, we have the Bangkok Symposium in Medicine. Besides that, HIVNY, also organized clinical trial training for doctors in Cambodia and doctors in Thailand. In China, they come maybe two weeks or four weeks for just clinical trials training.

I’m going to tell you about some –- this is large scale training time, because people just ask me, especially people from (MS?), “you trained 300 people at the Bangkok Symposium. How can you get thousands of Thai doctors to other countries knowing about HIV and AIDS? It’s an appropriate question to ask.

So what we’ve had to do was this one. We have training for the trainer course. We call it core training. We organize by the Thai society, by HIVNAT, by public health. The trainers will be members of the Thai Society, members of HIVNAT. The trainees will be so-called experienced and also junior staff from teaching hospitals, and also excellent senior staff on regional hospitals.

(MS) will be in Bangkok. There will be three to five days training. (MS). This will be also have (MS)? And they will have teaching materials for them. This will be supported by grants that we are going to request from some organizations. This is the second to last slide. And, after this last scale, core training, will be a second-level training, again to be organized by the organization. However, the trainers of this course will be the first year trainees. They will become the trainers, plus some expert making tips on epidemiology and the other things. And the trainees here, this is not trainer, trainees here will be doctors and nurses from each provincial hospital. And all this it comes from the same province. And it will be in the province itself.

It must be half a day cost. You cannot do it longer than half a day. The doctor has to work in the work. So just work in the afternoon. We connect up there with the email link. A number of such trainers, particularly in the province, will be identified and publicized as a local resource person so that other doctors can request from them, and the support will be from the Thai society, as is by the provincial authorities. So, thank you for you attention. I will stay here.

[applause]

MALE SPEAKER 1: The first question (MS?). Please. I’ll go back to that one first, and then you second.

MALE SPEAKER 2: Thank you, Dr. (MS?). He is my doctor. He is my overall doctor. My name is Paizan (MS?). People will (MS?) from Thailand. I would like to ask something more as a whole picture, what is happening in Thailand now. If one is –- many thing you say, and also, if important issue is we have to educate, and educate as a community. And people (MS?).

And I would like to ask, on behalf of people with HIV and AIDS network, the last time, we demand the most at most common -– how common, how to universal (MS?) –- but we demand the (MS?) must cover anti-(MS). The (MS?) expect that, but it (MS?). They accept as a principle, but in a practical way, what we face now is many serious (MS?). Because it’s still their attitude. It doesn’t want to treat people with AIDS. Another thing I want to say is, yes, even we –- in Thailand, yes, we have many people with HIV and AIDS, and we tie all the nice people with AIDS to demand what we need.

But, sometime we not like how we can get this. People with AIDS will be allowed to advocate them. I think, even HIVNAT, it doesn’t help people with AIDS in (MS?). You know, and we saw (MS?), which is when people with AIDS in Bangkok and in the (MS?) area, you know? When we (MS?) – it’s only people with AIDS from Bangkok.

I think it might be helpful if HIVNAT have some people with AIDS (MS?) and try to advocate people with AIDS. Also, because I think – this is – you cannot only say, “0h, well, we’re not involved.” But, you must start on your own soil.

Yeah, I think this is very important meeting. So, not many activists in (MS?). Not many, really. I think it’s cool for a lot of countries such as that, but I would like suggest also HIVNAT (MS?).

MALE SPEAKER 1: Thank you. Don’t go. Stay with us. Let me turn to David Cooper, perhaps, and ask him a quick response on HIVNAT. David, inclusion of people with HIV under management of HIVNAT, is it happening, will it happen?

DAVID BLOOM: Well, thank you very much. The synergistic relationship between the education training and therapeutics with Serf (MS?) components of Treat Asia will have a broader societal impact. In time, it could get – exert a far-reaching positive influence in the area of HIV prevention and (MS?) infrastructure for the treatment of people with HIV/AIDS.

Our last speaker today will be Dr. Suniti Solomon, who will be discussion care and treatment for people with AIDS in Asia. Dr. Solomon is the founder and director of the Center for AIDS Research and Education at the YR Guyton (MS?) Medical Educational and Research Foundation in Chennei, India.

In 1993, Dr. Solomon founded YRG Care, a non-profit institution that now provides healthcare for over –

[AUDIO GAP]

[applause]

: Thank you very much, David.

Unfortunately, in the morning, in the plenary session, I was the last speaker. And even here, I am the last speaker. And I’m glad here there are people still sitting here, but in the plenary, they all walked out.

I prepared a long talk, but I’m not going to read it. I’m going to just talk whatever I can in the shortest period. The other reason is I think I should also acknowledge that YRG Care is taking care of 4,000 patients is because of our collaboration with the Brown University. And I’m very honored that the whole team from the Brown University is here.

So I’m just going to talk about the issues of care and treatment in Asia. And I’ll make it very short. So what are the challenges we face taking care of people with HIV in India? One, there is a rapid increase. People have been talking about it. Second, and the most important is low perception of risk.

I would say 90 percent of people in Asia who are infected do not know that they are carrying the virus? Why? Because they perceive they are not at risk. Second, we need to have more voluntary counseling and testing services in Asia, especially in India, we have in the city I come from, we have just two. One which has set up at the Madras Medical College, and the other at YRG Care.

Until date, there are more than 12,000 people in the last nine years who have walked into our clinic for counseling and testing. And counseling is a new aspect in the Asian countries, health counseling.

I don’t think before the onset of HIV, we had what is known as counseling at all. The next most important is stigma and discrimination. And that is what is preventing people for coming up for testing. And we need to address this issue of stigma and discrimination if we want to treat people with HIV and AIDS.

The next is need for capacity building of healthcare workers. I think Dr. Profan (MS?) has put it so well. I don’t need to add anything onto that.

Lack of infrastructure in laboratories and generator back up. Like I said, you can have big laboratories in Asia, but we get one big cyclone and the electricity is cut for 48 hours. We have no current.

So we need a back-up generator. You know, there are many infrastructure we need, which we have built up because of our collaboration with the universities in the U.S.

Availability of drugs, both for OI and ARV and clinical research, which benefits Asia, which Dr. Cooper has put it up so well. So I won’t go into those details.

Now four other countries in Asia are – HIV/AIDS is only the eighth leading cause of mortality. So you can always hear our political people say that oh, HIV is not the major problem. We have other diseases.

The rapid increase – I’m just giving you an example from our center. You’ll see some 1997, every six months, how the numbers have increased. Today, we are taking care of more than 4,000 patients.

Perception of risk, just to give you one example, a little project we did to the Fogerty and the Brown University was the acceptability of microbicides, because I think microbicides would be a wonder thing for the (MS?) in India as an empowerment tool.

Did you ever feel that you are at risk of getting HIV? The gender population, women, said 12.9 percent and men said 3.6 percent. How many partners did you have sex with? 68 percent of the gender population, men, and 6 percent of women had multiple partners, but they still don’t perceive the risk.

Did you use condoms while having sex with partners, other than spouse? 13.7 percent across all groups used condoms always. Just 13 percent. And still, they feel that HIV won’t affect them.

These are our statistics from the voluntary counseling and testing center. From Chennei, as I told you, we had more than eight – 12,000 people who had walked in. And this disease, like some of us believe is not just of the poor. We have professionals. We have housewives. You’ll see 22 percent of women who have a single partner.

We have professionals. We have doctors, engineers, lawyers, film stars, almost every strata of the society. What is really a problem in India in voluntary counseling and testing is mandatory testing. So as Profan (MS?) said, in spite of your trying to train people, people are scared of Havafeur (MS?). So the training has to be hands-on, like we had a World AIDS Foundation project.

Along with the Brown University and John Hopkins, we did the training hands-on. They relaxed the patients -- handle patients – I mean, the doctors handle patients every afternoon for 15 days, which I think is – made a lot of difference, because mandatory testing happens for pre-operative surgery, anti-natal, employment, life insurance. Immigration to United States, you need to have an HIV test done, and overseas cashier workers.

Stigma was the one which affects us the most. I’m just giving you two stories of 1996, when I got the first anti-natal woman, who walked into our clinic. We took dozens of phone calls to get an OB/GYN, who would help this woman.

Finally, we succeeded for a one time soul. On April 14, 1996 at 6:00 p.m., she went into labor. But the kind soul went on a holiday because she knew that was her due date. And (MS?) had changed the names went from pillar to post. Finally, dumped her in a nursing home without disclosing her HIV status.

Six years later, this is the story. This is her first pregnancy of one of patients, twins. I just picked up the phone and called my friend, Shelia, who is here in the audience. And (MS?) informed everything is done a happy ending. And the last 35 cases, we have done a study with Brown University all the 35 babies are HIV negative.

The spectrum of opportunistic infections, you can see there are a variety of those. Some of these, I had not seen in my 30 years of experience at the government general hospital of Madras Medical College. And there are varying and different parts of Asia.

So it doesn’t matter the area you are taking. You have to think of cases, which you may not have ever seen in your life, because of the new diseases which are coming.

So clinical percentage in Asia, I would divide into four. Could it be HIV? Aggressive presentation, emerging opportunistic infection, and AIDS defining illnesses.

If a doctor sees this, the first thing they would have to think is of HIV. The feet you see are of a nun who was 50 years working in a school. She was 72-years old. She had been scratching her skin for two years and nobody ever suspected HIV, because she was a nun. She had a blood transfusion five years earlier, and that was the cause.

So – and multi domitomal (MS?) herpes. Many times, people miss. These are lessons I think healthcare workers need to know if you want to treat people aggressive presentation.

You’ll see this as a case of – I’m sure I don’t know how man of you will recognize this, a case of gama (MS?). I saw a last case of gama 35 years ago, when I was a house surgeon in Gama (MS?) General Hospital.

Today, the station came with just about four years of STD. I mean, VDR positive. And within four years, he had reached this tertiary stage of illness.

(MS?). We had never seen a case of Toxoplasmoses. This was diagnosed in Calcutta as a tumor in the brain, came to Madras for surgery, and then we found with the CT scan a (MS?) was done mandatory testing. And we found he was positive. My clinician treated him. He’s fine, back in Calcutta with his family.

This is a case of penicillium which we thought was not ever happening in India. But this patient traveled from the northeast, and a case of penicillium, which is very common for Profan.

When we started working with HIV, they said we’d only get TB and PCP is a disease of the western country. And this is the first report from India where PCP was done as a research study.

AIDS defining illness (MS?), the only case of Kaposis (MS?) sarcoma we have diagnosed from India for a drug user from (MS?).

Now for all these, we need definitely a good lab. When we started our organization, our lab was a kitchen. And we were just doing – tried outs and Western (MS?) lasers.

Today, our lab is quality assured by KAPS. And we have some rights from CDC to wider loads. And we are doing drug and system testing. We need in countries like Asia, not to depend on CD force, but look at inexpensive tests, like TLC, Dynafed (MS?), T-24 instead of CD-4s. And what Asia needs is a continuum of care, which never happens because of the stigma attached. We need daycare, home care, hospital care.

And this is what happens when a person has a good continuum of care. This was a study done with Horizon, where you’ll see in any stage they come in, early, late or advanced, with integrated care, they get a better quality of life, treatment of illness, episodes come down, and the cost as well comes down. And this study is being presented on Thursday at the Synergy USAID satellite session. So those who are interested can come for this.

The burden of cost and treatment normally increases with (MS?) stage, but in this study as the frequency of illness episodes reduced significantly expenditure also came down, both for the person and for the institution.

Treatment with a temo (MS?) prophylaxis is another thing which every Asian country can do. I don’t know why people don’t start off patients with TMPX. It not only reduces prophylaxis for PCP, but also for Toxoplasmoses, bacterial respiratory infections, and diabial (MS?) diffuses.

People talk about the cost of ART, but with quality of life and longevity, I don’t think any of these matter if we can give ART to our patients.

When people can spend so much on defense, I don’t know why our countries can’t spend more on health.

(applause)

With ART, and people with pulmonary tuberculosis, you’ll clearly see how life – the longevity of life is much more when a person is with ART and ATT.

I know that as cost combination of drugs I think upon went through all this interaction of OIs with – OI drugs with PI at the adverse effects, the adherence, but I think adherence is much better in Asian countries, because people buy the drugs.

There are side effects which can happen. These are access in Malaysia. People are on monotherapy still, dual therapy, triple therapy. Some of them are on nil. But these are type of skeins we need for Asia.

Where government subsidizes one drug, the Malaysian AIDS sponsor does one drug and the patient has to buy only one drug. And if the drug is going to cost $1.00 a day, I’m sure this would be easily available for all the patients in Asia.

Support services is a must. If you can’t give ART, don’t think that’s the end of a percentage HIV. With good nutrition, test reduction activities, support, arranging marriages, because these are cultural issues these days, education of children, grief counseling. Because 88 percent of our patients who are women are only a single partner and the infectionist.

The next major problem, we have 27 million live bots (MS?). And even in the anti-natal prevalence is 2 percent, you’ll see it will be about 226,000 babies being born with HIV unless we start Nevirapine (MS?) the government of India has started.

The next major problem, widows and orphans. And these will go on and on. A lot of unethical issues happening, which has to withstand early if we want.

And in conclusion, significant symptom control can be delivered at low cost. So don’t think treating HIV is expensive. Early detection of HIV optimizes OI prophylaxis. Management should take us on common OIs and symptoms. Reducing maternal, fetal transmission is a priority. Antiretrovirus is your – if the patient can afford, use it.

The best practice or don’t start at all, because there a number of patients who start and stop. And the resistance strains would definitely go up. Provide a continuum of care, using (MS?) disciplinary team. Enhance the universal precaution. And cost occasion care decreases with training and experience of doctors.

Thank you very much.

[applause]