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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

The face of global AIDS

Kathleen Ingley
Republic editorial writer
Sept. 26, 2004 12:00 AM

The hookers of Mumbai look at each other warily. Monsoon rain drums on the window as they consider my question. Does anyone want to explain to an American writer: How did you end up here?

The women, a couple of dozen, are sitting on the floor in a day center, a haven for sex workers during their off hours. Statistically, at least one in three is infected with the AIDS virus. I'm trying to understand what leads to that chilling statistic. And, the real issue, how to reduce it.

Finally, a young woman in a shimmering bronze sari gives a little nod. She'll answer. Sitting cross-legged in the angular way of a kid, all elbows and knees, she has a face of such translucent innocence. It's inconceivable that tonight she'll be servicing johns for no more than a couple of dollars a customer.

She used to live in a big family in a village. "When I was 11," she says through an interpreter, "a woman came to my school. She wanted to take me to Mumbai. She said that I'd meet movie stars and foreigners."

The other women burst out laughing. Maybe some of them were taken in, too. The movie-making capital of India, Mumbai (or Bombay, as most of us still know it) has all the allure of Hollywood for a girl out in the sticks.

But Mumbai also has Kamathipura, said to be the largest red-light district in Asia. That's where the starstruck 11-year-old was taken and sold to a brothel.

"How old are you now?" I ask.

"Twenty-one." The number jars me. It's the age of my daughter. While a Phoenix girl spent the last decade going to school, playing soccer, taking piano lessons and starting college, a Mumbai girl was turning tricks.

Can't she escape somehow? Run away home? She shakes her head. Her family would know she'd been a prostitute. And, she adds matter-of-factly, "They'd kill me."

Instead, she runs the risk that AIDS will kill her.

The infection rate with HIV, the virus that causes AIDS, is 30 to 50 percent among Kamathipura's sex workers and rising. The deck is stacked against her.

It shouldn't be. There's no excuse for writing her off as another statistic.

We don't have a cure yet for AIDS, and a vaccine is years away.

But we know how to prevent this deadly disease. We have the medicines to treat it, keeping infected people healthy and prolonging their lives.

That has given us a handle on HIV/AIDS in the United States. The number of new infections has leveled off - although at 40,000 a year, it's still way too high.

Treatment with anti-retrovirals, which suppress the virus, is widely available, and people have lived with the disease for years.

So it's easy to forget what a frightening global threat we're facing.

Secretary of State Colin Powell calls HIV/AIDS "the greatest weapon of mass destruction on the face of the earth today." It kills more than 330 people an hour. One in six of the dead is a child under 15, nearly always infected at birth or from breastfeeding.

Asia has become a critical front in the battle against HIV. An estimated 7.4 million people are infected - the equivalent of a mortal disease striking the entire population of Arizona and Nevada. Spread through unprotected sex, contaminated needles and tainted blood supplies, the infection is largely confined to high-risk groups: prostitutes, drug addicts and men who have sex with other men.

But the number of victims will grow explosively if HIV breaks out into the general population.

How bad can it get?

As many as three of 10 adults are infected in parts of southern Africa. By 2020, the average life expectancy in Bostwana is projected to sink below 30 - half of what it was just seven years ago.

Avoiding that dark future is the goal of the 15th International Conference on AIDS in Bangkok in mid-July. I'm attending it with a group of editorial writers from newspapers across the United States. It's the start of a two-week trip for a firsthand look at the AIDS crisis in Asia.

By the time we leave the conference, my head is stuffed full of statistics and policy. I'm prepared with lots of background on Cambodia, our next stop, including the fact that almost three out of 100 people are infected with HIV.

I'm just not prepared to see a mother cry.

The woman is 41, HIV-positive, infected by her husband. Her eyes fill as she talks to us through an interpreter. Suffering through bouts of blinding headaches, she knows exactly how the virus is poised to eat away her life. She nursed her husband through AIDS until he died four years ago.

He left her with five children to raise on her own in the vast slum on the edge of Phnom Penh. The youngest, a listless boy of 5 who looks far too tiny for his age, has HIV, too. Two doses of medicine, given to the mother in labor and the baby in its first three days, could have kept him well.

The tears begin to overflow, making slow, wet tracks down the woman's cheeks. She doesn't bother to wipe them away.

She rents a tiny three-walled space for $6 a month, an exorbitant price in this impoverished country. The back wall, in a surreal touch of irony, is decorated with AIDS-prevention posters. There's just room for the wooden platform that serves as all-purpose furniture - bed, table and seating - in Cambodia. When she feels well enough, she tries to make a little money selling produce.

In the United States, this woman would be treated with anti-retroviral drugs.

In Cambodia, she's not sick enough.

The cost of anti-retrovirals has plummeted, from $10,000 annually just four years ago to as low as $140 a year in developing countries. Not that the average Cambodian can afford the tab, which is half the per-capita annual income. Now it's feasible, though, for foreign aid and non-profits to support large-scale treatment. And funding has jumped in recent years.

But help still reaches a small fraction of those who need it. Of the 28,000 people in Cambodia who should be on anti-retroviral drugs, barely one in 10 is getting them.

Money is one problem, logistics is another. The challenge of delivering health services in a country like Cambodia is obvious.

The capital city has no towering high-rises, the side streets are dirt, motorcycles outnumber cars. And "bare bones" is a kind way to describe the facilities at the Russian hospital, which gets its name from the days when the Soviets were about the only ones building public works projects in Phnom Penh. Now it's mostly devoted to AIDS patients, 60 of the sickest of the sick.

With its open-air halls, louvered blue shutters and stained white walls, the two-story stucco building has more atmosphere than equipment. No air conditioning, no fans, no screens.

In one room, a man lies motionless in bed, a stick figure in long-sleeved pajamas with a blanket pulled up to his armpits. He's curled on a plastic mat spread over the vinyl mattress - the hospital doesn't furnish sheets. The man was a construction worker, and he felt sick off and on for three years. Now - he barely has the energy to get out the words - he knows it's AIDS.

The symptoms of HIV infection may not appear for years, but the virus is multiplying. Then come fevers, weight loss, rashes, bone-crushing fatigue and, finally, the collapse of the immune system into full-blown AIDS. Patients die from infections that their bodies are too weak to fight off.

The disease is insidious, striking the vigorous adults who support a family. Eating away the economic backbone of countries. And leaving children behind.

There is hope. The effect of anti-retroviral drugs is quite literally miraculous.

We visit Heng Chamroeun in a working-poor neighborhood, a crazy quilt of two-story buildings made from wood, metal, cement blocks and apparently whatever else was at hand. Baskets and pails are hung and heaped at the back of her cramped home - tools of the trade when she sells fish.

Sitting with her feet swept back, in a sleeveless print top and royal blue pants, this slender 34-year-old woman, with short, wavy hair, looks so healthy. But less than two years ago, she was too exhausted even to walk, struck over and over with diarrhea and fever.

In her own way, Heng is a heroine in the fight against HIV/AIDS. She refuses to hide her illness, as so many patients do. She shrugs off the way some people steer clear of her, afraid of getting sick.

Heng wants her neighbors to know about AIDS and how it's transmitted. No one, if she can help it, will first learn about the disease the way she did. Too late. When she was already infected.

Her husband was a soldier, a job with a high rate of HIV infection in Cambodia. He died of AIDS three years ago. Their children are now 4 and 14, and - she's almost afraid to say it, to tempt fate - so far their blood tests are negative.

More and more, the new cases of HIV are among women. A wife can avoid risky behavior herself. But if her husband doesn't, she rarely has the leverage to insist on using condoms.

Heng shows us two bottles, the anti-retroviral drugs that brought her back to life and keep her alive: One is a brand-name medicine made by Merck, and another is a generic version produced by an Indian company.

That's only the first-line drugs, though.

Eventually, Heng's lifesaving medicine will stop working, as the virus becomes resistant. She'll need second-line drugs. And then maybe third or fourth generations of medication - drugs that are far more expensive and barely available in Cambodia now.

Heng has no illusions about how tenuous the future is. Strong as she is now, she wonders, "Who will take care of my children when I die?"

The flip side of treatment is preventing people from getting infected in the first place. Prevention strategies are getting better. But they still need a megadose of steroids.

Nowhere is that clearer than in India.

The HIV infection rate is under 1 percent. But the figures are grimmer in a few states, where the disease threatens to break into the general population. And the sheer size of India means that a tiny increase in infection rates translates to a huge number of cases.

Flying into Mumbai, I can see vast warrens of slums, the rows of shacks so close together that it was hard to see how people got around.

The city is so crowded and chaotic - ox carts mingle with trucks, bikes, pedestrians and taxis on major streets - that tackling HIV seems overwhelming. The Indian government has shown far too little initiative in taking on the job.

But there are small successes.

One of them is SUPPORT, the acronym for the awkwardly named Society Undertaking Poor People's Onus for Rehabilitation. The program rescues street children who use drugs, giving them a place to live. The goals are to treat their addiction, put them in school, teach them a trade and keep them from getting HIV.

We visit the boys' facility in the middle of study time. Rows of elementary-age boys in crisp blue shirts and navy shorts sit on the floor in a long room, reciting lessons. Their eager smiles are irresistible, and it's hard to believe what an effort it takes to get them to this point.

These kids, some as young as 6, used to spend their time getting high, sniffing whatever they could find. Driven to the street by poverty or domestic violence, they lived for instant pleasures, getting beaten by police and abused by older boys, with lots of risks and no routines.

Around the corner, three older residents are painting a poster for an awareness rally about drugs and HIV. I don't have the heart to point out that the carefully lettered word "sponsored" is misspelled.

India recently replaced South Africa as the country with the largest number of HIV-infected people.

At the day center in Mumbai, the sex workers say they understand that condoms would protect them from HIV.

But many of the brothel owners don't want to do anything that might discourage business, not when customers will pay more for unprotected sex. So India loses out on a proven strategy to fight AIDS. In nearby Thailand, the government slashed HIV infection rates among sex workers by requiring them to use condoms and strictly enforcing the rule.

India has another challenge - most prostitution occurs outside of brothels. Hookers operate out of their homes or travel around, working festivals and truck stops.

India needs to target customers, and truckers are at the top of the list. They're becoming an express route for HIV infection. In one Mumbai clinic, 11 percent of the truckers who were tested came up positive.

The heat of the engine, goes the myth among truckers, is transferred to their bodies. If it isn't released through sex, they believe, they'll go blind.

At a terminal in Mumbai, a few miles from the red light district, the lines of trucks stretch as far as we can see. The vividly painted trucks are works of folk art, mixing geometric designs, birds and flowers.

The truckers mill around, desperate for entertainment. So groups like PSI/India combine a dollop of AIDS prevention with a lot of show business.

They're using all kinds of gimmicks to draw crowds as we walk through. An actor manipulates a monkey puppet, although his punch lines seem to be falling flat, judging by the sour expressions of the onlookers. A Charlie Chaplin look-alike is having better success (oddly, he's well-known in India, partly because of a local actor's parody).

A handful of men hoot with startled laughter at a skit nearby: The plot is a role reversal, with the wife on the road and being unfaithful, bringing the infection home to her husband.

HIV isn't a distant plague that we can ignore.

It's threatening to destabilize countries, creating a breeding ground for terrorists among people with no hope. The world economy will stumble if the epidemic becomes widespread in India and China, home to a third of the people on the planet. To top it off, we face the risk that new, drug-resistant forms of the virus will develop.

What do we have to do?

• Add money. Turning around the AIDS epidemic requires a dramatic boost in funding for low- and middle-income countries. We need $12 billion in 2005, more than double current spending, rising to $20 billion by 2007. These are big sums, but not impossible.

• Tap every resource. While the United States should step up its contributions, other developed countries, such as Japan, should chip in far more. India and China can finance much of the HIV battle in their own countries, but need the will to do it. Non-profits have raised a lot, but can do even more. Corporations in HIV hot spots are starting to treat and educate their workers. The poorest countries should get relief from their crushing foreign debt load, with the condition that they redirect much of the money to HIV/AIDS.

·  Support the Global Fund to Fight AIDS, Tuberculosis and Malaria. The United States helped found this public-private partnership to channel resources effectively. But, even with the help of farsighted lawmakers like Arizona Rep. Jim Kolbe, it's a struggle just to keep U.S. funding at last year's level.

·  Give women the tools to protect themselves. High on the list is supporting research to develop microbicides, HIV-killing products that women can apply before sex.

·  Cut through the dispute over generic and trademarked drugs. We need to uphold drug patents, while still allowing cheaper, generic versions to be made.

·  Promote the ABC strategy: abstinence, being faithful, using condoms. Overhyped by supporters and underappreciated by critics, it can be very effective but requires strong leadership, publicity and resources.

"Access for all" - to treatment, to prevention - was the theme of the Bangkok AIDS conference.

Access is such an abstract word.

It can't convey the human side of the HIV epidemic.

It doesn't show the way a Cambodian woman huddles at the edge of a mat, her legs drawn up and her arms wrapped around herself, as if she's trying to take up as little room on the planet as possible. As if, by imposing so little, she could improve her chances of getting help.

As a journalist, I know that it's dangerous to make policy by anecdote. But it's equally mistaken to forget the individuals whose lives are at stake.

Kathleen Ingley is a Republic editorial writer. She can be reached at or (602) 444-8171.