The face of global AIDS
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
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
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
So it's easy to forget what a frightening global threat we're
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
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
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
In the United States, this woman would be treated with
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
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
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
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
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
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
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"
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
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
• 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
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
email@example.com or (602) 444-8171.