An Interview with J.V.R. Prasada Rao—Bringing At-Risk Communities in From the Cold
September 2007—As the director of the UNAIDS Regional Support Team for Asia and the Pacific, J.V.R. Prasada Rao has been deeply involved on all fronts in the fight against HIV/AIDS in the region. Speaking with the TREAT Asia Report, Mr. Rao discussed the realities of prevention efforts in Asia and urged sharply increased attention to the region’s most vulnerable communities.
TREAT Asia Report: You’ve said that at least 80 percent of Asia’s vulnerable populations—including injecting drug users (IDUs), men who have sex with men (MSM), and sex workers—will need to be reached to achieve levels of condom use and harm reduction that could stop the spread of HIV/AIDS. Where do Asian nations stand today in relation to this goal?
J.V.R. Prasada Rao : If you look at the Asian scenario, we’re still nowhere near reaching 80 percent of target populations. In the case of sex workers, prevention programs reach only around 15 or 20 percent, in some countries even less. For injecting drug users, I think it’s just 10 to 15 percent. Coverage for men who have sex with men is very, very low. So there is a need for a very large scale-up if you are to achieve that 80 percent coverage.
TA Report: What are the primary obstacles to ramping up prevention measures in Asia?
Mr. Rao: The important part is to have the political will, and also to have adequate resources for the scale-up. We are close to that because in most Asian nations we have now realized that most of the time prevention needs are centered on three sectors of the population—sex workers, IDUs, and MSM. So we need to take a strong lead and put specific plans into place.
But what is lacking are resources—financial and, most importantly, technical resources. If you want to scale up, you need large-scale cooperation from civil society partners. These are not government programs—they need to be implemented by local partners. And many countries don’t have the capacity to create and implement programs on such a large scale. So the real challenge is scaling up technical support.
TA Report: What lessons can be drawn from the most effective local and national prevention programs in Asia?
Mr. Rao: A lot of money has gone into general awareness programs but their impact has not been adequate. Condom promotion strategies could be good but they are not really focused except in countries like Thailand and Cambodia. HIV is spreading among vulnerable populations, but money is being put somewhere else, so there is a mismatch in the effort. This needs to be corrected if we really want to have effective prevention strategies.
J.V.R. Prasada Rao
TA Report: You have recently spoken out strongly about the necessity and wisdom of expanding harm reduction and other prevention measures for IDUs, pointing out that prevention measures have shown significant results. What research can you point to in Asia that can persuasively make this point to opponents of harm reduction?
Mr. Rao: I think this is clearly evidence based. Wherever harm reduction programs have been implemented, HIV rates have dropped. The most effective programs I can see are those in China, especially in Yunnan Province, but we have some programs that are also very effective in Bangladesh, in parts of northeastern India, and in Lahore in Pakistan. So there are good examples where the evidence has shown that a strong harm reduction program can generate positive results. But only when you launch these programs in large numbers can you see the infection levels coming down. Otherwise, just having one or two very good programs is helpful but they won’t be effective in reducing the overall level of infection.
TA Report: Malaysia and other Muslim nations are embroiled in a theological disagreement over the acceptability of harm reduction measures. What role would you say international NGOs, such as UNAIDS or TREAT Asia, can have in such a debate?
Mr. Rao: In Asia, when you look at Muslim nations like Pakistan, Malaysia, and Indonesia, usually there is a segment of religious leaders who are opposed to harm reduction measures, but a large number are increasingly turning toward supporting these programs. In Indonesia we have very good support for harm reduction programs and in Pakistan syringe exchange programs are being implemented. In Malaysia, the government has announced a policy supporting harm reduction, but there is organized opposition to it from some clergy. What we need to do is mobilize the moderate and progressive segments of Islam and see that their voices are heard. In Indonesia a few months back, we organized a conference of Imams from the Muslim countries in Asia who came out with very powerful messages on prevention, both sexual and among IV drug users.
TA Report: If harm reduction measures present the most effective method of HIV prevention among IDUs, what strategies seem the most promising among MSM and among sex workers?
Mr. Rao: With sex workers and MSM, the emphasis needs to be on safe sexual practices, which, of course, emphasize the use of condoms. Condom promotion programs need to be of high quality, not just giving out condoms but ensuring their availability and affordability. Many times you find good programs but they may not have very strong condom supplies or they may issue substandard condoms. Some of these things are just a question of good implementation. But we need to have condoms because that is the only effective method of prevention available to these populations.
TA Report: What role do you think circumcision could play in Asia?
Mr. Rao: Circumcision has been shown to work—there is evidence that sometimes it lessens HIV transmission. But circumcision as a prevention measure is very dangerous to advocate because it is not 100 percent efficacious. And you need to take sociocultural practices into consideration if you’re advocating circumcision as an option. This isn’t a simple solution.
TA Report: In developed countries, mother-to-child transmission of HIV has essentially been halted. But in Asia and other resource-limited regions, infants are one of the most vulnerable groups of all. Because health-care networks for pregnant women exist throughout Asia, it seems as if treatment and prevention might be relatively easy to address, but statistics show rising numbers of pediatric HIV infections. What can be done to help reduce mother-to-child transmission in Asia?
Mr. Rao: Even though health-care systems are much stronger in Asia than in Africa, here you still find limited access to care, especially in rural areas. In fact if you look at India, not more than 40 to 50 percent of deliveries are done in institutions. A large percentage of infants are still delivered at home, particularly in South Asia.
If you want to have an effective program to prevent mother-to-child transmission, you need to have links with health-care institutions and the medical ability to follow up. But in Asia there is very limited coverage—at best you have no more than 20 to 25 percent coverage of programs to prevent maternal transmission. That’s a debilitating factor. So we need to look at alternative methods of service delivery such as using civil society partners or private health-care institutions, which have a much better reach in some countries than public health-care institutions.
TA Report: For a variety of reasons, women, particularly married women, continue to be unable to protect themselves from HIV. What would it take for women in Asia to be able to fight back against the epidemic?
Mr. Rao: HIV among married women is, in fact, the most serious problem in Asia, because almost 80 percent of Asian women who get infected are monogamous and they contract HIV from their husbands. They get it through no fault of their own, but they are more stigmatized than their husbands because of imbalanced sexual relationships.
This is a real problem that has not yet been addressed seriously. The prevention programs we have undertaken are very general, as I explained, and women who get HIV from their husbands have never been an object of focus. So we need a different strategy in Asia that addresses these married women.
TA Report: One issue that confronts HIV-positive people in Asia right now is second-line treatment, which is essentially unavailable to most for reasons of cost. How can the impasse be broken between the pharmaceutical companies and the governments of resource-limited countries that need to provide medication for their citizens?
Mr. Rao: This problem has not been properly addressed. If you look at the numbers, coverage should not be a big issue except in two or three countries such as India and Cambodia and Thailand, which have large infected populations. In many other Asian countries, the number of infected people and the number of those who need antiretroviral drugs at this moment is not large, so it should not be difficult for these countries to take up universal coverage of treatment for those who need it.
The distinction between first- and second-line medication is an artificial one because treatment is a continuous process. For some governments, it is more of a mental block than a serious operational issue. Generics are available—countries such as India produce quite a number of generic second-generation drugs—but still the cost is high. So I think governments just need to come up with different strategies to contain costs, such as using compulsory licenses or parallel importing. I think these are available under the World Trade Organization terms. And Thailand has shown the way when they issued a compulsory license for a second-generation drug. I think countries should look at the WTO flexibilities to make second-line antiretrovirals available.