AIDS

Health officals from across the globe met in Bangkok, Thailand July 11th - 16th for the XV International AIDS Conference. This year's participants noted that despite increasing awareness about HIV/AIDS in recent years, the epidemic continues to expand. What fuels the spread of the virus and what role does stigma, in particular, play? What were some of the most salient issues discussed at this year's conference? What are the implications for the United States coming out of the conference in Bangkok and where do we go from here?

Frank Beadle de Palomo, senior vice president and director of the AED Center on AIDS and Community Health, was online Friday, July 30, at Noon ET, to discuss the XV International AIDS Conference and U.S. AIDS prevention policy.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

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Frank Beadle de Palomo: I wanted to start out by saying hello to everyone logged-on, and to thank the Washington Post for creating important forums like this to discuss the global HIV/AIDS pandemic.

My name is Frank Beadle de Palomo, I am the Senior Vice President and Director or the Academy for Educational Development's Center on AIDS & Community Health.

The Academy for Educational Development (AED) is one of the world's foremost human and social development organizations. Our major areas of focus include health, education, youth development, and the environment. We work globally and in the U.S. on HIV/AIDS prevention and care programs that reduce stigma and discrimination, promote prevention with HIV-positives, provide care for orphans and vulnerable children, reduce transmission of HIV through workplace education and prevention efforts, prevent mother-to-child transmission of HIV, and diffuse effective behavioral and biomedical interventions.

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S.E. Washington, D.C. : Hello and thanks for this chat. At the conference, was there much discussion on models of integrated approaches toward controlling spread of HIV? Dealing with the multitude of social, economic, and health care availability problems that put people at risk of exposure is hard to do, but aren't there some resource-strapped countries out there successfully dealing with the poverty, the lack of basic amenities such as clean drinking water and access to preventive care (e.g., vaccines, treatments for STIs) and the dearth of free and accessible primary education, etc., that serve as substrates for the rapid-fire spread in many places? Making control of HIV/AIDS a political priority across Ministries or Agencies is important, too.

Frank Beadle de Palomo: Thank you for your comments and questions.

Yes, there are many resource-strapped countries across Africa, Asia, and Latin America that are doing focused work in basic health care, child survival, focusing on STIs, creating access for education, and other key activities.
These programs are critical: basic health, nutrition, education, and job training supports overall health outcomes and definitely mitigates the effects of AIDS.

However, as you allude to, if AIDS remains an AIDS or health sector issue, the full complement and resources of a country cannot be marshaled to comband mitigate its effects.
Multi-sectoral approaches offer realistic opportunities to provide prevention and treatment services in places that best reach those at risk. The immediacy of the AIDS epidemic for HIV-positive and high-risk negatives makes school settings, family-focused health services, and workplaces critical venues and options for ensuring access to linked prevention-treatment interventions.

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Cary, N.C.: What is the American government going to do about the staggering costs of maintenance medications that AIDS patients require?

Frank Beadle de Palomo: Your question is a good one. I am not a U.S. government representative, so I am unable to speak on behalf of the American government. Impressively, through U.S. efforts, European, private foundations, and others, we have learned that creating access is not the core problem. Moreover, as we ramp up access to HIV/AIDS medications (largely ARVs) in developing countries through the President's Emergency Plan for AIDS Relief in 12 African, 2 Caribbean, and one Asian country, we are seeing clear signs that a massive roll-out of AIDS-related treatment drugs can be accomplished.

I think, however, that the U.S. is going to have to focus on maintenance costs (i.e., access to ongoing meds), but also the infrastructure to support effective treatments such as laboratory tests and systems, ensuring geographic saturation, and social support systems.

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Gaborone, Botswana: What successful models of behavior change exist which address the "B" of the ABCs: i.e., in southern Africa and especially Botswana, the epidemic seems to be driven by social norms which condone multiple concurrent sexual partnering.

Frank Beadle de Palomo: The "B" in the ABCs refers to "Being Faithful/Partner Reducation," and is aimed at monogamy and reducing the number of sexual partners.

You ask for models, I can share the following with you:

1. In Nairobi, Kenya" Informal prevention strategies, and a political leadership that does not shy away from discussing AIDS, have helped drastically reduce the prevalence of the disease in Uganda, according to a study to be published in Science magazine.

2. In Uganda, the "Zero Grazing" approach has lead to a reduction in HIV prevalence.

The Ugandan approach has focused on advising people to reduce the number of sexual partners, rather than on increasing the use of condoms or promoting voluntary testing.

The study shows that informal prevention strategies, such as cautionary messages about casual sex, passed through networks of friends and family, seem more effective than mass media campaigns.

"The government communicated a clear warning and prevention recommendation: Aids, or "slim", was fatal and required an immediate population response based on "zero grazing", that is, faithfulness to one partner. Condoms were a minor component of the original strategy".

3. I cannot rememebr the country, now, but there has also been successful work using a couples-based counseling approach. The couple uses testing as the beginning point of a social contract with each other not to become infected and infect each other.

Lastly, as you know, "Being Faithful" can only be successful when there is a norm of marriage or permanence or long-term relationships. If the society is not marriage- or permanent-relationship-based, if the community is same-sex and not allowed to be in "marriages," then the Being faithful component cannot be as successful.

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Minneapolis, Minn.: I know that stigma and discrimination serve as major barriers to addressing HIV/AIDS in the developing world, are they also barriers to effectively addressing the epidemic in the United States?

Frank Beadle de Palomo: Unfortunately, HIV/AIDS-related sitgma and discrimination are alive and well in the U.S., not just in the developing world.

While those of us involved in HIV/AIDS prevention and care, have long combatted stigma in terms of understanding how the disease is transmitted, caring for people living with HIV/AIDS, and fear, little has been done, in the U.S., in terms of large-scale anti-stigma programs. It has been over ten years since the U.S. has even had a national communications campaign focused on HIV/AIDS.

In the U.S., AED has fostered a partnership with social scientists and CBOs to develop and document new approaches to combating HIV/AIDS-related stigma. Under this program, supported by the Ford Foundation, AED has awarded grants and provides technical assistance to five CBOs to develop innovative anti-stigma approaches and evaluate their effectiveness. Internationally, AED's USAID-funded CHANGE project has developed a user-friendly toolkit?based on research into the main causes of HIV-related stigma?that contains more than 100 group activities to help combat HIV-related stigma and discrimination. Building on tools and lessons learned garnered from these experiences, AED is now beginning a major anti-stigma campaign throughout Central America. You can learn more about our stigma activities though: HIVAIDSStigma.org

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Melbourne, Fla.: Sir,
Certainly medical treatment and an aggressive information campaign directed toward conquering aids must continue.

However, people, for example those in the developing countries, the Republlic of South Africa for example, must change their life styles and practice abstinence or aids will continue to take its deadly toll. All the preventive programs are merely treading water against an ever increasing tide.

Uganda has emphasized abstinence in conjungtion with treatment and education. As you undoubtedly are aware Uganda has stemmed the tide of aids in recent years.

What measures are being promoted that enkcourage countries to emphasize the need for abstinence?

Frank Beadle de Palomo: Your question is very similar to a core set of questions posed in Bangkok regarding whether or not abstinence is a real option.

A couple points of clarifcaition.

Uganda's success was not built on abstinence alone. Abstinence played a key role, however, it appears that it was really the comprehensive range of interventions that were implemented that created the dramtic change in the epidemic.

The abstinence component of Uganda's strategy focused on efforts to delay first intercourse among young people. As a result of these interventions, surveys indicate that the average age of sexual initiation among females rose from 16.5 years in 1988 to 17.3 in 2000. Among men, the age increased from 17.6 years in 1995 (the first year for which data are available) to 18.3 in 2000.

These figures, however, do not imply an overall decrease in sexual activity among unmarried youth in Uganda. While waiting longer to begin having sex, statistics indicate that higher proportions of young people became sexually active. The percentage of unmarried women aged 15-24 who were sexually active actually increased between 1995 and 2000, from 22 percent to 27 percent.

"Abstinence for all" is not a realistic approach for an entire country (this would leave no option for the creatin of future generations). Abstinence seems to be an important too, but it is only one fo the tools used in Uganda: we cannot forget about reducing sexual partners, risk behaviors, and increasing in condom usage.

As to the question of what measures are being taken to encourage countries to emphasize the need for abstinence, the U.S. is perhaps most strongly leading such efforts. Specifically, under the Presidents Emergency Plan for AIDS Relief, one-third of all prevention dollars targeted for international AIDS-related efforts are explicitely ear-marked to support abstinence until marriage. This translates into approximately 1 billion dollars for abstinence over five years, more than many countries in Africa have to expend on thier complete AIDS response budgets.

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McLean, Va.: Frank,

Thanks for the examples of "B", being faithful or partner reduction. Much of the reporting from Bangkok seemed to pit A against C, as though it were a mutually exclusive choice of abstinence or condoms. Why the polarization? Doesn't it make sense to offer a multitude of prevention strategies, including ABC as well as "CNN" (condoms, needles, and negotiating skills) and anything else that works? Why are we fighting each other?

Frank Beadle de Palomo: Yes! Pitting the "A" against the "C" is definitely not the right approach. Integrated and comprehensive HIV prevention approaches (those that address the A, B,C, and the Needles, and negotiating skills): reinforce messages,
prevent missed opportunities, and provide realistic options for infected and at-risk individuals.

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Washington, D.C.: Why is the world community so dead-set against abstinance programs and so pro condom programs? It seems to me that someone who does not care enought about their health to refrain from sex with suspicious partners won't go out of their way to use a condom.

Frank Beadle de Palomo: I don't think that it's that the world is dead-set against abstinence. I think that the issue is really more that abstinence is but one of many possible approaches that can used. Based on data that we are finding here in the U.S., "abstince-only" programs are most likley not effective, whereas "asbstinence-based" programs seem more effective.

In terms of science, we know, that the condom is curently the only technology available for protection against sexually transmitted HIV. Experts have concluded that the correct and consistent use of condoms provides an average 85 percent risk reduction for HIV transmission over habitual unprotected sex. The effectiveness of condoms can be further enhanced with education and familiarity, decreasing the probability of condom failure due to incorrect use.

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Arlington, Va.: The two primary methods to prevent AIDS are abstinence and long-term, monogamous relationships [i.e. heterosexual marriage]. Neither of these are promoted to a great extent, thus, the scourge of AIDS continues. When it appears all other control measures have failed, isn't it time to look at what actually works to prevent AIDS, rather than band-aid's that leave millions of additional people infected?

Frank Beadle de Palomo: Abstinence is a complex and critical issue at this time in the AIDS epidemic, around the world, and here in the United States. There are varying definitions of abstinence as well as varying types and levels of promotion in educational programs varying from abstinence only to abstinence plus to comprehensive sex education. In a hypothetical situation abstinence is an obvious way to avoid risky behavior, HIV/AIDS transmission, and unplanned pregnancy. However, in the real world people are not always able or willing to negotiate and choose abstinence as an option, so we must equip the public with a comprehensive knowledge base of their options to protect themselves and their partners.

Many have asked for evidence of why abstinence does not work for everyone. In fact, there is no current research to suggest that abstinence as a sole policy of risk reduction has had an influence on the AIDS epidemic. Rather, it is a comprehensive approach that meets the needs of most people. In fact, the overwhelming majority of Americans support this type of sex education. In a 1998 poll conducted by the Kaiser Family Foundation and ABC Television, 81% of adults said that sex education programs should teach both abstinence and pregnancy and STD prevention; only 18% thought programs should teach only abstinence.

The reality of the public's health needs is key in addressing the HIV epidemic. In the United States, as in other developed Western countries, the majority of adolescents become sexually active during their teenage years. Roughly two-thirds (63%) of U.S. teens have had sexual intercourse by their 18th birthday, and this level of sexual activity is hardly unique among developed countries. Research conducted by The Alan Guttmacher Institute between 1998 and 2001 indicated that U.S. teens are more likely to become pregnant because they are less likely to use any contraceptive method than young people in other developed countries and are also less likely to use methods that in actual use have the highest effectiveness rates, such as the pill ("Teen Pregnancy: Trends and Lessons Learned," TGR, February 2002, page 7). In 1995, one in four American adolescents did not use any method at first intercourse, and one in five were not currently using any method.

In addition, several recent studies and surveys suggest that sex education that includes information about both abstinence and contraception also has strong support among teachers and parents, as well as among teens themselves ("Sex Education: Politicians, Parents, Teachers and Teens," TGR, February 2001, page 9). One study published in Family Planning Perspectives in 2000 reported that more than nine in 10 public school teachers believe that students should be taught about contraception. In other research conducted for the Kaiser Family Foundation in 2000, parents overwhelmingly wanted schools to do more to prepare their children for "real life." More than eight in 10 believe sex education courses should discuss the use of birth control, including condoms. Three-quarters say abortion and sexual orientation should be discussed in a "balanced" way that presents different views in society.

To date, however, no education program in this country focusing exclusively on abstinence has shown success in delaying sexual activity. In fact, scientific evidence demonstrates that certain types of programs that include information about both abstinence and contraception help teens delay sexual activity, have fewer sexual partners and increase contraceptive use when they begin having sex. It is not clear what it is about these programs that leads teens to delay-a question that researchers need to explore. What is clear, however, is that no program of any kind has ever shown success in convincing young people to postpone sex from age 17, when they typically first have intercourse, until marriage, which typically occurs at age 25 for women and 27 for men.

In addition, an extensive evaluation of a five-session abstinence-only curriculum implemented in California found no impact on young teenagers' initiation of sex. The curriculum--Postponing Sexual Involvement (PSI)--served as the core of a statewide teenage pregnancy prevention initiative called Education Now and Babies Later (ENABL) which involved 187,000 twelve-to-fourteen-year-old youths in schools and community settings in 31 California counties. Based on the experience of a sample of 7,340 twelve-to-fourteen-year-old youths, half of whom received PSI, the evaluation found small changes in some of their sexual attitudes and sexual intentions three months after the start of the program. None of these desirable effects of PSI were sustained, however, by 17 months from the start.

The reality is that no single approach works for all people. It is by educating, reinforcing, and providing access to various methods of protection that will best serve those who are at risk of unsafe sexual practices.

For more information on this topic I recommend you looking at information provided by Kaiser at www.kff.org as well as the Alan Guttmacher Institute at www.agi-usa.org

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Washington, D.C.: How many AIDS orphans are there in Africa, and what are their lives likely to be like as they grow up? Do they get the same access to education, nutrition and medication? Are they discriminated against by their communities?

Frank Beadle de Palomo: There are an estimated 12 million AIDS orphans in sub-Saharan Africa today. (Eight out of every 10 children in the world whose parents have died of AIDS live in sub-Saharan Africa). According to statistics generated by the United Nations, during the last decade, the proportion of children who are orphaned as a result of AIDS rose from 3.5% to 32% and will continue to increase as the epidemic spreads. Recent reports show that many of the most severely affected countries in sub-Saharan Africa have no national policies to address the needs of orphaned children, including children orphaned and made vulnerable by HIV/AIDS.

Children and young people in an HIV/AIDS-affected household begin to suffer even before a parent or caregiver has died - income decreases or disappears, education is often interrupted and many children are forced to drop out either to care for a sick caregiver or to work. Children very often experience extreme forms of stigma and discrimination at school, among their peers, and throughout their communities. Depression and psychological distress are also common among these children. These problems are exacerbated by death.

The longer term effects that the epidemic will have on this region and others are often overlooked. High mortality rates will result in the depletion of much of the labor force and major economics.

AED is currently working with orphans (aged 0-5)in the Western province of Kenya (Speak for the Child School Program), which provides holistic care (physical, cognitive, psychosocial, and emotional) and development support through immunization campaigns, promotion of preschool enrollment, visits by community mentors, and involvement and support for caregivers. The program also offers training modules on home- and community-based care for young children affected by AIDS and sponsors exchange visits among CBOs and churches. The first cohort of child "graduates" currently enrolled and succeeding in primary school demonstrates the ability of a comprehensive intervention strategy to increase student enrollment and commitment to education by the child, caregiver, and community.

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Alexandria, Va.: I am a physician who will eventually work in Africa with HIV. I am excited about HAART therapy being available in Africa. However, I have this nagging voice in the back of my mind that we may be getting into something that will eventually set back the fight against HIV. Do you have any such concerns?

Frank Beadle de Palomo: Yes and no. Early on, I was most concerned about adherence and access. However, studies have shown that adherene in resource-poor settings is not an issue. Folks will take the drugs and follow treatment regimens. Also, access is ramping up. I do think, as I answered earlier, I most concerned about long-term access to laboratory tests and systems for viral load testing, etc., to make sure that we are implementing the best possible treatment approaches, without ramping up resistance. Good luck in Africa...

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Lyme, Conn.: Do you have an estimate as to what the annual cost to the United States would be to achieve the goals you wish to see from us? Personally, I believe we should be making these efforts, yet for those who insist it costs too much, I wonder how the bottom line cost compares to how much we spend on other areas such as the war in Iraq (but that's another topic, not for here).

Frank Beadle de Palomo: In 2001, Brookings Institute said we needed $5 billion/year globally to mitigate AIDS.

In 2004, UNAIDS estiamted that we would need $10 billion a year by 2005, and $15 billion a year by 2007.

Currently, $130 billion has been committed for war in Iraq through appropriations.

These are dautning numbers, but it does seem that where there is a will, there is a way....

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Silver Spring, Md.: I'm wondering if there was any discussion in Bangkok about the link between providing access to education and preventing HIV/AIDS. I understand Oxfam recently estimated we could prevent 700,000 new cases of HIV/AIDS a year if every child could finish elementary school.

Frank Beadle de Palomo: This is a personal favorite question. Sadly, I was very disappointed in the lack of sessions and evidence-based discussions on the link between Education (in terms of the formal sector and providing access) and AIDS.

Based on several studies, it does seem that creating access for young people to attend schools helps avert HIV transmission (this can be seen through girls education, studies in Uganda, etc.).

It makes sense. The starting point and the center of a holistic strategy is the school as a community treasure and as a community resource center. The school educates learners of all ages. It is - or can be - a singularly central community resource in the fight against the spread and the impact of HIV/AIDS because it has a service delivery capability that spans the education, health and social welfare sectors. Making it a more valued treasure and more effective resource can be achieved by projects targeted at several groups and community dynamics.

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Frank Beadle de Palomo: To all those who have asked questions, thank you...I hope that my responses were helpful. Again, thank you Washington Post for creating this environment, and thank you to my team for help on the questions.

I want to leave you with a personal push for comprehensive programming to mitigate and hopefully end the AIDS pandmeic.

My personal belief is that we know enough about HIV/AIDS to prevent transmission and to care for those already infected. What we lack, most often, is political and social will to implement a "social vaccine" to combat AIDS. A social vaccine is a leadership and community-led mobilization approach that encompasses: high-level political support and a multi-sectoral response; behavior change communication for target audiences and the general population; interventions focus on women and youth, stigma and discrimination; involvement of religious leaders and faith-based organizations active on the front lines; availability of confidential voluntary counseling and testing; aggressive condom social marketing; increased sexually transmitted infection control and prevention programs; and decreases in multiple sexual partners and networks. A social vaccine requires honest community dialogue, openness to the causes and routes of HIV transmission, support and care for persons living with HIV/AIDS (PLWHA), and a commitment to end HIV transmission and support PLWHA at all levels.

Thanks to all, and have a great day!

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