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HIV/AIDS IN ASIA

HEARING

BEFORE THE

SUBCOMMITTEE ON ASIA AND THE PACIFIC

OF THE

COMMITTEE ON 

INTERNATIONAL RELATIONS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

SECOND SESSION

JULY 21, 2004

Serial No. 108–135

Printed for the use of the Committee on International Relations

(

Available via the World Wide Web: http://www.house.gov/international—relations 

(II)

COMMITTEE ON INTERNATIONAL RELATIONS 

HENRY J. HYDE, Illinois, Chairman 

JAMES A. LEACH, Iowa 

DOUG BEREUTER, Nebraska 

CHRISTOPHER H. SMITH, New Jersey, 

Vice Chairman 

DAN BURTON, Indiana 

ELTON GALLEGLY, California 

ILEANA ROS-LEHTINEN, Florida 

CASS BALLENGER, North Carolina 

DANA ROHRABACHER, California 

EDWARD R. ROYCE, California 

PETER T. KING, New York 

STEVE CHABOT, Ohio 

AMO HOUGHTON, New York 

JOHN M. MCHUGH, New York 

ROY BLUNT, Missouri 

THOMAS G. TANCREDO, Colorado 

RON PAUL, Texas 

NICK SMITH, Michigan 

JOSEPH R. PITTS, Pennsylvania 

JEFF FLAKE, Arizona 

JO ANN DAVIS, Virginia 

MARK GREEN, Wisconsin 

JERRY WELLER, Illinois 

MIKE PENCE, Indiana 

THADDEUS G. MCCOTTER, Michigan 

KATHERINE HARRIS, Florida 

Vacancy 

TOM LANTOS, California 

HOWARD L. BERMAN, California 

GARY L. ACKERMAN, New York 

ENI F.H. FALEOMAVAEGA, American 

Samoa 

DONALD M. PAYNE, New Jersey 

ROBERT MENENDEZ, New Jersey 

SHERROD BROWN, Ohio 

BRAD SHERMAN, California 

ROBERT WEXLER, Florida 

ELIOT L. ENGEL, New York 

WILLIAM D. DELAHUNT, Massachusetts 

GREGORY W. MEEKS, New York 

BARBARA LEE, California 

JOSEPH CROWLEY, New York 

JOSEPH M. HOEFFEL, Pennsylvania 

EARL BLUMENAUER, Oregon 

SHELLEY BERKLEY, Nevada 

GRACE F. NAPOLITANO, California 

ADAM B. SCHIFF, California 

DIANE E. WATSON, California 

ADAM SMITH, Washington 

BETTY MCCOLLUM, Minnesota 

BEN CHANDLER, Kentucky 

THOMAS E. MOONEY, SR., Staff Director/General Counsel 

ROBERT R. KING, Democratic Staff Director 

SUBCOMMITTEE ON ASIA AND THE PACIFIC

JAMES A. LEACH, Iowa, Chairman 

DAN BURTON, Indiana 

DOUG BEREUTER, Nebraska 

CHRISTOPHER H. SMITH, New Jersey 

DANA ROHRABACHER, California 

EDWARD R. ROYCE, California 

STEVE CHABOT, Ohio 

RON PAUL, Texas 

JEFF FLAKE, Arizona 

JERRY WELLER, Illinois 

THOMAS G. TANCREDO, Colorado 

Vacancy 

ENI F. H. FALEOMAVAEGA, American 

Samoa 

SHERROD BROWN, Ohio 

EARL BLUMENAUER, Oregon 

DIANE E. WATSON, California 

ADAM SMITH, Washington 

GARY L. ACKERMAN, New York 

BRAD SHERMAN, California 

ROBERT WEXLER, Florida 

GREGORY W. MEEKS, New York 

JAMES W. MCCORMICK, Subcommittee Staff Director 

LISA M. WILLIAMS, Democratic Professional Staff Member 

DOUGLAS ANDERSON, Professional Staff Member & Counsel 

TIERNEN MILLER, Staff Associate 

(III)

C O N T E N T S 

Page

WITNESSES 

Kathleen Cravero, Ph.D., Deputy Executive Director, Joint United Nations 

Programme on HIV/AIDS [UNAIDS] ................................................................. 5

Bates Gill, Ph.D., Freeman Chair in China Studies, center for Strategic 

and International Studies, Washington, DC ...................................................... 16

Dr. Vijay V. Yeldandi, Chairman, HIV/AIDS Committee, American Association of Physicians of Indian Origin ..................................................................... 23

Holly J. Burkhalter, Physicians for Human Rights .............................................. 31

LETTERS, STATEMENTS, ETC., SUBMITTED FOR THE HEARING 

The Honorable James A. Leach, a Representative in Congress from the State 

of Iowa, and Chairman, Subcommittee on Asia and the Pacific: Prepared 

statement .............................................................................................................. 2

The Honorable Eni F.H. Faleomavaega, a Representative in Congress from 

American Samoa: Prepared statement ............................................................... 4

Kathleen Cravero, Ph.D.: Prepared statement ...................................................... 10

Bates Gill, Ph.D.: Prepared statement ................................................................... 19

Dr. Vijay V. Yeldandi: Prepared statement ........................................................... 26

Holly J. Burkhalter: Prepared statement .............................................................. 35

APPENDIX 

The Honorable Dan Burton, a Representative in Congress from the State 

of Indiana: Prepared statement .......................................................................... 63

The Honorable Barbara Lee, a Representative in Congress from the State 

of California: Prepared statement ...................................................................... 64

Additional material submitted for the record .................................................... 66

The Honorable Gregory W. Meeks, a Representative in Congress from the 

State of New York: Prepared statement ............................................................ 68

The Honorable Sherrod Brown, a Representative in Congress from the State 

of Ohio: Prepared statement ............................................................................... 68

Kathleen Cravero, Ph.D.: Additional material submitted for the record ............ 70

Bates Gill, Ph.D.: Additional material submitted for the record ......................... 85

Helene D. Gayle, MD, MPH, Director, HIV, TB and Reproductive Health 

Program, Bill & Melinda Gates Foundation: Prepared statement .................. 92

(1)

HIV/AIDS IN ASIA 

WEDNESDAY, JULY 21, 2004

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON ASIA AND THE PACIFIC, 

COMMITTEE ON INTERNATIONAL RELATIONS, 

Washington, DC. 

The Subcommittee met, pursuant to call, at 1:38 p.m. in Room 

2172, Rayburn House Office Building, Hon. James A. Leach presiding. 

Mr. LEACH. The Subcommittee will come to order. 

On behalf of the Subcommittee, I would like to welcome our distinguished witnesses. We appreciate your participation and look 

forward to your assessment of the scope of the AIDS problem. 

Parenthetically, I would like to note how pleased we are that the 

Chinese authorities have decided to release the well-known surgeon, Dr. Jiang Yanyong. Dr. Jiang became a national hero in 

China last year for his efforts to expose the cover-up of the scope 

of the SARS epidemic. Subsequently, Dr. Jiang was taken into custody for his appeal to China’s leaders for reappraisal of the tragic 

events that surrounded the Tienenman Square event of 1989. 

I understand that Dr. Jiang has indicated he now focuses his efforts on combating HIV/AIDS. And we wish him the best in this 

important endeavor. 

Turning to the subject of our hearing, it is self-apparent that I 

think the biggest challenge of our era and the biggest foreign policy 

of our times is the AIDS issue. And on the plus side, our Government has provided more assistance than all other governments 

combined in the world. On the minus side, we are probably doing 

about a tenth of what we should be doing. 

The stark reality is that the world today is confronted with the 

greatest health crisis in history. The latest figures released by 

UNAIDS show that approximately 40 million people are living with 

HIV/AIDS in 2003, including 2.5 million children under the age of 

15. World-wide, there are an astounding 14,000 new infections 

daily, with more than 95 percent in the developing world. 

Perspective is always hard to apply to events of the day. For example, if one were living in the 14th century, one would be hardpressed not to conclude that the most important event of that time 

was the bubonic plague, in which 20 million people died. That figure was reached several years ago with regard to AIDS, and within 

the decade the toll could be a multiple of this amount. So the AIDS 

epidemic is extraordinary, and it is destabilizing entire societies, 

and represents a formidable challenge to those it has not completely destabilized. 

2

As highlighted last week by the 15th International AIDS Conference in Bangkok, several countries in Asia and the Pacific are 

at a critical point in their efforts to curb the spread of the virus. 

The virus is devastating some high-risk groups and making inroads 

into the general population. So far, however, the epidemic has not 

exploded in Asia to the degree it has in sub-Saharan Africa. To 

date, about 20 percent of those living with HIV/AIDS live in Asia, 

while one in four new HIV infections in the world has also occurred 

in that region. 

Based on these trends, some experts believe that Asia will have 

more people with HIV in 2010 than the roughly 30 million in subSaharan Africa today. 

At this juncture, however, the scale of Asia’s epidemic would appear to have more to do with the size of the region’s population 

than the spread of the virus itself. No Asian country has reported 

a prevalence rate higher than 4 percent, and a relative few prenatal clinics have found infection rates above 1 percent, the standard measure for a generalized epidemic. By contrast, half a dozen 

African countries now have adult prevalence rates of 10 percent or 

more. 

But even if Asia avoids the high infection rates of Africa, health 

experts stress that a low prevalence rate in just one country, such 

as China or India, could spell disaster and have major ripple effects 

through the region and the world economy. 

Meanwhile, Burma, Thailand, and Cambodia have the highest 

rates of infection anywhere outside Africa. In this circumstance, 

complacency is not an option. 

It is clear the U.S. is compelling national interest in working 

with others to help stem the spread of the disease and care for victims of it. Infectious diseases know no borders. Millions of Americans travel and live abroad; many in this country live with this disease in their own families. 

The opportunity to do something about this scourge offers a fortunate coincidence of self-interest and moral imperative. Out of a 

sense of self-preservation, I thought simply a humanitarian concern 

for those affected, this disease has to be eradicated, whatever the 

cost. 

[The prepared statement of Mr. Leach follows:]

PREPARED STATEMENT OF THE HONORABLE JAMES A. LEACH, A REPRESENTATIVE IN

CONGRESS FROM THE STATE OF IOWA, AND CHAIRMAN, SUBCOMMITTEE ON ASIA AND

THE PACIFIC

On behalf of the Subcommittee, I would like to welcome our distinguished witnesses to today’s hearing on the challenge of HIV/AIDS in Asia. We appreciate your 

participation and look forward to your assessment of the scope of the problem as 

well as prospects for comprehensive prevention and treatment of the disease 

throughout the region. 

Parenthetically, I would like to note how pleased we are that the Chinese authorities have decided to release the well-known surgeon Dr. Jiang Yanyong. Dr. Jiang 

became a national hero in China last year for his efforts to expose a cover-up of the 

true scope of the SARS epidemic by authorities in Beijing. Subsequently, Dr. Jiang 

was taken into custody for his appeal to China’s leaders for a reappraisal of the 

tragic events in Tiananmen Square during June 1989. I understand that Dr. Jiang 

has indicated he will now focus his efforts on combating HIV/AIDS. We wish him 

all the best in this important endeavor. 

Turning to the subject of our hearing, AIDS is the biggest public challenge and 

foreign policy issue of our time. On the plus side, on a bipartisan and bi-instituVerDate Mar 21 2002 14:40 Oct 08, 2004 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6621 F:\WORK\AP\072104\94989.000 HINTREL1 PsN: SHIRL
3

tional basis the U.S. government has provided more than one half of AIDS assistance to the world; on the minus side, it is probably one tenth of what is necessary. 

The stark reality is that the world today is confronted with the greatest health 

crisis in human history. The latest figures released by UNAIDS show that approximately 40 million people were living with HIV/AIDS in 2003, including two and a 

half million children under the age of fifteen. Worldwide, there are an astounding 

14,000 new infections daily, with more than 95% in the developing world. 

Perspective is always hard to apply to events of the day. For example, if one was 

to look at the 14th century, one would be hard pressed not to conclude that the most 

important event of that time was the bubonic plague during which 20 million died. 

With regard to AIDS that awesome death number was reached several years ago, 

and within a decade, the toll could be a multiple of that figure. In a circumstance 

in which the HIV/AIDS pandemic is destabilizing entire societies, it is self-evident 

that discovering techniques to eradicate this deadly disease is the most important 

health science challenge ever. 

As highlighted by the 15th international AIDS conference in Bangkok last week, 

several countries in Asia and the Pacific are at a critical point in their efforts to 

curb the spread of HIV. The virus is devastating high-risk groups and making inroads into the general population. To date, about 20% of those living with HIV/AIDS 

live in Asia, while one in four new HIV infections in the world in 2003 occurred 

in the region. 

Based on these trends, experts believe that Asia will have more people with HIV 

in 2010 than the roughly 30 million in sub-Saharan Africa today. While the scale 

of Asia’s epidemic is not as great as Africa’s, the virus is just beginning to take hold. 

Today, no Asian country has reported a prevalence rate higher than 4%, and relatively few prenatal clinics have found infection rates above 1%—the standard 

measure for a generalized epidemic. By contrast, half a dozen African countries now 

have adult prevalence rates of 10% or more; nevertheless, without a massive public 

commitment to education and prevention in Asia, comparable problems could occur. 

Even if Asia avoids high infection rates, however, health experts stress that a low 

prevalence rate in a large country—such as China or India—can spell disaster and 

have major ripple effects through the region. Meanwhile, Burma, Thailand, and 

Cambodia have the highest rates of HIV infection anywhere outside Africa. In this 

circumstance, complacency is not an option. 

It is clear that the U.S. has a compelling national interest in working with others 

to help stem the spread of HIV/AIDS and care for the victims of this dread disease. 

Infections diseases, like HIV/AIDS, know no borders. Millions of Americans travel 

and live abroad. Many in this country live with this disease in their own families. 

The opportunity to do something about this deadly scourge offers a coincidence of 

self-interest and moral imperative. Out of a sense of self-preservation for mankind 

itself, if not simply a humanitarian concern for those currently affected, this disease 

must be eradicated, whatever the cost.

Mr. LEACH. Jerry, do you want to make an opening statement? 

Mr. FALEOMAVAEGA. Thank you, Mr. Chairman. I certainly want 

to commend you for your leadership, and for holding this hearing 

on the HIV/AIDS in the Asia-Pacific region. 

I also want to welcome my witnesses, and thank my good friend 

Sanjay Puri for his leadership on this very important issue, and on 

behalf of our Indian-American community. 

I am particularly pleased that Dr. Vijay Yeldandi, a leading expert on HIV/AIDS in India, will be one of our experts testifying on 

the panel this afternoon. 

Mr. Chairman, traditionally age has always been associated with 

Continental Africa. Ironic that the latest meeting that was held, 

international Conference that was held on AIDS was held in Asia. 

And I think it gives it a very striking need, not only for the national media, but for people around the world, that it is just as important and critical in tracking this issue in the Asia-Pacific region. 

To date, almost two-thirds of all HIV-positive Asians live in 

India. India reports 1,000 new AIDS cases per month, and it has 

the second-largest population of people living with HIV/AIDS in the 

world, with between 2.5 and 8.5 million people infected. By 2005, 

4

it is believed that India will hold the largest population of people 

infected with the virus. 

Many experts are particularly concerned about India because infections are starting to move from high-risk groups to the general 

population. Government spending on HIV/AIDS also remains relatively low, and U.S. assistance has been minimal. Like many of 

my colleagues, I was shocked when President Bush announced that 

Vietnam would become the 15th country under the President’s 

Emergency Plan for AIDS Relief. 

While I support Vietnam, Vietnam has a prevalence rate of less 

than 1 percent, a lower HIV prevalence than the United States. 

Burma has one of the worst HIV/AIDS problems in Asia. Cambodia 

has the second-highest HIV rate. One researcher predicts that 

West Papua, New Guinea may look like Africa in 5 years. 

And even if Asia holds high prevalence rates, health experts 

stress that a low prevalence rate in a large country such as India 

can spell disaster, and have major rippling effects throughout the 

region, and even throughout the world. 

I want to thank the Gates Foundation for making a number of 

grants to India. It is my understanding the Gates Foundation intends to spend a total of $200 million to help combat HIV/AIDS in 

India, and that the World Bank has loaned India $191 million to 

implement its HIV/AIDS programs. 

Mr. Chairman, I am also hopeful that the U.S. will now do its 

part, our country will do our part. And I look forward to working 

with you and other Members of this Committee in drafting appropriate legislation to curb the spreading of HIV/AIDS in the AsiaPacific region. 

I also want to offer my personal welcome to the members of the 

panel, Dr. Cravero, Dr. Gill, and Ms. Burkhalter, for their testimony. I look forward to hearing from them. 

Thank you, Mr. Chairman. 

[The prepared statement of Mr. Faleomavaega follows:]

PREPARED STATEMENT OF THE HONORABLE ENI F.H. FALEOMAVAEGA, A

REPRESENTATIVE IN CONGRESS FROM AMERICAN SAMOA

Mr. Chairman: 

I want to commend you for your leadership and for holding this hearing on HIV/

AIDS in Asia. I also want to welcome our witnesses and thank my good friend 

Sanjay Puri for his leadership on HIV/AIDS on behalf of the Indian American community. I am particularly pleased that Dr. Vijay Yeldandi, a leading expert on HIV/

AIDS in India, will be testifying. 

To date, almost two-thirds of all HIV-positive Asians live in India. India reports 

1,000 new AIDS cases per month and it has the second largest population of people 

living with HIV/AIDS in the world with between 2.5 and 8.5 million people infected. 

By 2005, it is believed that India will hold the largest population of people infected 

with the virus. 

Many experts are particularly concerned about India because infections are starting to move from high risk groups to the general population. Government spending 

on HIV/AIDS also remains relatively low and U.S. assistance has been minimal. 

Like many of my colleagues, I was shocked when President Bush announced that 

Vietnam would become the 15th country under the President’s Emergency Plan for 

AIDS Relief (PEPFAR). While I support Vietnam, Vietnam has a prevalence rate of 

less than 1%, a lower HIV prevalence than the United States. 

Burma has one of the worst HIV/AIDS problems in Asia. Cambodia has the second highest HIV rate. One researcher predicts that West Papua may look like Africa 

in five years. 

5

And even if Asia avoids high prevalence rates, health experts stress that a low 

prevalence rate in a large country such as India can spell disaster and have major 

ripple effects through the region and world economy. 

I thank the Gates Foundation for making a number of grants to India. It is my understanding that the Gates Foundation intends to spend a total of $200 million 

to help combat HIV/AIDS in India and that the World Bank has loaned India $191 

million to implement its HIV/AIDS programs. 

Mr. Chairman, I am also hopeful that the U.S. will now do its part and I look 

forward to working with you and members of this Committee in drafting and implementing legislation to curb the spread of HIV in Asia

Mr. BLUMENAUER. Mr. Chairman, I just wanted to say that I 

thought your comments were right on the money. We are doing 

more. It is not enough. And I am looking forward to the presentation of the panel. I think it is an important follow-up to the Conference. 

I would hope that if there is one thing that our Committee could 

do, with the help of the distinguished panel, is that we could get 

across the notion that we have made this important 5-year commitment; it has bipartisan support. 

If there is anything that we do around here that could not be 

back-loaded—we have made the commitment, I am convinced we 

are going to keep it—but this is one of the areas where we should 

accelerate the funding to meet this critical funding gap and inspire 

our neighbors, our friends, our allies, and our important partners 

in the private sector. 

And I hope that that is one thing that we can work on together. 

It will not destroy our 5-year budget projections. It is clearly within 

our capacity. And the consequences will be the saving of millions 

of lives. 

Mr. LEACH. Thank you very much. At this point let me introduce 

our panel. 

Kathleen Cravero is the Deputy Executive Director of the Joint 

United Nations Program on HIV/AIDS. 

Dr. Bates Gill is the Freeman Chair in China Studies at the Center for Strategic and International Studies. 

Dr. Vijay V. Yeldandi is the Director of Clinical Research at the 

Metro Foundation. 

And Ms. Holly Burkhalter is the U.S. Policy Director for Physicians for Human Rights, here in their Washington office. 

So welcome to all of you. 

Unless there is a prearrangement that would do it differently, I 

will just introduce you in the manner in which you have been presented. 

Let me say all of your statements, without objection, will be 

placed in the record. And you may proceed and summarize as you 

see fit. 

I would, if possible, like to hold you to 5 to 8 minutes. But let 

me proceed as informally as we can. 

Dr. Cravero. 

STATEMENT OF KATHLEEN CRAVERO, PH.D., DEPUTY EXECUTIVE DIRECTOR, JOINT UNITED NATIONS PROGRAMME ON 

HIV/AIDS [UNAIDS] 

Ms. CRAVERO. Thank you, Mr. Chairman. Distinguished Members of the Subcommittee, ladies and gentlemen, I thank you for 

the opportunity to testify before you this afternoon. I commend you 

6

for your longstanding leadership in the global fight against AIDS, 

and for now turning the attention of the Subcommittee and the 

Congress to the AIDS epidemic in Asia and the Pacific. 

This Committee shined a bright light on the burgeoning AIDS 

epidemic in Africa, and drove the enactment of the U.S. Leadership 

Against AIDS Act of 2003. 

I am confident that your focus on Asia will ultimately lead to 

much-needed action against AIDS in this region, as well. And for 

that, we thank you. 

As you know, the 15th International AIDS Conference took place 

in Bangkok last week. This Conference was intended as a wake-up 

call for Asia, and by all indications, it may be just that. 

The AIDS Conference in South Africa was a watershed moment 

for expanded access to treatment. We hope that the Thailand Conference will be remembered as the moment we collectively faced the 

challenge of AIDS in Asia. 

First, the facts. There is little doubt that in the fight against 

AIDS, we once again stand at a crossroads. Asia is now at the center of this gathering storm. 

Let us recap just a few of the facts that UNAIDS released last 

week. 

Mr. Chairman, as you have indicated, Asia now accounts for 

nearly 7.5 million people living with HIV. Last year alone, half a 

million people died from AIDS, and more than twice as many were 

infected with HIV, one in four of all new infections world-wide. 

Asia is now home to some of the fastest-growing AIDS epidemics 

in the world, primarily due to sharp increases in China, Indonesia, 

and Vietnam. 

In the Pacific, the HIV prevalence rate has reached 1 percent 

among women attending ante-natal clinics in Port Moresby, Papua 

New Guinea. High levels of sexually-transmitted infections, which 

indicate increased risk for HIV, have also been documented in 

Samoa. And as we have seen in the Caribbean, even a small number of infections can have a dramatic impact on small island populations. 

Although the national HIV prevalence rate in China and India 

is low—0.1 percent in China, and between 0.4 and 1.3 percent in 

India—both have extremely serious epidemics in a number of provinces, territories, and states. 

And let us keep in mind that because the region accounts for 60 

percent of the world’s population, even relatively low HIV prevalence translates into millions of lives. While less than 1 percent of 

adults in India are HIV-infected, this is about 5 million people, 

more than the entire populations of Botswana, Namibia, and Swaziland combined. 

In most places in the region, HIV remains largely concentrated 

among marginalized groups, such as injecting drug users, men who 

have sex with men, sex workers, and their clients and partners. 

But infection rates among these groups are skyrocketing, and ultimately will not remain contained. 

Monogamous women, whose only high-risk behavior is being 

married and faithful to spouses who engage in high-risk behavior, 

are being infected, and then, sadly, infecting their children. This is 

how a generalized epidemic begins. 

7

Timing matters, and Asia has a narrow window of opportunity. 

As we have seen, HIV levels can remain relatively low for many 

years, and then explode quite rapidly. Just look at what happened 

in South Africa. It took 5 years for the prevalence rate to rise from 

0.5 to 1 percent, but then shot to 20 percent over the next 7 years, 

in the absence of prevention. 

While we do not expect something quite this dramatic in Asia, 

it is vital to act decisively before hitting this tipping point. One 

thing is for certain: What happens in Asia will set the tone for the 

future of the epidemic globally. 

Asia is an investment opportunity. We should act now, or we will 

pay later. 

As you know, Asia is a region which has made great economic 

progress, and is now seriously threatened by AIDS. A joint study 

by UNAIDS and the Asian Development Bank estimates that economic losses due to AIDS were more than $7 billion in 2001 alone, 

borne overwhelmingly by AIDS-affected households. This has impoverished millions of men, women, and children. 

The region, and all of us, now have clear choices to make, with 

equally clear consequences. If the current trends continue and we 

fail to take comprehensive action in Asia, a total of 10 million 

adults and children will likely become infected in the region between now and 2010. The annual death toll will increase by 50 percent, to over three-quarters of a million people by 2010, and economic losses will more than double, amounting to $17 million annually by 2010. 

The good news is that we know what works. ‘‘ABC plus’’ works. 

Harm reduction programs work. Voluntary counselling and testing 

programs, especially those accompanied by treatment, work. Interventions to stop mother-to-child transmission work. Treating STDs 

works. Ensuring a safe blood supply and safe health care settings 

works. Micro-finance and other empowerment programs for women, 

and fighting stigma, fear, and discrimination while promoting hope 

works. 

The problem is in Asia, as in Africa, only a small fraction of 

those in need are currently receiving these lifesaving services. Increasing access to AIDS prevention and treatment will require a serious investment. Last year, $1.5 billion was needed for a comprehensive response to AIDS in Asia, yet only $200 million was 

spent by all public sources combined. 

This resource gap will continue to grow as unmet needs grow. 

And by 2007, the funding needed for AIDS prevention and treatment services in Asia will rise to $5.1 billion annually, or approximately $2.00 per capita. 

If the necessary leadership and resources are found from governments in the region and from donor support, and comprehensive 

programs are implemented, we can change the course of this epidemic, and perhaps the course of history. We can prevent six million new infections by 2010. We can reduce the death toll by nearly 

100,000 people each year. We can save $2 billion in economic losses 

in each year, from 2010. And we can alleviate unquantifiable 

human suffering in Asia alone. 

What is the role of the United States? The U.S. has long been 

a global leader in the fight against AIDS, and is now the world’s 

8

largest provider of global AIDS funding. To date, the U.S. global 

AIDS initiatives primary focus on 14 African and Caribbean countries has provided much-needed assistance to the two regions most 

heavily impacted by AIDS. We are grateful for this attention. 

However, as the epidemic expands around the globe, it is increasingly urgent that we accelerate concerted action on AIDS in Asia. 

The recent selection of Vietnam as the 15th United States focus 

country is an important step, and UNAIDS was pleased to have the 

chance to brief Ambassador Tobias on his recent trip to Vietnam. 

However, we must view this as a first step toward a comprehensive 

response to AIDS in Asia. 

Because overall HIV prevalence rates remain low in the Asia-Pacific region, the sense of urgency for action has yet to reach a fever 

pitch. However, the numbers do not lie, and AIDS in Asia is fast 

approaching a critical tipping point. 

The United States has much to offer as a key strategic partner, 

through a three-pronged approach to helping to ratchet up the 

Asian response to AIDS. 

Firstly, by promoting leadership through diplomacy. This includes encouraging Asian leaders to participate actively in international political fora, and to put AIDS on the agenda of regional 

institutions, such as ASEAN and APEC. The UNAIDS-supported 

Asia-Pacific Leadership Forum on HIV/AIDS and Development is 

designed to do just that. 

At national level, U.S. Ambassadors to Asia have a critical role 

to play, as they have in Africa through the new United States initiative. 

Secondly, investing and leveraging real resources for what works. 

The U.S. should also invest in what works, and urge others, including impacted countries, to do the same. This includes ‘‘ABC plus,’’ 

a model that builds on the foundation of abstinence, fidelity, and 

condom use, to promote female-controlled prevention methods, including female condoms and microbicides, and empowering women 

and engaging men. 

The fact is that women struggling to get through the day without 

suffering violence are not in a position to negotiate anything, let 

alone abstinence or condoms. That is what I heard from women 

leaders in the Mekong Region when they launched their coalition 

on women and AIDS, and that is what I have heard from women 

all over the world. 

Thirdly, sharing expertise and building capacity. In Asia, as elsewhere, there is a desperate need for capacity building, especially 

within the health sector; for technical assistance and program implementation and management; and for the training of doctors, 

nurses, and community workers needed to scale up treatment and 

prevention services. 

Asian countries also need help to monitor and evaluate both the 

scope and scale of the epidemic, and the value of ongoing interventions. The U.S. could help in this effort. 

Overall, the United States has a central role to play in the AsiaPacific region. Increased investments in AIDS in Asia by the 

United States and other donors now will help avert millions of new 

HIV infections and AIDS deaths, and ensure national and regional 

security, better governance, and sustained economic growth. 

9

UNAIDS is ready and able to make a difference. We know that 

business as usual will not stop AIDS. That is why the Joint United 

Nations Programme on HIV/AIDS, or UNAIDS, was created. 

Today, through the leadership of UNAIDS, 10 U.N. agencies and 

a Secretariat have joined forces in concerted action against AIDS 

worldwide. In reality, UNAIDS is U.N. reform in action. 

Working globally, regionally, and on the ground in more than 65 

countries, UNAIDS is helping to develop the leadership, build the 

capacity, and apply the expertise needed for a more effective response to AIDS. UNAIDS is focused not on mobilizing resources 

alone, but on maximizing their effectiveness on the ground, where 

the rubber meets the road. 

In Asia and the Pacific, UNAIDS has been key to galvanizing political leadership and commitment. For example, in India, where 

UNAIDS directly supported the creation of the Indian Parliamentarian Forum on AIDS, and nurtured its growth from a gathering 

of 15 Parliamentarians in 2000 to a convention of 1,500 in 2003. 

In China, where UNAIDS has been key to promoting awareness 

at the highest levels of government and developing a ‘‘Joint Assessment of HIV/AIDS Prevention, Treatment, and Care.’’

In Fiji, where we have helped the President of Fiji and the Chair 

of the Great Council of Chiefs commit themselves to action against 

AIDS, and call on all sectors to do their part. 

And at the Asia Regional level, UNAIDS supported the Association of the Southeast Asian Nations in convening a special summit 

on AIDS, and is now supporting implementation of their work plan. 

UNAIDS is also enlisting key partners throughout the region, 

where it is considered a neutral broker and a trusted facilitator. It 

helped mobilize business coalitions, unions, youth and women’s organizations, religious groups, police and military personnel, and 

sports organizations, including cricket councils across the region, 

just to name a few. 

It has helped to develop and disseminate strategic information, 

including access to user-friendly policies and best-practice information. It has helped mobilize and maximize resources. In 2003, 

UNAIDS provided technical assistance in the development of global 

fund proposals in 13 countries, and assisted other resource mobilization activities in 12 more. Countries receiving UNAIDS support 

were over four times more likely to be funded than those who did 

not. 

And most recently, UNAIDS has spearheaded, in cooperation 

with the U.S. Government and others, the adoption of three key 

principles to guide donor support for AIDS. Known as the ‘‘threeones,’’ these principles help to ensure that our action at country 

level is country-driven, and that whatever our respective role, we 

all agree to work with: One AIDS action plan that provides the 

basis for coordinating the work of all partners; one national AIDS 

coordinating authority, with a multi-sectoral mandate that involves 

all key players; and one monitoring and evaluation system for 

tracking progress toward results. 

We have a long way to go, but the ‘‘three-ones’’ gives us a muchneeded roadmap. The true test will come in the application of these 

principles, country-by-country, and in our ability to translate this 

10

opportunity into prevention, treatment, and support services for 

the millions in need. 

UNAIDS has been charged with moving this process forward, 

and this responsibility is a high priority for us. We look forward 

to working closely with the U.S., and are very pleased that the 

House Foreign Operations Appropriations Bill has requested a 

quick report on progress in this effort. 

In conclusion, Mr. Chairman, we are at a critical juncture in the 

global fight against AIDS, and the stakes are high, for Asia and for 

us all. Success will require more money, more action, and most of 

all it will require unprecedented coordination, and a framework for 

moving forward together, particularly at country level. 

We have the skill and the science to stop AIDS. What we need 

now is the political will, the strategy, and the unity to turn the 

tide. It is not about PEPFAR versus the Global Fund. It is not 

about prevention or treatment, condoms or abstinence, Africa or 

Asia, AIDS or poverty reduction. This is not an either/or proposition. We need them all, and more. We need a comprehensive 

strategy, a truly global response, and an arsenal of tools at our disposal to succeed. 

As Peter Piot, Ambassador Tobias, and Hillary Benn of the UK 

said in a recent op-ed piece:

‘‘It is high time we leave our flags and affiliations at the door, 

and find ever new and better ways to get the job done.’’

I hope you agree. 

Thank you. And we ask, Mr. Chairman, that the executive summaries of the reports we have submitted could be included in the 

record of this meeting. 

Thank you. 

Mr. LEACH. Without objection. 

[The prepared statement of Ms. Cravero follows:]

PREPARED STATEMENT OF KATHLEEN CRAVERO, PH.D., DEPUTY EXECUTIVE

DIRECTOR, JOINT UNITED NATIONS PROGRAMME ON HIV/AIDS [UNAIDS] 

INTRODUCTION

Mr. Chairman, distinguished members of the Subcommittee, ladies and gentlemen. 

I thank you for the opportunity to testify before you this afternoon. I commend 

you for your longstanding leadership in the global fight against AIDS and for now 

turning the attention of the Subcommittee and the Congress to the AIDS epidemic 

in Asia and the Pacific. 

This Committee shined a bright light on the burgeoning AIDS epidemic in Africa 

and drove the enactment of the US Leadership Against AIDS Act of 2003. I am confident that your focus on Asia will ultimately lead to much needed action against 

AIDS in that region as well. And for that, I thank you. 

As you know, the XVth International AIDS Conference took place in Bangkok last 

week for the first time ever in a developing country in Asia. This conference was 

intended to be a wake-up call for the region—and by all indications, it may be just 

that. Much as the AIDS conference in Durban, South Africa was a watershed moment for expanded access to treatment, it is our hope that the Bangkok conference 

will be remembered as the moment we collectively faced the challenge of AIDS in 

Asia. 

I. THE FACTS

There is little doubt that in the fight against AIDS we once again stand at a 

crossroads and Asia is now at the center of the gathering storm. 

11

Let’s recap just a few of the facts that UNAIDS released last week. 

• Asia now accounts for nearly 7 and 1/2 million people living with HIV. Last year 

alone, half a million died from AIDS and more than twice as many—1.1 million—

were infected with HIV. In fact, 1 in 4 new infections worldwide occurred in Asia 

in 2003, compared to 1 in 5 in 2001.

• Asia is now home to some of the fastest-growing AIDS epidemics in the world. 

This is primarily due to sharp increases in HIV infections in China, Indonesia and 

Viet Nam.

• In the Pacific, the HIV prevalence rate has reached 1% among women attending 

antenatal clinics in Port Moresby, Papua New Guinea. High levels of sexually 

transmitted infections, which indicate increased risk for HIV, have also been documented in Samoa and Vanuatu. As we have seen in the Caribbean, even a small 

number of infections can have a dramatic impact on small islands populations.

• Although the national HIV prevalence in China and India is low: 0.1% in China 

and between 0.4% and 1.3% in India—a closer look reveals that both have extremely serious epidemics in a number of provinces, territories and states.

• And let’s keep in mind that because the region accounts for 60% of the world’s 

population, even relatively low HIV prevalence translates into millions of lives. 

While less than 1% of adults in India are HIV infected—this is about 5 million 

people—more than the entire populations of Botswana, Namibia and Swaziland 

combined.

• In most places in the region, HIV now remains largely concentrated among 

marginalized groups such as injecting drug users, men who have sex with men, 

sex workers, their clients, and their partners. Unfortunately, because prevention 

programme coverage is still so sparse, infection rates among these groups are skyrocketing—and ultimately will not remain contained.

• Monogamous women, whose only ‘‘high-risk’’ behaviour is being married and 

faithful to spouses who engage in high-risk behaviour, are being infected and 

then, sadly, infecting their children. This is how a generalized epidemic begins.

• Timing matters and Asia has a narrow window of opportunity. Because of the dynamics of the epidemic, HIV levels may remain relatively low for many years and 

then explode quite rapidly. Just look at what happened in South Africa. It took 

five years for the prevalence rate to rise from .5 to 1% and then it shot to 20% 

over the next 7 years in the absence of effective care and prevention. While we 

do not expect something quite this drastic in Asia—it is vital to act decisively before crossing into that epidemiological danger zone.

• Given the size of the population, what happens in Asia will set the tone for the 

future of the epidemic globally. 

An investment opportunity: Act now or pay dearly later 

As you know, Asia is a region which has made great economic progress—which 

is now seriously threatened by AIDS. 

A joint study by UNAIDS and the Asian Development Bank (ADB) projects that 

the human, social and economic losses fuelled by the epidemic will reverse hardearned development gains if countries in the region fail to promptly establish comprehensive prevention and treatment programmes. 

Economic losses due to AIDS were estimated at $7.3 billion in 2001 alone, borne 

overwhelmingly by AIDS-affected households. This has impoverished millions of 

men, women, and children. 

The region, and all of us in the global community, have clear cut choices to make 

with very real consequences. If the current trends continue, and we fail to take comprehensive action in Asia and the Pacific:

• a total of 10 million adults and children will likely become infected in the region between now and 2010;

• the annual death toll will increase by 50% to over three quarters of a million 

people by 2010; and

• economic losses will more than double, amounting to $17 billion annually by 

2010.

The good news is we know what works and how to stop the spread of AIDS. ‘‘ABC 

plus’’ works; harm reduction programmes work; voluntary testing and counselling 

programs, especially those accompanied by treatment work; interventions to stop 

mother-to-child transmission work; treating STDs and opportunistic infections work; 

ensuring a safe blood supply and safe health care settings works; microfinance and 

12

other empowerment programmes for women that reduce their vulnerability work; 

and fighting stigma, fear, and discrimination, while promoting hope, works. 

The problem is—in Asia, as in Africa, only a small fraction of those in need are 

currently receiving these lifesaving services. For example: less than 1 in 6 of the 

estimated 2.2 million sex workers in South-East Asia receive basic prevention services. According to recent studies, 6 out of 10 sex workers in East Timor have never 

heard of a condom, nor have 1 in 3 truck drivers in Pakistan. Only 1 in 50 pregnant 

women in the Western Pacific have access to efforts to prevent mother-to-child 

transmission of HIV. In Vietnam, only 1 in 150 of those who need treatment are 

currently receiving government-provided antiretroviral drugs (ARVs). In China, only 

1 in 14 people have had access to HIV counselling and testing—the majority of those 

infected still do not know their own status. 

Increasing access to AIDS prevention and treatment in a meaningful way will require a serious investment. Last year, such a comprehensive effort in the region 

would have cost at least $1.5 billion—yet only $200 million was spent by all public 

sources combined. 

This resource gap will continue to grow as unmet need grows. And by 2007, the funding needed for AIDS prevention and treatment services in Asia will rise to $5.1 

billion annually—approximately $2 per capita. But unlike many countries in Africa, 

as a region, Asia-Pacific can afford much of this investment. Even when resource 

needs reach $5.1 billion—this is only 4% of all health expenditures in the region 

in 2001. 

If the necessary leadership and resources are found—from governments in the region and donor support—and comprehensive programs are implemented, we can 

change the course of this epidemic, and perhaps the course of history. Under this 

scenario, we can:

• prevent 6 million new infections by 2010;

• reduce the death toll by nearly 100,000 people each year;

• save $2 billion in economic losses each year from 2010; and

• alleviate unquantifiable human suffering in Asia alone.

The experience with the SARS epidemic taught leaders in Asia that public health 

can have a serious political and socio-economic impact—but with leadership, commitment, and swift action they can make great strides. Several countries, including 

China and India, have realized that investing in public health is essential to socioeconomic development. 

Recent statements by Premier Wen Jiabao have signalled China’s commitment to 

implementing strong care and treatment programs and targeting vulnerable groups. 

Speaking at the closing of the XVth International AIDS Conference, Mrs Sonia Gandhi affirmed the new government’s commitment to strengthen its AIDS control effort through increased national funding, greater involvement of civil society, more 

widespread education and better health facilities. The Prime Minister of Thailand 

also publicly recommitted to a comprehensive effort including access to 

antiretrovirals and outreach and treatment programmes for drug users. This type 

of leadership sets the stage for action and is an essential first step to stopping the 

march of AIDS in Asia. But more, much more is needed. 

II. THE ROLE OF THE UNITED STATES: A GLOBAL LEADER IN THE AIDS FIGHT

US leadership in the global fight against AIDS is highly valued and much appreciated. The US’ role has and will continue to be essential to mounting an effective 

global response, and to action against AIDS in Asia and the Pacific. The US has 

long been the global leader in providing expertise on AIDS and is now the world’s 

largest provider of global AIDS funding, primarily through the landmark US Leadership Against AIDS Act of 2003. 

To date, the US global AIDS initiative’s primary focus on 14 African and Caribbean countries has provided much needed assistance to the two regions most heavily 

impacted by AIDS. We are grateful for this attention. However, as the epidemic expands around the globe, it is increasingly urgent that we undertake concerted action 

on AIDS in Asia if we are to prevent an unprecedented explosion of HIV infections 

on the continent. 

The recent selection of Vietnam as the 15th US focus country is a very important 

step in this direction. However, we must view this as the first step of many—initial 

progress toward a more comprehensive response to AIDS in Asia—and, regrettably, 

we haven’t much time. 

Unfortunately, because overall HIV prevalence rates remain low in the Asia-Pacific region, the sense of urgency for action has yet to reach a fever pitch. However, 

the numbers do not lie, and there is no question that AIDS in Asia is fast approachVerDate Mar 21 2002 14:40 Oct 08, 2004 Jkt 000000 PO 00000 Frm 00016 Fmt 6633 Sfmt 6621 F:\WORK\AP\072104\94989.000 HINTREL1 PsN: SHIRL
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ing a critical tipping point. Given these conditions, it is now more essential than 

ever that the US and other key donors actively engage the region’s political leaders 

and encourage them to meet the AIDS challenge head-on. 

Promoting leadership, investing resources, and sharing experience 

The US has had a long and productive presence in the Asia-Pacific region, and 

is well positioned to provide critical assistance to promote, support, and inform expanded efforts to fight AIDS in the region. The US is already by far the largest 

donor and provider of expertise on HIV/AIDS in several countries, particularly with 

regard to strengthening HIV/AIDS surveillance capacity, mobilizing civil society engagement, and implementing and managing prevention, treatment, and care services. 

The US has much to offer as a key strategic partner through a three pronged approach to ratcheting up the Asian response to AIDS: (1) by promoting leadership 

through diplomacy; (2) by providing and leveraging increased resources from both 

donor and impacted countries; and (3) by offering the training and technical assistance to enhance national capacity. 

1) Promoting leadership and sustained political commitment 

Although leadership on AIDS in the Asia-Pacific is gaining momentum, the US 

can help nurture and promote this leadership at all levels through high level diplomacy, encouraging the real and sustained commitments required to implement and 

manage a comprehensive response to AIDS in the region. There are a number of 

useful steps that the US can take in this regard. 

In the global arena, the US should urge Asian leaders to participate actively in 

international political fora where AIDS is on the agenda, and help push for discussions around AIDS in Asia where it is not yet being considered. The US should also 

urge national and international businesses, religious organizations, foundations, 

academic institutions, and others—in the US and worldwide—with strong ties to 

Asia to become more engaged in regional AIDS efforts. 

At regional and sub-regional levels, the US, through its ongoing participation in 

key regional diplomatic fora, such as Asia-Pacific Economic Cooperation (APEC), the 

ASEAN Post Ministerial Conference (PMC), the ASEAN Regional Forum, and the 

Asia-Pacific Leadership Forum on HIV/AIDS and Development (APLF), should work 

to ensure that AIDS is and remains high on the political agenda and to build and 

sustain commitment at the ministerial level. 

Specifically, in the case of ASEAN, the US is already exhibiting leadership and 

supporting implementation of the ASEAN Work Programme on HIV/AIDS. This 

same level of involvement would be most welcome in the context of APEC, which 

recently formed a Health Task Force and will be seeking guidance on how best to 

contribute to the fight against AIDS. With the APLF, the US provides ongoing financial support, and could offer valuable technical assistance as the Forum works 

to support and strengthen political and civil society leadership on AIDS at the regional and national level. 

At the national level, the US should encourage its Ambassadors to Asia to actively 

engage in the fight, promoting and supporting leadership, leveraging resources, and 

providing technical expertise and training—responsibilities which US Ambassadors 

have successfully assumed in Africa and Caribbean as the US global AIDS initiative 

has rolled out. On the ground, US support should extend beyond national governments, and promote a broad, multisectoral response. 

2) Investing and leveraging real resources for what works 

To fight AIDS effectively in Asia, the region requires increased financial resources 

and technical expertise. The US is ideally positioned to provide meaningful assistance in both regards. In terms of resources, the US should invest in what works, 

leverage other donors and host governments to increase their spending on proven 

interventions, and promote coordination and cooperation among and between donors 

and host governments. As we have seen, a firm commitment by the US draws the 

attention of the international community and promotes healthy competition among 

donors. 

With regard to HIV prevention programs, spending must be dramatically increased to scale up prevention education, through support of an ‘‘ABC plus’’ model, 

which encourages: abstinence, being faithful, and using condoms—while also promoting female controlled prevention methods, such as females condoms and 

microbicides, empowering women and effectively engaging men. Given that for many 

women and girls, negotiating A, B, or C is often not a realistic option, we must provide them with the tools they need to protect themselves. That’s what I heard from 

women leaders in the Mekong region when they launched their coalition on women 

and AIDS—and that’s what I’ve heard from women all over the world. 

14

It is also essential that funding increase to expand voluntary counselling and testing, harm reduction, and drug treatment programs. Whether the US funds needle 

exchange programs directly or not, it should recognize the importance of these efforts and promote their implementation in Asia. With regard to AIDS treatment, the 

US can increase and leverage greater funding to expand access to antiretroviral 

therapy, as well as medicines to treat opportunistic infections and other sexually 

transmitted diseases. 

(3) Sharing expertise and building indigenous capacity 

The US is also well positioned to offer valuable technical guidance, through its 

enormous reservoir of experience and expertise, both in the US and on the ground. 

In Asia, as elsewhere, there is a desperate need for capacity building, especially 

within the health sector; technical assistance on program implementation and management; and training of doctors, nurses, and community workers to provide prevention and treatment services. 

There are also dramatic gaps throughout most of the region in terms of monitoring and evaluating, both in measuring the scope and scale of the epidemic and 

in assessing the value of ongoing interventions. Through its experience with establishing surveillance systems and results-based management, the US could be of real 

assistance in helping Asian countries strengthen their ability to build and conduct 

practical and effective systems. 

Overall, the US has a central and decisive role to play in the Asia-Pacific. Given 

the increasing openness, greater political commitment and leadership, and socio-economic development exhibited by many countries in the region, and the grave threat 

AIDS poses to political, economic, and social growth and stability, this role has 

never been more important, or more urgently needed. Increased investments in 

AIDS in Asia by the US and other donors will help to mitigate and avert millions 

of new HIV infections and AIDS deaths, and help to ensure national and regional 

security, better governance, and sustained economic growth. 

As the US considers increased action in Asia, UNAIDS looks forward to working 

closely with you in this effort. 

III. UNAIDS CAN HELP MAKE A DIFFERENCE

We know that business as usual won’t stop AIDS. That’s why the Joint United 

Nations Programme on HIV/AIDS, or UNAIDS, was created. Today, through the 

leadership of UNAIDS, ten UN agencies and a Secretariat have joined forces in concerted action against AIDS worldwide. In reality, UNAIDS is UN reform in action. 

Working globally, regionally, and on-the-ground in more than 65 countries, 

UNAIDS is helping to develop the leadership, build the capacity, and apply the expertise needed to shape a more effective response to AIDS. UNAIDS is focused not 

just simply on mobilizing resources—but on maximizing their effectiveness on the 

ground where the rubber meets the road. 

In many ways, UNAIDS is the global knowledge and action fund, capitalizing on 

the comparative advantage of each of its Cosponsors and partners, and helping to 

find solutions that bring governments, communities, and donors together to achieve 

real results. 

In Asia and the Pacific, UNAIDS has been key to: 

(1) Galvanizing political leadership and commitment: 

• In India, UNAIDS directly supported the creation of the Indian Parliamentary 

Forum on HIV/AIDS and nurtured its growth from a gathering of 15 Parliamentarians in 2000 to a convention of 1,500 Parliamentarians with the participation 

of the Prime Minister and the leader of the opposition in 2003. The commitment 

of the Parliamentary Forum continues to trickle down and 9 States have now created a State Parliamentary Forum on HIV/AIDS. With support from UNAIDS, 

similar fora are now being established in Pakistan and Bangladesh.

• In China, UNAIDS was key in promoting a high-level awareness of the seriousness and urgency of the growing HIV/AIDS epidemic, and a ‘‘Joint Assessment of 

HIV/AIDS Prevention, Treatment and Care’’ with China’s Ministry of Health. This 

has lead to leadership at the top and innovative policies adopted by the central 

Government. UNAIDS is now providing additional support to the government as 

it seeks to develop an effective multisectoral response and a cohesive and coordinated response at provincial level.

• In March of this year, at a workshop co-organised by UNAIDS, the President of 

Fiji and the Chair of the Great Council of Chiefs, committed themselves to the 

action against AIDS and called on community, business and religious leaders to 

similarly commit. UNAIDS is currently assisting other small pacific island counVerDate Mar 21 2002 14:40 Oct 08, 2004 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6621 F:\WORK\AP\072104\94989.000 HINTREL1 PsN: SHIRL
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tries with similar political structures in convening traditional leaders to discuss 

AIDS.

• And at the Asia regional level, UNAIDS supported the Association of Southeast 

Asia Nation’s (ASEAN) in convening a special summit on HIV/AIDS and provided 

resources for country- and regional-level preparations for this summit. Through 

UNAIDS, civil society, including people living with HIV/AIDS, were engaged in 

the process of preparing the ASEAN Summit Declaration on HIV/AIDS and the 

subsequent ASEAN Work Programme on HIV/AIDS. 

(2) Enlisting key partners: 

• Throughout the region, UNAIDS is considered a neutral broker and facilitator 

among governments, donors, NGOs, and civil society, including religious leaders 

and the business community. Recognizing that it will take all sectors of all societies to win this war—UNAIDS has engaged a broad array of partners including:

— The Asia Business Coalition on HIV/AIDS, the Federation of Chambers of 

Commerce and Industry in Nepal, the Confederation of Indian Industry, 

business coalitions on HIV/AIDS in Indonesia, Thailand, Myanmar, and 

Singapore and a range of private sector champions in the Philippines;

— Mass organizations such as unions, youth and women’s organizations in 

Laos, Vietnam, India, China;

— Religious groups such as the Council of the Indonesia Ulama, Lutheran 

World Federation and Church World Services in Indonesia, Buddhist groups 

in Laos, Thailand and Myanmar, and various faith-based groups (Muslim, 

Hindu, Buddhist, and Christian) in Bangladesh;

— The national police and military personnel in Laos, Thailand, Indonesia, and 

Myanmar; and

— The International Cricket Council across the region, just to name a few. 

(3) Developing and disseminating strategic information: 

• Providing user friendly policy guidance and best practice information is critical to 

ensuring effective evidence-based national responses. To that end, UNAIDS has 

supported countries throughout the region in the assessment of key programme 

and policy gaps and priorities and in the development of national HIV/AIDS laws 

and strategies. UNAIDS has also promoted the sharing of global and regional best 

practices, including positive experiences from Thailand and Cambodia. In China, 

30 UNAIDS publications have been translated into Chinese and widely distributed throughout the country. 

(4) And finally, mobilizing and maximizing resources: 

• In 2003, UNAIDS provided technical assistance in the development of Global 

Fund proposals in 13 countries and assisted in other resource mobilization activities in an additional 12 countries. Countries receiving UNAIDS’ support were over 

4 times more likely to be funded than those who did not. UNAIDS now stands 

ready in these countries to assist in ensuring that the Global Fund and other 

money gets out, is effectively utilized, and that program results are tracked and 

well documented.

• A major achievement in the region took place in Myanmar where, given the very 

difficult political situation and growing epidemic, UNAIDS helped establish and 

supports the management of the Fund for HIV/AIDS which channels $24 million 

from various sources for an integrated and harmonized programme rallying all 

partners;

• UNAIDS has helped to cost out national strategic plans and assess resources 

needs and gaps, strengthen the capacities of governments in the region in results 

based management, and establish monitoring and evaluation systems in 16 countries;

• And most recently, UNAIDS has spearheaded, in cooperation with the US government and others, the adoption of three key principles to drive donor support for 

concerted action against AIDS on the front lines.

Known as the ‘‘three-ones,’’ these principles will help to ensure that our action 

at country level is in fact country-driven—and that, whatever our respective roles, 

we all agree to work with:

• one AIDS action framework (strategy, plan) that provides the basis for coordinating the work of all partners;

• one national AIDS coordinating authority with a broad-based multisectoral 

mandate where all key players are at the table; and

16

• one monitoring and evaluation system for tracking progress towards achieving real results.

In April 2004, at a meeting held here in Washington, co-chaired by UNAIDS, and 

the governments of the US and the UK, all major bilateral donors, as well as UN 

organizations, the World Bank, and the Global Fund agreed to these basic principles. 

Too often, efforts to fight AIDS are designed in isolation. And all too often, program managers are forced into being data processors, spending huge amounts of 

time trying to satisfy dozens of duplicative reporting requirements. This talent and 

energy—this vital in-country capacity—needs to be freed up to contend with the 

pandemic, not the paperwork. By being more organized and coordinated in our AIDS 

action, we can do more and be more effective. This reality was clearly pointed out 

in the recent GAO report. 

We have a long way to go, but the ‘‘three ones’’ gives us a much needed roadmap. 

The true test will come in the application of these principles, country-by-country, 

and in our ability to translate this opportunity into prevention, treatment, and support services for the millions in need. UNAIDS has been charged with moving this 

process forward—and this responsibility is a very high priority for us. We look forward to working closely with the US and are very pleased that the House Foreign 

Operations Appropriations bill has asked for a quick report on progress in this effort. 

CONCLUSION: 

In closing, I would like to reiterate that we are at a critical juncture in the global 

fight against AIDS and the stakes are very high—for Asia and for us all. Success 

will require more money, more action, but most of all, it will require unprecedented 

cooperation, coordination, and a framework for moving forward together—particularly at country level. It will take a new way of doing business and a new way of 

relating to each other. 

We have the skill and science needed to stop AIDS. What we need now is the political will, the strategy, and the unity to turn the tide. 

It is not about PEPFAR or the Global Fund. It is not about prevention or care, 

condoms or abstinence, Africa or Asia, AIDS or poverty reduction. This is not an 

either-or proposition. We need them all and more. We need a comprehensive strategy, a truly global response, and an arsenal of tools at our disposal to succeed. 

If we take a stand together we can move from the band-aid approaches of the past 

to providing real and desperately needed HIV prevention and treatment services in 

communities worldwide. 

As Peter Piot, Ambassador Tobias, and Hillary Benn said in a recent op-ed 

piece—‘‘It is high time we leave our flags and affiliations at the door and find ever 

new and better ways to get the job done.’’ I agree. 

Thank you very much.

Mr. LEACH. Dr. Gill. 

STATEMENT OF BATES GILL, PH.D., FREEMAN CHAIR IN CHINA 

STUDIES, CENTER FOR STRATEGIC AND INTERNATIONAL 

STUDIES, WASHINGTON, DC 

Mr. GILL. Thank you very much, Mr. Chairman, and allow me 

to begin by thanking you and Members of this distinguished Committee for the opportunity to speak before you today. 

I congratulate you, Mr. Chairman, and your colleagues for taking 

up this issue and examining the looming challenge of HIV/AIDS in 

Asia more carefully, and gauging its impact on American interests 

in the region, around the world, and considering appropriate American responses. 

I am going to offer a brief summary of my remarks, in three 

parts. First, an overview. Then I will specifically focus on China, 

secondly. And third, offer some recommendations for the Committee. I will summarize these points and ask that my formal 

statement be entered into the record. 

17

Incredible as it seems, Mr. Chairman, each and every day more 

than 8,000 persons die of HIV/AIDS. Even more astonishingly to 

me, more than 13,000 persons become infected each and every day. 

And more people became infected with HIV in 2003—20 years since 

the outbreak of the epidemic, 5,000,000 new infections last year—

than have occurred in any year previously. 

With resources for prevention, treatment, and care coming well 

short of what is needed, the world is falling behind in its effort to 

reverse this deadly and destabilizing course. Of particular concern 

to this Committee, the United States and the world now face an 

even greater challenge, something we term the ‘‘Second Wave’’ of 

HIV/AIDS in Asia, as it gathers on the very near horizon. 

The center of gravity of this epidemic is shifting perceptibly eastward, from Africa, and increasingly affects Eurasia. However, unlike in the past, the devastating consequences of HIV/AIDS will increasingly envelop very large, highly populated, and geostrategically critical countries and regions across Asia, including China, 

India, Indonesia, and Russia. 

Some basic figures tell a troubling tale of the ‘‘Second Wave.’’ According to UNAIDS, 8.7 million persons are living with HIV/AIDS 

today in Eurasia, 1.3 million in Eastern Europe, Russia, and Central Asia, and 7.4 million across Asia. By some estimates, China, 

India, and Russia alone may account for between 10 and 15 million 

HIV/AIDS patients in just 6 short years. 

More troubling to me is the increasing evidence that the disease 

is spreading out of so-called source populations, such as injecting 

drug users and commercial sex workers, and into the general population, driven by pre-marital, extra-marital, and marital heterosexual contact. 

Mr. Chairman, our public and private sector here in the United 

States has not yet fully faced the reality of the ‘‘Second Wave,’’ and 

its implications for the United States, for the important Asian region, and for the world. As you know, China, India, Indonesia, and 

Russia, and other important Asian countries fall outside of the 

scope of the President’s Emergency Plan for AIDS Relief, or 

PEPFAR, which is America’s welcome and strategic response to the 

global epidemic. 

Given the importance of these countries in Asia to American economic, political, and security interests, however, we need to work 

on a more coherent and serious strategy to help stem and roll back 

the gathering threats posed by HIV/AIDS in this critical region. 

In the second section, Mr. Chairman, I want to draw largely from 

a report which we recently issued at CSIS, which focuses on the 

HIV/AIDS problem in China. Just a couple of findings. 

I think we should be heartened that HIV/AIDS has, just in the 

past 15 to 18 months, been more clearly recognized and acknowledged by the senior political leadership in China. According to official Chinese data, some 840,000 persons are living with HIV as of 

the end of 2003. But only about 62,000 to 64,000 of those persons 

have been formally tested and officially confirmed to be HIV-positive. 

What that means, Mr. Chairman, is that some 93 to 94 percent 

of those living in China today who are HIV-positive do not know 

it, and the government does not know who they are. 

18

If, as I suspect, the actual numbers of HIV-positive persons in 

China is even higher than the Chinese Government acknowledges, 

that percentage of HIV-positive persons who do not know their status would be much higher. 

The formal remarks that I have submitted into the record go into 

more detail on these subjects. But I want to make one key point 

here. 

As I have said already, in China, as already in other parts of 

Asia and the rest of the world, HIV is steadily moving from source 

populations, such as injecting drug users and commercial sex workers, and into the more general population, where we could expect, 

as it does, more exponential growth of the epidemic. 

Secondly, we should note and welcome that China has made important advances in policy, outlook, and resource commitments at 

the central government level. New leaders have emerged in China 

in the past 12 months who are more sensitive and aware of the 

challenges posed by HIV/AIDS and public health problems more 

generally. 

Very importantly, just last year China instituted, and is now trying to stand up, a comprehensive national treatment plan, known 

as China CARES. Other targets for China are relatively ambitious, 

but they hope to have 40,000 persons under treatment by the end 

of 2005, which will be a difficult target to meet. 

Unfortunately, however, owing I think largely to shortages of resources, and especially in terms of training and counselling, the 

drop-out rate in this treatment program is relatively high, at about 

20 percent. 

Thirdly with regard to China, formidable challenges lie ahead for 

them, in spite of these positive changes in terms of outlook and 

new resource commitments. Key challenges which China will face—

and let us face it, in a country with a territory and population as 

large as China, and also where the problems lie largely in remote 

and rural areas—lessons learned from other countries that have 

faced this epidemic may not so readily apply in the Chinese case. 

China has an enormous amount of work to do in terms of 

ramping up its weak and incomplete national testing and surveillance system. China’s health care system, formerly so widely recognized as a model for developing world countries, has become dysfunctional, and has unraveled, in fact, over the course of its 

marketization of its economy. 

China seriously lacks qualified personnel to deal with its HIV/

AIDS crisis. According to some estimates, China has fewer than 50 

doctors—fewer than 50 doctors—who are capable of diagnosing, 

treating, and monitoring HIV infection. How will it be possible, 

given the numbers that they face, that they can meet this challenge? 

China also lacks a strategic and well-coordinated plan which can 

invest provinces and localities where HIV/AIDS is at its worst in 

China to get on board in the same way that central government authorities have done. And also, for both political and normative reasons, China has yet to truly reach out to sensitive and ‘‘taboo’’ populations where HIV prevalence is at its greatest, such as among injecting drug users and commercial sex workers. 

19

In spite of these positive moves, then, in China, Beijing and its 

international partners can ill afford business as usual or incremental or reactive adjustments to dealing with HIV in China. The 

United States can seize upon this moment, I think, to build a far 

more robust partnership around public health, not just in HIV but 

other issues, with China. These steps are warranted on the basis 

of U.S. national interests, our increasingly critical relationship with 

China, and I believe hold the promise of obtaining substantial results. 

I have left a number of recommendations here in my formal remarks, but I just want to touch on some very briefly. 

I encourage Members of Congress, our Cabinet Secretaries, and 

other leading policymakers to integrate HIV/AIDS into their dialogue with counterparts in China. I am encouraged in this regard 

that we are seeing in our Government a reaching out beyond narrowly health care-related discussions with China on HIV/AIDS, and 

recognizing it as a problem which affects the spectrum of bureaucratic relationships with China, be it labor, education, and others. 

Secondly, we need to work more actively with China to see that 

it expands the space that it offers to corporate and non-governmental actors within its own society. After all, this disease is one 

that will have to be dealt with at a community- and grassrootslevel. 

But as you know, civil society is not highly developed in China. 

It seems to me that this is an opportunity for the United States, 

through funding and through political encouragement, to help develop civil society in China, community-based organizations and 

non-governmental organizations which can address such problems 

as HIV as it affects women and girls, as it affects AIDS orphans, 

as it affects injecting drug users, and other marginalized parts of 

Chinese society. 

Lastly, I would propose that Congress and the White House give 

serious consideration to establishing a joint U.S./China Commission 

on Public Health, which would focus high-level attention on building U.S. partnerships to strengthen public health in China, and 

mitigate the impact of China’s deteriorating public health care system upon U.S. interests. We can deepen our high-level engagement, 

both public and private, with China on HIV/AIDS, and we should 

encourage our Global AIDS Coordinator, Ambassador Tobias, to 

make a visit to Beijing in the near future. 

Obviously, bilateral and technical assistance can be further expanded. For example, helping underwrite the placement of external 

experts at both central and provincial levels to assist China in both 

the strategic planning and the technical execution of its muchneeded HIV/AIDS programs. 

Thank you very much, Mr. Chairman. 

[The prepared statement of Mr. Gill follows:]

PREPARED STATEMENT OF BATES GILL, PH.D., FREEMAN CHAIR IN CHINA STUDIES, 

CENTER FOR STRATEGIC AND INTERNATIONAL STUDIES, WASHINGTON, DC 

THE COMING ‘‘SECOND WAVE’’: HIV/AIDS IN ASIA

Introduction 

Allow me to begin by thanking the Chairman and members of this distinguished 

Committee for the opportunity to speak before you today. I congratulate you, Mr. 

20

1The statistics in this section draw in part from 2004 Report on the global AIDS epidemic

(Geneva: Joint United Nations Programme on HIV/AIDS, June 2004). 

Chairman, and your colleagues, for examining the looming challenge of HIV/AIDS 

in Asia more carefully, gauging its impact on American interests in the region and 

around the world, and considering appropriate American responses. 

I will offer a brief summary of my remarks in three parts: an overview, a specific 

focus on China, and recommendations for the Committee. In the interests of time, 

I will summarize these points, but would ask that my formal statement be entered 

into the record. 

The ‘‘Second Wave’’ of HIV/AIDS 

Incredible as it seems, each and every day, more than 8,000 persons die of HIV/

AIDS. More astonishingly, every day some 13,000 new infections occur.1 Nearly half 

of these infections will be in the world’s future—its young people, aged 15 to 24. 

More people became infected with HIV in 2003—5 million new infections—than in 

any year since the disease surfaced more than 20 years ago. With resources for prevention, treatment and care coming well short of what is needed globally, the world 

is falling behind in its effort to reverse the deadly and destabilizing course of the 

epidemic. 

Of particular concern to this Committee, the United States and the world now 

face an even greater challenge as a looming ‘‘second wave’’ of HIV/AIDS in Asia 

gathers on the near horizon. The center of gravity of the global epidemic is shifting 

perceptibly eastward from Africa and increasingly affects Eurasia. Unlike in the 

past, the devastating consequences of HIV/AIDS will increasingly envelop very 

large, highly populated, and geostrategically critical countries and regions in Asia, 

including China, India, Indonesia, and Russia. 

Some basic figures tell the troubling tale of the Second Wave. Approximately 8.7 

million persons are living with HIV/AIDS in Eurasia today—1.3 million in Eastern 

Europe, Russia and Central Asia, and 7.4 million in the rest of Asia. Of the 5 million new infections in the world last year, more than 20 percent—about 1.1 million—occurred in Asia. On the Eurasian landmass, India accounts for the largest 

number of these infections, some 5.1 million, making it the second—and soon to be 

the first—most afflicted country in the world. China officially counts about 840,000 

persons infected with HIV at the end of 2003, but many analysts believe the number 

is closer to 1 million or more, and that the figure could reach as high as 6 to 10 

million by 2010 if current trends continue. Indonesia’s epidemic appears largely concentrated in its population of injecting drug users (IDUs) Russia has an estimated 

1 million persons living with HIV/AIDS, and could have two or three times as many 

by 2010. Indeed, Eastern Europe and Central Asia, including Russia, have the fastest growing HIV epidemic in the world today, according to UNAIDS. By some estimates, China, India, and Russia alone may account for between 10 and 15 million 

HIV/AIDS patients in just six short years. 

The epidemics in Asia are centered primarily in two populations: injecting drug 

users and commercial sex workers and their clients. However, there is increasing 

evidence that the disease is spreading in the general population, driven by premarital, extramarital, and marital heterosexual contact. 

Mr. Chairman, our government and private sector have not yet fully faced the reality of the Second Wave and its implications for the United States, the Asian region, and the world. As you know, China, India, Indonesia, and Russia and other 

important Asian countries fall outside the scope of the President’s Emergency Plan 

for AIDS Relief, or PEPFAR, America’s strategic response to the global epidemic. 

Given the importance of these countries in Asia to American economic, political, and 

security interests, we must craft a more coherent strategy to help stem and roll 

back the gathering threats posed to them by HIV/AIDS. 

China’s HIV/AIDS Crisis 

Mr. Chairman, I will focus the remainder of my remarks on the HIV/AIDS crisis 

in China. These points are based on more than three years’ work examining the 

HIV/AIDS challenge in China, and more than two decades as a student of China 

more generally. Our work, generously supported by the Bill and Melinda Gates 

Foundation and the Henry J. Kaiser Family Foundation, has established regularized 

and extensive access to Chinese leaders, HIV specialists, health professionals, government and quasi-government organizations, and persons living with HIV, both at 

national and local levels throughout China. The findings and recommendations preVerDate Mar 21 2002 14:40 Oct 08, 2004 Jkt 000000 PO 00000 Frm 00024 Fmt 6633 Sfmt 6621 F:\WORK\AP\072104\94989.000 HINTREL1 PsN: SHIRL
21

2More detailed findings and recommendations in Bates Gill, J. Stephen Morrison, and Drew 

Thompson, eds., Defusing China’s Time Bomb: Sustaining the Momentum of China’s HIV/AIDS 

Response: A Report of the CSIS HIV/AIDS Task Force Delegation to China, April 13–18, 2004 

(Washington, D.C.: Center for Strategic and International Studies, June 2004), accessible at: 

http://csis.org/china/040617—China—AIDS—Timebomb.pdf.

sented here are based largely on a recent senior-level delegation visit to China at 

the invitation of the Chinese Minister of Health.2

HIV/AIDS is now recognized clearly as a growing threat to China. According to 

official Chinese estimates, China now has approximately 840,000 persons living 

with the HIV virus. As of the end of 2003, only 62,159 persons had been tested and 

officially confirmed to be HIV-positive. The remaining HIV-positive persons in 

China—estimated at 780,000 persons or more—are not known to public health authorities, and the individuals themselves probably do not know their status, posing 

significant risks for the further spread of HIV. 

Moreover, outside observers continue to believe that the number of HIV-positive 

persons in China is higher than China is prepared to acknowledge—perhaps 1 to 

1.5 million. Doubt persists, despite improvements in estimating techniques, because 

China’s HIV surveillance system remains inadequate, and indeed is a major obstacle 

to successfully confronting the spread of HIV in the country. The approximately 

62,000 persons officially reported to be HIV-positive represent only 7.4 percent of 

the total estimated HIV-positive population in China. In some parts of China, the 

gap between known and estimated cases is even more stark: Hubei provincial health 

authorities, for example, have confirmed approximately 1,300 HIV-positive persons, 

but this represents only 3.7 percent of the estimated 35,000 HIV-positive persons 

in the province. 

HIV today is apparently concentrated among injecting drug users (IDUs) and persons infected in the 1990s through blood donations. It is present in all 31 provinces, 

autonomous regions, and municipalities of China, although the greatest numbers 

are found in eight hardest-hit provinces and autonomous regions: Yunnan, Xinjiang, 

Guangxi, Sichuan, Henan, Guangdong, Anhui, and Hubei. However, senior Chinese 

officials, as well as international experts operational in China, now assert that HIV 

is steadily moving from source populations such as injecting drug users and commercial sex workers into the general population. 

China has made important advances in outlook, policy, and resource commitments 

at the central government level New leaders have emerged in China with a stronger 

commitment to improving social welfare and to addressing HIV/AIDS in particular. 

China has initiated a more proactive response to the HIV/AIDS challenge, including 

a national treatment and care program known as the China Comprehensive AIDS 

Response, or China CARES. China CARES aims to provide free antiretroviral (ARV) 

treatment to 10,000–15,000 persons by 2004 and 40,000 persons by 2005. As of the 

end of 2003, China CARES had initiated treatment for 7,011 patients, though the 

dropout rate stands at about 20 percent, largely owing to poor counseling, monitoring and drug side-effects and toxicities. 

In addition, new policy guidelines promote ‘‘four frees and one care’’: free 

antiretroviral drug treatment for poor citizens, free testing and counseling for poor 

citizens, free treatment to prevent mother-to-child transmission of HIV, free schooling for AIDS orphans, and care for families affected by HIV/AIDS. Senior leaders 

have committed to steadily ramping up certain sensitive harm reduction strategies, 

including condom promotion, needle exchange, and methadone substitution therapy 

for drug addicts. 

Also, in February 2004, China established the State Council Working Committee 

on HIV/AIDS. This move revamped and upgraded the former National Coordinating 

Committee on HIV/AIDS and Sexually Transmitted Diseases, which had met only 

four times between 1996 and 2003, and was operated out of a low-level office within 

the Ministry of Health. The new Working Committee is chaired by Vice Premier Wu 

Yi, comprises 23 ministries and seven provinces, and meets on an annual basis, with 

more regular meetings and consultations carried out at the working level. Importantly, the executive office of the new Working Committee is housed in the office 

of a Vice Minister of Health (currently the office of Vice Minister Wang Longde). 

Importantly, in 2003–2004, significant new lines of funding became available to 

combat HIV/AIDS in China. After being rejected twice, China’s application to the 

Global Fund in 2003 was accepted, promising $32 million during 2004 and 2005. 

Remaining support of up to $66 million would be made available in years three, 

four, and five of the grant contingent upon a satisfactory review by the Global Fund 

of the first two years of implementation. China’s application to the fourth round of 

Global Fund support has also been accepted and will focus additional monies on prevention among certain high-risk groups such as IDUs and commercial sex workers. 

22

Chinese central government funding has also substantially increased. For the fiscal 

year beginning April 1, 2004, the Ministry of Health is expected to receive some 400 

million renminbi (approximately $50 million at current exchange rates) in funding 

to combat HIV/AIDS, a quadrupling of funding over 2002–2003 levels. 

Formidable challenges lie ahead In spite of these many important changes in tone 

and policy, daunting challenges—political, technical, and normative—lie ahead for 

China to successfully meet the goals it has set to combat HIV/AIDS. It is difficult 

to overstate the scale of the challenge and the impediments confronting the implementation of an effective strategy in terms of planning, costs, logistics, human resources, technical capacity, and tackling the pervasive problems posed by stigma 

and misunderstanding about the disease. 

The scale of the challenge alone—in a country with a territory and population as 

vast as China, and where the most heavily affected areas lie primarily in remote, 

rural, and poor parts of the country—is unrivaled in many respects, meaning many 

‘‘lessons learned’’ from other countries will not readily apply to the China case. The 

political will and policy structure has turned in a more positive direction at the central level, but the challenge of combating HIV/AIDS in China must now move into 

a far more difficult ‘‘phase two’’ of policy and technical implementation at a national, 

strategic level, and on the ground at the provincial, county, township, and village 

levels. 

Key challenges include:

• Weak and incomplete national HIV testing and surveillance system;

• Debilitated and dysfunctional public health system, particularly in rural 

areas where HIV is hitting hardest, undermining an effective response to 

HIV/AIDS;

• Serious lack of qualified personnel and the necessary equipment and technologies to properly diagnose, counsel, treat, monitor, and care for HIV/AIDS 

patients;

• Major challenges in implementing an effective HIV drug treatment program, 

with strong risk of emergent drug-resistant HIV becoming more prevalent in 

China;

• Need for far greater emphasis on HIV education, awareness, and prevention;

• Lack of counseling and confidentiality to accompany expanded testing program;

• Lack of a strategic, well-coordinated plan aimed at winning provincial cooperation and forging effective external partnerships with the private sector 

and international donors; and

• Need to reform intra-governmental cooperation to stem and prevent the 

spread of HIV within socially marginalized groups such as drug users, sex 

workers, and economic migrants. 

Conclusions and recommendations 

In the past year, China has undergone a dramatic shift of focus, will, and consciousness vis-a-vis HIV/AIDS and public health. These promising changes have 

driven upward the priority attached to HIV/AIDS, empowered Ministry of Health, 

energized senior political leaders at many levels, changed the national discourse 

around HIV/AIDS, and opened the way for the first time in China to address HIV/

AIDS and other related infectious diseases seriously on a national scale. However, 

at this juncture, China and its international partners can ill afford a ‘‘business as 

usual’’ approach or incremental, reactive adjustments to dealing with HIV in China. 

The United States should seize upon this moment to build new, far more robust 

partnerships around public health in China. These steps are warranted on the basis 

of U.S. national interests, and hold the promise of attaining substantial results. 

Sustaining strong leadership Success in addressing HIV/AIDS in China will require continued high-level leadership, both in China and internationally. For engaged U.S. policymakers, members of Congress, and Cabinet secretaries, as well as 

country leaders and heads of international organizations, priority should lie in nearto medium-term steps which sustain Chinese leadership’s focus on HIV/AIDS and 

public health. 

Enhancing strategic planning and prioritization China’s formidable structural and 

organizational weaknesses must be addressed systematically. New national programs potentially pose unfunded financial burdens to provincial and local governments. Failure to implement a more strategically coordinated plan risks the loss of 

international support over time. Prevention and awareness should receive higher 

priority in China’s strategic national plan to combat HIV/AIDS. High priority should 

23

be given to advancing testing in China. Human resource development, through education and training of medical professionals, is crucial. 

Accelerating institutional restructuring and reform High priority should be given 

to addressing prevention and treatment more strenuously, especially within key atrisk groups. Present organizational structures to combat HIV/AIDS, dominated by 

the Chinese Center for Disease Control and Prevention, lack the technical expertise 

and human resources to plan and estimate costs, as well as develop, execute, coordinate, monitor, and evaluate complex national-scale treatment and care programs. 

China should incentivize health care delivery such that medical personnel become 

more actively engaged in HIV/AIDS prevention, education, treatment, and care. Particular attention should be given to improving communication and collaboration between central and provincial authorities. 

Expanding space for new Chinese and international actors. China’s business community and multiplying media outlets have not been meaningfully engaged in support of HIV/AIDS programs. Stronger signals are needed to welcome the special role 

of both indigenous and international nongovernmental organizations in fighting 

HIV/AIDS, including the contribution of international businesses in the form of 

worker education and training and charitable giving. Addressing the acute vulnerability to HIV of women and girls, as well as the growing number of AIDS orphans, 

increasingly will require enhanced support from communities, educators, and civil 

society. 

Strengthening joint U.S.-China partnership The United States faces an historic 

opportunity to help shape health-related outcomes in China in ways that are favorable to the interests of China, the United States, the Asia-Pacific region, and the 

world. Innovative U.S. policies and support to China on HIV/AIDS will contribute 

significantly to the formulation of a ‘‘Second Wave’’ strategy for such major states 

as China, India, and Russia which stand at risk of a generalized epidemic but which 

are presently not a priority focus of U.S. global HIV/AIDS efforts. 

Congress and the White House should give serious consideration to establishing 

a Joint U.S.-China Commission on Public Health to focus high-level attention on 

building U.S.-Chinese partnerships to strengthen public health in China. It would 

elevate the priority the two sides explicitly attach to issues of public health and underscore how public health challenges in China increasingly matter to U.S. interests. The Commission might enlist both congressional and administration involvement, and incorporate the widening array of important U.S. educational, religious, 

business, media, bio-medical/public health, and philanthropic institutions that are 

becoming significantly invested in health in China. 

Deepening high-level engagement by Americans in prominent public and private 

positions remains essential. The U.S. Global AIDS coordinator, Ambassador Randall 

Tobias could visit Beijing in 2004. Congressional and cabinet-level delegations to 

China should include HIV/AIDS issues on their agendas, as could senior corporate 

and philanthropic leaders in their visits to China. 

Bilateral, technical assistance can be further expanded. The United States can underwrite the placement of external experts at central and provincial levels to assist 

in the planning and execution of HIV/AIDS programs, and increase public and private support for U.S.-China training exchanges, including twinning arrangements 

between U.S. and Chinese biomedical and public health institutions, including between private hospitals and universities.

Mr. LEACH. Thank you, Dr. Gill. 

Dr. Yeldandi. And welcome, from Chicago. 

STATEMENT OF DR. VIJAY V. YELDANDI, CHAIRMAN, HIV/AIDS 

COMMITTEE, AMERICAN ASSOCIATION OF PHYSICIANS OF 

INDIAN ORIGIN 

Dr. YELDANDI. Thank you. Mr. Chairman, Members of the distinguished Committee, I thank you for the opportunity to speak with 

you this afternoon. And on behalf of U.S./India PAC, the American 

Association of Physicians of Indian Origin, and the people of the 

country of India, I thank you for caring. 

I would like to put a face on all of the numbers that we have 

heard this afternoon. There are estimates ranging from 2.5 million 

to 8.5 million. And these estimates come from a variety of different 

sources. 

24

They are inherently incomplete, because of the difficulties in 

working in India. As an Indian, I know how complex this country 

is, that I have so much difficulty myself understanding. Twentyeight different states, seven union territories, 602 districts, 16 

major languages, 844 dialects. You can move 100 miles from one 

place to another place, and everything changes: The cuisine, the 

culture, the clothes. It is a very difficult place to understand. 

The other point that is worth understanding is that India lives 

in the villages. The majority of India’s population is rural. The majority of India’s gross domestic product—which is important to us 

to understand how to deal with this epidemic, and to understand 

the socioeconomic consequences—is created by these people who 

live in the villages. These are not the people who are taking U.S. 

jobs by outsourcing or the information industry, or anything like 

that. They are simply trying to stay alive, just to get enough food 

to eat, clothes, and shelter. These are the people that we are talking about. 

Those of us who have worked in HIV/AIDS and infectious disease 

in this country, as I have for the last 20 years, have often thought 

how wonderful it would be if I could go back in time 20 years and 

try to do something in Africa, knowing what I know today. 

Mr. Chairman, we now have this opportunity in India. India is 

where Africa was. We have a critical time in history to intervene. 

The general population is impacted by HIV/AIDS. We now have 

data from rural parts of India that show that the general population is beginning to get infected with HIV/AIDS. In our own studies, 40 percent of the people who are infected are women. These are 

monogamous women and their major risk factor for getting HIV 

was getting married. And the major risk factor for their children 

getting HIV was they got infected themselves. 

So this is the problem that we face. The government of India, 

under the leadership of the National AIDS Control Organization, 

the National APEC body for HIV/AIDS, and all of the states’ bodies, in concert with the international organizations, have done a 

wonderful job in trying to address the issues of HIV/AIDS. And 

God bless them. 

The reality is that much of what needs to be done for rural India 

has not reached there. Ninety percent of the health care that is 

provided in India is actually in the private sector. This is not cared 

for by the institutions that are in the government sector. And this 

is the area that we have the greatest difficulty in reaching. These 

are the people we need to reach out and support, because they care 

for all of these poor, rural Indians. 

Now, the private sector ranges in sophistication from the best 

that you can find to completely inadequate facilities. And the latter 

are what is seen in the rural areas. Many of these rural areas do 

not have safe drinking water, let alone a competent health care 

professional who can take care of HIV. So Tuberculosis and Malaria and all of the other infectious diseases that were major public 

health problems continue to remain major public health problems. 

And even though NACO has made substantial progress in improving the safety of blood supply, which is a major accomplishment in India, I can tell you, from my own personal experience, 

25

that for every licensed blood bank there is in certain areas, you can 

find 10 that are unlicensed, and therefore still supply unsafe blood. 

It is extremely important, in order to be successful in averting 

economic catastrophe, to go in and address all of the public health 

issues comprehensively. We need to provide safe drinking water; 

we need to provide access to care for prevention of Tuberculosis, 

prevention of Leprosy, treatment of everything. 

Now, Indians are poor, particularly rural Indians are poor. But 

they are not stupid. It is impossible to go tell them to use condoms 

when you cannot provide them clean drinking water. It is impossible to tell them that it is important to avoid getting infected with 

HIV and avoid high-risk behavior, when we do not have the infrastructure that is needed to provide them a safe blood supply. 

The reality is that the government resources, both at the national level, the state level, and the local level, are stretched very 

thin. Effective monitoring of safety in the health care industry is 

very poor. And therefore, we need to step in and complement all 

of the efforts that have gone in at the state level, the national level, 

and the international level. 

What I would urge the United States Congress, the Government, 

the White House, all to do is to step in and provide the leadership 

here. You have the ability to avert a major socioeconomic and humanitarian catastrophe in one of the most populous countries, and 

one of the most beautiful countries, on earth; a country that has 

supplied 40,000 physicians to this country, an essential part of the 

health care system of this country. 

And I think that if we do a good job in helping India prevent this 

catastrophe, we will also have the ability to influence India in helping us with our own global agenda in fighting so many other wars 

in other places. 

Thank you, Mr. Chairman. 

[The prepared statement of Dr. Yeldandi follows:]

26

PREPARED STATEMENT OF DR. VIJAY V. YELDANDI, CHAIRMAN, HIV/AIDS 

COMMITTEE, AMERICAN ASSOCIATION OF PHYSICIANS OF INDIAN ORIGIN


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Mr. LEACH. Thank you. And thank you for that particular expertise on India. 

Holly. 

STATEMENT OF HOLLY J. BURKHALTER, PHYSICIANS FOR 

HUMAN RIGHTS 

Ms. BURKHALTER. Thank you so much for having me. I am really 

honored to be here among one of the heroes of the HIV/AIDS activist community, and that would be you. 

I remember having heard you speak out on a hot day in front of 

the Capitol years ago about HIV/AIDS in Africa. And it is very nice 

to see you chairing a hearing on the topic in the region that your 

Subcommittee covers. The staff and the board of Physicians for 

Human Rights are very grateful to you and to your colleagues for 

your attentiveness constantly throughout the last year, and particularly grateful to this Committee for its leadership in passing 

the comprehensive HIV/AIDS bill that created the special office in 

the White House. It has made an inestimable important change 

and I really can’t overstate the significance of it. 

Before beginning, I would like to also thank the Physicians for 

Human Rights researchers who helped me with my testimony: 

Aaron Fisher, Evelyn Miah, and Eric Friedman. 

The doctors for whom I work always talk in terms of best practices, a term that is somewhat overworked. And I was tempted to 

do that in speaking today because there are some of the best international practices to combat the pandemic and preventive spread 

may be found in the Asian region. 

But then I thought, no, I am a human rights activist; I have got 

to talk about worst practices. That is what I do for a living. 

So I think instead of talking about some of the positive examples 

from Asia—which you can find on UNAIDS’ wonderful Web site, 

where they have some of the really great examples of community 

efforts, many of them internationally-funded or U.S.-funded, to deal 

with HIV/AIDS—I thought instead I would talk about the nexus 

between human rights violations and the spread of HIV/AIDS, and 

talk about what a government would do if it actually wanted to 

spread the pandemic greatly. And I am going to limit my oral remarks to human rights violations. And though you will note in my 

written testimony, I deal with a lot of other more practically-oriented AIDS transmission means. 

If you really wanted to set the stage for the worst HIV/AIDS 

prevalence in the entire Asian region, you would do just what 

Burma has done. For example, you would unleash your army into 

the areas of upheaval in the minority tribal areas, and you would 

give them carte blanche to destroy and rape and pillage—especially 

rape—where there has been an absolute epidemic. And it would 

help drive women and girls and their family members out of the 

country and into Thailand, and into complete destitution. 

You would let your medical infrastructure completely decay. You 

would destroy civil society. You would jail those who spoke out 

against these depredations. And then you would, meanwhile, make 

a killing in profits from the narcotics trade in which you are heavily involved. And then you would end up with a terrifying AIDS 

32

rate, as well as a beautiful country that has been destroyed and 

has become an international pariah for that activity, as well. 

If you wanted to contribute to the spread of HIV/AIDS, you 

would ignore marginalized groups who are discriminated against 

within your society. We, at Physicians for Human Rights, just 

looked at this closely in a report we issued at the Bangkok meeting 

on Thailand, where a little-noticed aspect of the HIV/AIDS epidemic there are the Thai Hill Tribe women and girls, who are particularly vulnerable to the disease because of their lack of citizenship. 

These are people who have lived in Thailand for many generations but are among the 13 Thai minority tribal groups who don’t 

have citizenship, and thus are not able to participate in health care 

programs. They are those most likely to end up in the sex industry. 

They are the most likely to have the poorest jobs, the worst jobs 

in industry. They are the most likely to be raped on the job. 

You can double their numbers if you add the Burmese migrants 

in Thailand who are discriminated against and despised, many of 

them driven from their own country by the kind of behavior I described. 

Those people are at the highest risk of HIV/AIDS exposure. And 

the much-praised Thailand’s prevention program that was particularly strong in the mid-90s, but helped Thailand get a handle on 

the pandemic and serves as an international model, basically did 

not reach Burmese and Hill Tribe people, particularly women and 

girls in the sex industry, from those minority groups. 

Third, if you were to actively want to contribute to the spread of 

the pandemic, you would tolerate trafficking of women and children 

into the sex industry. Many of the countries of the region have a 

problem with trafficking. And three of the worst, I think, examples 

of countries in which child prostitution is tolerated may be found 

in Asia. India, Cambodia, Vietnam, and Thailand all have a terrible, terrible scourge. 

I don’t need to develop the concept of why child victims of sexual 

exploitation are particularly vulnerable. I would simply say that 

the AIDS pandemic itself drives the trade in ever-younger victims, 

as men—some of them from the West—purchase children on the 

notion that they would be safe sexual partners. Now child prostitution and trafficking in adult women, as well, is something that simply does not have to be tolerated and actually can be stamped out, 

unlike the task of trying to change sexual behavior, the most intimate activities of humanity, which does have to change, indeed. 

But really, with regard to trafficking and sexual crimes against 

children and women, proper policing is an essential health intervention. And it is found almost nowhere in the region. 

If an adult, who was set on purchasing a child for sex, can find 

the child, then the police can find them, too. So this notion that 

somehow the sex industry is invisible or underground, et cetera, or 

that if you tried to prosecute it, it would drive it underground, is 

hogwash. Not every poor country suffers a child prostitution problem. And those countries that would like to end this problem and 

regain some dignity in the world community will do so with alacrity and without further waste of time. And that goes for the countries that I named. 

33

A further way to contribute to the spread of AIDS is to criminalize and harass and abuse and harm members of populations 

who are particularly at risk. That would be women in the sex industry, drug users, men who have sex with men. 

Lest I appear to be proposing a contradiction about prosecution 

of trafficking and child prostitution—which I strongly favor—and 

police harassment and prosecution of non-child, non-trafficked sex 

workers, I think it is very important to make a distinction. One 

needs proper policing for what constitutes a violation of the law—

child prostitution and trafficking. One does not need police prosecution and abuse and shakedowns and harassment and exploitation 

of sex workers, which is the kind of thing that keeps them from 

getting health care. The same goes for IV drug users. 

You will find much in the literature from Asia about how few IV 

drug users, for example, take advantage of health care and prevention services. Or how few male prostitutes, for example, who can 

go to jail for this activity and die there. You can understand why, 

then, they would not come in to get tested or receive counselling, 

much less come in for treatment of sexually transmitted diseases. 

You could contribute to the spread of AIDS if you forbade condom 

sales, or use, or availability, and spread lies about the effectiveness 

of condoms. And I regret to tell you that one country in the region 

is doing just that: That would be the Philippines, a Roman Catholic 

country that has made many forward and positive movements in 

its human rights picture. But when it goes to education about the 

way AIDS is transmitted, and the only barrier protection currently 

available for it, the Philippine authorities and the Church—and I 

am speaking as a member of St. Peter’s Parish—has not done the 

people of the Philippines a good service. It is contributing to a 

spread of the disease among those most vulnerable to it. 

And finally, I think if you wanted to see the disease spread rapidly in your country, you would arrest the whistleblowers, and you 

would throw them in jail. And you would stamp out the civil society truth-tellers that are so vital to taking on the HIV/AIDS pandemic, as they were in our own country. 

And there, of course, the best examples may be seen in China. 

In one of the two cases that I am familiar with, Dr. Wan Yanhai, 

the great AIDS doctor—a very young man—was jailed for 4 weeks 

after he revealed the blood sale corruption scandal in the poorest 

provinces of China. Instead of attending to it immediately, the authorities threw him in jail. But he did come out. He is now in the 

United States. 

And we also heard mention from the Chairman about Dr. Jiang, 

one of China’s great heroic doctors, who was briefly jailed for being 

a truth-teller not only about SARS, but about the 1989 Tienenman 

Square massacre. 

On a much more cheerful note, now that I have given out a 

somewhat tongue-in-cheek litany of things that governments could 

do that are wrong and that are harmful, and that are occurring, 

there are some very positive things about the world today that I 

think have important bearing on the AIDS pandemic in Asia. And 

I would like to close by referring to a few of them. 

One is that there is a vast HIV/AIDS activist citizens’ network. 

And at the risk of appearing to be kind of a dewy-eyed internationVerDate Mar 21 2002 14:40 Oct 08, 2004 Jkt 000000 PO 00000 Frm 00037 Fmt 6633 Sfmt 6601 F:\WORK\AP\072104\94989.000 HINTREL1 PsN: SHIRL
34

alist, I must say that in my 25 years in the human rights field, I 

have never really seen anything quite like the AIDS activist community that is now linked up by computer so that a leaf doesn’t 

fall in Beijing, or Bangkok, or Seattle, that thousands and thousands of activists who support each other’s work everywhere—doctors, nurses, activists, students everywhere—don’t know of it. 

And let me tell you what that translates into when someone like 

Dr. Wan is jailed. The United States-based ACT UP, the activists 

that some of you are probably more familiar with when they hang 

U.S. policymakers in effigy or shout people down at meetings. I 

was very touched to see this important group of AIDS activists, 

these rowdies who are braver than I am in many instances, establish a ‘‘Where is Dr. Wan’’ Web site when their Chinese friend, who 

they had never met before in their lives, was jailed. And they held 

demonstrations and were very raucous and very rude outside of 

Chinese Embassies all over the world. And they kept their petitions and their noise going until, lo and behold, Dr. Wan came out. 

I thought it was a wonderful sight to behold. 

And that goes for an international group of activists who will 

beat up on the South Africans when they hold back Neviripine for 

the prevention of mother-to-child transmission of AIDS, and that 

goes for international joint efforts when the price of drugs gets a 

bit too high. I could go on. 

That linkage between communities and between activists is a resource that is more precious than pearls. And it is there for the 

countries of Asia, as well, as you can see from the international activists who joined with their colleagues to protest vile depredations 

against IV drug users in Bangkok this last week. 

A second positive note at this 21-year point in the pandemic, or 

wherever we are, is that the rights, or rather the lack of rights of 

women and girls, is on the agenda of every nation of this world—

most especially the donors—and of the international agencies that 

work so hard on these issues. Dr. Cravero is a leader of an effort 

to promote zero tolerance toward violence against women and girls 

that UNAIDS is spearheading. But you could duplicate that many, 

many, many places. 

I think that it is widely understood that if it were not for the familial and cultural and political and economic subjugation of 

women and girls, this would be a disease, not a pandemic. And 

thus, though we don’t have all of the answers and we certainly 

don’t have the ways to act on all the answers, we certainly know 

what the problems are in terms of AIDS transmission and women’s 

lack of ability to control what happens to their bodies in many, 

many, many situations. 

I mean, when we come to the realization that marriage is the 

highest risk factor for women and girls in Asia, at least we can talk 

about that. Then we might actually see increasing leadership about 

the kind of norm change that is desperately needed and that is an 

integral part of attacking that pandemic norm change with regards 

to fidelity, and violence, and abuse. 

Third, we have another very positive place in history. We have 

heretofore unimagined sums of money on the table, very much 

thanks to the Congress and the President of the United States. We 

can quarrel—and I love to do it—about certain ways the money 

35

could be spent, and must be spent, and should be spent. ‘‘I like 

this, but not that.’’

But the real point is that there is a huge, new sum of resources 

that has given hope to everybody, every AIDS activist. And I think 

that speaks so well for bipartisanship. For this issue, I favor a real 

big-tent approach on AIDS activism, from the farthest right to the 

farthest left, both in Congress and amongst the civil society in the 

United States, that is needed to support the kind of high spending 

we are going to require forever, as near as I can tell. 

The fact is there has been this extraordinary coalition for the 

first time in my time in Washington, and I think much farther 

back as well, that has produced vast sums of money and made it 

available for health in the poorest countries in the world. I, like my 

colleague, favor integrated AIDS approaches that are built right 

into primary health care, something that most of these countries 

don’t have at all. 

We can start talking about that now. Because we have the Global 

AIDS Fund, we have UNAIDS, we have the United States 

PEPFAR, and I hope Asia FAR or something like that. And it 

means it is a new day in terms of the possibilities of addressing 

some of the issues my colleagues have talked about. 

And then, finally, we have a very good sense of what works and 

what doesn’t work. There are good models to choose from and there 

are now resources to start practicing them. 

We have drugs that are now within the grasp of some of even 

the poorest countries of the world. And, on a happy note, the major 

generic producers are all in Asia. Which means that Thai and Indian and Chinese promises to treat everyone who needs it can actually be considered, once the health infrastructure and the other 

health impediments are addressed. 

So without meaning to go on too long, I wanted to give you the 

bad news first, and follow it with the good news. 

Thanks again for having me. 

[The prepared statement of Ms. Burkhalter follows:]

PREPARED STATEMENT OF HOLLY J. BURKHALTER, PHYSICIANS FOR HUMAN RIGHTS

Thank you for holding this important hearing, Chairman Leach, and for inviting 

me to testify. My name is Holly Burkhalter and I am the U.S. Policy Director of 

Physicians for Human Rights. PHR and its Health Action AIDS Campaign seeks to 

mobilize the American medical, public health, and nursing professions in support of 

generous American funding and effective policies to combat the global AIDS pandemic. At today’s hearing on HIV/AIDS in Asia, I will reflect on the factors that play 

a significant role in the transmission and spread of the disease in Asia, and offer 

some suggestions for U.S. policy. 

Before beginning, I would like to thank you, Chairman Leach, on behalf of the 

staff and board of Physicians for Human Rights, for your long-time commitment and 

leadership on the international AIDS pandemic. You have been a faithful friend of 

the poor, the sick, the orphans, and those who care for them since the earliest days 

of the pandemic at home and in Africa. Your leadership today in calling this hearing 

on HIV/AIDS in Asia is very much appreciated. 

The XV International AIDS Conference in Bangkok earlier this month has 

brought welcome attention to the so-called ‘‘next wave’’ of the global pandemic. 

While HIV/AIDS prevalence in even the hardest-hit Asian countries is far lower 

than in sub-Saharan Africa, even small percentages affected by the virus in the 

huge populations of India, Indonesia, and China mean tens of millions of new cases 

in just a few years. 

In its newly released report, UNAIDS states that AIDS in Asia is expanding rapidly, with especially sharp increases in China, Indonesia, and Vietnam. The U.N. 

agency estimates that 7.4 million people are living with HIV in the region and 1.1 

36

1 UNAIDS. 2004 Report on the Global AIDS Epidemic (June, 2004). 2 Anal sex is 30 times more likely to result in HIV transmission; accordingly male sex workers 

are especially vulnerable. 3P.H. Kilmarx et al., ‘‘Seroconversion in a prospective study of female sex workers in northern 

Thailand: continued high incidence among brothel-based women.’’ In: AIDS, 112, 1998, pp. 

1889–1898. 

million people became newly infected last year. India has the largest number of people living with HIV outside South Africa –5.1 million.1

The weak state of most Asian countries’ public health systems; the region’s endemic poverty; the deeply engrained cultural, economic, and familial subordination 

of women and girls; the enormous commercial sex industry that includes hundreds 

of thousands of children and trafficking victims; the growing numbers of intravenous drug users and the stigma and discrimination experienced by people with 

HIV/AIDS are key factors in the Asian AIDS pandemic. They provide fertile ground 

for exponential growth in the numbers infected, sick, and dying of HIV/AIDS and 

a challenge to governments, human rights proponents, and foreign donors to address 

them forthrightly. 

On a more hopeful note, Asia is home to the most important producers of generic 

antiretroviral drugs. Indian-made products that have been pre-cleared by the WHO 

are being used by tens if not hundreds of thousands of Africans and are working 

extremely well. China and Thailand also have ARV production capacity and have 

committed, as has India, to making them available to all. Another hopeful note is 

that HIV/AIDS has not broken into the general population in most Asian countries 

in the way it has in Africa, and there are effective strategies for addressing the 

locus of HIV/AIDS in many Asian countries—principally commercial sex workers 

and their clients and intravenous drug users—before it does. 

Another vital resource in confronting the AIDS pandemic is vibrant civil society, 

which many countries in Asia are blessed with. Women’s groups are very strong in 

Asia. And one country in the region, Thailand, is considered by many AIDS experts 

to be a model of early, coordinated response to HIV/AIDS containment, particularly 

in the commercial sex industry. Asian governments can learn from the successes 

and mistakes of the Thai approach, as well as from Latin American, African and 

Eastern European experiences with the pandemic. It is vital that they do so before 

the disease reaches the so-called ‘‘breakout’’ point. Experts estimate that once levels 

reach 5 percent, it often moves extraordinarily quickly throughout the population 

and becomes very difficult to contain. 

In sum, the HIV/AIDS pandemic poses enormous challenges to the people and 

governments of Southeast and South Asia that will require national leadership and 

public education about the disease on a much greater scale than has heretofore been 

seen; a concerted and unstinting effort to eliminate the grossest aspects of discrimination against and exploitation of women, girls, drug users, and people with AIDS; 

a large infusion of donor financial and technical assistance; immediate attention to 

dangerous conditions in medical settings that result in disease transmission through 

tainted blood supply and re-used syringes; and safe public space for civil society. 

The varied experiences of China, Burma, India, Vietnam, Thailand, Pakistan, the 

Philippines and other Asian countries provide examples of best and worst practices 

in these areas that can help inform U.S. policy makers committed to helping Asia 

address the worst public health crisis in human history. 

Details follow: 

HIV/AIDS Transmission in the Commercial Sex Industry: Whereas the commercial sex industry is not a principal driver of the pandemic in most African countries, 

it is considered to be one of the top two factors, along with intravenous drug use, 

in most of Asia. There are a number of reasons that women, men, and children engaged in commercial sexual activity are at very high risk of HIV exposure. First, 

they generally have many partners and frequently are forced to engage in unprotected or especially dangerous sexual practices.2 HIV/AIDS researchers and epidemiologists have found that women and children in the commercial sex industry 

are the most vulnerable to HIV exposure during their first six months, the time in 

which the victims have the least ability to protect themselves. They are sought out 

and purchased for unprotected intercourse because customers consider them safe 

partners because of their youth and/or inexperience.3

Moreover, women and girls in commercial sexual relations have often been subjected to sexual violence before entering into commercial sexual activity. Once they 

do, they commonly suffer rape and violence at the hands of pimps, predatory police, 

brothel owners, and customers, particularly when they are trafficked into prostitution against their will. Injuries and abrasions sustained during sexual contact 

37

4See UNAIDS, Women and AIDS, Best Practices Collection (Oct. 1997), at 3. Available at 

http://www.unaids.org/publications/documents/human/gender/womenpve.pdf (‘‘Tearing and bleeding during intercourse, whether from ‘rough sex,’ rape or prior genital mutilation (female ‘‘circumcision’’) multiplies the risk of HIV infection.’’). See also UNAIDS, HIV/AIDS and GenderBased Violence fact sheet, c. 1999. Available at http://www.unaids.org/gender/docs/

Gender%20Package/GenderBasedViolence.pdf. 5See UNAIDS, Women and AIDS, Best Practices Collection (Oct. 1997), at 3. Available at 

http://www.unaids.org/publications/documents/human/gender/womenpve.pdf. 6 ‘‘HIV Prevention with Commercial Sex Workers in Three Communities in India—Project 

Summary,’’ The Center for HIV Identification, Prevention, and Treatment Services at UCLA 

(CHIPTS). Available at http://chipts.ucla.edu/projects/chipts/india.html. 7 National Intelligence Community Assessment. ‘‘The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China’’ (September 2002). 8Shankaran S.S. (2002) ‘‘Intervention for women and children in the red light area,’’ Abstract. 

The XIV International AIDS Conference. 9Dutta et al. (2002) ‘‘Strategizing peer pressure in enhancing after safer sex practices in 

brothel setting,’’ Abstract. The XIV International AIDS Conference. 10Gorman, Christine. ‘‘Back on the AIDS Alert.’’ Time, 15 July 2004. 11MAP Network, AIDS in Asia: Face the Facts (2004), at 35–36. 

heighten physical vulnerability to AIDS transmission.4 And young girls’ physically 

immature bodies are often injured, significantly heightening their risk of infection. 

Exposure to other sexually transmitted diseases (STDs), a common problem among 

those in the sex industry, heightens the risk of contracting HIV by up to a factor 

of 10.5

Accordingly, Asian countries with large commercial sex industries and a significant trafficking problem have very high rates of HIV infection. In India, for example, researchers estimate that 75% of HIV infections have come from heterosexual 

contact, and commercial sex workers and their clients account for the majority of 

these cases.6 Thirty to 60 percent of prostitutes and up to 15 percent of all truck 

drivers are infected with HIV/AIDS, according to a study by the National Intelligence Council.7 Research into HIV/AIDS and the sex industry in Mumbai indicated 

that 70% of the sex workers in Mumbai are HIV-positive.8 A study in Surat found 

that HIV prevalence among sex workers had increased from 17% in 1992 to 43% 

in 2000.9

Intravenous drug use (see below) is another high risk factor for women, men, and 

children in the sex industry. In some countries there is considerable overlap between these two high-risk activities, with stigma attached to both that frequently 

discourages access to health care or AIDS prevention services. 

Thailand is often cited as an example of a successful effort to address HIV transmission in the commercial sex industry. It is worth dwelling on Thailand’s experience, and to look more closely at both its successes and failures. On the positive 

side, the early response to the pandemic by the government of Prime Minister 

Anand Panyarachun in 1991, who allocated substantial funds to publicize the dangers of HIV and launched a national education, prevention, testing, and care effort 

is a exemplary model of the impact that government leadership, provision of significant resources, public education and mobilization, and outreach to those most at 

risk of HIV transmission can have on incidence. The best-known feature of the campaign was its 100% condom program, in which millions of free condoms were distributed to sex workers and their clients. A ubiquitous mass media campaign promoting 

partner reduction and condom use, and the establishment of a visiting nurse program and local clinic services for sex workers contributed to the campaign’s remarkable success, as did the authorities’ concerted effort to require brothels to comply 

with the 100% condom program. From its peak of 143,000 in 1991, the number of 

new incidents of HIV infection fell to 19,000 in 2003.10

Thailand’s strategy succeeded in large part because it went beyond simply encouraging sex workers to use condoms, and providing them access to condoms. Studies 

in Asia have found that along with the problem of condoms simply not being accessible in some cases—something that may be a problem especially for street-based, 

as opposed to brothel-based sex workers—the other major reason that sex workers 

do not use condoms is because clients refuse to use them.11 It is of great significance, therefore, that Thailand involved clients in its interventions, both through its 

mass media campaign and the breadth of its condom distribution. The authorities, 

rather than treating sex workers as criminals, supported the 100% condom program. 

And the campaign went beyond simply encouraging condom use, to also encouraging 

partner reduction and providing health services for the sex workers. Treatment of 

sexually transmitted infections is another standard feature of effective prevention 

programs for sex workers. 

The failings of Thailand’s AIDS prevention strategies are less well known than 

its successes, but can help inform efforts in other Asian countries with significant 

38

12Physicians for Human Rights. No Status: Migration, Trafficking & Exploitation of Women 

in Thailand July 2004. 13 Human Rights Watch. ‘‘Unprotected: Sex, Condoms, and the Human Right to Health’’ (May 

2004). 14 Ibid. 15MAP Network, AIDS in Asia: Face the Facts (2004), at 37. 

commercial sexual activity and growing HIV/AIDS incidence. The 100% condom initiative and other prevention activities for those in the commercial sex industry apparently did not reach many of those most vulnerable within it. A report issued last 

week in Bangkok at the International AIDS Conference by Physicians for Human 

Rights, called ‘‘No Status: Migration, Trafficking & Exploitation of Women in Thailand,’’ notes that HIV rates and risks are higher for Burmese women and girls and 

for members of Thailand’s ethnic tribal groups in the commercial sex industry than 

for their Thai counterparts.12 Burmese migrant women and girls, including trafficking victims (see below) and members of Thailand ethnic minority groups suffer 

discrimination within Thailand and are usually barred from all but the most exploitative and dangerous employment; accordingly they are at risk of being trafficked 

into prostitution. And to this day, extreme social and legal discrimination against 

Burmese migrants and ethnic minority women and girls make it extremely difficult 

for them to access health services, including HIV/AIDS prevention supplies, treatment, and care. Both are prohibited from participating in Thailand’s national health 

plan (‘‘30 baht plan’’) and women and girls in prostitution are doubly stigmatized. 

Moreover, government spending on prevention in the sex industry has waned, and 

HIV rates are again climbing. 

Thailand’s failure to address HIV/AIDS prevention, health, and human rights 

among Burmese migrant women and stateless indigenous people has been largely 

invisible, but it is a problem involving a large number of individuals. There are approximately one million Burmese migrants and a million hill tribe people and they 

are subjected to an array of abuses that translate into poor health and high risk 

of AIDS. PHR’s team that carried out our investigation into this issue recently visited a clinic serving sex workers in Mae Sot. They found that all were Burmese, and 

14% were HIV positive—a dramatically higher rate than among ethnic Thais. 

Other lessons for addressing HIV/AIDS transmission in commercial sex venues 

can be found in India. Peer education, self-organization, STD clinics, and insistence 

upon condom use by sex workers promoted in the Sonagachi brothel neighborhood 

of Calcutta since the mid-1990’s have been cited by many HIV/AIDS experts as a 

model of successful outreach to women and girls who are very vulnerable to disease 

transmission. UNAIDS attributes an increase in condom use in brothels organized 

by the Durbar Mahila Samanwaya Committee (DMSC) from 10% to 92%, and states 

that efforts there have held HIV/AIDS prevalence to 10%, as compared to 60% in 

Mumbai. 

DMSC and other sex worker organizations’ success in achieving HIV/AIDS prevention victories, as well as helping provide other services for sex workers and their 

children, are exemplary. The interest of major donors in replicating the model could 

help provide similar benefits to larger numbers of vulnerable women elsewhere in 

India’s vast commercial sex industry. At the same time, sex worker organizations 

are not able to end trafficking or child sexual exploitation, which continues to be 

a serious problem in both organized and unorganized areas. 

Whereas Thailand and some states in India have made great strides in promoting 

condom use by women and men in the sex industry and their customers, the Philippines’ government stands out for its explicit decision to deny condoms in public 

clinics, and spread misinformation about their effectiveness. In a recent report, 

Human Rights Watch cited Government surveys indicating consistently low and decreasing levels of condom use among sex workers.13 As of 2002, 83% of reported 

AIDS cases in the Philippines were attributed to sexual transmission, of which 21% 

involved male-to-male sex.14 The Philippine authorities’ and Roman Catholic religious leaders’ opposition to condom promotion, inaccurate public information about 

condom efficiency, and dismantling of key prevention initiatives has considerably 

undermined efforts by the Philippines to confront the pandemic, both within the sex 

industry and the general population. Similarly, in some Asian countries, including 

Indonesia and Burma, women are arrested for possessing a condom, which is considered proof of prostitution.15 Successful prevention campaigns simply cannot be 

mounted in such an environment. 

HIV transmission to and from sex workers is a serious problem in China as well. 

According to reports, there are some peer educators in China, but there is no free 

condom distribution program to sex workers and their customers that has been an 

essential feature of AIDS prevention in the sex industry elsewhere in Asia. 

39

16 UNAIDS. 2004 Report on the Global AIDS Epidemic. (June, 2004). 17 Ibid. 18 ‘‘Vietnam News Briefs,’’ Financial Times. 26 August 2003. 19 Asian Political News, 7 June 2004. 20 Ibid. 

Trafficking and Child Sexual Exploitation: International health experts have consistently promoted the provision of health care and condoms to those within the 

commercial sex industry and their clients as an essential element of HIV/AIDS prevention strategy. They should add to their essential interventions strategies to an 

end the sexual exploitation of children and sex trafficking of women. Victims of 

these crimes are not ‘‘sex workers,’’ and providing them with condoms does not assure their rights. Country studies in Asia found that 69% of sexually exploited children in Bangladesh and 70% of those in Vietnam were infected with a sexually 

transmitted infection, which compounds their risk of becoming infected with HIV/

AIDS.16 Because of their unique vulnerability to HIV/AIDS, injury, and death, their 

protection and deliverance from the commercial sex industry should be a priority 

among disease prevention experts, as well as human rights activists. Because child 

prostitution and sex trafficking are legal nowhere and because the victims of these 

crimes are offered to the public on a daily basis, it should be possible for the authorities to successfully end such exploitation by providing even minimally competent enforcement of national law. Indeed, there are very few success stories in 

Asia that could be modeled and replicated. 

The PHR report on migration, trafficking and health of Burmese refugees and 

women and girls from ethnic hill tribes in Thailand found that women and girls 

trafficked into brothels, bars, factories and domestic service are exposed to HIV because of rape by traffickers, factory bosses, and employers. Trafficking victims in 

such industries lack language skills, are subjected to abuse and discrimination, and 

are denied access to health services. As trafficking victims, they are at the mercy 

of employers and have no access to the protection of local police, who are often 

complicit in trafficking. Physicians for Human Rights’ investigators found that discrimination against both women and girls of Thai minority ethnicity and against 

Burmese migrants and refugees are a factor in their vulnerability to being trafficked 

across borders or internally into dangerous, unhealthy, and abusive labor conditions, 

especially the commercial sex industry. 

Several Asian countries have the worst records of child sexual exploitation in the 

world. Thailand, India, Vietnam and Cambodia have the ugly distinction of being 

destinations of choice for foreign sex tourists seeking ever-younger partners as protection against HIV/AIDS. Figures on the number of children and adults trafficked 

into commercial sex are imprecise and vary widely, but there are certainly hundreds 

of thousands in the countries named. In Thailand alone, some scholars estimate that 

upwards of 25% of those in the commercial sex industry are minors—some 66,000 

of an estimated 250,000 to 300,000 women and girls.17

Vietnam, which was recently designated the fifteenth PEPFAR country of focus 

by President Bush and Ambassador Tobias, is an important choice and provides an 

excellent opportunity for U.S. policy makers to promote a number of AIDS prevention strategies, including a serious response to trafficking and child prostitution. A 

survey by the Vietnamese Women Union’s Central Committee and the Asia Fund 

indicated that the smuggling of women and children showed that an estimated 

3,511 women and children were sold to Cambodia over the past five years, and that 

such trafficking is on the rise.18

A welcome collaboration to end trafficking in Vietnamese women and children was 

announced last week by UNICEF, in cooperation with China and Vietnam.19 According to news reports, Vietnam and China have agreed to jointly strengthen border 

administration, improve repatriation procedures, establish transition centers, share 

information to facilitate joint rescue actions, and promote education and awareness 

of trafficking.20

Vietnam is the country of origin for some of the youngest child prostitutes in the 

world, those found in the notorious brothel neighborhoods of Sway Pak in Phnom 

Penh, Cambodia. Vietnamese children are sexually exploited after they have been 

either sold by their parents within Cambodia or trafficked across the border by 

agents. An unprecedented NGO investigation and a subsequent rescue conducted by 

the Cambodian police resulted in the seizure of 37 young girls, many of whom were 

under ten years old, and the youngest of whom was five, from brothels last April. 

In January of this year, the Cambodian judiciary successfully prosecuted and convicted five perpetrators, who received stiff jail terms. This unprecedented legal action against those who sell tiny children to foreign pedophiles is a rare success 

story, and Cambodia has been deservedly praised for it. Unfortunately, it is but a 

40

21 Reid, Gary. ‘‘Intravenous Drug Use Accelerates HIV/AIDS Epidemic in Asia,’’ Global AIDS 

Link (December 2002). 22 UNAIDS. 2004 Report on the Global AIDS Epidemic. 4th Global Report. June 2004. 23 Reid, Gary. ‘‘Intravenous Drug Use Accelerates HIV/AIDS Epidemic in Asia,’’ Global AIDS 

Link (December 2002). 24 YOUANDAIDS: The HIV/AIDS Portal for Asia Pacific. 25 ‘‘India Facing Serious HIV–AIDS Epidemics, Warns U.N.,’’ Deutsche Presse-Agentur, July 3, 

2002. 26 Hurley SF, Jolley DJ, Kaldor JM. Effectiveness of needle-exchange programmes for prevention of HIV infection. Lancet. 1997; 349:604–608, as cited in ‘‘Does HIV Needle Exchange Work? 

By Public Citizen’s Health Research Group (December 1998). 

first step. Human rights investigators based in Phnom Penh report that the trade 

in young children continues and is likely to do so unless the Government of Cambodia commits itself to investigating child prostitution, and prosecuting and convicting those responsible, including Western customers, on a regular and ongoing 

basis. 

Intravenous Drug Users: Injecting drug users constitute another of the groups 

most vulnerable to HIV transmission, and this constituency is thought to be the 

locus of infection in many Asian countries. Enormous quantities of opium drugs are 

produced and transited throughout South and East Asia—particularly in Burma 

and Afghanistan—and drugs are widely available even to the very poor. A number 

of Asian countries are now confronting this important source of HIV transmission, 

but much remains to be done. 

With the development of large-scale production of high-grade heroin in the late 

1980’s, the number of injecting drug users in Asia has grown exponentially. The 

first, second, and third largest producers of opium are all in the region—Afghanistan, Burma, and Laos. As one researcher put it, the region is experiencing ‘‘twin 

epidemics of injecting drug use and explosive rates of HIV/AIDS.’’ 21 Pakistan, for 

example, is thought to have 3 million heroin users, and the first outbreak of HIV 

infection among injecting drug users occurred in 2003. According to UNAIDS, a behavioral survey of injecting drug users in the Pakistani city of Quetta found that 

a very high proportion used nonsterile injecting equipment and over half said they 

visited sex workers. Few had heard of AIDS, and even fewer had ever used a 

condom.22 Indonesia is home to an estimated two million drug users, half of whom 

inject.23

Intravenous drug users have been the ‘‘first wave’’ of those infected with HIV/

AIDS in most Asian countries, including Vietnam, where 65% of all HIV infections 

are among injecting drug users. This sub-population is at particularly high risk of 

exposure to HIV/AIDS and other infectious disease. Shared needles, poor health, 

and unsafe sexual activity contribute, as does stigma, discrimination, and violence, 

which keep many drug users from accessing prevention and health services. 

Levels of HIV prevalence among intravenous drug users are difficult to determine 

with certainty, but various estimates suggest extremely high rates of HIV among 

intravenous drug users. Among injecting drug user populations, the prevalence rates 

of HIV/AIDS indicate the advance stages of a major epidemic. In China, HIV prevalence among drug users in Xinjiang is an estimated 35–80%, in Guangdong 20%, 

and in countries bordering Burma HIV infection levels of 60–75% have been found 

among injecting drug users. In Thailand, the prevalence among injecting drug users 

has remained at approximately 40% for the last fifteen years. 

An indication of how swiftly HIV can spread among injecting drug users may be 

seen in Nepal, where HIV prevalence among injecting drug users rose from about 

2% in 1991 and 50% six years later.24 Likewise, in Manipur, India, a region lacking 

in any significant intervention program, UNAIDS estimates that HIV rates among 

intravenous drug users has ballooned to as high as 69%.25

Harm reduction services for injecting drug users can play an important role in 

preventing transmission of HIV. Treatment for drug addiction should be a national 

priority in most Asian countries—both to secure the rights of injecting drug users 

and also to address the spread of HIV/AIDS while it is still largely confined to individuals engaged in high-risk activity. Today, it is nowhere adequate to the needs 

of injecting drug users. Needle exchange, while politically controversial, is considered by most health specialists to be an important weapon in the arsenal of prevention initiatives, and not scientifically controversial at all. A study by the University 

of California at San Francisco of 81 cities around the world compared HIV infection 

rates between those cities with needle exchange programs and those without. They 

found that HIV transmission rates decreased on average by 5.8% in cities with needle exchange programs and increased by 5.9% in those without them.26

Needle exchange programs do not encourage drug use. This has been the finding 

of at least eight federally-funded reports since 1991. An extensive study of a needle 

41

27 University of California, San Francisco, AIDS Research Institute, Does HIV Needle Exchange Work? (Dec. 1998). 28MAP Network, AIDS in Asia: Face the Facts (2004), at 50. 29 Ibid., at 50–51. 30 ‘‘Thailand: Drug War Darkens AIDS Success,’’ Human Rights Watch, July 8, 2004. 31 ‘‘Bridging the Gap: Addressing Gender and Sexuality in HIV Prevention,’’ International 

Center for Research on, 1998. 32 UNAIDS. ‘‘The Impact of AIDS on Humans and Society’’ (July 2004). 33 Cohen, Jon. Science Magazine, April 23, 2004. 

exchange program in San Francisco from December 1986 to June 1992 even found 

that during the course of the study, injection frequency among injecting drug users 

in the area decreased from 1.9 injections per day to 0.7, and the level of new injecting drug users also fell significantly.27 The Monitoring the AIDS Pandemic (MAP) 

Network recently reviewed more than 400 surveillance reports and papers on needle 

exchange programs, and found no evidence whatsoever that HIV prevention services 

for injecting drug users, including providing them clean needles, was associated 

with increased drug use.28 There is also powerful evidence that needle exchange 

programs can facilitate access to a range of prevention services, including those that 

reduce sexual risk of contracting HIV. A survey of injecting drug users in Bangladesh found that injecting drug users who participated in a needle exchange program were about five times less likely to report a symptom of a sexually transmitted 

infection in the past year than those who did not participate (17% of participants 

reported an STI, compared to 90% of non-participants). Participants were also significantly more likely to seek medical treatment for sexually transmitted infections.29 It is clear that providing drug users with drug treatment, health care, prevention education, and harm reduction will not increase drug use, but are key strategies in reversing the spread of AIDS in Asia. 

Nepal is cited by prevention experts as a model of harm reduction and AIDS prevention among injecting drug users. A national campaign includes targeted education about the dangers of sharing injecting equipment, outreach workers and peer 

educators, needle and syringe programs to make available sterile equipment, and 

some counseling, testing, and therapy. 

At the other end of the spectrum is present-day Thailand, where an all-out antidrug crackdown by the Thaksin government has resulted in thousands of 

extrajudicial executions of not only drug dealers but drug users. Thousands of arbitrary arrests of drug users, forced confessions, and other abuses have so terrorized 

injecting drug users that most are in hiding, and few would risk coming forward 

for health, prevention, or testing services. The number of injecting drug users in 

Thailand range from 100,000 to 250,000. HIV prevalence among them is estimated 

at 40% or more.30 The current approach is radically different from Thailand’s comprehensive AIDS prevention program launched in the early 1990’s that was a model 

of harm reduction and humanitarian services for injecting drug users. That approach, in contrast to the one being carried out today, is fairly credited with helping 

dramatically reduce HIV transmission among injecting drug users. 

Through sexual networks and the sex work of some injecting drug users, HIV can 

spread quickly from injecting drug users to other members of the population. Ensuring effective prevention and treatment programs for injecting drug users is therefore 

critical both to protect their health and to prevent HIV/AIDS from reaching epidemic levels in countries where drug use is prevalent. 

Violence and Discrimination against Women and Girls: Public health experts and 

human rights advocates have long been aware that women and girls around the 

world have less control than men over sexual relationships. This reality, and factors 

such as the desire to have many children, the frequent contact of many men with 

commercial sex workers, women’s economic dependence upon men, girls’ lack of education and opportunity and high levels of domestic violence have important bearing 

on HIV/AIDS in Asia and elsewhere.31

Violence against women and girls relates to HIV/AIDS in many ways. The violent 

transmission of the virus through rape alone is a very important factor, especially 

in war torn or post-war societies where rape and violence escalate. Partner violence 

and partner relationships with sex workers, however, is the factor that is most likely to put wives and girlfriends at risk of HIV. In Thailand, for example, one study 

found that 75% of HIV-infected women were likely infected by their husbands. Nearly half reported heterosexual sex with their husbands as their only HIV-risk factor.32 Studies in India indicate an even more striking vulnerability among married 

women: Reportedly 90% of women who test positive at antenatal clinics report 

monogamous relationships.33 Inability to negotiate fidelity or condom use has made 

marriage one of the highest risk factors for women and girls in sub-Saharan Africa 

in the context of the generalized epidemic; as HIV moves beyond high risk groups 

42

34 ‘‘Empower Women, Halt HIV/AIDS.’’ UNIFEM, United Nations Fund for Women. 35The term ‘‘Men who have sex with men’’ is used by health researchers and AIDS activists 

because many individuals in non-Western countries do not identify themselves either sexually 

or socially as gay or homosexual, and many are married but have occasional homosexual contacts. 36MAP Network, AIDS in Asia: Face the Facts (2004), at 57. 37 Ibid. at 59. 38 Ibid. at 59–60. 

and into the general population in Asia, these factors will be increasingly relevant 

there. 

Moreover, women’s vulnerability to violence at home discourages them from seeking testing, counseling, or even care and treatment for HIV/AIDS. The health and 

human rights literature includes many references to this phenomenon in Africa.35 

It is often the case that women are the first to learn of their sero-status because 

of testing in the context of prenatal or child birth services. When they do they are 

at risk of being beaten or shunned within the family and community because the 

person whose status is first revealed is frequently thought to be the one bringing 

the disease into the home, although in most cases it is not the woman. HIV/AIDS 

programs that are sensitive to women’s vulnerability to domestic violence related to 

their HIV status are providing confidential whole-family, simultaneous testing and 

family counseling. 

The United Nations, led by UNIFEM and UNAIDS, is promoting strategies to protect women from exposure to the virus, including community training programs to 

enhance women’s ability to negotiate safe sex, wide distribution of affordable female 

condoms, and increased funding for the development of microbicides, a barrier method of HIV prevention that is controlled by the woman who uses it. The U.N. is also 

calling for increased resources for battered women’s programs, including shelter and 

legal assistance, reform of legal impediments to inheritance for widows, and programs to keep girls in school.34

Men Who Have Sex with Men: Men who have sex with men35 are a significant 

at-risk group in Asia, though numbers can only be estimated, due to the fact that 

this is a largely hidden population because of extreme social stigma and in some 

cases, laws, barring homosexual activity and penalizing those who engage in it. The 

Indian penal code, for example, prohibits ‘‘carnal intercourse against the order of nature’’ and proscribes punishment of up to ten years imprisonment. As a consequence, men who have sex with men generally do not access HIV/AIDS prevention, testing, care, or treatment services. 

In some countries, understanding of HIV/AIDS is very low, while high risk behavior among men who have sex with men is common. In China, for example, a 2003 

study found that 49% had had unprotected anal intercourse during the previous sex 

months. This finding, mirrored in studies in Vietnam and Pakistan that show that 

men who have sex with men are often unaware of the very high risk of contracting 

HIV through sex between men, likely reflecting the inadequacy of prevention efforts 

aimed at them. With most prevention efforts targeted to commercial sex between 

men and women, men are often unaware that male-male sex poses an even greater 

risk of HIV transmission. This lack of knowledge translates into risky behavior. 

Studies from across Asia have almost all found that men who have sex with men 

are less likely to use condoms than men who have sex with female sex workers.36

Inadequate prevention efforts have also limited knowledge on sexually transmitted 

infections common in men who have sex with men. The Monitoring the AIDS Pandemic (MAP) Network states that appropriate sexual health services for men who 

have sex with men, which should be an ‘‘important component of HIV prevention 

services for men in the Asian region,’’ are ‘‘currently badly overlooked.’’ 37

Just as prevention efforts pay inadequate attention to men who have sex with 

men, male sex workers are often a forgotten population in Asia. Yet surveys indicate 

that in a number of Asian countries, a significant proportion of men who have sex 

with men also buy sex from male or transgender sex workers. Surveillance of men 

who have sex with men at ‘‘hot spots’’ for seeking new sex partners found that more 

than one-third of men who have sex with men in five cities in India had bought or 

sold sex in the five months before a surveillance in 2002, and 22% of men who have 

sex with men in Vietnam had bought sex from a man in the preceding year, while 

31% had sold sex.38 Prevention strategies targeted at sex workers and men who 

have sex with men must be sure to include interventions for the overlap of these 

groups. 

The fact that many men who have sex with men in Asia also have heterosexual 

relationships means that there is high potential for the disease to spread to their 

female partners. In this way, like injecting drug users and clients of sex workers, 

43

39 Human Rights Watch. Epidemic of Abuse: Police Harassment of HIV/AIDS Outreach Workers in India. July 2002. Available at: http://www.hrw.org/reports/2002/india2. 40 ‘‘Chinese Pressure Dissident Physician; Hero of SARS Crisis Detained Since June 1.’’ The 

Washington Post, 5 July 2004. 41 Joseph Khan, ‘‘China Releases the SARS Whistle-Blower.’’ New York Times, July 21, 2004. 42Tan Ee Lyn, ‘‘Chinese police detain four HIV villagers-activist’’ Reuters, July 14, 2004. 43 ‘‘AIDS in India,’’ The Economist. 17 April 2004. 

HIV can spread from men who have sex with men into the general population, making prevention efforts that target this group one of the keys to an HIV/AIDS prevention strategy in Asia. 

Stigma: The discrimination, abuse, and marginalization suffered by people with 

HIV/AIDS is not only a violation of their rights, but a significant impediment to addressing the pandemic successfully. Ironically, in some sub-Saharan African countries stigma has been reduced because so many individuals across the social spectrum have been affected by it. But in most Asian countries, where the disease is 

still overwhelmingly associated with the commercial sex industry, homosexuality, or 

drug use, people with AIDS are reluctant to reveal their status for fear of being associated with such groups. 

There is no substitute for government leadership to reduce stigma and discrimination against both people living with AIDS and those most vulnerable to it. Leaders 

in several Asian countries have recently taken welcome actions that have been widely publicized. When the Indian Minister of Health, Sushma Swaraj, publicly hugged 

two AIDS orphans who had been excluded from school, she helped victims of discrimination everywhere. Also striking out against discrimination, China’s Premier 

Wen Jiabao shook hands with three people with AIDS this past World AIDS Day. 

Civil Society: A vital component of good governance in the era of HIV/AIDS is tolerance and protection of civil society—especially those groups and individuals who 

offer desperately needed education on risk reduction and health. Human Rights 

Watch describes the vulnerability of those who offer such services in India: ‘‘The 

most effective education on HIV transmission is done by those trusted by the community at risk. This means that sex workers have the best chance of helping other 

sex workers protect themselves from HIV. But peer education is not getting a fair 

chance in India. The police apparently do not recognize the lifesaving work done by 

AIDS educators, and these people face consistent abuse.’’ Human Rights Watch’s report documents dozens of brutal attacks on AIDS educators over a two-year period 

between April, 2000 and April, 2002; these attacks have included arbitrary arrest, 

rape, and even killings.39

The most extreme example of government intolerance of civil society in the context of HIV/AIDS can be seen in China, where the authorities are clearly of two 

minds about the pandemic. Its first response to life-affirming whistle blowers like 

Dr. Wan Yanhai, a young medical doctor who two years ago revealed publicly the 

blood sale scandal and official complicity in it, was to jail him without charge for 

four weeks. Only after a concerted international effort on his behalf by governments 

and AIDS activists was Dr. Wan released. That same reflexive clamp down on physician who tell the truth—and inestimably aid their countrymen and women by so 

doing—can be seen in the arrest of 72-year old Dr. Jiang Yanyong, a semi-retired 

surgeon in the People’s Liberation Army who revealed the government’s attempt to 

cover up the SARS outbreak when he recently urged the government to reconsider 

its depiction of the 1989 Tiananmen Square event.40 (Dr. Jiang was released from 

prison two days ago, July 19, through he is expected to remain under surveillance.41) And earlier this month, authorities in Henan Province are reported to have 

closed a school for AIDS orphans and children whose parents were HIV-positive 

after the school’s founder informed them that he was going to join AIDS activities 

in protests and rallies at the 15th International AIDS Conference. When four HIVinfected farmers tried travel to Beijing to protest the school closing, they were detained.42

China has the leadership and outreach to mobilize against infectious disease, as 

it did during the SARS epidemic. But it will not be able to take on HIV/AIDS if 

it does not fundamentally alter its approach to civil society. Without courageous 

whistle blowers like Dr. Wan, the blood sale-generated AIDS epidemic in China’s 

poorest provinces could have remained unnoticed for years. 

As in Africa, Asian governments, religious leaders, and civil society must shoulder 

the burden of massive and ubiquitous public education. The level of knowledge 

about AIDS in much of India, for example, is staggeringly low. Even those at highest risk—sex workers, truckers, homosexuals—reportedly do not know how AIDS is 

transmitted, or do not use protection in risky sexual encounters.43

44

44 Hauri, Armstrong, & Hutin, ‘‘The global burden of disease attributable to contaminated injections given in health care settings.’’ Journal of STD and AIDS, 2004. 45 Conversation with Safe Blood International, a U.S. and South Africa-based NGO that is assisting the Government of China. 46World Health Organization, Investing in a Comprehensive Health Sector Response to HIV/

AIDS (2004). 47 Rupa Chinai, Antiviral misuse in Mumbai, India.’’ Bulletin of the World Health Organization (2003) 81(2): 153. 

Medical Transmission: One of the least noticed HIV transmission modes—unsafe 

medical injections or blood transfusions, accounts for a significant number of infections in Asia. 

Injections: According to the World Health Organization (WHO), transmission from 

reused syringes in health care settings may account for as many as 24.3% of HIV 

transmissions in a region that includes India, Bangladesh, Bhutan, Korea, Maldives, 

Burma and Nepal. The same study indicated that 75% of syringes were reused in 

the absence of sterilization.44 The fact that people have a great deal more injections 

than are medically necessary—a study at five health clinics in Indonesia found that 

82% of curative injections were unnecessary, for example—and that syringes are 

used and reused many times translates into hundreds of thousands of wholly preventable HIV/AIDS transmissions every year. While sterile syringes and fully 

screened blood supply are taken for granted in the West, these standard features 

of infection control are not the norm in poor countries. Neither governments nor donors have made these important prevention interventions a priority until this year, 

when the U.S. funded a series of targeted interventions in the context of PEPFAR. 

Asian countries, like their African counterparts, require technical assistance, supplies, and training to address unsafe health care. 

Blood Transfusions: Blood-borne HIV transmission through commercial sale of 

plasma is thought to be the driver of HIV exposure in China’s poor, rural provinces, 

Anhui, Henan and Shandong. The practice, now discontinued, of poor farmers selling plasma many times, and being re-injected with commingled blood thereafter, 

caused an extraordinary and concentrated epidemic in communities in these areas. 

Whole families died, and rates reached as high as 60% in some areas. 

Technical experts working with the Chinese government report that the Chinese 

Ministry of Health estimate that transmission of HIV/AIDS through the transfusion 

of untested, infected blood accounts for approximately 30% of the spread of AIDS 

in that country. In India, the experts’ sources within the government estimate that 

approximately 10% of the spread of AIDS in that country is through transfusion of 

untested/infected blood.45

All health facilities must immediately be assured the capacity to test blood for 

HIV, including the necessary test kits and staff training. Meanwhile, the United 

States and other donors should provide the technical and financial assistance to enable the countries of Asia to develop comprehensive and effective safe blood distribution networks, that includes recruitment of enough voluntary, unpaid donors to 

meet national blood transfusion needs; the training and resources to ensure that all 

blood is screened for HIV and other diseases based on WHO guidelines; a national 

quality control system, and the appropriate clinical use of blood. 

Treatment Preparedness and Infrastructure: The level of treatment in Asia remains low. The World Health Organization estimated that in June 2004, only 

55,000 of 1,030,000 people with HIV/AIDS in Asia in immediate need of treatment 

were receiving it.46 However, a growing number of countries are pledging to scaleup anti-retroviral treatment and to ensure universal access to AIDS medication, including by providing the drugs for free. As these countries work towards fulfilling 

their pledges, at least two features will determine the success of AIDS treatment 

in Asia: the availability of support for treatment, including trained health care 

workers and community support systems, and the adequacy of rural health infrastructure. 

Training: The availability of generic drugs in many Asian countries provides great 

promise for the rapid roll-out of AIDS medication in Asia. For this roll-out to be successful, however, patients must receive the necessary information and care from 

trained health professionals. When patients are simply given drugs without the necessary knowledge and support, they are likely to stop taking the medications because of side effects, or because they believe that if they feel better, they no longer 

need the medicine. Last year, for example, an Indian NGO in Mumbai warned that 

many HIV-positive people in that city were using anti-retroviral drugs only as their 

financial circumstances permitted, unaware of the need to continue on the medications once they initiated treatment.47

45

48 UNAIDS. 2004 Report on the Global AIDS Epidemic. 4th Global Report. June, 2004. 49Lawrence K. Altman, ‘‘Drug Companies in Asia Rushing to Produce Anti-HIV Drugs.’’ New 

York Times, July 7, 2004. 50 Ibid. 51Zhang Feng, ‘‘Free AIDS Drugs Trigger Strong Side Effects.’’ China Daily, April 22, 2004. 52Lawrence K. Altman, ‘‘Drug Companies in Asia Rushing to Produce Anti-HIV Drugs.’’ New 

York Times, July 7, 2004. 53More information available at http://www.aaacp.org/. 54Peter Wonacott, ‘‘In Rural China, Health Care Grows Expensive and Elusive.’’ Wall Street 

Journal, May 19, 2003. 55Gerald Bloom & Fang Jing (Institute of Development Studies), China’s rural health system 

in a changing institutional context, IDS Working Paper 194 (July 2003). 56 Antoaneta Bezlova, ‘‘AIDS doctors dispatched to China’s countryside.’’ Asia Times Online. 

May 8, 2004. 57 ‘‘Injecting More Funds into Rural Health Systems.’’ China Daily, April 15, 2003. 

The problem of too few health professionals trained in AIDS treatment is perhaps 

most severe in China. In a country that officially has 840,000 people with HIV/

AIDS,48 but may in fact have several times that number, fewer than 200 health professionals are trained in comprehensive AIDS care and management, including antiretroviral therapy.49 Patients are frequently given AIDS medication without proper 

consultation. The result has been a very high drop-out rate. Overall drop-out rates 

are estimated at 20–40%.50 One investigation in the heavily affected Henan Province found that 40% of people who started on anti-retroviral therapy stopped, often 

within one month of initiating treatment.51 The adherence problem in China is compounded by the combination of drugs used in China, which lead to especially strong 

side effects.52 China and other Asian countries are therefore in urgent need of training more health professionals in comprehensive HIV/AIDS care. While a multipronged approach is likely necessary, one important strategy to consider to quickly 

reach many health professionals is a ‘‘train the trainers’’ approach, where training 

is focused on health professionals who will be able to return to their own health facilities and communities and provide training there. A good example is the HIV/

AIDS training center that the Academic Alliance for AIDS Care and Prevention in 

Africa has established in partnership with Makerere University in Uganda.53

Trained health personnel are only one component of a successful treatment program. People with HIV/AIDS should have access to community support structures 

that will both prepare people for treatment through treatment literacy programs, 

and support those who are on AIDS medication, including by promoting adherence. 

People need to be educated about the availability and requirements of treatment, 

so that they will seek treatment and understand how they can make it succeed. As 

they suffer side effects or other difficulties resulting from treatment, and from HIV/

AIDS generally, support from community organizations and other people living with 

HIV/AIDS is quite important. Through funds and technical assistance, the United 

States should nurture and encourage these community-based organizations and programs. 

Rural Infrastructure: Especially as HIV continues to spread deeper into rural 

areas in Asian countries, a particular risk because of the enormous numbers of migrant workers in countries such as India and China, the adequacy of rural health 

infrastructure will be an important factor in how many people can be reached by 

treatment initiatives in Asia, and how successful treatment will be for those who 

are reached. AIDS treatment requires chronic care, which entails lifelong contact 

with the health system, and effective communication between different levels of the 

health systems. It requires access to trained health personnel who can provide confidential, voluntary counseling and testing. Comprehensive HIV/AIDS care also requires diagnosis and treatment of sexually transmitted infections, treatment of opportunistic infections, education, and condom distribution. 

Yet in much of Asia, rural health services are underfinanced and underdeveloped. 

In 2000, WHO ranked China 188 of 191 nations for fairness of government contributions to health care costs.54 Government funding covered only about 10.5% of health 

care expenditures at the township health centers of rural China in 1998, with clinics 

receiving even less support.55 What money the Chinese government spends on 

health mostly goes to urban areas. At least two-thirds of government health spending is directed to cities, even though more than two-thirds of China’s population 

lives in rural areas. Meanwhile, only about 10% of China’s rural population has 

health insurance; the other 90% must pay fast-rising health care costs out-of-pocket.56

The Chinese government has recently (October 2002) committed to increasing its 

spending on the health sector.57 And in May 2004, the government committed $121 

46

58 ‘‘China invests 1b yuan in rural health care.’’ Xinhua, May 23, 2004. 59 Nirupam Bajpai, India’s health needs a dose of funds, reforms.’’ Hindu Business Line, April 

9, 2004. 60 Celia W. Dugger, ‘‘Deserted by Doctors, India’s Poor Turn to Quacks.’’ New York Times, 

March 25, 2004, at A1. World Bank researchers found that public sector medical personnel were 

absent from work 35–40% of the time in India, Indonesia, and Bangladesh. Ibid. 

million to rural health care as capital for infrastructure projects that would be completed in the next three to five years.58 While an important start, this amounts to 

only about an additional 13–15 cents per person in rural China. 

India’s government also underfunds the health sector. The Indian government 

spends only 0.9% of GDP on the health sector, less than half the 2.2% average of 

lower-middle-income countries.59 Studies have found very high rates of absenteeism 

in government clinics, and rural clinics frequently lack clean water, electricity, 

phone service, and an adequate supply of essential medicines. The poor conditions 

of the public sector health services force many Indians to turn to private doctors.60

Building strong rural public health systems in India and China will take time, 

but are crucial to the long-term success of AIDS treatment, care, and prevention in 

these countries. The United States should provide financial and technical resources 

to developing these systems, and encourage leaders in India and China to dramatically increase funding for their government’s own health systems, especially in rural 

areas, and to implement reforms as needed. 

Moving Forward: Based on the preceding points, I encourage Congress to take the 

following steps:

• Encourage the Office of the Global AIDS Coordinator to include in its interventions for regions with a substantial sex industry the best features of Thailand’s 100% condom use program and prevention efforts in Calcutta, India. 

These include: the distribution of free condoms to sex workers; the inclusion 

of clients in the intervention, including through condom distribution and mass 

media messages on partner reduction; the support of the police and other authorities to support and encourage the program; peer education and strong involvement of the sex workers themselves in designing the programs; the support of brothel owners, and; the provision of health services for sex workers.

• Encourage and fund a ‘‘zero tolerance’’ campaign towards child sexual exploitation and forced prostitution of adult trafficking victims. Pressure governments to enforce the law against such crimes, assist in the deliverance of 

child and adult sex trafficking victims from the sex industry, promote the 

closing of venues where such victims are found and the prosecution, conviction, and punishment of pimps, traffickers, brothel owners, and clients who 

prey on minors and women held in prostitution against their will.

• Urge that US-funded prevention and treatment programs reach the most vulnerable populations, who are likely to be left out of national programs. Further, Congress should encourage diplomatic interventions to ensure that these 

most vulnerable populations are fully included in national prevention and 

treatment programs. Such vulnerable populations include Burmese and ethnic hill tribe women and girls in Thailand.

• Support and fund harm reduction services for injecting drug users. These include needle exchange programs which have been consistently proven to lower 

HIV transmission rates without encouraging drug use.

• Support HIV services for men who have sex with men, who are often neglected in HIV programs. These programs should also target male commercial 

sex workers, another often forgotten population.

• In addressing the commercial sex industry and injecting drug use in the context of HIV/AIDS, human rights must be preserved and protected. The terrorizing of injecting drug users and the neglect of Burmese and hill tribe sex 

workers in Thailand should not be tolerated by the United States. Nor should 

the United States tolerate harassment and prosecution of men who have sex 

with men and those who provide HIV prevention, care, and treatment services.

• Support programs that encourage behavior change among men. These are essential to protecting women, many of whom are sexually faithful to husbands 

who seek contact with commercial sex workers, thereby putting themselves 

and their families at risk of HIV infection.

• Increase funding and other support for education, including special measures 

to ensure that girls are able to attend school.

47

• Request the Office of the Global AIDS Coordinator to report back to Congress 

on efforts to eliminate legal impediments to inheritance for widows and other 

codified forms of gender inequality. Encourage the Office to include in country 

strategies such programs that support battered women, including shelter and 

legal assistance. Allocate additional funds to a more comprehensive effort to 

address domestic violence against women.

• Support interventions and resources that will enable women to protect themselves from HIV/AIDS. Wide distribution of affordable female condoms and increased funding for the development of microbicides are essential in this pursuit. The discrimination and abuse suffered by HIV-positive women must be 

addressed through confidential testing services and public education campaigns.

• Urge that diplomatic pressure be directed at government leaders in Asian 

countries to reduce stigma and discrimination against both people living with 

AIDS and those most vulnerable to it. Symbolic action will go a long way in 

this regard.

• Provide funding for developing rural health infrastructure in Asia, including 

in India and China. Encourage efforts to India and China to increase their 

spending on the rural health sector.

• Scale up US support for community-based HIV/AIDS care and support organizations and for training health professionals in India, China, and other Asian 

countries in comprehensive HIV/AIDS management, including anti-retroviral 

therapy.

• Support safe health care interventions in Asia.

Conclusion: I have only touched on some aspects of HIV/AIDS in Asia—those that 

reflect human rights issues that Physicians for Human Rights has focused on in recent years. I believe that Asia possesses resources and leadership that can contain 

HIV/AIDS before it becomes the kind of generalized pandemic that has destroyed 

much of sub-Saharan Africa. The United States Government is playing an inestimably important role in addressing the pandemic in Africa. I hope and believe that 

Asian needs will also become a priority here, and that Congress and the executive 

branch can work together to support effective prevention, care, and treatment initiatives to address it.

Mr. LEACH. Well, thank you very much, to all of you. And I 

would like to just comment from a governmental perspective on 

several things Ms. Burkhalter just mentioned. 

And that is that, obviously governments of the world have to 

lead, both from our perspective and from the perspective of governments in the field. 

Just as obviously, in the new world we have there is a huge decentralized private sector thought and capacity that is playing an 

integral role in all of this. And the note that there is a network of 

Internet followers of issues is suddenly consequential. And government can’t step back because of it, but government has to express 

its appreciation. 

And for those Americans who think that maybe America’s smartest entrepreneur is Bill Gates, it is interesting that the Bill & 

Melinda Gates Foundation has really determined that it is going to 

sink massive resources into research on cures and viruses and their 

cures and vaccines. And that says a lot for the private sector, as 

well. 

Let me just begin with a very particular aspect of India. It is my 

understanding, Dr. Yeldandi, that there is maybe the most interesting research being done in combining antiretroviral drugs in single packages for experimentation in India. Do you know much 

about this? Has it made an impact? Is it a positive new approach? 

Dr. YELDANDI. Mr. Chairman, I do think that it has made a positive impact in the sense that instead of having the ability to only 

48

take care of the super-rich, we now have the ability to at least give 

treatment to some segments of Indian society that can afford it. 

The reality is that, even with the new combinations, the prices 

you are still talking about are approximately $1,000 to $2,000 a 

year, which is still out of reach for the majority of the people that 

are afflicted and are at risk. That is one part of it. 

The second part is that those of us that take care of people with 

HIV disease spend an enormous amount of time and energy and 

money monitoring them—both for the toxicities of the drugs that 

they use and also the efficacy. 

A particular concern of mine has been that what I have seen in 

India is that since antimicrobials are available in that country at 

much lower prices, and a larger segment of society has access to 

them, there has been an explosive increase in resistance to antimicrobial agents. And I fear that without adequate infrastructure 

to monitor the use of antiretroviral agents and the training that is 

required from the health care professionals that manage these 

things, that the next problem we will see will be antimicrobials not 

working because of emergence of resistance in HIV. 

Also, the currently-available agents are efficacious. They are not 

necessarily not toxic. The major reason why we use them at levels 

of toxicity that we will not tolerate in other antimicrobial agents 

is desperation. These are lifesaving agents. We have nothing else 

available. 

The pharmaceutical industry needs to be prodded into developing 

the next generation of antiretrovirals, which will be as efficacious 

at least, but substantially less toxic, easier to use. And we also 

need to invest a great deal in simply finding and making less expensive the monitoring for all of these treatments that we are proposing. 

So I think that the problem is quite complex, particularly when 

you talk about trying to monitor somebody on therapy in rural 

areas that don’t have roads, don’t have safe drinking water, have 

Tuberculosis. So there are good things and there are not so very 

good things. 

Thanks. 

Mr. LEACH. Well, I am told—and let me turn to Dr. Gill—that 

one of the problems in parts of Asia, there are high instances of 

TB. And then as you combine AIDS with TB, the likelihood of TB 

becoming much more virulent is very high. And that TB could become a massive new killer in Asia. 

Is that a valid observation, or not? Does anybody on the panel 

follow this issue? Yes, Doctor? 

Ms. CRAVERO. Thank you very much. We actually are seeing, and 

have seen in Africa, parallel epidemics of TB. And it is the most 

common opportunistic infection. And very often people finally get 

tested for HIV because they have TB. 

This was given much more attention at this Conference than 

ever before and will continue to be given priority. In fact, for the 

Global Fund to fight AIDS, TB, and Malaria, there is a growing 

emphasis on proposals from countries that propose to look at TB 

and HIV together. So this is a very serious problem that needs attention. 

49

I was just commenting on what the doctor said earlier on ARVs. 

UNAIDS agrees that the widespread distribution of ARVs is going 

to need very careful monitoring and needs the development of 

health systems. But we can’t wait for one in order to do the other. 

And I think that the current thinking is that we have to pursue 

scaled-up treatment programs while we build the health systems, 

and while we carefully monitor resistance. Because people are 

dying now. Countries are collapsing. We have to keep people alive 

long enough to have a critical mass to build the health systems. 

So I think everything the doctor said is very true. It is just, given 

the situation right now, we have to move on several fronts at once. 

Mr. LEACH. Fair enough. Let me just make one final question to 

Dr. Gill. 

You commented on the infrastructure in China, and the problem 

with the lack of doctors, as well as the numbers issue. And you also 

suggested that we ought to be sending Ambassador Tobias to Beijing. 

And I am just trying to think in terms of perspective. We have 

a number of issues that we may have confrontation with China, 

from economics to politics. It strikes me that we ought to be stressing cooperation in this area as maybe the number one American 

agenda, vis-a-vis China. Does that seem to be a credible perspective, or not? 

Mr. GILL. Two points in response, Mr. Chairman. As the doctor 

has already noted about the emergence of resistance and the problems of monitoring and treatment in India, so too, this is going to 

be a major concern in China as well, as most of the disease at the 

moment is afflicting rural and remote and resource-poor parts of 

the country. 

And already, in fact, we have learned of black markets in drug 

treatment in China with substandard quality, which is already 

driving a sort of new resistant epidemic within China, which will 

not be treatable by any currently-known drug. 

So this is a problem which I presume affects a lot of resourcepoor places around the world. But when you are looking at the 

numbers which we are about to face in countries like India or 

China, the problem becomes all the more difficult. 

I quite agree with you, Mr. Chairman, that, given the many, let 

us call them great power difficulties we might face with China 

going forward, whether it be in security areas, obviously perhaps 

in the form of trade competition, we could do a lot more, I would 

think—and I think the Chinese would welcome, in fact—greater cooperation in, let us call them non-traditional areas of great power 

cooperation and security. Like on drug trafficking, counter-terrorism, HIV/AIDS, and other public health challenges. 

And I am encouraged, actually. I do believe that this is something that can receive bipartisan support. It is just that so far, because of the nature and the enormous challenges we already know 

about in Africa, that thus far, the question of whether or not this 

should be a central aspect of our relationship with major countries 

in Asia has not really risen up to the top of, or near the top of, the 

agendas where it needs to be. 

So I would strongly encourage this Committee and others across 

our Government to see this as an opportunity for building a more 

50

constructive relationship with this important country, China, and 

others, given some of the other difficulties we do have with them. 

Mr. LEACH. Thank you, Doctor. Eni. 

Mr. FALEOMAVAEGA. Thank you, Mr. Chairman. I just wanted to 

ask Dr. Cravero a couple of questions about the operation of her 

agency, the UNAIDS. 

I am pleading ignorance here, so you will have to help me in 

terms of how does your organization relate to the operations of 

UNESCO and the World Health Organization? And I believe there 

is also within there the Planned Parenthood problems of population, and realizing also that two-thirds of the world’s population 

resides in the Asia-Pacific region. 

But I am curious. Does your organization have a very visible appearance in the United Nations in terms of your operations and the 

kind of priorities? You are saying that we have to make this a real 

high, high priority. And I want to ask, is this a real high, high priority with the United Nations in terms of allocations of the resources that are given to operate? 

Ms. CRAVERO. Thank you very much. The UNAIDS is a very different organization. It is unique in the U.N. system. It is actually 

a partnership of 10 organizations, with a Secretariat that exists to 

facilitate their efforts. 

So UNDP, UNICEF, UNFPA, and the World Food Program, as 

well as UNESCO, WHO, ILO, the World Bank, and the U.N. Office 

for Drugs and Crime, and the U.N. High Commissioner for Refugees are all co-sponsoring organizations of UNAIDS. 

It is the only area of work of the U.N. where there is that kind 

of partnership. And we actually have a joint or unified budget and 

work plan that we put together every 2 years, which again is the 

only area within the U.N. where such a collective work plan is put 

together. And that actually does reflect the U.N.’s conviction that 

we have to approach this epidemic differently; that all the agencies 

doing their own thing and getting together once a year is not going 

to work. 

We actually are in constant touch. There are peer reviews of programs making sure that we don’t have gaps, that we are not duplicating each other’s work and that we are making the most of the 

resources that are available to us. 

And as I indicated in my testimony, one of the key areas of work 

for the U.N. is coordination, because the U.N. has a certain amount 

of funding. But our funding is very, very little compared to the 

Global Fund to Fight AIDS, TB, and Malaria, or big bilateral programs like the President’s new initiative. 

One of our key roles is to make those other investments work 

better. Which, as I said, we have been on the ground in over 30 

countries, working with governments and national partners to develop their proposals to the Global Fund, or to develop their proposals that the U.S. Ambassador will then put forward for 

PEPFAR. 

So it is really a leveraging function that we play, and bringing 

everyone to the table. Making sure that when governments are 

putting their Global Fund or PEPFAR proposals together, they 

have civil society represented there working with people living with 

HIV, et cetera. 

51

So it is a very different kind of organization and operation. And 

we think has a clear value added in an increasingly crowded field 

with more money. In fact, as the money gets bigger, the role gets 

more important. 

On Asia, we have offices in almost all Asian countries. And we 

work very closely with the representatives of the other U.N. agencies. So we have something on the ground called AIDS Action 

Groups, or theme groups, where the U.N. representatives of all the 

agencies work together in supporting national partners. 

Mr. FALEOMAVAEGA. So with all these regional U.N. organizations that are coordinating with your operations, so the staffing of 

UNAIDS alone is, what, you are talking about, what, 1,000 people 

working? 

Ms. CRAVERO. Well, it depends on how you look at UNAIDS. The 

Secretariat—that is, for instance, in any given country—would 

have a small staff of maybe one or two people. But the role of the 

Secretariat of UNAIDS is to work with the staffs of our co-sponsoring agencies. 

So if you take a country like India, the UNAIDS Secretariat perhaps has five people in India, but we are coordinating and facilitating the work of all the U.N. agencies on AIDS in India. 

Now, if you put all those staff together, you are talking about at 

least 100 in India. So it is elsewhere——

Mr. FALEOMAVAEGA. Okay. I am sorry, I have listed a couple of 

things. I am just impressed with the way the whole thing was 

being organized. I thought the United Nations was bureaucratically 

over everything. I mean, it needed to cut down on so much of the 

bureaucracy that goes on there. But the way it sounds, you seem 

to be operating very effectively among all those regional organizations. 

I have got a couple of listings here, competing interests, competing priorities, limited resources, and the complexity of the issue 

itself. 

In terms of the priorities of how the United Nations is addressing this very issue, how does AIDS come into the listing of maybe 

the five highest priorities that the United Nations is currently addressing? Where would you put AIDS in the list of the five highest 

priorities that the U.N. is now addressing? 

Ms. CRAVERO. I think the Secretary General has made it clear 

that in terms of development priorities, HIV/AIDS is his numberone priority globally. Because it is his belief, he has made it very 

clear and I think has driven that home with the Executive Directors of U.N. organizations, that——

Mr. FALEOMAVAEGA. Well, not just from the Secretary General. 

I just want to get a sense from the United Nations as a whole. 

Ms. CRAVERO. As a development issue, it is the top priority right 

now. 

Mr. FALEOMAVAEGA. Okay, good. And I was going to ask Dr. 

Yeldandi if he was any relation to Vijay Singh. Are you related to 

Vijay Singh? 

Dr. YELDANDI. No, sir, I am not. 

Mr. FALEOMAVAEGA. Unfortunately. You are not my friend, then. 

You have made some very eloquent statements about the crisis 

that we face in India. Obviously because of limited resources, what 

52

can we do? Even by the commitments of our own Government, 

while we have made a lot of commitments, but when it comes to 

substance, very little. But I can say, at least, for our own country, 

we are making a bigger commitment than most other countries. 

What would be your recommendation on how we could look at 

the picture of the Asia-Pacific region, how we can best address it? 

As we have done in Sub-Sahara Africa and other regions. 

Dr. YELDANDI. Thank you, sir. I think the key issue is how we 

get to strengthening the entire public health infrastructure. Therefore, what we need to insure is that each and everybody gets the 

basic needs addressed: Clean water, access to immunizations, access to antenatal care, basic nutrition. And that HIV, Tuberculosis, 

Malaria, everything needs to be included in this comprehensive approach. 

The major reason why our own organization has been able to go 

into rural areas in a very conservative society and talk openly 

about sexuality, HIV and AIDS, is because of our track record with 

public health over there. We have been working with immunizations and micro-nutrients for pregnant women, so——

Mr. FALEOMAVAEGA. I know my time is up, Dr. Yeldandi. But let 

me tell you, it isn’t just your country that has these cultural problems with sexuality. I can tell you a whole story about that, but 

I am going to wait for another round. 

I am sorry, my time is up. But I will follow up on that. 

Mr. LEACH. Thank you. Jerry. 

Mr. WELLER. Thank you, Mr. Chairman. And I want to thank 

your panel for what is a very enlightening and informative discussion this afternoon. 

Recognizing my time is limited, I will get right to my questions. 

And I would like to direct this question to Dr. Cravero. And if others on the panel would like to respond, I would like to hear from 

you. 

But we focused quite a bit on India in this discussion today. A 

very large country with a large population, but it is projected by 

many experts that India is going to have the largest HIV/AIDS 

population by 2005 in the world. I think today is it number two. 

We expect it to be number one within a year. 

And many experts and observers have also stated that the government of India’s commitment to this crisis has not been very 

high. In fact, some of them say it is questionable, considering the 

amount of resources that the government of India has devoted to 

this challenge in comparison to what the international community 

is doing. 

And Dr. Cravero, would you say this is a fair assessment? And 

from your perspective, what concrete steps have you seen the Indian Government take to address this crisis? 

Ms. CRAVERO. I think it is a fair assessment to say that the government of India has been slower than we would have liked to see 

to really take this problem in hand. 

I think we have seen a great improvement in the last 2 to 3 

years, not only at the national level, but more importantly for 

India, at the provincial level. Because as you know, there are states 

in India that are as populous as the United States. So to say whatever the national government does in India is one thing, but it is 

53

the provincial governments you have to reach, also, as I think the 

doctor has pointed out. 

So we think there has been an improvement. In India it is very 

uneven. There are some states with very big problems. You know, 

overall it is between 0.4 and 1.3 percent. But in some states in 

India it is a huge problem; in other states it is much less. So we 

can’t just take a national approach, and that has been an issue. 

It is probably worth stating that Sonia Ghandi came to the closing session of Bangkok, and that was seen as very significant. Because it was the first time an Indian leader had addressed an 

international Conference, and had talked about the problem in her 

own country and what the government intended to do about it. So 

that was a very positive sign. 

Mr. WELLER. Thank you. Dr. Gill, others on the panel, want to 

respond to my question? 

Dr. YELDANDI. I think that they should be commended for doing 

all that they could do and can do in the short time. 

The government of India and all of the state governments have 

very limited resources. They don’t have much money. That is the 

reality. And whatever little money they have they have been trying 

to use. 

This is the reason why it is so important for the United States 

and other international agencies to come in and augment what 

they are doing, and complement the deficiencies. We need to step 

in there. 

No matter how hard you try, when you are working as a government agency, like NACO or the States AIDS Control Society, they 

have inherent limitations in what they can do. And we need to step 

in and complement them by strengthening the other private sector, 

and the non-governmental organizations that are out in the field, 

in the trenches, so to speak. 

Thank you. 

Mr. WELLER. Dr. Yeldandi, as a follow-up to that, obviously you 

are an observer and directly involved in trying to address this challenge in India. You have stated that you feel that they have done 

quite a bit. What more can they do? Are there specific initiatives 

from your experience that you would recommend that they adopt, 

recognizing the resources that they have available? 

Dr. YELDANDI. From the perspective of the American Association 

of Physicians from India, what we would like to see is that India, 

both at the national level and at the state level, really beef up their 

infrastructure support. Laboratories for testing, training for health 

care professionals, and also increasing access of antiretroviral 

agents. 

These have to be done in parallel, like Dr. Cravero said. We have 

a lot of people who are going to die today or tomorrow, so we cannot wait for better agents to come along. We have to use the agents 

that we have. But we need to use them wisely. And therefore, an 

enormous investment needs to be made in building the infrastructure that is required to monitor them. 

This is where the United States can come in. This country has 

the technology. This country has the management expertise. And 

most importantly, we are a generous people and we care for people 

who are less privileged than we are. We have demonstrated that 

54

for many years. And we need to come in. And I think that we will 

make a difference if we come in. 

Mr. WELLER. Well, Dr. Yeldandi, I certainly want to thank you 

for participating. Since I represent the Chicago area, it is good to 

have someone from the neighborhood. 

Dr. Gill or Ms. Burkhalter, do either of you have some comments, 

particularly on India and how they are devoting their resources 

and efforts? 

Ms. BURKHALTER. If you will permit an Iowan to speak for just 

a moment on that point. 

I wanted to talk about a technical issue, largely technical issue, 

that I didn’t raise up in my oral remarks, but you will find it in 

my written statement. It is less of a conventional human rights 

issue, like those I was talking about, and more of a classical disease prevention method. And that is AIDS transmissions through 

tainted blood, unscreened blood in blood transfusions or in reused 

needles. 

I worked on this a lot last year with regard to Africa, where it 

is less of a problem than it is in Asia. But it has been somewhat 

minimized by international health people. The disease is customarily referred to as a sexually-transmitted disease. 

Really, not to be pedantic about it, but HIV/AIDS is a bloodborne disease. And you cannot neglect classical infection control. 

If you have a blood transfusion from a person who has AIDS to 

a person who doesn’t have AIDS, there is a 100-percent chance that 

the person to whom the transfusion has been given will get the disease. 

And it is worth saying that in Africa and in Asia, there are not 

blood banks like we have here, where blood is tested, and you have 

donors who are not paid for blood and the rest of it. 

If you need a transfusion, you bring in your transfusion with you. 

It is a family member, most often. And for people with Malaria, 

who have to have a transfusion right away, there is no way to test 

these people. There is no testing availability, quick test for HIV/

AIDS in the blood. 

And even if there was, there isn’t another place to go to get a 

blood transfusion. So you either get this transfusion or you are 

going to die. 

And in the Asian region, according to WHO, something on the 

order of 25 percent of HIV/AIDS transmission is from these unsafe 

health care contacts. I am not talking about street use of IV drug 

use; I am talking about dirty needles, reused needles, or blood supply. 

The Chinese, for example, some have estimated that 30 percent 

of their AIDS transmission comes from blood transfusions. 

Now, it is not a minor matter to clean up a blood supply or to 

substitute non-reusable or self-destruct syringes for the reusable 

type. It is not minor. But nor is it impossible. It is not rocket 

science. I mean, these are relatively cost-effective interventions 

that are technical and practical in a nature that can solve the problem. 

If you think about a third of the infections that could be prevented, and if you compare that to trying to change sexual norms 

and promote condom use in every single household in some of these 

55

high-prevalence countries—I absolutely agree with Dr. Cravero. 

You don’t pit one prevention initiative against another. And that 

is the last thing I would want to do. 

But I think that this has been a bit of a neglected kind of stepchild, because it is not sexually transmitted. And because of the 

international community’s eagerness to address what has been neglected in the past, which is sexual transmission, and speak frankly about it, this issue has been somewhat left behind. 

I mean, India has a huge problem with this. Both reused needles, 

as well as infected blood supply. And—and this will be my last 

statement about this—the amount of medical injections that poor 

people in poor countries receive is vastly higher than here. 

I had one injection last year; it was a flu shot. But a poor Indian 

woman might have 10 or 12. And there is a very good chance that 

it will be with a reused needle. 

You know, if you will permit me a personal observation, 9 years 

ago when my husband and I went to China and adopted our daughter, Gracie, the adoption agency told us to be sure and take safe, 

clean syringes. And we said, ‘‘Why? What for?’’ I never worked on 

AIDS before, what did I know about this? Well, if you get sick, you 

certainly don’t want to get an injection from a Chinese hospital. 

And I think any United Nations employee and anybody who works 

in our Embassies in Asia and Africa would say the same. 

When we got to China, our daughter was very sick, as were 

many of the other kids. They are all fine now, by the way; they just 

flourish there. A wonderful, wonderful Chinese gift to the United 

States. 

But some of our kids were sick and we took them to a clinic. And 

the first thing these wonderful providers wanted to do for these foreign-adopted kids, who they wanted to offer the best thing they had 

in their generosity and kindness, was to give them a shot. 

They were just sick; they had diarrhea, they were sick from poor 

orphanage conditions. We didn’t let them give the kids a shot. 

But I think that little personal story suggests to you what we actually know about one form of disease transmission. And if you 

think AIDS is transmitted in large numbers, you wouldn’t believe 

the Hepatitis numbers, which are in the tens of millions. 

And this is just plain fixable. And this is a kind of technical fix 

and help that, the blood supply is a bit complicated, but can be 

done. It takes some money, it takes some help. 

Now, China, I am informed, is working with the, I should say the 

Clinton Foundation is assisting the Chinese Health Ministry with 

their blood supply and other technical issues. It is going very well. 

So I would really like to second Chairman Leach’s suggestion and 

Professor Gill’s suggestion about a different kind of a relationship 

around this issue, where two great nations of the world can exchange experiences on public health. It would make me very, very 

happy, as the mother of a Chinese-American child. 

Mr. WELLER. Thank you, Mr. Chairman. I realize I have gone 

well beyond my allotted slot of time, but thank you. It was a very 

worthwhile discussion. 

Mr. LEACH. Your contributions are always outstanding. 

Mrs. Lee, a leader in Congress on so many AIDS issues. 

56

Ms. LEE. Thank you, Mr. Chairman. And let me first thank you 

for allowing me to participate in the Subcommittee hearing, and 

also commend you for your leadership at this very important time, 

this very critical time. 

And I always remind people when I talk to individuals, those involved in this whole pandemic, that really the precursor and the 

framework for the Global Fund was through the legislation which 

we co-authored together, that created the World Bank AIDS Trust 

Fund. And I think we have seen at least a glimmer of hope and 

some progress. And it is very important that we continue to move 

forward and try to get to the $1 billion, $2 billion which the fund 

so desperately needs. 

Let me just say also, I think the Subcommittee hearing is coming 

at a very important time, especially since the International AIDS 

Conference in Bangkok just ended its proceedings. And I had the 

privilege, actually, to participate in that Conference. It was only 

maybe 3 days, but I think it was a worthwhile 3 days. 

And I must say to you that I talked to many, many people at the 

Conference. And the issue as it relates to the vulnerability of 

women and girls in the new face of HIV and AIDS was on everyone’s mind. 

I would like to, Mr. Chairman, insert for the record Secretary 

General Kofi Annan’s statement at the Conference in Bangkok. I 

would like to ask for unanimous consent for that. 

Mr. LEACH. Without objection, so ordered. And the Secretary 

General has played a really extraordinary role on the AIDS issue. 

And given all of the controversy that surrounds the United Nations, I think that we ought to be very firm in expressing our appreciation when it is doing well. And both UNAIDS, as well as the 

Secretary General, have shown extraordinary leadership. 

Ms. LEE. Thank you, Mr. Chairman. So I will insert his statement into the record. 

Let me just read a quote from the opening ceremonies in Bangkok. He said:

‘‘Over the past few years, we have seen a terrifying pattern 

emerge: all over the world, women are increasingly bearing the 

brunt of the epidemic. . . . And yet, one third of all countries 

still have no policies to ensure that women have access to prevention and care.’’

In many cases, and I mentioned this when I was in Bangkok, 

and I would like to ask any of the panelists to respond to this 

point. The point I made that I have heard over and over, and that 

I know, is that oftentimes women and girls don’t really have the 

option to abstain, because of everything that we have heard today. 

And while many people—it is very interesting—in our own country understand this and commented on my comments, I was 

amazed at some of the most vicious communications that I received 

within the last week with regard to my statement. 

It was very interesting because some of those vicious, very ridiculous comments said that—and let me just read a couple of them. 

One said that women can always say no, so why are you saying 

this? Another comment which frequently came up was that Congresswoman Lee, you are a wacko. It is only through rape that 

57

women have no choice, and you can’t force a rapist to use condoms. 

I mean, the type of bizarre type of response that I received from 

many people concerned me quite a bit, in terms of just the thinking 

and the mentality of those who really don’t seem to get it. 

So we have introduced—and Ms. Burkhalter, I think you mentioned in the Philippines—this whole issue around condoms, the 

misinformation and not allowing the sale of condoms certainly contributes to the spread of AIDS. Well, that is just the point. 

And so we are trying to figure out a way to develop legislation 

that would put together a focus with regard to access to female 

condoms, reducing the child/marriage issue, reduction of violence, 

helping to increase micro-enterprises for women, generating income 

generation initiatives, increasing access to health care services, and 

to promote overall gender equality. 

I am proud to say we have a bill that is pending, H.R. 4792, with 

about, I guess, 54–55 co-sponsors. And I would just like to ask, 

well, starting with Dr. Cravero, your comments on what you think 

a focus strategy on behalf of our Government should look like as 

it relates to women and girls, so that we can begin, one, to address 

the pandemic in a very real way for these millions of women and 

children. 

But secondly, to educate the American public as to why this not 

allowing the distribution of condoms, not allowing for a comprehensive strategy that involves education, prevention, abstinence, be 

faithful, and condom use—how do we convince the American people 

that this is the only way we can address this pandemic? 

Ms. CRAVERO. Thank you very much. And I would like to thank, 

on behalf of UNAIDS, Congresswoman Lee for what she has done 

in this new bill we plan to use as a model—model legislation to 

share with other countries about the kind of legislation that is required to address the realities of women and girls’ lives. 

As I said in my testimony, we believe that for women and girls, 

truly there needs to be a comprehensive prevention approach. 

It is clear, if you look at how women and girls live in developing 

countries and what their situation is—not only in developing countries, and not just young women in particular, but women of all 

ages—they simply don’t have the ability to abstain. They are not 

in a position to demand faithfulness, and they are not in a position 

to negotiate condoms. 

And as part of the Global Coalition on Women and AIDS, which 

UNAIDS has spearheaded, we are trying to build the evidence base 

for some of this. And we do have evidence for it. 

In South Africa there was a recent study published which 

showed that women who lived with partners who were violent or 

controlling—and it was a proper operational research study, so 

they defined violence and controlling. But women who lived with 

partners that were violent or controlling were five times more vulnerable to HIV than those who were not. 

We know that in Thailand, 40 percent of new infections are 

spouse-to-spouse or partner-to-partner infections, male to female. I 

mean, the evidence is growing, if people needed to be convinced by 

such evidence. 

And what we are saying very clearly is that abstinence, fidelity, 

and condoms are a good start, but we need to go further. If you 

58

don’t reduce violence against women, they are never going to be in 

a position to negotiate anything. If you don’t protect women’s property rights after their partners die, they will inevitably engage in 

high-risk sexual behaviors in order to survive. If you don’t guarantee girls access to education, they will have to sleep with older 

men to pay their school fees. 

Again, as was said earlier on, this is not rocket science. Now, we 

are trying to build the evidence base. Some people are never going 

to be convinced of this because they don’t want to be convinced. 

But I think if you look both at how transmissions are occurring 

and anything about the way girls and women live, you can see how 

an ‘‘ABC plus’’—emphasis on the ‘‘plus’’—strategy is absolutely necessary. 

Dr. YELDANDI. If I may make a comment on that. I think that 

what you have brought up is vital to understand. And 40 percent 

of the women that we are seeing, 40 percent of the people that we 

are seeing infected with HIV are women. 

And one of the major issues that we face is that there is a lot 

of alcoholism involved. And alcohol and violence in the domestic 

setting is a major contributor to all of the HIV spreading. 

You know, it is very interesting that Mr. Chopra, who is one of 

the founders of the Freedom Foundation, once told me about alcohol and sex. And he said you know, these commercial sex workers, 

you think that these people really enjoy what they are doing? They 

have professional gratification? No. They have to do it 10, 12 times 

a day to make a living. And they dull the pain by using a lot of 

alcohol. And their clients do the same. And it contributes to the 

spread. 

So in addition to the legislative activity that is absolutely imperative to empower women, what we also need to do is, on the 

ground, we need to empower women. Now, we have done that by 

making sure that all of our community health volunteers are 

women. These are women with 6th-grade educations. They are 

leaders in their own community because they are our liaison with 

the entire community as health care workers. This has raised their 

profile in the community. They are respected. And that enables 

them and empowers them to take more control over their own lives. 

Ms. LEE. Mr. Chairman, may I have an additional couple seconds? 

Mr. LEACH. Absolutely. 

Ms. LEE. Thank you, Mr. Chairman. I had the privilege of being 

able to visit India in January. Actually I went to Mumbai and visited a brothel and was very startled at what I saw. 

But in visiting the brothel, as in visiting commercial sex workers 

in Zambia last year, 99.9 percent of the women said to me that 

they would not be doing this type of work if they had an alternative, one. And secondly, they wanted to know more about how to 

protect themselves, two. And thirdly, really asked for a lot of assistance, just in terms of basic kind of assistance, in terms of living 

arrangements, in terms of health care, in terms of day care and 

what-have-you. 

So it is common worldwide. And I believe, just as it relates to 

India, Mr. Chairman, the bill, and I think you are a co-sponsor of 

H.R. 4449, we are trying to ensure that India becomes a country 

59

of focus by the President in terms of his initiative. I believe Vietnam was the 15th country, but that doesn’t mean that we can’t add 

additional countries in terms of the focus of our strategy in this 

country. 

And I would just like to get your take on, well, I don’t know if 

you have read this legislation or not. But basically it would just require our own efforts to add India as a focused effort. Do you think 

that would help us move forward in terms of addressing this pandemic before it grows to over 1 percent? Because now, with 4.5 million people, we are right on the cusp of a very, I think, serious situation. 

Dr. YELDANDI. You are exactly right. We are where Africa was 

10, 15 years ago. And this is the time that we need to move forward with all deliberate speed and seize this opportunity. 

India has done some work. And we may quibble with whether 

their efforts are adequate or inadequate. But clearly, so much more 

needs to be done that it is beyond the resources of that society to 

do it all alone. We need to step in. And the United States of America needs to take a leadership position on this. 

Thank you. 

Ms. LEE. Thank you, Mr. Chairman, very much. And thank you 

again for your leadership. 

Mr. LEACH. Well, it is your leadership I want to thank. And I 

want to tell you, you certainly have my mandate to do the Committee’s investigation on brothels. I am not sure that my constituents 

want me to explain my investigations in such circumstances. But 

I appreciate very much your insights. 

If you have any callers that suggest you are wacko, tell them to 

talk to me, and I will whack them. 

Ms. LEE. I will do that. Thank you very much, Mr. Chairman. 

Mr. LEACH. At least verbally. And as everybody knows, Barbara 

is really the leader of Congress on some very profound issues. 

Eni, do you have any further questions? 

Mr. FALEOMAVAEGA. I just want to add, Mr. Chairman, to the 

gentlelady’s comment about her being described as a wacko. I just 

want to say for the record that Ms. Lee has been the wacko, and 

also has been the leading advocate and the stalwart in this Committee. In fact, one of the most powerful voices in advocacy about 

the AIDS/HIV crisis and the development of the legislation that 

came off from the Committee. And I want to compliment the 

gentlelady for her leadership and her efforts in fighting this dreaded disease. 

So I don’t know whether to say that being described as a wacko 

is a compliment or a criticism. But I want to say that I associate 

myself with Ms. Lee as a wacko, if that is how they think of her, 

as a wacko. But as far as I am concerned, they don’t know the extent of how the gentlelady has been one of our best advocates. Not 

only has it given national attention, but international attention 

about the HIV/AIDS. And I just want to say that for the record. 

And to say also, Mr. Chairman, that, as Ms. Burkhalter has said, 

there are so many issues interconnected, it isn’t just with HIV/

AIDS. You are talking about Hepatitis, you are talking about Malaria, you are talking about TB. And every country, especially developing countries, have these basic fundamental needs. 

60

So it is such a—I say it is a contradiction. We claim to be a sophisticated country; I don’t know about that. When we talk about 

sex issues, and how Viagra and Levitra comes out in the middle 

of a football game. And children ask their parents what is erectile 

dysfunction, whatever that means. It causes me to wonder if we 

know ourselves about sexuality. And how do you describe a 

condom? 

In cultures, in my own culture, you talk about sex, it is almost 

the forbidden story. Or to the extent that you don’t talk about it 

as freely as you would maybe in our society. And do we say that 

would be hypocritical? I don’t know. But there definitely is a strong 

cultural problem to overcome. 

To say that we are more educated in that process, I doubt it. I 

think we are just as ignorant ourselves in trying to figure that one 

out. The constitutional proposal about prevention of gay marriages 

and all this is health-related, as well. 

I think I come away more—not frustrated—but I come away 

more concerned that the issues are so tremendous. And I sincerely 

hope that maybe what we can do is start off with India. Let us 

start with India. If we can address that issue, maybe we will move 

on to the next area in addressing this very serious issue. 

And again, Mr. Chairman, I thank you for calling the hearing. 

And I want to commend our panelists for the tremendous contributions that they have given. And hopefully, as a result of this hearing, we will come out with some good policy decisions by way of legislation to help the President, and help our country, as well. 

Thank you, Mr. Chairman. 

Mr. LEACH. Thank you, Eni. And I want to thank our panelists. 

Your testimony was excellent. 

By the way, at hearings you have three, four, five Members of 

Congress sitting through. But we are going to put your testimony 

up on various Web sites, one of which is the U.S./China Commission, but others, as well. So with your permission, we will do that. 

Personally, I am very impressed with the emphasis on the word 

‘‘plus’’ today. And it has taken on dimensions that I think we all 

have to think more about. One, Ms. Burkhalter’s emphasis on needles and blood supply. A second, which I have given almost no 

thought to, is Dr. Yeldandi’s emphasis on alcohol. 

And so, with the leadership of Barbara Lee and one of her predecessors in spirit, Cary Nation, we can move on. 

But these are very extraordinary circumstances. 

I also, which is a new concept to me, am impressed with the 

thought that if you address a health care problem of one kind, that 

you can use that to develop other positive circumstances. So that 

a clinic on AIDS can be a clinic for more general health care needs, 

and vice-versa. 

And that notion that AIDS can be the cutting-edge issue to deliver greater health care of a broad assortment to less-sophisticated 

health care delivery societies, which to some degree includes the 

United States—that is, we are at the forefront of virtually everything in health care, except our delivery mechanisms are not as 

perfect as they might be. 

And AIDS as a technique of addressing, or an emphasis on AIDS 

is a technique of addressing other health care issues is, I think, 

61

something that deserves a lot more attention. And I am glad that 

as a set of panelists you have raised that to our attention. 

In any regard, I thank you all for sterling testimony. And hopefully we can get your perspective out to larger numbers of people. 

Thank you all very much. 

[Whereupon, at 3:29 p.m., the Subcommittee was adjourned.] 

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A P P E N D I X 

MATERIAL SUBMITTED FOR THE HEARING RECORD

PREPARED STATEMENT OF THE HONORABLE DAN BURTON, A REPRESENTATIVE IN

CONGRESS FROM THE STATE OF INDIANA

Mr. Chairman, I commend you for convening this hearing today to examine the 

prevalence of HIV/AIDS, and strategies to combat the spread of the disease in the 

Asia-Pacific region. The Asia-Pacific region is home to 60% of the world’s population 

and to 19% of the men, women, and children living with HIV according to the latest 

statistics. Infection rates in Asia are low compared to some continents, particularly 

Africa, but because the populations of many Asian nations are so great, even low 

HIV prevalence translates into large numbers of people living with HIV/AIDS—

some 5.1 million men, 2 million women and 158,000 children according to the most 

up-to-date estimates from UNAIDS/WHO. 

There are alarming rates of transmission in Cambodia, Thailand, Myanmar, parts 

of Southern China and India where efforts to limit exposure and reduce infection 

levels have not been succeeding. 

In 2003, close to half of the intravenous drug users (IDUs) receiving treatment 

in the Indonesian capital, Jakarta, were living with HIV. While in 2002 in Nepal, 

HIV prevalence among male intravenous drug users ranged from 22% to 68% across 

the country. Parts of China, India, Myanmar, Thailand and Vietnam have all recorded very high levels of HIV infection among IDUs. 

In some places (including Myanmar, Thailand and the Indian state of Manipur), 

HIV infection rates have ‘‘stabilized’’ among IDUs, but they have stayed at levels 

of between 40% and 60% for nearly a decade. Unfortunately, even stable prevalence 

means that one person becomes infected for every HIV-infected person who dies or 

drops out of the population because they stop injecting drugs. 

Clearly, the problem is severe and immediate. A few of the countries in the region 

have recorded significant successes in their campaigns to prevent HIV/AIDS infection, but there are obviously a number of other countries in the region that need 

to substantially strengthen their policies in order to combat their growing HIV 

epidemics. 

From the outset let me say that I support the Bush administration’s $15 Billion 

U.S. AIDS relief plan. The President’s Emergency Plan for AIDS Relief (PEPFAR) 

grants funds to health care groups in individual countries that emphasize a focused 

‘‘A–B–C’’ approach to HIV/AIDS prevention: ‘‘Abstinence,’’ ‘‘Be Faithful’’ and 

‘‘Condom Use.’’ Some may argue that this is too simplistic an approach but the fact 

of the matter is that not having sex is a sure way to avoid contracting a sexually 

transmitted disease. 

Let me also point out to those critics who say that the United States isn’t paying 

its fair share for the global fights against HIV/AIDS, that the U.S. contribution to 

the global HIV/AIDS fund continues to be greater than those of all other donor governments combined. In 2004 alone, our contribution will be approximately twice 

that of all other donor governments combined. 

I believe this Administration is firmly committed to the battle against HIV/AIDS 

and I know that in Asia, our government working through USAID will continue to 

step up efforts to assist governments and non-governmental organization in their 

prevention and treatment efforts. 

Based upon my own travels throughout the region and from the hearings this 

Subcommittee has convened in recent months, I have gained an acute appreciation 

for the wonderful diversity of the peoples and cultures of the Asia-Pacific region. 

Likewise, the HIV/AIDS epidemics in the region share a similar diversity. Prevention efforts that ignore the social, political and cultural contexts that push people 

into engaging in risky behavior will simply not encourage people to adopt safer beVerDate Mar 21 2002 14:40 Oct 08, 2004 Jkt 000000 PO 00000 Frm 00067 Fmt 6601 Sfmt 6621 F:\WORK\AP\072104\94989.000 HINTREL1 PsN: SHIRL
64

haviors. Efforts that ignore or minimize the risks of this devastating disease or are 

conducted piece meal to narrowly targeted groups are also likely doomed to failure. 

I think we’ve seen the evidence of this in our own country as we struggled to deal 

with the HIV/AIDS crisis during the 1980s. 

Public health practitioners seem to have a natural tendency to target interventions towards people who engage in certain risk behaviors, and to classify them as 

special ‘‘risk groups,’’ somehow separated from the ‘‘general population.’’ As a Nation, we have learned through years of combating this debilitating disease that we 

are all part of the ‘‘general population,’’ and it is in our collective best interest to 

provide prevention services and care for all those among us who may be at risk of 

contracting and passing on HIV/AIDS. We have also seen around the World that 

countries and regions that have chosen to provide prevention services on a large 

scale to those who are most in need of them, have turned their HIV/AIDS epidemics 

around or at least significantly delayed the onset of looming epidemics. 

Attitudes towards drug abuse, commercial sex, and sex trafficking are all factors 

contributing to the complexity of designing public health interventions to combat the 

spread of HIV/AIDS. For example, when we look at behavioral patterns in Asia, I 

find it alarming that a seemly high percentage of HIV/AIDS prevention programs 

have focused strongly on reducing unprotected commercial sex between men and 

women, and very little on tackling risky sex between men or between men and 

transgender individuals. Similarly, in most Asian countries, a majority of both female sex workers and intravenous drug users are younger than 25; and a significant 

proportion of men who buy sex and who have multiple male sex partners are also 

adolescents or young adults. Yet, intervention and prevention programs aren’t appropriately reaching out to this generation. 

There is obviously a great need for technical assistance—particularly in the area 

of education—to appropriately design programs to modify behavior patterns in these 

countries. For our own sakes, we must do more to help the Asia-Pacific region deal 

with this epidemic. The solution isn’t necessarily throwing more money at the problem, rather it is throwing new ideas at local policymakers and helping them work 

through the challenges and stereotypes they face when trying to put prevention and 

intervention programs in place. I look forward to hearing the thoughts and suggestions of our witnesses in just how to go about doing this. 

In closing, I would like to submit for the record today a study by the Monitoring 

the AIDS Pandemic Network—an international network of epidemiologists and public health professionals who contribute data and analysis in their individual capacities. I have found this study to be extremely helpful in my own understanding of 

the subject of HIV/AIDS, and I commend it to all colleagues. Thank you. 

PREPARED STATEMENT OF THE HONORABLE BARBARA LEE, A REPRESENTATIVE IN

CONGRESS FROM THE STATE OF CALIFORNIA

Thank you Mr. Chairman for allowing me the opportunity to participate in today’s 

very important hearing. 

Let me also just say that your leadership on this critically important issue has 

been extraordinary over the last few years. It’s truly been a privilege to work with 

you so closely in drafting and passing legislation that truly makes a difference in 

the lives of people throughout Africa, Asia and the developing world. And I look forward to our continued collaboration. 

Mr. Chairman, I’m pleased that the Subcommittee is holding this very timely 

hearing today, especially coming as it does on the heels of the XV international 

AIDS Conference in Bangkok, Thailand. 

As the only Member of Congress to attend this incredibly important event, I want 

to take a few minutes to give this committee and the panelists my impressions of 

the conference. 

Each time I’ve returned from one of these conferences, I’m filled with great hope, 

but also a very profound realization of just how much it is that we have left to do. 

Having spent this last week among the international leaders on the global pandemic, I can tell you that the international community is very disappointed by the 

rate of progress, particularly in meeting the goal of the conference ‘‘Access for All’’. 

There was also great concern about the US position on a number of issues including funding, HIV prevention, drugs, support for the Global Fund, and even just the 

number of US government attendees at the conference. 

In fact, that point was reinforced by Secretary Tommy Thompson’s decision to 

allow a delegation of only 50 people from HHS to attend the World AIDS conference 

this year, down from 236 the year before in Barcelona. 

65

It is shameful that they have prevented many of our very best and brightest scientists at the Center’s for Disease Control, and the National Institutes of Health 

from gaining new insights from their colleagues in the international community. 

It is tragic that this Administration’s unilateralist and ideological tendencies have 

now spread to the fight against HIV/AIDS. 

It is morally wrong to allow right-wing ideology to trump science when it comes 

to the Administration’s HIV/AIDS prevention policies. Their policies set aside 33% 

of all funding for abstinence only programs which deny access to life saving education and technology, including condoms. 

Simply put: this is irresponsible, unethical, and inhumane. 

I believe it is unethical that their AIDS treatment policies are focused more on 

protecting patents and big pharmaceutical companies than on the urgent need to 

get fixed dose combinations into the hands of those who need them, 98% of whom 

lack access to treatment. The emphasis should be on saving lives. 

It is disingenuous that they have proposed cutting our support for the Global 

Fund by over 60% this coming fiscal year, proposing a measly contribution of $200 

million rather than the $1.2 billion that is needed. 

We need to encourage the sharing of information by our scientists and researchers. 

We need to do a lot better in coordinating our bilateral programs with national 

governments, the NGO community, and our field missions. 

We need to simplify our anti-retroviral treatment programs by purchasing fixed 

dose combinations, drugs that are already available, and we must standardize our 

treatment programs according to the wishes of each individual country. 

We have to Fund the Fund! 

Last week I offered an amendment to the Foreign Operations Appropriations bill 

to bring our total level of funding up to $1.2 billion this year. And I was very disappointed that a point of order was raised to kill the amendment, because I believe 

the fund is the best way to get the money out into the hands of the NGO’s immediately. 

The Fund takes a multilateral approach, and it has the potential to leverage vast 

new resources. We are the wealthiest country in the world. And we should be leading the charge. 

Perhaps most importantly, we must stress and implement a balanced, comprehensive, HIV prevention policy that includes Abstinence, Being faithful and Condoms. 

But, Mr. Speaker, we must also go further. As UN Secretary General Kofi Annan 

said so eloquently in his remarks during the opening ceremonies on Sunday, we 

must place a special emphasis on reducing the cultural, social, economic, and political factors that increase the vulnerability of women and girls to HIV. 

On July 9th, just before leaving for Bangkok, I introduced H.R. 4792, The New 

United States Global HIV Prevention Strategy to Address the Needs of Women and 

Girls Act of 2004—with 54 original co-sponsors—that would do just that. 

While in Bangkok, I participated in one meeting with women leaders. There were 

maybe 50 to 75 women in the room. Over half of them were living with the virus. 

One woman happened to share a story with us, and she indicated that she had 

recently gotten married. She did not know that her husband was HIV infected. Four 

months later, after her marriage, lo and behold she had the virus. Unfortunately 

in her society, she had no way to protect herself beforehand. 

The UN Secretary General, the Global Coalition on Women & AIDS, activists, and 

women all around the world are calling for an initiative just like this. 

We must pass this bill. We owe it to women all over the globe who are oftentimes 

powerless to control their own lives and their own risk of infection. More often than 

not, women and girls do not have the option to abstain. 

I look forward to working with you Mr. Chairman, and the members of this subcommittee and the full committee to move this issue forward. 

Thank you. 

66

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD BY THE HONORABLE BARBARA

LEE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA

Press Release 

SG/SM/9418 

AIDS/77 

12/07/2004

STRONGER LEADERSHIP NEEDED AT EVERY LEVEL IN FIGHT AGAINST 

HIV/AIDS, SAYS SECRETARY-GENERAL IN ADDRESS TO BANGKOK CONFERENCE 

Following is Secretary-General Kofi Annan’s address to the XV International 

AIDS Conference in Bangkok, 11 July: 

I am delighted to be here today, among so many leading lights in the fight against 

HIV/AIDS. It is the dedication and resolve of people like you that is our best hope 

in the struggle. 

It is fitting that we are meeting in Thailand, which has had such remarkable success in curbing the spread of HIV/AIDS. Prime Minister, your recipe for success was 

a powerful combination: visionary political leadership at an early stage of the epidemic; allocation of serious resources; strong civil society involvement; along with 

massive campaigns for public awareness and condom use promotion. Thank you, 

Thailand, for showing us that progress is possible. Continued leadership is now crucial in ensuring that you sustain that success, despite very real challenges. 

It is also appropriate that this conference is being held in Asia, where the virus 

is spreading at an alarming rate. One in four infections last year happened on this 

continent. There is no time to lose if we are to prevent the epidemic in Asia from 

spinning out of control. 

At this conference, many countries around the world are being represented by 

their health ministers. But let us be clear: the fight against HIV/AIDS requires 

leadership from all parts of government—and it needs to go right to the top. AIDS 

is far more than a health crisis. It is a threat to development itself. 

That is why, three years ago, the Governments of the world made a promise. At 

the General Assembly Special Session on HIV/AIDS—the first General Assembly 

session devoted to a disease—they pledged to deliver the resources and action needed to defeat the epidemic. They adopted a number of specific, time-bound targets, 

in a document we know as the Declaration of Commitment. 

Three years on, there has been progress on many fronts. 

Significant new resources have been pledged, both by individual Member States 

and through the Global Fund to Fight AIDS, Tuberculosis and Malaria. 

The vast majority of Member States have adopted comprehensive, national strategies to combat HIV/AIDS. 

Increasingly, Governments are working with civil society as a full partner in the 

struggle. 

And yet, we are not doing nearly well enough. 

We failed to reach several of the objectives the Declaration set for last year. 

Even more important, we are not on track to begin reducing the scale and impact 

of the epidemic by 2005, as we had promised. 

Meanwhile, over the past few years, we have seen a terrifying pattern emerge: 

all over the world, women are increasingly bearing the brunt of the epidemic. 

Women now account for nearly half of all adult infections. In sub-Saharan Africa, 

that figure is around 58 per cent. Among people younger than 24, girls and young 

women make up nearly two thirds of those living with HIV. 

And yet, one third of all countries still have no policies to ensure that women 

have access to prevention and care. Knowing what we do today about the path of 

the epidemic, how can we allow that to be the case? 

It is clear that if the Declaration of Commitment is to live up to its name, we 

will have to do much, much better on several fronts. 

Today, allow me to outline three specific areas we must focus on. 

First, we need to scale up infrastructure to support both treatment and prevention. 

Successful programmes in Africa, in Latin America, and here in Asia, have demonstrated that prevention and treatment can work in any setting, but only if:

— interventions are scaled up to reach whole societies;

— they are developed inside the country, rather than imposed from outside;

— there is strong engagement by people living with and affected by HIV; and

67

— there are enough trained people to implement successful programmes—from 

community centres for awareness-raising, counselling and testing, to clinics 

for treatment and care.

That means doing everything possible to ensure that health workers living with 

HIV have access to anti-retroviral therapy. In many of the most affected countries, 

AIDS drives a cruel and vicious circle by striking at those who are most badly needed to fight the epidemic. 

It means stepping up efforts to train new people, and calling in reinforcements 

among health workers not yet involved in the struggle. 

And it means drawing on unconventional capacity where formal skills may be 

lacking. Enlisting and empowering untapped talent among community workers, volunteers, and people living HIV/AIDS will both help to scale up the efforts and contribute to breaking the stigma and silence. 

No less pressing is our second priority: empowering women and girls to protect 

themselves against the virus. 

Why are women more vulnerable to infection? Why is that so even where they 

are not the ones with the most sexual partners outside marriage, nor more likely 

than men to be injecting drug users? 

Usually, because society’s inequalities puts them at risk—unjust, unconscionable 

risk. 

A range of factors conspires to make this so: poverty, abuse and violence, lack of 

information, coercion by older men, and men having several concurrent sexual relationships that entrap young women in a giant network of infection. 

These factors cannot be addressed piecemeal. What is needed is real, positive 

change that will give more power and confidence to women and girls. Change that 

will transform relations between women and men at all levels of society. 

In other words, what is needed is the education of girls. 

Only when societies recognize that educating girls is not an option, but a necessity, will girls and young women be able to build the knowledge, the self-confidence 

and the independence they need to protect themselves from HIV/AIDS. 

Once they leave school, we must work to ensure they have job opportunities, as 

well as enjoy the rights to land ownership and inheritance that too many are denied 

today. 

And we must ensure they have full access to the practical options that can protect 

them from HIV—including microbicides, as they become available. 

That brings me to the third priority: stronger leadership at every level—including 

at the top. 

Leadership means showing the way by example:

— by breaking the deadly wall of silence that continues to surround the epidemic;

— by achieving the cultural shift needed to fight it effectively;

— by working to scale up the response—including providing treatment to all 

those who need it.

We need leaders everywhere to demonstrate that speaking up about AIDS is a 

point of pride, not a source of shame. There must be no more sticking heads in the 

sand, no more embarrassment, no more hiding behind a veil of apathy. 

Your leadership must then translate into adequate resources from national budgets. It must mobilize the entire state apparatus, from Ministries of Finance down 

to local governments, from Ministries of Education to Ministries of Defence. And it 

must generate partnerships with every sector of society—business, civil society, and 

people living with HIV/AIDS. 

But leadership comes not only from those who hold positions of power. Leadership 

comes from partners who make sure they always use a condom. Leadership comes 

from fathers, husbands, sons and uncles who support and affirm the rights of 

women. 

Leadership comes from teachers who nurture the dreams and aspirations of girls. 

Leadership comes from doctors, nurses and counsellors who listen and provide care 

without judgement. Leadership comes from the media who bring HIV/AIDS out of 

the shadows, and encourage people to make responsible choices. 

Leadership comes from men working to ensure that other men assume their responsibility—in abstaining from sexual behaviour that puts others at risk. 

Leadership means freeing boys and men from some of the cultural stereotypes and 

expectations that they may be trapped in—such as the belief that men who don’t 

show their wives ‘‘who’s boss at home’’ are not real men; or that coming into manhood means having your sexual initiation with a sex worker when you are 13 years 

old. 

68

Leadership means finding ways to reach out to all groups, and devising approaches for prevention and treatment that are suited to their needs—whether 

young people, sex workers, injecting drug users, or men who have sex with men. 

Leadership means daring to do things differently, because you understand that 

AIDS is a different kind of disease. It stands alone in human experience, and it requires us to stand united against it. 

I am grateful to every one of you for joining me in that mission. Thank you very 

much. 

PREPARED STATEMENT OF THE HONORABLE GREGORY W. MEEKS, A REPRESENTATIVE

IN CONGRESS FROM THE STATE OF NEW YORK

Thank you Mr. Chairman for calling this hearing. With my district housing the 

largest southeast Asian population in the US, I have long thought of that region 

as a second home. 

It is for this reason that I have been so deeply disturbed by the news that the 

AIDS epidemic in Asia could parallel that of Africa’s in the future if more is not 

done now. 

Asia is home to 20% of the HIV/AIDS cases in the world. 1 in 4 new HIV infections in the world occur in Asia, meaning that about 37.8 million people are now 

infected. 

The ease with which technology has allowed population movements between the 

US and Asia and even the entire world, means that AIDS knows no borders and 

is a problem that the world must come together on to find a solution. 

We must find ways to gain wider support from all governments to increase initiatives that would stop the epidemic. 

We must find ways to address the stigma surrounding HIV/AIDS such that persons will no longer have to fear the actual act of being tested or the repercussions 

of a learning that one is HIV positive. 

We must be able to ensure that those that do test positive have access to the newest treatments and we must be able to work together to support companies that 

have the ability to create vaccines, pills, and other treatments that prevent the 

transmittal of HIV. These solutions must be readily available to women and children, who are particularly vulnerable, and for whom because of trafficking, rape, 

and for other reasons, an ABC approach may not always be realistic. 

We must ensure that global solutions are also adequately funded, which is why 

I support full funding of the Global Fund. 

We must simply do more. 

Thank you. 

PREPARED STATEMENT OF THE HONORABLE SHERROD BROWN, A REPRESENTATIVE IN

CONGRESS FROM THE STATE OF OHIO

TB AND HIV/AIDS

I would like to thank the Chairman Leach for holding this hearing today. 

I know that you are very aware of the HIV/AIDS crisis in Asia, and have led in 

making this issue a priority. 

I’m here to talk a bit about the co-infection between tuberculosis and AIDS. For 

the most part, TB doesn’t receive much attention in the United States. Relatively 

few Americans know that TB is a continuing problem in this country, much less a 

severe global health threat. 

Last week, the 15th Annual AIDS Conference was held in Bangkok (I know Dr. 

Gayle you were there an probably others of you). Asia not only has fast growing 

rates of HIV but also the largest number of cases of TB on the planet. 

It is estimated that the majority of people with HIV in Asia will eventually get 

TB and that rates could skyrocket with HIV. 

TB is the number one killer of people with AIDS and can be cured with drugs 

costing just $10 for a full 6 to 8 month treatment. TB treatment can extend AIDS’ 

patients lives from just weeks or a few months to 2–5 years. 

Expanding TB treatment to all those co-infected with TB and HIV treatment 

could extend the lives of hundreds of thousands of people co-infected with TB and 

HIV. 

Also, TB programs provide a model and potentially an infrastructure for delivering ARV treatment. 

69

For example, India’s National TB program has scaled up 40-fold in the last 5 

years and treated 3 million people with TB. This is the kind of scale we need for 

ARV delivery. 

Expanding TB treatment is the number one way to extend and improve lives of 

people living with AIDS right now as we scale up ARVs. 

I believe strongly that expanding TB treatment should be a centerpiece for any 

efforts to adequately address the AIDS pandemic. 

Expanding TB treatment and linking DOTS programs to voluntary counseling and 

testing for HIV will be perhaps the most important way to identify patients with 

AIDS who are candidates for ARVs and I feel that making expanded TB programs 

a priority will accelerate HIV treatment. 

GLOBAL FUND TO FIGHT AIDS, TB AND MALARIA

The Global Fund to Fight AIDS, TB and Malaria (GFATM) is an important funder 

of HIV and TB efforts in Asia. 

However, it faces a funding shortage and indeed may not be able to schedule a 

next round of grants for 2005, unless the US and other donors provide their fair 

shares of funding. 

Postponing new grant rounds will essentially brings the momentum of efforts to 

reverse these killer diseases to a grinding halt. 

Why the funding shortage? Alarmingly, the Bush Administration requested only 

$200 million dollars be allocated as the U.S. share for the Global Fund in 2005—

a 60 percent decrease from what Congress provided in 2004. 

However, the House Foreign Operations Subcommittee, restored funding to last 

year’s level. But we must do more as this will only allow for renewals of existing 

grants and no new grant rounds. 

The Global Fund is a critical complement to the President’s Emergency Plan For 

AIDS Relief (PEPFAR)—especially in terms of Asia, as the President’s plan focuses 

on only one country in the region—Viet Nam. 

HIV AND WOMEN’S HEALTH

HIV is a women’s health issue as well. HIV and reproductive health issues are 

linked. 

For countless women in the developing world, abstinence is not a choice. For 

women who are married, women who are victims of rape, and women forced into 

prostitution in order to feed their children, risk of HIV infection—not abstinence—

is the reality in which they live. 

As governments—including the U.S.—move forward in fighting this epidemic, 

they must recognize that HIV/AIDS is a reproductive health issue. Failure to recognize this link will perpetuate women’s vulnerability to HIV infection. 

Thank you again Mr. Chairman. 

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ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD BY KATHLEEN CRAVERO, PH.D., 

DEPUTY EXECUTIVE DIRECTOR, JOINT UNITED NATIONS PROGRAMME ON HIV/AIDS 

[UNAIDS]


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ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD BY BATES GILL, PH.D., FREEMAN

CHAIR IN CHINA STUDIES, CENTER FOR STRATEGIC AND INTERNATIONAL STUDIES, 

WASHINGTON, DC


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PREPARED STATEMENT OF HELENE D. GAYLE, MD, MPH, DIRECTOR, HIV, TB AND

REPRODUCTIVE HEALTH PROGRAM, BILL & MELINDA GATES FOUNDATION

Mr. Chairman, members of the Committee, 

Let me begin by thanking you for inviting me to appear before the committee. The 

topic of AIDS in Asia is of great concern to the Gates Foundation, and having just 

returned from the International AIDS Conference in Bangkok, I am grateful to be 

able to share my thoughts on this critical subject. 

It was appropriate that this year’s AIDS Conference was held in Thailand. Thailand has been a model of success in the fight against AIDS, in a region that is likely 

to see many millions more HIV infections over the coming years, unless we act boldly to prevent that now. 

The HIV/AIDS epidemic in Asia is growing at a very alarming pace.

• China faces the prospect of 10 million people infected by 2010.

• Infections in India already top 5 million, and the response to AIDS in that 

country is only just beginning.

• Even Thailand, correctly praised by so many as a model for turning around 

its AIDS epidemic, is now seeing infection rates increase due to complacency 

about AIDS and a two-thirds cut to the country’s HIV prevention budget.

• And in many Asian countries with previously low HIV prevalence rates, HIV 

is beginning to move out of high risk groups and into the general population.

We have a window of opportunity now to avert a widespread epidemic in Asia, 

and despite the reports of rancor and division that emanated from the Bangkok conference, I left there feeling that never before have we had such a powerful opportunity to turn back the tide of the pandemic. Resources—on a scale unimaginable 

just a few years ago—are starting to flow from donors and are being directed to lifesaving interventions thanks to PEPFAR, the Global Fund, and the World Bank. 

UNAIDS and the WHO are working together to provide expanded technical assistance and maximize the impact of new programs, and strong and powerful voices—

many from AIDS-effected countries themselves—are emerging to help energize the 

response. The U.S. Congress has played a critical role in this regard, and I want 

to thank and salute this Committee for its efforts to keep AIDS high on the Congress’ and the Administration’s agenda. Please continue to press all of us to do 

more, as much more will be required if we are to succeed. 

Asia is the region that will boldly test our resolve in fighting the global epidemic. 

I want to focus the Committee’s attention on three critical areas in HIV prevention 

that, if aggressively pursued, could avert a widespread epidemic in Asia, and help 

contain the epidemic worldwide:

1) Stemming HIV transmission among populations at highest risk in Asia

2) Ensuring that HIV prevention strategies are developed concurrently with 

anti-retroviral treatment programs as they expand in the developing world

3) Accelerating research into expanding prevention tools such as an HIV vaccine and microbicides. 

I. STEMMING HIV TRANSMISSION AMONG HIGH-RISK GROUPS IN ASIA

There is no single solution—no magic bullet—to prevent the spread of HIV/AIDS. 

The right strategy is one that combines a range of proven approaches to meet the 

needs of populations at risk. We all need to move past false dichotomies about abstinence versus condoms and focus on providing access to the full range of prevention 

interventions that will reduce vulnerability to HIV for all populations at risk. This 

is especially important to consider as more women are becoming infected and a one 

size fits all approach will not meet the need of the growing number of women, including married women, who are at risk. 

In Asia, as in much of the world, the populations at greatest risk for HIV are also 

those that are already marginalized within societies—commercial sex workers and 

their clients, men who have sex with men, and injection drug users. But it is exactly 

those people we will need to reach—very quickly—if we hope to contain the AIDS 

epidemic in Asia. To do so will require far greater resources and fearless leadership 

to fight the stigma associated both with HIV and with the behavior that leads to 

HIV infection. 

Proven HIV prevention strategies 

Many people today equate HIV prevention with providing education messages 

about behavior change. While information and education about abstinence, fidelity 

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1The Global HIV Prevention Working Group is an international panel of nearly 50 AIDS experts co-convened by the Gates Foundation and the Kaiser Family Foundation. The Working 

Group seeks to inform global policy-making, program planning, and donor decisions on HIV prevention, and to advocate for a comprehensive response to HIV/AIDS that integrates prevention 

and care. 

and condoms are the foundation for behavior change, behavior change and reducing 

risk for HIV requires a combination of approaches. 

Proven HIV prevention strategies include:

• Behavior change programs (information, counseling and condom use)

• HIV counseling and testing

• Treatment of sexually transmitted diseases

• Screening of the blood supply

• Harm reduction for injecting drug users

• Infection control in health care settings

• Medications to prevent mother to child transmission

Countries that have been most successful in reducing rates of HIV, such as Uganda and Thailand, have done so by putting in place comprehensive approaches using 

the combination of strategies above. 

It is critical that we expand our definition of HIV prevention to acknowledge these 

extremely effective approaches. 

Access to HIV prevention in Asia 

In Asia, access to HIV prevention interventions is extremely low. As the Global 

HIV Prevention Working Group1 reported last year, in 2002 only a quarter of people 

in need in Asia had access to condoms, just 10% of injection drug users had access 

to harm reduction programs, only 14% had access to STD treatment, less than 6% 

of infected women had access to drugs to prevent mother-to-child transmission of 

HIV, and basic awareness of HIV and how it is spread was extremely low. 

Priorities for HIV prevention in Asia should include:

• Greater resources. Dramatically increase donor government and national government resources for HIV prevention. As the Prevention Working Group reported last year, Asia needs at least $1.9 billion annually for HIV prevention 

by 2005. But in 2002, only $421 million was spent on HIV prevention in the 

region. Resources for prevention must not be taken from treatment programs, 

nor should treatment funding be taken from prevention budgets. The entire 

pie must grow. UNAIDS projects that annual HIV prevention, treatment, and 

care needs will total $12 billion in 2005 and $20 billion in 2007.

• Focus on high-risk populations. Reach high-risk populations to prevent HIV 

from spreading into the general population, with a particular focus on sex 

workers and their clients, injection drug users, and men who have sex with 

men—depending on the groups at highest risk in each country.

• Political leadership. Encourage greater political leadership on HIV/AIDS 

throughout the region to break the stigma of the disease. Every country that 

has successfully contained or reversed its AIDS epidemic has had forceful 

leaders willing to openly address HIV transmission and embrace people living 

with the disease. 

HIV prevention on a large scale—Avahan 

The Gates Foundation is funding what I hope will be a model HIV prevention program in Asia. It’s called Avahan, and it’s the foundation’s large-scale HIV prevention initiative, conducted in partnership with the Indian government, major industries, and NGOs throughout the country. Let me emphasize that the Indian government has been a key partner in this effort, but the challenges it faces are huge. The 

new government has pledged to strengthen the fight against AIDS, but it will require the support of many other parties beyond the Gates Foundation. Although the 

U.S. government through USAID and CDC is involved in fighting HIV/AIDS in 

India, we think the U.S. government could/should play an even larger role at this 

crucial time in the evolution of the HIV epidemic in India. 

The foundation has committed $200 million over 10 years for the program, and 

has granted $126.9 million to date. The initiative is focused on HIV prevention in 

6 states with high HIV prevalence, and along national highways to reach sex workers and truckers who are both highly vulnerable to HIV and have the potential to 

spread HIV throughout the country. 

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Comprehensive HIV prevention initiatives are being launched targeting high-risk 

groups in Tamil Nadu, Maharashtra, Karnataka, Andhra Pradesh, Manipur and 

Nagaland. The state programs are targeting those at greatest risk of infection, including sex workers and their clients, truckers and other mobile populations, injection drug users, and men who have sex with men. 

Interventions being provided include: HIV counseling and testing; behavior 

change information and interventions; condom promotion; diagnosis and treatment 

of sexually transmitted diseases; and harm reduction for injection drug users. 

These efforts are being implemented by Avahan’s grantees—Indian and international NGOs who are working closely with state governments. The Transport Corporation of India and the India Oil Corporation are also partnering to help reach 

truckers with HIV prevention services at rest stops along national highways in 

these states. 

Recognizing that these efforts will only be successful if India simultaneously combats the powerful stigma of HIV, Avahan is also supporting mass media campaigns, 

efforts to train journalists to improve the quantity and quality of media coverage 

on AIDS, and involving leaders from all sectors of Indian society to speak out about 

HIV. 

One such project is a national public education campaign that will engage Indian 

celebrities and popular media to build awareness of the epidemic, fight stigma, and 

establish a national climate for action on AIDS. In addition, the Indian division of 

Star, Asia’s largest satellite network, will provide free air time for 26,000 public 

service messages delivered by leading entertainment and sports celebrities. 

The foundation will be working closely with its Indian partners to monitor the 

success of Avahan grantees, and to share lessons of the program with other countries. 

II. SIMULTANEOUS IMPLEMENTATION OF HIV PREVENTION AND TREATMENT ACTIVITIES

There has been a lot of attention given recently to increasing access to antiretroviral therapy (ART). However, long-term success against HIV/AIDS requires simultaneous expansion of both ART and HIV prevention. Unless the incidence of 

HIV is sharply reduced, HIV treatment will not be able to keep pace with all those 

who will need therapy. For example, while WHO and UNAIDS have established the 

goal of having 3 million people on ART by 2005, 5 million new infections occur every 

year. 

Delivering HIV prevention in health care settings 

Expanding HIV treatment access provides an unprecedented opportunity to simultaneously expand access to HIV prevention. As access to antiretroviral therapy 

grows, millions of people will be drawn into health care settings, providing crucial 

new opportunities to deliver HIV prevention messages and interventions. 

A new report by the Global HIV Prevention Working Group, entitled HIV Prevention in the Era of Expanded Treatment Access, calls for every treatment program 

to have a prevention component, and for HIV prevention counseling and tools to be 

integrated into a wide range of health care settings—including:

• Anti-retroviral treatment sites

• STD treatment clinics

• Reproductive and family planning clinics

• TB clinics

• Hospitals

• Drug treatment facilities

• Prenatal settings

• Prevention of mother-to-child HIV transmission settings 

Adapting HIV prevention messages 

The report also recommends that HIV prevention messages and strategies change 

as treatment access expands. As experience in industrialized countries has shown, 

HIV treatment access—if not accompanied by a parallel HIV prevention strategy—

can alter people’s perception of the risk associated with HIV, and can lead to increases in risk behavior and new infections. 

The report recommends that HIV prevention messages be adapted to stress that 

antiretroviral therapy is not a cure, and that risk reduction remains critical in the 

era of expanded treatment access. Messages should also be adapted to speak to the 

different needs of HIV-positive and HIV-negative people. 

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Expanding access to HIV testing 

HIV testing rates will need to dramatically increase in order to provide treatment 

to all those who need it. It is estimated that 90% of people with HIV in the developing world are unaware of their infection. 

Expanding access to HIV testing will greatly enhance opportunities for both treatment provision and prevention counseling. The Prevention Working Group report 

recommends that, in settings where there is access to HIV treatment, HIV testing 

and counseling should be universally offered in all health care settings—from hospitals to STD and TB clinics to prenatal care settings. However, individuals must 

always have the opportunity to opt out of testing; mandatory HIV testing is not an 

effective public health strategy, nor is it ethical. 

III. ACCELERATING RESEARCH TO EXPAND PREVENTION TOOLS

While increasing access to existing HIV prevention strategies is critical, the best 

long-term hope for bringing the global AIDS epidemic under control is an effective 

HIV vaccine. 

More than 20 years since the discovery of HIV, however, only one vaccine candidate has completed Phase III efficacy trials, and it was shown to be ineffective. 

The Gates Foundation has co-convened the Global HIV Vaccine Enterprise to accelerate R&D on HIV vaccines by bringing new collaboration, resources, and strategic focus to the field. 

The Enterprise is an alliance of independent organizations committed to accelerating the development of a preventive vaccine for HIV/AIDS, and involves government research agencies in both developed and developing countries, private industry, non-governmental organizations, and private foundations. The Enterprise is in 

the process of developing a strategic scientific plan to guide and accelerate HIV vaccine research. 

The Gates Foundation welcomes and appreciates the recent endorsement by the 

G–8 of the Enterprise’s objectives, and the announcement by the United States of 

an additional $15 million for HIV vaccine research. The foundation looks forward 

to working with the United States and other governments over the coming year to 

encourage their continued and increased support of HIV vaccine research. 

Significant progress has already been made in implementing the vision of the 

Global HIV Vaccine Enterprise. The Enterprise has established six working groups 

involving more than 120 experts from 15 countries to analyze critical scientific and 

logistical challenges in the following areas: vaccine discovery, product development 

and manufacturing, laboratory standardization, clinical trials capacity, regulatory 

issues, and intellectual property issues. 

The analyses from the Working Groups are being used as the basis for developing 

a comprehensive strategic scientific plan to guide the HIV vaccine field. That plan 

will be finalized and released in the fall of 2004. 

In addition, important research continues to advance on a number of other prevention technologies and strategies. Foremost among them is the development of a 

microbicide, which could markedly improve a woman’s ability to control her exposure to HIV. Research is also ongoing to look at reducing HIV transmission by treating genital herpes, male circumcision, female barrier methods such as female 

condoms and diaphragms, and preventive use of antiretroviral drugs. All of these 

show promise for expanding options for reducing HIV transmission. 

In sum, the challenges ahead are enormous, but there is real reason to feel hopeful that they are not insurmountable. With the advent of expanded access to treatment, comes a real opportunity to stop the potential tidal wave of AIDS in Asia. 

The U.S. has played an important role in this effort to date, but even greater U.S. 

engagement on this issue—particularly with India and China—could prove decisive 

in helping those governments take the actions they must both to scale-up treatment 

and accelerate access to prevention.

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