peripheries

INTERMEZZO: Understandind HIV/AIDS Surveillance Data in the US

Blogging has slowed down due to an increased work overload. Today,  this intermezzo is provided courtesy of Kaiser Network

In this narrated slide tutorial, Jen Kates, M.A., M.P.A., vice president and director of HIV policy at the Kaiser Family Foundation, defines basic surveillance terms and explains the federal and states’ role in surveillance of the U.S. epidemic. The tutorial also features a guide to reading a surveillance report from the Centers for Disease Control and Prevention and explains the various data contained in the report.

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Under the tip of the iceberg: prevention amongst MSM in Asia (2006)

This piece was written in September 2006. The AIDS conference it mentionned was the one before that of 2008 where vulnerable groups where at last put under the spotlights. Names, places and minor details have been modified to protect people’s privacy.

Bedtime story

Wat, my neighbour has a new lodger, a 35-year old Thai from a village near Kantchanabury named Keaw. Keaw left his town 3 weeks ago ro come to Bangkok looking for a job. His dream job is to be a driver but he does not have the money needed for the deposit to buy a car. Wat met Keaw at his restaurant when he applied for a job as a waiter. Wat told him to come the next day for a trial. When Wat asked him where he was sleeping, Keaw answered in a temple two hours from central Bangkok, but tonight he will sleep outside Hualompong railway station. Wat offered him to stay in his room for the night. That’s where I met him and heard his story.

Keaw has done all kind of jobs. He worked as a barman, a driver, an electrician, a handyman and was even a monk for several years. He recently left his home town hoping to find a job away from a demanding family whilst still being able to send them money regularly.

Keaw happily talks about his life. He told me that he only found out recently that he prefers men to women and was able to put a name on it: gay. Keaw feels more conformable in the company of men like him than surrounded by straight people. He is not coming out; he is defining himself in a moving and evolving society. He has had mixed experiences with men. Years ago, when 18 and working as a barman in Pattaya, he was abused, not to say raped, by the foreigner who owned the place. But still, he had a “farang man” later “a nice man from Europe” but who has since died.

The following day, his assessment goes well and he is happy to be given a chance to work but he worries because he does not have much money and does not know how if he will be able to get a pair of black trouser and a pair of shoes for the job. We told him not to worry and while we are having lunch, I give 1000 Baht to Wat and tell him to lend it to Keaw. It’s not charity, it’s micro credit or “tambun” or simply giving a chance to someone if you can afford it.

I don’t worry too much about his future now that he has a job in a gay-friendly restaurant. On the day he applied to work in the restaurant a customer invited him for diner and the following day, another customer hearing that he had no money gave him 300 Baht and asked him to come later to his room to give him a massage.

When I met him again two days later he told me that his evening did not go as expected with the first customer who wanted him to play a sexual role that was not his but he nevertheless spent the night with him. His second customer, who suggested a massage, only had dollars, “mai bpen rai”, they will meet again. He still got 300 Baht that he has already sent to his family. Life goes on…

Beneath the tip of the iceberg

This might be a story with a happy ending but it is more an everyday story with a potential for an unhappy ending. Keaw is one of many men-who-have-Sex-with-men (MSM) who escape surveys and statistics. Keaw does not go to parks, he does not go to saunas, he does not use the internet and he does not frequent the trendy Silom Soi 4. In a country were the latest survey reveals a HIV prevalence of more than 28% amongst MSM, what does Keaw know about HIV and AIDS?

How many men like Keaw are out there, beneath the tip of the iceberg, a world away from information and prevention campaigns about HIV and AIDS? In the urbanized slum of Phra Pha Beng Toy a 25-years old factory worker from Buriram buys sex from straight Thai boys with whisky. In a shopping complex off Silom, Ton from Sukhotai waits all day chatting up foreigners hoping someone will take care of him for the day. Outside a business tower, Eek an office worker spends his lunch break looking for possible encounters in the public toilet of the complex. At 9 PM in the bookstore of a famous shopping mall, Wit disingenuously flicks through a magazine waiting for someone to have some “fun” with. Keaw, Toy, Ton, Eek, Wit and many others rarely see the glossy information leaflets and condom packs given by community workers. They hardly see a community worker in their everyday lives. They are the invisible ones; the one most at risk to contract HIV.

Time for a rethink

The segmentation of the MSM population is often quoted as an explanation why it is so difficult to reach MSM. Then stigma, discrimination and lack of political will contribute equally if not more to the lack of appropriate prevention message and the poor penetration of prevention campaigns.

A few courageous political figures prepared to challenge the social and cultural establishment, a politically trained grass root movement that could act as a pressure group and a proper understanding and acknowledgement of same-sex male interactions could change this.

Thailand has already a strong and outspoken political figure in Mechai Viravaidya; more are needed. But what is missing in Thailand and in Asia is vocal grass root MSM organisations, committed politically and socially to fight stigma and challenge discrimination. NGOs could extend their support to MSM organisations from public health initiatives to providing them with political training and lobbying skills. Engaging in initiatives aiming at developing a political consciousness amongst MSM should be part of community based organisations’ capacity building.

Only understanding and acknowledging that MSM are not a group of people that can easily be singled out, that MSM are everywhere and from every walk of life can overcome the segmentation issue. As a consequence, the need for multiple piecemeal actions targeting individual groups will become ancillary to interventions at the national level. The political will to make prevention campaign a national issue could ensure that all receive proper and relevant information. Neighbouring Cambodia is paving the way with huge billboards advertise condoms on the roadside.

The XVIth International AIDS conference in Toronto brought back prevention to the frontline of the fight against HIV and AIDS. In Asia, it will be crucial not to forget the MSM populations and give them the means and power to fight a growing epidemic that will have rippling repercussions on the general population unless bold actions are taken.

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The Lobbyist versus the people

Or the case of Thailand compulsory licensing vs. right wing pharmaceutical lobbyists

This article was written in May 2007, revised in June 2007 and minor edits were made on 17/11/08. I decided to republish it after my attention was drawn by the Wisdom of Whores to a recent opinion piece written by Roger Bate for the New York Times. In his latest article for the NYT, Bate conflates generic and counterfeit medicine finding another occasion to held high the flag of a sometimes unscrupulous pharmaceutical industry. The text below is a rather vitriolic piece that is however well referenced and documented. Access to life saving medicine is an issue I have at heart and I am afraid I have little tolerance for fantasy or corporate interests when it comes to saving life.

On 19 September 2006, the Royal Thai Army staged a coup against the government of caretaker Prime Minister Thaksin Shinawatra. Soon after, in November, the Thai Ministry of Public Health Mongkol Na Songkhla issued a compulsory license (CL) for the first-line Aids-fighting drug Efavirenz (Sustiva/Stocrin) manufactured by Merck, sparking a row that turned in to a war when in January compulsory licenses were issues for the heart disease drug Plavix, made by Bristol-Myers Squibb and Sanofi-Aventis, and Kaletra (Aluvia) a heat-stable HIV protease inhibitor made by Abbott Laboratories.

In February, Merck agreed to lower the price for Efavirenz to 700 baht per bottle from the pre-compulsory licence price of 1,400 baht. In contrast, Abbott Laboratories opted for a punitive reaction and withdrew its applications to market new drugs in Thailand. The rippling effect of Thailand’s CL soon propagated across the developing world. In May 2007, Brazilian President Luiz Inacio Lula da Silva signed a decree to issue a CL for Efavirenz and Brazil was promptly accused of an “IP opportunism” that threatens the US private property rights.

Back in 2006, the Intellectual Property war machine of the US Pharmaceutical industry was swiftly set in motion and a huge propaganda campaign started against Thailand’s decision to use the provisions contained in the international Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement signed at Doha in 2001.

One of the advocates of the Pharmaceutical Industry is Roger Bate, a resident fellow at the American Enterprise Institute (AEI). According to his bio at the AEI, “Economist Roger Bate researches U.S. and international aid policy in Africa and the developing world, evaluating the performance and effectiveness of USAID, the World Bank, the Millennium Challenge Corporation, NGOs, as well as other aid organizations and development policy initiatives.”

Roger Bate is a distinguished academics who holds a Ph.D. in economics and an M.Phil. in land economy from the University of Cambridge (UK), an M.Sc. in environmental and resource management from the University College, London University (UK) and a B.A. in economics from the Thames Valley University (UK).

Roger Bate has been a vocal if not vociferous contributor to the dispute opposing the US pharmaceutical giant Abbott and the Thai military-led government. He published a series of opinions, articles and reports both for the AEI, in the mainstream media and for online publications, disapproving of and condemning the Thai decision to use the TRIPS provisions.

With such academic credential, one could hardly be tempted to question Roger Bate professional integrity and expertise. But on a closer look it happens that his support of the pharmaceutical industry is often rooted in half truth, misinformation, bias and sometimes plain lies.

A brief Internet search on the American Enterprise Institute reveals that the AEI is an influential, pro-business right-wing think tank founded in 1943 by Lewis H. Brown. It is funded by one of the world’s largest oil companies (ExxonMobil) and has close links with the Bush Administration.

In February 2007, the London based newspaper The Guardian revealed that scientists and economists have been offered $10,000 each by the AEI to undermine a major climate change report due to be published by the UN’s Intergovernmental Panel on Climate Change (IPCC). The AEI sent letters offering payments for articles emphasising the shortcomings of the report. Such practices shed light on what kind of “Think Tank” the AEI is.

A review of the articles written by Roger Bate on the issue of compulsory licensing reveals a regular pattern that is epitomised in The Cost of Cheap Drugs, published on June 1, 2007. Right from the start, Roger Bate showed his ability to report well documented events with inaccuracy and questionable innuendo.

“In September 2006 the former Thai government was overthrown in a largely bloodless military coup”, wrote Bate in the opening line of The Cost of Cheap Drugs of a coup that was totally bloodless. Thailand has lived through numerous coups in the last 70 years and the purpose of such innuendo is unclear if it wasn’t to question the legitimacy of a decision taken in the interest of the public by a military junta. But lest we forget, Thailand successful fight against HIV was initiated whilst a similar junta was in charge of the country in the 90s and later lost steam under the Thaksin administration.

Roger Bate often indulges in partial and biased reporting for instance when emphasizing the reaction of Dr Margaret Chan, the director of the WHO, who, he wrote “…was shocked by Thailand’s move. Back in February, when she visited Thailand, she cautioned against such hasty action.” But at the World Health Organization’s annual summit in Geneva (14-23 May 2007) where intellectual property issues were prominent a resolution on “Public Health, Innovation and Intellectual Property” was adopted in plenary session of the 60th World Health Assembly encouraging the WHO Director-General to guide the process to draw up a global strategy to remedy the problem of IP, R&D and costs of drugs and to provide technical and policy support to developing countries for that purpose. In other words to provide support to the developing world to use and apply the TRIPS Agreements.

In her closing remark the allegedly “shocked” Dr. Chan commented that she was “fully committed to this process and have noted [the WHO member’s] desire to move forward faster.” She added that “We must make a tremendous effort. We know our incentive: the prevention of large numbers of needless deaths and suffering.”

Roger Bate also often refers to the corruption pervading the Thai Government Pharmaceutical Organisation (GPO, manufacturer of the GPO-vir) quoting “Mr Jaruvan Maintake”, Auditor General at the Constitutional Court of Thailand (whose appointment to this position had been the object of a controversy). (Note : Bate most likely wanted to refer to Mrs Jaruvan Maintaka, a women whose patronym is Maintaka, but he can be excused for the difficulty to transliterate Thai names and for being unfamiliar with Thai first name even though he writes a lot about Thailand.)

Further disinformation followed when Roger Bate recalled “a 2005 study by Thailand’s Mahidol University’s faculty of medicine [that] found at least 40% and up to 59% resistance in the 300 patients investigated.” Roger Bate teamed up with another Right Wing lobbyist group USA for Innovation who ran a libelous advert in the Bangkok Post earlier in 2007. USA for Innovation executive director is Ken Adelman, who also works for Edelman Public Relations Worldwide, which counts Abbott Laboratories as one of its biggest clients. Bate and Adelman were later contradicted by Wasun Chantratita, chief of Mahidol University’s virology and molecular microbiology unit, who said in the Thai newspaper The Bagkok Post (May 12, 2007) that, “the advert that cited his study was only half-true. He said the study on drug resistance was conducted in 2000 _ two years before GPO-VIR even existed. It focused on three individual original drugs _ Nevirapine, Lamivudine (3Tc) and Stavudine (d4T) _ not GPO-VIR. GPO started to produce GPO-VIR, which combines Nevirapine, Lamivudine and Stavudine, in 2002.” Then the GPO was seeking criminal-defamation action against USA for Innovation and was seeking 1bn Baht in compensation.

Bate often insists that, “even the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has arguably shown enormous tolerance of the GPO, finally withdrew financial support last August”. Little mattered that the World Bank was planning to provide Thailand with a $750,000 three-year grant aimed at providing HIV-positive people with increased access to antiretroviral drugs and help address funding issues associated with the country’s universal health care system, as well as providing training for nurses and doctors in an effort to overcome the shortage of health care personnel in the country (The Nation, February 6, 2007). (Note: See here for an update on the global Fund position towards Thailand)

But again, Bate expressed his concerns that “cheaper drugs do not make cheaper healthcare if they don’t work properly.” Of course, as pointed out by Daniel Ten Kate in the Asia Sentinel (May 10, 2007), “USA for Innovation and other propaganda groups will never cite an August 2006 World Bank study that calls for Thailand to resist Big Pharma and use compulsory licensing to reduce HIV/AIDS drug costs by up to $3.2 billion by 2025. It also won’t refer to letters of support sent to the Thai government from the World Health Organization, UNAIDS and countless NGOs, including the Clinton Foundation headed by former President Bill Clinton.”

The picture would not be complete if Bate had refrained from nursing the myth that “World Trade Organization rules have made compulsory licenses available to poor countries suffering an epidemic. But Thailand is a middle income country, and, while a case may be made for HIV, heart disease, cholesterol and leukemia are not epidemics.” This ignores the assessment made by the Associate Director of Washington College of Law’s Program on Information Justice and Intellectual Property (PIJIP) which concluded that “Thailand’s issuance of compulsory licenses for three patented medicines is legal under domestic laws and complies with WTO rules, and Abbott’s decision to withhold its new products from the Thai population violates Thai antitrust laws” but also ignores that in its 2007 Special 301 Report the “United States acknowledges a country’s ability to issue such licenses in accordance with WTO rules”.

Bate should also well know that compulsory licenses issued under the TRIPS agreement are not limited to poor countries or situation of medical emergency since the USA have been using the same TRIPS agreements for their benefit in situation hardly close to medical emergencies ranging from patent related to the Blackberry device to Toyota hybrid transmissions and material used in F-22 fighter jets. Indeed the TRIPS agreement clearly states that each member is free to determine the grounds upon which such licenses are granted.

One can only expressed bewilderment with a lobbyist’s ability to broadcast so many inconsistencies, inaccuracies, biased and one-sided reporting, and fallacies in less than 800 words. Lacks of integrity and professionalism, partisanship, or genuine professional incompetence are the choices left to the readers. One is justified having reservations about the credibility of such lobbyist to contribute meaningfully and honestly to such an important debate.

Many other are perpetuating the same myths, printing the same fallacies and misleading the public, including Bibek Debroy, a professional economist, Secretary-General of the PHD Chamber of Commerce and Industry, India, and former consultant to India’s Ministry of Finance (Obsession with lower cost leads to deadly mistake, The Bangkok Post, December 6, 2006), Philip Stevens, director of the health programme at the International Policy Network, a corporate-funded, London-based development think tank (Licensing policy fatal for HIV/Aids sufferers, The Nation, February 14, 2007), USA for innovation, the Baker & McKenzie law firm (Compulsory drug licenses violate world trade treaty, The Bangkok Post, April 23, 2007), some serious news outlets such as the Wall Street Journal, the Financial Times and some less scrupulous professional who do not check their facts.

That these people and interest groups wish to support the Pharmaceutical industry is their right, but that they do so with lies, misrepresentation and misinformation is not acceptable.

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Thailand’s ladyboys: nearly human?

Miss Pink Competition 2006 © peripheries

In an article strangely entitled “Thailand’s lady-boys are in a class of their own, at last”, The Independent reports on the Bangkok Suan Dusit University where young male transgenders are allowed to wear make up and female uniform. It is this “at last” that is rather strange.

There is no question that Thai ladyboys deserve to be treated like any other human beings within the Thai society. In this regard Thailand is much more liberal than most western societies, though this liberalism is very much codified and not has accepting as most foreigners would like to think. But this “at last” suggests that the Suan Dusit university resolved the matter by segregating ladyboys into specific class with special needs and obligations.

I happened to live next to an annex of the Suan Dusit University near the Suan Lum Night Bazaar and to have had lunch with the students at a nearby food market (This annex is now closed). I was first surprised to see male students wearing male trousers as required by the University dress code but also heavy make up, long hair and overtly behaving like women. I got used to it and I guess this is part of the Katoey persona; as noted in the Independent article “If you want to be a woman, act like one”. They were often overdoing it but this was not the always the case as I witnessed during ladyboys’ competition.

As I am not convinced that separate toilets will facilitate the recognition of equal rights for Katoye, I am much more in favour of unisex toilet, I am not convinced that giving Katoye “a class of their own” will end discrimination against them. The evidence is in the comment of the vice-president for student affairs, Pacharee Suankaew: Katoey “can study everything on offer, except education. ‘We can’t have them teaching kindergarten children and they accept that’ and “In return, she says, the students must be ladylike.”

So long as Katoey stay in their well defined Katoey-box, it is all fine. Can this be called equal rights?

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Ageing AIDS - Forgetting Nan and Grandad

Earlier in September, peripheries commented on HIV amongst people over 50 and the importance of not excluding them from VCT on the basis that they were too old.

In this week’s New York Times, Karen Barrow noted that “Today, because of antiretroviral therapy and an array of drugs to treat both symptoms and side effects, AIDS has become a chronic condition to be managed, at least in the developed world. No longer is the face of AIDS emaciated and covered with lesions; Americans with the disease are stronger and healthier, their concerns fading from public view.”

According to the CDC, 29% of people living with AIDS in the U.S. are over 50 and they account for 15% of all new HIV/AIDS diagnosis in 2005. Myron Gold, 67, former fashion designer turned AIDS and gay-rights activist after being diagnoses with HIV aged 42, asked “What about people 65 and older?”, “They’re having unprotected sex, they’re using drugs.”

Nobody wants to hear about grandpa’s sex life and even less about grandma’s sex life. If it is clear that to date the Seniors are not a very attracting category of people to feel for when it comes to HIV, not as interesting as women and children, not as ignored as MSM and not as looked down on as sex workers,  they will nonetheless weight heavily on the health care system when it comes to treatment.

Though the cost of antiretroviral is expected to go down, new molecules as well as second and third line therapy will remain expensive. Treatment of HIV-related diseases will also weight in particularly in undiagnosed population, who will incidentally continue infecting other as they often consider that they are exempt from condom use. HIV also complicates the treatment of other diseases associated with ageing such as cancer.

The burden of treating an ageing but still sexually active population must be factored in the big HIV/AIDS equation before its cost overtakes the medical care system. And lest we forget, it is still time to prevent the next generation to follow in the steps of this generation.

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