Fogarty AIDS International Training and Research Program
The Lifespan/Tufts/ Brown Center for AIDS Research (CFAR) supports
the training of clinical, laboratory, and public health researchers
from East Asia to slow down HIV spread for more than a decade, through
a direct collaboration with the NIH-funded Fogarty AIDS International
Research and Training Program (AITRP) at Brown University. This
program is administered by the International Health Institute at
Brown. Kenneth H. Mayer, MD, Prevention Sciences Core Director of
the CFAR is director of the AITRP program. Tufts University School
of Medicine is an affiliate of this program with Sherwood Gorbach,
MD on the AITRP's
Executive Committee. CFAR Director Dr. Charles CJ Carpenter is also
a member of the Executive Committee.
Geographically focused in South and Southeast Asia, the Brown AITRP
program sites are
India:
Several Brown medical trainees had prior ties to Tamil Nadu,
which led to the increasingly productive collaborations between
Brown and an NGO in Chennai, YRGCare (see below), in community-based
AIDS research. India is one of the most densely populated countries
in Asia with 960 million people. It faces enormous public health
problems including a high prevalence of diarrheal disease, tuberculosis,
malaria, hepatitis, and sexually transmitted diseases. In India,
recognized HIV infection rates, at under 1% of the total adult
population, are still low in comparison to many countries. Surveillance
is fragmentary, but it is now estimated that about 5 million people
in India are living with HIV. This makes India the country with
the largest number of HIV-infected people in the world (2). A
rise of just 0.1% prevalence among adults in India would add over
half a million people to the national total of adults living with
HIV. In addition, a majority of hospitals are reported either
to turn away HIV-infected patients or to serve their needs inadequately.
In a study of discrimination in the health system many health
workers said that treating patients with HIV was a waste of time
and money because the patients would go on to die anyway. Interestingly,
they did not express similar views about other chronic or fatal
diseases that strike young adults.
The available results show that the prevalence of HIV among women
attending antenatal clinics has gone up from 2.5% (1994) to 4.3%
(1997) in Mumbai, the major metropolitan city in the Western part
of India. Another city from south India (Pondicherry) also showed
4% prevalence among the antenatal women in 1996. Prevalence of
HIV among STD patients for 1996 was 17% and 31% (33% in 1997)
in Chennai and Mumbai. Monitoring different components of STD
control can also provide information on HIV prevention within
India. In Mumbai, as of March 31, 1998, 5204 persons have been
diagnosed as having AIDS of which over 21% are women. Probable
source of infection in this area of India is: 74.7% through sex;
7.3% through injecting drug users; 7.0% through blood transfusion;10.9%
others.
Because of the high rate of heterosexual transmission of HIV
in India, special effort is being made in India to focus research
and training on vertical transmission, prevention, and assessing
knowledge, attitudes, and behaviors. For example, a research project
following the Thai model where short course antiretroviral therapy
given to pregnant women during the two weeks prior to and during
labor was shown to successfully cut the rate of vertical transmission
by half, is currently underway in India to see if the same rates
of prevention of vertical transmission can be achieved. Because
the Thai women were also given safe alternatives to breast milk
and did not breastfeed, the short course of treatment was able
to cut overall mother-to-child transmission in the study population
to 9%, compared with a norm in developing countries of up to 35%.
Our India project follows this model.
In India, from 5-12% of all HIV infections are estimated to have
occurred through contaminated blood. Half of all blood banked
is acquired from professional sellers. Since 1989, the Government
of India has passed laws mandating the screening of all donated
blood for TTIs. However, as of 1996, it was estimated that only
50% of the donated blood in India was properly screened. Studies
have shown that 10% of paid donors are HIV positive. Seroprevalence
surveys of blood donors showed the following rates of HIV infection:
0.92% Mumbai (Bombay); 0.2% Chennai (Madras); 0.31% Vellore; 0.2%
New Delhi (voluntary) and 0.1% New Delhi (paid). There are numerous
commercial blood banks in major cities throughout India which
rely on professional donors. A ban on paid donations has been
in effect since 1997, but it has not yet stopped the practice.
About 40-50% of donated blood in India is used to correct nutritional
anemia. It is clear that while not a dominant source of HIV infection,
the blood supply in India is clearly threatened with high rates
of contamination by HIV, HCV, and other TTIs.
Brown/YRGCare have undertaken a vaginal microbicide acceptability
study that aims to 1) evaluate women's attitudes, knowledge, beliefs
and acceptance of vaginal products, and 2) study men's attitudes
and preferences regarding topical microbicides and other vaginal
products. This study will improve the capacity of YRGCare to undertake
further behavioral research studies and become a site for the
enrollment of women and men in future microbicide studies. Brown
University, in conjunction with Fenway Community Health, has applied
with YRGCare to participate in the NIH's HIV Prevention Trials
Network (HPTN), which would create an international network for
performance of large scale microbicide efficacy interventions
and other prevention trials.
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Cambodia:
A Brown faculty member, Dr. David Pugatch, first worked in Cambodia
to deal with the aftermath of the "killing fields,"
subsequently married to a Cambodian nurse, and has spearheaded
our Fogarty collaborations in Cambodia. UNAIDS has reported that
Cambodia is experiencing one of the highest HIV-1 rates among
Southeast Asian countries (3,4,5). In Cambodia,1 in 30 pregnant
women, 1 in 16 soldiers and policemen, and nearly 1 in 2 sex workers
tested positive in sentinel HIV surveillance. HIV-1 is spread
predominantly by heterosexual contact. Although a flourishing
commercial sex industry has fueled the epidemic, HIV infection
and other sexually transmitted diseases (STDs) in women have been
disseminated into the more general population of childbearing
women (4). HIV prevalence among pregnant women in 1998 exceeded
2% in 12 out of the country's 19 provinces. Nationwide, on average,
some 3.7% of married women of reproductive age were living with
HIV in 1998. Prevalence in men may be somewhat higher-4.5% of
male blood donors were infected with HIV compared with 2.5% of
female donors. A 1997 UNAIDS-sponsored serosurvey of pregnant
women attending antenatal clinics in Cambodia reported that for
the 21 sites surveyed, median HIV-1 prevalence was 2.9% (range
0.5%- 19.5%). (3) This survey reported that 2.9% of pregnant women
attending an antenatal clinic in Sihanoukville were infected with
HIV-1. These data demonstrate high rates of HIV-1 infection among
women of childbearing age in Cambodia.
Due to the high rates of HIV-1 infection among women in Cambodia,
UNAIDS included Cambodia in 1999, as one of eleven countries to
participate in a pilot program broadly designed to develop public
health strategies for the prevention of mother to child transmission
of HIV-1(6). It is stressed that these strategies will need to
conform to the particular needs and infrastructure of each country.
In keeping with these goals, HIV-1 seroprevalence surveys are
needed in obstetrical hospital settings where future antiretroviral
mother to child transmission interventions are likely to be carried
out. Studies slated for Cambodia include: seroprevalence of HIV
among pregnant women in Sihanoukville and two projects. One examining
the etiology of chronic diarrhea in HIV-infected patients admitted
to PBNSH and another on the spectrum of opportunistic infections
among hospitalized AIDS patients in Phnom Penh.
It is estimated that 3.5% of blood donors in Phnom Penh are HIV
infected. Blood banks seek out persons willing to donate for money.
Paid blood donors are common despite a law against it. A pint
of blood sells for between USD $50 and $200, which is several
times more than the average monthly salary. Many Cambodian PBDs
are commercial sex workers and/or injection drug users. According
to the National Blood Transfusion Center in Phnom Penh, paid donors
are 10 times more likely to be infected with HIV, syphilis, and
other STDs. About 6.5% of blood donations at the Center test positive
for HIV. About 30% of the donors were paid at the Center due to
a severe lack of voluntary donors. Since 1996, paid donors have
been officially banned. Since 1990, donated blood has been routinely
screened for HIV at both the national and provincial level. However,
Cambodia is one of the most HIV-affected countries in southeast
Asia and the blood supply is therefore still at risk for contamination.
Better donor screening is urgently needed. Often, in spite of
regulations, blood is so desperately needed that unsuitable donors
are accepted.
HIV testing among sex workers in the Philippines has been conducted
since 1986. No evidence of HIV infection was found in the Manila
area until 1992. In 1994, 0.3 percent of sex workers tested in
Manila were HIV positive. Outside of Manila, HIV testing of sex
workers has also been conducted since 1986. Median prevalence
among the various sites has remained at 0% through 1994 (1).
HIV infection may be less prevalent in the Philippines than in
many other parts of Southeast Asia, because of well-designed and
carefully-focussed prevention programs that have managed to arrest
HIV trends (1). The interventions currently in place in the Philippines
through funding from the World AIDS Foundation and the Fogarty
AIDS International Training and Research Program work simultaneously
on many levels. They increase the knowledge of HIV and create
an environment where safer sexual or drug-taking behaviors can
be discussed and acted upon, provide services such as HIV testing
and treatment for other sexually transmitted diseases (which if
left untreated greatly magnify the risk of HIV transmission),
and help people acquire the skills they need to protect themselves
and their partners.
It is estimated that 2.1% of AIDS cases in the Philippines are
attributable to contaminated blood. However, a recent survey showed
no HIV infection among donors, while HBV, HCV, and syphilis were
evident. A study commissioned by USAID concluded that only about
half the blood banks in the Philippines were capable of HIV testing,
even though government regulation requires all donated blood be
screened for HIV, syphilis, HBV, and malaria. Professional blood
donors are a significant source of the blood supply.
Our studies in the Philippines have focussed on prevention efforts
including vertical transmission. Studies underway include studies
on 1) cervical dysplasia among HIV-seropositive and HIV-seronegative
women; 2) human immunodeficiency virus in plasma and cervicovaginal
secretion in HIV positive Filipino women; 3) prevalence of HIV
infection among pregnant women at the Philippine General Hospital
and HIV among women with STD and pelvic inflammatory disease;
4) knowledge, attitudes, beliefs, and behavior among health care
workers in the care of HIV/AIDS patients; and 5) an evaluation
of the UP Manila/Brown University AIDS Education and Prevention
Program. In addition, we have collected seroprevalence data in
the Manila State Penitentiary and provided counseling for the
women prisoners since they are considered to be at high risk.
Projects that are planned will examine HIV risk taking behaviors
and seroprevalence among substance abusers in Manila and Cebu.
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Bangladesh:
Brown medical trainees from Bangladesh initiated this joint
collaborations (based in Chittigong) several years ago. Bangladesh
has a low prevalence of HIV infection(<1%) in spite of the
fact that it borders two of the most affected regions in Asia,
the Indian State of Assam and northern Burma. A survey of female
sex workers revealed that HIV infection rates ranged between 0
to 15 per 1000 in different sites. Coupled with the findings that
approximately half of all prostitutes in Dhaka have been infected
with syphilis and fewer than 20% of sex workers reported regular
condom use, HIV rates could rise quickly. In addition, some 13%
of sex workers questioned in a behavioral survey said they had
injected drugs and about 25% of single men surveyed said they
have had sex with commercial sex workers. There have been various
hypotheses as to what has protected Bangladesh thus far from an
HIV epidemic, including the idea that the predominantly Muslim
culture has a protective benefit. Injection drug use is also low.
Bangladesh estimates that it has 25,000 drug injectors who share
needles and syringes daily. While HIV prevalence in this group
is relatively low for the moment, about 2.5 per 1000 in Chittagong,
the virus is bound to spread rapidly unless needle exchange programs
and other prevention measures are urgently undertaken (1).
Because of the stigma associated with HIV, blinded seroprevalence
studies are currently being conducted at the STD clinic in the
Chittagong Medical Hospital. Along with this, blinded chart data
is being collected.
Like India, blood banks rely on donations from professional blood
donors. A recent study of PBDs and blood donation staff in Dhaka
and five other cities yielded some alarming results. The level
of knowledge of HIV and other TTIs was very low among blood donation
staff. They were unaware of safe blood handling guidelines. Donated
blood was rarely screened for any TTIs. Donors were not screened
for high-risk behaviors. The majority of PBDs interviewed were
illiterate and had never heard of HIV/AIDS. Over 30% reported
a history of penile ulcer or urethritis. Close to 60% had a history
of jaundice. A significant portion knew they carried syphilis
and/or hepatitis B when they donated. More than 75% reported multiple
contacts with commercial sex workers. The blood supply of Bangladesh
is clearly at high risk for contamination with multiple TTIs.
Paid donors are a mainstay for the blood banking system. The country
is also host to more than 1.5 million migrant workers from countries
with epidemic rates of HIV infection. The level of education among
staff at blood donation centers is alarmingly low. These factors
could easily create a situation where transfusion becomes a significant
source of infection with HIV, HCV, and other TTIs.
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Indonesia:
Brown faculty first started biomedical collaborations with Gadjah
Mada University more than a decade ago, initially focusing on
child nutrition, and subsequently encompassing AIDS research.
HIV prevalence appears to be low in Indonesia. HIV testing of
sex workers has been conducted in numerous sites outside of Jakarta.
In 1995-96 in 24 sites, no evidence of HIV infection among sex
workers was found and as of January 1997, the Indonesian Ministry
of Health reported only 509 cases of HIV/AIDS. However, 0.3 percent
of the military tested in 1992-93 were found to be HIV positive
(9). Though the growth of HIV infection so far appears to be slow,
some estimates predict that these numbers are far off because
nearly all Indonesians who have been reported to have HIV/AIDS
have been individuals who were in the late symptomatic stage of
the disease and who were seeking care for opportunistic infections
(10,11). Very few asymptomatic HIV infections have been uncovered
through community based surveillance of high risk groups (11).
A study conducted by the Brown Fogarty program found that female
sex workers in Jakarta are at high risk for HIV infection given
the prevalence of other STDs and limited knowledge of HIV/AIDS
(12). STD prevalence in this group was; 31% trichomoniasis; 15%
gonorrhea; 6% syphilis; and 6% chlamydia (12). AIDS cases attributed
to receiving contaminated blood are estimated at 4.1%, however
recent serosurveys of blood donors in Indonesia yielded a zero
rate of HIV infection. Since 1992, of the 2, 465,000 bags of donated
blood tested for HIV by the Indonesian Red Cross, 39 bags were
found to be infected.
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For more information on any of these international programs, please
contact,
Eileen Caffrey, by email at ECaffrey@Lifespan.org.
For additional information on the Fogarty AIDS International Training
and Research Program, you may access this web link:
http://www.lifespan.org/tmh/services/aids/fogarty_aitrp/
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