HIV/AIDS: The Challenge in Asia
The Citigroup and Asia Society Global Issues Series

David Ho, CEO, Aaron Diamond Research Center (moderator)
Marina Mahathir, President, Malaysian AIDS Council
Mechai Viravaidya, Chairman, Population and Community Development Association
Wan Yan Hai, Director, Beijing AIZHIXING Institute of Health Education

Hong Kong, March 24, 2004

Mr. Ho: It is indeed a great pleasure for me to be here today. I am David Ho, and my co-panellists are here. First, let me thank Asia Society and Citigroup for putting this event together. We will endeavour not to disappoint. Basically I am serving in the capacity of a setup person today. It is my responsibility to provide the introduction and then pass the baton on to the subsequent speakers. After each of the presenters have given his or her speech, there is a video that will be shown to describe the situation of HIV/AIDS in China.

Let me begin by telling you that HIV/AIDS no doubt has come to Asia and it is here in a very prominent way as you will hear. But of course, we have to put this in context. The epidemic has already affected 70 million people throughout the world, cumulatively speaking. About 25 million have died, leaving us with 42 million living with the lethal viral infection.

As this first slide shows you, you could see approximately two out of three infected individuals live in sub-Saharan Africa. Well over a couple million in the Americas, about half a million in Western Europe, and you will also notice that there is a growing problem in Asia. And the epidemic rages on. At every single day, we will add to the total 14,000 new cases, most of them in developing countries, including 2,000 children.

Here is another graphic that will show you the enormity of the problem. Using one example from South Africa, you could see that throughout the decade of the 1990s, HIV infection rate among pregnant women increased steadily, exceeding now 20 or even approaching 25 per cent. And of course, some of these women will pass the virus to their offspring. Even the offspring that escape HIV infection tend to end up as orphans, and already in sub-Saharan Africa, we know that there are over 11 million orphans due to HIV/AIDS.

And here is another very striking statistic: if one is a teenager growing up in the country of Botswana, he or she would have a one in two chance of becoming infected with HIV in his or her lifetime, and the number is only slightly lower for South Africa.

As would be expected by everyone here, life expectancy in the continent is changing very very dramatically, beginning in the late 1980s, and the decrease in life expectancy is almost entirely due to this epidemic. And as you can see, some of the countries would have projected life expectancy of only about forty. So this sort of devastation must be avoided in this part of the world.

Now shifting to Asia , this slide will show you what has been happening since 1980 through 2001. There is no doubt that the infection has arrived and is now widespread throughout this region. By this date there are probably 10 million or more infections in the region and the numbers are rising rapidly. In fact this map will show you the countries in this region that are more severely affected. Today, unfortunately, we do not have a discussion on India, but it must be said that India would account for four or five million of the infections in Asia.

As this slide would indicate, we are going to hear a presentation on Malaysia, a presentation on Thailand, a presentation on China. But I will simply say that Thailand certainly was among the earliest in this region to experience a serious epidemic reaching probably a number around one million for a relatively small country but it has made major advances, which I hope we will hear shortly. But of greatest concern in terms of absolute numbers would be India and China and these two collectively could have anywhere from 25 to 40 million infections by the end of the decade if the current trajectory is allowed to continue.

So, in closing, I would just say that the final presentation will be given by Dr Wong. He will describe the epidemic in China and that will be followed by a video that my colleagues and I have prepared on the same subject to emphasise to this particular audience. So let me end my introduction here and turn the podium over to our first speaker, who is Ms Marina Mahathir, to talk about the situation of HIV/AIDS in Malaysia.

This map shows you the progression of the epidemic from the mid-1980s through 2001 in sub-Saharan Africa. Let me just say that it has devastated the continent. About ten per cent of the African population is infected. There are well over ten or a dozen countries where the prevalence of infection exceeds ten per cent. There are four sub-Saharan, southern African countries where the infection rate exceeds 25 per cent of the adult population and you could just imagine the devastation that follows. HIV/AIDS already is the number one killer in Africa exceeding all the other causes listed on this slide, including the combination of malaria and TB.

Ms. Mahathir: Thank you, Dr Ho. First of all, I would like to thank Asia Society and Citigroup for inviting me to Hong Kong to talk about HIV/AIDS. Some ten years ago, I was invited by Asia Society to the Williamsburg conference as a young Asian leader and at that time I spoke about HIV/AIDS and it was met with polite but lukewarm response. Ten years later, I am not a young Asian leader anymore, but I have two Asia Society AIDS meetings this week, so I guess progress has been made. So thank you very much.

I am here to talk about the situation in Malaysia. It may come as a surprise to many people that a country like Malaysia which is fairly developed, a Muslim country, a small country, should have an HIV/AIDS problem, but unfortunately it does.

Since 1986, we have had HIV/AIDS within our midst and as of July last year, we have about 57,000 reported cases cumulative since 1986. Now this might seem a very small number in a population of about 22 million, but what we are seeing is that every year, we have had more new people infected than the previous year and last year, we had more than 7,000 people and that is more than any other previous year. So it is a cause for worry.

As a way of comparison, if we compare it with a country like Australia, which has a similar size population, their annual increase is about 700. And Malaysia has ten times that in a single year. So those are the types of comparisons which really tell you what sort of situation we are in.

A large part or a large number of those infections occur among drug users. Again, Malaysia is probably well known for its mandatory death penalty for drug trafficking. That has been there for 20, 30 years. But we still have a drug problem. In the past 20 years or so, the link between that problem and HIV/AIDS has been seen to be a very very clear link. It is clear and obvious to almost everyone except those people who work in the anti-drug agencies, as a matter of fact. But there they are in the reported cases – 72 per cent are drug users.

But increasingly, we are seeing people from all groups, particularly women and babies, also becoming infected, and many of these women are in fact the wives and partners of those drug users themselves. As Dr Ho will probably tell you, if we start seeing infections among women and children, it means it is going into the general population. It is no longer confined to what people like to say are "the high risk groups" and therefore it is another cause for worry.

So what have you been doing in Malaysia in the past 20 years? The government has certainly been alert to HIV since 1986. That is why we know it started in 1986 because that is when they started surveillance. In the early days, they also instituted many public education programmes, which in fact were very very frank. They talked about sex in very frank terms, both heterosexual and homosexual sex. They talked about sharing of needles and they talked about condoms. However, for various reasons, those messages have become diffused, become more vague, and the government has become much more restrained about putting them out, which I can explain later why.

As a result, many many Malaysians think that HIV/AIDS is something that does not concern them. It only concerns certain groups of people, such as drug users, such as sex workers, such as gay people, and that is it. This type of stereotyping of HIV/AIDS has been very dangerous. We have any number of shocked young men in our hospitals who cannot understand why they are there with HIV because as they say, "I am not gay, I am not a drug user", but of course they have been exposed to HIV through various behaviours, unsafe behaviours.

Having said that, the government is concerned and supports the training of our doctors to treat HIV/AIDS. Interestingly enough, actually, it has become very interested in treatment issues. After a long time of saying prevention is better than cure, the Malaysian government has now taken on treatment in fighting to bring in cheaper drugs, bring in generic drugs and wanting to provide a large number of people living with HIV/AIDS who meet certain criteria with free treatment. And that is an incredible example for many countries in our region.

They are also very supportive of the NGO sector which works in communities, works at the grassroots level. The umbrella organisation that I head has 37 NGOs, most of whom are small ones, but I work in various communities, both in KL and outside KL. I am doing the real on-the-ground, face-to-face work, and this needs a lot of support and after many many years of begging and pleading, we are now getting a good size annual grant from the government.

The private sector has been rather slow in also taking up the issue. It has been difficult for us NGOs to talk to the private sector because we have not been able to speak the language, so to speak. We need the numbers, as the private sector basically understands numbers and in a situation where HIV/AIDS is still largely invisible, it has been very difficult. If we talk about Africa, what we get back is "well, that is Africa. Malaysia is not Africa." This is a common mistake made in many countries. Khun Mechai will talk about that too.

However, most recently, we have had a godsend in a way, because Standard Chartered – I do not know if they are here – sent Mr Kinnex to Malaysia. He had come from Africa where he saw HIV face on and knew all the issues and immediately started publicly talking about the private sector role in HIV/AIDS and that has really bumped up the visibility of HIV/AIDS in Malaysia and sets a wonderful, wonderful example to the rest of the private sector. As a matter of fact, when I go back, I am giving a talk to the British-Malaysia Chamber of Commerce on the same topic organised actually with the help of Standard Chartered.

So it is coming along, but the hard part is trying to convince Malaysian companies to get interested in a topic that in fact affects Malaysians more than anyone else.

What are the barriers in Malaysia? There are several. There is still a lot of denial. We have commitment at the top. We have in some ways the political will to want to do certain things, but in the mid-levels and in the bureaucracies, we are still facing a form of denial because of the lack of understanding of how HIV is affecting our communities.

There is also – and I do not know, it is probably just an excuse – a worry about doing necessary things such as promoting safe sex, such as doing harm reduction programmes among drug users, doing these things because they might open up fronts for criticism by the political opposition, which, as you may know, has been until a couple of days ago, a very conservative opposition, a conservative religious type opposition. So I am not the only one who is thrilled about the results of the election. We may now actually make progress.

There has also been a lack of multi-sectoral coordination. Despite fine examples from nearby, including Thailand, HIV/AIDS in Malaysia is still parked in the Ministry of Health and it has been difficult to get other sectors of the government interested in it, when in fact, many of the issues that we have to deal with have nothing to do with doctors and hospitals. Who takes care of orphans, for instance? Is that Welfare Department or someone else? Who deals with issues affecting women when they are unable to negotiate for safer sex with their own husbands? That is not really a Ministry of Health problem. It might be some other ministry's problem. We have a Ministry of Women.

This lack of coordination has meant that we are doing piecemeal work rather than having a comprehensive plan on how to tackle the issue and giving a common direction for everyone. Everyone is going in different directions and doing their own thing. But we are hoping that this again will happen very soon, to have a national coordinated response.

The last thing that is a barrier in Malaysia and in many countries round the world is the issue of stigma and discrimination. It is incredible how people still have so many prejudices against HIV and people living with HIV because of those stereotypes, because of the early reports, the early sensationalist reports in the media, and this has incredible effects all over the place.

How do we get people to come in for testing when they think that if they come in, at best they might have some horrible stares from health care workers, or at worst they might actually be arrested? It is very hard. So they are out there. While they are out there, we cannot talk to them about prevention. They have no idea how they can or cannot infect another person and we are not able to control the infections.

When people are afraid that if they get tested, you might tell their bosses and then they are going to lose their jobs, there is no incentive to come in to be tested either.

For women particularly, they stop themselves or they limit their own access to treatment because they are afraid that, even though they are housewiveswho might be infected by their own husbands, if they go into hospitals, people might think they are sex workers. Why would you want to do that? They do not want to go for treatment because they have children who need looking after, and if they need to be hospitalised, who is going to look after them? They might have neighbours who could take of them, but that means having to explain to these neighbours why they have to be hospitalised.

We have a problem with orphans because they are being either left on their own or being cared for by grandparents or aunts, most of whom already have children of their own. They are unwilling to go to the welfare department to ask for support because it means having to explain why their parents died.

Stigma has an insidious effect all over the place and the only way to alleviate that is to increase people's knowledge, factual knowledge, about HIV/AIDS and also to try and dismantle the types of myth or even cultural and religious support for these types of myth.

One of the things that we are very proud of currently working on is that we are working with Islamic religious leaders on HIV/AIDS and training them on the facts about HIV to gain their support and it has been very successful. We are still continuing. And they are now talking to their congregations on the facts about HIV/AIDS and not relying on the types of prejudicial statements that they used to make about who gets HIV and whether AIDS is punishment from God.

I am happy to say at one of the last sessions – Khun Mechai will be happy about this – we had a room full of Islamic religious leaders, men and women taking out condoms from packets and looking at them finally. They had never never seen one and they have been condemning these without ever knowing what they were. And after they did that, they said, "We were afraid of this little rubber thing?" I think I will stop there first. Thank you.

Mr. Mechai: Ladies and gentlemen, firstly let me say that you have booked yourself into the right hotel, because I checked with the staff first. Everywhere I go, if there is anything on AIDS, to see whether the hotel has trained its staff, and this hotel has. But that is only halfway. I hope to see the management after lunch, so if you have alcohol in your mini-bar, you must have condoms. It is very simple. Do not expect the government to do everything for you. Governments are followers, not leaders. I say this with all sincerity and a lot of affection for governments.

So if we have the hotel sector, the entire world coming out and say "Do a Marriott, ... taking the lead" and say "From now on, we will ask every hotel in the world to educate all its staff and we will pass on information to our clients." Imagine how many more people in the world would be enlightened, how many more lives would be saved.

Imagine you have got Nike and the rest who have manufacturing right around the world in this part of the world and Nike and the rest say, "From now on, we insist all our workers, be it in Vietnam, Indonesia, Thailand, China must now be educated in HIV/AIDS." How many lives would that save? We must remember it is enlightened self-interest. Sick staff cannot work, dead customers do not buy. So I hope next time you buy a Big Mac, you get a condom with it.

Talking of condoms, I did bring some condoms from Thailand. In the queuing, I was very careful to give mostly to young people who are students here, because they have more time to learn about it than a lot of the people on this side. At these queueings, we give them out and we sell them for fund-raising. But firstly, let me warn you – and that is why I did not bring too many – because these are Thai size. They are too small for Hong Kong people.

In addition to that, my work began 30 something years ago in the area of family planning, and you have to have political commitment even if they do not know what they are doing. You get help from politicians, so in family planning, I got the help of Sir Winston Churchill, and this is what the t-shirt says, and that is what Winston Churchill was trying to tell the world. Winston is not so prominent in the days of AIDS. However, there are many people in the world who believe in God. Unfortunately, I come from Thailand, and the God that has been assigned by the UN to Thailand is always on holiday. He is probably in Hong Kong.

So we find that we have to help ourselves a lot more, and if you look at the US dollar – and after you have looked at it you can give it to me if you like – you will see that it has a statement on it. But that does not help HIV/AIDS. We believe that this helps HIV/AIDS. It says, if you can’t read it in the back it says, "In rubberwe trust." And this is a very friendly statement to my neighbour, Malaysia.

My point is that you have to educate the public. The more you educate the public, the more you inform the public, the more likely that they are going to learn about every aspect of HIV, be it prevention, or discrimination or treatment or care. Unless we do that, it will not work.

And I have not yet seen many signs around Hong Kong when I arrived about HIV/AIDS. Of course I do not read Chinese, so if there is something I do not see, but I talked to other people. Nobody in the world has that luxury of having done enough, no country, no city in the world. We must all do more. This must be regarded as a battle of soft drinks. Keep on advertising. Keep on promoting. You cannot stop. When you do stop, you begin to see the problems.

I will very briefly I show you what we did in Thailand. But now the government has shown interest in other areas, so public education on HIV/AIDS has come down to the extent that a woman who is a manager in a restaurant in a hotel in Bangkok said to me just two days ago, "Is HIV/AIDS still around?" She thought it was gone, like cholera comes and goes, or like the Americans come and go. That was a very clear indication that we have not done enough. So our fight against HIV/AIDS cannot stop. Public education must go on. Whatever we are doing in terms of care and treatment, that is fine.

You must remember, we now have people who are infected and some have died, let's say condemned to an earlier death. More than twice the number of soldiers in any country that died during the second world war. That is how serious it is. Therefore, it is not a health problem. It is a behavioural issue, a societal issue, development issue. Everyone is to be involved, in particular the leader of that country. Otherwise the leaders of those countries will be known in history of allowing their own citizens to die in larger numbers than all the soldiers that have in human conflict.

So the responsibility is very clear. And we hope more and more leaders take interest in this. And perhaps the next Asia society and Citigroup could invite daughters of leaders from China and India and others to come together in Hong Kong and say, "Hey, if your old man's not doing it, you had better start doing something, because we have seen here already what a daughter can do to the Prime Minister.

Let me very briefly go through some of these things (that we are doing in Thailand). I pressed the button. It's not moving. It must be made in Thailand. I just want to show you a few pictures.

If you remember a fellow called Colin Powell and he has stopped talking about Iraq, Afghanistan. He is talking about AIDS and there is no war more serious. This is the man that Thailand owes a great deal to. He was Prime Minister for a couple of years and he said, "Okay, I will move with HIV/AIDS. We will increase the budget fiftyfold. Every ministry was given money and he became the chairman of national AIDS committee. We even have AIDS education in the zoo. The reason is that because the zoo and our parliament are opposite, and sometimes you take the wrong turn, and you cannot tell the difference. Public information, public education, every form.

In 1991, he (Anand Panyarachun) became Prime Minister and he agreed I was the workhorse and he was the general. Let us go ahead. Every governor was called into Bangkok and he said, "We now have a new policy. No more denial in the dark days. We denied, we had no problem, no problem. In reality the numbers were at least ten times higher than the numbers admitted by the Ministry of Health people".

So any problems, every district, AIDS education all over Thailand. Every policeman, every soldier also, and they helped us a lot when it came to public education. Religious leaders, religious institutions, schools, media. Everyone in media was trained and public information, programmes were given out. Every hour broadcast, it was compulsory for a half a minute of AIDS education. China can do this. It is very voluntary. What we did was we gave them half a minute extra for advertising. Every hour broadcast on the 500 radio stations, half a minute of AIDS education, TV and television and all the producers, newsreaders, newscasters were trained and there was a question and answer.

Every government official was trained to understand HIV/AIDS. How can you expect the public to understand when government officials do not? So this was a very good start – this was government officials. Movie stars were called in to participate and help with HIV positive people, with AIDS safety tips , cards out. Movie producers were asked to come in and we gave you a subsidy if you put HIV/AIDS correctly into your movies and soap operas. China can do this. Bollywood and India can do it. Even Hong Kong can do it. You can save the world with 12 men in Hong Kong. You know something about the condom, something about safe sex. After all, the world is interested in sex. So these were like the baseball cards in America. These were the movie stars that people admired.

We had companies, insurance companies, banks that gave out information to their customers to keep the customers safe and keep on returning to bank with them. Dead customers do not bank. And so gas stations were involved, giving out condoms if you fill up at gas stations. Now we have a bank that has agreed, when you put in your ATM card, message on AIDS and a condom on the side will come out. Fantastic! You do two things at once. You do not have to go to hospital. You do not have to go to chemist's shop.

Also when you go through the – in Bangkok, the World AIDS Conference next July – when you come through immigration, you get your passport stamped, also a condom. Why not? And you will see a lot more can be done. AIDS education in the workplace, every factory, universities, schools, young kids blowing up condoms and there is a school condom-blowing championship.

It is a lifesaver. Condom is a wonderful product. You can use it as balloons, tourniquets for snake bites and deep cuts, lubrication can be used for after-shave lotion, the ring can be used for your hairband and nowadays you can put your mobile telephone in the condom during the rainy season. So very good for Hong Kong because you are always using your mobile. When it rains, put it in the condom, so always have the condom with your mobile phone.

So young kids are blowing up condoms. Throughout Thailand – this was 1991, 1992 – because AIDS was estimated to have four million by the time 2001 came along. But because we took action, it came down to a million. It is a huge number coming down but still a million was a great number because we started very late.

So kids in the villages had information and gave condoms to every household, using kids as agents of change, not just subjects alone. Schools have English learning through AIDS. You had condom (inaudible)4.27.22 programme going through all the sex areas. We make no moral judgements about condom use, saving your lives and premarital sex came down, those visiting commercial sex came down, infections came down, and today, we have one-twelfth of what we used to have in the year 1991, one-twelfth of new infections.

Thanks for that clap, but you will find it may be like England winning the rugby. They have already lost to Ireland and who next? Right now, Thailand is very quiet, in a state of suspended animation. We have to wake up our *current) Prime Minister, come out and talk more about HIV/AIDS, give out condoms by the Prime Minister and the leaders of the world are coming to Bangkok in July for the World AIDS Conference.

So these are the programmes that go on. We have condom-blowing championships, we have Miss Condom like Miss Universe. Imagine having Miss Condom, Hong Kong. Miss Universe only sells perfume, Miss Condom saves lives. So we have these condom nights going all over the place, safe sex darts. You land on so many aspects of unsafe sex they did not know existed. It is fund-raising as well. Three darts for a dollar. And if you land on any disease, you get a condom. You land on "Safe", you get a t-shirt, saving lives.

And then go back to the bars. Get the girls to educate the girls. Taxi-drivers give out condoms. Policemen also help. Stop traffic, give out condoms. These is our cops and rubbers programme. Imagine the quality of life of the Hong Kong police if they also gave out condoms with parking tickets. I really suggested that to the Berlin police because they do not look very happy there. This might improve their quality of life. So anyone can give out condoms. Policemen do it, they stop cars, and sometimes in Bangkok you do not have to stop, it stops naturally. And so we give out condoms. Gas stations give out condoms and the only one that we just started now.

For those living with HIV, we have a loan fund, Micro Credit. You must find yourself a negative, non-positive partner, so a positive person can borrow if you have a negative partner. The job of the negative partner is to change attitude and behaviour of community. So you have two groups working and the rate of return is about 90 per cent, better than most of the fat cat borrowersof Bangkok. No haircuts are needed. They are very honest. Even some of them, if somebody has died, they still want to pay back. So these are the programmes that is going on for HIV positive people.

I have come to the end now. What we need, and here is an Internet café opened by HIV positive people, negative laundry servers. They need an income. They have run out of their savings. They cannot rely on their relatives any more. So you need to add a third element. Prevention, yes, care yes, economic survival of people living with HIV in China, in India, in any country.

This is just what I want to end with. We cannot sit back and expect governments alone to do it. Business sector can take care of quite a large element of society. Take care of your own workers. Take care of your customers.

And then educational institutions. You have got to start young. People at nine know about sex, especially in Hong Kong, maybe not, because you do not see chickens running around anymore, and you are not dogs or cats, but most people do see it. Start young. Do not wait until you have got hairs on your leg. Start before then.

With that, I would like to stop now because I have taken up enough time, but just to say it has to move forward. You do not need just doctors. We need everyone to help. And we need political leadership. We need political commitment and financial commitment. Without political leadership, it is not going to work and I hope China really wakes up and really runs well. Thank you.

Mr. Wan: I am very delighted to talk about the AIDS situation in China. Dr Ho has introduced AIDS epidemic in the world and there will be a video about AIDS in China after my talk. Mechai and Marina has talked a lot about AIDS prevention work, treatment and culture and religious issues, also government leadership. I want to talk about China. I think many of you have read a lot of news reports about the AIDS epidemic, children orphaned and responses from government and from the community. Today I will briefly introduce some recent developments of Chinese government in welcoming AIDS campaign and also the relation between government and the NGO.

Last December, the Premier Wen Jiabao visited Beijing Ditanhospital and talked with patients with AIDS. Wen Jiabao made a very strong commitment about China's government policy towards AIDS treatment, testing, supporting children orphaned and also preventing mother-infant transmission. Wen Jiabao's commitment was described as for free treatment for all patients in rural communities and all poor patients in the cities and free testing, free drugs for the preventing of mother-infant transmission and also education for children whose parents died of AIDS.

After the visit to Beijing Ditanhospital, Deputy Premier Wi also visited Hunan province, the Wenlo village. It is the first time that the Deputy Premier visited affected communities.

In another trip, Madam Wu also meet with Dr Gao Yaojie,who spoke quite loudly about the AIDS epidemic in Hunan province, the blood-selling scandal and children orphaned by AIDS.

Also last year Tsinghau University and Dr Ho organised a summit on AIDS and a SARS summit. Former US president Bill Clinton went to that conference and made a speech. Clinton hugged Mr Song Huangfei who was infected in 1998 through blood transfusion in Shangxi province.

Some recent developments. Last month Hunan provincial government sent 76 provincial officials to more than 30 villages, mostly in Shangxi county and some villages in other counties. It is kind of the style of the Chinese community movement in Cultural Revolution. The government sent officials to the countryside working with farmers to help them develop agriculture and other economic situations.

But this time when we look at the situation, the government was forced, was pushed by the public, by the international society. It was the people who first went to the countryside, and students and groups in cities went, and journalists visited the affected communities in Hunan and some other provinces. Eventually, all these efforts helped our government face the challenge and take leadership in the AIDS campaign.

But unfortunately, on one hand we see our government has taken very strong leadership in the AIDS campaign but also we can see in Hunan province efforts based on home communities by people were closed by government. Early last month, a care programme for orphans in Hunan province in Shuangmiao village were closed by the local government. Just last week, a school organised by some volunteers in Beijing and Hunan to help children orphaned by AIDS in Hunan province in (Changsha) city. Local authorities closed this school last Thursday and it was described as illegal school. The school manager tried to get official registration but they failed. Last week they were described as illegal school and were closed.

When we talk about China's AIDS problems, SARS problems, we talk a lot about their transparency. Recently our government announced that there is about 840,000 infected people in China but the real number could be much higher but we still do not know how many people got infected in China.

According to Ministry of Health, the former Minister of Health Zhang Wenkang told the Congress in December 2000, the blood cell-caused AIDS epidemic in 23 provinces, almost two-thirds of the whole country had blood cell-caused AIDS epidemic. In many villages, the infection rate among blood donors is 10-20 percent and in some villages, the infection rate among blood donors is 60 percent. This is by the former Minister of Health in Congress. As we know, in many villages, we know in Hunan, the infection rate among blood donors is about 50 percent, 60 percent. Many of them have already died. Maybe more than 20 people have died. Many orphans left.

Last July there was a report in Hong Kong. There was a news report in Hong Kong Shingdao Daily . It quoted from a doctor in Beijing that the number of blood donors in Hunan province in the 1990s was 3 million. So if that number is true, the number of infected people in Hunan province could be one or two million, just by blood, just by selling blood. If 20 of them died, the children orphaned by AIDS could be hundreds of thousands in that single province. It could be millions by the year 2010.

Recently our government has started some programmes on treatment but the number of free treatments is still very limited. Last year, our government provided free treatment for 5000 people in Hunan, but unfortunately, because of severe side effects, about 70 or 80 per cent of patients stopped the treatment. They gave up because of severe side effects.

Recently our government has started some programme on condom promotion, and it is promoted by Mr Mechai. Last year, our government started a programme to support, to allow a harm reduction programme in China. Our government also applied a global fund and also from other Western governments and some foundations.

There are a lot of community-based involvement, community-based organisations involved in AIDS work. Gay-lesbian communities have workorganised and people with AIDS in cities and the rural areas organised their own organisations, and the Chinese students started to get involved in the AIDS campaign, especially many organisations organised programmes to support children orphaned in Hunan province.

You can see there are about 20 organisations in China, in Hong Kong, in Taiwan, in the United States, have organised some programmes to support children orphaned in Hunan province. This is the end of my talk.

QUESTION (Leong Chee Hong): I am not speaking in the capacity of the Hospital. I am speaking as an ordinary citizen in Hong Kong and somebody who is concerned with AIDS and also the Hong Kong AIDS Foundation. Can I congratulate David for this very dynamic and very moving movie, in particular the fact that social contact and stigma should be out completely. We also congratulate the Asia Society group and Citigroup for bringing experts here. I think we all learned a lot from them.

Hong Kong is blessed with the fact that we do not have that many AIDS patients and we do not have that many HIV, and we are lucky. Let us put it this way. Our concern is not so much Hong Kong but because of the fact that we are now one country, the problem that we face in the mainland. There is no doubt that in the mainland, there is no more denial. There is no doubt that in the mainland that the leaders are politically concerned and politically motivated in AIDS. I have seen that personally and we have seen that on the TV too. But then China is such a vast country where communication, where means of spreading information is difficult. What we really need to do is: how do we maintain the education programme in China? How do we spread information? How do we maintain this sort of programme? I think that is very, very important.

What we are doing in Hong Kong among the NGO groups – I am heading one of them – we are trying our best to do what we can to help the spread of education, the way that we do it into China, but we still face the problem of how we maintain the programme once we have sort of trained the trainers.

Recently we have developed a global Chinese AIDS centre, in which David is one of our patrons in that, where every single person round the world who works in a Chinese community with AIDS can contribute that aid work where we can coordinate. I do hope that that will be something which can really help the whole Chinese population around the world to do that. I am sure that Dr Wan will be able to contribute that to a certain extent.

We have learned a lot from Marina and Mr Mechai. I am looking forward to bringing a group to Bangkok in July not just for the conference but also to receive all the condoms as we pass along yours.

One question which has been burning in me, which is not so much for Asia, but for David. Perhaps he could elucidate that. David, you have produced a marvellous cocktail. Everybody is now saying that "Okay, I have the cocktail. I probably will not suffer from AIDS." Has that, in your mind, actually dampened the prevention programme or the awareness or the alertness to AIDS? People will say, "Look, why do I care anymore? I can take the cocktail and I am going to be all right." Thank you.

Mr. David Ho: Thank you for your comments. In terms of your question, obviously having therapy that could prevent death in places where such treatment is accessible could result in complacency and has resulted in complacency in places such as the US and Europe. Of course, most of these medications are not available in developing countries and the urgency is greater than ever.

The complacency issue is very tragic. I think we are seeing among the young in the US a resurgence in infection rates, particularly in young gay men. Despite all the lessons learned over the past few decades, the same mistakes are being repeated now and it is truly tragic. This is why, as you said, education needs to continue and needs to continue in very forceful ways as we have heard from the panellists.

For China, it is not just education in the schools. Public education in general and education of the leadership are all very important and it is something that we will endeavour to do. It obviously has to be done on an enormous scale . Certainly within China, you see lots of worthy projects here and there, but they are all tiny and pilot in nature. What needs to happen is to take this to scale. This is why we have formed a consortium to deal with this humanitarian crisis with a very very comprehensive approach that involves training advocacy, treatment, prevention and so forth.

QUESTION (Christine Mar): I am with Project Hope Hong Kong and recently in China, especially in Shanghai, we are working with the Second Medical University in Shanghai to do HIV education through peer education using first-year medical students to go into the Shanghai high schools and educate the students there on prevention, AIDS infection and things of that sort. I have a question for Ms Mahathir and also Mr Mechai: if these kinds of education programmes have been tried in your countries and what have been your impressions of these kinds of programmes?

Ms. Mahathir: Thank you. Yes, we have several peer education programmes and peers in terms of young people, in terms of, for instance, sex workers talking to other sex workers, drug users talking to other drug users. Generally these types of peer education programmes work very well because they know the situation for their peers, they know what language to speak in and their peers identify with these peer educators.

But it is something that needs to be developed in the proper way. For instance, the government, the Ministry of Health, has a programme called Pro-Star, which is a peer-education programme for young people, but it is pretty much an imposed thing in that the government decides what the message is and then train the young people and they go out. There has been no official evaluation of the programme and so far as we can see, it has not had very much effect because of the lack of relevance for these young people and they are unable to really identify.

But now we are trying to persuade them to reach out to other young people – for instance, out-of-school youth – the young people who are out in the streets, because those are very much at risk, and they will not come into school or a college hall or some sort of club to listen to the goodie-goodie types . You have to really make sure that you do have peers talking to real peers and that they are communicating in the right way. But yes, it is a good approach.

Mr. Mechai: Let me just very briefly add to that . You have to get to youth. We have been doing it 30 years, firstly in family planning, so when it comes to AIDS, it is mostly between the navel and the knee, so we are still relevant.

Obviously, we started 30 years ago with a Snakes and Ladders game. You throw a dice. Thais, Chinese, we all like to gamble a bit. They see adults gambling, so kids gamble. You throw a dice and you land on numbers that are anti or positive towards or negative towards, in this case, family planning. The mother takes a pill every night, great mother, move ahead five. Uncle buys condom, very good uncle, moves six. Uncle gets ... use condom, come back 15. All those things. We do a lot of that, and we have been doing it.

We also came up with an alphabet, where B for birth, C for condom, I for IUD, V for vasectomy. You can also do an alphabet to do with environment, or HIV/AIDS or family planning.

We also had a song. We took an old Thai song for children. Everyone knew it. I guess in the West, it would be like Jingle Bells. Everyone knows Jingle Bells. We changed the wording to do with the misery of having too many children, and every contraceptive method, and the kids knew that music. So when the song came, the words came, so they knew what it is. This was 30 years ago.

So what we are doing is just adapting what was done before. But keep it up. Get to the people who are in it. Call it edutainment, entertainment. Get to the entertainment sector, not the educational sector. They're dull. How many professors are exciting? So you go to the people who makes games for television, Nintendo games and you can download onto your mobile phone about safe sex messages and so on and so forth. Be relevant . Do what the kids do today. Then you will get to them. Otherwise, you get the grandparents and they do not get an erection anymore. Keep it up. Keep it going. Aim at the young.

QUESTION: I am Chong Chan Yau from Oxfam Hong Kong. Thank you very much for these speakers for sharing with us on the increasing seriousness of the HIV/AIDS problems. We are doing programmes in Asia and Africa on two fronts. One is on education and the other is on a campaign to increase access to treatment because affordable drugs are still not available in Asia. How much do the speakers think this is a problem, the expensive treatment, and how much is being done in the Asia region to increase access to treatment? Should the pharmaceutical companies have a responsibility? Thank you.

Mr. Ho: This is David Ho. Let me try to answer that . I think everyone has a responsibility. The treatment prices in the West are too high. No one really could afford $10,000, $12,000 per year. It is certainly way out of reach for people in developing countries.

Since the late 1990s, the prices have been steadily coming down, some voluntary, some pressured by community groups or country groups. We know today in developing regions, one could get these lifesaving medications for somewhere between $300 and $600 per person per year, depending on where you are, and largely on the basis of use of generic medications. Certainly, of late, President Clinton and his foundation have argued and negotiated hard for further reduction and it is now possible to get from certain generic manufacturers medications that come to about $140 per person per year.

It is a dramatic reduction, but we have to still put it in the context of what the per capita income is for people in Africa and Asia, particularly the rural poor. If that hundred some dollars might be the total income for the person per year, much less thinking about what is the health per capita expenditure. That may be only a few dollars per person per year for all their health needs.

So it is still way out of question and the only solution is for the rich countries to provide help with the poor ones. We know there are probably approximately a billion people in the wealthier nations and if on average each person would contribute $10 in those countries, then you would have $10 billion, which is what is required to launch a sizeable treatment programme. When distributed in such manner, it is not a heavy burden for any one of us to help. Certainly for the Hong Kong community it is not an issue. Yet the willingness to help is quite inadequate and this is not speaking about Hong Kong. This is speaking about all the wealthy nations.

Mr. Mechai: David, May I add to what you have just said ? It is very well to say, "Let us help and make it charitable. Charity does not last. Therefore, why do not we combine, make it sustainable? We are trying it out now in Myanmar and Thailand. And that is a loan fund, and the repayments have been excellent. Even if we have half repayment, some people can help themselves. It is also a great sense of pride.

Now, for some of you may not know that , WTO allows a country to declare a national health emergency and then you can produce your drugs. In Thailand, it is available for just under a dollar a day for the average person, so it is about, let us say, $350 a year. For most people, it is affordable, if you help some to earn that extra income. So that loan fund is helping them to pay for transportation, extra food and to pay for the drugs if they cannot get it themselves.

If we take the approach that we will do some lending, and you just take a look at let us say, 30 million families, that is nothing. Look at the haircuts, look at Enron, look at WorldCom, the rest, what they have done. So in this case, if we come together, and let us say I want you to lend money, not to give, lend money with no interest, and we will try and get it back. In that way, more people would be willing and the chances of success are pretty good.

So you do not need huge amounts of money but use an approach which is business by nature, rather than welfare by nature. I think that is one way of looking at it. No, some people cannot help themselves, then that is another matter. But a lot of people are in a position to be able to help themselves.

Ms. Mahathir: Can I also add: in the old days it used to be, that everyone said, "Prevention is better than cure" and all the emphasis was on prevention. But ever since the arrival of the antiretroviral drugs, it has changed somewhat, even with the prices being high, and so much work has gone into reducing the prices and generics and all that.

The thinking now is that prevention and treatment actually go together, because they complement each other. There are really really many benefits to treatment, not just for treatment, but because it helps prevention. It brings people into healthcare, settings where you can talk to them about prevention. You help to reduce the stigma surrounding AIDS because people used to think of it as incurable, and a fatal disease always has that stigma. It helps to eradicate some of that. The approach now is to put the two together and to work on both together and it is not a matter of "one will take away money from the other". You have to work on both.

There is going to be an excellent report coming out soon by a group called the Global HIV Prevention Working Group of which Khun Mechai and I are on – we all seem to be in the same committees – which makes that link very very convincingly. I hope it will get the coverage that it needs when it comes out.