Tough measures in Russian prisons slow spread of TB.

261Bulletin of the World Health Organization | April 2006, 84 (4) News China’s pragmatic approach to AIDS International public health experts are praising China for a new openness that will be key to effective control of HIV/AIDS. Despite a recent downward revision of its HIV/AIDS estimates, China faces a growing epidemic. Its ambitious public health plans include free HIV testing and AIDS treatment and a nationwide rollout of methadone therapy to help drug users lower their risk of contracting HIV. As recently as the late 1990s, Chinese experts projected that the country’s HIV infections would top 10 million by 2010. Now the government is aiming to keep that number below 1.5 million. In 2003, an estimated 840 000 people in China were infected with HIV, but in 2005 the estimate was revised down to 650 000. Taking these numbers on face value, it may seem that China is winning the war on HIV/AIDS, but the reality is not so rosy. The HIV/AIDS epidemic continues to spread particul larly among vulnerable populations in China: last year alone there were an estimated 70 000 new infections. Implementing the country’s ambitious HIV/AIDS prevention, treatment and care prol gramme is no easy task. China, a vast country of 1.3 billion people, faces tremendous logistical challenges. Even with strong policy measures in place, one challenge is to ensure that central government policy is implemented at provincial and local levels. In late January 2006 China’s Ministry of Health, UNAIDS and WHO released the 2005 Update on the HIV/AIDS Epidemic and Response in China, a report that presents China’s new, lower HIV/AIDS estimates as well as progress made in responding to the epidemic, the challenges that remain, and the government’s vision for the future. Joel Rehnstrom, UNAIDS Counl try Coordinator in China, recalls some concern in the Chinese Government about releasing lower estimates for fear of appearing to massage the figures — estimates that are attributable to more accurate surveillance in 2005. What the report very clearly says is that China has a growing epidemic. Joel Rehnstrom, UNAIDS Country Coordinator in China. Poster in a campaign to raise awareness about HIV/AIDS in Beijing, China. W HO /P . V iro t “The government wanted to make sure that UNAIDS and WHO were behind it. We have endorsed the new esl timate, but cannot certify the provincial and prefectural estimates which are the basis for the national one,” he says. “This report represents several years of work by UNAIDS and WHO and others in strengthening surveillance in China, training people in epil demiology and surveill lance, getting people to understand more the dynamics of HIV transmission in a low prevalence situation. This is not something that was come up with overnight; it’s not a back of the envelope estimate. What the report very clearly says is that China has a growing epidemic,” Rehnstrom adds. Injection drug users (IDUs) and sex workers comprise the majority of the estimated 650 000 people in China who are infected with HIV. An estimated 288 000 — 44% of the total — are IDUs, while 127 000 (19.6%) are sex workers and their clients, and 109 000 (16.7%) are the partners of HIVlpositive people or other members of the population. The remaining 126 000 include men who have sex with men, children born to HIVlpositive mothers, and donors infected through unsafe coml mercial blood and plasma collection practices in the 1990s. An estimated 55 000 people (8.5%), down from the 2003 estimate of 199 000, have been infected in this way. This group constil tute a distinctive aspect of the country’s HIV/AIDS epidemic. The sharp downl ward revision is because many donors have died and unsafe blood collection practices have long ceased. The HIV/AIDS epidemic started to emerge in China in the early 1990s, but it was not until Premier Wen Jiabao became the first senior leader to visit villages affected by blood and plasma trading and shake hands with AIDS patients on World AIDS Day in 2003 that central government sent a signal to provincial and countyllevel leaders to address HIV/AIDS. The 2005 rel port with revised estimates is a further example of China’s determination to control the disease. “Although the Chinese Governl ment was a bit slow to respond in 262 Bulletin of the World Health Organization | April 2006, 84 (4) News the beginning, it is now starting to make up for lost time,” says Katharine Poundstone, HIV/AIDS Technical Ofl ficer with the WHO Country Office in China, adding: “While the time it has lost in the past means it has serious problems to face, the current response is quite forwardllooking and promisl ing, and backed by the highest levels of government”. “Five years ago I would have said that China is 10 years behind other countries and not taking full advantage of lessons learned in other parts of the world; now I would say China is bel coming one of the leaders in the global HIV response. Over the coming years, the world will probably learn a lot from the various programmes that China is now launching to combat its HIV epil demic. Some are very ambitious, such as the nationwide rolllout of methal done maintenance therapy to help drug users manage opiate addiction and lower their risk of HIV, and some are rather controversial, such as China’s mass HIV screening programmes,” Poundstone says. The screening programmes that started in 2004 raise ethical concerns as to whether they adhere to three main principles of effective voluntary counsell ling and testing (VCT): confidentiality, counselling and consent, and practical concerns that regular mass screening is not costleffective in a vast country with low HIV prevalence. Screening programmes have fol cused on former blood donors, IDUs and sex workers. Drug use and sex work are illegal in China, so many IDUs and sex workers live in detention centres where it is easy to provide screening and education. At coml munity level, however, the illegality of drug use and sex work makes education and prevention difficult, explains Graham Smith, Country Director for the Interl national HIV/AIDS Alliance China, headquartered in Kunming, Yunnan Province. “If HIV/AIDS really has a low prevl alence then there’s still plenty of scope to step in and turn the situation around, China is becoming one of the leaders in the global HIV response. Katharine Poundstone, HIV/AIDS Technical Officer with the WHO Country Office in China. but it’s about prevention coverage in IDUs and sex workers, and the problem there is the public security angle. The government response is a public order response and that response contradicts public health objectives. It makes it very difficult to get access to the population but there are incremental steps that can make it easier,” he says. Smalllscale projects are part of that incremental approach. For example, the charity AIDS Concern, based in Hong Kong Special Administrative Region, recently secured funding to set up a droplin and informal tion centre in Shenl zhen, across the border from Hong Kong SAR, covering two districts frequented by sex workers and their clients. The centre will distribute condoms and provide free, rapid and anonymous HIV testing to sex workers and their clients. “We are very excited about working together with the Shenzhen Center for Disease Control and Prevention on this project. It’s further proof of an official attitude change,” says Loretta Wong, Executive Director of AIDS Concern. While Chinese society remains conservative, attitudes to sexuality are changing and AIDS has forced the health authorities to be pragmatic when dealing with highlrisk groups such as sex workers and men who have sex with men, says Smith. Even as China gears up its response to HIV/AIDS, obstacles remain, not least the implementation of free HIV testing and AIDS treatment prol grammes within a crumbling health service where hospitals are profitlmaking entities and rural healthlcare provision has been reduced in the era of economic reform. Official reluctance to fully embrace nongovernmental organizal tions in the fight against HIV/AIDS also continues to frustrate organizations from within highlrisk groups. “It’s still a lowlprevalence, concenl trated epidemic, both geographically and in terms of population groups, so China has the opportunity to bring the epidemic under control, but there are so many challenges especially at the lower levels,” says UNAIDS’ Rehnstrom. By its own admission the central government has an uphill struggle to translate its message into action at local level. “What happens on the ground in a country the size of China is that there is great variability and still a long way to go, says Rehnstrom. “Despite impressive steps forward, the response to HIV/ AIDS is still in its infancy in China.” O Jane Parry, Hong Kong SAR A Chinese orphan whose parents both died of AIDS looks away as a nurse takes a blood sample for HIV testing in Hefei, Anhui, eastern China, in 2004. Many people in the child’s village became infected with HIV when they sold their blood in the 1990s. About 18 orphans from her village received HIV testing. Ke ys to ne /A P Ph ot o 263Bulletin of the World Health Organization | April 2006, 84 (4) News New fund-raising scheme fuses profit with philanthropy A new approach to fund-raising in the battle against AIDS in Africa has appeared in the consumer marketplace. Product RED, launched by U2 lead singer Bono, went on sale this spring. Unlike traditional fund-raising vehicles, such as philanthropic foundations, RED blurs altruism, profit motive and consumer appeal. But can it overcome the ethical and practical pitfalls of fusing commerce with charity? The concept is simple enough: particil pating companies American Express, Gap, Nike’s footwear brand Converse, and Giorgio Armani each market one RED product and divert a percentage of profits to the Global Fund To Fight AIDS, Tuberculosis and Malaria. American Express launched a credit card in the United Kingdom (UK) on 1 March; 1% of spending on it will go to the Global Fund. Converse is offering a shoe in the UK and the United States on 1 April inspired by Bogolanfini, a dyed cloth produced by the Bamana people of Mali. Gap’s red Tlshirt made in Lesotho del buted on 1 March in the UK and Giorgio Armani’s metal wrapl around sunglasses are the only RED product to go on sale worldl wide this spring. Gap will allocate 50% of RED profits to the Global Fund, Armani will give 40%. Converse has not yet announced its figure, but RED insiders hint it will also be 40%. All three clothing companies plan to expand their RED collections later this year, and extend these to other markets if sales go well. Bono predicted that RED could generate “hundreds of millions of dollars” for the Global Fund when he launched RED in February. The partnership is timely as the Fund has seen a drop in government donations of late. Spokeswoman Rosie Vanek said it is uncertain whether the Fund will be able to award new grants this year. “We are still looking for extra funds for the period 2006–7. The last round of pledges only covered US$ 3.7 billion of the US$ 7 billion we need to cover our grants for that period.” The RED money, Vanek added, “will basically go to existing grants that are proven successes.” Until now, only a “very small prol portion” of donations came from private donors, said Dr Richard Feachem, the Fund’s Executive Director. Less than 1% came from corporations. New apl proaches are needed, he said. “RED is not a charity or public fundlraising caml paign,” Feachem said at the RED launch in January, but “a business proposition that brings together partners with distinct priorities into a mutually beneficial relationship.” “Companies expand their customer base and bottom line,” said Feachem, “while the Global Fund and its recipients gain not only critical financial resources but also publicity for their work. As a result, RED has the potential to be larger and more sustainable than other private sector fundlraising initiatives to date.” The chief executive of the new RED brand is Bobby Shriver, Chairman of Debt, AIDS, Trade Africa (DATA), the advocacy group he colfounded with Bono in 2002. Shriver downplays the altruism and trumpets the profit motive that he hopes will keep RED sustainable, sayl ing he has no illusions about his giant commercial partners: “Private sector companies, American, Italian, Japanese, have almost no interest in this. There’s not even a little bit of altruism. When I go to see these companies, I don’t even get through the door on altruism,” he told the Bulletin. “Sustainability was very important to us when we started out. We’re trying to create a concept that will sustain itself on its own success, not on Bono’s celebrity or my relentlessness. That can’t be an altruistic concept. It has to have a market.” “Nobody cares about AIDS in Africa,” said Shriver, recounting his two years of seeking partners in the corpol rate world. “They [companies] don’t care about the concerns of the political world, the WHO world. All they care about is will it sell a cup of coffee or not. And if they conclude it won’t, it’s ‘have a nice day, see you later’. … In the real world, they don’t care about the things that we care about, which is part of what makes this venture scary and exciting.” “Ethical brands” are nothing new. One of the “conscience” companies, the UK’s Coloperative Bank, was founded in Manchester in 1872. It does not invest in industries deemed unethical, such as the arms trade. More recently, Britain’s Fairtrade mark, launched in 1994, has sold products with the guarantee that a fair share of profits will go to producers in developing countries. In the United States, Pink Ribbon products made by a range of companies have donated small portions of proceeds to breast cancer research. None have come close to RED’s 40–50% share. But Breast Cancer Action’s caml paign Think before you Pink argues that Pink Ribbon tricks consumers into feeling they have contributed substantially to cancer research, when in fact they have contributed pennies. Pink Ribbon has also been criticized because some of the companies I personally, and most people that I’ve talked to, are very positive about RED. It’s dealing with creative partnerships, which is the only way the issue will ever be dealt with. So far in the AIDS fight, the private sector has made very limited commitments to the Global Fund. Katherine Marshall, Director and Counsellor to the President of the World Bank. American Express launched a credit card in the United Kingdom on 1 March, bearing the message: “This card is designed to eliminate HIV in Africa”; 1% of spending will go to the Global Fund, rising to 1.25% for over US$ 8700 spending a year. If it proves attractive to British cus- tomers, the card will be offered in the United States. Am er ica n Ex pr es s 264 Bulletin of the World Health Organization | April 2006, 84 (4) News involved generate pollutants linked to breast cancer. RED is likely to face similar challenges, said Katherine Marshall, who is Director and Counsellor to the President of the World Bank on ethics issues and previously ran the Bank’s Africa programmes. “The main ethical pitfall is that these big companies have very farlflung holdings, and there’s bound to be quesl tions raised about some aspect of their operations. That puts them to some extent at risk and also puts the cause at risk,” warns Marshall. “When people look at RED, it’s important to have an understanding of the complexities of the global trade arena. Otherwise if there’s a small violation and someone starts yelll ing fire all hell breaks loose.” Shriver said this is already happenl ing. “We’re being asked, ‘how come you haven’t policed this factory in upl country Thailand?’ “We hope that they will do the right thing because we can’t possil bly police these giant multinational corporations,” said Shriver, adding that other partners say they are doing their best to ensure their factories provide acceptable working conditions. “If it’s proved that the brand is making products fly off the shelves, then I’ll say: ‘now, to get my brand you’ve got to do the following campaigns … But RED’s marketl ability has yet to be proved.” There are grounds for optimism. Britain’s “ethical consumer” market was worth US$ 44 billion in 2003, according to the researchers for Amex. The company estimates 1.5 million “conscience conl sumers” in the UK today, and expects four million by 2009. “What we are seeing,” one rel searcher reported to Amex, “is a blurl ring of moral, social and lifestyle issues that is unprecedented. Brands can no longer separate their profits from how they make them.” While 33% of British consumers in the survey identified themselves as “conl RED has to find that balance where nobody is taking anybody for a ride. We do want companies to be able to derive revenue and profit through this campaign. Otherwise it wouldn’t be sustainable. Rajesh Anandjan, Manager of Private Sector Partnerships at the Global Fund. science consumers”, only 8% described themselves as “apolitical shoppers” who completely ignored the social implical tions of their consumption. “We found a real desire among consumers to do more,” said Gail Wasserman of Amex. “But so often, these good intentions come to naught because it just isn’t convenient. Somehow, in between the goodwill and the physical act of getting the cheque book out, life tends to get in the way. The beauty of RED is that it’s so easy. You don’t have to do anything different, rather you can help just by going about your normal business.” “I personally, and most people that I’ve talked to, are very positive about RED. It’s dealing with creative partnerships, which is the only way the issue will ever be dealt with. So far in the AIDS fight, the private sector has made very limited commitments to the Global Fund,” Marshall told the Bulletin. The Global Fund will be watching to ensure that the partnership does not become an exploitative one after the brand is established. Rajesh Anandjan, Manager of Private Sector Partnerl ships at the Global Fund, said that a contribution of 40% of gross margin “is internally a general expectation we have.” “RED has to find that balance where nobody is taking anybody for a ride. We do want companies to be able to derive revenue and profit through this campaign. Otherwise it wouldn’t be sustainable, they wouldn’t invest real marketing dollars in it, and it would not grow. The way it’s structured right now we feel that the agreements in place are very fair, and we fully expect that they will remain that way.” Speaking at the launch of Product RED, at the World Economic Forum in Davos, Switzerland, Bono acknowll edged that the partnership with big business might generate unease among his fellow activists. Flanked by corpol rate executives he described as “fat cats in the snow,” Bono said: “Some people will be very upset we’re working with big business. But the problem just has to be sorted and we can’t do it with governments alone.” Now Shriver is just hoping someone will buy the products. Days after the first RED products went on the market, the first sales of the RED Tlshirts looked promising: “Gap tells us those sales are better than expected, thank God.” O Owen Dyer, London From left to right, David Maddocks, CEO of Converse; Richard Feachem, Executive Director of the Global Fund; Irish rock musician Bono wearing the RED wrap-around sunglasses by Armani; John Hayes, CEO Ameri- can Express; Andrew Rolfe, President of GAP; Giorgio Armani, CEO of Armani; and Bobby Shriver, CEO of RED present some of the new products at the World Economic Forum in Davos, Switzerland, 26 January 2006. Ke ys to ne /A P/ M . E ul er 265Bulletin of the World Health Organization | April 2006, 84 (4) News Tough measures in Russian prisons slow spread of TB Nearly a decade after starting work with the Russian Federation to stem a tuberculosis (TB) epidemic, WHO is reporting slow but steady progress. The WHO-recommended DOTS treatment strategy is gradually taking hold across world’s largest country, but its vast network of prisons and labour camps remains a hotbed of the disease. When Russian billionaire Mikhail Khodorkovsky was sent last October to a remote Siberian labour camp near a uranium mine to serve an eightlyear fraud and tax evasion sentence, friends and relatives accused the Kremlin of trying to ruin his health. Yet Anatoly Rusin, who was released from prison last year, told the Bulletin that Khodorl kovsky had better worry about a far less exotic threat to his health. “I have not heard of inmates dying of radiation, but I have seen them die of TB,” Rusin said. Until the 1990s, Soviet authorities kept tuberculosis (TB) unl der control. With the collapse of the Soviet Union, falling living standards, mass migration and a crumbling health system contributed to a 7.5% annual increase in new cases from 1991 to 1999. Professor Margarita Shilova, Head of the Tuberculosis Epidemiology Department at Moscow’s Phthisiopull monology Research Institute, recalls those days with horror. “Suddenly, the money stopped. There were no drugs, communication with local hospitals broke down as telel phones were cut off over unpaid bills, there were no stamps or envelopes to send letters, doctors could not use a car to see their patients, it was impossible to transport patients to hospitals, the system broke down,” Shilova said. “Discipline among patients and doctors — which is key to treating the disease — was no longer there,” she told the Bulletin. By the end of the 1990s, tuberl culosis had reached alarming proporl tions, particularly in the country’s vast penal system. Virtually every prisoner was exposed to tuberculosis. Many became sick, many died, and thousands of I have not heard of inmates dying of radiation, but I have seen them die of TB. Anatoly Rusin, former prisoner who contracted tuberculosis in a Siberian prison. infected exlconvicts were being released into the general population every year. It was not until 1995 that tuberl culosis cases among prisoners were included in official statistics, revealing a concentration in the penal system. While prisoners account for 0.5% of the 143lmillion population — there were 765 000 prisoners at the end of 2004 — about 12% of cases are detected in prisons alone coml pared with 27% in 1995, Shilova said. In recent years tuberculosis cases and deaths have fallen slightly across the country, largely due to this decline of the disease in prisons, but also improved control and general health improvements, according to WHO’s Global Tuberculosis Report 2005: Global Tuberculosis Control — Surveillance, Planning, Financing. WHO experts started working with the ministries of health and jusl tice to revise the national tuberculosis strategy in 1999. WHO’s help was timely and welcome, but the first pilot projects were difficult because of a diversity of approach. “Russia has a very rich history of TB control,” said Dr Wieslaw Jakubowiak, WHO’s Tuberculosis Control Prol gramme Coordinator in Moscow. “But the Russian school took a different approach to WHO and, at first, it was not easy to talk the same language and establish the same definil tions,” Jakubowiak said. “Since then, we have been able to sit down around one table and to reach a consensus,” Jakubowiak said. WHO reckoned that the counl try’s unwieldy Xlray machines were too expensive and exposed patients to unhealthy doses of radiation. In response, Shilova said the Russians dropped their old methods and switched to the WHOlrecommended DOTS strategy. DOTS once stood for Directly Observed Treatment (Short Course). Now the acronym refers to a fivel element treatment strategy encompassl ing: government commitment, diagnosis through sputum microscopy, regular drug supply, 6–8 months of regularly supervised treatment including direct observation of drugltaking for at least two months; and reporting systems to monitor treatment progress and programme performance. DOTS was first introduced in the Russian Federation in 1994. Initially it encountered resistance from some Russian tuberculosis experts, but WHO experts say it was often misinterpreted. ���� ����������������������������������������������������������������������� ��������� ������������ ���� �� ��� �� �� �� �� �� �� �� �� � ��������� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ���� ��� � ���� ���� ���� ���� ���� ���� ���� ���� ��� ��� ��� ��� ��� ��� ��� ��� ������������������������������������������������������������������������������������������������������������������� 266 Bulletin of the World Health Organization | April 2006, 84 (4) News We have preserved all the best that we had, adding to it all the good things that the WHO had to offer. Professor Margarita Shilova, Head of the Tuberculosis Epidemiology Department at Moscow’s Phthisiopulmonology Research Institute. The Siberian city of Tomsk was chosen as a test ground in a project run by nongovernmental organizations, Merlin of the United Kingdom and the Public Health Research Institute of the United States. “It did not work,” Shilova said. “They dismantled a system of early TB detection and introduced DOTS, it led to a deterioration. Very soon the health ministry realized and relestablished all the old procedures, adding to those WHO’s microscopy and shortlcourse treatment. I think it was the time when both sides started to realize that putting all the eggs into one basket was wrong and began listening to each other much more carefully.” WHO experts say that DOTS has always complemented radiology with microscopy and culture examination. By the end of 2004, DOTS had been implemented in 37 regions of the Russian Federation covering 45% of the population. “There is a new dynamic now in place in the Russian Federation, prompted by stronger collaboration between the government and WHO. We are seeing growing government commitl ment and effective coordination with all partners and this is producing good results,” said Dr Mario Raviglione, Director of the WHO’s Stop TB Department. Thanks to joint efforts by Russian doctors and WHO experts, and to a series of new laws and regulations, the spread of tuberculosis has been more or less contained over the last three years. Under a 2001 law, tuberculosis detection, treatment and care are free of charge. A more controversial part of that law stipulates that tubercul losis caselfinding is obligatory with mandatory examination of tuberculosis patients — a provision doctors say has been applied in prisons but not in the civilian sector. Rusin, like many other prisoners, contracted tuberculosis in jail. Today he earns a living as a salesl man shuttling 400 km between his native region of Tver and the Rusl sian Federation’s secondlbiggest city of St. Petersburg. Rusin is a textbook example of why strenuous efforts to combat tuberculosis often yield only limited results. Behind bars inl mates have little chance of escaping treatment, as prison guards stand by to make sure they take their medicine. Once released, they often stop taking medil cation, particularly when they start feeling better. In an attempt to instil some order into the chaotic lifestyles of former prisoners, WHO has been working closely with the Russian justice authorities. By 2005, there were 37 hospitals and 57 other facilities providing tuberl culosis treatment in the penitentiary sysl tem, according to the Global Tuberculosis Report 2005: Global Tuberculosis Control — Surveillance, Planning, Financing. “WHO has established quite good cooperation with the Ministry of Justice. Many WHO recommendations on tuberculosis treatment and prevention have been adopted in the prison sector, and we jointly organized workshops to train prison staff,” Jakubowiak said, adding that this work included initial tives to encourage former prisoners to continue treatment after their release. Two big challenges are a growing HIV/AIDS epidemic and multidrugl resistant tuberculosis (MDRlTB) in patients, who are resistant to firstlline drugs and require longer treatment with more expensive secondlline drugs. These and other issues are addressed by WHO’s new Stop TB Strategy, launched last month. While effective control measures have cut the overall number of new tuberculosis cases from the 2000 peak of 90 per 100 000 people to 83 in 2004, health officials hope additional funds will help reduce cases further. The Russian Government has increased its budget allocation for tuberculosis control. The country has been granted a US$ 150lmillion World Bank loan, twol thirds of which is earmarked for tuberl culosis, and received a US$ 91lmillion grant from the Global Fund To Fight AIDS, Tuberculosis and Malaria. “Now we work together very posil tively,” Shilova said. “Over the years we have learned to listen to each other and respect each other. As a result, we have preserved all the best that we had, adding to it all the good things that the WHO had to offer.” O Andrei Shukshin, Moscow A prison doctor tells a prisoner to lie down for an examination for tuberculosis in the city of Tula, the Russian Federation. Overcrowded prison conditions contribute to the risk of prisoners transmitting and contracting tuberculosis. Ke ys to ne /A P/ I. Se kr et ar ev