Aids

In The Pacific

Containing the killer virus is of prime importance to the island nations.

By John Ballard

PACIFIC and Asian ministers of health, and senior health officials, received a thorough initiation in the problems and prospects of AIDS at a con ference organised by the World Health Or ganisation (who) in Sydney late in July.

The spread of the AIDS virus (the Hu man Immunodeficiency Virus, HIV) is as yet limited in Asia and the Pacific, by comparison with other world regions, and this offers the region an exceptional op portunity to establish programs of sur veillance and education before the virus becomes epidemic.

Dr Jonathan Mann, Director of WHO’s Special Program on AIDS, said, “we now know enough about AIDS to stop its fur ther spread.” Since it is unlikely that a vac cine against the AIDS virus will be developed in the next few years, he argued that what is needed is education about transmission of the virus and appropriate changes in behaviour.

Within the Asian-Pacific region, Aus tralia has the most substantial experience of coping with AIDS. Since 1983, 562 cases of AIDS have been identified, compared with 39 reported from New Zealand, 38 from Japan, 32 from the rest of Asia and three from the South Pacific as of June.

But this is only the “tip of the iceberg”, since there can be, on average, at least five years between infection by the virus and the development of symptoms classified as AIDS. And, given the impossibility of widespread testing for the virus, there are only very rough estimates of the numbers presently infected.

In Australia it is estimated that 50,000

people are now carrying the AIDS virus, 100 times the number of those who have developed AIDS. Elsewhere in the Pacific estimates depend on antibody testing, which has focused primarily on blood do nors and those attending clinics for sex ually transmitted diseases.

According to a recent survey by the South Pacific Commission, 29 carriers have been identified through testing in French Polynesia (11 of them recipients of blood transfusions in Europe or the US), nine in New Caledonia, and four in Guam.

In addition there are three carriers re cently identified in Papua New Guinea and one case in Tonga in a returnee from the United States.

Numbers are almost certainly higher than those officially reported. For in stance, Les Nouvelles (Noumea), of July 22 claimed a survey of doctors indicated more than 20 persons had tested anti body-positive in New Caledonia. In Papua New Guinea and Fiji it is acknowledged that several carriers and AIDS cases have probably moved to Australia for testing and care.

The AIDS virus is thus present and thriving in the South Pacific and the WHO Conference addressed the problems of containing it. As Jonathan Mann, and several other speakers, made clear, de spite regional variations in the current dis tribution of AIDS cases, the modes of transmission are the same throughout the world. The virus can be passed through exchange of fluids during sexual contact, exposure to contaminated needles, trans fusion of contaminated blood or blood

products, and transmission from mother to child before or during birth or through breast-feeding.

Because of earlier attention to trans mission through an intercourse between homosexual partners, which still accounts for a substantial majority of AIDS cases in North America, Europe, Australia and New Zealand, Mann and others stressed the evidence for vaginal transmission.

Not only is the African evidence pre dominantly of this nature, but there are many instances of male-to-female and fe male-to-male transmission in Western so cieties and in the Asian-Pacific region. In the Philippines, for instance, most anti body-positive test results so far have come from prostitutes working near US bases, and there are recorded cases of heterosex ual transmission in Papua New Guinea and French Polynesia.

Dr Mann presented to the conference the World Health Organisation’s goals and its model national program for consider ation by each government. WHO’s basic goals are not only the prevention of fur ther transmission of the AIDS virus and the development of services for people with AIDS within their communities, but also “the unification of communities to avoid the stigma which has developed around AIDS, revealing ethnic, sexual and reli gious prejudices”.

The proposed national program, already adopted by several African and Latin American countries, involves the es tablishment of a National Advisory Com mittee involving relevant specialist and community groups, assessment of the

prevalence of the AIDS virus, develop ment of blood-testing facilities and a sur veillance system for reporting AIDS cases, education of health workers and the pub lic, and establishment of a system of care for people with AIDS.

A number of island states have already taken the first steps towards comprehen sive AIDS programs and the WHO Spe cial Program is planning visits to assist in their development. The South Pacific Commission has been asked to set up a re gional surveillance system in collabora tion with WHO.

Dr Mann pointed out that each na tion’s priorities depend on likely entry points and local modes of transmission of the virus. There is a temptation to see screening of the blood supply as a first priority since it is a technical matter which gives government a sense of control and its own data; but in fact screening is relatively costly and education and voluntary exclu sion of blood donors may prove easier and adequate. In any event, Mann argued, public education should always have top priority, despite the difficulty in framing messages so as to reach effectively those most at risk.

Mann agreed with the conclusions of Justice Michael Kirby, President of the New South Wales Court of Appeals, con cerning the limitations of legal solutions for AIDS problems. Kirby noted the temptation for governments to respond defensively with measures such as quar antine, compulsory detention, mandatory testing and reporting, and the closure of places of sexual activity.

But he stressed the limitations of the law in modifying behaviour and the danger that laws can merely stigmatise and pun ish rather than provide support for effec tive public health measures. The futility of screening international travellers was em phasised by several speakers.

On the basis of past experience of legal attempts to deal with epidemics, Kirby propounded five “commandments” for AIDS legislation. Law is local, but AIDS requires international cooperation, hence the need for collaboration among neigh bouring states.

Law must be mobilised to promote pre vention, hence the need to repeal laws against the sale of condoms if these ob struct the higher value of saving lives. In efficient laws, such as those for mandatory testing of “high-risk groups”, often en acted so that governments can be seen to be doing something about AIDS, must be avoided. Law must minimise discrimi nation. And the overreach of criminal and tort law must be avoided.

There was plenty of opportunity, at the conference, for discussion of scientific and medical aspects of AIDS, with several presentations by leaders in Australian medical research. But attention was fo

cused primarily on educational strategies.

Australia, which has identified AIDS as its top health priority, has been praised by WHO for its emphasis on public educa tion. During the conference, Neal Blewett, who has provided leadership for Aus tralia’s complex federal-state programs, was re-appointed as Commonwealth Minister for Community Services and Health and raised to cabinet membership.

In his speech to the conference Blewett strongly defended Australia’s controver sial Grim Reaper television campaign as a necessary dramatic statement of the gen eral risk of AIDS to the population. He also warned of the dangers of allowing AIDS to become a party-political issue and stressed the need to involve all community groups and all parties in planning and education.

Some of the more imaginative Aus tralian educational programs were presented.

Grace Smallwood, Aboriginal mem ber of the National Advisory Committee on AIDS, explained the scheme by which Aboriginal communities are developing their own educational programs, includ ing videos and posters in local languages and pidgin. Phil Carwell of the Victorian AIDS Council and the National Advisory Committee outlined the strategies behind the “safe sex” programs developed by the gay community, which have led to a dra matic fall in sexually transmitted diseases.

There were a few statements on the ex perience of other countries in the region, but most of these were focused on epide miological statistics. The exception, which caught the attention of the conference, was that of Dr John Ah Ching, chairman of the Western Samoan AIDS Monitoring Committee.

Western Samoa has carried out very limited blood testing since May, with no antibody-positive results. Tourism, ex panding with the opening of a new inter national airport in June, is the most likely source of arrival of the virus. Formation of a National Committee on AIDS, with representation from government depart ments, women’s groups and churches, has been proposed to Cabinet.

Dr Ah Ching discussed the problems of carrying out an educational campaign among groups such as younger promis cuous men and women, or among fa ’afafine transsexuals. He concluded that only a general campaign, focused on ur ban and rural communities, would avoid stigmatisation of specific groups and suc ceed in altering attitudes and behaviour.

But he stressed the difficulties for com munication raised by the gap between the formal language required for official health education and the informal language tra ditional appropriate for discussion of sex ual matters.

Dr S I Okware, Director of the AIDS Control Program in Uganda, also stressed

education in his country, where there were 1138 reported cases of AIDS in May. Strong political support has been given, with the president and ministers making AIDS ed ucation a part of almost every public speech. Local government, churches and schools have all been mobilised around the theme of “loving faithfully and loving carefully”. Dr Okware advocated “Zero grazing”, a Ugandan term for tethered grazing, hence, having only one sexual partner.

After three days of intensive confer ence presentations and discussion, Friday was set aside for visits, with delegates given a choice among research and testing lab oratories in Melbourne, medical clinics in Sydney, and a cross-section of clinical and educational facilities in Sydney.

The largest number chose the latter, which included an afternoon of visits to the Albion Street Clinic, the Ankall organ isation offering care for people with AIDS, the AIDS Council of New South Wales, the Australian Prostitutes Collective and the AIDS Drug Information Collective

(Adic).

Many of the delegates felt that this op portunity for direct contact with the con duct of clinical, care and education programs was the high point of the con ference. At the Australian Prostitutes Col lective, for instance, they were confronted with the details of a program to encourage the use of condoms in the parlours of Syd ney through a visiting “AIDS roadshow” and a gradual boycott of uncooperative parlours. They also heard from ADIC about the problems of exchanging clean syringes for used ones while working among intravenous-drug-using street prostitutes.

Perhaps this symbolised the impact of the conference as a whole. None of the del egates, even among the Australians most experienced with AIDS issues, could have escaped a substantial expansion of knowl edge about the virus and the extraordin ary ramifications of its spread.

For those who came with limited awareness it provided an intensely sober ing baptism in the complex discourse of AIDS, which demands a major readjust ment in the understanding of difficult subjects. The nature of sexuality, of inter course, of prostitution, and of human re lationships generally were never directly addressed, but assumptions about each were challenged.

As Dr Mann emphasised at several points, Asia and the Pacific have the op portunity to learn cheaply and quickly what others have had to learn at great cost. But it requires political will, honesty and subtlety to apply the lessons. □

* John Ballard is a senior lecturer at the Department of Political Science at the Australian National University.