"Because AIDS is such a long-duration disease, in order to identify risk factors and behavior and evaluate whether prevention is effective or not, you have to monitor so many things," says Chuleeporn Jiraphongsa Ph.D. ’00, a former trainee who runs the Field Epidemiology Training Program at the Thailand Ministry of Public Health. "But when it comes to surveillance, we are the best in the region. Other countries come to learn from us."

Through much of Asia, cultural norms encourage men to have multiple sex partners, even after marriage, while women are to remain monogamous. The disparity results in a thriving commercial sex industry and a potential hotbed for HIV transmission. Thailand, followed by Cambodia, put economic pressure on brothel owners by threatening to shut them down unless all clients in their establishments used condoms. Most other countries in the region have attempted to suppress commercial sex, driving the trade underground and making it more difficult to track the high-risk population — and more likely that the sex workers, who wield little power in their relationships with clients, will fail to demand the protective method.

Cambodia — which, like Thailand, undertook a massive health-education campaign — has the highest national rate of HIV infection in Asia but is beginning to see a downturn in new cases among high-risk groups, an extraordinary feat for a small country ravaged by civil war and genocide. Detels has assisted with Cambodia’s sentinel-surveillance program and continues to be called on to evaluate the program, which is staffed by many former UCLA/Fogarty trainees and a current one, Chhorvann Chhea, who notes that despite making headway in the sex-worker population, Cambodia has begun to see an ominous increase in HIV prevalence among pregnant women. "That tells us it’s moving from the high-risk group into the general population," he says.

In other countries, culture and politics pose barriers to an effective response. Talking about sex is largely taboo in India, where an estimated 4.5 million people are infected with HIV (second only to South Africa). Condoms are forbidden from being discussed in schools, despite the fact that a large percentage of girls are married by age 16; infection rates among women and newborns are increasing. Poor and rural communities tend to be among the most conservative, with women unlikely to be in a position to insist on safe sex.

<previous> <next>