Transcript: U.S. and Russia Cooperate in Fighting AIDS

01 August 2001

Transcript: U.S. and Russia Cooperate in Fighting AIDS

July 31 State Department "Dialogue" with U.S. HIV/AIDS experts

Since 1998, the United States and Russia have been cooperating in an effort to slow the fast-growing HIV/AIDS epidemic in Russia, according to two U.S. AIDS experts who spoke with viewers in Moscow and Yekaterinburg July 31 on the State Department's "Dialogue" interactive television program.

"The epidemic is still in the early stages" in Russia, according to John Novak of the U.S. Agency for International Development (USAID) -- but the number of cases is growing fast: Russia's Ministry of Health reports that the number of registered HIV cases has reached 105,000 so far this year -- almost quadruple the number registered between 1987 and 1999 -- and that the actual number of cases is probably substantially higher that that.

On the program with Novak, who coordinates USAID's efforts with those of national governments and other international donors, including UNAIDS, the World Bank, the European Union and the Soros Foundation, was George Swales, a health educator at the private Whitman Walker Clinic in Washington.

Describing how USAID works with other organizations on the AIDS problem in Eurasia, Novak said UNAIDS "provides the political leadership, and works very closely with governments in the region. The Soros Foundation does a lot of harm-reduction work ...with injecting-drug users -- and can provide syringes and needle exchange programs, which we cannot do."

For its part, USAID works with government agencies in Russia and non-governmental organizations (NGOs) "to provide [HIV] prevention programs to at-risk populations in those two oblasts [Saratov and Moscow], and hopefully working very closely with our Russian partners to develop model programs that can be disseminated and used throughout the country," Novak said. Also, the National Institutes of Health is working with Russian researchers in several areas.

"Originally our program was prevention," he added. "As the epidemic develops and as more people become HIV-positive, USAID and other donors, and the government itself, will be emphasizing the care and support of HIV-infected individuals to a greater extent."

Novak said he expects an increase in program support for training medical personnel to deal with the epidemic. This year USAID will pilot programs to reduce the transmission of HIV from mother to child.

Swales said the Whitman Walker Clinic has provided technical assistance in Saratov Oblast in outreach, information exchange, program planning, running an effective needle exchange program, and other aspects of HIV/AIDS prevention.

The challenge is to try to change attitudes, "which is brought about by education," and then try to actually change behavior, such as through "condom distribution and behavior modification instructions," he said.

The United States has pledged $200 million for the Global Fund, a public-private partnership established to fight HIV/AIDS, TB (tuberculosis) and malaria around the world. The fund, which was formally launched at the G8 Summit in Genoa last month, now has approximately $1.7 billion [$1,700 million] from the private sector, the United Nations and the major donors, according to Novak.

He said USAID would support the use of Global Fund resources to help expand Russia's HIV/AIDS program.

Beyond the Global Fund, the United States has dedicated more than $1.6 billion ($1,600 million) -- through USAID -- for the prevention and mitigation of AIDS in the developing world.

Novak said USAID puts much of its resources in Eurasia and throughout the world into the development of NGO programs, as this is often the best approach for reaching high-risk groups such as homosexuals, prostitutes, drug users, and adolescents who do not trust government officials and "are most amenable to receiving information and support from peers."

On the question of an HIV/AIDS vaccine, he referred to the many governmental and private research programs working toward that goal, plus ongoing field trials, but said, "we probably will not be seeing results for another three to four years at the earliest."

Swales said he was "encouraged" by advances in medical technology for treating HIV/AIDS, "but there is so much more to be done, and progress is much, much too slow when compared to the cost of lives involved."

He also pointed out that "clinical treatment alone is not sufficient," and that "there has to be social support systems in place to help [patients] adhere to the treatment regimen. And that can be very difficult on 40 to 80 pills a day."

Cooperative efforts to combat HIV/AIDS relies on political support from local police and local governments, and the United States is trying to reach such agreements with local entities in the Russian Federation, Novak concluded.

Swales concurred, saying "the success or failure will depend on the building of relationships."

Following is a transcript of the broadcast:

(begin transcript)

"DIALOGUE"

United States Department of State
Office of Broadcast Services
Washington, D.C.

GUESTS: John Novak, HIV/AIDS program Coordinator for Eastern Europe and Central Asia, Office of Health and Nutrition, U.S. Agency for International Development (USAID)

George Swales, Director of AIDS Education and Prevention Services at the Whitman Walker Clinic, Washington, D.C.

TOPIC: U.S.-RUSSIAN COOPERATION IN FIGHTING AIDS

POSTS: Moscow, Yekaterinburg

HOST: Rick Foucheux

DATE: July 31, 2001

TIME: 08:00 - 09:00 EDT

SECRETARY OF STATE POWELL (from videotape): Ladies and gentlemen, the world has entered an age of immense promise, the spread of democracy and market economies, breakthroughs in technology permit us to envision a day in this century when most of humanity will be free from tyranny and poverty.

Yet we have been blind to the fact that this promising new century has arrived at a time of plague. It is 20 years since the onset of the HIV/AIDS crisis. But we have only just begun to grasp the threat it poses for this promising new world. AIDS is often linked with the bubonic plague of the 14th century which killed one-third of Europe. But this is not the Middle Ages, ladies and gentlemen. Back then people did not know what caused the pestilence or how it spread. They thought it resulted from an alignment of the planets, or was visited upon them for their sins by a wrathful god.

We of the 21st century know better. We know that a virus causes AIDS, and we know how to prevent its spread. Treatments have been developed. Science has given us grounds for hope for vaccines and ultimately for a cure. AIDS respects no man, woman or child. It knows no race, religion, class or creed. No community, country or continent is immune from its ravages. Let us resolve that from this moment on our response to AIDS must be no less comprehensive, no less relentless and no less swift than the pandemic itself.

President Bush joins Secretary General Annan in the conviction that AIDS is so immense in its scope and profound in its impact that it compels new thinking and concerted action. As the president has said, only through sustained and focused international cooperation can we address problems so grave and suffering so great. In this global war against AIDS, everyone can and must be a leader. Everyone can and must be an ally. We are all vulnerable -- big nations and small, the wealthy and the poor. We cannot let AIDS divide us. My country is ready to work with all nations to build a global coalition of action against this common foe.

[end videotape]

MR. FOUCHEUX: Hello, and welcome to "Dialogue," I'm Rick Foucheux.

The Russian Health Ministry reported the number of registered HIV cases reached 105,000 this year -- almost quadruple the amount registered between 1987 and 1999. And experts predict the actual number of cases in Russia to be substantially higher than registered.

In response to the global AIDS pandemic, tuberculosis and malaria, President Bush announced in May a pledge of $200 million to jump-start the Global Fund, a new public-private partnership. Beyond the Global Fund, the U.S. government, through the U.S. Agency for International Development, has to date dedicated over $1.6 billion [$1,600 million] for the prevention and mitigation of AIDS in the developing world.

Here today to discuss the U.S.-Russia partnership in the fight against AIDS are our distinguished guests: Dr. John Novak, the HIV/AIDS program coordinator for Eastern Europe and Central Asia for USAID's Office of Health and Nutrition here in Washington, D.C.; and we also have with us today George Swales. Mr. Swales is director of AIDS education and prevention services at the Whitman Walker Clinic, also in Washington.

We welcome our participants who are standing by in Moscow and Yekaterinburg. But before we join them: Dr. Novak, let me see here, you coordinate the USAID response with those of national governments and other international donors, including UNAIDS, the World Bank, the EU and the Soros Foundation -- that's quite a list. Can you briefly describe how all of these groups are working together to combat AIDS in the NIS?

DR. NOVAK: We formed an alliance a few years ago because the epidemic is still in the early stages in this part of the world. We have relatively few resources to work with at this point in the epidemic, and we all bring comparative advantages to this fight against the disease. For example, UNAIDS provides the political leadership, and works very closely with governments in the region. The Soros Foundation does a lot of harm-reduction work -- that is, harm reduction with injecting-drug users -- and can provide syringes and needle exchange programs, which we cannot do. USAID cannot provide syringes and work directly with injecting drug users. And of course, USAID has a long history, as you mentioned, of working around the world in HIV prevention programs. So all of us bring our comparative advantage, and we work closely together to of course maximize our effect on the epidemic.

MR. FOUCHEUX: Mr. Swales, the Whitman Walker Clinic here in Washington is working in partnership with USAID to combat AIDS in Russia. Can you describe for us some of those efforts?

MR. SWALES: Whitman Walker Clinic was the lead agency in conjunction with two other U.S. partners here in Washington, each of which specializes in different areas. And in a sub-agreement under a USAID contract with Population Services International. And we provided technical assistance in the Saratov Oblast in Russia -- capacity building, skills building, information exchange, knowledge exchange, outreach -- a number of things including sustainability and planning.

MR. FOUCHEUX: All right. Well, thanks for that overview. And once again we welcome you to the program -- appreciate having you for an interesting conversation today.

And now we go to Moscow and Yekaterinburg for your questions. Hello in Moscow. Please go ahead with your first question or comment for our guests on "Dialogue."

Q: (Off mike) -- organization in Moscow. My question is as follows -- it deals with securing speeds (?) in Russia. Unfortunately here in Russia it's a prerogative of the government, and if you work in the Saratov region, is there any medical help that can be offered there, or any kind of training and securing of medical personnel itself? Thank you.

DR. NOVAK: Well, number one, USAID is working in Saratov and also in Moscow with the government and with NGOs to provide prevention programs to at-risk populations in those two oblasts, and hopefully working very closely with our Russian partners to develop model programs that can be disseminated and used throughout the country as we expand our program, and as the Ministry of Health and Civil Society expands their response to the HIV/AIDS epidemic in Russia.

Originally our program was prevention, because again, the ounce of prevention versus a pound of cure -- investing in prevention early on would avert many AIDS cases in the future. As the epidemic develops and as more people become HIV-positive, USAID and other donors, and the government itself, will be emphasizing the care and support of HIV-infected individuals to a greater extent.

I can't speak directly to the services offered in Saratov, but our mission in Moscow, I am sure, and the local ministry officials can address that issue, and I would expect that part of the program either now or in the future will be in training medical personnel to deal with the epidemic and the number of HIV-positive that will appear in the future.

MR. FOUCHEUX: We thank you for that first question in Moscow. Let's move on now to our guests who are in Yekaterinburg. Hello there, please go ahead with your first question or comment. Hello in Yekaterinburg, please go ahead with your first question today on the subject of HIV/AIDS. (Technical difficulties.) Okay, we are still waiting for Yekaterinburg. Okay, let's go back to Moscow for more questions. We'll get back to Yekaterinburg in just a moment. Moscow, please go ahead with more questions for our guests.

Q: (Off mike) -- from the Russian Association on Sexually-Transmitted Diseases. A question to John Novak. Do you plan within the framework of this program to work with NGOs who deal with treatment of sexually-transmitted diseases, and to what extent do you plan to work with them?

DR. NOVAK: I can I think answer from a regional perspective more than from a Russia-specific perspective. As many of you know, USAID is decentralized, and our missions in our countries determine priorities and plan and implement most of our programs. We do of course provide support from Washington, and there are some regional initiatives also within Eastern Europe and Central Asia. But again, our mission in Moscow is the USAID technical group, which sets priorities.

We have worked with SANAM in the past, and I would expect that we would continue to work with SANAM in the future. One of our global strategies, three global strategies, is to control STI, sexually-transmitted infections, along with of course condom availability and behavior change towards safer sex practices. And we will be putting more emphasis on STI control and treatment around the world in the future. And since the rates of STIs are so high in the region, we of course will be putting emphasis on this.

So in answer to your question, I think we should expect an increased emphasis in this area in the future.

MR. FOUCHEUX: And we remain in Moscow for more questions. Please go ahead once again.

Q: I am -- (inaudible) -- the Russian Association of SANAM (ph), sexually-transmitted diseases. What kind of interference along with the non-governmental organizations working interventions working against AIDS infections do you consider effective, especially working with epidemiologists?

DR. NOVAK: As you know, especially early in an epidemic it is critical that we work with high-risk groups, groups that are most vulnerable to the infection. And those groups usually are men who have sex with men, commercial sex workers or prostitutes, adolescents, and in the case of Eastern Europe and Central Asia, injecting-drug users. The best approach to reaching these groups is usually working through NGOs and non-governmental organizations. Many of these groups are stigmatized. They feel discrimination. They do not trust government officials in many cases, and therefore they are most amenable to receiving information and support from peers. So, again, for many around the world this is the best approach in most cases. So USAID puts much of our resource in the region into the development of NGO programs as well as around the world. And we would continue I think to do this in Russia over the next several years.

MR. SWALES: I think that there is a matter of two approaches in working with STDs [sexually-transmitted diseases] and particular HIV. There is the adjustment of attitudes towards behavior change in the first place, as well as the skills-building for actual prevention of the transmission of the virus. We really like the harm-reduction principles in terms of adjusting of attitudes, which is brought about by education, and then of course the condom distribution and behavior modification instructions and recommendations for changing that behavior.

MR. FOUCHEUX: Okay, thank you in Moscow. We'll return to you of course for more questions in a moment. Let's move on though first to Yekaterinburg for questions again. Please go ahead again in Yekaterinburg.

Q: Hello -- (inaudible) -- chief of the infectious disease clinic. My question is as follows. It is no secret that today the number of HIV-infected people is about 4,000 people. The HIV infection is spreading among narcotic users. How can we help this contingent of the population? And one way to do that, we would say, is through exchange of needles. Do you think this is possible within the framework of this organization?

DR. NOVAK: I go back to one of the reasons for our initial collaboration among donors which we referred to at the beginning of this program. While USAID as a government agency cannot provide needle exchange -- that is not something we can do -- we do work with other donors that can provide this service. DIFID (ph), the British development agency, has several needle exchange programs and can provide this service, as well as the Soros Foundation, which has over 100 needle exchange programs and harm-reduction programs around the region.

So while we can provide condoms and provide behavior change and care and support to these populations, and in many cases we work alongside these groups to provide services -- again, a complete, comprehensive prevention program to these affected populations. We can certainly provide you with the contact information of these other institutions and organizations that provide services in this area after this broadcast.

MR. FOUCHEUX: Okay, thank you, Yekaterinburg. We will be returning to you in a moment of course for more questions. Let's move back now to Moscow though. Please go ahead once more in Moscow.

Q: Hello, I am -- (inaudible) -- newspaper. Do you have vaccinations which could prevent HIV infections?

DR. NOVAK: That has been an area where the U.S. government has invested billions [thousands of millions] of dollars over the last many years attempting to develop a vaccine. The National Institutes of Health in the United States has a very large program in this area. Of course several private sector firms and pharmaceutical firms are also attempting to develop a vaccine.

There are several trials in the field presently to see if several of these supposed vaccines may have an effect. There are no results from those yet, and I have been told we probably will not be seeing results for another three to four years at the earliest. So in answer to your question, there is no vaccine available to date. But, again, we are working and others are working very, very feverishly on trying to develop one.

Q: (Off mike) -- Institute. The question that I have is as follows. The problem is that the way AIDS is treated in Russia through mono-therapy. And how do you see improving the therapeutical treatment for AIDS, and what can you suggest in this area? Thank you.

DR. NOVAK: I am not a medical doctor; I am a social scientist. And my training is in sociology, demography and other social sciences. I think I can probably answer in general terms that as you well know there have been very, very significant advances in drug therapies for HIV-infected individuals and those that have HIV itself. In fact, we have several people in our health division whose primary responsibility is to keep abreast of these changes and to brief us as to how they might be used in our programs.

So I guess I would have to defer a more technical response to others. But of course as you know these advances are really happening on a day-to-day basis, and we hope again in the future that there will certainly be more therapy for HIV-infected individuals.

MR. FOUCHEUX: Mr. Swales, from the standpoint of the Whitman Walker Clinic, are you encouraged by the amount of advances in medical technology for AIDS?

MR. SWALES: I'd say we are encouraged. But there is so much more to be done, and progress is much, much too slow when compared to the cost of lives involved.

MR. FOUCHEUX: Let's stay in Moscow for more questions.

Q: This is Igor -- (inaudible) -- who asked the first question. My question is to both Dr. Novak and George Swales, about mitigating the effect. Do you have any specific facts about how this program is effected? Because those who are for and those who are against the program are numerous. Do you have any numbers on the treatment programs?

DR. NOVAK: Now, is this drug treatments? Of course, our main focus is still on HIV/AIDS prevention. However, we do have an expanding program presently in what we call care and support. Up to 15 to 20 percent of our current budget is allocated toward the care and support of HIV-infected individuals and their families.

Now, to date most of this care and support has been in palliative care, in alleviating and treating secondary infections, providing psychological and economic support to families and infected people.

Only recently of course with these changes in the availability and costs of anti-retrovirals -- and this has taken place over the last several months, much of this in response to an initiative by the U.N. to of course make them more accessible to the world at large. And USAID at this point is developing pilot programs in several countries, because we need to learn the most effective way of distributing these drugs to HIV-positive people, and of course this will vary by region and even maybe by country. So this initiative is still under development. We'll certainly very soon be establishing several pilots in countries. But again, since this is a completely new area, we are in the design stage rather than in the implementation stage.

MR. SWALES: But at the community level our projects were small, and we have considerable evidence of the effectiveness of our teaching and training techniques. We were working of course with the Saratov regional branch of the Russian Public Charity Foundation in Balakovo (ph), Man Balakovo (ph) with -- (inaudible) -- and we were doing harm reduction, teaching effective needle exchange techniques, although we could not provide the needles. And the reports from Balakovo (ph) suggest very strongly the effectiveness of those techniques because of the increased numbers of drug users who would return to clinics for exchange of the needles. In Saratov, also working with the HIV/AIDS Center, which was focused on the commercial sex workers, we were able to see clear evidence of effectiveness as the commercial sex workers begin to trust, believe and return for further instruction, for condoms, for understanding of the techniques. So across the board we have at the community level evidence that prevention techniques that were being introduced were effective.

Q: Once again hello, this is -- (inaudible). My question is about how the international agencies can work not only with the HIV-infected group but with the general population, because the general population has very little information and knows very little about HIV. And will such programs be conducted in conjunction? Thank you.

DR. NOVAK: Public education is very important. In fact, the World Bank published a report several years ago, Confronting AIDS, where it stated that one of the responsibilities of the governments is to educate its population in the seriousness of HIV and how to prevent the transmission of HIV, as well as of course providing prevention services and as well as providing treatment. So public education is very important. And generally public education and raising awareness in the general population also gives credence to the individual prevention programs. If people hear for example from their peers that HIV prevention is important, and that certain changes in their behavior are important, or the use of condoms is important, and they hear the same message over the mass media and through official channels, then these two sources of information reinforce each other and give credibility to the program. So that is an extremely important part of an overall comprehensive program to prevent HIV/AIDS.

MR. FOUCHEUX: Okay, Moscow, please go ahead with more questions. Okay, while we are waiting for Moscow, let's see if there are questions coming out of Yekaterinburg. Hello again in Yekaterinburg. Please go ahead one more time.

Q: I am from the newspaper -- (inaudible) -- and the question is as follows: Does the United States have a problem of HIV terrorism, people who intentionally infect others? And are there any ways to protect against that?

DR. NOVAK: There have been some newspaper accounts in the United States of occasional episodes as you refer to. One example recently was a young man in New York State who knew he was HIV-positive -- he was in his mid-20s -- and he had sex with a number of adolescent girls, mainly from 16 to 20, and over a period of many months, and out of 13 or 14 sexual contacts, he infected six young women. He was brought to trial, and he was convicted. So that is one case I know of through the newspaper. Mr. Swales may know of others. But this is an issue. How serious an issue inside the United States I don't know. But again, going back to practicing safe sex, using condoms and reducing the number of sexual partners of course would go a long way towards averting this sort of issue.

MR. SWALES: I only know of the exact same cases. Of course we would depend on the criminal prosecutorial system to address that. And from a prevention standpoint we would redouble our efforts at education and prevention. I don't know how that can be controlled. I would think that the nation could only respond to such events.

Q: Hello, I am Roxana Grebenic (ph). I represent the information agency, European News. At the last meeting of the heads of state, an International Fund of Health was created, which in addition will work on the AIDS issue. To what extent can this fund help your program in Western Europe and in Russia specifically? Thank you.

DR. NOVAK: The Global Fund for HIV, TB and Malaria now has approximately $1.7 billion [$1,700 million] from both private sector, the U.N. and the major donors. And we expect it to grow, and hopefully we expect this to continue over the next several years. We, USAID and other donors, are working very closely with the U.N. to establish a secretariat to set priorities for the fund, to manage the fund, and to allocate the fund to country programs. In fact, there was a meeting in Brussels I think just last week, or a couple of weeks ago, and it was again the outlines for this secretariat were established, and to the best of my knowledge this will be organized within the next several months. In fact, I think one deadline is to get the fund operational by the end of 2001, by December.

It is still I think undecided exactly how to allocate the funds. I do know that the secretariat and the technical committee will be deciding I think on a country-by-country basis, based on the severity of the epidemic, the capacity in countries to absorb the funds and probably to a certain extent the political commitment to support an expanded program. But you will be hearing much more about this fund over the next several months. And of course it is in all of our interests to involve as many people in governments and institutions as possible, and again all work together to make sure this money is allocated in the most effective manner.

Q: Hello -- (inaudible) -- from Yekaterinburg, the local newspaper. What kind of treatment measures are most effective in practice? Could you just enumerate them? Thank you.

DR. NOVAK: Treatments? Again, this is a very technical area. I assume you are mentioning the treatment of people with advanced stages of HIV or people that have full-blown AIDS. There again anti-retrovirals have proven very effective. There have been changes, however, in how they are administered. Originally the idea was you might provide anti-retrovirals early in the disease rather than later. I think because some of them are fairly toxic and some people cannot adjust to them very well -- in fact, some people cannot tolerate them at all -- the new treatment regimes wait until the disease is more advanced and then of course the anti-retrovirals are applied at that time. So just being HIV-positive does not mean that you probably should be taking these new drugs. You may have to wait for the appropriate time.

Now, the other issue is you need a sophisticated medical infrastructure to take T cell counts and to monitor, because in many cases the HIV virus will mutate, will adjust, and you will have to apply a new mix of the drugs. So, again, this is a fairly complicated treatment. We are still learning. It is being adopted, but it has of course proven effective in reducing HIV mortality rates in many countries around the world. Although I repeat, these drugs are toxic; you have to be very disciplined to take them in an effective way, and of course medically you have to be followed to track the progress of your disease and to be sure that the drugs you are taking are appropriate.

MR. SWALES: And our experience has been that of course the clinical treatment alone is not sufficient. There's a fairly strong requirement of a social support system for those persons who are on treatment, because they have other needs that impact both their mental health and their health status. So there has to be social support systems in place to help them adhere to the treatment regimen. And that can be very difficult on 40 to 80 pills a day.

MR. FOUCHEUX: And is this support offered by groups like the Whitman Walker Clinic?

MR. SWALES: It is true of the Whitman Walker Clinic. We are a comprehensive AIDS service organization providing the whole range from prevention through diagnosis through treatment and social support service, through legal services, to reemployment.

MR. FOUCHEUX: Did I understand you correctly -- did you say 40 pills a day in some cases?

MR. SWALES: It can be as many as 80.

Q: (Off mike) -- chief, infectious diseases clinic. In Yekaterinburg the number of HIV-infected patients is rising, as well as women who are pregnant. Now we have 68 births by HIV-infected women. We are expecting as much this year. But we cannot diagnose the children for HIV because we don't have enough facilities to do it in Russia, in Yekaterinburg in particular. The question is do you have any ways to provide the aid in treating the processes for diagnosing and testing for HIV in such children?

DR. NOVAK: Part of USAID's expanded HIV prevention and mitigation program beginning in this year, 2001, will be to pilot effective mother-to-child transmission programs, and to expand these programs. Part of our congressional earmark on these funds is to expand these programs, and this is of course one of many of our prevention and treatment priorities.

I have been told by a colleague in my division again, one of the experts in this area, that it is very difficult to diagnose HIV in infants under two years of age. He said that the tests are expensive and they are more difficult to administer than the normal HIV tests for people who are older. Also, many infants have HIV antibodies in their blood. They don't have the virus -- they may not have the virus, but they may have their mother's antibodies. And therefore manyinfants may or will test HIV-positive -- they are false positives -- they test positive when they don't have the virus.

So I guess in partial answer to your question this is a more technically sophisticated area with infants. And again in maybe a broader context, we are developing pilot mother-to-child transmission programs in order to reduce of course, as you well know -- you can reduce by 50 percent or more the transmission of HIV from mother to child using Nevarapin and other effective interventions.

Q: Hello, my question is as follows. Have you had any chances -- had times when you noticed that HIV has been transmitted when organs were replanted? What information do you have about that?

DR. NOVAK: To the best of my knowledge I know of no instances where that has occurred, although of course it could be. It's possible. I'm not sure in the United States what the medical procedures are. Are people tested for HIV before they can provide organs? Or are organs tested? I really can't answer that question. I would expect it would be a relatively minor transmission route, since of course there are relatively few organs which are transplanted. Of course for the donor that's not an adequate response.

I would expect that the Department of Health and Human Services in the United States has protocols for this, and I have been advised that probably WHO [World Health Organization] also would have maybe universal protocols. So that might be a place to start. Number one, Are there protocols? And then of course, number two, Are governments and the private sector implementing those protocols to protect donors against this possibility?

MR. SWALES: I believe there are protocols, and I would expect them to be among the most rigid and strictly adhered to, when you consider the protocols that we use in the blood donation process. I would certainly think that when considering transplantation of organs that those protocols would be extremely strong.

Q: Roxana Grebenic (ph), European Agency News. We have already talked about the numbers for Yekaterinburg -- 4,000 infected in Yekaterinburg, 10,000 in the oblast. But we are not quite sure whether we can call this an epidemic. It depends on the various programs. What do you think is the level at which a disease can be considered epidemic in proportion? Thank you.

DR. NOVAK: Probably defining an epidemic is I think part science and part art. I think to a large extent it depends on the concentration of cases and the time period in which they take place, and how serious public health officials consider this as a danger to the general population. I guess on a national level UNAIDS and the World Bank and other donors have three levels of HIV -- I guess HIV, the seriousness of the epidemic. The first is called a low-grade epidemic, where less than 5 percent of the high-risk populations are HIV-positive, populations such as sex workers, men who have sex with men, injecting-drug users, et cetera. And this usually is concentrated mainly in these high-risk groups in the population.

The second stage is called a concentrated epidemic, where the levels in these high-risk groups exceeds 5 percent. For example, sex workers in several cities around the region can have HIV-positive seral prevalence rates of 45 or 50 or 60 percent. Another example is Mikailyov (ph) in Ukraine, where between 1995 and 1996 the seral prevalence rate among injecting-drug users in that city went from about 10 percent to 60 percent in one year. Again, HIV can travel very quickly through injecting-drug user populations because of course of sharing needles and blood exchange. So a concentrated epidemic again is where you have high levels within these at-risk populations.

The third, or generalized epidemic, is when the seral prevalence in the general population is 1 percent or more. And generally the measure is antenatal women, pregnant women, and when the percentage exceeds 1 percent we can say the virus has entered the general population, and of course the prevention activities should be expanded.

I don't know the population of your oblast or your city, but if you are talking in the thousands of HIV-positives, and if they have been identified in a relatively short time period, and because HIV travels so quickly through injecting-drug user populations, I would consider that you probably have a local epidemic, and should take serious measures to contain it.

MR. SWALES: He certainly made my point. The speed at which the epidemic travels would be very, very significant in defining an epidemic. Other than that I certainly confer.

MR. FOUCHEUX: We thank you for those questions in Yekaterinburg. And we move on once again in Moscow. Please go ahead once again in Moscow.

Q: Once again hello, Igor -- (inaudible). My question is for George Swales. As a practicing medic, how do you view nontraditional methods to support people with HIV, such as various Chinese nontraditional medical means and others?

MR. SWALES: I should clarify that I am not a clinician. I am not a medical doctor. I am a health educator, professional health educator. Nevertheless, in the United States the nontraditional practices are becoming very, very widespread. We are using at the Whitman Walker Clinic many, many techniques. In community-based organizations which are largely based on volunteer manpower, one of the benefits is that the volunteers bring to us the skills that they use in their normal conduct of their business. At Whitman Walker Clinic we have traditional medical physicians, we have mental health clinicians, mental health practitioners, various alternative care techniques, and they are welcomed and they are tried within the bounds of standards of practice. Other community-based organizations have different leanings, depending on geography where they are. Obviously rural centers are very regionally traditional. The more urban centers are more adventurous.

MR. FOUCHEUX: Please go ahead once more in Yekaterinburg now.

Q: Hello -- (inaudible) -- I represent the Ural Association of Women, and that's why I am interested in the following question: What is the women's movement doing in the United States in order to solve this problem? Do you have any information regarding this? And are there specific examples of cooperation of your organizations with Russian organizations?

MR. SWALES: I am not aware of any specific examples. The women's organizations with which I am most familiar have dedicated most of their energy into prevention through means of education of women and the population at large. Also, women have emphasized, rightly so, the impact of HIV on families.

DR. NOVAK: I would agree with that. We do have many strong women's organizations within the country, within the United States, and I would expect that this is one of their priorities -- at least many of them who are members of or have relatives who are in high-risk populations within the United States. I guess that would be a question that we would have to follow up with and maybe provide you with more information after this broadcast.

MR. FOUCHEUX: Okay, thank you for that question in Yekaterinburg. We are in our round robin section of the program now where we are going back and forth. So we return once more to Moscow.

Q: (Off mike) -- Russian Association. My question is for John Novak and George Swales both. When the Global Fund to fight AIDS, malaria and tuberculosis has just been created -- when do you think in real terms this partnership between Russia and the United States will start, and will there be any programs for prevention education in HIV/AIDS which -- will you have first the pilot programs or will these programs be federal programs? How do you see that developing? Thank you.

DR. NOVAK: I think there are two parts to the answer to your question. Number one is that the United States already has a partnership with Russia. We have established that partnership in 1998, and we have been jointly working to combat HIV/AIDS in Russia, hopefully learning many of the mistakes we made in the United States initially of not taking the epidemic seriously enough, and of course also sharing some of the better approaches to preventing HIV among vulnerable populations. So USAID has a relationship with the Ministry of Health and the Russian HIV/AIDS Commission.

Number two, the National Institutes of Health are working with Russian researchers in several areas -- I would expect in vaccine research as well as in many other areas. So again that is an established relationship, an ongoing relationship.

With reference to the Global Fund, I would expect that Russia, because of your technical expertise and because of your emerging epidemic, and hopefully political commitments, I would expect that some of the global funds would be allocated to expand your program, and the U.S. and USAID and the U.S. government would be expecting and supporting this development and working closely with the fund to hopefully make this happen.

MR. SWALES: I would agree. The partnership certainly already exists. And, as I cited before, one of the functions of our work with Population Services International was exactly to plant innovative models of education, of outreach, of needle exchange, community outreach, in the local oblasts, the local regions. So it's already there. It's simply a matter of growing it.

DR. NOVAK: And if I could mention one more partnership, ongoing partnership. A portion of the USAID program of our funds supports a CDC program in Russia, working with SANAM (ph), working with sex workers, improving STI diagnostics and STI treatment protocols. So the Centers for Disease Control and Prevention is also a partner, along with USAID and NIH, in this partnership with Russia.

MR. FOUCHEUX: And I'd like to mention here that before we close out our program today in just a few moments we will be giving some Internet addresses where you can go and find out more information about these places.

But let's return now once more to Moscow. Please go ahead again in Moscow. I beg your pardon, that was Moscow. Let's go on now to Yekaterinburg. Thank you.

Q: Hello, Nikolai Stroyn (ph), Center for Epidemiological Control. AIDS and tuberculosis problems in jails. How will the cooperation partnership in Russia and the United States be developing in this area? Thank you.

DR. NOVAK: As you well know, tuberculosis in prisons is a very, very serious problem -- overcrowding, people living very close to each other, and again not in many cases receiving the appropriate treatment. USAID -- I believe a part of the USAID program, although probably a small part at this point -- is working with inmates to prevent and treat TB. USAID also has a separate TB program in Russia, and this is operated by another unit within our agency. So I am not as I guess well versed in its priorities or how it's being implemented.

I do know for example that several of our other partners are very interested -- NSF, who has worked in Russia for many years, I think has done some assessment work in prisons in Russia. And I do know that the Soros Foundation again is thinking about expanding their program into several prisons. So I guess I can't give you a complete answer at this point, but we all are well aware that this is a very, very serious issue, and hopefully it will become a higher priority and an expanded program in the future.

MR. SWALES: We do not have any expertise in prisons in Russia. We were invited to visit one such place in Saratov for the purpose of observation and to do minimal education. That to us illustrated an interest on their part in confronting a problem that they clearly recognize they have. But as the doctor says, prison populations, because of the proximity and the close living and many, many hazards there. Here we have other agencies whose thrust and interest and emphasis is on prison populations. So that expertise would be available should USAID choose to contract for those services I am sure.

MR. FOUCHEUX: We are almost out of time, unfortunately, but let's move on for one final question, and I'll ask you to be brief in Moscow please. A final question, go ahead in Moscow.

Q: (Off mike) -- Epidemiological Institute. I have a question to both Novak and Swales. The fact is that many prevention programs are stopped in Russia because local authorities are against it, including the police. This is the exchange of needles, handing out condoms, working with sex workers. Could you tell us about your experience and help us in this issue? Is there some kind of an agreement on a governmental level between the two sides to provide support in this? Thank you.

DR. NOVAK: Okay, basically much of this relies on political support at the local level with local police and local governments. And a successful program requires that. And we attempt of course to reach these agreements. George?

MR. SWALES: Exactly. And the success or failure will depend on the building of relationships.

MR. FOUCHEUX: Great, gentlemen. Thank you for being brief on that answer. Regrettably we have run out of time and have to conclude our program for today. But for more information on the U.S. response to the global AIDS crisis, click on the World Wide Web at www.state.gov, and www.usaid.gov.

We'd like to thank once again Dr. John Novak and George Swales for joining us today, as well as all of our participants in Moscow and Yekaterinburg. From Washington, for "Dialogue," I am Rick Foucheux. Thanks for watching, and good day.

(end transcript)