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Harden: But was this AIDS institute clinical, to take care of patients, to do research, or both?
Quinn: To do research. The problem with clinical care of AIDS patients in India was that they did not have the drugs or the money to pay for them. Just like in Africa, once you were diagnosed with HIV, there was not much to do about it.
What he wanted to know was this the same virus in India? Who was susceptible? How was it spreading? What can we do to stop its spread? And can we make a vaccine here? Because we were in the 1990s and everyone was talking vaccine, vaccine. That is exactly what he did. He set aside a new institute, built it from scratch, called NARI, National AIDS Research Institute. And it was the sister institute to NIV.
Now, the then-director of NIV was not very happy about this. He thought it should all be part of NIV. So there was a political struggle about this. In India, everything is very political. But the two institutes function separately. At the present time, each one has its own director. Hopkins and the NIH are affiliated with NARI at this point for AIDS research. Now, [Dr. Robert] Bob Purcell here at NIAID, who does hepatitis research and other virologic research, is still working with NIV. So NIAID itself works with both. I work for NARI and Bob Purcell and others with NIV. Then Hopkins got pulled in through this Dr. Bollinger to help facilitate the U.S. funding.
What the Indians said they would do is match the U.S. money. So if the United States gave $500,000 a year, which is what the funding was, the Indians would put in $500,000. But in fact they put in more because they built the big institute. It is a beautiful institute. It was completed in 1993 or 1994, so it has been occupied for the last two or three years. Their scientists go to Johns Hopkins under a Fogarty International Training Grant, and they shuttle back and forth. We basically take four of their scientists every year, and they either get an MPH [Masters in public health] in epidemiology or they get laboratory science instruction in technology transfer. In fact, the director of NARI just came over and spent six months with me and Dr. Bollinger and Dr. Fauci in Dr. Fauci’s laboratory, and he just returned. Dr. Gadkari is his name.
So there is a very nice working relationship between the Americans and the Indians on this project. Now we are not the only ones. Other projects have started to develop in Bombay, where the epidemic is very bad. There are a number of other groups working there. The University of Texas has a group working out there with a Dr. Hera. Other sites: Dr. Jacob John, still in Vellore, is building an AIDS program there. We have been into Hyderabad and also a couple of other cities where we have been looking at truck drivers. Again, truck drivers played a key role in the spread of HIV in Africa. We wanted to see if they were doing the same in India, and the answer is yes, they were. There are very high rates of infection from truck drivers as they move from town to town. They are basically responsible for the movement of the virus into the rural areas of India. In the urban settings, where we have been working, it is all heterosexual transmission. In the north, in a state called Manipur, it is injecting-drug use. Manipur borders onto Burma and surrounding areas as part of the golden triangle for heroin exportation, and so HIV is very widespread in that area.
Although it took the Indians maybe four or five years to recognize that HIV was there and spreading, as the government turned over with different scientists, different appointees from the ministries and so forth, a recognition came about that there was a problem and they needed to do something about it.
The sad part is that back in 1986, when we first started, there were only a few infected people in India, a country of almost a billion people. It was almost a negligible epidemic. If they had alerted the population, tried to implement some very vigorous educational campaigns, they might have been able to slow it. But by waiting four years, the epidemic had already gone from just a few cases to probably two million, that fast, because of the sheer population. Now it is at 41⁄2 million in India. No other country in the world has as many HIV-infected people at this time as India does, and it has only been there for the last eight or nine years. So it is a very sad situation in which the Indians could have learned from others.
But India should not be singled out. Almost every country that I have worked with from the very beginnings of its epidemic, if the numbers of AIDS cases are low, does not think they need to put many resources into fighting this epidemic. America is no different. We started out with AIDS cases because we did not know HIV was about. But after you learn that HIV is the cause, then you start doing surveillance for HIV, and you go to the government and say, “You have got infected people. Do something. Start a campaign.” They say, “But we only have a few cases of AIDS. We are not as bad as you in America.” That is the normal reaction. We were just in Malaysia. They gave us that same reaction; Indonesia, same reaction. And many of the African countries during those early years of the epidemic were saying, “You are only here to point the blame at us, but your country has the most cases. You should have the blame.” It became a finger-pointing contest in many of the early years of this epidemic. I think that has changed. We are not doing that as much.
Harden: Do you think that is primarily because of political expediency, the people in power at a given time do not want to deal with it? Or do you think it is lack of understanding of the science and the medicine of how it works? Is there a way to change this?
Quinn: It is definitely the latter. In India, it was a definite misunderstanding about this disease, that HIV could take that long to become positive. They also really thought that Asians were resistant to this epidemic. I remember in 1986, they said, “Look, we are the only area in the world that does not have any AIDS cases except those that got infected in the United States and came here to die.” It was true, if you looked at all of Asia, in two to three billion people, no one had AIDS in 1986, 1987, or 1988. It was almost nonexistent. Back then everyone was saying, “I will bet you there is a genetic resistance and that the Asians have that genetic resistance.” That is not the case anymore. So there was a misunderstanding of the science. Then the second was, it was political expediency to deny that there was this big problem because you would have to put resources into it, and you had limited resources.
Hannaway: Resources are finite.
Quinn: Right. Also, it went against the grain of the country to say, hey, we have a heterosexual epidemic of HIV. No one wanted to admit that. Certainly, I know from visiting in Malaysia, which is a Muslim country, by and large, that prostitution is not supposed to occur in a Muslim country. Injecting-drug use? That cannot occur. Well, it does whether people like it or not. There is travel abroad, there is poverty. Poverty and travel interlinking brings HIV to the poor, where they are trying to service people’s sexual needs, if that is what you want to call it, and certainly Thailand knows that. They have learned their lesson, and they have closed many of the brothels down as a result. Injecting-drug users are getting certain types of rehabilitation to try and slow down the spread of HIV through injecting-drug use.
There are many lessons that one learns about society from this epidemic. I think it reflects many of the faults of the worldwide society, and it also reflects the cultures of individual countries, because AIDS spreads differently in different countries, depending on what their culture is. For us, in the 1970s, we had this free love, come-out-of-the-closet, gay-life time, and that is what caused AIDS to spread like wildfire. As we moved into the 1980s, we had a real drug problem. It was not as big in the 1970s. But in the 1980s, we had a real drug problem. You know that from the number of visits to emergency rooms due to crack cocaine. There were approximately 10-fold increases everywhere in the mid-1980s. As that becomes part of your culture–and that is one of the ways HIV gets spread–it moves into that. It changes the face of the epidemic. When you go to Thailand, you have two things happening in their culture. One is a drug trade, which is up in the north of Thailand along the Burmese and the Chinese border. It is the golden triangle and so forth. And you have a sex trade. So, as the virus moves in, it quickly gets into those two high-risk groups and that becomes a part of the epidemic, first drugs and then the heterosexuals. Why it took so long to get there, I do not know, because that culture has been like that for the last 20 to 30 years, or even longer.
Hannaway: The sex trade really developed in conjunction with the Vietnam war. Thailand was a place for soldiers from Australia and America to have R and R [rest and recreation].
Quinn: Right. I do not understand why it did not take off sooner. It is well known that Europeans, Americans, and others go to Thailand and engage in some of that sex tourism, I guess it is called. But HIV was not a problem until the late 1980s. It really took a much longer period of time to start. That was not true for the Caribbean, South America, the Americas in general, Europe, or other places.
We have been talking about what is happening in Asia, and it is very interesting working in Japan as well, because the Japanese right off the bat said they did have an AIDS problem, but it was all in their hemophiliacs and it was due to exported blood from the United States. They were absolutely correct. The beginning of their epidemic was solely in hemophiliacs, and it was due to blood products from the U.S. prior to our implementation of screening. Tens of thousands of hemophiliacs got infected. For the next 10 years, that was all they said.
But meanwhile, as HIV was starting to spread in Thailand and neighboring countries, it was also starting to get into Japan. For the early years of the 1990s, the Japanese refused to acknowledge that any Japanese nationals were getting HIV-infected because they just did not think their nationals would engage in this sex tourism or anything. They said, “HIV is now in two groups in our country: foreigners and hemophiliacs, and that is it.” It has only been within the last year that Japan, a very well-developed, economically well-off country, has come to the realization, “Oops, it is now in our own nationals due to heterosexual spread, drug use, and back and forth from other infected people, the hemophiliacs to their spouses.” They clearly now recognize it is endemic in their country. But it took them so long to realize that, because it went against the grain of their culture. Their culture does not want to admit that there might be promiscuity or a drug problem.
Harden: How does that compare to the Communist Chinese? Do you have data on that situation?
Quinn: The Chinese are very interesting. Now I have not been to China, but a couple of my colleagues have. What is interesting in China is that China has readily admitted they have a problem with HIV in Hunan Province, which is a southern province. It is part of the golden triangle. It is the southern border of China. They are worried about the area neighboring Hong Kong. It is called the Guangxi Province. I think I am saying it right, Guangxi. But the Chinese now say that they probably have anywhere between 50,000 to 100,000 infected people, and two years ago they said they had none. So they have come to the realization that it is moving in. It is moving into hot areas, those being the injecting-drug users through the Hunan Province and then some of the sex activities–I do not want to call it sex trade–but there is that element to it near Hong Kong. As China takes over Hong Kong, that could be a concern.
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