# News this Week

Science  11 Jul 2014:
Vol. 345, Issue 6193, pp. 122
1. # This week's section

## Random samples

### Scuffle over sage grouse

Conservation biologists aren't happy with U.S. government plans to largely adopt the state of Wyoming's strategy for protecting the greater sage grouse (Centrocercus urophasianus)—a declining grassland bird at the center of a national controversy. The strategy fails to preclude intrusive development in key habitat and preserve the bird's wintering range, the scientists say in a report issued this week by Defenders of Wildlife. The critique comes in response to last month's decision by the federal Bureau of Land Management to start implementing elements of the state plan on some 800,000 hectares of federal land in Wyoming. Grouse numbers have declined by half in recent decades and the state, which holds an estimated one-third of the remaining population, developed its strategy in 2011 in a bid to prevent the bird from being added to the federal endangered species list. Such an endangered species listing worries officials in the 11 states where the grouse lives because it could trigger extensive regulation of oil and gas drilling and other land uses.

### A font of cosmic rays

Physicists have long sought the sources of ultra–high-energy cosmic rays, which can strike the atmosphere with as much energy as a well-thrown baseball. Now, researchers with the Telescope Array, a collection of 507 particle detectors covering 700 square kilometers of desert in Utah, have observed a broad “hotspot” in the sky in which such cosmic rays seem to originate. In 2007, researchers with the Pierre Auger Observatory, an even bigger array in Argentina, reported that ultra–high-energy cosmic rays appeared to spring from certain galaxies, but that correlation weakened with more data. The Telescope Array team took a simpler approach, looking only for evidence that the cosmic rays do not arrive in equal numbers in all directions. From 2008 to 2013, they spotted 72 ultra–high-energy rays, 19 of which clustered in a hotspot (in red) in the sky about 20° in radius, as the team reports in a paper in press at The Astrophysical Journal Letters. http://scim.ag/rayhotspot

### Ancient ‘pyramid’—or volcano?

A controversial research project in West Java, Indonesia, claims that piles of columnar andesite rock littering the site of Gunung Padang represent remnants of “the world's oldest civilization.” But Indonesia's scientific community disputes the claim, saying that the rocks are likely just remnants of a volcano. Lead scientist Danny Hilman Natawidjaja, who received a Ph.D. in geology from the California Institute of Technology and is now at the Indonesian Institute of Sciences, says that beneath the jumbled rock columns lies an underground pyramid constructed more than 10,000 years ago. A tomographic analysis of the site reveals a low-velocity zone that he says is likely humanmade—like a large room. But geologists dispute this; for example, Awang Satyana, a senior geologist at Indonesia's Ministry of Energy and Mineral Resources, told Kompas.com in October 2013 that the low-velocity zone could be due to the presence of partial melt or even a natural cave—consistent with a volcanic origin. Natawidjaja, however, says he is undaunted by the skepticism. “We're not stupid to put our reputation at risk,” he says. The project has drawn some support from Indonesia's president, Susilo Bambang Yudhoyono, who issued a presidential regulation to protect it from vandals after local villagers attacked the site last year for fear that drilling could generate landslides.

## Around the world

### Lompoc, California

Carbon observatory in orbit

### Des Moines

The case of the stolen seeds

Expanding an existing case, U.S. prosecutors have accused a Chinese agricultural scientist of conspiring to smuggle patented corn seed to China. The 1 July indictment of Mo Yun, a research head at Beijing-based Dabeinong Technology Group, increases the number of defendants in the trade secrets case to seven. Prosecutors allege that Mo Yun helped her brother, Mo Hailong, coordinate a group that roamed rural Illinois, Indiana, and Iowa in rented cars, digging up seedlings, stealing ears of corn, and illegally obtaining packages of seed. The investigation began in 2011, after an employee of corn breeding giant DuPont Pioneer spotted one defendant on his knees in a field, digging. According to court documents, the alleged thieves also attempted to smuggle patented seeds to China in microwave popcorn boxes. http://scim.ag/seedtheft

### Bethesda, Maryland

Smallpox found in federal lab

Federal researchers discovered six forgotten vials of smallpox virus in a storage room at the National Institutes of Health (NIH). The vials, apparently dating to the 1950s, were found in a Food and Drug Administration lab at NIH, according to the Centers for Disease Control and Prevention (CDC). On 7 July, CDC transferred the vials to its high-containment lab in Atlanta, where testing confirmed they contained variola virus DNA. CDC says the vials will be destroyed per a 1979 World Health Organization agreement that allows smallpox stocks to be retained only at CDC and at Russia's VECTOR laboratory in Novosibirsk. Most Americans born since 1972 are not vaccinated against smallpox, which killed hundreds of millions before it was declared eradicated in 1980.

2. Australia

# First, do harm reduction

Australia's aggressive efforts to stop HIV's spread via injecting drugs averted a catastrophe.

Shortly after a test for HIV came to market in 1985, researchers at St. Vincent's Hospital in Sydney looked for the virus in 200 people receiving treatment for addiction to heroin and other injection drugs. At that point, the small but frightening AIDS epidemic was concentrated in gay men, and only one drug user tested positive. But a closer examination of this man's sexual and needle-sharing contacts, who were not in the initial study, told a more unsettling story: Four of six people tested had the virus. “That study was a real call to action,” says Alex Wodak, director emeritus of the hospital's alcohol and drug service. “We knew that we had to do something quickly and what we did had to work.”

Wodak convened a meeting of people who injected drugs and professionals who worked with them. “Everybody in the room had exactly the same focus and obsession,” Wodak says. “We all wanted to stop the epidemic. And we were all prepared to do whatever it took.” They collectively agreed on what was then a radical plan: They would launch needle and syringe exchange programs as widely as they could to provide clean equipment to users. This was in violation of the country's drug laws, but they so fervently believed in what today is called harm reduction that they decided to take the risk.

The program began in November 1986, and the police vice squad soon called in Wodak, the public face of the effort, for a grilling. “I spoke without pausing for breath and explained to them that this was a serious issue,” Wodak recalls. He barraged the police with statistics about how quickly HIV can spread among people who inject drugs, infecting 50% of a needle-sharing population within 6 months and dramatically accelerating sexual spread. Contaminated needles and syringes, not drugs, transmit viruses, he stressed. A senior policeman then pulled Wodak aside and told him that they wouldn't be pressing charges. “I knew then that we had won,” Wodak says.

When it comes to HIV infections in people who inject drugs, “we have the most boring graph in the world,” says epidemiologist John Kaldor of the Kirby Institute for Infection and Immunity in Society, a branch of the University of New South Wales in Sydney. In many of Australia's neighboring countries, including Indonesia and Malaysia, people who inject drugs account for a high percentage of infections. But in Australia, only 17 out of 3490 injecting drug users who received yearly HIV tests between 1995 and 2012 became infected, Kaldor and his colleagues reported in the 14 January issue of AIDS. The Kirby Institute's latest annual HIV surveillance report found that between 2008 and 2012, injecting drug use accounted for just 2% of new HIV diagnoses in Australia. Men having sex with men accounted for most new diagnoses (67%), followed by heterosexual sex (25%).

By 1987, the state of New South Wales endorsed needle and syringe programs, and in 1989, the first national HIV/AIDS strategy plan said this would be a key component of the country's response. Overall, needle and syringe programs had averted more than 57,000 HIV infections by 2009, according to Australia's Department of Health and Ageing. Between 2000 and 2009, the country's investment of just over US$200 million had saved US$1.2 billion in health care costs.

Today, Australia has more than 3000 sites that distribute some 30 million needles and syringes to drug users each year. The U.S. government, in contrast, bans funding of similar programs, although about 200 sites operate legally in various states. According to the U.S. Centers for Disease Control and Prevention, 16% of the people living with HIV in the country were infected by sharing needles and syringes.

Australia's early embrace of HIV harm reduction strategies was sparked in no small part by a “national psychodrama” that was playing out at the time, Wodak says: When the AIDS epidemic emerged in Australia, the prime minister's daughter was battling heroin addiction. Other factors entered in as well. Neal Blewett, the minister of health, rallied bipartisan support for a strong HIV/AIDS response and included representatives from the drug-using community in the discussions. And Wodak believes that Australia's history as a British penal colony helped, too. “Convicts are practical people—they're not ideologues,” he says.

The Australian government soon went beyond its support of needle and syringe programs, allowing a center to open in 2001, under the auspices of a church group, where users could inject drugs with clean equipment under medical supervision—without fear of prosecution. Located near a busy subway stop, the Sydney Medically Supervised Injecting Centre (MSIC) was the first facility of its kind outside of a few European countries, and the feedback from clients has been overwhelmingly positive, says the center's medical director, Marianne Jauncey. “The single starkest, most commonly repeated phrase is, ‘Thank you for treating me like a human being,’” Jauncey says.

A series of independent reviews has found that MSIC has delivered on its promise. The latest, published by the accounting firm KPMG in 2010, found that the center had supervised more than 600,000 injections, referring about one-third of its clients to drug treatment. It managed nearly 3500 overdoses without a single death and saved the health system some US\$600,000 per year. Since the site's opening, HIV infection rates have dropped in the nearby neighborhoods, although the review did not have enough data to link MSIC to the decline.

### Video

Harm reduction in Australia, http://scim.ag/hiv2014.

Australia's harm reduction effort has had its limits, which the hepatitis C virus (HCV) spotlights. HCV is transmitted by needle and syringe sharing much more easily than HIV is, and it was already widespread when harm reduction efforts began for HIV. According to Department of Health and Ageing estimates, this liver-damaging virus had infected more than 80,000 people by 1986. That number grew to 200,000 by 2000, despite needle and syringe programs. Yet, without those programs, the country would have faced a much larger HCV epidemic: The health department estimates that they prevented more than 100,000 new HCV infections.

Harm reduction programs for both HIV and HCV also overlooked some marginalized populations for a time. A study published in the October 2006 issue of Addiction found few services were available for “ethnic minorities”—a group that included indigenous Australians and immigrants from Vietnam and other Southeast Asian countries—who injected drugs in Sydney and in less urban sites around New South Wales. “It was a harm reduction nightmare,” says Lisa Maher, an epidemiologist at the Kirby Institute who led the study. Over 3 years, 31% of the ethnic minorities in the 368-person study became infected with HCV, a rate three times higher than seen in the non–ethnic minority group. Needle and syringe programs and the accompanying health services for people who inject drugs have since expanded to these communities.

Wodak stresses that harm reduction can only do what its name implies. “We're happy to make a bad problem less bad,” Wodak says. “We don't have to eradicate the problem in order to feel that we've succeeded.”

3. # The limits of success

Increasing prevalence in Australia's men who have sex with men raises questions about treatment as prevention.

Only 1253 people received an HIV diagnosis in Australia in 2012, a testament to nearly 3 decades of aggressive prevention efforts. But there's a troubling caveat: The number of new diagnoses jumped 10% from the preceding year, and cases have steadily risen since 1999. And 70% of the new infections occurred in men who have sex with men (MSM).

Every country in the world has struggled to slow the spread in MSM. But the growing problem in Australia has spotlighted the limitations of one of the most promising new prevention tools. A landmark 2011 study proved that if infected people faithfully took their antiretroviral (ARV) drugs and had undetectable viral levels on standard tests, the risk of transmission via heterosexual sex was nearly eliminated, falling by 96% (Science, 23 December 2011, p. 1628). Hopes soared that adding treatment as prevention to the arsenal of proven interventions could bring AIDS epidemics in communities to a halt.

Australia has universal health care and access to the latest ARVs, and most people who learn they are infected promptly start treatment. In a study published in the July 2012 issue of PLOS Medicine, epidemiologist David Wilson of the Kirby Institute for Infection and Immunity in Society in Sydney noted that as many as 75% of MSM in Australia reported taking an HIV test annually, and 70% of infected people received ARVs. In 90% of those, viral levels were fully suppressed. But that has not stopped the rise in new cases among MSM. “Why's there a disconnect with ‘test and treat?’” asks David Cooper, who heads the Kirby Institute.

One possible answer is that treatment as prevention simply doesn't work as well with MSM. Anal intercourse has an 18-fold higher probability of transmitting HIV than vaginal intercourse, according to a 2010 study. MSM also tend to have more partners, increasing the odds that the virus will spread.

Wilson, a mathematical modeler and head of the Kirby's surveillance division, also notes that more treatment means more HIV-infected people survive who can potentially spread the infection, as some undoubtedly will remain infectious. Treated people may also engage in riskier behavior that, in a population sense, overwhelms the benefits of the drugs. And the virus is often transmitted by recently infected people who have yet to develop high enough antibody levels to be detected on standard tests.

Clearly, if every infected person took ARVs every day and had undetectable viral levels, transmission would likely plummet in MSM communities. But that's unrealistic. So Wilson and his team published a modeling exercise online on 7 February in Sexual Health that explored what it would take to lower new HIV infection rates in Australia's MSM population. The researchers looked at the impact of earlier detection of infection and initiation of treatment. But the factor that stood out most was the effect treatment has on transmission.

If ARVs indeed lower the risk of transmission in MSM by 96%—as much as it does in heterosexuals—then treating 90% of people would cut new infections by 55% in 5 years. On the other hand, if ARVs offer a mere 26% protection in MSM, the same scenario would avert a measly 9% of infections. “The jury is still out with regard to how much treatment decreases infectivity with male-to-male sex,” Wilson says.

Even if it does work as well in MSM, which the Kirby Institute is now studying, the country still must substantially increase the number of people on ARVs—and it's notoriously difficult to improve on success.

4. Papua New Guinea

# In PNG, the epidemic that wasn't

Data vacuum despite improved surveillance.

A decade ago, the forecast for the island of New Guinea was dire. A heterosexual epidemic was set to explode, a team of leading international epidemiologists predicted in a report called AIDS in Asia: Face the Facts. They warned that “there is every indication that the island is facing an epidemic which resembles those seen in parts of sub-Saharan Africa.” Papua New Guinea (PNG), which shares the island with Indonesia, structured its response to its epidemic based on those early predictions. But the bomb never went off.

To this day, PNG struggles to describe not only why those early predictions were so wide off the mark, but also the exact contours of the smaller, but still serious, epidemic the country is experiencing today. That confusion has come at a steep price, particularly when it comes to decisions about where to target prevention efforts. “It gives rise to a very unfocused program,” says Stuart Watson, country coordinator in PNG for the Joint United Nations Programme on HIV/AIDS (UNAIDS). “We don't know exactly what we're responding to, and, as a result, we respond to everything.”

Epidemiologists have long had good reason to fear a serious heterosexual epidemic in PNG. Reported condom use is low. Medically supervised circumcision, which protects heterosexual men from HIV, is rare. Sexual violence, in contrast, is rampant; a survey published in the October 2013 issue of The Lancet Global Health found that 40% of PNG men interviewed reported having raped a female “non-partner.” One recent study in a highlands community and Port Moresby, the capital, found that more than 20% of the 154 people tested at sexual health clinics were infected with chlamydia or gonorrhea.

Early predictions suggested that by 2014, 10% of the adults in PNG would be infected with HIV. According to the PNG National Department of Health, the estimate of the adult prevalence today is 0.65%. Watson thinks that understates the true prevalence. “Ask most people cold-face if they believe those figures: no,” he says. But he believes the actual figure is well short of 10%.

“The epidemic in PNG doesn't make a lot of sense in some ways,” says epidemiologist Andrew Vallely, who lives in Milne Bay province and works with both the PNG Institute of Medical Research (IMR) and the University of New South Wales (UNSW) in Sydney. “Why has HIV not taken off?”

In trying to gauge HIV prevalence in PNG, epidemiologists have had far more assumptions than hard data. Joanne Robinson, a strategic information adviser at UNAIDS in PNG, notes that from 1993 to 2001, the only official HIV prevalence data came from one antenatal clinic at the general hospital in Port Moresby. “They did have very high prevalence rates, but it wasn't representative of the rest of the country,” Robinson says. Today, data come from 380 sites, and as surveillance has expanded to ever more remote, rural areas, the overall prevalence has dropped.

But the data still give an incomplete—if not outright misleading—picture. “Our estimates are based on extremely limited samples of the population to this day,” Watson says. He notes that only 60% of pregnant women attend antenatal clinics and a mere 40% receive HIV tests. The government has not done systematic, large-scale studies of several “key populations” that often have high HIV prevalence: men who have sex with men (MSM), transgenders, and sex workers. A small study done in Port Moresby by IMR in 2010 did show extremely high HIV prevalence in people who sold sex, whether they were females (19%), males (8.8%), or transgender women (23.7%).

Moreover, the epidemic is geographically patchy, with high heterosexual prevalence in some regions. As the PNG health department noted that year, just five of the country's 22 provinces, all in the highlands, accounted for 60% of reported HIV cases even though they have just 40% of the population. “PNG is now experiencing an epidemic concentrated in particular geographical locations and population groups,” states an HIV/AIDS response progress report it filed in March with UNAIDS.

Such patchiness complicates surveillance. For one, it is hard to access many isolated communities on this island of steep volcanic mountains. To reach the highland town of Goroka from Port Moresby, for example, requires either an expensive flight or a torturous 7-day hike. And the 800 different languages spoken on the island reflect cultural variation, including sexual practices that can affect transmission, such as polygamy and the age of initiation. “What you say about one place is not what you say about another place,” says social anthropologist Angela Kelly-Hanku, who lives in Goroka and works on Vallely's team.

One surprising cultural factor that may have had a role in curbing the epidemic is traditional penile cutting. Several large-scale studies in Africa have shown that medical circumcision—which removes the entire foreskin under sterile conditions—reduces the risk of sexual transmission of HIV from women to men by about 60%. While medical circumcision is uncommon in Papua New Guinea, up to 70% of men in some communities report having had a traditional penile cut as a boy, a procedure that involves cutting different types of slits into the foreskin but not removing it.

### Videos

Circumcision practices in PNG, understanding HIV's scope in PNG, and HIV in a PNG picture house, http://scim.ag/hiv2014.

Following a recommendation from UNAIDS and the World Health Organization in 2007 that prevention programs in high-prevalence countries should incorporate male circumcision, PNG health officials became interested in launching a national program. With funding from the Australian government, Vallely's group collaborated on a 4-year study to gauge the procedure's acceptability and potential impact. What they found surprised them.

When the researchers assessed penile cutting around the country, the places that practiced it the most had the lowest HIV prevalence. “It may help explain why the epidemic looks as it does in PNG,” Vallely says. “To be honest, we never imagined when we heard of these practices that this would be the result.”

In collaboration with colleagues in PNG, Vallely and co-workers are now conducting epidemiologic studies to see if the link holds up. At UNSW's Kirby Institute for Infection and Immunity in Society, another group is doing lab studies with foreskins from PNG to explore fundamental mechanistic questions: How does medical circumcision thwart HIV, and does traditional cutting have any impact (see sidebar)? Vallely says if traditional penile cutting does prove capable of lowering the risk of HIV infection, it may ultimately alter public health campaigns. “We don't want to stop something that prevents HIV from taking off in PNG,” he says.

Watson maintains that confusion about the epidemic's contours and its drivers wastes precious resources. In 2012, most government spending went toward managing the response, not delivering services like prevention, treatment, and care. “We have a very top-heavy national response that gobbles up nearly 80% of the funding,” he says, noting that the National AIDS Council employs more than 100 people.

The painful Catch-22 is that PNG is left with little money to improve surveillance and figure out how best to curtail its epidemic. “We don't have the resources for that because we're still responding to an epidemic we don't have,” Watson says.

5. # Prevention, Papua New Guinea style

A community gathers to watch a video about HIV's impact on a local family and meet the star.

Early on a Friday evening in March in Kids Kona, one of the many villages tucked into the hills that surround the town of Goroka, some 75 people cram into a mud-floored hut with a corrugated tin roof and excitedly wait for the show to begin. This village cinema, or haus piksa in the local pidgin, has a generator that provides electricity—a rarity here in the country's Eastern Highlands province—and, of course, a screen, which in this case is an old TV set. The standing-room-only audience is so swept up by tonight's video that no one leaves when the generator cuts out, candles are lit, and someone has to make a trip to town for more fuel.

This is not Rambo or a rugby match, both of which are wildly popular in this country known by the shorthand PNG. The slick video, a University of Goroka production titled One More Chance, is part of an innovative campaign to prevent HIV's spread, which has hit some PNG communities hard (see main story). It tells the story of Siparo Bangkoma, a local man whose complicated family life was turned upside down by HIV. Siparo became deathly ill from the virus, but he hid his infection from his two wives until the second wife became weak herself and confronted him. When he confessed, the ailing wife told the other. Both women discovered they, too, had become infected. Rage eventually gave way to acceptance, and the two mothers decided they would raise their children together, but agreed that Siparo would no longer have a physical relationship with the second wife.

Siparo is at the screening and speaks to the crowd when the video ends. “You can get HIV and you can live with it,” he announces. “I'm happy because I can stand in front of you and talk out. In my country, many people feel ashamed. I'm not ashamed. God gave me one more chance. Make sure your children are educated. This is a true story. It's my life story. You have to change your attitude and thinking,” he says.

“This is a way to do HIV prevention that's really true to PNG,” says Angela Kelly-Hanku, an Australian social anthropologist who studies HIV/AIDS with the PNG Institute of Medical Research in Goroka, where she lives, and the University of New South Wales in Sydney. After the screening, Kelly-Hanku shows off a bottle of antiretroviral (ARV) drugs. “When you take the ARVs, it's like putting a gate around your garden,” Kelly-Hanku says. “Now, the pigs can't go inside.”

The student filmmakers who produced One More Chance have made four other HIV/AIDS videos as part of a project called Komuniti Tok Piksa. They target rural communities, which are missed by mass media campaigns and often have low levels of literacy, teaching people how HIV is spread, the importance of testing, and that lifesaving treatments exist. The stories are told in pidgin.

Verena Thomas, who leads the project, says the 110 screenings so far have all been well attended. Says Thomas: “People on the screen are the heroes, whether they're Rambos or Siparos.”

6. # The circumcision conundrum

No clear mechanism explains how removing a foreskin protects men from HIV, but traditional penile cutting in Papua New Guinea may help clarify.

Stuart Turville had a surprising item to declare last September when he arrived here from Papua New Guinea (PNG) on a Friday evening flight: a cooler that contained five freshly harvested foreskins packed on ice. “Coming in with samples like this is always somewhat amusing to customs officials in Australia,” says Turville, a virologist at the Kirby Institute for Infection and Immunity in Society in Sydney.

Turville's team regularly imports this precious cargo from its neighbor to answer a fundamental but underexplored question: How does male circumcision protect against HIV?

Studies have clearly shown that medical circumcision works, but confusion remains about the mechanism. Foreskins surgically removed from men in PNG who opt to go through medical circumcision offer an intriguing opportunity to address the question. Whereas some had fully intact foreskins, many had various traditional penile cuts as boys (see main story).

Turville is leading lab studies that incubate these different foreskins with fluorescently labeled HIV (pictured). That allows researchers to assess how the transmission process is affected by factors that vary among the foreskins, including the degree of keratinization (in red) and the presence of immune target cells.

Surprisingly few groups have published studies about the protective mechanism of circumcision, says virologist Thomas Hope of Northwestern University's Feinberg School of Medicine in Chicago, Illinois, a veteran researcher of foreskins and HIV who has begun collaborating with the Kirby Institute group. “And a lot of it is wrong.”

7. Indonesia

# A consummate insider pushes ideas from outside Indonesia

Sex and drugs rock Health Minister Mboi's reign.

On 14 June 2012, Nafsiah Mboi's first day on the job as this country's minister of health, she announced a new campaign to distribute condoms to people at high risk of HIV infection. A loud uproar followed, leading Mboi—more commonly known by the honorific Ibu Naf—to post a YouTube video to explain that she was not advocating distributing condoms in high schools, as rumors had it.

### Video

Interview with Nafsiah Mboi, http://scim.ag/hiv2014.

Indonesia's HIV/AIDS politics are fiery—and Ibu Naf seems to like the heat. A pediatrician by training, Ibu Naf has had a prominent political life, first as the wife of the governor of East Nusa Tenggara province and then as a member of parliament for 5 years in the 1990s. She went on to do a stint in Geneva, Switzerland, at the World Health Organization as the director of gender and women's health, and in 2006, she was appointed secretary of Indonesia's National AIDS Commission. She held the job for 6 years before being tapped to serve as minister of health. In June 2013, the Global Fund to Fight AIDS, Tuberculosis and Malaria appointed her chair of its board.

Indonesia has a serious epidemic: New infections jumped 2.6-fold between 2001 and 2012, according to the Joint United Nations Programme on HIV/AIDS. The epidemic began mainly in injecting drug users, but today the highest spread occurs in men who have sex with men (MSM), sex workers and their clients, and transgenders. One exception is the two Indonesian provinces on New Guinea, which have a largely heterosexual epidemic that mirrors the one on the other side of the island in Papua New Guinea (see p. 158).

Ibu Naf has successfully lobbied for expanded access to antiretroviral drugs for HIV-infected people. She pushed through legislation that decriminalized drug use and allows government-run clinics to provide methadone and clean needles and syringes. Tuti Parwati Merati, a clinician who heads a nongovernmental organization (NGO) devoted to HIV/AIDS in Bali and also works at Udayana University in Denpasar there, says Ibu Naf “can pick the most difficult and make it happen.”

Yet Ibu Naf acknowledges that serious problems remain. Police harassment of drug users continues, and the epidemic in MSM is largely ignored. Science spoke with Ibu Naf at her office in Jakarta about the country's response to HIV/AIDS and the challenges it faces. This interview has been edited for clarity and brevity.

Q:Reports long warned that HIV/AIDS would become a huge problem if you didn't ramp up harm reduction for people who inject drugs. Did this take too long?

A:For my taste, yes, but indeed the fight was not easy. When I became the secretary of the National AIDS Commission in 2006, we already knew that we had prevalence rates of more than 60% in several areas because of people who inject drugs. The first thing I did was invite everybody: the legal beagles, as well as people from the health sector, several ministries, the police, the narcotics boards, welfare, and said, “OK, what do we do? It is estimated that we have 330,000 kids injecting. Do we want to kill them or save them? If we don't do anything, if we keep fighting, they will die. They will die of AIDS. They will die of overdose. They will die of hepatitis. They will die in prison because they'll beat them in there. If we want to save them, we have to work together.” There was silence. Total silence. But then I was very happy because it was the police who said, “Ibu, you're right. We have to save our kids. Actually, my son is a drug user and I don't know what to do.”

Q:What happened?

A:First of all, I said, “The law says they're criminals and we should decriminalize them.” We put a new regulation together, but it was very hard to convince the different ministers. So I invited our colleagues from Australia to do a cost analysis and presented that in front of all the ministers and said, “This is what it will cost us if they all get HIV infected and hepatitis.” That was the thing that changed it.

Q:Did you have needle and syringe exchange right away or was that a battle also?

A:I knew that the NGOs had started it, but they were hiding under cover. It was illegal and if they were caught, they went to prison. But I'm very proud to say we have very courageous NGOs. These NGOs got together with the networks of people who inject drugs. And then the Global Fund provided the resources.

Q:The government accepted it?

A:Not always very happy, but we did it.

Q:When you became minister, you had to very quickly fight over condoms.

A:We've been fighting about condoms since the minute I came back from Geneva when I was secretary of the National AIDS Commission. As the minister it was different, you see. Here was an amoral minister of health who is promiscuous who wanted to distribute condoms to schoolchildren. So they demonstrated. I said, “OK, come in.” So we talked and I gave them the data of sexual transmission, of housewives being infected and babies born. I said, “Look, what else can we do? You're religious leaders, and you have been telling them that they are not allowed to go to brothels or whatever, but I cannot do that. I'm just the minister of health. All I can do is prevent the transmission of the disease and I can only do that with condoms.” Then they said, “Yeah but it's wrong if the government does it.” And they said, “You have to beat them in public. Beat them to death. It's the Islamic Shariah.” And I said, “But it's not in our law.” So I said, “Let's agree to disagree. You do your work so that no man will ever go to brothels and no young person will ever have sex before marriage. I will do my work with those who engage in risky sex and tell them to wear condoms.”

Q:You came from a Muslim background and converted to Catholicism. How do you view the Islamic community that challenges prevention interventions because they violate their moral tenets?

A:It has changed a lot actually. From the beginning, there was only a small group who were really aggressively looking at [HIV/AIDS] from the moral point of view. A lot of people actually knew that yes, what we were doing was the right thing to do. All they needed was somebody to be the—how do you call that?—the one to get the stones thrown at.

Q:They're still throwing stones at you. Muslim leaders attacked National Condom Week in December 2013, and the Health Ministry halted the annual event.

A:Yes, yes. But not as fiercely as before.

Q:One criticism is that the government hasn't spent enough on the MSM community. What do you think?

A:Yeah. It is because we believe that MSM can only be reached by their peers. It's not that I don't want to spend money. Unfortunately, there are still a lot of districts or provinces where this cannot be done by our local government. Once I had to basically fire the secretary of the local AIDS commission because he said, “Ibu, I will do anything you say, but don't ask me to work with men who have sex with men. It's against my conscience.” And I said, “Then you cannot be the secretary of the local AIDS commission.” MSM is still much hated in many areas in Indonesia, I'm sorry to say.

Q:Your supporters are worried about you getting kicked out of office with the elections coming up.

A:Most probably so, yes.

Q:Are you worried about whether there will be continuity?

A:I am, but the only thing I can do is strengthen my colleagues who will still be here, empowering them, as well as the NGO community. We have a strong NGO community, and they need a stronger voice in the government. And I can still do things from outside, I think. I may not be as powerful as the minister, but I can always say what I want.

8. Malaysia

# Malaysia tries to follow Australia's path

A top researcher and advocate pushes for change.

In 1997, a year after Adeeba Kamarulzaman returned here with a medical degree from Australia and a specialty in infectious diseases, she spoke with the head of the Malaysian AIDS Council (MAC), Marina Mahathir, who was the daughter of the country's prime minister at the time. “I asked her, ‘Do you have needle and syringe programs here?’” Kamarulzaman recalls. It was a pertinent question given that Malaysia had a budding epidemic in people who inject drugs—and Australia had all but derailed HIV with its harm reduction efforts (see p. 156). “She said, ‘Are you kidding? We can barely say the word ‘AIDS.’”

Kamarulzaman set out to change the HIV/AIDS response in Malaysia, a multiethnic country with a Muslim majority that has ultraconservative views on many social issues. “It was clear to me that this was crazy,” Kamarulzaman says. “Patient after patient became infected by drug use and we weren't doing anything about it.”

That's no longer true, thanks in part to her efforts, but Kamarulzaman, dean of the faculty of medicine here at the University of Malaya, still has serious misgivings about her country's approach to its HIV/AIDS epidemic. “We have done all right in terms of getting harm reduction programs off the ground, but even so, I think the coverage is still far from where we should be,” she says. “And the real problems are now with prevention for MSM [men who have sex with men], transgenders, and sex workers. There's almost no kind of nationwide program to make any dent in the epidemic amongst these populations.”

Kamarulzaman, who also attended high school in Australia and speaks English with a slight Aussie accent, is related to Malaysian royalty and can speak her mind with little fear of serious consequences. She continues to do so. “She makes a lot of enemies, particularly in government offices,” says Hisham Hussein, who serves with her on the executive committee of MAC. “I can't see anyone in the country who can speak up like she can without fear or favor. No one. No one.”

Kamarulzaman has published more than 100 studies of HIV/AIDS in Malaysia that look at everything from harm reduction efforts to the molecular epidemiology of viral spread to the efficacy of new treatments. She also has won passionate supporters in affected communities. “She's my idol,” says Elisha Kor, an HIV-infected transgender woman who runs a program for sex workers at the PT Foundation, a nongovernmental organization (NGO) here that also helps MSM. “She brings a lot of opportunities to Malaysia, and opens the eyes of my government with HIV/AIDS issues.”

Stopping the spread of HIV among injecting drug users was Kamarulzaman's first campaign. In 2003, she received a grant from the U.S. National Institutes of Health that set out to influence drug policy, which then heavily focused on punishment, by gathering comprehensive data about HIV and users who injected—and accounted for 76% of the infections. She also created a harm reduction working group with help from Australian experts. But their data did little to sway the National Anti-Drugs Agency and the police. “It became clear that we were not going to get anywhere until we got the attention of the politicians,” Kamarulzaman says.

In January 2005, she secured a meeting with the Cabinet Committee on Drugs, which later approved a pilot project to convert injecting drug users to methadone. That June, the government, to Kamarulzaman's astonishment, announced it would also allow small-scale needle and syringe exchange. As these efforts grew, the government slowly moved away from a strictly punitive attitude toward drug users to a more compassionate view that they had health issues. Prisons began offering methadone maintenance programs. And in 2010, voluntary “cure and care” centers began to replace compulsory drug rehabilitation centers.

Harm reduction in Malaysia still faces many challenges, including excessively harsh drug laws. (Hanging remains a sentencing option even for marijuana.) The country relies mainly on NGOs to supply needles and syringes. But as Kamarulzaman wrote in a commentary in the 15 June 2013 issue of The Lancet titled “Fighting the HIV epidemic in the Islamic world,” harm reduction advocacy in both Malaysia and Indonesia has succeeded in part because it has emphasized “Islamic values about the preservation of life.”

Those same arguments, however, have not persuaded the government to confront sexual transmission. “It's a little bit more difficult to argue for sex work and MSM along those veins,” she says. Indeed, Shariah law in some states can imprison Malay Muslims for simply cross-dressing.

To Pang Khee Teik, one of the country's few openly gay HIV/AIDS activists, the government's inaction toward the lesbian, gay, bisexual, and transgender (LGBT) community has strong political overtones. In two infamous trials known as Sodomy 1 and Sodomy 2, the government beginning in 1998 prosecuted a former deputy prime minister who was hoping to lead the country, Anwar Ibrahim, for allegedly having sex with men. “They see LGBT as a political force and this has to do with the targeting of Anwar Ibrahim,” Teik says.

The Ministry of Health recognizes the problem; its recent report to the United Nations noted that in relatively small surveys of MSM, HIV prevalence had a “whopping increase from 3.9% to 12.6%” between 2009 and 2012. “New HIV infections via sexual transmission have outnumbered drug injection for the past 3 years,” says MAC's Hussein. “And until today, the government has not done anything new, and they are fully aware of what is happening.”

Kamarulzaman says the government “urgently” needs to address its shortcomings, but she takes the long view, saying, “Given where we were, I guess we have made a good start.”