Nancy Padian Interview. September 23, 2003.

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Describe the sense of urgency you feel right now with respect to the HIV/AIDS crisis in Zimbabwe?
It’s very hard to describe the magnitude of the epidemic in a country like Zimbabwe unless you’ve been there. It’s staggering. Everywhere you look, there it is. There are cottage industries that build coffins. There are orphan feeding programs, virtually everywhere. If you go into the hospitals, there’s complete overcrowding. There’s no one that I work with there who hasn’t been touched by it somehow. It’s completely common that when someone’s not around, they’re attending a funeral. About one-third of the population is infected, and it cuts across all socioeconomic levels.

You founded the Women’s Global Health Imperative (WGHI) in 2001. What is its main objective?
Our main objective is to deal with HIV/AIDS and other sexually transmitted infections and even unintended pregnancy in the context of addressing our over-arching theme: gender disparities and gender inequities, and how that gender imbalance places women at greater risk for HIV, other sexually transmitted infections, and unintended pregnancy. We have two major areas of research right now. The first is exploring women controlled methods of prevention of these outcomes. Male condoms, when used correctly and consistently, are the most effective way to prevent HIV transmission heterosexually. The problem with male condoms is that men control their use and, insofar as a woman would have control over when her male partner uses condoms, it requires negotiation and willingness on his part. So we’re looking at methods that women might be able to control, such as microbicides and the diaphragm - methods that women can use themselves without having to rely on negotiating with their male partner. The other way we’re looking at gender and vulnerability to HIV is by way of economic intervention. Our hypothesis is that if you can provide young women with economic opportunity and make them economically independent, then they will be less reliant on sexual partners, particularly older sexual partners, for material goods and, in some cases, even survival.

Who is part of the WGHI network?
In Zimbabwe, our major collaborators are with the University of Zimbabwe and the medical school. In India, our major collaborator is Samuha, a non-governmental organization. In Mexico our major collaborator is the National Institute for Public Health, in Cuernavaca. In the U.S., we are an institution based in San Francisco, and we collaborate with many community groups. Most of our work here is done in what’s called the Mission District in San Francisco, where there are a lot of Latino immigrants.

And what is the HIV Prevention Trials Network?
The HIV Prevention Trials Network, the HPTN, is a large program funded by the National Institutes of Health here in the U.S. Essentially, the way the network works is that you apply to be a member of the network - and the reason why such a network is critical is because most prevention studies require huge sample sizes. In order to assess whether the trial that you’re working on was effective and really prevented HIV, you need very large numbers of people; you need to see that enough HIV infection was prevented. The HPTN is a network because it requires more than one country, more than one site to participate in a prevention trial. It’s a very effective means of launching prevention trials, and that’s how we’re doing our microbicide studies. In my diaphragm study, we had to create such networks on our own.

Medical ethicist Solomon Benatar once said, “Saving lives in poor countries almost never results predominantly from costly, novel medical research. Existing options must be explored as part of our HIV prevention strategy.” Talk about the diaphragm in this context.
After much examination, biologically, we have reason to believe that the diaphragm, a readily available technology, can protect against HIV in a similar way to how it protects against pregnancy. We believe, at the very least, it’s worth testing. So as we are simultaneously looking for new strategies, new microbicides, we are testing this promising method that already exists. There are so many reasons why the diaphragm is very appropriate to the locality. Number one, it’s an existing option that we can get in the hands of many women in Zimbabwe, and it allows for clandestine use, which is so important where there’s this gender power imbalance, and resistance on the part of men to using male condoms. But testing the diaphragm has its challenges. I think people inherently have a more difficult time believing that you can have a new use for something that’s been around for a long time versus something brand new. Convincing people that the diaphragm might actually be a strategy that would work for HIV prevention is very difficult.

Do you think the solution is to not rely entirely on political leadership but more on philanthropy, like the Bill and Melinda Gates Foundation?
I have to believe this because I work in Zimbabwe. If I thought that the only effective solution would come from political involvement, I would be working in the wrong country. The Bill and Melinda Gates Foundation has been incredible in really filling an unfilled niche both in terms of resources and willingness to fund my study and other similar studies where the priority is placed on the kinds of things Benatar was referring to - projects that have a high likelihood of being sustainable. I think they’ve been absolutely at the forefront of that. If you believe that change will only occur with governmental support then what does that mean for countries where the government’s in turmoil? Do you not work there? Do those people then have to suffer as a result? If anything, the need is greater in these places. There are religious leaders and leaders at other levels, and you have to believe that the network that you’re putting together will be able to maintain itself once good, strong, stable leadership is in place.

This strengthens the point about empowering women worldwide in a health care context.
Yes, and I’m really glad you brought it up because that is the theme of our research. In terms of changing social norms, Uganda is a great success story. They’ve been able to reduce new infection rates. And one of the hallmarks of its program is that it implemented multi-centre involvement in not only dealing with HIV but in promoting women’s rights and having women have a strong voice that’s heard not only in terms of HIV prevention but in other aspects as well, in terms of having a voice in parliament and being involved in decision-making positions. AIDS has allowed us to focus on these gender power imbalances. Now is the galvanizing moment where clearly we have to make a change. Empowering women will have an effect not only on their vulnerability to HIV, but also on all other health outcomes and, by extension, the countries themselves. There can be nothing but good that comes out of this. If this is what it took to get us here, then maybe that’s a collateral benefit of this epidemic.

Are countries such as India, Asia, and areas in Eastern Europe at the tipping point with HIV/AIDS at this point?
I think rather than debate whether India’s going to be the next Sub-Saharan Africa, we need to acknowledge that a huge number of people are infected there. If you look at the rate of infection over the population, yes, it looks like it’s at the beginning of the epidemic. So let’s get in there, do something now, and not even answer, “Is it going to be like Africa?” We must prevent that from even being a possibility.

Kofi Annan said for there to be any hope of success in the fight against HIV/AIDS, the world must join together in a great global alliance. What would it take, Nancy, to be able to say that we did everything in our collective power to provide some sort of solution?
At UCSF, we’re developing a coalition of everyone who’s working on HIV in the international scene, so that we work together as one larger organization and focus on international health. I’m hoping that there will be more willingness on the part of researchers, activists, and community-based people to work together as one coalition too. I know it sounds a bit like “it’s a small world,” but I think that if we can all work towards this in our own line of work, that we will change the social norm of research. I hope too that this coalition will equally involve resource rich countries and resource poor countries, working together.

Nancy Padian is the executive director of the Women’s Global Health Imperative based at the University of California San Francisco.

Massive Change Radio was broadcast on the University of Toronto’s CIUT 89.5 FM from September 2003 to June 2004. Created and hosted by Jennifer Leonard, co-author with Bruce Mau of Massive Change (Phaidon Press, 2004) and former Institute without Boundaries team member, the entire season of multidisciplinary interviews is archived for download.

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