HIV / AIDS in Asia

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The earliest cases of HIV in Asia were reported in 1984 and 1985. The potential for widespread epidemics was not appreciated until the early 1990s, however, with the more extensive spread of HIV in Cambodia, Myanmar, Thailand and in parts of India. Today, these four countries have the highest adult infection levels in the region (see the table below):

By contrast, Bangladesh, Laos and the Philippines have some of the lowest HIV rates in the world. China, Indonesia, Nepal and Vietnam have epidemic in transition, characterised by recent increases in infection levels after an extended period of low prevalence.

Despite strong evidence that HIV is spreading, national responses in most countries remain weak. Surveillance systems are inadequate, and the coverage of prevention and care programme is extremely limited.

What Drives Asian Epidemic :

The HIV situation in Asia consists almost entirely on multiple, interrelated epidemics in key at risk populations and their immediate sexual partners. These populations are :

Injecting drug users - Epidemics among drug users have played an important role in the spread of the virus in many countries, for example China, Vietnam and Malaysia.
Men who have sex with men - This population group has been largely ignored by HIV programmes in Asia, but recent surgery in Bangkok and Phnom Penh found roughly one in seven of these men infected with HIV.
Clients and sex workers - This is by for the largest component of the HIV epidemic in Asia and the source of many female and most male heterosexual infections. The epidemic is also affecting the low-risk female partners of high-risk men. More than three quarters of the women who have become infected with HIV in Asia have no risk behaviour at all by conventional definitions. They contacted HIV in what they thought were monogamous relationships with their husbands.
The largest group at risk of HIV infection in Asia - male clients of sex workers - comprise a significant proportion of population. In the early 1990s, the percentage of adult men reporting visits to sex workers in the previous year ranged from a low of roughly 5 per cent in Singapore and Hongkong to a high of around 20 per cent in Thailand and Cambodia.

The epidemic took off in the early 1990s in high-risk countries, in the mid-2000s in middle-risk countries, and very much later in low-risk countries. Growth of the epidemic can be greatly accelerated, however, by the linkages between sub-epidemics among clients and sex workers and among injecting drug users and men who have sex with men. Behavioral studies in several countries have shown that anywhere from one-third to three-quarters of injecting drug users visited a sex worker in the previous year. Some drug users sell sex, some sex workers use drugs, and some men who have sex with men also visit female sex workers. The drug-related epidemic starts among a small group in 1990 but spreads quickly because needle sharing spreads HIV so efficiently. Because drug users also visit sex workers, growth of the sex-work epidemic is accelerated, driving up overall national epidemic growth rate. The effect is particularly striking for the middle and low-risk countries, the epidemic could begin almost 10 years earlier than an epidemic fuelled by sex work alone; in the low-risk countries it could begin 20 years earlier. Indonesia, for example, the epidemic among injecting drug users took off in 1998. Today about half of this group is HIV positive. At the same time, the prevalence rate among sex workers has risen to more than 6 per cent in four provinces.

Similar influences might be expected from a major outbreak among men who have sex with men or migrant and returning overseas workers. Where might these epidemic end up? In the high risk countries, 15-17 per cent of the adult population could become infected. In the middle risk countries, 507 per cent of adults could become infected, and in the low risk countries 9-3 per cent. These are not minor epidemics by any standard.

What is to be Done :

While the potential for expanding HIV epidemics is high, there is a positive side to the nature of risk in Asia - focused prevention can be incredibly effective in the region. Thailand and Cambodia offer good examples of what can be accomplished with a well targeted prevention programme. However, neither of these countries reached national prevalence levels of 15 per cent or more. Why? Both the Thais and Cambodians identified sex work as the key source of new infections and both governments mounted pragmatic and well founded campaigns aimed at clients and sex workers. In both countries the number of sex work clients went down by half over a three to four year period. Without effective prevention, Thailand would have more than 8 million people living with HIV today, or roughly 15 per cent of the adult population. The situation in Cambodia would be much the same. Are the other countries in Asia prepared to apply the lessons learned in Thailand and Cambodia?

The outlook is only worrying. Current prevention programmes only cover a fraction of clients and sex workers. In the two largest countries of Asia, China and India, recent surveys show that half the populations lacks even the most basic information on how to prevent HIV. The clearest evidence of inadequate prevention programmes is the low level of condom use among clients of sex workers. In China, Indonesia and Bangladesh, fewer than one in five sex workers use condoms consistently. It is to be noted that while the threat of expansion of the epidemic is real, the situation in Asia also presents a significant opportunity. Because risk tends to be concentrated in specific groups, well-targeted interventions can be very effective.

What will Work in Asia ?

To be successful, prevention programmes must be implemented with high coverage. Yet many political leaders may find it difficult to work with the stigmatised population groups who can help halt the epidemic -clients and sex workers, drug users, men who have sex with men, and people living with HIV. To be successful, prevention progammes must be initiated and then sustained over many years. When it comes to addressing issues of sex and drugs, most Asian countries, face considerable religious and political resistance, which will take time to overcome.

Finally, prevention efforts must continuously adapt if they are to stay relevant. Even in the countries widely viewed as successful there are major gaps. Neither Thailand nor Cambodia has addressed risk among men who have sex with men, despite HIV prevalence of about 15 per cent in this group. In Thailand, programmes for infecting drug users are limited and ineffective, and little has been done to address the increasing number of infections occurring within marriage as current and former sex work clients infect their wives. The stakes are high. If HIV prevalence reaches even 2-3 per cent in Asian countries there will be a tremendous care burden. Despite Thailand's successful prevention efforts, more than one million Thais have been infected with HIV, and 450000 have died. The growing care needs of the 600,000 Thais living with HIV in 2004 will remain a challenge for atleast the next decade.

What can The International Community Do?

First donor governments and other organisations must advocate for and support appropriate, pragmatic, and effective responses. This means programmes that focus on behaviours that make some people uncomfortable - sex work, injecting drug use, and male-male sex. Working with these groups today is the only way to protect the 'general population' tomorrow. Teaching people how to protect themselves and providing them with the means to do so will be more effective than trying to change culturally embeded behaviour overnight. Asian governments, for their part, must anticipate care needs and provide compassionate, non-discriminatory and appropriate care for those leaving with HIV and AIDS. At the same time, they must build up and maintain focused prevention programme.

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