Prevention of HIV infection: How effectively are countries responding to changing epidemics in the Asia Pacific Region? 30 March 2011 Slide 1 A brief introduction to the thematic track “Increasing sustainable financing, national ownership and capacity for improved programmatic effectiveness.” 1

HIV epidemics in Asia Pacific Centred mainly around unprotected paid sex, sharing of contaminated needles and syringes and unprotected sex between men. Most new HIV infections will result from unprotected sex with female, male and transgender sex workers and their clients, people who inject drugs and men who have sex with men. Significant numbers of ostensibly ‘low-risk’ women who are the wives/intimate partners of these men are exposed to HIV. Slide 2 – HIV epidemics in Asia Pacific 2

How effective are country responses? Few countries have scaled up prevention with these key affected populations to a level sufficient to have an impact at population level . HIV prevention has shown variable coverage across Asia, with one in two sex workers, one in three people who inject drugs, and one in four men who have sex with men reached with services . Slide 2 – How effective are country responses? 3

Priority Issues: Taking harm reduction to scale The principle of ‘harm reduction’ accepted at the policy level, implementation only beginning in most. Many challenges: improvement in service quality, scale up services, respond to hepatitis C, TB and other health consequences. The two most effective interventions necessary to prevent and halt the HIV epidemic among and from people who inject drugs – needle and syringe programs and Opioid Substitution Treatment – currently low level of coverage, which will not impact on the epidemic. Slide 2 – Priority issues: Taking harm reduction to scale 4

Priority Issues: Taking harm reduction to scale Disconnection between the public health and judicial and extra judicial approaches to drug use. Potential for exchange of best practices from the innovative work being implemented in Asia to scale up harm reduction with Bangladesh, China, Indonesia, Malaysia and Pakistan highlight differing models for delivering harm reduction services, including services implemented by governments, governments and civil society in partnership and civil society led responses. Slide 2 – Priority issues: Taking harm reduction to scale 5

Priority Issues: Effective scaled up prevention in the context of sex work Shift from ‘direct’ channels of sex work (brothels, street-based sex workers), to ‘indirect’ settings (karaoke, massage parlours, cafes and bars). Expanding dimensions of sex work and impact of migration and mobility present new challenges to effective HIV prevention. Sex workers raise human rights concerns with 100% CUP: doesn’t include sex workers, compulsory testing, deprivation of income and health care, and police harassment. Slide 2 – Priority issues: Effective scaled up prevention in the context of sex work 6

Priority Issues: Effective scaled up prevention in the context of sex work Limited health services for sex workers, existing services largely focus on HIV prevention. Major gaps in provision of sexual and reproductive health services for female sex workers, while male and transgender sex workers are often ignored. Sexual and reproductive health services should be tailored to their needs and delivered in a supportive and non-judgmental manner. Good examples in the region, Cambodia, India (Avahan), Myanmar (TOP) Slide 2 – Priority issues: Effective scaled up prevention in the context of sex work 7

Priority Issues: Responding to prevention needs of men who have sex with men & transgenders A diverse group ranging from men who maintain conventional masculine identities to transgenders who do not accept their gender and identify as women. Includes married men and men who have sex with women. More than 90 percent of men having sex with men and transgenders in the Asia Pacific region do not have access to HIV prevention and care services. Slide 2 – Priority issues: Responding to the needs of men who have sex with men and transgenders 8

Priority Issues: Responding to prevention needs of men who have sex with men & transgenders Need to address punitive laws, discrimination and violence against MSM and transgenders. Comprehensive sexual and reproductive health services should be provided. Good examples in the region – TOP Myanmar, Avahan India Slide 2 – Priority issues: Responding to the needs of men who have sex with men and transgenders 9

Priority Issues: Effective prevention for intimate partners ‘Low-risk’ women often the wives/intimate partners of clients of sex workers or men who inject drugs. Many are unaware of the risk or not empowered to protect themselves against infection. Very few linkages between HIV prevention programs and the limited range of sexual and reproductive health education and services, (including family planning and safe abortion services) and gender based violence initiatives. Slide 2 – Priority issues: Effective prevention for intimate partners 10

Priority Issues: Responding to most at risk young people Young people constitute a high proportion of key populations at higher risk and 95% of new HIV infections in young people are among key populations at higher risk. Young people among key populations at risk are reached less by prevention programs. Philippines Department of Health inclusion of 15-17 year old most at risk adolescents in Integrated HIV Behavioural and Serologic Surveillance for people who inject drugs, female sex workers and men who have sex with men – 2009. Slide 2 – Priority issues: Responding to most at risk young people 11

Priority Issues: Community engagement in scaling up effective prevention The space for public/civil partnership is expanding as Governments and donors recognizing the civil society role in scaled up service delivery, access to key affected populations and program planning and accountability. Increasing participation in Global Fund grants as Principal Recipients and Sub Recipients. Urgent need for progress in providing appropriate legal status for non-governmental and community-based organisations to access financial, technical and organizational development assistance. Slide 2 – Priority issues: Community engagement in scaling up effective prevention 12

Priority Issues: Removing key barriers to effective prevention Laws in many countries criminalise behaviour of sex workers, men who have sex with men and people who use drugs; in some countries services and organisations providing them are also criminalized. Continuing tension between public security measures to control drug use and sex work and public health programs operating within a harm reduction approach. Some countries taking a progressive approach with regard to rights, including classification of people who use drugs as patients and legal recognition of transgenders. Slide 2 – Priority issues: Community engagement in scaling up effective prevention 13

Priority Issues: Removing key barriers to effective prevention Stigma and discrimination from health service professionals towards sex workers, people who use/inject drugs, men who have sex with men and transgenders reported in many countries, together with a lack of familiarity with many of their presenting health issues. Slide 2 – Priority issues: Community engagement in scaling up effective prevention 14

Questions for reflection: How to scale up enrolment in OST and NSP? How to create effective multisectoral management across health, public security and the community sectors? How to scale up rights-based prevention for all sex workers? How to effectively deliver the required package of services? How to scale up prevention for MSM and transgenders? Slide 9 – Questions for the working group

Questions for reflection: How to raise understanding of the specific service needs of MSM and transgenders? When will national legal contexts be aligned to international commitments? What are the critical actions required for effective partnership with community organizations? Slide 9 – Questions for the working group