“Epidemiological snapshot” Introduction to session on working with the highest-risk populations in ANE & E/E regions Daniel Halperin Behavioral Change Specialist AID-W, Office of HIV/AIDS

OFTEN-ASKED QUESTIONS: 1) Why the great variation in national-level HIV prevalence across the region(s)?

2) Why the great difference in HIV rates between these regions compared to others (SSA)? 2a) Will Asia (or eastern Europe) be “the next Africa”??...

2b) Does prevalence of other STDs (inevitably) = potential for HIV epidemic?

Evidently the main factors explaining regional and sub-regional variations: Sexual networking dynamics: rates of multiple partnering (incl. sex worker visits) among men/ among women… Circumcision (potential for widespread female-to-male/heterosexual transmission) ( UNAIDS multi-site study in Africa examined wide variety of potential co-factors, incl. sexual behavior, socio-economic, viral sub-strains, etc.) IDU/needle-sharing/blood transmission…

UNAIDS/WHO Estimates of HIV Prevalence in South and South-East Asian Countries (having relatively similar risk factors for heterosexual HIV Epidemic): 90% Circumcised Cambodia2.40 Pakistan 0.09 Thailand2.23 Philippines 0.06 Myanmar1.79 Indonesia 0.05 India0.82 Bangladesh 0.03 Nepal 0.24 [From Halperin D, Bailey R. “Male Circumcision and HIV Infection: Ten Years and Counting,” Lancet 1999; 354: ]

Is “everyone at equal risk”?? Differential risks of different behaviors: a) needle sharing (extremely efficient mode) b) receptive anal intercourse (15-20 times riskier, per-act, than receptive vaginal sex) c) co-factors such as male circumcision, type of vaginal intercourse (forced, dry, etc.)… d) WHO is my partner(s)?: Sexual (and IDU) networks extremely important…

*misconception: National-level HIV prevalence = “prevalence in the general population”

Will Asia or eastern Europe be “the next Africa”??... 1)No, b/c widespread generalized heterosexual epidemics unlikely -- due to socially/culturally-ingrained, limited sexual networks (and in some cases circumcision), etc... or 2) Yes, bridging to gen. population is possible/likely (inevitable?...)

The bottom line?: Whichever answer is “right,” ultimately the same interventions will be most effective: I.e., targeting of highest-risk/currently most affected (sub)populations: IDU (extremely high biological risk, pervasive and dynamic networks, youth…) MSM (very high HIV risk from anal sex, extensive/dynamic networks, bisexuality) CSW (high rates of “partner exchange,” proven effectiveness of interventions…)

Front-line, basic Interventions : Targeted condom promotion: CSW!! (female and male), MSM, casual sex, highly-active youth… Focus on risky behaviors: anal intercourse, multiple partners, etc. IDU (what else can we do besides/in addition to needle exchange??...)

So, what about when focusing more on “youth”/gen. population?: “ABC” strategy(ies) (What does that mean?? ) Many possibilities, incl. but not limited to: *Delay of sexual debut among youth *Partner reduction: Thailand & Cambodia experiences, MSM in various places, etc... * “ C” (also) = Contraception? (Circumcision??...)