HIV/AIDS IN ASIA

HIV/AIDS is a growing problem in every region of Asia. East Asia has been identified by UNAIDS as one of the areas of the world where ‘the most striking increases’ in the numbers of people living with HIV have occurred in recent years. Although national HIV prevalence rates in Asia appear to be relatively low (particularly in comparison with sub- Saharan Africa), the populations of some Asian countries are so vast that these low percentages actually represent very large numbers of people living with HIV. The latest statistics compiled by UNAIDS suggest that at the end of 2007, 5 million people were living with HIV in Asia.

HIV prevalence (%) in adults in Asia,

COMPARISON TO AFRICA Various factors make Asia vulnerable to the spread of HIV, including poverty, inequality, unequal status of women, stigma, cultural myths about sex and high levels of migration.3 4 Some experts predict that Asia may eventually overtake Africa as the part of the world with the highest number of HIV-infected people. Others, however, argue that Asia’s epidemics are on a different trajectory to those found in Africa, as HIV infection in Asia is still largely occurring among members of ‘high- risk groups’, unlike Africa where HIV and AIDS are widespread amongst all sections of some countries’ populations.5

A global view of HIV infection 33 million people [30–36 million] living with HIV,

WHY VULNERABLE? Various factors make Asia vulnerable to the spread of HIV, including poverty, inequality, unequal status of women, stigma, cultural myths about sex and high levels of migration.3 4 Some experts predict that Asia may eventually overtake Africa as the part of the world with the highest number of HIV-infected people. Others, however, argue that Asia’s epidemics are on a different trajectory to those found in Africa, as HIV infection in Asia is still largely occurring among members of ‘high- risk groups’, unlike Africa where HIV and AIDS are widespread amongst all sections of some countries’ populations.5

Percentage of most-at-risk populations reached with HIV prevention programmes, 2005–2007 Sex workers Injecting drug users Men having sex with men % Median 60.4%* (39 countries) 46.1%** (15 countries) 40.1%* (27 countries) * Percentage of sex workers and men having sex with men reported knowing where they can receive an HIV test and that they were given condoms. ** Percentage of injecting drug users who reported knowing where they could receive an HIV test and be provided with condoms and sterile injecting needles and syringes. Source: UNGASS Country Progress Reports

INJECTED DRUG USERS  Injecting drug use is a major driving factor in the spread of HIV throughout Asia, notably in China, Indonesia, Malaysia and Vietnam. In China, nearly half of all people infected with HIV are believed to have become infected through injecting drug use, and in North-East India injecting drug use is the most common HIV transmission route.10 There is often an overlap between communities of IDUs and communities of sex workers in Asia, as those who sell sex may do it to fund a drug habit, or they may have become involved in sex work first before turning to drug use.11 Injecting drug use

Percentage of countries reporting laws, regulations or policies that present obstacles to services for injecting drug users 5.11 Source: UNGASS Country Progress Reports Oceania (7) Caribbean (12) East Asia (3) Eastern Europe and Central Asia (16) Latin America (19) Middle East (4) North America (1) South and South- East Asia (13) Sub- Saharan Africa (41) Western and Central Europe (13) Percentage of countries (%)

SEX WORKERS  When HIV is transmitted through unprotected sex in Asia, it’s often during paid sex. More people in Asia engage in sex work (either as a client or a worker), than any other type of behaviour that can carry a high risk of HIV infection.8 High levels of HIV infection have been documented among sex workers and their clients in parts of India, and this situation is mirrored in other Asian countries; in South and South East Asian countries outside India, it’s thought that sex workers and their clients accounted for almost half of people living with HIV in sex work

MSM  Sex between men accounted for some of the earliest recorded cases of HIV in Asia, and transmission through this route is still a prominent feature of many countries’ epidemics. Most men who have sex with men (MSM) in Asia do not identify themselves as gay because of cultural norms that discourage homosexuality; in some cases they may even be heads of families, with children.12 This means that MSM can serve as a ‘bridge’ for HIV to spread into the broader population. HIV outbreaks are becoming evident among MSM in Cambodia, China, Nepal, Pakistan, Thailand and Vietnam.13men who have sex with men

MOTHER TO CHILD TRANSMISSION  Mother-to-child transmission is also a significant HIV transmission route in Asia. At the end of 2007, it was estimated that 140,000 children in South and South-East Asia, and 7,800 children in East Asia, were living with HIV, most of whom became infected through mother-to-child transmission.14 Mother-to-child transmission

Index of policies related to women’s vulnerability to HIV Eastern Europe and Central Asia Latin America Oceania Middle East Caribbean South and South-East Asia East Asia Sub-Saharan Africa Scale of (0–14) Source: UNGASS Country Progress Reports 2008.

TREATMENT IN ASIA Asia has been the base for some extremely successful large-scale HIV prevention programmes. Well-funded, politically supported campaigns in Thailand and Cambodia have led to significant declines in HIV- infection levels, and HIV prevention aimed at sex workers and their clients has played a large role in these achievements. The Indian state of Tamil Nadu is another area where HIV prevention has had a substantial impact. Here high-profile public campaigns discouraged risky sexual behaviour, made condoms more widely available, and provided STI testing and treatment for people who needed them. These efforts resulted in a large decline in risky sex.15sex workers

Number of people receiving antiretroviral drugs in low- and middle income countries, 2002−2007 Source: Data provided by UNAIDS & WHO, end end end end Millions Year end end North Africa and the Middle East Eastern Europe and Central Asia East, South and South-East Asia Latin America and the Caribbean Sub-Saharan Africa 5.2

Percentage of most-at-risk populations reached with HIV prevention programmes, 2005–2007 Sex workers Injecting drug users Men having sex with men % Median 60.4%* (39 countries) 46.1%** (15 countries) 40.1%* (27 countries) * Percentage of sex workers and men having sex with men reported knowing where they can receive an HIV test and that they were given condoms. ** Percentage of injecting drug users who reported knowing where they could receive an HIV test and be provided with condoms and sterile injecting needles and syringes. Source: UNGASS Country Progress Reports

There are very few developing countries in the world where public policy has been effective in preventing the spread of HIV/AIDS on a national scale, but Thailand is an exception. A massive programme to control HIV has reduced visits to commercial sex workers by half, raised condom usage, decreased the prevalence of STIs (Sexually Transmitted Infections) dramatically, and achieved substantial reductions in new HIV infections.

EDUCATION

THAILAND: CURRENT STATS Estimated total population, ,493,000 Estimated number of people living with HIV, end of the year 2007= 610,000 Adults (15+) = 600,000 Women (15+) = 250,000 Children (0-15) = 14,000 Estimated adult HIV prevalence = 1.4% Estimated number of AIDS deaths in 2007 = 31,000 The majority of Thailand’s HIV infections (around 80%) occur through heterosexual sex. 34 HIV affects more men than women in Thailand; the male-female ratio is 7:5. 35 HIV prevalence among pregnant women, which reached a peak of 2.35% in 1995, had fallen to 1.18% by An estimated 1 in 5 new HIV infections in Thailand are attributable to unprotected sex between men. 37

SUCCESS IN THAILAND Sex workers The ‘100% condom’ program, which enforced mandatory condom use in brothels, played a significant role in reducing Thailand’s HIV prevalence in the 1990s. Campaigns that reduced the demand for sex work also contributed to this decline.

TREATRMENT MEDS In November 2006, the newly installed Thai government – which had come to power following a military coup two months earlier – decided to issue a compulsory license for the ARV efavirenz. The patent owner, Merck, was already selling this drug for a non-profit price of 1,400 baht per month, but by producing generic versions of the drug, the government could offer it to patients for half of this price. 59 The government followed this by announcing in February 2007 that it would also break the patent on the drug Kaletra, and that more compulsory licenses would follow. 60 Most developing countries have hesitated to break patents on AIDS drugs, for fear of trade repercussions, so the Thai government’s decision was a brave move, and has been widely applauded by activists and AIDS organisations.

STILL NEEDS WORK Men who have sex with men (MSM). It was not until February 2006 that Thailand’s first campaign to prevent HIV among MSM was initiated. In Bangkok (Thailand’s capital and largest city), HIV prevalence among MSM rose from 17% to 28% between 2003 and Young people. There have not been any mass public prevention campaigns carried out in Thailand for over a decade. This has led to a decline in awareness and possibly an increase in unsafe sexual behaviour, especially among young people who are often not old enough to remember campaigns that were carried out during the 1990s.

Migrant workers They form an important part of Thailand’s workforce, but the difficulties that they commonly face - such as language difficulties or fear of arrest and deportation – can prevent them from accessing information about HIV and AIDS, as well as healthcare and other social services

Injecting drug users Since a heavy- handed government operation to crackdown on drug trafficking in 2003, drug use has been driven underground, making it more difficult for prevention campaigns to target this group.

HIV prevalence (%) in adults in Oceania,

Annual diagnoses of HIV infection and AIDS in Australia 1981– AIDS diagnosesHIV diagnoses Year Number of diagnoses Source: National Centre in HIV Epidemiology and Clinical Research, Data available at