1. The HIV Epidemics in Asia and the Pacific Ohio Leadership Conference April 15, 2008 Thu Vuong MBA, MPH Candidate Ohio State University

2. My Background Former Senior Program Officer, IDU Interventions, FHI Vietnam Chair, Vietnam Harm Reduction Technical Working Group, 2005-2006 Trained Drug Addiction Treatment Counselor MBA, 2003 MPH Candidate June 08, HSMP, OSU

3. Outline Epidemiology of HIV in Asia What works in HIV prevention: Why is Asia different? US government support and policies regarding HIV prevention, care, and treatment in developing countries Country case study: Vietnam The future: Continuing challenges

4. Adults and children estimated to be living with HIV as of end 2005 Total: 40.3 (36.7 – 45.3) million Western & Central Europe 720 000 [570 000 – 890 000] North Africa & Middle East 510 000 [230 000 – 1.4 million] Sub-Saharan Africa 25.8 million [23.8 – 27.9 million] Eastern Europe & Central Asia 1.6 million [990 000 – 2.3 million] South & South-East Asia 7.4 million [4.5 – 11.0 million] Oceania 74 000 [45 000 – 120 000] North America 1.2 million [650 000 – 1.8 million] Caribbean 300 000 [200 000 – 510 000] Latin America 1.8 million [1.4– 2.4 million] East Asia870,000 [440 000 – 1.4 million] Source: UNAIDS

5. Asian epidemics show great diversity and have become more serious over time 4.8 million PLHAs in 2007 (UNAIDS) 19891994 19992003 < 0.05% 0.05 - 0.1% 0.10 - 0.5% 0.50 - 1.0% > 1.0%

6. Stages of the HIV Epidemic by UN/WHO classification Low Grade –Prevalence of HIV is consistently below 5% in any “high risk groups” and below 1% in the “general population” Concentrated –Prevalence of HIV has surpassed 5% on a consistent basis in one or more “high risk groups” but remains below 1% in the “general population” Generalized – Prevalence of HIV has surpassed 1% in the “general population” Source: UNAIDS

7. HIV Epidemic Summary in Asia- Pacific Region Three countries in Asia have generalized epidemics: –Cambodia (1.6%), Thailand (1.4%), and Myanmar (1.3%) Rapidly expanding concentrated epidemics include India, Indonesia, Nepal, Vietnam and several provinces in China One country in the Pacific now is also on the verge of a generalized epidemic – Papua New Guinea –Possibility for an ‘African-style’ epidemic

8. HIV Epidemic Summary in Asia- Pacific Region (cont’d) But even within one country, there is significant variation in epidemic spread –India, China

9. Adult HIV prevalence among African countries in 2005 Source: UNAIDS/WHO 2006 Report on the global AIDS epidemic

10. Adult HIV prevalence among Asian countries in 2005 Source: UNAIDS/WHO 2006 Report on the global AIDS epidemic Note: * <0.1

11. With a few exceptions, Asia epidemics will not reach the high levels seen in the highest prevalence in sub-Saharan African countries So what ’ s the big deal? Even a low-grade epidemic in Asia means millions of people (60% of world population – 4 billion) What's the big deal with HIV in Asia?

12. Every percentage point in Asia adds a huge number to the global epidemic CountryAdult population1% adds this to global pandemic China726 million7.3 million India533 million5.3 million Indonesia118 million1.2 million Bangladesh72 million720,000 Pakistan67 million670,000 Vietnam43 million430,000 Total=15.5 million 1% increase in adult HIV prevalence in SS Africa=2.9 million

13. What drives the spread of HIV in Asia?

14. Factors that drive the spread of HIV Major behavioral factors –Unsafe blood transfusion –Needle sharing –Multiple heterosexual partners engaging in unprotected sexual intercourse –Multiple homosexual partners engaging in unprotected anal sex –Commercial sex Major co-factors –Presence of other STI –Non-circumcision

15. Socio-economic factors that may affect HIV epidemic spread Poverty –Higher levels of commercial sex –Higher levels of drug use –Less access to quality health care Travel/Migration –Long-distance truck drivers, seafarers… –Men living without their families; Higher use of sex workers –Female migrants

16. Social and cultural factors in Asia promoting or inhibiting HIV spread? A tolerance for men, strict prohibition for women Loosening sexual norms in Asia Increasing age at marriage producing large pool of unmarried youth Gender inequality –Reduces employment opportunities, promoting sex work –Limits negotiating ability in relationships

17. “It’s very difficult to speak about ‘the Asian epidemic’. Whatever we come up with, we always find a big exception in Asia.” (Dr. Peter Piot, UNAIDS Executive Director)

18. So what explains the variations between countries? Levels of risk –Frequency of needle sharing, sexual activity –Sizes of at-risk populations, especially drug users, sex workers and clients of sex workers Linkages among at-risk sub-populations Behavior change in response to prevention Timing of HIV introduction into the high-risk groups Biological factors such as STI and circumcision

19. HIV prevalence among IDUs far outstrips sex worker prevalence in most places (Source: National surveillance reports)

20. If HIV infection is highest among IDUs, why is it claimed that commercial sex is the main driver of HIV epidemics in Asia? Absolute numbers IDU more likely to be infected More HIV infections overall will be transmitted sexually

21. Dynamics of Asian HIV/AIDS epidemics Newborns Clients Low or no risk males MSM IDUs FSW Low or no risk females Early infections focused in at-risk groups: Clients & FSW, IDU and MSM. These groups strongly linked behaviorally

22. IDUs visit sex workers Percent of injectors visiting sex workers last year Sources: National surveillance systems. *Bangladesh values are for the last month.

23. Impediments to HIV Prevention in Low Prevalence/Emerging Epidemic Countries Low Prevalence = Low priority = We’re different - “Risk behavior does not happen here so there’s no need to respond” = Lack of capacity = Tendency to focus on politically popular but epidemiologically inefficient groups, e.g. general population = Vicious circle of lack of data → no response → lack of data….

24. Low prevalence among whom? Asian countries have overall low HIV prevalence Higher prevalence in higher risk populations Need to focus on these higher risk populations

25. SOUTH & SOUTH-EAST ASIA Estimated number of injecting drug users (IDUs) HIV prevalence among IDUs (mid est.1998/2005) IRAN: 206,000 AFGHANISTAN: 34,080 PAKISTAN: 462,000 NEPAL: 41,000 BHUTAN: INDIA: 1,294,000 BANGLADESH: 98,000 MYANMAR: 195,000 THAILAND: 57,000 MALAYSIA: 19,500 INDONESIA: 580,000 VIET NAM: 128,000 SRI LANKA: 28,241 PHILIPPINES:17,000 MALDIVES unknown SINGAPORE: 15,000 0.5% unknown 68.4% Up to 60% unknown Up to 79.5% 2.6% 54% 64% 1% 35.5% 1.7% 47% unknown LAOS: 8,000 unknown

26. Factors that increase HIV transmission associated with IDU Sharing and re-using injecting equipment (due to lack of clean needles & syringes or fear of arrest and beatings by the police) Professional injectors and shooting galleries Sexual behaviour of IDUs –Selling sex to buy drugs Women IDUs selling sex to buy drugs Male IDUs selling male-male sex to buy drugs –Drug injectors buying sex Imprisonment or drug treatment centers (Source: SHARAN Archives. 2000)

27. A IDU Network HIV -ve B IDU Network HIV +ve C IDU Network HIV -ve D IDU Network HIV -ve C A DB A IDU Network HIV +ve B IDU Network HIV +ve C IDU Network HIV +ve D IDU Network HIV +ve PRISON IDU “Mixing” in Prisons

28. Epidemics among FSW often follow IDU epidemics

29. Essential HIV prevention package: weighting varies by country Confront stigma and discrimination –National leadership, mass media, education Prevent sexual transmission –Condoms and social marketing for FSW, clients, MSM –Reducing number of sexual partners –Delaying sexual debut Prevention of IDU transmission –Harm reduction programs including substitution therapy –Peer counseling Voluntary counseling and testing –Confidentiality and consent

30. Essential HIV prevention package: weighting varies by country Prevention of MTCT –Antenatal screening Focus on HIV prevention among youth –Peer counseling, mass media campaigns, school education Integrate prevention into treatment services Treatment of STIs Workplace programs Ensuring safety of blood supply –Transfusion screening Preventing HIV transmission in healthcare settings – Universal precautions

31. Example of a full HIV prevention, care, and treatment program: Vietnam

32. HIV/AIDS in Viet Nam Initially largely driven by injection drug use and, to a lesser extent, by sex work Moved into general population with husband-to- wife-to-child transmission, through the sexual networks of drug users and clients of sex workers Women now account for one-third of all new infections

33. How the US government supports HIV programs in developing countries Two major US government agencies: USAID, CDC These agencies can provide funding directly to ministries of health They can also provide them through technical organizations and universities –FHI and UNC are two that are very active in HIV and other diseases internationally

34. US government policies regarding HIV prevention: myths and realities The PEPFAR initiative has brought tremendous resources to HIV treatment in addition to prevention and care –15 focus countries; $15 billion for 5 years –President Bush has just requested a doubling of this amount Contrary to the belief of many, PEPFAR fully supports condom promotion to FSW, their clients, and MSM

35. US government policies regarding HIV prevention: myths and realities (cont'd) 20% of prevention funding must go to abstinence programming (some countries receive a waiver, e.g. Vietnam) No funding can be used to support the purchase or distribution of syringes or needles for IDUs Partners must sign a pledge that they do not support the legalization of prostitution nor will funds be used for this. –In 2005, DKT International is challenging this in court because they refused to certify its opposition to prostitution

36. FHI HIV Program focus in Vietnam Prevention interventions to address behaviors at the core of the epidemic – drug use, commercial sex work and sex among men (i.e., IDUs, FSWs and their clients, and MSM) Care and treatment interventions at district level to provide treatment, care and support for people living with HIV/AIDS (PLWHA) Integrated bio-behavioral surveillance to understand the direction of the epidemic, behavior change, and estimates of HIV infection

37. Interventions for IDU: strategic approaches Peer outreach to shooting locations and drop-in center services Drug addiction treatment counseling with relapse prevention Substitution treatment: Methadone substitution treatment planned for 3 sites for 2008

38. Strategic approaches to reaching clients of FSW Reaching at-risk men at entertainment establishment (beer houses, bars, restaurants, coffee houses) with “Live Like a Real Man" messages A dedicated hotline with experienced counselors Strong linkages with the mass media component

39. Strategic approaches for FSW Peer outreach to FSW based on mapping of commercial sex Condom distribution Drop-in centers with integrated services (VCT, STI, counseling, edu-tainment, referrals)

40. Interventions for MSM: strategic approaches Peer outreach to discos, bars, and locations where men meet for sex Drop-in center for edu- tainment and peer discussions Internet intervention

41. Drug "rehabilitation centers": a unique challenge in Vietnam Government of Vietnam (GoV) began addressing drug “problem” 10 years ago with a “social evils” perception. Main strategy was placement in drug rehabilitation centers (known as 06 Centers – “labor and education”) –Mandatory detoxification –Rehabilitation through lectures on drug use, risk of HIV transmission –Vocational training

42. Drug "rehabilitation centers": a unique challenge in Vietnam By 2006, 83 rehabilitation centers were in operation, with up to 57,000 residents GoV noticed high rates of relapse (>90%) from 2 year rehabilitation period and so increased the length of time to up to 5 years Spiraling costs of 06 centers and high HIV rates (up to 50% HIV+) forced willingness to view alternative approaches With PEPFAR support, FHI and others are "rehabilitating" the rehabilitation centers

44. Knowing what we (Asia) do, why are HIV programs still failing? Focus and misdirection Capacity for quality programming Coverage Political will

45. Why do we fail?: Focus and misdirection Global and national program misdirection –African paradigms in Asian settings – ABC –USG restrictions on harm reduction (needles and syringes) –Social order and social evil campaigns

46. Why do we fail?: Capacity National program capacity –Understaffed, overburdened, lacking some skills sets NGO and community capacity –Great development capacity –Little experience with HIV & marginalized groups International support capacity –Limited technical staffing and consultant base, largely from outside

47. Most countries do not yet have size estimates of critical groups: –Sex workers, clients, IDU, MSM Difficult to know: –what each group ’ s role is in the epidemic –what coverage goals should be to make a difference Why fail?: lack of size estimation/ coverage data

48. Why do we fail? Political will Countries successful against HIV have –Leadership from the top –Grass roots efforts working upward –Societal mobilization But many Asian leaders (& their replacements): –do not acknowledge risk – HIV/AIDS is not really an Asian problem –do not understand their epidemics – infection will restrict itself to high-risk groups –do not support work with marginalized groups

49. Asia – Boom or Bust? The next sub-Saharan Africa? No 3-5% possible in some countries? Yes Can we stop it? Yes, by –Focusing in the right places, with the right prevention services, and for the right people –Mobilizing the resources to go to scale; The time for “boutique” pilot projects is long past –Building country capacity to respond in the most effective manner

50.  Robert Ali, University of Adelaide, Australia  Stephen Mills, FHI Vietnam  Tobi Saidel, FHI India  Dimitri Prybylski, FHI Bangkok  Tran Vu Hoang, FHI Vietnam  Tim Brown, University of Hawaii, Hawaii, USA  Fritz Van Grievsen, US-CDC, Bangkok  Philippe Girault, FHI Bangkok Thank You Slide