HIV and AIDS
statistics and features, end of 2002 and 2004
|
| |
Adults and children
living with HIV |
Number of women
living with HIV |
Adults and children
newly infected with HIV |
Adult prevalence (%)
|
Adult and child
deaths due to AIDS |
|
| 2004 |
8.2 million
[5.4–11.8 million] |
2.3 million
[1.5–3.3 million] |
1.2 million
[720 000–2.4 million] |
0.4
[0.3–0.6] |
540 000
[350 000–810 000] |
|
| 2002 |
7.2 million
[4.6–10.5 million] |
1.9 million
[1.2–2.8 million] |
1.1 million
[540 000–2.5 million] |
0.4
[0.2–0.5] |
470 000
[300 000–690 000] |
|
A handful of countries are still seeing very
low levels of HIV prevalence, even among people at high risk
of exposure to HIV. These countries have golden opportunities
to pre-empt serious outbreaks.
National HIV infection levels in Asia are low compared with
some other continents, notably Africa. But the populations of
many Asian nations are so large that even low national HIV
prevalence means large numbers of people are living with HIV.
Latest estimates show some 8.2 million [5.4 million–11.8
million] people (2.3 million [1.5 million–3.3 million] adult
women) were living with HIV at the end of 2004, including the
1.2 million [720 000–2.4 million] people who became newly
infected in the past year. AIDS claimed some 540 000 [350
000–810 000] lives in 2004. Among young people 15–24 years of
age, 0.3% of women [0.2–0.6%] and 0.4% of men [0.3–0.8%] were
living with HIV by the end of 2004.
Asia is not just vast but diverse, and HIV epidemics in the
region share that diversity, with the nature, pace and
severity of epidemics differing across the region. Overall,
Asian countries can be divided into several categories,
according to the epidemics they are experiencing. While some
countries were hit early (for example, Cambodia,
Myanmar and Thailand), others are
only now starting to experience rapidly expanding epidemics
and need to mount swift, effective responses. They include
Indonesia, Nepal, Viet Nam, and several provinces in
China. In Myanmar and in parts of India
and China, HIV has become well-entrenched in some sections of
society, despite modest efforts to halt the virus’ spread.
Other countries are still seeing extremely low levels of HIV
prevalence, even among people at high risk of exposure to HIV,
and have golden opportunities to pre-empt serious outbreaks.
These countries include Bangladesh, East Timor, Laos,
Pakistan, and the Philippines (MAP,
2004).
Some countries, by sheer virtue of size, simultaneously fit
several of those descriptions: China and India are examples.
These two countries, home to some 2.35 billion people, are
experiencing several distinct epidemics, some already very
serious.
CHINA
Although moving at a varied pace, HIV has spread to all of
China’s 31 provinces, autonomous regions and municipalities.
In some, such as Henan, Anhui, and Shandong, HIV was already
spreading a decade ago among rural people who sold blood
plasma to supplement their incomes. Elsewhere, the virus has
established a more recent but firm presence among injecting
drug users and, to a lesser extent, sex workers and their
clients (Zang, Ma and Xia, 2004). Much of the current spread
of HIV in China is also attributable to injecting drug use and
paid sex. HIV prevalence among drug injectors was measured at
between 18% and 56% in six cities in the southern provinces of
Guangdong and Guangxi in 2002, while in Yunnan province some
21% of injectors tested positive for HIV in 2003 (China
National Center for AIDS/STD Control and Prevention, 2003).
Sexual transmission of HIV from injecting drug users to their
sex partners looks certain to feature more prominently in
China’s fast-evolving epidemic. Some 47% of surveyed female
drug injectors in Sichuan province and 21% in neighbouring
Yunnan province reported selling sex for money or drugs in the
previous month, according to recent studies. Condom use was
reportedly quite high but it was hardly the norm. Once HIV
becomes well-established in commercial sex circuits, onward
spread of the virus could be quite rapid if current behaviour
trends persist. In 2003, almost one quarter of surveyed sex
workers in Guangxi never used condoms and about one half used
them only occasionally (China National Center for AIDS/STD
Control and Prevention, 2003). In Sichuan, only around 40% of
sex workers reported using condoms with all their clients in
the previous month, according to a 2002 study. Little is known
about the possible role of sex between men in China’s
epidemic. A rare survey of men who have sex with men in
Beijing, conducted in 2001-2002, found that approximately 3%
of the men were HIV-infected (almost all of whom had been
unaware of their serostatus) (Choi et al., 2003).
If China is to shape the course of its
epidemic, it needs to
move swiftly and with great resolve.
There are signs that efforts to boost public knowledge
about HIV are bearing fruit but there remains much room for
improvement. A 2003 survey found that two-in-five Chinese men
and women could not name a single way to protect themselves
against infection (Shengli, Shikun and Westley, 2004). In
Sichuan province, more than one third of sex workers (and a
similar proportion of clients) did not know that condoms offer
good protection against HIV. Research suggests that few
brothels in China have condom policies of the sort that helped
Cambodia and Thailand bring their epidemics under control, and
even fewer are keeping condoms on the premises (MAP, 2004).
China can still shape the course of its epidemic. But it needs
to move swiftly and with great resolve.
INDIA
India’s epidemics are even more diverse
than China’s. Latest estimates show that about 5.1 million
[2.5–8.5 million] people were living with HIV in India in
2003. Serious epidemics are underway in several states. In
Tamil Nadu, HIV prevalence of 50% has been found among sex
workers, while in each of Andhra Pradesh, Karnataka,
Maharashtra and Nagaland, HIV prevalence has crossed the 1%
mark among pregnant women. In Manipur, meanwhile, an epidemic
driven by injecting drug use has been in full swing for more
than a decade and has acquired a firm presence in the wider
population (UNAIDS/WHO, 2003). HIV prevalence measured at
antenatal clinics in the Manipur cities of Imphal and
Churachand has risen from below 1% to over 5%, with many of
the women testing positive appearing to be the sex partners of
male drug injectors. Several factors look set to sustain
Manipur’s epidemic, including the large proportion (about 20%)
of female sex workers who inject drugs and the young ages of
many injectors (40% of male injectors surveyed in 2002 were
under 25 years of age) (MAP, 2004).
There are signs that injecting drug use is playing a bigger
role in India’s epidemics than previously thought. Most
surveillance sites for injecting drug users are in the
northern states where injecting is common behaviour, but other
parts of the country have yielded equally troubling evidence.
In the southern city of Chennai, for example, 26% of drug
injectors were already infected with HIV when a sentinel site
was established there in 2000; by 2003, 64% were infected. In
most cities where injecting drug users have been surveyed, at
least one quarter of them—and, in Chennai, 46%—said they lived
with a wife or regular sex partner (MAP, 2004). This has
probably contributed to the fact that Chennai also has among
the highest HIV-prevalence rates among pregnant women in the
country. It is likely that many of those women were infected
by partners who injected drugs.
Reducing risk works
All the scientific evidence points to
the fact that programmes which provide opiate substitution
treatment, increase access to sterile needles and provide
other prevention services reduce new HIV infections among
people who inject drugs. A recent review of over 400
surveillance reports and scientific papers found no
evidence that HIV prevention services for drug
injectors—including the provision of clean needles—are
associated with an increase in the number of people
injecting drugs (MAP, 2004). The review found that
countries that promote safer injecting practices
(including sterile needle access) are successful in
encouraging lower-risk behaviour. These programmes often
reach out to socially disadvantaged groups of drug users
and offer a range of HIV prevention and primary health
care services. Such HIV prevention programmes for drug
injectors complement a range of other efforts aimed at
preventing drug use among young people in the first place,
known as demand reduction programmes. Thus, these
programmes pursue a range of goals—including discouraging
people from using drugs at all, from injecting drugs, or
from using non-sterile needles and syringes.
The clearest evidence that large-scale
needle-exchange programmes can reduce harm for injectors
comes from a city in Bangladesh, where it has been
shown that needle-exchange programmes can promote healthy
sexual behaviour as well as safer injection—thus reducing
the risks of HIV transmission. There was a striking
association between participation in needle-exchange
programmes and reduced use of non-sterile injecting
equipment. In addition, injectors who used the
needle-exchange were far less likely to report symptoms of
a sexual infection in the previous 12 months than people
who did not participate in the programme. This clearly
shows that safer-injecting programmes can bring people
into contact with a range of HIV prevention services that
can reduce their sexual as well as their injecting risk.
The key is to achieve wide enough coverage with effective
programmes. A similar project in another Bangladesh city,
where the services reached just under half of the
injectors, had less impact.
Because AIDS epidemics criss-cross
national boundaries, joint efforts like the border area
needle exchange programme run by China and Viet
Nam since 2002 make sense. Outreach workers collect
used syringes from users for safe disposal, and provide
vouchers which can be used to acquire new needles from
participating pharmacies. The programme grew from the
realization that the epidemics among injectors in China’s
Guangxi province and Viet Nam’s Quang Ninh and Langson
provinces were closely linked (they share a unique variant
of HIV-1 subtype CRF01_AE), due to the fact that the areas
straddle a drug trafficking route through the Golden
Triangle (Yu et al., 1999; Kato et al., 2001). The
programme is based on a successful trial which showed a
drop in the use of non-sterile injecting equipment in the
previous month from 61% to 30% among all injectors in
Guangxi (China National Center for AIDS/STD Control and
Prevention, 2004). Harm-reduction programmes have also
helped trigger a dramatic fall in reported non-sterile
needle use among injectors in China’s Sichuan province.
Reported re-use of non-sterile needles at last injection
fell from 30% to 17% among male injectors in 2002-2003,
while in the same year it fell from 24% to 15% among
female injecting drug users (MAP, 2004). |
Like Manipur, the states of Maharashtra, Tamil Nadu and
Andhra Pradesh have long-established HIV epidemics, but theirs
are driven mainly by commercial sex. Available evidence
suggests that prevention efforts in some of those states have
done little to alter the epidemics’ advance. Sentinel
surveillance has revealed no significant drop in HIV
prevalence among female sex workers in Mumbai, for example,
despite decade-old safer-sex programmes for sex workers. It
appears the programmes have been either too scattered or
short-term to reach a large enough proportion of sex workers
to make a difference. In some of these states, HIV has been
rising steadily among pregnant women, most likely because
clients have transmitted the virus to their regular partners.
Fortunately, India does boast some significant prevention
successes, such as the drop in unprotected casual sex reported
in the southern state of Tamil Nadu. In 1996, 14% of truck
drivers reported recent unprotected sex with a sex worker. By
2002, after concerted prevention programmes were introduced,
that had fallen to just 2% (AIDS Prevention and Control
Project, 2003).
In parts of India, Myanmar and China,
inadequate prevention efforts have allowed HIV to filter from
people with the highest-risk behaviours to their regular sex
partners.
As elsewhere in the region, the role of sex between men in
India’s epidemics remains poorly understood. What is clear is
that a considerable number of men in India do have sex with
other men. In a household-based survey in a low-income area of
Chennai, India, 6% of men reported sex with other men. These
men were over eight times more likely to be infected with HIV
than other men in the survey, and 60% more likely to be
infected with other sexually transmitted infections. A high
proportion of men who have sex with men also reported sex with
women (Go et al., 2004). For example, in a household study in
India, 57% of men reporting sex with other males were married
(NACO, 2002).
High risk behaviour and sharp rises in HIV
HIV prevalence is rising sharply in several places where it
stayed low for many years. These rises are most dramatic among
people whose behaviours carry a high risk of exposure to
HIV—drug injectors, sex workers and their clients, and men who
have sex with men. In Indonesia, Nepal, Viet
Nam and parts of China, rapid, recent rises in HIV
infection among drug injectors appear to have spurred
subsequent rises in HIV infection among non-injectors who have
sexual risk behaviours, “kick-starting” wider epidemics, as
Figure 15 illustrates. Given the very large population numbers
in these countries, continued HIV spread among those with risk
behaviours and their sex partners will give rise to several
million new infections. These countries stand at a cross-road;
they dare not delay introducing effective responses.
One in two injecting drug users in Jakarta
now test positive for
HIV, while in cities such as Pontianak more than 70% of drug
injectors are being found to be HIV-positive.
On a vast archipelago such as Indonesia, where
research has revealed ample opportunities for wider HIV
transmission, the epidemic will assume diverse patterns. Risk
behaviour among injecting drug users in Indonesia is very
common. A recent survey in three cities found 88% of the
injectors had used non-sterile needles or syringes in the
preceding week, yet fewer than one third said they felt at
high risk of HIV infection (Pisani et al., 2003). When
injecting drug users are tested for HIV, very high infection
levels are found. One in two injecting drug users in
Indonesia’s capital, Jakarta, now test positive for HIV, while
in far-flung cities such as Pontianak (in West Kalimantan
province on the island of Borneo) more than 70% of drug
injectors who request HIV tests are discovering that they are
HIV-positive (MAP, 2004).
Figure 15
Conditions also favour HIV spread through sex work. In
seven Indonesian cities, an average 42% of sex workers had
either or both gonorrhoea or chlamydia in 2003. Condom use
ranges from irregular to rare. In 2002, fewer than one in five
sex workers operating out of massage parlours and discotheques
in Jakarta said they used condoms consistently (MAP, 2004).
Among sex workers in brothel areas (a group that ought to be
easier to reach with interventions), rates of condom use with
all clients in the previous week stood at a meagre 4% (MAP,
2004). The situation is even more troubling in parts of
Indonesia’s easternmost province of Papua, where HIV
prevalence among sex workers in Sorong, for example, had
reached 17% by 2003, over five times the national average for
sex workers. There are strong signs that the virus is
spreading beyond sex workers and their clients. One recent
serosurvey among adults in five villages found that close to
1% were HIV-positive (MAP, 2004). Household surveys of young
men and women in Jayapura and Merauke show that both young men
and women in Papua report far less drug use and far more
sexual activity than those in other parts of Indonesia. The
data are inconclusive, but they suggest patterns of sexual
networking that could favour dynamic HIV spread in the general
population on Papua (Indonesia Central Bureau of Statistics
and MACRO International, 2004).
HIV behind bars
Prisons are playing a growing role in
Indonesia’s emerging epidemic. In Jakarta’s jails,
HIV prevalence started to rise in 1999, two years after it
had taken off among drug injectors, reaching 25% in 2002.
Some of the rise reflected the fact that injecting drug
users were more likely to have been infected by the time
they entered prison. But there is evidence that HIV
transmission is occurring inside jails. Surveillance data
from a West Java prison has shown HIV prevalence soaring
from 1% in 1999 to 21%, then “falling” sharply to 5% in
2002. The 2002 “drop” was an illusion, though, reflecting
a change in sampling: only newly-registered inmates were
tested for HIV. When a random sample was used again in
2003, HIV prevalence was found to be 21%. This discrepancy
suggests that HIV is being transmitted inside the prison,
either through drug injection with contaminated needles or
through unprotected anal sex between prisoners (MAP, 2004;
data from Indonesian national surveillance).
A huge prevention opportunity beckons.
Unlike their counterparts outside the prison walls, jailed
drug injectors are not a “hard-to-reach population”.
HIV-prevention programmes are needed inside prisons, with
reinforcement in preparation for prisoners’ release. Jails
can provide an entry point for treatment for both
antiretroviral and drug substitution treatment. Referral
systems between jail and services outside can help
introduce essential health, prevention and care services
to people who might otherwise potentially be hard to track
down in the community after release. |
Unsafe injecting drug use is the wellspring of
Nepal’s epidemic, too. Use of non-sterile injecting
equipment is widespread and accounts for the high HIV
prevalence—22% to 68% across the country in 2002—among male
injectors, many of them younger than 25. Younger injectors
appear more likely to report risky practices in parts of
Nepal; in the east, for example, injectors under 25 were three
times as likely to report using non-sterile equipment at last
injection compared with older injectors (MAP, 2004). Nepal’s
epidemic also highlights the potential links between HIV
infection and mobility. Injecting drug users from cities with
low prevalence, but who had injected drugs elsewhere, have
been found to be two to four times more likely to have
acquired HIV than those who had remained in their home cities.
Half of the sex workers surveyed in central Nepal and who said
they had worked in Mumbai (India) were HIV-infected, compared
with 1.2% of those who had never been to India.
Risky business
Most new HIV infections in Asia occur
when men buy sex—and large numbers of men do so.
Household-based surveys in a number of Asian countries
suggest that between 5% and 10% of men buy sex, which
makes commercial sex a large and lucrative industry in
Asia. Many sex workers—especially very young women from
rural areas—are either coerced into the industry or join
it under duress, because they lack other employment
opportunities. Studies among sex workers in China,
for example, have found that young and ill-educated women
from rural areas sell sex because they could not find
other work. However, others sometimes opt for the
profession instead of arduous, low-paying jobs. In Viet
Nam for example, sex workers have reported earning up
to seven times the average income of other workers in the
areas where they plied their trade. Their counterparts in
Nepal have reported earning around 2200 rupees or
US$ 30 a week, six times the average wage income (MAP,
2004).
The majority of the women who did not
use condoms with their last client in places where condoms
were easily available said it was because their clients
refused to use them. Because many men are willing to pay
more for sex without a condom, many women find it
especially difficult to negotiate condom use. In India,
one quarter of street-based sex workers said that if a
client refused to use a condom they simply charged more
money and went ahead with sex. Sex workers in China’s
Yunnan province have reported that they earn about 60%
more for sex without a condom, while non-brothel-based sex
workers in Indonesia charged around 20% more. In
addition, some clients threaten or use violence when sex
workers try to insist on condom use.
Who’s doing the buying? In southern
Viet Nam, sex workers reported that more than one third of
their clients were businessmen or white-collar workers,
while over half in five northern provinces were said to be
government officials. Women selling sex in Indonesia,
Laos and Pakistan also said that civil
servants and businessmen were among their most frequent
clients, while in India, over one-quarter were
businessmen or service sector employees. Many of these men
are married or in steady relationships. Those who have
unprotected sex with sex workers are at risk therefore not
just of contracting HIV but of passing it on to their
wives and girlfriends. Indeed, in a study in the southern
Chinese city of Guangzhou, some 72% of women with sexually
transmitted infections said they had only had sex with
their husband or regular partner in the previous six
months—a clear sign that they were put at risk by their
partners’ behaviour rather than their own. Expressed in
these ways are deeper social inequalities, not least the
imbalances in men and women’s social power, and women’s
stunted earning and career opportunities in most countries
of Asia (and, indeed, the world). Prevention efforts that
neglect these wider dynamics are likely to achieve just
short-lived success, if any.
It’s easy to forget, though, that not
all sex workers are women. Asian men also buy sex from
male and from transgender sex workers. For example, 48% of
men who have sex with men in Lahore, Pakistan, and 20% in
Sichuan, China, said they had paid for sex in the previous
six months. Over one third of men in five cities in India
who have sex with men, reported in 2002 having bought or
sold sex in the previous month, while a 2001 study in the
city of Chennai found that one in five men who have sex
with men had exchanged money for sex at some point (Go et
al., 2004). The high rates of commercial sex between men
reported in surveys do not represent the habits of all men
who have sex with men, but they highlight the forgotten
population of male sex workers and the high risks of HIV
infection they have. In one Bangkok study, for example,
32% of men who have sex with men who reported selling sex
were infected with HIV. |
Widespread injecting drug use by sex workers makes
Viet Nam’s epidemic particularly explosive. In Ho Chi
Minh City, 38% of almost 1000 sex workers included in one
survey injected drugs—and fully 49% of those injecting sex
workers were infected with HIV (compared with 8% of those who
didn’t use any drugs). In the northern port city of Haiphong,
nearly 40% of all sex workers said they injected drugs,
compared to one in six sex workers who did likewise in the
capital, Hanoi. Drug-using sex workers are about half as
likely to use condoms as those who do not use drugs, according
to another study in Ho Chi Minh City. These trends probably
explain a good deal of the steep rises in HIV prevalence
detected in some of Viet Nam’s cities, where the virus now
appears to be spreading freely among groups that are at high
risk of exposure to HIV. HIV prevalence of 8% was detected in
a 2003 Ho Chi Minh city survey among men who have sex with
men.
Most new HIV infections in Asia occur when
men buy sex—and large numbers of men appear to do so.
High prevalence and HIV spreading among wider population
In some areas, including parts of India, Myanmar
and south-western China, HIV has acquired a
strong foothold among people who have been exposed to a high
risk of infection for several years. Inadequate prevention
efforts have allowed the virus to filter from people with the
highest-risk behaviours (such as non-sterile drug injection
and unprotected commercial sex) to their regular sex partners,
which accounts for rising HIV- infection levels among women
who report having only one sexual partner. Myanmar,
which has one of the most serious epidemics in Asia, is an
example. The situation varies across the country, but HIV has
already become entrenched in lower-risk populations in several
parts of Myanmar. By 2003, 12 out of 29 sentinel sites for
pregnant women were recording HIV prevalence above 2%. At Pyay
and Hpa-an, respectively, 5% and 7.5% of pregnant women tested
HIV-positive. About 2% of new military recruits tested
HIV-positive at two sites in 2003 (Ministry of Health Myanmar,
2003). Exceptionally large proportions of injecting drug users
have acquired HIV: in some places, 78% of drug injectors
tested positive in 2003. Between 45% and 80% of drug injectors
have tested positive for HIV infection in sentinel
surveillance each year between 1992 and 2003. HIV among sex
workers rose significantly from around 5% to 31% over the same
period. Meanwhile, the proportion of male and female patients
at sexually transmitted infection clinics who tested positive
for HIV rose to 6% and 9%, respectively, in 2003 (Ministry of
Health Myanmar, 2003; MAP, 2004).
What’s in a name?
From the perspective of HIV prevention,
the definition of “sex work” or “commercial sex” or
“prostitution” carries important implications for policy
and programme development. To date, no single term
adequately captures the range of transactions that involve
the commoditisation of sex worldwide. “Sex work” or
“commercial sex” appears to thrive where a demand for
sexual services occurs in settings marked by socioeconomic
disparities. Even then, “sex work” or “commercial sex”
takes on various forms. It can be “formal or direct” and
based in establishments such as brothels, saunas and
massage parlours, or it can be “informal or indirect” and
based in bars, restaurants, truck stops and taxi ranks and
on the streets. The transactions can be overtly
commercial—the exchange of sex for a set fee—or they can
be much more opaque—sex rewarded with gifts or favours,
for example. In addition, numerous paths lead women and
girls (as well as men and boys) into selling or exchanging
sex. Many, especially the very young, are trafficked and
forcibly enslaved in the sex industry. It is estimated
that hundreds of thousands of people, including women and
children, are trafficked every year. Economic
necessity—their own and often that of their
families—compels many others to sell or exchange sex
temporarily or on an ongoing basis. In some places, still
others temporarily opt for selling sex seasonally, when
income is low, for example in farming economies, instead
of arduous, low-income employment. Not all these women
(and boys) regard themselves as “prostitutes” or “sex
workers” either, particularly when sex is exchanged for
“gifts” and favours. Moreover, there are not always clear
distinctions between these varieties of “commercial sex”,
making it difficult to accurately attach particular terms
to specific instances. The term “sex work” may suggest the
sale or exchange of sex by people who act with a certain
degree of volition, however circumscribed it is by
socioeconomic pressures. It does not, however, refer to
trafficking, situations of enslavement or naked coercion. |
Strong prevention efforts that have shown results
Asian countries that have introduced large-scale prevention
programmes addressing sexual transmission of HIV—notably
Cambodia and Thailand—have
seen significant reductions in risk behaviour, and have
recorded declining levels of new HIV and other sexually
transmitted infections. In Cambodia, fewer men are now
visiting sex workers and there has been a significant rise in
condom use in commercial sex. The combined effect has been a
steep drop in sexually transmitted infections and a steady
decline in HIV prevalence. New testing technologies that allow
researchers to estimate what proportion of infections were
recently acquired show a significant drop in new HIV
infections (or incidence), as Figure 16 shows.
Out of sight, out of mind?
Generalized stigma towards men who have
sex with men has meant that few surveillance systems in
Asia capture HIV-related information on sex between men.
As is the case with female sex workers and injecting drug
users, if reliable data are limited, access to prevention
will probably be limited, too.
Recent research has begun to lift this
veil of secrecy. In a number of countries (including
Bangladesh, India and the Philippines),
the proportion of men in household studies reporting
recent male-male sex has been found to range between 5%
and 10%. Ad hoc surveys have been finding very high levels
of HIV infection: 14% at an area popular with men seeking
casual sexual partners in Phnom Penh, Cambodia; 17%
in a community sample in Bangkok, Thailand; and 22%
in a study of men who have sex with men in Jakarta,
Indonesia (MAP, 2004; Van Griensven et al., 2004). The
findings represent the high-end of the risk spectrum, and
should not be generalized to all men who have sex with
men. However, they serve as a warning to Asian countries
that they dare not neglect male-male sex in their
prevention programming. Not only do men who have
unprotected sex with other men risk infecting each other,
but many of them also have sex with women (who often are
unaware of the other liaison). In a survey in central
Thailand, one in three of the men who reported sex with
other men also bought sex from women, and almost half had
non-regular female partners. Behavioural surveillance in
five Indian cities found 27% of men who had sex with men
were married or living with a female sex partner (NACO,
2002). |
A 2003 survey of men aged 15–24 years in a low-income area
of the capital, Phnom Penh, found that only 8% of them had
ever bought sex from a sex worker (Douthwaite, 2003).
(Although not directly comparable, 19% of adult men of all
ages in the city in a study conducted three years earlier said
they had bought sex in the previous year.) (MAP, 2004). And
new studies show that men in their teens are about nine times
more likely to use condoms than older men. A strategy that
centres on reducing the risk of HIV transmission in commercial
sex, while also tackling other risk behaviours such as
unprotected sex between men and unsafe drug injection will
enable Cambodia to sustain the inroads against the epidemic.
Thailand has also shown that a
well-funded, politically-supported and pragmatic response can
change the course of the epidemic. National adult HIV
prevalence continues to edge lower, with the latest estimates
putting it at 1.5% [0.8–2.8%] at the end of 2003 (UNAIDS,
2004). Recharged commitment and revised strategies are now
needed, however, to confront an epidemic that has entered a
new phase. As many as half of annual, new HIV infections have
been occurring among cohabiting couples, as more women are
infected by husbands who are (or were) clients of sex workers.
While still an important factor in HIV spread, brothel-based
sex work has been overtaken by other patterns of risky
behaviour. An estimated one fifth of all new HIV infections
are occurring through unsafe injecting drug use, compared with
about one twentieth a decade ago (Thai Working Group on
HIV/AIDS Projections, 2001). Exceptionally high levels of HIV
infection are being detected in parts of the country. In
northern Thailand, 30% of drug injectors are infected with
HIV, while median HIV prevalence as high as 51% has been found
in other parts of the country. Yet, scant prevention resources
are deployed on this front. The fact that injecting drug use
is illegal should not block the path of effective action. A
pragmatic approach—such as that adopted toward sex work in the
1990s—is much more likely to bring success. The same holds for
men who have sex with men, among whom HIV prevalence as high
as 17% has been detected (UNDP, 2004).
In Cambodia, fewer men are now visiting sex
workers and there
has been a significant rise in condom use in commercial sex.
Thailand, too, has shown that a well-funded,
politically-supported and pragmatic
response can change the course of the epidemic
At the same time, infection levels among pregnant women
remain high in parts of the country, including the South,
where they exceeded 2% in eight provinces in 2002. It is
likely that many of these women have been infected by male
partners who either inject drugs or frequent sex workers.
While keeping up the pressure to reduce brothel-based HIV
transmission, prevention efforts must now also reach the
increasing numbers of sex workers who operate in settings that
are less easily regulated. Meanwhile, it is estimated that
less than 5% of young people are being reached by adequate
prevention services, while public awareness campaigns have
dimmed. Just 20% to 30% of sexually active young people are
using condoms consistently (UNDP, 2004).
Very low HIV prevalence, big prevention opportunities
Several countries still have a rare opportunity to prevent
a significant epidemic from taking hold at all. There,
very-low rates of HIV infection are being recorded, even in
populations whose behaviours put them at great risk of HIV
infection, as Figure 17 shows. These countries still have an
opportunity to deny the virus a firm foothold, by providing
prevention services to those most at risk of HIV infection.
Asia’s successful HIV efforts were pragmatic.
They zeroed in on behaviours that were causing the most
infections. They mounted large-scale programmes. And they
tried to improve the social and legal environments in which
people most at risk live and work.
As other countries have discovered, where risky behaviours
are occurring, HIV will follow—unless prevention efforts are
effective. Bangladesh and the Philippines have
taken such lessons to heart and are trying to reduce risky
behaviours before the virus acquires a firm presence. The
efforts have had partial success to date, particularly among
the clients of sex workers. In 2003, for example, over one
half of registered sex workers in the Philippines’s Angeles
City said they used condoms with all clients last week;
however just 6% of hostesses in karaoke bars and night clubs
consistently used condoms. But if sustained and expanded,
prevention efforts could enable these countries to avoid the
sorts of epidemics recorded elsewhere. The AIDS picture in
Malaysia is far from clear, mainly because it is derived
largely from HIV and AIDS case reports that focus on injecting
drug users. Such reports indicate that 55% of people detected
with HIV between 1998 and 2001 were drug injectors. A study
carried out in Penang has found that 17% of drug injectors who
agreed to testing were HIV-positive (Navaratnam et al., 2003).
It is possible, though, that other significant factors in the
epidemic are being missed. For example, when surveillance was
last conducted among sex workers, in 1996, HIV prevalence was
6.3% in Kuala Lumpur and 10.2% in Selangor.
Some countries, including East Timor and Pakistan,
could be poised for HIV outbreaks. Until very recently the
majority of HIV infections and AIDS cases reported in Pakistan
were among migrant Pakistani workers who had been deported
from the Gulf States. However, there has been a recent report
of an HIV outbreak among injecting drug users in a small town
in Pakistan’s Sindh province. Just under 10% of the drug
injectors in the town of Larkana reportedly tested
HIV-positive (Shah et al., 2004.) Studies among Pakistani
truck drivers have found that one in three has never heard of
condoms, and 19 out of 20 who bought sex from women did not
use condoms. Meanwhile, nearly six out of 10 sex workers in
East Timor have never heard of AIDS, four out of 10 do not
recognize a condom when shown one, and zero out of 10
consistently use condoms with their clients (Pisani and Dili
STI survey team, 2004).
Data from Japan show that HIV prevalence has risen
steadily among male blood donors in that country, while
staying relatively stable among women. This suggests that HIV
transmission is occurring mainly among men who have sex with
men, some of whom might also be transmitting the virus to
female sex partners. In 2003, there were some 340
newly-reported HIV cases among Japanese men who had contracted
their infection through sex with other men, just over three
times the number of reported infections among men who report
acquiring the virus heterosexually. Indeed, since 1999 there
has been a rapid increase in the annual number of HIV
infections attributed to male-to-male sex (MAP, 2004).
Getting the balance right
Much as they need to be sustained and adapted to changing
realities, the achievements made in Cambodia and
Thailand show that countries that choose to provide
prevention services on a large scale to those people most in
need can bring their epidemics under control. In varying
degrees, Asia’s HIV-prevention successes have shared key
features. They were pragmatic and zeroed in on behaviours that
were causing the most infections, providing services to reduce
the risk of HIV transmission. They mounted large-scale
programmes to achieve adequate coverage. And they tried to
improve the social, legal and political environments in which
those most at risk live and work. Similar approaches can stem
the epidemic’s advance in other countries of the region
(Brown, 2004).
With 8.2 million [5.4 million–11.8 million] people already
living with HIV in Asia, treatment, care and support need to
move higher up the agenda, too. In 2004, fewer than 6% of the
estimated 170 000 people who needed antiretroviral treatment
in Asia were receiving it. A few countries are taking up that
challenge. Thailand appears on track to reach its target of
providing 50 000 people with antiretroviral treatment, while
others have committed themselves to drastically expand
treatment access—including Cambodia, China (which has pledged
free treatment), India (which has pledged free treatment in
several states) and Indonesia.
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