In the early to mid-1980s, while other parts of the world were beginning to deal with serious HIV and AIDS epidemics, Asia remained relatively unaffected. By the early 1990s, however, AIDS epidemics had emerged in several Asian countries and by the end of the decade; HIV was spreading rapidly in many areas of the continent.
Today, around 4.7 million people are living with HIV in Asia. Although national HIV prevalence rates in Asia appear to be relatively low, the populations of some Asian countries are so vast that these low percentages actually represent very large numbers of people living with HIV. India, for example, has an estimated HIV prevalence of 0.3%, which seems low when compared to prevalence rates in some parts of sub-Saharan Africa. However, with a population of around one billion, this actually equates to 2.5 million people living with HIV in India.
Although it is useful to understand the overall impact that AIDS is having on the Asian region as a whole, there is no single ‘Asian epidemic’; each country in the region faces a different situation. Progress has been made in countries such as Cambodia, Myanmar and Thailand, where there has been evidence of a decline in HIV prevalence. On the other hand, in Indonesia, Pakistan and Vietnam the number of people living with HIV has increased.
Some have warned that epidemics in Asia could escalate to the extent of rivaling those in some parts of Africa. 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 concentrated among members of ‘high-risk’ groups.
There are three main HIV transmission routes in Asia:
- Unprotected paid (and unpaid) sex. Unprotected sex, both paid and unpaid, accounts for a significant share of new HIV infections in many Asian countries. A large number of men buy sex regularly and the level of condom use during paid sex in many countries is still low. These factors have contributed to a high HIV prevalence among sex workers and their clients across Asia. In addition, an increasing number of women who are married and considered ‘low-risk’ of HIV infection are becoming infected with HIV. Estimates suggest that around 25-40 percent of new HIV infections in several Asian countries are among wives and girlfriends of men who became infected through paid sex, having sex with other men or injecting drugs.
- Injecting drug use. 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. 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.
- Sex between men. 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.7 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.
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 who became infected through mother-to-child transmission.
Asia has been the base for some extremely successful large-scale HIV prevention programs. 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. In Tamil Nadu, India, HIV prevention initiatives have had a substantial impact. High-profile public campaigns discouraged risky sexual behavior, 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.
Successes such as these prove that interventions can change the course of Asia’s AIDS epidemics. As HIV infection rates continue to grow however, it’s clear that more needs to be done. The groups most at risk of becoming infected – sex workers, IDUs, and MSM – are all too often being neglected. For instance, although injecting drug use is one of the most common HIV transmission routes in Asia, it is estimated that less than one in ten IDUs in the region have access to prevention services.11Similarly men who have sex with men are overlooked and poorly monitored by most governments, even though it is firmly established that this group play a significant role in some countries’ epidemics.
“In countries without laws to protect sex workers, drug users, and men who have sex with men, only a fraction of the population has access to prevention. Conversely, in countries with legal protection and the protection of human rights for these people, many more have access to services. As a result, there are fewer infections, less demand for antiretroviral treatment, and fewer deaths. Not only is it unethical not to protect these groups: it makes no sense from a health perspective.”Secretary-General Ban Ki-moon, speaking at the opening address to the International AIDS Conference
It is not only legal barriers that are preventing people from accessing effective HIV prevention; problems also arise when prevention programs do not contain information that will be most useful. For example, young people in Asia are generally not taught about the kinds of behaviors that put this group most at risk: unprotected sex through sex work, injecting drug use, and sex between men. Instead they focus on heterosexual transmission and reproductive health, which have a limited impact on preventing new HIV infections among young people in Asia.
The coverage of prevention of mother-to-child transmission (PMTCT) services is also very low in Asia. In East, South and South-East Asia, around 17% of pregnant women were offered an HIV test in 2009 – a very low percentage compared to other regions of the world such as Europe and Central Asia (75%), Eastern and Southern Africa (50%) and Western and Central Africa (21%). In 2009 across East, South and South-East Asia, only 32% of HIV-infected pregnant women received ARVs to prevent mother-to-child transmission of HIV.
Due to the stigma that often surrounds those groups most at risk of HIV infection, coverage of HIV voluntary counseling and testing (VCT) services in South-East Asia remains very low. An estimated 0.1% of the adult population in the region received testing and counseling in 2005. Certain countries are making progress, however; testing services in India have been expanded with about 5135 testing centers now open to the public. Even so, far more needs to be done across Asia to ensure VCT is available to those most at risk of acquiring HIV.
The availability of antiretroviral treatment more than tripled between 2003 and 2006 in Asia. Although this seems encouraging, only a third of people in East, South and South-East Asia who are in need of HIV treatment are receiving it. In addition, access to HIV treatment varies widely across the region. Thailand and Cambodia has an estimated treatment coverage of between 61-94 percent, whilst estimated treatment coverage in Malaysia and the Philippines ranges between 23-37 percent.
A major barrier to treatment access is the high cost of antiretroviral drugs, as both first- and second-line drugs are still unaffordable to many governments. Cheaper HIV drugs are now produced by a number of pharmaceutical manufacturers in Asia, and together with the increasing availability of lower-cost branded ARVs, it will be easier for governments to obtain and distribute the drugs. Yet even where drugs are available, the poor state of healthcare in many Asian countries, particularly a shortage of trained doctors, is hindering governments’ abilities to organize life-long treatment programs for millions of people living with HIV.
Cambodia’s HIV epidemic can be traced back to 1991. After an initial rapid increase, HIV infection levels declined after the late 1990s and by 2003 HIV prevalence was estimated at 1.2%. Results published in 2009 from the first national population-based survey estimated HIV prevalence at 0.6%. It’s believed that interventions with sex workers, carried out by the government and non-governmental organizations (NGOs), played a role in this decline. The adoption of a ‘100% condom’ policy that enforced condom use in brothels led to a substantial rise in condom use among sex workers and their clients and a drop in HIV infection levels among brothel-based sex workers. However, ongoing concerns include low levels of condom use among MSM, an increase in sex work occurring outside of brothels (making it harder to reach sex workers with interventions), and mother-to-child transmission of HIV – around one third of new infections occur through this route. HIV is mostly transmitted through heterosexual sex in Cambodia, and concerns are growing about the number of married women who are infected through their husband.
Around 314,000 people are living with HIV in Indonesia, which has the fastest growing epidemic in Asia. This number has risen sharply in recent years and is expected to more than double by 2014 if approaches to HIV prevention are not improved. This rise is due to several factors including: the country’s extensive sex industry; limited testing and treatment clinics; a highly mobile population; a rapidly growing population of people who inject drugs; and the challenges created by major economic and natural crises (the Asian financial crisis heavily affected the country in 1997, and the 2004 Tsunami devastated parts of Northern Sumatra, the largest island in Indonesia).
High levels of HIV infection are found amongst high risk groups, such as injecting drug users, sex workers and their clients and to a lesser extent, men who have sex with men. However, local regulations often criminalize high-risk groups and it has been identified that some members of the National AIDS Commission, responsible for tackling HIV/AIDS in Indonesia, are failing to address the issue of HIV/AIDS among high-risk groups.
Lao People’s Democratic Republic (Laos)
Despite being surrounded by countries that have relatively high HIV infection levels (Thailand, China, Vietnam, Cambodia and Myanmar), Laos has a comparatively small HIV problem. There are various reasons for this: the government was quick to acknowledge AIDS when it first emerged in the country, and took action to warn people about it; Laos has not seen the same level of large-scale migration that has occurred in other parts of Asia; there are relatively high rates of condom use among sex workers and their clients; and it’s thought that very few people in the country inject drugs. However in recent years there has been an increase of HIV infection among the most vulnerable groups, especially MSM and migrant workers.
HIV and AIDS statistics from Malaysia show that an estimated 0.5 percent of the population are living with HIV.34 Although most people infected with HIV in the country are male, there has been a steep increase in the number of new cases among women. During the late 1990s women made up around 5 percent of new infections, compared to around 20 percent in 2006.
Malaysia’s epidemic is largely driven by injecting drug use, but heterosexual transmission is accounting for an increasing number of new infections. Recent trends have demonstrated a promising decrease in annual HIV infections, from 7,000 in 2002 to 5,830 in 2006. In 2006 the government launched a five-year strategic plan to tackle HIV, which includes drug substitution therapy and needle exchange programs for drug users. In 2007, 3,900 people died from AIDS in Malaysia.
Myanmar is facing a serious epidemic – an estimated 240,000 of the adult population is infected with HIV. Myanmar’s authoritarian military regime is widely condemned for its human rights abuses, and in 2005 these concerns led the Global Fund to fight AIDS, TB & Malaria, to withdraw its proposed $98.4 million grants for the country.39 Prevention services for injecting drug users are severely lacking with needle exchange programs operating in just a few locations. Drug users are dealt with heavy-handedly and crackdowns on drug production have led to a scarcity of opium and heroin. This has resulted in drug inhalation being replaced by injecting, as a more cost-effective way of drug consumption, carrying with it a higher risk of HIV transmission. In 2006 methadone substitution therapy was introduced in a small number of government locations.
An estimated 8,300 people were living with HIV in The Philippines in 2007. The country has traditionally had a very low HIV prevalence, with under 0.1% of the population infected. Even in groups such as sex workers and MSM that are typically associated with higher levels of HIV, prevalence rates above 1% have not yet been detected. In the case of sex workers, this is possibly due to efforts to screen and treat those selling sex since the early 1990s. However, there are reasons to believe that this situation may not last. In early 2010 the Department of Health in the Philippines stated the country was now on the brink of a “concentrated epidemic”, due to a rise in prevalence.43 Condom use is not the norm in paid sex, drug users commonly share injecting equipment in some areas, and among Filipino youth, there is evidence of complacency about AIDS. National HIV prevalence among the most at risk populations (MARPs) which includes sex workers, men who have sex with men and injecting drug users, has increased more than five fold from 0.08 % in 2007 to 0.47 % in 2009.
Although the number of people living with HIV in Singapore is relatively small, the country’s status as an international travel and business hub, along with the high number of infections found in surrounding countries, make it possible that the country will experience a more serious epidemic in the future. The number of annual new infections has been rising in Singapore. In 2006, a record 357 people were newly diagnosed with HIV, compared to 423 cases in 2007 and then 456 in 2008. The majority of these new infections (50%) are diagnosed at a late-stage of HIV infection, by which point HIV treatment should already have started. To combat these rising figures, the government has chosen to focus on preventing mother-to-child transmission, but controversially, has rejected widespread condom promotion.48 Another controversial policy in Singapore is the strict law banning sex between men, which campaigners argue undermines efforts to promote safe sex among MSM.
Thailand is an example of a country where a strong national commitment to tackling the HIV and AIDS epidemic has paid off, with widespread access to treatment and an admirable history of HIV prevention efforts. However, some of these past prevention successes are starting to be undermined by a current lack of HIV prevention and rising STD rates. New infections are highest among MSM and women who have become infected by their husbands or sexual partners. An estimated 610,000 people (equating to a prevalence of 0.43 %) are now living with HIV and AIDS in Thailand.
Around 254,000 people are living with HIV and AIDS in Vietnam. Vietnam’s epidemic is still in a concentrated phase; injecting drug users, female sex workers and men who have sex with men are the groups primarily affected. The number of people living with HIV in Vietnam doubled between 2000 and 2005. This rise included a large increase in the number of people who became infected through injecting drug use. There is evidence of HIV increasing among the MSM population with approximately 60% of HIV-positive MSM reporting inconsistent condom use with male partners in the previous month.
China’s first AIDS case was reported in Beijing in 1985. Today, an estimated 740,000 people in China are living with HIV58 and it is feared this number will increase dramatically in future years, as HIV spreads from the groups most at risk to the general population. In 2007 an estimated 39,000 people died from AIDS in China. Yunnan, Guangxi, Henan, Sichuan, Xingiang and Guangdong are most affected, representing around 70 to 80 percent of the national reported number of HIV and AIDS cases.
In 2007, around 9,600 adults and children were living with HIV in Japan. Data released by the Japanese government in February 2007 showed that annual numbers of new HIV infections and AIDS cases had risen to an all time high in 2006, to 914 and 390 people respectively. In 2008, this number rose again: there were a total 1,126 new cases of people living with HIV registered that year. MSM are particularly affected as they account for around 60% of annually reported HIV infections in Japan.
Afghanistan is one of the world’s leading producers of opium, and drugs are widely available. The use of opiates, such as heroin and opium, has seen a dramatic increase over the last four years with a 53 percent rise in the number of regular opium users and a 140 percent rise in the number of heroin users in the period 2005 to 2009. Further to this, a study of three major cities in 2009 found HIV prevalence among IDUs had more than doubled since 2006. As a result, Afghanistan is now considered to have a concentrated epidemic. It is estimated that 8 percent of the adult population use drugs, yet only 10 percent of drug users access harm reduction services. Moreover, awareness of the risk of HIV transmission is low among this high risk group, particularly among young IDUs. A study found that 85 percent of IDUs interviewed shared a needle or syringe when injecting drugs.
Prevalence among the general population is less than 0.5 percent, based on the most recent data available.71 However, HIV surveillance is minimal. Conditions are in place for a generalized epidemic to develop, including high numbers of displaced people, high levels of illiteracy, low social status of women, and a shortage of health facilities. The epidemic among high risk groups must be curbed to avoid HIV bridging into the wider population.
The first HIV/AIDS case in Bangladesh was reported in 1989. Since 1994, HIV infection levels have increased, although the problem is still relatively small scale, with around 12,000 adults – 0.2% of the total population – infected. It is nonetheless predicted that Bangladesh may gradually be heading towards an epidemic, unless a greater response is developed. At the moment HIV is mainly confined to groups such as IDUs, migrant workers and MSM, and it is reported that this focus on risk groups has led to a lack of urgency among policy makers in dealing with the problem.
India is experiencing a diverse HIV epidemic that affects states in different ways, and to different extents. In India the groups most affected include injecting drug users, sex workers, truck drivers, migrant workers, and men who have sex with men. Some have predicted that India will soon be experiencing a ‘generalized’ epidemic, where the HIV prevalence rate – currently 0.3% in India – rises above 1%. Others have played down current estimates of the numbers infected, and have argued that, because HIV transmission in India still largely occurs among risk groups, it is unlikely that HIV will spread widely among the general population. Regardless of the future path of India’s epidemic, it is undeniable that AIDS is having a devastating impact, and that there are still many major issues – including stigma and poor availability of AIDS treatment – that urgently need to be addressed.
An estimated 70,000 people are living with HIV and AIDS in Nepal, which equates to an adult prevalence of 0.5%. HIV is primarily transmitted through injecting drug use and unprotected sex. Seasonal labor migration is an important source of income for many Nepalese, but it is associated with a higher risk of HIV infection and nearly 50% of total HIV infections are recorded along the highway districts of country. 77Around 41% of all HIV cases in Nepal are among seasonal labor migrants, 16% are clients of sex workers and 21% are partners or wives of HIV positive men. The Nepalese government has responded to the epidemic despite political instability; in 2009 Prime Minister Madhav Kumar Nepal said the government would increase resources and actions for preventing, treating and controlling the country’s epidemic.
Pakistan’s first reported case of HIV occurred in 1987. Until the late 1990s, most subsequent cases occurred in men who had become infected while living or working abroad. The most at risk populations in Pakistan include injecting drug users, sex workers and prisoners. Despite a low overall HIV prevalence (0.1%), social and economic conditions in Pakistan – including poverty, low levels of education, and high levels of risk behavior among IDUs and sex workers – are likely to facilitate the spread of HIV in coming years. HIV prevalence among IDUs has already significantly increased – from 10.8 percent in 2005 to 21 percent in 2008. Hijra (transgender) sex workers are also disproportionately affected by HIV/AIDS in Pakistan; HIV prevalence among this group is 6.1%.