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Overview of AIDS and HIV in Asia

In the early to mid-1980s, while other parts of the world were beginning to deal with serious HIV & AIDS epidemics, Asia remained relatively unaffected by this newly discovered health problem. By the early 1990s, however, AIDS epidemics had emerged in several Asian countries, and by the end of that decade, HIV was spreading rapidly in many areas of the continent.

Today, 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 (along with Eastern Europe and Central Asia).¹ 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.²

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

Although its 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.

“It’s very difficult to speak about ‘the Asian epidemic’. Whatever we come up with, we always find a big exception in Asia.” Peter Piot, head of UNAIDS ⁶

Asian countries are experiencing different trends. HIV infection rates are growing in parts of India, but have stabilised or declined in other parts of the country. In Cambodia, Myanmar and Thailand, there has been evidence of declines in HIV infection levels. In Indonesia, Pakistan and Vietnam, meanwhile, the number of people living with HIV has rapidly increased. In Vietnam, this number more than doubled between 2000 and 2005, and HIV has now been detected in every province and city in the country. It is feared that the the speed and severity of the growing HIV epidemic in Pakistan, is outpacing the response. The number of people newly infected with HIV is also rising in China and Bangladesh, although at a much slower pace.⁷

How HIV is transmitted in Asia

• 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 2005.⁹

• 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

• 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.¹³

• 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

HIV prevention 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.¹⁵

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.¹⁶ Similarly 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.¹⁷

Prevention programmes focusing on young people in South Asia have been found to have limited success. Prevention initiatives have generally not focused on the kinds of  behaviours that most put this group at risk: unprotected sex through sex work, injecting drug use, and sex between men. Instead they have focused on heterosexual transmission and reproductive health.¹⁸

Due to the stigma that often surrounds those groups most at risk of HIV infection, coverage of HIV testing and counselling services in South-East Asia remains very low. An estimated 0.1% of the adult population in the region received testing and counselling in 2005.¹⁹ 

Progression is being made in China though where free HIV testing has been made available at more than 3000 sites in all 31 provinces of the country.
Testing services in India have also been expanded recently with about 3600 testing centres now open to the public.²⁰

Despite efforts being made across the region, more still needs to be done to make testing available to those most at risk.

The coverage of prevention of mother-to-child transmission (PMTCT) services is also very low in Asia. In South-East Asia, less than 5% of pregnant women are offered HIV counselling and testing.²¹ Across East, South and South-East Asia, the proportion of HIV-infected pregnant women receiving ARVs is just 5%.²²

See our HIV prevention around the world page for more about efforts to stem the spread of HIV in Asia and other parts of the world.

AIDS treatment in Asia

The availability of AIDS treatment has more than tripled in Asia since 2004. At the end of 2007 an estimated 420,000 people in the region were receiving antiretroviral drugs (ARVs). Although this rise is encouraging, access to treatment varies widely across the region. There is evidence that the majority of countries in Central, South and South-East Asia have laws that impede access to HIV services among injecting drug users.²³ Overall it is estimated that three quarters of people in need of ARVs in Asia still have no access to them.²⁴

A major constraint is the high cost of ARVs, as both first- and second-line drugs are still unaffordable to most governments. Cheaper generic drugs are now produced by a number of pharmaceutical manufacturers in Asia, and together with the increasing availability of lower-cost branded ARVs, it’s hoped that this will make it 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 organise life-long treatment programmes for millions of people living with HIV.²⁵

For the latest statistics for treatment provision in individual countries in Asia, see our AIDS treatment targets page.

Country profiles - South East Asia

Cambodia

Cambodia’s HIV epidemic can be traced back to 1991. After an initial rapid increase, HIV infection levels declined after the late 1990s, and have reached a steady level in recent years. It’s believed that interventions with sex workers, carried out by the government and non-governmental organisations (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. Despite these achievements, Cambodia still has the second highest HIV prevalence rate in Asia, with 0.8% of the adult population infected. 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 almost half of those infected are women.^{26 27}

Indonesia

High levels of HIV infection are found amongst IDUs in Indonesia, and also among sex workers and their clients. Around 270,000 people in Indonesia are living with HIV, this number has risen sharply in recent years due to several factors: the country’s extensive sex industry; limited testing and treatment clinics and laboratories for sexually transmitted infections (STIs); a highly mobile population; a rapidly growing population of people who inject drugs; and the challenges created by major economic and natural crises that Indonesia has experienced (the Asian financial crisis heavily affected the country in 1997, and the 2004 Tsunami devastated parts of Northern Sumatra, the largest island in Indonesia).²⁸

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.^29 30

Malaysia

Malaysia’s HIV epidemic is largely driven by injecting drug use. Other than IDUs, HIV is spreading quickly amongst women, fishermen, lorry drivers and factory workers. A senior health official in Malaysia has warned that the number of people living with HIV in the country – currently around 80,000 – could rise to 300,000 by 2015 if nothing is done. The government launched a five-year strategic plan to tackle HIV in 2006, which includes drug substitution therapy and needle exchange programs for drug users.³¹

Myanmar (Burma)

After first appearing in the mid-to-late 1980s, HIV became increasingly common in Myanmar. Today, with an estimated 240,000 of the adult population infected, the country faces a serious epidemic.³² Myanmar’s authoritarian military regime is widely condemned for its human rights abuses, and in 2005 these concerns led the Global Fund to Fight HIV, TB and Malaria to withdraw it’s proposed $98.4 million grants for the country.³³ Prevention services for injecting drug users are severely lacking with needle exchange programmes 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. Methadone substitution therapy was introduced in a small number of government locations in 2006.³⁴

The Philippines

The Philippines has a very low HIV prevalence, with well 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 ³⁵ – in the case of sex workers, this is possibly due to efforts to screen and treat those selling sex since the early 1990s. There are reasons to believe that this situation may not last, however. 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.

Singapore

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. In 2006 a record 357 people in Singapore were newly diagnosed with HIV. To combat these rising figures, the government has chosen to focus on preventing mother-to-child transmission, but controversially, has rejected widespread condom promotion.³⁶ Another controversial policy in Singapore is the strict law banning sex between men, which campaigners argue undermines efforts to promote safe sex among MSM.³⁷

Thailand

Thailand is an example of a country where a strong national commitment to fighting AIDS 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, rising STI rates, and a growing number of MSM becoming infected with HIV. In 2005 1 in 5 new HIV infections in all of Thailand were attributable to men having unprotected sex with men. ³⁸

Vietnam

Around 40,000 people are becoming infected with HIV each year in Vietnam, mostly through injecting drug use or paid sex. The number of people living with HIV in Vietnam doubled between 2000 and 2005, and this rise included a large increase in the number of people who became infected through injecting drug use.³⁹ There is also 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.⁴⁰

See our South East Asian statistics page for more data on this region.

East Asia

China

China is seen as a major source of concern by many AIDS experts, because of the large size of its population and the existence of social, economic and cultural factors that make it easy for HIV to spread. At the moment 700,000 people in China are living with HIV (0.1% of the adult population), but it’s feared that this number will increase dramatically in future years, as HIV spreads from the groups most at risk – injecting drug users and those who buy or sell sex – to the general population.^{41 42}

Japan

In 2007, around 9,600 adults and children were living with HIV in Japan.⁴³ Data released by the Japanese government in February 2007 showed that annual numbers of new HIV infections and AIDS cases has risen to an all time high in 2006, to 914 and 390 people respectively.⁴⁴ The most prominent rise occurred among MSM, who it’s previously been documented account for at least 60% of annually reported HIV infections in Japan.⁴⁵

South Asia

Afghanistan

There have only been a small number of cases of HIV in Afghanistan, in contrast to the relatively large numbers recorded in the neighbouring nations of Pakistan and Iran. Nonetheless HIV and AIDS are growing problems. Conditions are in place for an epidemic to develop, including high numbers of displaced people, high levels of illiteracy, low social status for women, and a shortage of health facilities. Afghanistan is one of the world’s leading producers of opium, and the availability of drugs could lead to increased levels of injecting drug use. A 2006 study found that around one third of IDUs in the capital city of Kabul had shared contaminated injecting equipment, and that 4% were infected with HIV.⁴⁶

Bangladesh

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's 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's reported that this focus on risk groups has led to a lack of urgency among policy makers in dealing with the problem.⁴⁷

India

India is experiencing a diverse HIV epidemic that affects states in different ways, and to different extents. 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 ‘generalised’ 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, its unlikely that HIV will spread widely among the general population.⁴⁸ Regardless of the future path of India’s epidemic, it’s 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.

Pakistan

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. After 1999, HIV and AIDS cases began to be recorded among Pakistani sex workers, IDUs, and prisoners.⁴⁹ 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 behaviour among IDUs and sex workers – are likely to facilitate the spread of HIV in coming years.⁵⁰

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• HIV & AIDS in Asia
• Timeline of AIDS in Asia
• HIV & AIDS in China
• Funding for the HIV & AIDS epidemic