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HIV and AIDS in Asia
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, almost 5 million people are living with HIV in South, East and South-East Asia.1 Although national HIV prevalence in most Asian countries is relatively low, the population of some countries is so vast that these low percentages actually represent very large numbers of people living with HIV. In India, for example, the most recent statistics show that an estimated 0.1 percent of adults aged 15-49 are living with HIV, which seems low when compared to HIV prevalence in some parts of sub-Saharan Africa. However, with a population of around 1 billion, this actually equates to 2.3 million adults living with HIV in India.2 Nonetheless, the situation is improving; the number of new infections in Asia went down from 450,000 in 2001 to 369,000 in 20113 and in India the rates have fallen by 56 percent since 2006.4
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 a 25 percent decline in HIV prevalence between 2001 and 2011. On the other hand, in Bangladesh, Indonesia, and the Philippines the number of people living with HIV has increased by more than 25 percent between 2001 and 2011.5 There are also huge variations within countries. In China, for example, the six provinces with the highest HIV prevalences account for 75.5 percent of the people living with HIV.6
Asia has had the largest AIDS-related death toll outside of sub-Saharan Africa.7 Some have warned that epidemics in Asia could escalate to the extent of rivalling 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.
How is HIV transmitted 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. Clients of sex workers make up the largest key population at higher risk;8 between 0.5 and 15 percent of men buy sex regularly9 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.10 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.11
- 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, 28.4 percent of all people infected with HIV are believed to have become infected through injecting drug use,12 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.13 This means that MSM can serve as a ‘bridge’ for HIV to spread into the broader population. New factors appear to be affecting the spread of HIV among MSM such as Internet dating, soft drug use, mobility and other forms of social change.14 HIV prevalence is rising amongst MSM populations of many South and South-East Asian countries, however in 2011, only 1 in 3 MSM reported having a HIV test in the past 12 months throughout this region.15
Mother-to-child transmission is also a significant HIV transmission route in Asia. Encouragingly, there has been a 12 percent decline in HIV infections amongst children since 2009; however prevention of mother-to-child transmission (PMTCT) coverage was only 18 percent in South and South-East Asia at the end of 2011. More needs to be done to make PMTCT available to a greater number of people so that child infections can reduce further.16
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.17 18 In Tamil Nadu, India, HIV prevention initiatives have had a substantial impact. 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.19
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. It is suggested that in order for Asia's epidemic to stabilize, interventions should cover between 60 and 80 percent of individuals considered high risk.20 Although injecting drug use is one of the most common HIV transmission routes in Asia, Bangladesh is the only country in the region reporting high coverage of needle and syringe programmes; Thailand and Pakistan report low coverage.21 Similarly men who have sex with men are overlooked and poorly monitored by most governments: Bangladesh, Indonesia, The Philippines and Viet Nam all report less than 25 percent access to MSM prevention initiatives, and only China and Nepal report more than 75 percent.22 Globally, the South and South East Asian region performed the worst in terms of the delivery of HIV prevention to MSM.23
"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 Conference24
It is not only legal barriers that are preventing people from accessing effective HIV prevention; problems also arise when prevention programmes do not contain information that will be most useful. For example, young people in Asia are generally not taught about the kinds of behaviours 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.25
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 30 percent of pregnant women were offered an HIV test in 2010. This was a great improvement compared to the 18 percent of 2009, but still a very low percentage compared to other regions of the world such as Eastern Europe and Central Asia (59 percent), Eastern and Southern Africa (61 percent) and Latin America and the Caribbean (61 percent).26 In 2011 across South and South-East Asia, only 18 percent of HIV-infected pregnant women received ARVs (excluding single-dose nevirapine) to prevent mother-to-child transmission of HIV. This is the lowest percentage only to Middle East and North Africa (7 percent).27
Due to the stigma that often surrounds those groups most at risk of HIV infection, coverage of HIV voluntary counselling and testing (VCT) services in South-East Asia remains very low. An estimated 0.1 percent of the adult population in the region received testing and counselling in 2005.28 Certain countries are making progress, however; testing services in India have been expanded with about 5135 testing centres now open to the public.29 Even so, far more needs to be done across Asia to ensure VCT is available to those most at risk of acquiring HIV.
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.
Antiretroviral treatment in Asia
In 2011, antiretroviral treatment was accessed by 47 percent of people in need of it in South and South-East Asia, and 18 percent in East Asia.30 In addition, access to HIV treatment varies widely across the region. Thailand and Cambodia have an estimated treatment coverage of 71 percent and >95 percent respectively, whilst estimated treatment coverage in Malaysia and the Philippines is 37 percent and 51 percent.31
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 organise life-long treatment programmes for millions of people living with HIV.32
South East Asia
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 percent.33 As of 2011, HIV prevalence has halved to 0.6 percent.34 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 percent 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. The use of condoms rose from 40 percent in 1997 to 99 percent in 2009; however HIV prevalence among sex workers is high at 15 percent.35 36 UNAIDS estimate that without the prevention efforts, this figure would have been more than 50,000.37
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.38 39 Cambodia also deny HIV testing to people under 18 years of age without parental consent, which has shown to hamper HIV prevention efforts among young people globally.40
Around 380,000 people are living with HIV in Indonesia, which has the fastest growing epidemic in Asia.41 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.42 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; the denial of sexual health and reproductive services to unmarried people;43 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.44 In 2012, HIV prevalence was reported as high as 36 percent among people who inject drugs.45 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.46 47 Additionally, campaigns to promote condom use among people who engage in high-risk sex have met resistance from some religious groups, who feel that condoms should only be promoted to married couples.48
In 2012, the Indonesian government issued compulsory licenses allowing local drug companies to legally bypass drug patents and make their own, cheaper versions for the treatment of HIV and Hepatitis.49 This development will hopefully increase access to affordable ARV drugs. Currently only 24 percent of people with HIV in Indonesia have access to treatment, with coverage falling even lower among children; the number of children eligible for treatment who are receiving it is estimated to be as low as 11 percent.50 51
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, with HIV prevalence of 0.2 percent.52 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.53 54 However in recent years there has been an increase of HIV infection among the most vulnerable groups, especially MSM and migrant workers, with the main transmission route being 'unsafe sexual activity'. 55
HIV and AIDS statistics from Malaysia show that an estimated 0.4 percent of the population are living with HIV.56 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 21 percent in 2011.57 Malaysia, like Indonesia, denies sexual health and reproductive services to unmarried people, perhaps accounting for increasing HIV infections among women.58
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 3,479 in 2011.59 In 2006 the government launched a five-year strategic plan to tackle HIV, which includes drug substitution therapy and needle exchange programmes for drug users, which the government is still committed to in 2013.60 The Ministry of Health has also developed a training module to teach religious leaders about HIV, which is important in a country where the majority of people are Muslim.61 In 2011, 5,910 people died from AIDS in Malaysia.62
Myanmar is facing a serious epidemic - an estimated 220,000 of the population is infected with HIV.63 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.64 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. In 2006 methadone substitution therapy was introduced in a small number of government locations.65 Furthermore, in some cities the HIV prevalence among MSM is extremely high with 23.5 percent of MSM infected with HIV in Yangon and 35 percent infected in Mandalay.66 However, in 2011 Myanmar implemented a four-year plan to use mass media as a tool for HIV education and reducing discrimination around HIV and AIDS.67
An estimated 19,000 people were living with HIV in The Philippines in 2011.68 The country has traditionally had a very low HIV prevalence, with under 0.1 percent of the population infected.69 Even in groups such as sex workers and MSM that are typically associated with higher levels of HIV, prevalence rates are only 0.3 and 2 percent respectively.70 In the case of sex workers, this is possibly due to efforts to screen and treat those selling sex since the early 1990s. However, when looking at The Philippines HIV epidemic as a whole, there has been a 1,490 percent increase in HIV diagnoses between 2005 and 2012.71 Condom use is not the norm in paid sex, drug users commonly share injecting equipment in some areas leading to HIV prevalence among IDUs being 14 percent,72 and among Filipino youth there is evidence of complacency about AIDS.73 74
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 2010, a record 441 people were newly diagnosed with HIV, compared to 357 in 2006.75 76 The majority of these new infections (54 percent) are diagnosed at a late-stage of HIV infection, by which point HIV treatment should already have started.77 To combat these rising figures, the government focuses on preventing mother-to-child transmission, but controversially, condom use is only 'emphasized to those at risk'.78 79 Another controversial policy in Singapore is the strict law banning sex between men, which undermines efforts to promote safe sex among MSM.80 This is concerning considering the HIV prevalence among MSM is 3 percent.81
Thailand is an example of a country where a strong national commitment to tackling the HIV and AIDS epidemic has paid off, with 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.82 Increases in HIV prevalence among MSM is particularly marked in Bangkok, where HIV prevalence among this group has risen from 17.3 percent in 2003 to 31.3 percent in 2009; this is in comparison to the national average of 1.2 percent.83 84 An estimated 490,000 people are now living with HIV and AIDS in Thailand.85
Around 250,000 people are living with HIV and AIDS in Vietnam.86 Vietnam's epidemic is still in a concentrated phase; male injecting drug users, female sex workers and men who have sex with men are the groups primarily affected.87 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.88 Despite previous concerns about condom use among sex workers being worryingly low, in 2011 it was reported that 87 percent of sex workers used a condom with their last client.89 90 In 2013, a mathematical study was published which predicted an 80 percent decrease in annual HIV infections and great cost-savings, if every person had an annual HIV test, and those who tested positive were offered ARV immediately. The greatest results would be achieved if prevention efforts were targeted at high-risk groups.91 It is hoped this will encourage HIV prevention services to increase their current scope.
Laws that criminalise sex workers and drug users often cause people that fall under these groups to fear accessing HIV prevention services; in Vietnam, the enforcement of such laws has lead to the incarceration of people in detention centers.92 Reassuringly, laws that protect the rights of these groups have recently been implemented.93
Adults and children living with HIV in Vietnam still face high levels of stigma and discrimination.94 One reason for this is that HIV is often strongly associated with immorality. The connection between HIV and ‘social evils’ is exacerbated through the official use of this type of language, with HIV and AIDS falling under the remit of the Government ‘Department of Social Evils Prevention'.95 One reported result of this stigma is that people living with HIV remain untreated due to a fear of being seen taking medication, and their status being publicly discovered.96 In order to dispel myths and misconceptions about HIV life, prevention programmes have been introduced in secondary schools since 2009.97
See our South East Asian statistics page for more data on this region.
China’s first AIDS case was reported in Beijing in 1985. Today, an estimated 780,000 people in China are living with HIV 98 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.99 In 2011 an estimated 28,000 people died from AIDS in China.100
The six most affected provinces (Yunnan, Guangxi, Henan, Sichuan, Xingiang and Guangdong) represent 75.5 percent of the national reported number of HIV and AIDS cases.101
Find out more about HIV and AIDS in China.
In 2011, around 7,900 adults and children were living with HIV in Japan.102 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.103 In 2010, this number rose again: there were a total 1,075 new cases of people living with HIV registered that year.104 MSM are particularly affected as they accounted for 52 percent of annually reported HIV infections in 2010.105 106
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 2009.107 Further to this, a study of three major cities in 2009 found HIV prevalence among IDUs had more than doubled since 2006; this is now at 7 percent in 2011.108 109 As a result, Afghanistan is now considered to have a concentrated epidemic.110 It is estimated that 8 percent of the adult population use drugs, yet only 10 percent of drug users access harm reduction services.111 Moreover, awareness of the risk of HIV transmission is low among this high risk group, particularly among young IDUs. In 2010, it was reported that 40 percent of IDUs are sharing injecting equipment.112
Prevalence among the general population is less than 0.1 percent,113 however, HIV surveillance is minimal. Conditions are in place for a generalised 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 7,700 people infected.114 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.115 However, in Dhaka, harm reduction programmes have been credited with slowing the spread of HIV among people who inject drugs. HIV prevalence in this population rose from 1.4 percent in 2000 to 7 percent in 2007, but thereafter dropped to 1 percent in 2011, well below the levels observed in areas without prevention programmes.116
India is experiencing a diverse HIV epidemic that affects states in different ways, and to different extents. India's most affected groups 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 percent among adults in India117 - rises above 1 percent. 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.118 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 49,000 people are living with HIV and AIDS in Nepal, including 0.3 percent of the adult population.119 4 out of 5 HIV infections are transmitted via unprotected sex, with the rest a result of injecting drug use.120 Seasonal labour migration is an important source of income for many Nepalese, but it is associated with a higher risk of HIV infection and nearly 30 percent of total HIV infections are among male seasonal migrants.121 Around 4.4 percent of all HIV cases in Nepal are among clients of sex workers and 14.4 percent are MSM.122 The Nepalese government have 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.123 However, at the end of 2011 the proportion of eligible people receiving antiretroviral therapy was just 24 percent.124
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.125 Despite a low adult HIV prevalence (0.1 percent126), 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.127 HIV prevalence among IDUs has already significantly increased - from 10.8 percent in 2005 to 27.2 percent in 2011.128 Hijra (transgender) sex workers are also disproportionately affected by HIV/AIDS in Pakistan; HIV prevalence among this group is 5.2 percent.129
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