Asia and the Pacific is the region with the second highest number of people living with HIV in the world – an estimated 5.1 million in 2015.1. Three countries - China, India and Indonesia – account for around three-quarters of the total number of people living with HIV in the region.
In 2015, there were an estimated 300,000 new infections in the region. Though the period 2010 – 2015 saw an overall decline of 5% in new infections, progress in reducing new infections has slowed in recent years and new HIV infections are on the rise in some countries.2
The epidemic is largely characterised by concentrated and growing epidemics in a variety of countries, particularly among key affected populations including men who have sex with men (sometimes referred to as MSM), sex workers, people who inject drugs (also referred to as PWID) and transgender people.3 Low national prevalence masks much higher prevalence among these groups and in specific locations, particularly urban areas.4
The HIV epidemic varies widely from country to country and within certain countries depending on context. This highlights the importance of tailoring responses to each country context. UNAIDS suggests that a ‘location and population’ approach would maximise the impact of scarce resources.5
Progress in tackling the epidemic varies by geographical area. The epidemics in South and South-East Asia are decreasing, while in East Asia, HIV infections are rising.6
Key affected populations in Asia and the Pacific
Key affected populations who are at higher risk of HIV must be the focus of the HIV response in Asia and Pacific if the epidemic is to be controlled.7 8 Creating supportive and safe environments for these groups to seek help and access services is critical.
Men who have sex with men
Men who have sex with men are one of the key affected populations in Asia and the Pacific. In 2015, HIV prevalence among men who have sex with men was higher than 5% in nine of the 19 countries that reported data.9
HIV prevalence among men who have sex with men is particularly high across urban areas.10 Cities such as Bangkok in Thailand, Yangon in Myanmar and Yogyakarta in Indonesia have estimated HIV prevalence rates of between 20% and 29%.11
Across the region it has been found that men who have sex with men are becoming infected by HIV at a young age.12 One study carried out in Bangkok found that HIV incidence among those aged 18 to 21 was more than double the incidence among men over 30.13 Around half of all men who have sex with men in the region are under 25. However, HIV prevention and testing services were reaching fewer young men who have sex with men and they reported lower condom use than their older counterparts.14
Condom use has been found to vary greatly across different areas. Over two-thirds of men who have sex with men reported using condoms the last time they had anal sex, but this figure is lower for men who have sex with men in cities and urbanised areas, where under half of men who have sex with men reported doing so.15
A further example of the HIV epidemic among men who have sex with men in a high-income country within the region is in Australia. A 2012 study found that while HIV prevalence in Australia had declined overall, HIV prevalence rose among men who have sex with men,16 with 11.2% of men who have sex with men living with HIV.17 This rise is despite an increase in access to antiretroviral treatment.fn]Beyrer, C., (2012) ‘Global epidemiology of HIV infection in men who have sex with men’, The Lancet, Vol 380, Number 9839, Pages 367-377 Data is also very varied for condom usage among this population, with between 39% and 89% of men who have sex with men reporting using a condom the last time they had sexual intercourse.18 Increasing awareness of both testing and HIV prevention are therefore crucial for this population.
People who inject drugs (PWID)
One third of all people who inject drugs (sometimes referred to as PWID) live in Asia and the Pacific.19 HIV prevalence among this population varies greatly across Asia and the Pacific. In 2015, 20 – 65% of all new adult HIV infections were among people who inject drugs in Afghanistan, Myanmar, Pakistan and Vietnam.20
Evidence clearly highlights the link between using clean needles and injecting equipment, and low HIV prevalence. In Katmandu, Nepal, increases in the use of safe needles led to a dramatic reduction in HIV prevalence - from 68% in 2002 to 6.3% in 2011.21 This highlights the importance of promoting harm reduction programmes for people who inject drugs. Harm reduction has become more integrated into HIV prevention programmes in countries such as India, Vietnam and Pakistan.22
In Asia and the Pacific, the incarceration rate of people who inject drugs is very high. Combined with a negligible number of harm reduction programmes in prisons (opioid substitution therapy is only available in prisons in Indonesia and Malaysia and one prison in India, while needle and syringe programmes are not available in any prison in the region), this fuels the HIV epidemic both in prisons and among drug users.23
Drug detention centres remain a common feature in many Asian societies but their effectiveness and impact on the HIV response is strongly disputed. The human rights record of many drug detention centres is poor and many deny individuals access to HIV treatment and drug treatment such as opioid substitution therapy (OST). UN agencies requested the closure of drug detention centres in 2012, promoting a more voluntary and rights-based approach to services for people who inject drugs.24
Since then, some small-scale community-based harm reduction and drug treatment centres have opened, although their reach and funding opportunities are limited. They advocate patient choice, voluntary access and drug reform policy, putting the rights and health of people who use drugs first, which in turn benefits the community.25
HIV remains a critical concern for many transgender populations across Asia. Particularly high HIV prevalence rates have been found among transgender populations in cities such as Delhi (49%) and Mumbai (42%) in India, and Phnom Penh (37%) in Cambodia. For a lot of these cities, HIV prevalence is much higher among transgender populations in comparison to men who have sex with men.[26
Transgender populations are very often isolated by societies in many Asian and Pacific countries. This has serious knock on effects for obtaining both health-related information and also developing health policies and programmes that effectively support this key affected population.27
"Absence of experts in health services in low-resource areas can lead transgender people ‘underground’ to undertake transition operations and hormone treatment within non-regulated settings which can in turn lead to greater health complications and increase vulnerability to HIV." - Steve Kraus, Director of UNAIDS Asia and the Pacific 28
Stigma, discrimination and legal barriers remain a major obstacle for providing and accessing services for transgender populations in Asia.29 Many countries are starting to show signs of progress in recognising transgender identity and inclusion of their rights, especially in Pakistan where transgender rights are widely included into various settings such as work and education.30 Challenging these laws and addressing social, sexual and gender norms which increase transgender people’s vulnerability to HIV is vital in future HIV responses across Asia and the Pacific.31
HIV testing and counselling (HTC) in Asia and the Pacific
Late diagnosis is a serious barrier to tackling HIV across Asia and the Pacific. Late diagnosis results in many people starting treatment with very low CD4 counts. An estimated 1.9 million people living with HIV did not know their status in 2015.32 Promoting HIV testing is crucial for more people across the region to know their status and maximize the effectiveness of antiretroviral treatment. This is particularly crucial for key populations such as people who inject drugs and men who have sex with men, with over two thirds of these populations unaware of their HIV status.33
Stigma and discrimination remain barriers to individuals accessing testing services. Voluntary testing and counselling (VCT) has been widely promoted by UNAIDS and the WHO across the region to reduce levels of discrimination and stigma.34 Indonesia is one country that has scaled-up their testing facilities. Through decentralising services and aiming to establish 475 community-based facilities across the country, Indonesia plans on reaching more people than ever in their HIV response.35
HIV prevention in Asia and the Pacific
Asia and the Pacific has made progress in reducing new HIV infections with a 5% decline between 2010 and 2015.36 HIV prevention programmes have played an important role in reducing HIV incidence.37 Some of the key prevention programmes across the region are outlined below.
Prevention of mother to child transmission (PMTCT)
Prevention of mother to child transmission (PMTCT) has been significantly scaled-up across Asia and the Pacific.38 The period between 2009 and 2015 saw a decline of 30% in new HIV infections among children.39 However, PMTCT treatment coverage throughout the region remains shockingly low at 19%,40 much lower than other regions of the world including sub-Saharan Africa (59%)41 and the global average of 62%.42
Some countries in Asia and the Pacific have made significant progress in PMTCT treatment access including Cambodia (75.3%),43 Malaysia (85.5%) and Myanmar (90.2%)44. Furthermore, AIDS-related deaths among children have declined, dropping from 18,000 in 2004 to 15,000 in 2009.45
Malaysia is one example of a country that has made substantial progress with its PMTCT programme, increasing treatment coverage from 68.5% in 2012 to nearly 85.5% in 2013. MTCT rates have also declined, from 18% in 2012 to 8% in 2013.46 Malaysia demonstrates a clear commitment to eliminating new infections among infants and is leading the way in HIV prevention interventions, ensuring more pregnant mothers living with HIV are receiving the lifesaving treatment they need.
The number of harm reduction programmes is increasing across Asia and the Pacific in response to the HIV epidemic. The majority of countries in the region have harm reduction policies, but this excludes countries such as Bhutan, Japan, Korea, Singapore and Sri Lanka. Most countries provide both needle and syringe programmes (NSP) and opioid substitution therapy (OST), which have been found to be highly effective in reducing HIV prevalence among people who inject drugs.47
The provision of these services however varies across the region. Malaysia is an example of a country that has sharply increased the number of NSP sites from 297 in 2012 to 729 sites in 2013. Other countries have experienced a reduction in NSP services. For example, Afghanistan, has services available in only nine provinces across the country.48
Two thirds of people who inject drugs do not know their HIV status and only 18% of people who inject drugs eligible for antiretroviral treatment are accessing it. Vietnam has aimed to address these challenges by integrating OST services, HIV testing and counselling and treatment services. This combination for PWID has shown promising results, with individuals having higher retention rates for treatment and more likely to be receiving HIV care and support than those who are not receiving OST services.49
HIV treatment in Asia and the Pacific
Several countries in Asia and the Pacific have made substantial progress in HIV treatment coverage, however achieving the 90-90-90 target by 2020 will require radically extending the reach of HIV services and treatment. This will need to include diagnosing 1.3 million people living with HIV who do not know their HIV status, starting an additional 2 million people on antiretroviral treatment so that an additional 1.9 million people living with HIV achieve viral suppression in the next five years.50
Some countries in the region including Pakistan and Indonesia are struggling to provide antiretroviral treatment.51 In 2015, only 6% of people needing treatment in Pakistan were receiving it. However, in Thailand, 65% of people needing treatment were receiving it.52 The stark contrast across the region highlights the differences in national responses and funding for HIV treatment.
Indonesia is one example of a country that is tackling its low treatment coverage and in 2013 the government began to dramatically scale-up access. Indonesia has shown a strong commitment to implementing the 2013 WHO treatment guidelines, providing access to treatment for all with a CD4 count of below 500 and for all pregnant women, key affected populations and people with TB. These expanded services are available in at least 10 districts, with the aim of reaching 74 districts across Indonesia.53
Barriers to HIV prevention in Asia and the Pacific
Legal and punitive barriers
Scaling-up prevention, treatment and care services for key affected populations is crucial; however, many punitive laws are preventing services reaching and being accessed by these population groups.
HIV restrictions on entry, stay and residence are still very prominent in many countries across Asia and the Pacific, with 11 countries including Malaysia and Papua New Guinea still enforcing HIV restriction laws.54 China and Mongolia lifted travel bans on people living with HIV in 2012, an important steps towards reducing HIV stigma and discrimination.55
Numerous other punitive laws are hindering the HIV response in the region, disproportionally affecting key-populations. For example, for men who have sex with men, same-sex activities are criminalised in 18 countries including Bangladesh, Pakistan and Malaysia.56 This ultimately means that for many men who have sex with men in these countries, accessing prevention and treatment services can be very difficult.
Significant legal recognition has been made in many countries, including India and Pakistan in the last decade. Transgender identity and transgender rights have been increasingly accepted at a national level in Pakistan and India, where in 2009 and 2010 respectively, a third gender was formally recognised.57 Nepal is an example of a country that has enhanced and strengthened the rights of many key populations, amending discriminatory laws and creating a more favourable environment for people to access HIV services and treatment.58
Stigma and discrimination
Stigma and discrimination sadly remains a common feature of daily life for many people living with HIV and other key affected populations in Asia and the Pacific.
Research has found that more than 80% of people living with HIV in the region have experienced some form of discrimination whether that be in the work force, community or among family members.59 For example, in New Zealand, which has a very low HIV prevalence of 0.01%, HIV stigma is apparent throughout society. Research showed that more than 50% of people would feel uneasy about eating food that was prepared by a person living with HIV.60 A further area where stigma and discrimination is pervasive is within the health sector with 54% of people living with HIV reporting discrimination when accessing HIV services..61
"Too many people are facing isolation, loneliness, hopelessness…we need an Asia-Pacific community of compassion to end discrimination." - Aung San Kyi, UNAIDS Global Advocate for Zero Discrimination 62
Stigma and discrimination have a huge impact on key affected populations, especially transgender communities who face a daily battle with prejudice and discrimination. Research in Thailand has found that a low percentage of transgender women took an HIV test (21%) in 2010.63 The low uptake of testing is linked with the increased stigma levels that these populations face which create barriers to accessing such services.
Increasing HIV knowledge throughout the general population is critical to addressing the prejudices faced by people living with HIV and key affected populations. However, it is not enough to increase HIV knowledge and raise awareness of the epidemic, supportive policy environments at a national level, that protect rights and facilitate access to services, are crucial for many people living with HIV who experience stigma and discrimination.
The future of HIV and AIDS in Asia and the Pacific
The HIV epidemic in Asia and the Pacific is complicated, with each country epidemic very different. However, there are some commonalities that highlight areas of critical concern, namely the rising HIV epidemic among men who have sex with men and low HIV treatment coverage.
Addressing the legal barriers that increase stigma and discrimination as well as promoting more supportive policies needs to be nationally prioritised for most countries across the region.
A further challenge is ensuring that funding for the response is sustained. Domestic funding for national HIV responses has increased across Asia and the Pacific in the face of dwindling donor support for the HIV response.64 In 2014, an estimated US$ 2.4 billion was spent on the HIV response in the region. Countries including China, Malaysia and Thailand are leading the way, nationally funding between 89% to 99% of their HIV responses.65 The challenge ahead will be for more countries to increase their domestic spending on HIV, ensure that their national responses are sustainable, include prevention and effectively target populations most at risk of HIV.
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