Asia and the Pacific has made tremendous progress in tackling the HIV epidemic. The majority of people living with HIV across the region (90%) live in 12 countries; China, Cambodia, India, Indonesia, Malaysia, Myanmar, Nepal, Nepal, Pakistan, Papua New Guinea, The Philippines, Thailand and Vietnam.1 India accounts for 2.1 million of those living with HIV.2 The number of new infections has dramatically reduced since 2001 by 26%, with 350,000 new infections in 2012.3
The epidemic is largely characterised by concentrated and growing epidemics in a variety of countries, particularly among key affected populations, especially amongst men who have sex with men (MSM).4 The HIV epidemic also widely varies depending on the context, highlighting the importance of looking at individual countries and their HIV epidemic and responses.
Treatment coverage has steadily increased over the last five years, equating to 51%, a 46% rise since 2009.5 Progress in tackling the epidemic varies by geographical area, with the epidemics in South and South-East Asia decreasing. In East Asia, HIV infections are rising.6
Key affected populations in Asia and the Pacific
Key affected populations are an increasing concern for the Asia and Pacific HIV response, with the aim to ensure that no one is left behind.7 There needs to be an increased focus on these populations at higher risk of HIV if the epidemic is to be controlled.8 Creating supportive and safe environments for these groups to seek help is critical.
Men who have sex with men (MSM)
Men who have sex with men (MSM) are one of the key affected populations in Asia and the Pacific. They are the only key affected population where the HIV prevalence is rising in some countries and has been described as a “matter of urgency” by UNAIDS.9
Rising HIV prevalence is particularly high across urban areas.10 Cities such as Hanoi and Bangkok have estimated HIV prevalence rates of between 15% and 25%.11 Across the region it has been found that MSM are becoming infected by HIV at a young age.12 High percentages of unprotected anal intercourse have been found to increase the spread of HIV in MSM across Asia.13 Furthermore, condom use has been found to vary greatly across different areas. Over two-thirds of MSM during their last anal sex stated using condoms, but this figure decreases for MSM in cities and urbanised areas, with under half of MSM reporting using condoms.14
A further example of the MSM HIV epidemic in a high-income country within the region is Australia. Whilst HIV prevalence in Australia has declined overall, HIV prevalence has risen amongst MSM,15 with 11.2% of MSM living with HIV.16 This rise is despite an increase in access to antiretroviral treatment.17 Data is also very varied for condom usage among this population, with between 39-89% of MSM reporting using a condom the last time they has sexual intercourse.18 Increasing awareness of both testing and HIV prevention are therefore crucial for this population.
People who inject drugs (PWID)
HIV prevalence among people who inject drugs (PWID) varies greatly across Asia and the Pacific. It is as high as 50% in some areas but much lower in others like Pakistan (25%) and Bangladesh (2%).19 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 has seen a dramatic reduction in HIV prevalence - from 68% in 2002 to 6.3% in 2011,21 highlighting the importance of promoting harm reduction programmes for PWID. Harm reduction has become more integrated into HIV prevention programmes in countries such as India, Vietnam and Pakistan.22
Drug detention centres remain a common feature in many Asian societies but their effectiveness and conduciveness to the HIV response is greatly debated. Many drug detention centres lack human rights and often 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 PWID.23
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.24
HIV remains a critical concern for many transgender populations across Asia. Particularly high HIV prevalence rates have been found amongst transgender populations in cities such as Delhi (49%), Phnom Penh (37%) and Mumbai (42%). For a lot of these cities, HIV prevalence is much higher amongst transgender populations in comparison to MSM.25
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.26
"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 27
Stigma, discrimination and legal barriers remain a major obstacle for providing and accessing services for transgender populations in Asia.28 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.29 Challenging these laws and addressing social, sexual and gender norms which increase transgender peoples risk to HIV is vital in future HIV responses across Asia and the Pacific.30
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. 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 PWID and MSM, with over two thirds of these populations unaware of their HIV status.31
Stigma and discrimination remain barriers to individuals accessing testing services. Voluntary testing and counselling (VCT) has been widely promoted by UNAIDS and the World Health Organisation (WHO) across the region to reduce these levels of discrimination and stigma.32 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.33
HIV prevention in Asia and the Pacific
Since 2001, there has been a 26% reduction in new HIV infections and HIV prevention programmes have played an important role in reducing HIV incidence.34 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 in the last ten years.35 New infections among children have also dramatically reduced by 28% between 2001 and 2012.36 However, PMTCT treatment coverage throughout the region remains shockingly low at 19%,37 much lower than other regions of the world including sub-Saharan Africa (59%)38 and the global average of 62%.39
Some countries in Asia and the Pacific have made significant progress in PMTCT treatment access including Cambodia (75.3%),40 Malaysia (85.5%) and Myanmar (90.2%)41. Furthermore, AIDS-related deaths amongst children have declined, dropping from 18,000 in 2004 to 15,000 in 2009.42
Malaysia is one example of a country that has made substantial progress with regards to the country’s 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 2013.43 Malaysia demonstrates a clear commitment to eliminating new infections amongst infants and is leading the way in HIV prevention interventions, ensuring more pregnant mothers living with HIV are receiving the lifesaving treatment they need.
Harm reduction programmes are becoming increasingly implemented across Asia and the Pacific to curb 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 PWID.44
The provision of these services however varies across the region. Malaysia is an example of a country that has sharply increased number of NSP sites from 297 in 2012 to 729 sites in 2013. Other countries have experienced a reduction in NSP services, such as Afghanistan, with services available in only nine provinces across the country.45
Two thirds of PWID do not know their HIV status, with only 18% of PWID eligible for antiretroviral therapy accessing treatment. 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.46
HIV treatment in Asia and the Pacific
Several countries in Asia and the Pacific have made substantial progress in HIV treatment coverage, however a large proportion of the region is behind in achieving the 2015 target of reaching 15 million people with antiretroviral treatment.47 With regards to the 2010 WHO guidelines, Asia and the Pacific have an estimated treatment coverage of 51%.48 This coverage is still 10% below the global treatment coverage, and with the new 2013 WHO guidelines this is just 33%.49 Much more work needs to be done to increase the amount of people receiving lifesaving antiretroviral drugs. Antiretroviral treatment coverage for children, however, is way above the global average with 42% of children in the region receiving antiretroviral drugs in comparison to a global average of 34%.50
2012 estimates reveal that countries including Pakistan and Indonesia are struggling to provide ART, with only 2,996 out of 21,000 eligible for antiretroviral treatment in Pakistan receiving the drugs. However, in countries such as Thailand, which has a much higher number of adults eligible for ART, 232,816 people out of 280,000 who are eligible for ART are receiving it.51 The stark contrasts across the region highlight the national response and funding differences towards increasing access to HIV treatment.
Increasingly, countries in the region are adopting the 2013 WHO recommended guidelines that a CD4 count of 500 or less should be eligible for antiretroviral treatment.52 Indonesia is one example of a country that is tackling their low treatment coverage and in 2013 the government called to dramatically scale-up access to HIV treatment. Indonesia has exemplified a full 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
The HIV epidemic in Asia and the Pacific is particularly serious amongst key affected populations such as MSM, PWID, transgender populations and male and female sex workers. Scaling-up prevention, treatment and care services for these populations is crucial; however, many punitive laws are preventing services reaching and being accessed by key populations.
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 Countries including China and Mongolia have recently lifted the travel bans of people living with HIV, demonstrating important steps to reducing HIV stigma and discrimination.55
Numerous punitive laws are hindering the HIV response in the region, which especially affect 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 MSM populations 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 years. Transgender identity and transgender rights have been increasingly accepted at a national level in Pakistan and India, who in 2009 and 2010 respectively, formally recognised transgender as a third gender.57 Nepal is an example of a country that has enhanced and strengthened the rights of many key populations, amending discriminatory laws, creating a more favorable 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 in Asia and the Pacific. Research has found that over 80% of people living with HIV (PLHIV) have experienced some form of discrimination whether that be in the work force, community and amongst family members.59 An example of HIV-related stigma is in New Zealand, which has a very low HIV prevalence of 0.01%. HIV stigma is apparent throughout society with research finding that over 50% of respondents would feel uneasy about eating food that was prepared by an person living with HIV.60 A further area where stigma and discrimination is pervasive is within the health sector with 54% of PLHIV 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 profoundly affects key affected populations, especially transgender communities who face a daily battle with prejudice and discrimination. Research has found in Thailand 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.
Increasing HIV knowledge among all populations is critical to addressing the prejudiced beliefs that many have regarding HIV and key affected populations. However, it is not just enough to increase HIV knowledge and raise awareness of the epidemic, supportive policy environments at a national level 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 amongst MSM populations 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 many countries across the region.
A further challenge will be 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 Countries including China and Thailand are leading the way, nationally funding 88% and 85% of their HIV responses.65 The challenge ahead will be for more countries to increase their domestic spending on HIV, ensuring that their national responses will be sustainable, providing the lifesaving prevention, treatment and care so many people need across Asia and the Pacific.
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