HIV and AIDS in Asia & the Pacific regional overview

KEY POINTS

There is huge variation in the scale of the Asia and Pacific region’s HIV epidemics as well as countries’ responses.
Prevention programmes have succeeded in reducing new infections by 9% since 2010 but late diagnosis remains a key area of concern.
Sustained and focused efforts to reach key populations have led to major reductions in HIV infections in Cambodia, India, Myanmar, Thailand and Vietnam since 2010.
However, new infections are rising in Bangladesh, Pakistan, the Philippines and Papua New Guinea and AIDS-related deaths are growing in Bangladesh, Pakistan, the Philippines, Afghanistan and Indonesia.
Many countries in the region have punitive and stigmatising laws that prevent key affected populations from accessing services, as well as reinforcing HIV stigma.
HIV risk among young people within key populations is of particular concern, especially among young men who have sex with men.

Explore this page to read more about populations most affected by HIV, testing and counselling, prevention programmes, antiretroviral treatment availability, civil society’s role, HIV and tuberculosis, barriers to the response, funding and the future of HIV in Asia and the Pacific.

The Asia and Pacific region was home to an estimated 5.9 million people living with HIV in 2018.1 China, India and Indonesia account for almost three-quarters of the total number of people living with HIV in the region.2

It is increasingly clear that the Asia and Pacific region is falling behind regions in Africa in its HIV response. In 2018, 69% of people living with HIV in this region were aware of their status. Among those diagnosed with HIV, 78% were on treatment of which 91% were virally suppressed. In terms of treatment coverage this equates to 54% of all people living with HIV being on treatment and just 49% being virally suppressed.3

The epidemic is largely characterised by concentrated and growing epidemics in key populations in a variety of countries, particularly clients of sex workers and other sexual partners of key populations, people who inject drugs (sometimes referred to as PWID), and men who have sex with men (sometimes referred to as MSM). Low national prevalence masks much higher prevalence among these groups and in specific locations, particularly urban areas.4

In 2018, 310,000 people became infected with HIV in the region.5 Three-quarters of these infections occurred among key populations and their partners.6

Although new infections declined by 9% between 2010 and 2018, progress has slowed in recent years and new infections are on the rise in some countries.7 In particular, Bangladesh, the Philippines, Pakistan and Afghanistan are facing rapidly expanding HIV epidemics. The Philippines is experiencing the steepest rise, with new infections up by 200% between 2010 and 2018. Over the same period, new infections rose by 57% in Pakistan, 56% in Bangladesh, 49% in Afghanistan and 26% in Papua New Guinea.8 The political climate in the Philippines under President Duterte, where extrajudicial killings against people who use drugs have been sanctioned and condom use discouraged, suggests this worrying trend is likely to continue.9 10

Around 200,000 people died due to an AIDS-related illness in the region in 2018, 24% fewer than in 2010. However, a number of countries are experiencing rises in the number of AIDS-related deaths, including Afghanistan, Bangladesh, Indonesia, Pakistan and the Philippines.11

Asia and the Pacific 90 90 90 targets 2019

Key affected populations in Asia and the Pacific

Men who have sex with men (MSM)

The HIV epidemic among men who have sex with men is growing. In 2018, 30% of all new HIV infections in the region occurred among men who have sex with men.12 Sexual activity between men remains illegal in a number of countries and is widely stigmatised.13

HIV prevalence among men who have sex with men is particularly high in urban areas.14 In Bangkok in Thailand, Yangon in Myanmar and Yogyakarta in Indonesia, estimated HIV prevalence among men who have sex with men ranges from 20% to 29%.15

Across the region it has been found that men who have sex with men are becoming infected with HIV at a young age.16 One study carried out in Bangkok found HIV incidence among those aged 18 to 21 was more than double the incidence among men over 30. Around half of all men who have sex with men in the region are under 25. 17

A further example of the HIV epidemic among men who have sex with men a high-income country within the region is in Australia. HIV prevalence rose among this population group from 11% in 2011 to 18% in 2015.18This rise is despite an increase in access to antiretroviral treatment.19

People who inject drugs (PWID)

One third of all people who inject drugs live in Asia and the Pacific.20 In 2018, 13% of new HIV infections in the region occurred among people who inject drugs.21

Although limited, data suggests the proportion of people who inject drugs who are HIV positive and aware of their status is low, except in Australia and Nepal where diagnosis rates are 85% and 98% respectively. Access to antiretroviral treatment (ART) for people who inject drugs is also poor, ranging between 14% in Myanmar and 69% in China.22

Although the need for harm reduction is increasingly accepted across the region, a largely punitive policy and legal environment continues to fuel the HIV epidemic among drug users. Eleven countries in the region still operate compulsory detention centres.23 China, Singapore, Malaysia, Indonesia and Vietnam continue to execute people who use drugs in high numbers.24

Elsewhere in the region, people who use drugs face brutal law enforcement that drives them away from harm reduction services. In the Philippines, official statistics released in July 2018 suggested around 4,500 people who use drugs had been killed due to extrajudicial killing, however civil society organisations say the actual death-toll could be as high as 20,000.25

Transgender people

HIV remains a critical concern for many transgender people across Asia. According to data from 13 Asian and Pacific countries reporting to UNAIDS in 2018, the median HIV prevalence among transgender people is 3.1%. However, a lack of data from the region means HIV prevalence among transgender people is likely to be much higher.26

Transgender people in many Asian and Pacific countries are very often isolated. This has serious knock-on effects for obtaining both health-related information and developing effective health policies and programmes to support this population.27 This social exclusion, coupled with a lack of employment opportunities, means that many transgender people in the region engage in sex work. One study estimated that the proportion of transgender people who sell sex to be 90% in India, 84% in Malaysia and 81% in Indonesia.28

Stigma, discrimination and legal barriers remain a major obstacle for providing and accessing services for transgender people in Asia.29 It also means that data on transgender access to HIV treatment and testing services is limited.

Sex workers

When the HIV epidemic began in Asia and the Pacific, it was heavily concentrated among sex workers and their clients. Significant progress in reducing new infections among female sex workers across the region has been made since then, particularly in Cambodia, India, Myanmar and Thailand. This is linked to the broad implementation of ‘100% Condom Use’ programmes in Thailand, Cambodia, Philippines, Vietnam, China, Myanmar, Mongolia and Laos, aimed at sex workers and their clients.30

Despite this, HIV prevalence among female sex workers is over 5% in several countries (Indonesia, Laos, Myanmar and Papua New Guinea)31, and female sex workers are around 29 times more likely to be living with HIV compared to other women of reproductive age in the region.32 Clients of sex workers remain the largest population at risk of HIV infection in the region, with data suggesting the proportion of men buying sex in the previous year ranges from 0.5% to 15%, depending on the country.33

The highest reported national HIV prevalence among female sex workers is in Papua New Guinea where 17.8% are living with HIV.34 Prevalence is even higher in some cities, even when national trends have declined. For example, in Ha Noi in Vietnam 18% of female sex workers are living with HIV, almost seven times the national average.35

Data on male and transgender sex workers is scarce, but where available shows high HIV prevalence. According to data gathered between 2012 and 2015, national HIV prevalence among male sex workers was higher than 5% in Indonesia, Nepal and Thailand. This underscores both the need for better data regarding male and transgender sex workers, and for HIV programming that addresses the needs of female, male and transgender sex workers.36

Migrant workers

Economic upheaval in the region over several decades has resulted in increased population mobility, encouraging people to move to cities in search of employment. Sexual transmission of HIV is exacerbated by this, with people spending long periods of time away from home and engaging in high-risk behaviours. Throughout the region, new HIV infections continue to be concentrated along trucking routes, among truck drivers, sailors, fishermen and other migrant workers.37

Migrant women are at a heightened risk of sexual violence, including rape, being forced into commercial sex and being forced to have sex without condoms. At the same time, legal barriers imposed by host governments, language barriers, movement restrictions and discrimination block access to HIV prevention and treatment services.38

HIV testing and counselling (HTC) in Asia and the Pacific

Late diagnosis is a serious barrier to tackling HIV, resulting in many people starting treatment with very low CD4 counts. Around 69% of people living with HIV in the region were aware of their status in 2018, up from 58% in 2015. However, this means around 1.9 million people did not know they were HIV positive.39

Progress on testing varies greatly between countries. In Thailand, 94% of people living with HIV were aware of their status in 2018, as were 86% of people living with HIV in Malaysia and 82% in Cambodia. At the other end of the spectrum, only 37% of people living with HIV in Bangladesh and 14% of people in Pakistan were aware of their status.40

Stigma, discrimination and punitive legal environments prevent many people from key populations from accessing testing services. Testing is generally better among sex workers, transgender people and men who have sex with men than it is among people who inject drugs, although all these groups struggle to access testing services in certain contexts, particularly when they are criminalised.41

Fifteen countries are piloting or implementing community-based HIV testing for key populations.42 Many schemes are using rapid finger-prick testing technologies to replace traditional tests that require laboratory analysis.

These pilots are proving successful. For instance, a study of 1,230 people from key populations in Vietnam found community-based testing resulted in a higher HIV positivity rate compared to facility-based testing, particularly among first-time testers, and led to a higher proportion of people beginning treatment.43

Self-testing kits, which enable people to carry out tests in private and so help overcome the barrier of stigma, are slowly becoming available in the region.44 Innovative pilots offering online, supervised self-testing to key populations in Bangkok and Pattaya in Thailand were found to attract a much higher proportion of first-time testers than face-to-face HIV counselling and testing (47% compared to 18%) and lead to a larger proportion of HIV diagnoses (16% versus 3.%).45

However, supportive policies do not always lead to broad implementation. For instance, although HIV self-testing kits have been legal in Australia since 2014, as of 2018 no self-testing kit has been approved for sale.46

China is the country in the region that has most keenly adopted HIV self-testing with impressive results. By 2017, approximately one-third of men who have sex with men in China were estimated to be using HIV self-testing kits, with many of these self-tests representing the first time the men had ever tested.47 However, there are some concerns about the quality of self-testing kits on offer.48

HIV prevention programmes in Asia and the Pacific

In 2018, 310,000 people became newly infected with HIV in the region. Overall the region is making progress in reducing new infections, with a 9% decline between 2010 and 2018.49

Some countries have seen a much steeper decrease over this period, with Cambodia, Nepal, Thailand, Singapore, Sri Lanka and Vietnam all experiencing at least a 50% reduction in new infections since 2010. By contrast, infections have increased by 203% in the Philippines, by 57% in Pakistan and 56% in Bangladesh.50

There were 12,000 new HIV infections among children in the region in 2018, around a third fewer than in 2010.51 HIV prevention programmes have played an important role in reducing HIV incidence.

Map of new HIV infections by country in Asia and the Pacific, 2010-2018

Condom availability and use

Condom programmes have been the cornerstone of prevention in Asia and the Pacific since its HIV response began. Condom use varies greatly across different areas and populations. In 2017, condom use among men who have sex with men is reported to be 95% in Nepal, 82% in India and Thailand, and 81% in Indonesia – and among sex workers 91% in India, 93% in Sri Lanka and 81% in Thailand. However, condom promotion programmes for people who use drugs are not as developed: India reports the highest rates for the region at 77%.52

Overall, two-thirds of men who have sex with men report 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.53

A study on condom use involving around 7,800 people living with HIV (aged 18–50) from Bangladesh, Indonesia, Lao, Nepal, Pakistan, the Philippines and Vietnam found 43% of 3,800 study participants did not use condoms consistently with their regular sexual partner. Participants from the Philippines had the highest risk behaviour and those from Lao the lowest.54

The rising epidemic in the Philippines has been linked to the government’s failure to offer effective prevention programmes, particularly condom distribution and sex education, to meet the demands of populations most affected by HIV. This is reflected by findings from the country’s 2015 Integrated HIV Behavioral and Serologic Surveillance survey, which found that only 33% of men who have sex with men and transgender women used a condom in the previous 12 months. The primary reason for a lack of condom use was that it was “not available”.55

For an epidemic that is affecting primarily MSM [men who have sex with men] because of low condom use, you’d think we’d be flooded with advertisements promoting condoms with MSM but that’s not the case.

- Carlos Conde, a researcher with Human Rights Watch in the Philippines.56

HIV education and approach to sex education

There are a number of major barriers to the implementation of effective HIV and comprehensive sexuality education (CSE) in schools in Asia and the Pacific.

An analysis of CSE in Bangladesh, Cambodia, China, India, Lao, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka and Vietnam found that, despite all countries having multiple laws and policies in place in relation to CSE, there were significant gaps in terms of the scope and content of the CSE on offer. For instance, issues such as safe abortion, sexual rights, sexual orientation, gender identities and consent are not being covered.57 As a result, less than half of young people in all countries in the region are thought to have comprehensive knowledge of HIV.58

Prevention of mother-to-child transmission (PMTCT)

Prevention of mother to child transmission (PMTCT) has been significantly scaled-up across Asia and the Pacific.59 The period between 2009 and 2015 saw a decline of 30% in new HIV infections among children.60

In the region as a whole, coverage of programmes to prevent mother-to-child transmission has more than doubled since 2010, but there is wide variation between countries.61 In 2018, more than 95% of pregnant women who attended an antenatal appointment or had a facility-based delivery were tested for HIV in Mongolia, Thailand, Sri Lanka and Vietnam, and more than 85% received HIV testing in Cambodia, Malaysia, Nepal and Singapore. At the other end of the spectrum, only around a third of pregnant women received HIV testing in Indonesia, Lao and Papua New Guinea.62

Overall, 56% of pregnant women living with HIV were on antiretroviral treatment (ART) in the region in 2018. Coverage ranges from around 10% to 15% in Afghanistan, Pakistan, Indonesia and the Philippines, to above 80% in Cambodia, Malaysia, Myanmar, Papua New Guinea, Thailand and Vietnam.63

In June 2016, Thailand became the first country in the region to eliminate mother-to-child transmission of HIV and syphilis after reducing transmission rates to less than 2%, and providing ART to more than 95% of pregnant women.64 In October 2018, Malaysia was certified by the World Health Organization (WHO) Western Pacific Region as having eliminated mother-to-child transmission of HIV (and syphilis). The country started antenatal HIV screening in 1998 which is provided free of charge, and nearly all women have access to health services.65

Harm reduction

Access to harm reduction programmes is uneven in Asia and the Pacific, with some countries expanding programmes and others closing them or refusing to offer these services. In recent years, increasingly punitive approaches to drugs have been growing, both in countries that had previously been open to progressive drug policy reform and in countries that have long been hostile to the rights of people who use drugs.

Needle and syringe programmes (NSP) are now available in 15 countries, with Afghanistan, Bangladesh, Cambodia, China, India and Pakistan distributing the highest amount of needles per person per year. However, Laos and the Philippines closed all NSPs between 2016 and 2018, and Brunei, Hong Kong, Japan, Laos, the Maldives, Singapore, South Korea and Sri Lanka remain unsupportive of this intervention.66

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 6.4% in 2015.67

A total of 15 countries also provide opioid substitution therapy (OST), which has been found to be highly effective in reducing prevalence among people who inject drugs, although the provision of these services varies greatly across the region.68

Although OST is offered In Malaysia and Vietnam, adherence tends to be low and many people who inject drugs leave care. Reasons for low OST retention rates include a lack of local clinics and poor treatment from OST providers.69

China has an expansive harm reduction programme. There are currently 767 OST sites operating in 28 provinces, with 184,000 people receiving methadone maintenance therapy in 2015. However, those delivering services operate in a difficult policy environment. China continues to support severe, punitive policies, including the death penalty, for drug-related offences.70

In Thailand, detoxification and long-term maintenance with methadone has been provided free since 2014, as it is included in the universal health insurance scheme as well as the social security scheme.71 In 2017, the country took the decision to improve the legal status of people who use drugs, reducing penalties for drug possession, trafficking and production and abolishing the mandatory death penalty for selling drugs.72

Pre-exposure prophylaxis (PrEP)

Awareness and use of pre-exposure prophylaxis (PrEP), a daily course of HIV drugs taken by HIV-negative people to reduce their risk of HIV infection, is relatively low in the region but it is growing in some countries, particularly in relation to men who have sex with men and transgender women.73

A growing number of people from across the region are buying PrEP online, which suggests increasing demand.74

PrEP clinical trials and demonstration projects have been carried out in Vietnam, Taiwan, New Zealand and China, while Thailand and Australia are conducting larger-scale implementation studies.75 In July 2019, Indonesia announced it would also begin piloting PrEP, through a project working in four cities with high levels of HIV prevalence.76

Almost no PrEP-related data exists about population groups other than men who have sex with men, significant efforts are underway to study and implement PrEP programmes for female sex workers in the region.77

In 2018, PrEP MAP was launched, which provides a comprehensive guide to PrEP in the region, including information about how to access PrEP and how people from at-risk communities across the region can help advocate for improved access to the drug.78

Antiretroviral treatment availability in Asia and the Pacific

Around 3.2 million people living with HIV in the region were accessing antiretroviral treatment (ART) in 2018, up from 2.1 million people in 2015.79

Most countries have expanded HIV treatment guidelines to include all those living with HIV regardless of CD4 count, which indicates the level of HIV in someone’s body. This move is partly driven by the notion of ‘treatment as prevention’ because individuals who are virally suppressed – the result of effective, continual treatment and monitoring – are unable to transmit HIV to others.80

As the total number of people living with HIV in the region has increased, so too has treatment coverage, from 37% of all people living with HIV in the region on treatment in 2015 to 54% in 2018 (equating to 78% of people diagnosed with HIV on treatment).81 If growth remains steady over the next few years, it is likely the region will miss the UNAIDS’ target of 81% of all people living with HIV on treatment by 2020.82

Children and younger adolescents (0-14 years) who are living with HIV are considerably more likely to be receiving treatment than adults, with 78% of all children living with HIV on treatment in 2018.83

Linkage to HIV treatment and care services varies between countries, reflecting the differences in national responses and funding for HIV treatment. It is particularly poor in Afghanistan and Indonesia, where more than half of those who were aware of their status in 2018 were not accessing ART. In Bangladesh, Lao, Malaysia, the Philippines, Sri Lanka and Vietnam, around a third of people living with HIV who were aware of their status were not on treatment. In comparison, almost all those diagnosed with HIV in Cambodia were receiving treatment, as were close to 80% or more in China, Myanmar, Nepal and Thailand.84

Retention rates for treatment are high in Bangladesh, Kiribati, the Maldives, Samoa, the Solomon Islands and Tonga, with 95% of people still accessing treatment after 12 months. The lowest levels of retention were reported by Brunei (72%), India and Indonesia (both 74%). 85 Adherence rates among adolescents and young people (12-24 years) are also high, estimated at 84%.86

The percentage of people living with HIV on treatment who achieved viral suppression increased from 89% in 2015 to 91% in 2018, equivalent to 2.9 million people. However, this equates to only half (49%) of all people living with HIV in the region overall due to poor testing and treatment coverage in some contexts.87 In addition, viral load testing is limited in many countries.

The emergence of HIV drug resistance is of deep concern when scaling up ART. However, routine HIV drug resistance testing is not recommended for people starting ART in the region, leading to limited data on this issue. A systematic review of studies in the region published between 2000 and 2011 found that most reported relatively low levels of drug resistance.88 However, a separate review of a range of low- and middle-income countries reported an annual increase in the odds of pre-treatment HIV drug resistance of 11% in Asia.89

CASE STUDY: Analysing the HIV care cascade in Indonesia

To understand issues with the HIV treatment cascade among key populations in Indonesia, researchers followed around 830 newly diagnosed HIV positive men who have sex with men, female sex workers, transgender women and people who inject drugs.

Their findings revealed poor retention rates in relation to both treatment and viral suppression. Of those enrolled in the study, 85% were linked to HIV care, of whom 86% started ART. Among those who started treatment, 75% were retained in care. Of these, around 70% had a viral load test after 6 months, and 90% of those tested were virally suppressed. Overall, around one in four people who started treatment dropped out of care.

The analysis found that people who enrolled at sites that offered both testing and treatment were more likely to start treatment than those who enrolled at sites offering testing only. Participants who had been linked to care who had a high school or university education were significantly more likely to achieve viral suppression than those with a primary school or lower level of education.90

Civil society’s role in Asia and the Pacific

Civil society varies widely in Asia and the Pacific. Even in countries where a strong civil society has been established, political changes have seen some countries, such as mainland China and the Philippines, experience severe restrictions in recent years.91

The establishment of community networks representing people living with HIV, sex workers, people who use drugs, men who have sex with men and transgender people as formalised organisations at the regional, sub-national and national level has led to a vibrant, community-led HIV-movement across the region. As a result, in many countries there is widespread participation of people living with HIV and other key populations in the HIV response, including within policy development, and the planning and delivery of HIV services.92

Empowered, highly-skilled HIV activists have also been successful in demanding greater transparency and accountability from governments and pharmaceutical companies. For example, in India and Thailand, networks of people living with HIV have been instrumental in challenging medicine patents and treatment access.93

HIV and tuberculosis (TB) in Asia and the Pacific

Nine out of the world’s 22 ‘high burden’ tuberculosis (TB) countries are in the Asia and Pacific region, which is home to more than half of all people living with TB globally. Many countries are also facing alarming epidemics of multi-drug resistant TB.94

TB and HIV control programmes have improved, but joined-up programmes still need to be strengthened in countries with a high TB burden. Routine testing of people with TB for HIV is not universally implemented, compromising people’s health and hampering accurate data collection. In 2013, less than half of all TB cases were tested for HIV, although testing rates vary greatly between countries.95

The highest rates of HIB/TB co-infection among people newly enrolled in HIV care are in the Philippines (26.1%) and Indonesia (21.8%), while the lowest rates are in Singapore (2.7%), Afghanistan (3.1%) and Malaysia (4.7%).96 However, the region has responded well to treating TB. In 2017, there were 36,000 TB-related deaths among people living with HIV, compared with 62,000 in 2014.97

Despite the clear need for TB preventative therapy for people living with HIV, provision is poor in most countries. Malaysia and the Philippines are the exception to this where, respectively, 78.8% and 56.5% of people newly enrolled in HIV care were given medication to stop them from developing active TB in 2017.98

Barriers to the HIV response in Asia and the Pacific

Legal, cultural and socio-economic 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.

In the Philippines, the 2018 AIDS Act is set to expand human rights for people living with HIV. In 2018, India also passed a comprehensive law prohibiting HIV-related discrimination.99

Nepal is an example of a country that has enhanced and strengthened the rights of many key populations during the past decade, amending discriminatory laws and creating a more favourable environment for people to access HIV services and treatment.100 101

Yet despite these advances, numerous punitive laws continue to hinder the HIV response in the region. HIV restrictions on entry, stay and residence and laws that criminalise HIV transmission and non-disclosure are held by 13 countries, with Malaysia, New Zealand and Papua New Guinea still enforcing HIV restriction laws.102China and Mongolia lifted travel bans on people living with HIV in 2012, an important step towards reducing stigma and discrimination.103

Same-sex activities are criminalised in 10 countries in the region, making it very difficult for many men who have sex with men and people who are lesbian, gay, bisexual or trans (LGBT) to access prevention and treatment services. Bangladesh, Bhutan, the Maldives, Papua New Guinea, Sri Lanka and Singapore impose prison terms of up to 14 years for homosexuality, and in Afghanistan, Brunei and Pakistan, same-sex sexual activity is punishable by death.104

In 2013, New Zealand became the first country in the region to legalise same-sex marriage.105 It was followed by Australia in 2017 and Taiwan in 2019.106

In 2018, homosexuality was decriminalised in India as a result of a Supreme Court ruling. However, Brunei increased its penalty for homosexuality in 2019, making it punishable by death.107

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.108 Advancing this further, specific laws protecting the rights of transgender people were passed in India in 2016 and in Pakistan in 2018. In 2017, a new Civil Code in Vietnam gave transgender people the right to register their change of gender.109

Stigma and discrimination

Stigma and discrimination still pose major barriers for people living with, or affected by, HIV to seek prevention or treatment services. For example, national survey data from seven countries suggest at least 40% of people would not buy vegetables from a vendor who was living with HIV. In five countries, more than 20% of people expressed the opinion that children living with HIV should not be allowed to go to school with other children.110

As a result of widespread stigma and discrimination, around three-quarters (75%) of men who have sex with men surveyed in Lao said they avoided healthcare. In Thailand, around 8% of female sex workers and 6% of transgender people also reported avoiding healthcare due to negative healthcare provider attitudes.111

Although they have put in place a lot of testing sites people don’t go and get tested. People don’t trust the healthcare workers to keep their results confidential.

– Respondent in Pacific PLHIV Stigma Index survey.112

In 2018, the People Living with HIV Stigma Index Study, conducted by the Fiji Network of People Living with HIV (FJN+), conducted surveys in Micronesia, Kiribati, Palau, the Marshall Islands, Samoa, Tonga and Vanuatu. More than 70% of respondents reported feelings of shame, guilt, self-blame and/or low self-esteem in the previous 12 months due to their positive status and 22% had felt suicidal.113

Stigma and discrimination have a huge impact on key affected populations, especially transgender communities who face daily prejudice and discrimination. In 2016, in-depth interviews with 30 transgender people and members of the hijra community in India found all had experienced traumatic experiences in relation to their gender identity. Participants also reported two types of stigma within healthcare settings: firstly from healthcare providers, and secondly from self-stigma associated with their appearance and gender expression.114

Funding in Asia and the Pacific

Between 2010 and 2018, funding for the region’s HIV response increased by 32%. This is mainly due to a doubling of domestic resources, from US$ 1.4 billion to US$ 2.8 billion.115 Domestic funding now supports 81% of the region’s HIV response (compared to 53% in 2010). The majority of funding for the HIV response in China, India, Malaysia and Thailand now comes from the government and other domestic sources.116

By contrast, international support for HIV in the region fell by 48% between 2010 and 2018. This is largely due to a decrease in bilateral funding from the US (a 14% reduction), and the Global Fund to Fight AIDS, Malaria and Tuberculosis (a 35% reduction).117

Of particular concern is the impact that Global Fund withdrawal may have, as traditionally this has provided funding for programmes specifically targeted at key populations, particularly in relation to HIV prevention. For instance, in Thailand, key populations account for more than 50% of new infections but are allocated only 22% of HIV prevention programming.118

In total, it is estimated that an additional US$ 5 billion is needed to reach the region’s 2020 Fast-Track targets, an increase of around 40% in spending. However, between 2017 and 2018 funding increased by just 10% overall (in constant 2016 US dollars).119

The future of HIV in Asia and the Pacific

The HIV epidemic in Asia and the Pacific is complex, with each country epidemic significantly different. However, there are some commonalities that highlight areas of critical concern, namely the rising epidemic among men who have sex with men and people who are transgender and, in some contexts low testing and treatment coverage.

If risk behaviours among men who have sex with men and transgender people, such as multiple sex partners and low rates of condom use, are not challenged, the rising epidemic among these groups will continue. By 2020, almost 50% of all new infections in Asia could be among men who have sex with men, according to the UN Commission on AIDS in Asia.120 Also of concern are growing epidemics among people who inject drugs in some countries, coupled with shrinking harm reduction services, reflecting an increasingly hostile environment to drug users.

Without supportive national policy environments, many people living with, and most affected by HIV, will continue to experience stigma and discrimination that prevents them from accessing prevention and treatment. Challenging laws and addressing harmful social, sexual and gender norms that increase the vulnerability of key populations to HIV are vital for effective HIV responses across the region.

As international donors continue to withdraw funding from many Asian countries, more governments need to increase their domestic spending on HIV in ways that ensure their national responses are sustainable. This includes allocating more funds to prevention services, effectively targeting populations most at risk and continuing to push for affordable ARVs, particularly those that can better address HIV drug resistance.