1 where have we failed? findings of the commission on aids in asia tim brown east-west center modes...
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Where have we failed?Findings of the Commission on AIDS in Asia
Tim BrownEast-West Center
Modes of Transmission in the Philippines Stakeholders’ meetingManila, the Philippines
November 27, 2009
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The Commission on AIDS in Asia
• An independent body created by UNAIDS• Purpose:
– With fresh eyes, review HIV epidemic in Asia and responses to it
– Analyze course and impacts of the epidemic– Provide region-specific recommendations to
improve:• Prevention,
• Treatment and care, and
• Impact mitigation
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The Commission found a slowing regional epidemic that was about to resurge
0
5,000,000
10,000,000
15,000,000
20,000,000
1985 1990 1995 2000 2005 2010 2015 2020
Cumulative HIV Current HIV New HIV
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The pattern of new infections was evolving
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1985
1990
1995
2000
2005
2010
2015
2020
New
infe
ctio
ns in
yea
r
Clients Sex workers MSM IDU
Lo-risk male Lo-risk female Children
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This pattern results from a mixture of prevention successes and failures
• For sex workers and clients– Early prevention success in higher risk, high prevalence
countries – near universal coverage– Limited prevention success in moderate & lower-risk countries– Coverage 34% on a regional basis– New infections fell, but moderate risk country contribution is now
growing
• For IDU & MSM– A legacy of abysmal failure– < 2% coverage for IDUs, < 5% coverage for MSM– New infections climbing rapidly for MSM– Sustained high prevalence among IDU
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Today – all transmission modes in play
0
100,000
200,000
300,000
400,000
2005
2006
2007
2008
2009
2010
New
infe
ctio
ns in
yea
r
Clients Sex workers MSM IDU
Lo-risk male Lo-risk female Children
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But new infections in every country differ
0
100,000
200,000
300,000
400,000
2005
2006
2007
2008
2009
2010
Clients Sex workers MSM IDU
Lo-risk male Lo-risk female Children
Indonesia
0
50,000
100,000
150,000
200,000
1985
1990
1995
2000
2005
2010
2015
2020
New
infe
ctio
ns in
yea
r
Cambodia
0
5,000
10,000
15,000
20,000
1985
1990
1995
2000
2005
2010
2015
2020
New
infe
ctio
ns in
yea
r
Burma
0
25,000
50,000
75,000
1985
1990
1995
2000
2005
2010
2015
2020
Ne
w in
fect
ion
s in
ye
ar
Japan
0
5,000
10,000
15,000
20,000
1985
1990
1995
2000
2005
2010
2015
2020
Ne
w in
fect
ions
in y
ea
r
8
…and to focus, a country needs to know where its new infections are occurring
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…so countries need to assess their own situation and act on it
• Collate local knowledge of– The sizes of key populations:
• IDU, MSM, sex workers & clients
– Their levels of risk behavior– Their HIV and STI prevalence
• Estimate new infections by population
• Select programs for max impact using this
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The Commission also reviewed what worked in HIV prevention
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Effective efforts addressed new infections with high coverage, e.g., Thai sex work
• Response start: 1991• Data collected 1990-91
– Most men getting infected were clients of sex workers
– STIs enhancing HIV
• Prevention targeted:– Condom promotion in
sex work– STI treatment
Proportion new infections by population in Thailand
0.0
0.2
0.4
0.6
0.8
1.0
1988 1990 1995
IDU MSMClient from FSW Husband from wifeFSW from client Wife from husbandCasual sex
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..but if prevention coverage was low in a population, countries saw major failures
17.3
28.330.7
0
5
10
15
20
25
30
35
2003 2005 2007
HIV prevalence among MSM in Bangkok (Wipas 2008)
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At-risk population focused efforts have more impact & are more cost-effective
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Interventionsfocused on sex
workers andtheir clients
Interventionsfocused on men
who have sexwith men
Harm reductioninterventions for
injecting drugusers
Prevention ofspousal
transmissionthrough
VCT/PMTCT
Mainstreamyouth
interventions
Generalworkplace
intervention andcondom
marketing
Health caresettings (blood
safety, safeinjection,universal
precautions)
% or resources required % of infections averted
Figure 3.9: Comparison of prevention interventions, according to distribution of resources and percentage of new infections averted, 2007-2020Source: Redefining AIDS in Asia: Crafting and Effective Response
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Early harm reduction efforts with IDUs prevent many downstream infections
0
20
40
60
80
100
120
2005 2010 2015 2020 2025 2030
New
HIV
infe
ction
s av
erte
d ('0
00s)
ChildrenMSMMSWLow-risk womenLow-risk menClientsFSWIDU
• 192,000 IDU infections
• 60,000 FSW infections
• 460,000 client infections
• 200,000 infections in low-risk adult populations
• 50,000 infections in MSM
• 30,000 infections in children
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But in too many countries, prevention efforts are proving less than effective
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Emerging epidemics in different populations
0
20
40
60
80
1988
1993
1998
Per
cen
t H
IV+
Rangoon, Burma Guangxi, China
Bangkok, Thailand Hanoi, Vietnam
Jakarta, Indonesia
0
20
40
60
80
100
120
1985
1990
1995
2000
2005
Rep
ort
ed H
IV in
fect
ion
s
0
10
20
30
40
1995
2000
2005
Per
cen
t H
IV+
0
2
4
6
8
10
Round
II
Round
III
Round
IV
Round
V
Round
VI
Round
VII
Per
cen
t H
IV+ Central A (M)
Central A (F)
Central E
SE D
NW F1
Among MSM, e.g., Hong Kong Among FSW, e.g., Indonesia
Among IDU, e.g., Bangladesh Elsewhere IDU stays high
Indo
nesi
a U
NG
AS
S r
epo
rt
SP
P,
Hon
g K
ong
HS
S,
Ban
glad
esh
HS
S d
ata
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Why are efforts failing? Coverage
10 8
38
2 3
20
0
20
40
60
80
100
MSM IDU FSW
East-Asia and Pacific Southeast Asia
Source: Stover and Fahnestock 2006
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…and why is coverage so low?
• Resource constraints
• Inappropriate targeting of resources
• Limited community engagement– Awareness issues– Lack of ownership– No resources allocated for communities
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We need to do better!!!
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How do we improve our responses?
1. Build capacity to:– Identify the sources of new infections – Evaluate prevention coverage & impact
2. Direct prevention to those sources 3. Achieve high coverage in populations with
high incidence4. Mobilize and resource communities and
partners to engage the epidemic5. Act early in an epidemic