7 th ias conference on hiv pathogenesis, treatment and prevention tracking the hiv/aids epidemic in...

7th IAS Conference on HIV Pathogenesis, Treatment and Prevention

Tracking the HIV/AIDS epidemic in

Asia and the Pacific

Mr. J.V.R. Prasada Rao

UN Secretary General Special Envoy on HIV/AIDS in Asia Pacific

3 July 2013Kuala Lumpur, Malaysia

1. Epidemic and response

2. Financing AIDS response

3. Legal environment

4. HIV/AIDS and post 2015

development agenda

Epidemic and response

State of the epidemic: Global and Asia-Pacific

Global Asia-Pacific

People living with HIV 34,000,000[31,400,000 – 35,900,000]

4,900,000[3,900,000 – 6,100,000]

Women living with HIV 15,000,000 [13,900,000 – 15,700,000]

1,600,000[1,200,000 – 2,100,000]

New HIV infections 2,500,000 [2,200,000 – 2,800,000]

370,000[250,000 – 550,000]

Adult HIV prevalence 0.8 %[0.7% – 0.8%]

0.2 %[0.2% – 0.2%]

AIDS-related deaths 1,700,000[1,500,000 – 1,900,000]

310,000[240,000 – 400,000]

Source: Prepared by www.aidsdatahub.org based on HIV estimates and projections data for UNAIDS (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012

Epidemic and response: Asia-Pacific and Sub Saharan Africa

Asia-Pacific Sub-Saharan Africa

Type of epidemic

Populations affected by

AIDS

Burden of epidemic

Prevention interventions

Concentrated among key populations Generalized

Sex workers and their clients, Men who have sex with men,

Transgender, People who inject drugs, and all of their

intimate partners

General population: men, women, and young people

4.9 million People living with HIV

370,000 New infections

23.5 million People living with HIV

1.8 million New infections

Relatively smaller populations but more

difficult to reach due to stigma and legal barriers

Larger population sizes but relatively easier to

reach

Disease burden: Asia and Sub-Saharan Africa

South-East Asia, East Asia, and

OceaniaSouth Asia Sub-Saharan Africa

3.2%5.6%

16%

Dea

th (

%)

Source: http://www.healthmetricsandevaluation.org

New HIV infections in Asia-Pacific region

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

100,000

200,000

300,000

400,000

500,000

Ne

w H

IV in

fec

tio

ns

(N

um

be

r)

18 % decline

Stagnated de-cline between 2008 and 2011


Significant decline in new HIV infections in the last decade, but slow-down between 2008 and 2011

Same is true for countries where the epidemic is slowing down

69% decline

2008

Cambodia

42%decline

2011

57%decline

2008

27% decline

2011

Myanmar

73% decline

2008

Nepal

48% decline

2011

28% decline

2008

19% decline

2011

PNG

Example of countries with declining new HIV infections


Half of all new infections among MSM by 2020 if ‘business as usual’- Commission on AIDS in Asia

MSM

Source: Commission on AIDS in Asia. (2008). Redefining Aids in Asia: Crafting an Effective Response.

Estimated annual new HIV infections by population group, Asian Epidemic Model

Rising HIV epidemic among MSM in many regions across the worldSource: Beyrer, C., Baral, S. D., Griensven, F. v., Goodreau, S. M., Chariyalertsak, S., Wirtz, A. L., & Brookmeyer, R. (2012). Global epidemiology of HIV infection in men who have sex with men. Lancet, 380(9839), 367-377.

HIV prevalence among MSM vs. adults

Key populations are central to the epidemic but not enough are reached by prevention services

0

20

40

60

80

100

0

100

200

300

400

500

51

37

57

118

Pre

ve

nti

on

pro

gra

mm

e c

ov

era

ge

(%

)

Nu

mb

er

of

ne

ed

les

an

d s

yri

ng

es

d

istr

ibu

ted

pe

r P

WID

pe

r y

ea

r

Source: Prepared by www.aidsdatahub.org based on UNAIDS. (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012

Key populations reached by prevention services, regional median, 2011

Stagnating consistent condom use among MSM - impact on HIV prevalence

Source: Prepared by www.aidsdatahub.org based on 1) Mishra, R. M., Dube, M., et al. (2012). Changing epidemiology of HIV in Mumbai: an application of the Asian epidemic model. Glob J Health Sci, 4(5), 100-112.; 2) Lan, W., Lu, W., et al. (2012). HIV Prevalence and Influencing Factors Analysis of Sentinel Surveillance among Men who have Sex with Men in China, 2003-2011. Chinese Medical Journal, 125(11), 1857-1861.; 3) Data from UNAIDS Country Office Thailand.

0

20

40

60

80

100

0

5

10

15

20

2580

9.2

Mumbai, India (2004-2009)

Consistent condom use HIV prevalence

con

sist

ent

con

do

m u

se %

HIV

pre

vale

nce

%

2005 2006 2007 2008 2009 2010 20110

20

40

60

80

100

0

5

10

15

20

25

43

6.3

China (National), 2005-2011


con

sist

ent

con

do

m u

se %

HIV

pre

vale

nce

%

2005 2007 2009 20100

20

40

60

80

100

0

5

10

15

20

25

69.8

20

Thailand (Bangkok, Chiangmai, Phuket), 2005-2010


con

sist

ent

con

do

m u

se%

HIV

pre

vale

nce

%

Proportion of consistent condom use and HIV prevalence among MSM

Consistent condom use among female sex workers with their clients

0

20

40

60

80

10081.5

89.29483

Cambodia, 1997-2010

FSW with 2 or less client/day

FSW with more than 2 clients/day

Direct FSW

Beer Promoters

%

0

20

40

60

80

10094

Thailand, 2004-2008%

0

20

40

60

80

100

75

Andhra Pradesh, India, 2006-2010%

0

20

40

60

80

100 95

Mumbai, India, 2004-2009%

Source: Prepared by www.aidsdatahub.org based on 1) Chhorvann, C. (2011). Behavioral Sentinel Surveillance 2010. Power Point Presentation. National Center for HIV/AIDS Dermatology and STD; 2) Thailand UNGASS Report 2010; 3) Erausquin, J. T., Biradavolu, M., et al. (2012). Trends in condom use among female sex workers in Andhra Pradesh, India: the impact of a community mobilisation intervention. J Epidemiol Community Health, 66(2), 2011-200511; 4) Mishra, R. M., Dube, M., et al. (2012). Changing epidemiology of HIV in Mumbai: an application of the Asian epidemic model. Glob J Health Sci, 4(5), 100-112.

2005 2006-07

2008 2009 2010 20110

20

40

60

80

100

05101520253035

45 4327.5

3.8

30.8

Pakistan, Lahore (2005-2011)

Sa

fe in

jec

tio

n in

th

e p

as

t m

on

th(%

)

HIV

pre

va

len

ce

(%

)

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

0

20

40

60

80

100

0

20

40

60

80

54.1

78.388.1 93.1 97.4

68

6.3

Nepal, Kathmandu (2002-2011)

Sa

fe in

jec

tio

n in

th

e p

as

t w

ee

k(%

)

HIV

pre

va

len

ce

(%

)

020406080

100

2838 45 47

58

97

31 36

5 14 166

Consistent use of sterile injecting equipment * HIV prevalence

%

Correlation between safe injecting and HIV prevalence among PWID

* Duration of consistent use of sterile injecting equipment varies from last week to last 6 months;** Behavioral data for 2006-07, Never used used-needles and syringes; *** Behavioral data for 2008

Source: Prepared by www.aidsdatahub.org based on National HIV Sentinel Surveillance reports, Integrated Biological and Behavioral Surveillance reports and other reports

Prevention of mother-to-child transmission coverage, by region, 2010 and 2011

Source: 2012 country progress reports (www.unaids.org/cpr) and UNAIDS estimates.

Only one in five pregnant women living with HIV received effective ART regimens for PMTCT in South and South-East Asia

Middle East and North

Africa

South and South-East

Asia

East Asia and

Oceania

Caribbean Latin America

Low- and middle-income

countries

Sub-Saharan Africa

100

80

60

40

0

20

%

20112010

0

5

10

15

20

25

30

35

40

45

50

3632

24 24

13 12

24

% r

ed

uc

tio

nPercentage reduction in new HIV infections among children, 2009 to 2011

Progress NOT apparent in eliminating new HIV infections among children


Though HIV is concentrated among key populations, less than half of them know their HIV status

Female sex workers

Male sex workers Men who have sex with men

People who inject drugs

0

20

40

60

80

100

44 44

3329

HIV

te

sti

ng

co

ve

rag

e (

%)


HIV testing coverage among key populations, regional median, 2011

2003 2004 2005 2006 2007 2008 2009 2010 20110

200,000400,000600,000800,000

1,000,0001,200,000

1.1 mil-lionNumber of people receiving ART

1.1 million people are receiving antiretroviral therapy – lagging behind global trend

Source: Prepared by www.aidsdatahub.org based on 1)UNAIDS. (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012.; 2) www.aidsinfoonline.org

Global Asia-Pacific 0%

20%

40%

60%

80%

100%

36%

18%

46%37%

54%46%

Recent trends in global and Asia-Pacific ART coverage

2009

2010

2011

Number and proportion of eligible people receiving ART at the end of 2011

Correlation between high level of treatment coverage and decline in new infections

Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

2004 2005 2006 2007 2008 2009 2010 20110

50,000

100,000

150,000

200,000 Botswana

People receiving ART

Nu

mb

er (

in t

ho

usa

nd

s) o

f p

eop

le o

n A

RT

44% of people currently on ART have been on treatment since 2006

2004 2005 2006 2007 2008 2009 2010 20110

5,000

10,000

15,000

20,000

New HIV infections

Nu

mb

er o

f n

ew H

IV in

fect

ion

s

36% decline in new HIV infections

2004 2005 2006 2007 2008 2009 2010 20110

100,000

200,000

300,000

400,000

500,000

600,000 Kenya

People receiving ART

Nu

mb

er (

in t

ho

usa

nd

s) o

f p

eop

le o

n A

RT

23% of people currently on ART have been on treatment since 2006

2004 2005 2006 2007 2008 2009 2010 20110

35,000

70,000

105,000

140,000

New HIV infections

Nu

mb

er o

f n

ew H

IV in

fect

ion

s

17% decline in new HIV infections

As ART coverage continues to grow, there is evidence of drug resistance emerging

Source: Stanford University HIV Drug Resistance Database at http://hivdb.stanford.edu/surveillance/map/

SDRM = Surveillance Drug Resistance Mutations

HIV-1 drug resistance in ARV-naïve populations

Financing AIDS response

Trends in domestic public and international AIDS spending, global and the Asia-Pacific

2008 43%57

%

2009 44%

56%

2010 50%

50%

2011 51%

49%

Global

2008 50%

50%

2009 51%

49%

2010 57%

43%

2011 66%

34%

Asia-Pacific

Domestic public (%)

International (%)

Source: Prepared by www.aidsdatahub.org based on 1) UNAIDS. (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012.; 2) www.aidsinfoonline.org

Decreasing dependence on external aid

23

HIV expenditure from domestic sources, Asia-Pacific

Malaysia (2011) China (2011)

Thailand (2011)Sri Lanka (2010)

Philippines (2011)Indonesia (2010)

Pakistan (2011)Mongolia (2011)

PNG (2010)Fiji (2011)

Viet Nam (2010)India (2011-12)

Myanmar (2011)Lao PDR (2011)

Bangladesh (2011)Cambodia (2009)

Nepal (2009)Afghanistan (2011)

0 25 50 75 100

9490

855352

40.1736.8

3123.621

1710.4

7

8.52019253345856

43

10

Low income

Lower-middle income

Upper-middle income

%

90% Committed for NACP IV

Source: Prepared by www.aidsdatahub.org based on 1) UNAIDS. (2012). Global Report: UNAIDS Report on the Global AIDS Epidemic 2012.; 2) www.aidsinfoonline.org

Investing in AIDS: Shared responsibility in Asia-Pacific

Total AIDS spending and amount spent on key populations prevention programmes

0

200,000,000

400,000,000

600,000,000

800,000,000

1,000,000,000

1,200,000,000

1,400,000,000 1,332,000,000

345,774,484

66589202.26 11651172.3 22006042.33 32938247.7

Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org

AIDS spending in Asia Pacific – low on High Impact Prevention

Legal environment

Adverse legal environment - Why the law matters?

HIV/AIDS in post 2015 development agenda

Goal 6: Combat HIV/AIDS, malaria and other diseases

Goals and Targets

Africa Asia

OceaniaLatin

America & Caribbean

Caucasus & Central Asia

Northern Sub-Saharan Eastern South-

Eastern Southern Western

Halt and begin to reverse

the spread of

HIV/AIDS

Low incidence

High incidence

Low incidence

Low incidence

Low incidence

Low incidence

Low incidence

Low incidence

Low incidence

Halt and reverse

the spread of TB

Low mortality

High mortality

Low mortality

Moderate mortality

Moderate mortality

Low mortality

High mortality

Low mortality

Moderate mortality

The progress chart operates on two levels. The word in each box indicate the present degree of compliance with the target. The colours show progress towards the target according to the legend below:

Target already met or expected to be met by 2015.

Progress insufficient to reach the target if prevailing trends persist.

No progress or deterioration.

Millennium Development Goal 6: Global progress by region, 2012

Sources: Statistics Division, Department of Economic and Social Affairs, United Nations. (2012). Millennium Development Goals: 2012 Progress Chart.

Status of progress towards MDG targets in Asia-Pacific, 2010-11

Country MDG Goal 6

HIV prevalence TB incidence TB prevalence

Asia Pacific

Cambodia

China

India

Indonesia

Lao PDR

Malaysia

Myanmar

Nepal

Pakistan

Philippines

Thailand

Viet Nam

Early achiever On track Slow Regressing/No progress

Source: Prepared by www.aidsdatahub.org based on UNESCAP, ADB, & UNDP. (2012). Accelerating Equitable Achievement of the MDGs : Closing Gaps in Health and Nutrition Outcomes , Asia- Pacific Regional MDG Report 2011/12. Bangkok.

Post 2015 development agenda

• UNSG’s High Level Panel of Eminent Persons

• Rio + 20 Conference on Sustainable Development

• Task Team for Global Thematic Consultation on Health

Is HIV/AIDS a priority ?

HLP report - Proposed new health MDGs: Post 2015

• 4a. End preventable infant and under-5 deaths,• 4b. Increase by x% the proportion of children,

adolescents, at-risk adults and older people that are fully vaccinated

• 4c. Decrease the maternal mortality ratio to no more than x per 100,000

• 4d. Ensure universal sexual and reproductive health and rights

• 4e. Reduce the burden of disease from HIV/AIDS, tuberculosis, malaria, neglected tropical diseases

and priority non-communicable diseases

MDG on AIDS 2015 and 2030

Millennium Development Goal of 2015 Post 2015

Goal 6: Combat HIV/AIDS, malaria and other diseases

4e. Reduce the burden of disease from HIV/AIDS, tuberculosis, malaria, neglected tropical diseases and priority non-communicable diseases

Target 6.A: Have halted by 2015 and begun to reverse the spread ofHIV/AIDS

Target 6.B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it

Target 6.C: Have halted by 2015 and begun to reverse the incidence ofmalaria and other major diseases

• Country support in UN General

Assembly for a specific MDG for ending AIDS by 2030.

• Donors and UN agencies need to support the call to end AIDS by 2030.

• Civil society pressure crucial

Sai Subhasree Raghavan

We need powerful summary slides (Global and region)

Global response to HIV/AIDS is delicately balanced.

We need to firmly tilt it towards the goal of elimination.

Thank you

7 th ias conference on hiv pathogenesis, treatment and prevention tracking the hiv/aids epidemic in...

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