commission on aids in asia – projections and implications 1 the nature of asia’s hiv epidemics...
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Commission on AIDS in Asia – Projections and Implications 1
The Nature of Asia’s HIV EpidemicsProgramme and Policy Implications
Tim BrownMember, Commission on AIDS in Asia
Leading the AIDS Response in Asia: Recommendations from the Commission on AIDS in Asia
XVII International AIDS ConferenceAugust 5, 2008
Commission on AIDS in Asia – Projections and Implications 2
The Commission’s charge
• Take a fresh look at HIV in Asia:– Review socio-economic dimensions of HIV– Assess epidemic dynamics in the region– Provide Asia-specific recommendations for
effective strategies
Commission on AIDS in Asia – Projections and Implications 3
Guiding principle: making sound policy requires good epidemic understanding
• Commission’s charge required knowing:– What do Asian epidemics look like?– What drives them and how does this vary?– How do Asian epidemics evolve and how
do response needs change over time?– What are the policy and programme
implications of an understanding?
Commission on AIDS in Asia – Projections and Implications 4
Where is the risk in Asia that fuels HIV?
WomenMen
75 million Men in Asia visit
sex workers(2-20% of adult men)
50 million Women married to men who visit
sex workers
10 millionMen who
inject drugs
10 millionMen who have sex with men
10 millionWomen sell sex
Infants and children
Asian Population: 3.1 billion
Commission on AIDS in Asia – Projections and Implications 5
Sex work gives epidemics their reach… but varies substantially by country
Country % clients Number Year
Thailand 22% / 10% 4 / 1.8 million 1990/1997
Cambodia 13% 0.5 million 2000
Japan
Hong Kong
11%
11-14%
3.2 million
0.15 million
1999
early 2000s
Bangladesh 10% 4.0 million 2006
China 9% 34.0 million 2000
Philippines 7% 1.6 million 2000
Singapore 7.6% 0.1 million early 1990s
3 to 20% of adult males visit sex workers
Commission on AIDS in Asia – Projections and Implications 6
To account for local variations, the Commission generated a set of models
• Made specific models to understand where epidemic was going in each country
• Use these Asia-appropriate models to conduct analytic comparisons of:– Effectiveness of different prevention approaches– Cost-effectiveness of programs– Different prevention alternatives
• After review, chose Asian Epidemic Model
Commission on AIDS in Asia – Projections and Implications 7
AEM takes behavioral inputs, translates them to HIV infections & compares against actual trends
Sizes & behavioral trends in clients, sex workers, injecting drug users, men who have sex with men, population at large
AEMCalculation Engine
ObservedHIV trends(white lines)
Injecting drug users Female sex workers
Adult males Adult females
Probabilities of transmission and start years
Commission on AIDS in Asia – Projections and Implications 8
Process for preparing country models
• Collect data from published and unpublished sources– Over 4,500 papers and extensive data sets
• Extract behavior & HIV/STI trends by country• Fit AEM to observed HIV in country• Validate the model by comparison with
– Observed prevalence trends – Reported HIV, AIDS and M/F ratios if available– Other country-specific projection work
Commission on AIDS in Asia – Projections and Implications 9
Four patterns were seen in the region
• Cluster 1 – higher risk with prevention success– Thailand, Cambodia, Myanmar, Tamil Nadu and high prevalence
Indian states
• Cluster 2 – moderate risk with limited success– China, Indonesia, Malaysia, Nepal, Vietnam and low prevalence
states of India
• Cluster 3 – currently low HIV, higher risk and potential– Bangladesh and Pakistan
• Cluster 4 – lower risk and/or successful prevention– Hong Kong, Japan, Lao PDR, the Philippines, Republic of Korea,
Singapore, Sri Lanka
Commission on AIDS in Asia – Projections and Implications 10
Regional patterns in the epidemic
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
1985 1990 1995 2000 2005 2010
Cluster 1 Cluster 2 Cluster 3 Cluster 4
Commission on AIDS in Asia – Projections and Implications 11
The overall regional epidemic has slowed, but will soon accelerate again
Late 2007:• 5.1 million living with HIV• 376,000 new infections• 418,000 deaths
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
Commission on AIDS in Asia – Projections and Implications 12
New infections in the regional epidemic
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 IDULo-risk male Lo-risk female Children
Commission on AIDS in Asia – Projections and Implications 13
Why this pattern? The result of mixed prevention successes and failures
• For sex workers and clients– Early prevention successes in higher risk countries– Limited prevention success in moderate risk– Coverage 34% on a regional basis– But failure to address husband-to-wife transmission
• For IDUs and MSM– A legacy of abysmal failure– < 2% coverage for IDUs, < 5% coverage for MSM– New infections will be climbing rapidly for MSM
Commission on AIDS in Asia – Projections and Implications 14
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 IDULo-risk male Lo-risk female Children
Commission on AIDS in Asia – Projections and Implications 15
Casual sex does not drive Asian epidemics
0
200,000
400,000
600,000
800,000
1985 1990 1995 2000 2005 2010
New
infe
ctio
ns in
yea
r
At-risk populations Husband-wife Mother-to-child Casual sex
Commission on AIDS in Asia – Projections and Implications 16
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, 2007-2020 Source: Redefining AIDS in Asia: Crafting and Effective Response
Commission on AIDS in Asia – Projections and Implications 17
Prioritisation of resources: Averting new infections
Cost of Interventions
Low-cost, High-impact
(prevention among most-at-risk populations)
High-cost, High-impact
(antiretroviral treatment and prevention of mother-
to-child transmission)
Low-cost, Low-impact
(general awareness programmes through
mass media and other channels)
High-cost, Low-impact
(universal precautions and injection safety)E
ffec
t (a
vert
ing
n
ew in
fect
ion
s)
Commission on AIDS in Asia – Projections and Implications 18
Cost of a Priority Response – high impact
Interventions Total Cost (millions USD)
% of total
High-impact prevention $1,338 43%
Treatment by ART $761 24%
Impact mitigation $321 10%
Programme Management $363 12%
Creation of an Enabling Environment $359 11%
Total $3,143 100%
Average total cost per capita ranges from $0.50 to $1.70, depending on the stage of the epidemic.
Commission on AIDS in Asia – Projections and Implications 19
Commission prevention recommendations
• Prioritize the most effective interventions• Focus on high impact interventions to reverse
the epidemic and lessen impacts• Leverage other resources to address other
drivers and impediments• Increase local investments in responses
– Return on investment is high
Commission on AIDS in Asia – Projections and Implications 20
But new infections in every country differIndonesia
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
r0
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
Myanmar
0
25,000
50,000
75,000
1985
1990
1995
2000
2005
2010
2015
2020
New
infe
ctio
ns in
yea
r
..and effective prevention targets new infections
Commission on AIDS in Asia – Projections and Implications 21
Countries must assess situation and prioritize accordingly
• Requires comprehensive strategic analysis capacity– Today data collected, but not guiding programs for
maximum impact
• Each country needs an analysis unit linked into program and policy decisions– Able to pull data together to determine what’s driving
the local epidemic today– Strongly linked to decision making– Adapts the response as the epidemic evolves
Commission on AIDS in Asia – Projections and Implications 22
What can such programs mean for the regional epidemic?
Commission on AIDS in Asia – Projections and Implications 23
If we make the right choices
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
Commission on AIDS in Asia – Projections and Implications 24
..but ART will keep overall prevalence stable
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
Commission on AIDS in Asia – Projections and Implications 25
So, which will it be?
A resurgent epidemic?
Or a contained one?
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1985
1990
1995
2000
2005
2010
2015
2020
Ne
w in
fect
ion
s in
ye
ar
Clients Sex workers MSM IDU
Lo-risk male Lo-risk female Children
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1985
1990
1995
2000
2005
2010
2015
2020
Ne
w in
fect
ion
s in
ye
ar
Clients Sex workers MSM IDU
Lo-risk male Lo-risk female Children
Commission on AIDS in Asia – Projections and Implications 26
The choice is ours
Commission on AIDS in Asia – Projections and Implications 27
Supplementary slides for follow-on discussions
Commission on AIDS in Asia – Projections and Implications 28
Causes of death 15-44 year olds in Asia
Year TB IHD Diabetes CancerAIDSOld
WHO
AIDS Comm-ission
2005 292.1 164.1 25.9 318.6 366.4 383.9
2010 197.9 160.3 29.2 318.1 516.6 346.4
2015 140.9 155.6 30.9 307.2 882.8 319.2
2020 90.3 152.8 30.1 301.2 1207.4 369.2
Commission on AIDS in Asia – Projections and Implications 29
Important things to understand about Asian epidemics
Commission on AIDS in Asia – Projections and Implications 30
Key findings on Asian epidemic dynamics
• Sex work is the key driver of Asian epidemics with female infections primarily from husbands who are clients
• MSM epidemic proceeds in parallel and can contribute substantially to total prevalence
• Both risk and HIV are disseminated throughout the “general population”
• Asian epidemics will not go “generalized”, i.e., be driven by boyfriend-girlfriend sex
• But…– large number of current & past clients, MSM, IDU, and FSW
creates potential for HIV to reach a few percent
Commission on AIDS in Asia – Projections and Implications 31
So most current infections remain in the “general population” from risk in the past
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
1995
2000
2005
2010
2015
2020
2025
2030
Cur
rent
adu
lt in
fect
ions
Client FSW IDU MSM General male General female
“Lo-risk”general
population
MSM/IDUs
Currently active in SW
Commission on AIDS in Asia – Projections and Implications 32
Injecting drug users kick start Asian epidemics, but clients drive them
0
40,000
80,000
120,000
160,000
200,000
240,000
280,000
1995
2000
2005
2010
2015
2020
An
nu
al n
ew
infe
ctio
ns
in g
rou
p
Clients Injecting drug users Currently lo-risk menFemale sex workers Men having sex with men Currently lo-risk women
Clients
Client wives
Injecting drug usersMen having sex with men
Commission on AIDS in Asia – Projections and Implications 33
The way Asian epidemics evolve
0
80,000
160,000
240,000
320,000
400,000
480,000
560,000
New
infe
ctio
ns in
yea
r
Sex work Husband-wife sex Casual sex
Sex between men Injecting drug use
Latent
Expanding Maturing
Commission on AIDS in Asia – Projections and Implications 34
When HIV in sex work is addressed other groups become quite important
0
50,000
100,000
150,000
200,000
New
infe
ctio
ns in
yea
r
Sex work Husband-wife sex Casual sex
Sex between men Injecting drug use
Declining
Commission on AIDS in Asia – Projections and Implications 35
The most effective components of the response vary by epidemic stage
The source of most new infections shows where to focus for impact
Commission on AIDS in Asia – Projections and Implications 36
Programs for injecting drug users and sex work have maximum impact in latent stage
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
1995 2000 2005 2010 2015 2020
Ad
ults
livi
ng
with
HIV
Injecting drug user program
Injecting drug user + sex work program
No intervention
Commission on AIDS in Asia – Projections and Implications 37
During expanding stage programs for sex work have maximum impact
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
1995 2000 2005 2010 2015 2020
Adu
lts li
ving
with
HIV
Sex work programSex work + husband-wife programSex work + husband-wife + injecting drug user programSex work + husband-wife + injecting drug user + men having sex with menNo intervention
Commission on AIDS in Asia – Projections and Implications 38
In declining phase, programs for men having sex with men and injecting drug users most effective
0
200,000
400,000
600,000
800,000
1,000,000
1995 2000 2005 2010 2015 2020
Adu
lts li
ving
with
HIV
Men having sex with men programMen having sex with men + injecting drug use programMen having sex with men + injecting drug use + husband-wife programNo intervention (sustain program for sex work)
Commission on AIDS in Asia – Projections and Implications 39
So prevention in Asia should stay focused in nature but adapt over time
• Programs needed for most at-risk populations:– sex workers & clients, MSM, IDUs, husband-wife
• But balance changes over time:– Latent epidemics
• Focus on IDUs buys time for sex work prevention• But, must prepare for sex work epidemic
– Expanding epidemics• Focus most resources on sex workers and clients
– Declining epidemics• Sustain sex work programs to avoid resurgence• Expand programs for MSM and IDU• Expand to address husband-wife transmission
Commission on AIDS in Asia – Projections and Implications 40
Asian epidemics follow similar patterns…
Low or no risk females
Clients
Low or no risk males
MSM IDUs
FSW
• New infections strongly focused in a few behaviorally linked at-risk groups
- IDUs, clients and FSW, MSM• And then spread to their lower-risk partners
…but the details vary from country to country
Commission on AIDS in Asia – Projections and Implications 41
Membership of the Commission• Chakravarthi Rangarajan
– Chair, Economic Advisory Council to Prime Minister of India
• Nerissa Corazon Soon-Ruiz– Congressional Representative for Cebu, Philippines
• Rajat Kumar Gupta– Global Fund for AIDS, Tuberculosis and Malaria
• Tim Brown– Senior Fellow, East-West Center
• Tadashi Yamamoto– President, Japan Center for International Exchange
• Wu Zunyou– Director NCAIDS, China
• Mahumuda Islam– Professor of Sociology, Dhaka University
• Frika Chia Iskandar– Coordinator, Women’s Working Group APN+
• JVR Prasada Rao– Director UNAIDS RST and former Director of NACO in India
Commission on AIDS in Asia – Projections and Implications 42
The Commission on AIDS in Asia
• June 2006, UNAIDS creates Commission as independent body
• Purpose:– With fresh eyes, review HIV epidemic in Asia and the
responses to it– Analyze course and impacts of the epidemic– Provide region-specific recommendations to improve:
• Prevention, • Treatment and care, and • Impact mitigation
• Report was launched last week at the UN