The HIV Epidemics in Asia and the Pacific
Ohio Leadership ConferenceApril 15, 2008
Thu Vuong MBA, MPH CandidateOhio State University
My Background
• Former Senior Program Officer, IDU Interventions, FHI Vietnam
• Chair, Vietnam Harm Reduction Technical Working Group, 2005-2006
• Trained Drug Addiction Treatment Counselor • MBA, 2003• MPH Candidate June 08, HSMP, OSU
Outline
• Epidemiology of HIV in Asia• What works in HIV prevention: Why is Asia
different? • US government support and policies regarding
HIV prevention, care, and treatment in developing countries
• Country case study: Vietnam• The future: Continuing challenges
Adults and children estimated to be living with HIV as of end 2005
Total: 40.3 (36.7 – 45.3) million
Western & Central Europe
720 000720 000[570 000 – 890 000][570 000 – 890 000]
North Africa & Middle East510 000510 000
[230 000 – 1.4 million][230 000 – 1.4 million]
Sub-Saharan Africa25.8 million25.8 million
[23.8 – 27.9 million][23.8 – 27.9 million]
Eastern Europe & Central Asia1.6 million 1.6 million
[990 000 – 2.3 million][990 000 – 2.3 million]
South & South-East Asia7.4 million7.4 million[4.5 – 11.0 million][4.5 – 11.0 million]
Oceania74 00074 000
[45 000 – 120 000][45 000 – 120 000]
North America1.2 million1.2 million
[650 000 – 1.8 million][650 000 – 1.8 million]
Caribbean300 000300 000
[200 000 – 510 000][200 000 – 510 000]
Latin America1.8 million1.8 million
[1.4– 2.4 million][1.4– 2.4 million]
East Asia870,000870,000
[440 000 – 1.4 million[440 000 – 1.4 million]]
Source: UNAIDS
Asian epidemics show great diversity and have become more serious over time4.8 million PLHAs in 2007 (UNAIDS)
1989 1994
1999 2003
< 0.05%0.05 - 0.1%0.10 - 0.5%0.50 - 1.0% > 1.0%
Stages of the HIV Epidemic by UN/WHO classification• Low Grade
– Prevalence of HIV is consistently below 5% in any “high risk groups” and below 1% in the “general population”
• Concentrated– Prevalence of HIV has surpassed 5% on a consistent
basis in one or more “high risk groups” but remains below 1% in the “general population”
• Generalized– Prevalence of HIV has surpassed 1% in the “general
population”
Source: UNAIDS
HIV Epidemic Summary in Asia-Pacific Region
• Three countries in Asia have generalized epidemics:– Cambodia (1.6%), Thailand (1.4%), and Myanmar
(1.3%) • Rapidly expanding concentrated epidemics include
India, Indonesia, Nepal, Vietnam and several provinces in China
• One country in the Pacific now is also on the verge of a generalized epidemic – Papua New Guinea– Possibility for an ‘African-style’ epidemic
HIV Epidemic Summary in Asia-Pacific Region (cont’d)
• But even within one country, there is significant variation in epidemic spread– India, China
0
5
10
15
20
25
30
35
40
Adult HIV prevalence among African countries in 2005
Source: UNAIDS/WHO 2006 Report on the global AIDS epidemic
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
Cambo
dia
Thaila
nd
Burm
a
Indi
a
Nepal
Vietn
amChi
na
Mal
aysia
*
Philip
pines
*
Bangla
desh
*
Singa
pore
*
Adult HIV prevalence among Asian countries in 2005
Source: UNAIDS/WHO 2006 Report on the global AIDS epidemic
Note: * <0.1
• With a few exceptions, Asia epidemics will not reach the high levels seen in the highest prevalence in sub-Saharan African countries
• So what’s the big deal?
• Even a low-grade epidemic in Asia means millions of people (60% of world population – 4 billion)
What's the big deal with HIV in Asia?
Every percentage point in Asia adds a huge number to the global epidemic
Country Adult population 1% adds this to global pandemic
China 726 million 7.3 million
India 533 million 5.3 million
Indonesia 118 million 1.2 million
Bangladesh 72 million 720,000
Pakistan 67 million 670,000
Vietnam 43 million 430,000
Total=15.5 million
1% increase in adult HIV prevalence in SS Africa=2.9 million
Factors that drive the spread of HIV• Major behavioral factors
– Unsafe blood transfusion– Needle sharing – Multiple heterosexual partners engaging in unprotected
sexual intercourse– Multiple homosexual partners engaging in unprotected
anal sex– Commercial sex
• Major co-factors– Presence of other STI– Non-circumcision
Socio-economic factors that may affect HIV epidemic spread
• Poverty– Higher levels of commercial sex– Higher levels of drug use– Less access to quality health care
• Travel/Migration– Long-distance truck drivers, seafarers…– Men living without their families; Higher use of sex
workers– Female migrants
Social and cultural factors in Asia promoting or inhibiting HIV spread?
• A tolerance for men, strict prohibition for women• Loosening sexual norms in Asia• Increasing age at marriage producing large pool of
unmarried youth• Gender inequality
– Reduces employment opportunities, promoting sex work
– Limits negotiating ability in relationships
“It’s very difficult to speak about ‘the Asian epidemic’. Whatever we come up with, we
always find a big exception in Asia.”
(Dr. Peter Piot, UNAIDS Executive Director)
So what explains the variations between countries?
• Levels of risk– Frequency of needle sharing, sexual activity– Sizes of at-risk populations, especially drug users,
sex workers and clients of sex workers• Linkages among at-risk sub-populations• Behavior change in response to prevention• Timing of HIV introduction into the high-risk groups• Biological factors such as STI and circumcision
HIV prevalence among IDUs far outstrips sex worker prevalence in most places
(Source: National surveillance reports)
If HIV infection is highest among IDUs, why is it claimed that commercial sex is the main driver of HIV epidemics in Asia?
• Absolute numbers
• IDU more likely to be infected
• More HIV infections overall will be transmitted sexually
Dynamics of Asian HIV/AIDS epidemics
Newborns
Clients
Low or no risk males
MSM IDUs FSW
Low or no risk females
Early infections focused in at-risk groups:Clients & FSW, IDU and MSM.These groups strongly linked behaviorally
IDUs visit sex workersPercent of injectors visiting sex workers last year
0
20
40
60
80
Surab
aya
2002
Bdesh
SE 2
002
Bdesh
Cen
tral 2
002
Bangko
k 19
89
Jaka
rta 2
002
Hanoi 2
000
Bandung
200
2
Bdesh
NW
200
2
Hai p
hong 2
000
HCMC 2
000
Can th
o 20
00
Pe
rce
nt
vis
itin
g s
ex
wo
rke
rs
Sources: National surveillance systems. *Bangladesh values are for the last month.
Impediments to HIV Prevention in Low Prevalence/Emerging Epidemic Countries
Low Prevalence= Low priority= We’re different - “Risk behavior does not
happen here so there’s no need to respond”= Lack of capacity= Tendency to focus on politically popular but
epidemiologically inefficient groups, e.g.general population
= Vicious circle of lack of data → no response → lack of data….
Low prevalence among whom?
• Asian countries have overall low HIV prevalence
Higher prevalence in higher risk populations
Need to focus on these higher risk populations
SOUTH & SOUTH-EAST ASIA Estimated number of injecting drug users (IDUs) HIV prevalence among IDUs (mid est.1998/2005)
IRAN: 206,000AFGHANISTAN:
34,080
PAKISTAN:
462,000
NEPAL: 41,000BHUTAN:
INDIA: 1,294,000
BANGLADESH: 98,000
MYANMAR: 195,000
THAILAND:
57,000
MALAYSIA: 19,500
INDONESIA: 580,000
VIET NAM: 128,000
SRI LANKA: 28,241
PHILIPPINES:17,000MALDIVES
unknown
SINGAPORE: 15,000
0.5%
unknown
unknown
68.4%
Up to 60%
unknown
Up to 79.5%
2.6%54%
64%
1%
35.5%
1.7%
47%
unknown
LAOS: 8,000
unknown
Factors that increase HIV transmission associated with IDU
• Sharing and re-using injecting equipment (due to lack of clean needles & syringes or fear of arrest and beatings by the police)
• Professional injectors and shooting galleries• Sexual behaviour of IDUs
– Selling sex to buy drugs• Women IDUs selling sex to buy drugs• Male IDUs selling male-male sex to buy drugs
– Drug injectors buying sex • Imprisonment or drug treatment centers
(Source: SHARAN Archives. 2000)
A
IDU Network HIV -ve
B
IDU Network HIV +ve
C
IDU Network HIV -ve
D
IDU Network HIV -ve
C
ADB
A
IDU Network HIV +ve
B
IDU Network HIV +ve
C
IDU Network HIV +ve
D
IDU Network HIV +ve
PRISON
IDU “Mixing” in PrisonsIDU “Mixing” in Prisons
Epidemics among FSW often follow IDU epidemics
0
10
20
30
40
50
60
70
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Guangxi, IDU Guangxi, sex workers Hanoi, IDUHanoi, sex workers Jakarta, IDU Jakarta Sex workers
Essential HIV prevention package: weighting varies by country
• Confront stigma and discrimination– National leadership, mass media, education
• Prevent sexual transmission– Condoms and social marketing for FSW, clients, MSM– Reducing number of sexual partners– Delaying sexual debut
• Prevention of IDU transmission– Harm reduction programs including substitution therapy– Peer counseling
• Voluntary counseling and testing – Confidentiality and consent
Essential HIV prevention package: weighting varies by country
• Prevention of MTCT– Antenatal screening
• Focus on HIV prevention among youth– Peer counseling, mass media campaigns, school education
• Integrate prevention into treatment services• Treatment of STIs• Workplace programs• Ensuring safety of blood supply
– Transfusion screening
• Preventing HIV transmission in healthcare settings
– Universal precautions
HIV/AIDS in Viet Nam
• Initially largely driven by injection drug use and, to a lesser extent, by sex work
• Moved into general population with husband-to-wife-to-child transmission, through the sexual networks of drug users and clients of sex workers
• Women now account for one-third of all new infections
How the US government supports HIV programs in developing countries• Two major US government agencies:
USAID, CDC• These agencies can provide funding
directly to ministries of health• They can also provide them through
technical organizations and universities– FHI and UNC are two that are very active in
HIV and other diseases internationally
US government policies regarding HIV prevention: myths and realities
• The PEPFAR initiative has brought tremendous resources to HIV treatment in addition to prevention and care– 15 focus countries; $15 billion for 5 years– President Bush has just requested a doubling of
this amount• Contrary to the belief of many, PEPFAR fully
supports condom promotion to FSW, their clients, and MSM
US government policies regarding HIV prevention: myths and realities (cont'd)
• 20% of prevention funding must go to abstinence programming (some countries receive a waiver, e.g. Vietnam)
• No funding can be used to support the purchase or distribution of syringes or needles for IDUs
• Partners must sign a pledge that they do not support the legalization of prostitution nor will funds be used for this.– In 2005, DKT International is challenging this in
court because they refused to certify its opposition to prostitution
FHI HIV Program focus in Vietnam
• Prevention interventions to address behaviors at the core of the epidemic – drug use, commercial sex work and sex among men (i.e., IDUs, FSWs and their clients, and MSM)
• Care and treatment interventions at district level to provide treatment, care and support for people living with HIV/AIDS (PLWHA)
• Integrated bio-behavioral surveillance to understand the direction of the epidemic, behavior change, and estimates of HIV infection
Interventions for IDU: strategic approaches
• Peer outreach to shooting locations and drop-in center services
• Drug addiction treatment counseling with relapse prevention
• Substitution treatment: Methadone substitution treatment planned for 3 sites for 2008
Strategic approaches to reaching clients of FSW
• Reaching at-risk men at entertainment establishment (beer houses, bars, restaurants, coffee houses) with “Live Like a Real Man" messages
• A dedicated hotline with experienced counselors
• Strong linkages with the mass media component
Strategic approaches for FSW
• Peer outreach to FSW based on mapping of commercial sex
• Condom distribution
• Drop-in centers with integrated services (VCT, STI, counseling, edu-tainment, referrals)
Interventions for MSM: strategic approaches
• Peer outreach to discos, bars, and locations where men meet for sex
• Drop-in center for edu-tainment and peer discussions
• Internet intervention
Drug "rehabilitation centers": a unique challenge in Vietnam
• Government of Vietnam (GoV) began addressing drug “problem” 10 years ago with a “social evils” perception.
• Main strategy was placement in drug rehabilitation centers (known as 06 Centers – “labor and education”)– Mandatory detoxification– Rehabilitation through lectures on drug use, risk of HIV
transmission – Vocational training
Drug "rehabilitation centers": a unique challenge in Vietnam
• By 2006, 83 rehabilitation centers were in operation, with up to 57,000 residents
• GoV noticed high rates of relapse (>90%) from 2 year rehabilitation period and so increased the length of time to up to 5 years
• Spiraling costs of 06 centers and high HIV rates (up to 50% HIV+) forced willingness to view alternative approaches
• With PEPFAR support, FHI and others are "rehabilitating" the rehabilitation centers
Continuum of services for individuals transitioning from 06 centers back to their communities
Proposed interventions:
• case management• VCT• Assessment• HIV prevention• Drug relapse and
addictions counseling• Psycho-social needs care• ARV and OI treatment
06 center services Community-based services
•Pre-departure planning and “handover” from 06 center
case managers to community-based case managers
Proposed interventions:
• Continued case management by case managers and social workers in community• Linkages to:
• Health facilities, VCT, ARV • Support groups• Home care teams
• Relapse prevention including:• Narcotics Anonymous• Job placement• Methadone • Family and peer support groups
Breaking the cycle:
Ensuring services to prevent drug use relapse and reduce placement back in centers
Knowing what we (Asia) do, why are HIV programs still failing?
• Focus and misdirection
• Capacity for quality programming
• Coverage
• Political will
Why do we fail?: Focus and misdirection
• Global and national program misdirection– African paradigms in Asian settings – ABC– USG restrictions on harm reduction (needles
and syringes)– Social order and social evil campaigns
Why do we fail?: Capacity
• National program capacity– Understaffed, overburdened, lacking some skills
sets• NGO and community capacity
– Great development capacity– Little experience with HIV & marginalized groups
• International support capacity– Limited technical staffing and consultant base,
largely from outside
• Most countries do not yet have size estimates of critical groups:– Sex workers, clients, IDU, MSM
• Difficult to know:– what each group’s role is in the epidemic– what coverage goals should be to make a
difference
Why fail?: lack of size estimation/ coverage data
Why do we fail? Political will
• Countries successful against HIV have– Leadership from the top– Grass roots efforts working upward– Societal mobilization
• But many Asian leaders (& their replacements):– do not acknowledge risk – HIV/AIDS is not really an
Asian problem– do not understand their epidemics – infection will
restrict itself to high-risk groups– do not support work with marginalized groups
Asia – Boom or Bust?
• The next sub-Saharan Africa? No• 3-5% possible in some countries? Yes• Can we stop it? Yes, by
– Focusing in the right places, with the right prevention services, and for the right people
– Mobilizing the resources to go to scale; The time for “boutique” pilot projects is long past
– Building country capacity to respond in the most effective manner