HIV/AIDS in Asia
August 2014—Asia is confronting a complex and devastating HIV/AIDS epidemic. Although HIV did not hit Asian countries until the late 1980s, by the late 1990s the epidemic was well established across the region. UNAIDS reports that in 2013, more than 350,000 Asians/Pacific Islanders were newly infected with HIV, bringing the total number living with HIV/AIDS in the region to nearly 5 million. In the same year, approximately 250,000 people died from AIDS-related illnesses in this region, which is a 37% decline in deaths since 2005.
National HIV Data
The overall prevalence of HIV in most Asian countries remains low, but with a regional population that is roughly 60% of the world’s total, even low prevalence translates into large numbers of infected people:
• In Thailand, where the AIDS epidemic started earliest and prevention efforts have achieved some success, HIV prevalence is 1.1%. By the end of 2013, approximately 440,000 Thais were living with HIV/AIDS, with an estimated one-third of all new infections in 2013 occurring through intercourse between intimate heterosexual partners. Prevalence among people who inject drugs (PWID) remains high, ranging between 25–30%. And HIV among men who have sex with men (MSM) is on the rise: HIV prevalence among MSM in Bangkok rose from 17% in 2003 to 25% in 2013.
• In India, the estimated number of HIV/AIDS cases in 2013 was 2.1 million, down from 2.4 million in 2009, and the overall adult prevalence was 0.3%. The number of people on antiretroviral therapy more than doubled between 2009 and 2013, but a high percentage of people do not get tested or access treatment until their disease has progressed to dangerous levels.
• In China, approximately 815,000 people were living with HIV/AIDS in 2013. Although injection drug use and male-male sexual contact continue to be significant drivers of the epidemic, heterosexual sex has become the predominant mode of HIV transmission, and the proportion of women living with HIV in China has doubled during the past decade.
• Though epidemics in Cambodia, India, Malaysia, Myanmar, Nepal, Papua New Guinea, and Thailand declined by at least 25% since 2001, in several countries, including China, Indonesia, Pakistan, and the Philippines, rates of new infection are increasing, and in Indonesia and Pakistan, AIDS-related deaths quadrupled between 2005 and 2013.
• Indonesia, the world’s fourth most populous country, has seen a 48% increase in HIV infections since 2005, especially among sex workers, MSM, and PWID. In 2013, 36% of all PWID were HIV-positive and 640,000 people were living with HIV/AIDS, including 240,000 women. According to UNAIDS, only 8% of them were receiving antiretroviral therapy.
• The estimated number of people living with HIV in Vietnam has more than doubled since 2000, from 120,000 to 250,000; however since 2005 the rate of new infections has decreased by 46%. In 2011, 70% of HIV infections in the country were among PWID.
• In May 2013, new HIV diagnoses in the Philippines were reported to be 50% higher than in 2012, and greater than any period since 1984.
People Most at Risk
The prevalence of HIV varies widely between and within Asian countries, and vulnerable segments of the population have disproportionately high HIV infection rates. Male and female sex workers and PWID were the first groups to be seriously affected by HIV/AIDS in most of Asia and the Pacific, and they remain key affected populations. In Cambodia, Indonesia, Pakistan, and Thailand, over 20% of PWID are HIV-positive, and while HIV rates have fallen in female sex workers across the region, in many provinces the rate remains above 10%. UNAIDS has indicated that the overlap of injection drug use and sex work is an important factor in China’s HIV epidemic.
Economic upheaval over the past two decades has resulted in increased population mobility and environmental degradation, which encourage people to move to cities in search of better employment opportunities. Sexual transmission of HIV is exacerbated by this mobility, with migrant workers spending long periods of time away from home and frequently visiting sex workers. They then return home and infect their spouses, who in turn pass the virus to their newborns. Throughout the region, HIV continues to spread along trucking routes, among traveling sailors, fishermen, migrant workers, and within the sex industry, which is itself fueled by economic disparity.
Injection drug users
Growing poverty in some areas is also driving increased injection drug use. According to UNAIDS, nearly four million people in Asia are estimated to inject drugs, putting them at risk for HIV and hepatitis C infection. Many countries in the region still lack effective harm reduction programs, though some have taken steps in recent years to expand access to syringe exchange, overdose prevention, and opioid substitution therapy. However, in many countries drug laws conflict with national HIV plans, and the financial resources available for harm reduction are still far below what is needed. According to Harm Reduction International, 16% of PWID in the region are HIV-positive, and Asia has the highest rate of opioid overdose of any region in the world.
The sharp rise in the number of new HIV infections among MSM in the region has continued, while sexual activity between men is frequently stigmatized and kept hidden. Approximately 15% of MSM in South and Southeast Asia were infected with HIV in 2012, and many MSM also have female partners. Male-male sex remains illegal in at least 12 countries in the region and prevention programs for MSM remain limited. Studies in several countries have found high levels of risk behaviors among MSM, including having multiple sex partners and low rates of condom use. Countries need to scale up their HIV programs that target MSM and reduce the stigma and discrimination they frequently encounter in healthcare settings to prevent higher HIV rates both among MSM and the general population.
By 2020, almost 50% of all new infections in Asia could be in MSM, according to the UN Commission on AIDS in Asia. Unless we change the course of the HIV epidemic among MSM, new infection rates among this population will surpass those among every other high-risk group in the region.
As elsewhere in the developing world, sex-based socioeconomic disparities play a significant role in the spread of HIV. The highest risk factor for HIV infection among women is often marriage. Even when women know or suspect that their husbands are HIV-positive or are having sex with multiple partners, they have little power to insist on condom use. As a result of these and other factors, women accounted for 35% of adults with HIV in Asia at the end of 2013—up from 21% in 1990.
Children and adolescents
The number of HIV-positive children in Asia continues to grow. In 2013, approximately 190,000 children and adolescents were living with HIV in the region. Programs to prevent mother-to-child-transmission in the Asia-Pacific had expanded to reach approximately 30% of HIV-positive pregnant women in 2013—a figure was far below the global average of 67%. Many HIV-positive women are understandably reluctant to seek antiretroviral therapy or to bottle-feed their infants for fear of arousing suspicion regarding their HIV status and confronting the stigma surrounding HIV/AIDS. Access to pediatric treatment remains limited; in 2013 only 32% of HIV-positive children and adolescents in the region were receiving antiretroviral treatment. In addition, many children who have been living with HIV since birth are approaching adolescence, presenting a new set of challenges for programs originally designed for young children.
Mounting an Effective Response
Evidence from successful interventions in the region shows that prevention efforts targeting those at greatest risk can stem the spread of HIV. Above all, to be effective in Asia, prevention messages will have to both acknowledge and challenge cultural stereotypes and expectations that often prevent frank discussion of issues surrounding sex and drug use. Communities face persistent challenges to overcoming the stigma that surrounds the disease and creates barriers to prevention and care.
Mounting an effective response to the epidemic in Asia and the Pacific will require increasing the level of resources committed to HIV/AIDS programs, and balancing the need for continued prevention efforts with the growing demand for HIV treatment. International recommendations continue to call for earlier treatment and more effective prevention, posing significant challenges to both national healthcare budgets and existing healthcare infrastructures.