Asia and the Pacific
HIV/AIDS was late coming to Asia. Until the late 1980s, no country in the region had experienced a major epidemic and, in 1999, only Cambodia, Myanmar and Thailand had documented significant nationwide epidemics. This situation is now rapidly changing. In 2001, 1.07 million adults and children were newly infected with HIV in Asia and the Pacific, bringing to 7.1 million the total number of people living with HIV/AIDS in this region. Of particular concern are the marked increases registered in some of the world's most heavily populated countries.
Surveillance data on China's huge population are sketchy, but the country's health ministry estimates that about 600,000 Chinese were living with HIV/AIDS in 2000. Given the recently observed rises in reported HIV infections and infection rates in many sub-populations in several parts of the country, the total number of people living with HIV/AIDS in China could well have exceeded one million by late 2001. Reported HIV infections rose by 67.4% in the first six months of 2001, compared with the previous year, according to the country's ministry of health. Increasing evidence has emerged of serious epidemics in Henan Province in central China, where many tens of thousands (and possibly more) of rural villagers have become infected since the early 1990s by selling their blood to collecting centres that did not follow basic blood donation safety procedures.
HIV levels in specific groups are known to be rising in several other areas. Seven Chinese provinces were experiencing serious local HIV epidemics in 2001, with prevalence higher than 70% among injecting drug users in a number of areas, such as Yili Prefecture in Xinjiang and Ruili County in Yunnan. Another nine provinces are possibly on the brink of HIV epidemics among injecting drug users because of very high rates of needle sharing. There are also signs of heterosexually transmitted HIV epidemics in at least three provinces (Yunnan, Guangxi and Guangdong), with HIV rates reaching 4.6% (up from 1.6% in 1999) in Yunnan and 10.7% in Guangxi (up from 6%) among sentinel sex worker populations in 2000.
Vast and populous India faces similar challenges. At the end of 2000, the national adult HIV prevalence rate was under 1%, yet this meant that an estimated 3.86 million Indians were living with HIV/AIDS -- more than in any other country besides South Africa. Indeed, median HIV prevalence among women attending antenatal clinics was higher than 2% in Andhra Pradesh and exceeded 1% in five other states (Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu) and in several major cities (including Bangalore, Chennai, Hyderabad and Mumbai). India's epidemic is also strikingly diverse, both among and within states.
Indonesia -- the world's fourth-most populous country -- offers an example of how suddenly a HIV/AIDS epidemic can emerge. After more than a decade of negligible rates of HIV, the country is now seeing infection rates increase rapidly among injecting drug users and sex workers, in some places, along with an exponential rise in infection among blood donors (an indication of HIV spread in the population at large). HIV infection in injecting drug users was not considered worth measuring until 1999/2000, when it had already reached 15%. Within another year, 40% of injectors in treatment in Jakarta were already infected. In Bogor, in West Java Province, 25% of injecting drug users tested were HIV-infected, while among drug-using prisoners tested in Bali, prevalence was 53%.
Behaviours that bring the highest risk of infection in Asia and the Pacific are unprotected sex between clients and sex workers, needle sharing and unprotected sex between men. But infections do not remain confined to those with higher-risk behaviour. Many countries have seen major epidemics grow out of initially relatively contained rates of infection in these populations. Northern Thailand's epidemic in the late 1980s and early 1990s was primed in this way. Over 10% of young men became infected before strong national and local prevention efforts, including the "100% condom programme," reduced high-risk behaviour, encouraged safer sex and lowered HIV prevalence.
Commercial sex provides the virus with considerable scope for growth. The limited national behavioural data collected in the region to date show that, over the past decade, the percentage of surveyed adult men who reported having visited a sex worker in a given year ranged from 5% in some countries to 20% in others. India and Viet Nam are countries where levels of infection among clients and sex workers are rising. In Ho Chi Minh City, the percentage of sex workers with HIV has risen sharply since 1998, reaching more than 20% by 2000.
Few countries are acting vigorously enough to protect sex workers and clients from the HIV virus. Yet, it is from the comparatively small pool of sex workers first infected by their clients that HIV steadily enters the larger pool of still-uninfected clients who eventually transmit the virus to their wives and partners. Although recent behaviour surveillance surveys show that, in 11 out of 15 Asian countries and Indian states, over two-thirds of sex workers report using a condom with their last client, the need to boost condom use remains. In Bangladesh, Indonesia, Nepal and the Philippines, for instance, fewer than half of sex workers report using condoms with every client.
Sharing injecting equipment is a very efficient way of spreading HIV, making prevention programmes among injecting drug user populations another top priority. Upwards of 50% of injecting drug users have acquired the virus in Myanmar, Nepal, Thailand, China's Yunnan Province and Manipur in India. Recent surveys show that a third of injecting drug users in Viet Nam said they recently shared needles with other users, while 55% of male injecting drug users in northern Bangladesh and 75% in the central region reported sharing injecting equipment at least once in the week prior to being questioned.
Extensive harm reduction programmes can and do work. By the late 1980s, Australia had prevented a major epidemic from occurring among injecting drug users and, quite likely, from spreading beyond them. Such examples are being followed by several other countries, but in an isolated fashion. The SHAKTI Project in Dhaka, Bangladesh, offers injecting drug users needle exchange, safer injecting options and safer sex education, as well as condoms. IKHLAS, in the Malaysian capital of Kuala Lumpur, provides peer support services, but the estimated 5,000 injecting drug users reached are only a fraction of the country's drug-injecting population.
The need to expand such programmes nationally is patent if these concentrated epidemics are to be brought under control before they spill into the wider population. Many injecting drug users are sexually active young men. Many have steady partners; others buy sex. The overlap between injecting drug use and buying sex is striking. In some Vietnamese cities, 17% of male injecting drug users reported having recently bought unprotected sex. Between half and three-quarters of male injecting drug users in several cities of Bangladesh have reported buying sex from women during the past year, with fewer than one-quarter of them saying they had used a condom the last time they paid for sex. There also is increasing evidence of female sex workers taking up injecting drug use in Viet Nam.
Some self-identified "gay" communities exist throughout the region but, in most of Asia, many additional categories of men engage in same-sex intercourse. Many men who prefer sex with men also have sex with women. Indeed, many marry and raise families. This creates a huge potential for men who have unprotected sex with men to act as "bridges" for the virus in the wider population. In Cambodia, for instance, some 40% of men who have sex with men reported also having had sex with women in the month prior to being surveyed.
At the same time, there is ample evidence that early, large-scale and focused prevention programmes, which include efforts directed at both those with higher-risk behaviour and the broader population, can keep infection rates lower in specific groups and reduce the risk of extensive HIV spread among the wider population. Cambodia's prevention measures, which began in earnest in 1994-95, saw high-risk behaviour among men fall and condom use rise consistently in the late 1990s. As a consequence, HIV prevalence among pregnant women declined from 3.2% in 1997 to 2.3% at the end of 2000, suggesting that the country is beginning to bring its epidemic under control (see Figure 4).
In large parts of Asia and the Pacific, prevention programmes are poorly funded and resourced. Typically, small projects are scattered across countries and do not acquire the scale or coherence that is needed to halt the epidemic's spread. Because many high-risk practices are frowned upon and even criminalized, there are serious political hurdles to prevention.
This article was provided by UNAIDS. It is a part of the publication AIDS Epidemic Update: December 2001. Visit UNAIDS' website to find out more about their activities, publications and services.