HIV/AIDS in Asia Overview

December 2010—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 2009, more than 360,000 Asians/Pacific Islanders were newly infected with HIV, bringing the total number living with HIV/AIDS in Asia and the Pacific to more than 4.9 million. In the same year, approximately 300,000 people died from AIDS-related illnesses in this region.

The prevalence of HIV in some Asian countries remains relatively low, but with a regional population that is roughly 60 percent of the world’s total, even low prevalence translates into huge numbers infected:

• In Thailand, where the AIDS epidemic started earliest and prevention efforts have achieved some success, HIV prevalence is 1.3 percent. By the end of 2009, approximately 530,000 Thais were living with HIV/AIDS, with a third of all new infections occurring among low-risk women who are infected by their husbands or regular partners. Prevalence among injection drug users (IDU) remains high, ranging between 30 and 50 percent. And HIV among men who have sex with men (MSM) is on the rise: In Bangkok, HIV prevalence among MSM rose from 17 percent in 2003 to 30 percent in 2008.
•  In India, the estimated number of HIV/AIDS cases in 2009 was 2.4 million and overall adult prevalence was 0.3 percent. The number of people on antiretroviral therapy increased significantly between 2008 and 2009, but by the end of 2009 only about a quarter of those needing treatment were receiving it.
• In China, 740,000 people were living with HIV/AIDS in 2009. Although injection drug use continues to be a significant driver of the epidemic, heterosexual transmission 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, Myanmar, and Thailand show overall declines, those in Indonesia and Vietnam are growing:

• Indonesia, the world’s fourth most populous country, has seen a significant increase in HIV infections, especially among sex workers, MSM, and IDUs. Half of all IDUs were HIV-positive, according to 2008 figures. In 2009, 310,000 people were living with HIV/AIDS in Indonesia, including 88,000 women. Condom use in the country remains very low, and the HIV epidemic is among the fastest growing in Asia.
• The estimated number of people living with HIV in Vietnam more than doubled between 2000 and 2009, from 120,000 to 280,000. Primary risk groups include sex workers and IDUs; among the latter, HIV prevalence increased from nine percent in 1996 to about 34 percent in 2005.

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 IDUs were the first groups to be seriously affected by HIV/AIDS in most of Asia and the Pacific, and they remain key drivers of the epidemic. In four states in southern India, 2008 surveys showed that HIV prevalence among female sex workers was 14.5 percent, and the UNAIDS 2009 update indicated that the overlap of injection drug use and sex work is an important factor in China’s HIV epidemic. 

Transmission through male-male sexual contact accounts for an increasing number of new infections in the region. By 2020, almost 50 percent 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.

Social forces 

Social forces are at the root of Asia’s HIV/AIDS 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 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 returning 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 salesmen, sailors, soldiers, fishermen, migrant workers, and within the sex industry, which is itself fueled by economic disparity.

Injection drug use 

Growing poverty in some areas is also driving increased injection drug use. According to UNAIDS, more than 4.5 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 opiate substitution therapy. But the financial resources available for harm reduction only cover about 10 percent of what is needed region-wide.

Gender-based disparities 

As elsewhere in the developing world, gender-based socioeconomic disparities play a significant role in the spread of HIV. In a bitter irony, 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 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 percent of adults with HIV in Asia in 2009—up from 21 percent in 1990.

Children and adolescents 

The number of HIV-positive children in Asia continues to grow. In 2009, 160,000 children and adolescents were living with HIV in the region. Programs to prevent mother-to-child-transmission have expanded to reach 32 percent of HIV-positive pregnant women in 2009, but this figure was far below the global average of 53 percent. 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 enormous stigma surrounding HIV/AIDS. Access to pediatric treatment remains limited; at the end of 2009, only 44 percent of children in Asia in need of antiretroviral therapy were receiving it. 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.

MSM 

There has also been a sharp rise in the number of new HIV infections among MSM in the region, where sexual activity between men is frequently stigmatized and kept hidden. MSM in Asia have nearly a one in five odds of being infected with HIV, according to a 2007 study, and many MSM also have female partners. Male-male sex remains illegal in at least 11 countries in the region and prevention and outreach programs for MSM remain limited across the region. Studies in several countries have found high levels of risk behaviors among MSM, including having multiple sex partners and low rates of condom use. Despite these factors, many of these men believe they are at low risk for HIV.

Tuberculosis 

The spread of HIV/AIDS is compounded by the high prevalence and incidence of tuberculosis in many parts of Asia. As HIV progresses to AIDS, patients become increasingly susceptible to tuberculosis, which in turn wreaks havoc with immune cells, drives up HIV viral loads, and puts people at greater risk of other opportunistic infections.

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 mores that often prevent frank discussion of issues surrounding sex and drug use, and will need to overcome 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. As the millions of

HIV-positive Asians progress from HIV to AIDS, the demand for earlier and more effective treatment will inevitably increase, posing a significant challenge to both national healthcare budgets and existing healthcare infrastructures.