HIV/AIDS in Asia
August 2013—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 2011, more than 370,000 Asians/Pacific Islanders were newly infected with HIV, bringing the total number living with HIV/AIDS in Asia and the Pacific to nearly 5 million. In the same year, approximately 310,000 people died from AIDS-related illnesses in this region.
National HIV Data
The overall prevalence of HIV in most Asian countries remains low, but with a regional population that is roughly 60 percent 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 1.2 percent. By the end of 2011, approximately 490,000 Thais were living with HIV/AIDS, with an estimated one-third of all new infections in 2012 occurring through intercourse between intimate heterosexual partners. Prevalence among injection drug users (IDU) remains high, ranging between 30 and 40 percent. And HIV among men who have sex with men (MSM) is on the rise: HIV prevalence among Thai MSM rose from 17 percent in 2003 to 29 percent in 2011.
In India, the estimated number of HIV/AIDS cases in 2011 was 2.1 million, down from 2.4 million in 2009, and the overall adult prevalence was 0.27 percent. The number of people on antiretroviral therapy nearly tripled between 2009 and 2011, but a high percentage of people do not get tested or access treatment until their disease has progressed to dangerous levels.
In China, 780,000 people were living with HIV/AIDS in 2011. 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 25 percent between 2001 and 2011, those in Indonesia, the Philippines, Bangladesh, and Sri Lanka rose by more than 25 percent in the same period.
Indonesia, the world’s fourth most populous country, has seen a significant increase in HIV infections, especially among sex workers, MSM, and IDUs. In 2011, 36 percent of all IDUs were HIV-positive and 380,000 people were living with HIV/AIDS, including 110,000 women.
The estimated number of people living with HIV in Vietnam more than doubled between 2000 and 2009, from 120,000 to 250,000. Primary risk groups include sex workers and IDUs. In 2011, 70 percent of HIV infections in the country were among IDUs.
In May 2013, new HIV diagnoses in the Philippines were reported to be 50 percent 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 IDUs 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, Myanmar, Pakistan, and Thailand, over 20 percent of IDUs are HIV-positive, and while HIV rates have fallen in female sex workers across the region, in many provinces the rate remains above 10 percent. 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, 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 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. Sixteen percent of IDUs 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 percent 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 11 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 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.
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 40 percent of adults with HIV in Asia at the end of 2010—up from 21 percent in 1990.
Children and adolescents
The number of HIV-positive children in Asia continues to grow. In 2010, 180,000 children and adolescents were living with HIV in the region. Programs to prevent mother-to-child-transmission in South and Southeast Asia have expanded to reach approximately 18 percent of HIV-positive pregnant women in 2011, but this figure was far below the global average of 57 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 stigma surrounding HIV/AIDS. Access to pediatric treatment remains limited; in 2010 only 39 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.
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 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. International recommendations continue to call for earlier treatment and more effective prevention, posing significant challenges to both national healthcare budgets and existing healthcare infrastructures.