Can Asian Countries halt and reverse
the AIDS epidemic by 2015?
JVR Prasada Rao
Special Advisor to UNAIDS Executive Director
International Epidemiological Association Meeting, Colombo
May 24, 2010
May 24, 2010
There is an increased understanding of
the Asian epidemics
 The principal modes of HIV transmission
 HIV is generally concentrated among certain populations.
 Infections appear first among IDUs, SWs and Clients, and MSM, but
then it spreads to wives and children
 The driving forces of Asian epidemics
 sharing of needles during Injecting Drug Use – kick-starts and
accelerates the epidemic
 unprotected Commercial sex – gives it range and power
 Sexual networking among Asian men markedly higher than women
 Projections into the future based on various scenarios
UNAIDS
May 24, 2010
2
The HIV epidemic in Asia
appears to be slowing down overall
Adults and children living with HIV
4,500
# HIV+ in Thousands
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
Year
Adults & Children S & SE Asia
UNAIDS
May 24, 2010
Adults & Children East Asia
Source: 2009 AIDS Epidemic Update. UNAIDS, WHO, 2009
3
However, new infections
in different countries and their sub-regions differ
Indonesia
Cambodia
20,000
New infections in year
150,000
100,000
50,000
400,000
15,000
10,000
5,000
Myanmar
100,000
Clients
Lo-risk male
Sex workers
Lo-risk female
Source: Commission on AIDS in Asia 2008
MSM
Children
20
20
20
15
20
10
20
10
20
08
20
07
20
20
5
20
2006
1
10
20
5
00
00
20
95
19
90
20
0
2 5
0
19
85
20
05
..based on how effectively
prevention targets new
infections
200,000
0
19
20
00
300,000
25,000
UNAIDS
May 24, 2010
19
95
19
85
20
20
20
15
20
10
20
05
20
00
19
95
New infections in year
50,000
19
90
19
85
New infections in year
75,000
19
90
0
0
20
09
New infections in year
200,000
IDU
4
For the first time the CAA
estimated the large numbers of people at risk of
HIV infection in Asia
Asian Population: 3.3 billion
4 million
75 million
Men who
inject drugs
Men in Asia visit
sex workers
(2-20% of adult men)
16 million
10 million
Women
sell sex
50 million
Women married
to men who visit
sex workers
Men who have
sex with men
Men
UNAIDS
May 24, 2010
Women
1 million
infants and
children
5
A causal model showing linkages
among factors that influence HIV transmission
in intimate partners relationships
UNAIDS
April 8, 2015
6
“People on the Move” in Asia’s fastest growing economies China, India, Indonesia, Malaysia, Thailand, and Vietnam
 Asia was host to 26.3 million migrants, or about 13.8 per cent of the world's
total migrant stock, in 2005 (University of Sussex and the World Bank)
 Malaysia and Thailand are expected to absorb large numbers of foreign
workers considering the economic growth prospects
 Asia an important source of international migration, sending 54.2 million
migrants abroad or 28.4 per cent of the world's total (ibid)
 By 2030, India and China are projected to account for 40 per cent of the
global workforce (World Migration Report 2008)
 Sri Lanka, Philippines and Indonesia contribute a large female work force
working abroad
 Gendered dimension of migration – the numbers of women migrating from
the six countries will continue to rise - particularly as domestic workers, care
givers, service employees, moving across borders and within the country
UNAIDS
May 24,2010
Source: AIDS 2031. UNAID, 2009
7
This migration and mobility
exposes migrants to HIV risk .. particularly
internal rural-urban migration
• Commercial sex work is concentrated in
areas of circular migrants – more Clients
• Large numbers of rural female migrants
moving to urban areas engage in the
entertainment industry – more FSWs
• Expands the triangular sexual networks
of migrants, both the men and the
women
• Lack of access to health services,
particularly those living outside their
countries
UNAIDS
May 24, 2010
8
Mobile men can be more
vulnerable to HIV infection
Percentage of non-mobile / mobile
men paying for sex in the past 12 months (FHI 2006)
33%
33%
32%
21%
15%
9%
4%
2%
China
UNAIDS
May 24, 2010
Cambodia
Indonesia
Viet Nam
9
The epidemic data show this emerging
dynamic of HIV spread - about 200,000 more Asian
women are living with HIV in 2008 compared to 2001
Regional Trends in People living with HIV
4,500
4,000
# HIV + in Thousands
3,500
3,000
2,500
2,000
1,500
1,200
1,300
1,000
500
180
290
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
-
Year
Women S&SE Asia
Adults & Children S&SE Asia
UNAIDS
May 24,2010
Women East Asia
Adults & Children East Asia
Source: 2009 AIDS Epidemic Update. UNAIDS, WHO, 2009
10
People are still dying of AIDS in Asia –
an estimated 330,000 deaths in 2008
HIV-related Deaths of Adults and Children
350
# Deaths in Thousands
300
250
200
150
100
50
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
Year
Deaths Adults & Children S & SE Asia
UNAIDS
May 24, 2010
Deaths Adults & Children East Asia
Source: 2009 AIDS Epidemic Update. UNAIDS, WHO, 2009
11
The Asia Commission projections suggest that we
are at a cusp in the epidemic progression…
1,200,000
New infections in year
1,000,000
where a resurgent
epidemic …
800,000
600,000
400,000
200,000
1,200,000
20
20
UNAIDS
May 24, 2010
Source: Commission on AIDS in Asia 2008
600,000
400,000
200,000
Clients
Sex workers
MSM
IDU
Lo-risk male
Lo-risk female
20
20
20
15
20
10
20
05
20
00
0
19
95
can be avoided if
prevention and treatment
reach universal coverage
800,000
19
90
IDU
19
85
MSM
Children
20
15
20
10
20
05
20
00
Sex workers
Lo-risk female
1,000,000
New infections in year
Clients
Lo-risk male
19
95
19
90
19
85
0
Children
12
Better information but the response
is lagging
• Response is a mixed picture country to country and
provinces within the same country ( in India and
China ).
• There are excellent prevention efforts, but not to
scale.
• Babies are still getting infected - PM TCT coverage
in the region is very low ( 25%)
• If reducing the new infections to half by 2015 is the
goal, many countries need to act fast.
UNAIDS
May 24, 2010
13
HIV prevalence among IDUs in Bangkok,
2000-2009
60
50
40
% 30
20
10
0
HIV prevalence among MSM in
Thailand, 2003-2007
UNAIDS
May 24, 2010
Source: Bureau of Epidemiology, Thailand Ministry of Public Health
Thailand's
early
successes in
reducing sex
work-related
infections,
have given
way to
increasing
infections
among IDUs
and MSM
14
100
HIV prevention coverage among IDUs,
2005-2009
%
80
60
40
20
0
2005
UNAIDS
May 24, 2010
2007
2009
Source: UNGASS country progress report_2006, 2008 & 2010
* Calculated median value
2009 data is provisional
15
HIV prevention coverage among MSM
2005-2009
100
%
80
60
40
20
0
* Calculated median value
2005
UNAIDS
May 24, 2010
2007
2009
Source: UNGASS country progress report_2006, 2008 & 2010
2009 data is provisional
16
PMTCT coverage, 2006-2009
100
80
60
40
20
0
2006
UNAIDS
May 24, 2010
2007
2008
2009
Source: UNGASS country progress report_2006, 2008 & 2010
2009 data is provisional
17
Enabling environment and unseen
challenges
• Political leaders in Asia must be credited for seeing the danger
of a looming epidemic and acting early ...
• But, the political rhetoric is often not translated into
measurable programme outputs which have an IMPACT on
the epidemic.
• Disturbing trend of reversal of earlier gains – new legislations
in countries like Cambodia which enhance stigma. New
conservatism around issues like sex work, male to male sex …
• Impact mitigation is the missing piece. No effective measure
to mitigate the effects of stigma and discrimination. No
earmarked funding.
UNAIDS
May 24, 2010
18
No country spends enough
resource per capita ($)
3
2
Thailand
Cambodia
1
Vietnam
Sri Lanka China
Indonesia
Bangladesh
Pakistan
0 Philippines
0.00%
India
Nepal
Myanmar
0.50%
1.00%
1.50%
With a
normative
value of $1
per capita, 9
countries
still fell
short on
resource
commitment
to AIDS
programmes
HIV prevalence (%)
The region needs $ 3.2 bn for reversing the epidemic,
but availability hovers around $ 1.2 bn.
UNAIDS
May 24, 2010
Source :Commission on AIDS in Asia 2008
19
Sources of AIDS funding, selected countries
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Afghanistan (2008-2009)
Cambodia (2008)
China (2009)
Fiji (2008)
India (2007-2012)
Indonesia (2008)
Lao PDR (2008-2009)
Public
International
Private
Malaysia (2009)
Mongolia (2009)
Nepal (2007)
Pakistan (2009)
Thailand (2009)
Vietnam (2008)
UNAIDS
May 24, 2010
Source: UNGASS country progress report 2010
20
Percent distribution of
AIDS spending per key area, selected countries
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Afghanistan (2008-2009)
Bangladesh ( 2007-2009)
Cambodia (2008)
India (2009)
Indonesia (2008)
Lao PDR (2008-2009)
Malaysia (2009)
Mongolia (2009)
Nepal (2007)
Pakistan (2009)
Thailand (2009)
Vietnam (2008)
Prevention
UNAIDS
May 24, 2010
Care and treatment
Source: UNGASS country progress report 2010
Others
21
The brighter side
• Countries understand the need for information and are starting
to generate more data and fill data gaps.
• Behavioral surveys are identifying and characterising the risk
factors.
• Successful interventions which can bring down new infections
effectively have been demonstrated.
• Stronger health system support for treatment and PMTCT
programmes is resulting in fast scale up. Treatment coverage
increased impressively to 565,000
• Good scale up in resources - GF and PEPFAR and BGMF as
new donors have added much needed resources.
• Social environment changing in countries like India and Nepal
with a proactive judiciary leading the way to social reforms.
UNAIDS
May 24,2010
22
Strategic information systems are improving across
the region and risk factors better understood
100%
No survey
8 countries
At least 2 populations among FSW, IDU, MSM
80%
4 countries
All 3 populations
60%
40%
12 countries
20%
0%
24 countries
% of countries with HIV prevalence surveys among
populations at higher risk, in the last 2 years (2009)
UNAIDS
May 24, 2010
23
HIV prevention coverage is improving
across most the region
100
%
80
60
40
20
0
2005
2007
2009
* Calculated median value
2009 data is provisional
UNAIDS
May 24, 2010
Source: UNGASS country progress report_2006, 2008 & 2010
24
ART coverage is scaling up fast
in many countries
ART coverage among adults and children, 2006-2009
* Only for adults
UNAIDS
May 24, 2010
Source: UNGASS country progress report_2006, 2008 & 2010
2009 data is provisional
25
The MARPs agenda- opening the doors
for social sector reform
• Acceleration of gender and HIV activities in the
region
 By the end of 2009, 3 countries had gender reviews of their
NSPs and 2 policies for systematic inclusion of gender. 4
more countries currently working on them.
 Regional Report on Intimate Partner Transmission of HIV
was launched at 9th ICAAP based on analysis in 13 countries
UNAIDS
May 24, 2010
26
The MARPs Agenda – opening the doors for
social sector reform .. ( cont’d )
•
UNAIDS Agenda for Women and Girls to be promoted in
2010 to support engendering of new National Strategic AIDS
Plans and Global Fund Grants.
•
Social environment changing in countries like India and
Nepal with a proactive judiciary leading the way to social
reforms.
•
Establishment or improvement of remedial instruments and
legal reform, and agencies where PLHIV can seek redress and
legal services.
UNAIDS
May 24, 2010
27
Empowerment of positive people
• Strong networking of PLHAs in most Asian countries and linking
with Regional body APN+
• Representation on NACs and CCMs at national level.
• Core funding for organizational development to APN+ from
UNAIDS
• Involvement in development of strategies for prevention of Intimate
Partner Transmission
• HIV Bill in India to guarantee the rights of positive people
• Stigma Index roll out commenced in 2008 with PLHIV groups
involvement.
 Five countries completed the index and are disseminating
findings (Sri Lanka, Bangladesh, China, Myanmar and Thailand).
 Seven more countries (Cambodia, Fiji, Malaysia, Pakistan,
Philippines, PNG and Viet Nam) implementing index through
PLHIV networks with universities support.
UNAIDS
May 24, 2010
28
Global Fund Round 6 & 8 HIV spending in
Asian countries: Priority areas
Round 6
Round 8
Mass Media
0%
PMTCT
2%
PMTCT
2%
Migrants/
Mobile
populations
1%
Condom Social
marketing
0%
VCT
13%
MARPs
24%
Workplace
Blood
safety
intervention
2%
0%
STI treatment
6%
VCT
46%
Youth
1%
MARPs
59%
Migrants/Mobi
le populations
17%
Youth
17%
Blood safety
9%
Workplace
intervention
STI treatment
0%
1%
UNAIDS
May 24, 2010
Mass Media
0%
29
Global Fund Round 9 HIV spending in
6 Asian countries: Priority areas
Workplace intervention
0%
Youth
0%
MARPs
Blood safety
0%
Prevention
27%
Migrants/Mobile
populations
10%
STI treatment
2%
MARPs
73%
Condom Social marketing
3%
VCT
5%
Treatment &
Care
46%
PMTCT
7%
Mass Media
0%
UNAIDS
May 24, 2010
Source: Global Fund Round 9 budget tracking_2010
30
Why is this the right
time to act?
UNAIDS
April 8, 2015
31
Countries with highest prevalence in Asia show
good progress on MDG 6 targets for HIV and TB,
but less progress on infant and maternal targets MDGs 4 & 5
Country
MDG Goal 4
Under-5
mortality
MDG Goal 5
Maternal
mortality
Antenatal
care
MDG Goal 6
At least
once birth
by skilled
professional
HIV
prevalence
TB
incidence
TB
prevalence
China
India
Indonesia
Myanmar
Thailand
Vietnam
Early achiever
UNAIDS
May 24, 2010
On track
Slow
Regressing/No progress
Source: UNESCAP, ADB & UNDP_ Achieving the millennium development goals in an
era of global uncertainty_2010
32
With 2015 MDG targets approaching,
HIV and AIDS interventions should be integrated into
Health Systems strengthening
UNAIDS
May 24, 2010
Source: UNESCAP, ADB & UNDP_ Achieving the millennium development goals in an
era of global uncertainty_2010
33
UN is reinforcing its role
• AIDS affords an opportunity for the UN system to
deliver as ONE
• The one programme where this has been successfully
done was the AIDS programme where the secretariat
and the 10 Co-Sponsors work together in a joint
programme to provide support to countries.
• This needs to be intensified, taking advantage of the
Outcome Frame Work of UNAIDS and the Division
of Labour between agencies.
UNAIDS
May 24, 2010
34
What needs to be done in Asia and the Pacific?
•
•
•
•
•
In the next 5 years,
Understand the characteristics of the epidemic and tailor the response.
AIDS should get to the top of the agenda for activists and social reformers
 It provides a platform for civil society no other movement was able to
provide earlier.
Focus on programmes that produce impact and results, and don’t waste
money on low impact interventions.
Coverage and scale up is the Mantra - Attempt and attain more than 80%
coverage of populations who need prevention and treatment services.
In the long term,
impact mitigation is the key
 special focus on orphans and women.
 AIDS related stigma and discrimination should be wiped out.
 CAA estimated that for the entire Asia they are not going to cost more
than $ 300 m per year.
UNAIDS
May 24, 2\010
35
Thank you!
Acknowledgements
• UNAIDS RST
• HIV and AIDS Data Hub for Asia and the
Pacific www.aidsdatahub.org
UNAIDS
May 24, 2010
36