According to Foundation for AIDS Research: “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. [Source: Treat Asia, Foundation for AIDS Research]

The International AIDS-HIV charity Art reports: Although national HIV prevalence in most Asian countries is relatively low, the population of some countries is so vast that these low percentages actually represent very large numbers of people living with HIV. In India, for example, an estimated 0.1 percent of adults aged 15-49 are living with HIV, which seems low when compared to HIV prevalence in some parts of sub-Saharan Africa. However, with a population of around 1 billion, this actually equates to 2.3 million adults living with HIV in India. Nonetheless, the situation is improving; the number of new infections in Asia went down from 450,000 in 2001 to 360,000 in 2010 and in India the rates have fallen by 56 percent since 2006. [Source: Avert, International AIDS-HIV charity website]

Although it is useful to understand the overall impact that AIDS is having on the Asian region as a whole, there is no single “Asian epidemic”; each country in the region faces a different situation. Progress has been made in countries such as Cambodia, Myanmar and Thailand, where there has been evidence of a decline in HIV prevalence. On the other hand, in Indonesia, Pakistan and Vietnam the number of people living with HIV has increased. There are also huge variations within countries. In China, for example, five provinces account for 53 percent of the people living with HIV.

Asia has had the largest AIDS-related death toll outside of sub-Saharan Africa. Some have warned that epidemics in Asia could escalate to the extent of rivalling those in some parts of Africa. Others, however, argue that Asia's epidemics are on a different trajectory to those found in Africa, as HIV infection in Asia is still largely concentrated among members of 'high-risk' groups.

AIDS and HIV in Asia in the 1990s

Asia had the world's fastest growth rate for AIDS in the late 1990s. At that time there were more new cases of AIDS in Asia than anywhere else in the world. Asia had about 10 million people infected with the AIDS virus around the year 2000, when it surpasses Africa with the new number of new cases of infection each year. Of the 28 million people with HIV in the world in 1996, 19 million were in sub-Sahara Africa, 5 million were in South and South Asia and 1.6 were in Latin America. The number of new cases in Africa peaked in 1995-96 will the rate in Asia continued to rise. In the year 2000 there were 44 million AIDS cases, with 60 percent of them in Africa; 21 percent in south and southeast Asia; 7 percent in Latin America; and 5 percent in North America, Australia and western Europe.

In Asia HIV/AIDS, according to AP, “first devastated Thailand's infamous sex industry, later reached millions in India and has pushed once-isolated communist Vietnam to the brink of an HIV explosion.” The disease was partly spread by male workers who left their hometowns to find work and while away from their homes slept with prostitutes infected with the virus and brought the disease back home. "Teen AIDS" rose among young people who engages in sex at younger and younger ages and traveled around more.

In 1997 there were 6 million AIDS cases in South Asia and Southeast Asia. More than 30 percent of the people with HIV/AIDS were women (1996). Heterosexual activity was the main mode of HIV transmission. 1997 there were 440,000 AIDS cases in East Asia and the Pacific. About 20 percent of the people with HIV/AIDS were women (1996). The main modes of HIV transmission were : 1) intravenous drug use; 2) heterosexual activity; 3) male homosexual activity.

Thailand, Cambodia, India, Bhutan, Burma and Malaysia had the highest HIV and AIDS infection rates in Asia in the 1990s. In 1997, between 2 and 8 percent of the population between 15 and 49 had the virus in Thailand and Cambodia, and between 0.5 and 2 percent of the population between 15 and 49 had it in India, Bhutan and Malaysia (compared to 0.5 to 2 percent in the United States and 26 percent in Zimbabwe, the highest rate in the world). [Source: United Nations]

The vice president of the Asian Development Bank said that the AIDS epidemic threatens Asia's prosperity. According a 1995 survey, one third of the child prostitutes in Southeast Asia tested positive for HIV. Since then more and more prostitutes have tried to convince their client it in their interest to use condoms.

AIDS and HIV in Asia in the 2000s

Margie Mason of Associated Press wrote in 2006: “India is home to more HIV/AIDS-infected people than any other country, according to new UNAIDS numbers. Its estimated 5.7 million infections last year comprise more than two-thirds of all cases in the Asia-Pacific region. In a country of more than 1 billion people, that number shrinks to a small fraction -- 0.9 percent of adults compared to South Africa's almost 19 percent. But a small percentage can cause the problem to be neglected. ''Because of this low percentage, the issue doesn't seem to be a priority for political leaders and also for the man on the street,'' said Dr. Shigeru Omi, the Western Pacific regional director for the U.N.'s World Health Organization. [Source: Margie Mason, Associated Press, June 2, 2006]

”India's epidemic is largely driven by heterosexual sex -- mainly prostitutes and their clients who do not use condoms. In the country's south, a recent report found, prevention campaigns targeting sex workers have resulted in a 35 percent drop in new cases among 15- to 24-year-olds. But there has been little progress in India's highly populated north or drug-ridden northeast, said one of the report's authors, Prabhat Jha of the University of Toronto. ''It's too early and one wouldn't want to be the fellow on the Titanic who said 'all clear' because the north is 70 percent of the population,'' said Jha, who's spent a decade researching AIDS in India. ''If it explodes, you can imagine what would happen.'' Chandi Sayeed, 39, of Bombay's gritty brothel district, said she was sold into prostitution at age 16 when she was already a mother of two. ''The problem is most women don't use condoms with their husbands or with customers they love,'' she said. ''They only use it with men who aren't regulars. They say, how can we use it with our lovers” But women must think of their children and their family first.''

”Another trouble spot is Papua New Guinea, which shares an island north of Australia with Indonesia's easternmost Papua province. The country of 5.7 million is plagued by political instability, poverty and rampant sexualviolence against women. It has the Asia-Pacific's highest adult per capita infection rate of 1.8 percent, but the political will to tackle the problem is absent. ''Papua New Guinea is a very, very, very serious situation,'' Omi said. It ''needs some special attention, otherwise there's a possibility that Papua New Guinea will become like Africa in the future.'' In China, the AIDS picture is still a bit unclear. But its sheer size -- some 1.3 billion people -- is enough to worry experts.

“In January, China and the United Nations lowered HIV/AIDS estimates there, saying roughly 650,000 people were infected in 2005 -- nearly 200,000 fewer than an earlier projection. Injecting drug users accounted for nearly half the infections in China, where the government was accused of being slow to address the problem. HIV took off in China in the early 1990s when farmers began selling blood plasma to earn extra money. AIDS activists and people infected with the virus have been harassed, buttop leaders have finally admitted publicly that a problem exists.

“In late 2004, President Hu Jintao was photographed shaking hands with HIV-infected Zhang Hulin. It was a major step for the communist government, but Zhang says he and his family suffered even greater stigma and discrimination after the photos circulated. Still, he remains hopeful a cure will be found. ''It's one of these diseases that the whole world is concerned with and doing research on,'' said Zhang, who tested HIV-positive in 1997. ''So maybe it can be eradicated, but it's hard to say.''

“If more isn't done to combat HIV/AIDS now, Asia could surpass Africa in the number of people living with the virus, said Jeanine Bardon, regional director of U.S.-based Family Health International. The tragedy would be all the greater because today people know how to prevent it. ''We'll have lost an enormous opportunity to avert thousands of infections and eventually millions of lives saved,'' she said. ''It's not that we don't know what we're doing.''

AIDS and HIV in Southeast Asia in the 2000s

Margie Mason of Associated Press wrote in 2006: “In Vietnam, the bulk of infections are among prostitutes and injecting drug users. But the virus has spread to all provinces and cities, and the country is at a very critical moment, said Omi of the World Health Organization. With prevention campaigns, ''they may be able to avert transmission into the community. But if they fail, they may end up having widespread transmission among the general public,'' he said.Vietnamis the only Asian nation among 15 countries selected to receive emergency HIV/AIDS funding under a US$15 billion (euro11.8 billion) Washington plan. [Source: Margie Mason, Associated Press, June 2, 2006] “Thailand and Cambodia, in contrast, have been hailed as two bright spots in Asia. Both still have adult per capita infection rates over 1.4 percent, but the governments have largely reversed once-devastating epidemics by promoting 100 percent condom use among prostitutes working in brothels. But both countries must refocus and refresh their prevention campaigns, said Bardon, “Trends have shifted and HIV has latched on to new risk groups, including men who have sex with men; young people with multiple sex partners; injecting drug users; and monogamous women whose husbands have sex outside marriage. ''It's not just sex workers and their clients. It's much more complicated now,'' she said. ''The new infections are now occurring between the men who got infected (by prostitutes) in the '90s and their wives.''

“Children are among the most tragic AIDS victims. There were an estimated 1.5 million children orphaned by AIDS in the Asia-Pacific region, with more than 120,000 of them infected in 2004, UNAIDS estimated. Often, the children AIDS sufferers are unwanted, said Joseph Maier, a Catholic priest who runs Mercy Center orphanage, school and hospice in a Bangkok slum. ''Nobody's talking about, 'Come on, why don't we adopt some of these kids?' Nobody's talking about, 'Hey, these kids are bright, they're geniuses, there's poets among them,''' said Maier, known to everyone as Father Joe.

“Thailand has made cheap antiretroviral drugs easily available, which has increased life spans but not reduced the stigma and discrimination. ''We walk around to all the schools in this area here and say we've got some kids with HIV/AIDS, we want you to take them in,'' Maier said. ''They wouldn't let them in.''

Transmission of HIV in Asia

The International AIDS-HIV charity Art reports: There are three main HIV transmission routes in Asia: 1) Unprotected paid (and unpaid) sex; 2) Injecting drug use; 3) Sex between men; and 4) mother-to-child transmission [Source: Avert, International AIDS-HIV charity website]

Unprotected sex, both paid and unpaid, accounts for a significant share of new HIV infections in many Asian countries. Clients of sex workers make up the largest key population at higher risk; between 0.5 and 15 percent of men buy sex regularly and the level of condom use during paid sex in many countries is still low. These factors have contributed to a high HIV prevalence among sex workers and their clients across Asia. In addition, an increasing number of women who are married and considered “low-risk” of HIV infection are becoming infected with HIV. Estimates suggest that around 25-40 percent of new HIV infections in several Asian countries are among wives and girlfriends of men who became infected through paid sex, having sex with other men or injecting drugs.

Injecting drug use is a major driving factor in the spread of HIV throughout Asia, notably in China, Indonesia, Malaysia and Vietnam. In China, nearly half of all people infected with HIV are believed to have become infected through injecting drug use, and in North-East India injecting drug use is the most common HIV transmission route. There is often an overlap between communities of IDUs and communities of sex workers in Asia, as those who sell sex may do it to fund a drug habit, or they may have become involved in sex work first before turning to drug use.

Sex between men accounted for some of the earliest recorded cases of HIV in Asia, and transmission through this route is still a prominent feature of many countries’ epidemics. Most men who have sex with men (MSM) in Asia do not identify themselves as gay because of cultural norms that discourage homosexuality; in some cases they may even be heads of families, with children. This means that MSM can serve as a “bridge” for HIV to spread into the broader population. New factors appear to be affecting the spread of HIV among MSM such as Internet dating, soft drug use, mobility and other forms of social change. HIV outbreaks are becoming evident among MSM in Cambodia, China, Nepal, Pakistan, Thailand, Vietnam, India, Indonesia, Myanmar and the Philippines.

Mother-to-child transmission is also a significant HIV transmission route in Asia. At the end of 2010, it was estimated that 150,000 children in South and South-East Asia, and 8,000 children in East Asia, were living with HIV, most of whom became infected through mother-to-child transmission.

HIV Prevention in Asia

The International AIDS-HIV charity Art reports: Asia has been the base for some extremely successful large-scale HIV prevention programmes. Well-funded, politically supported campaigns in Thailand and Cambodia have led to significant declines in HIV-infection levels, and HIV prevention aimed at sex workers and their clients has played a large role in these achievements. In Tamil Nadu, India, HIV prevention initiatives have had a substantial impact. High-profile public campaigns discouraged risky sexual behaviour, made condoms more widely available, and provided STI testing and treatment for people who needed them. These efforts resulted in a large decline in risky sex. [Source: Avert, International AIDS-HIV charity website]

Successes such as these prove that interventions can change the course of Asia's AIDS epidemics. As HIV infection rates continue to grow however, it's clear that more needs to be done. The groups most at risk of becoming infected — sex workers, IDUs, and MSM — are all too often being neglected. It is suggested that in order for Asia's epidemic to stabilize, interventions should cover between 60 and 80 percent of individuals considered high risk. For instance, although injecting drug use is one of the most common HIV transmission routes in Asia, it is estimated that less than one in ten IDUs in the region have access to prevention services. Similarly men who have sex with men are overlooked and poorly monitored by most governments, even though it is firmly established that this group play a significant role in some countries’ epidemics. Despite this, globally, the South and South East Asian region performed the worst in terms of the delivery of HIV prevention to MSM.

"In countries without laws to protect sex workers, drug users, and men who have sex with men, only a fraction of the population has access to prevention. Conversely, in countries with legal protection and the protection of human rights for these people, many more have access to services. As a result, there are fewer infections, less demand for antiretroviral treatment, and fewer deaths. Not only is it unethical not to protect these groups: it makes no sense from a health perspective."Secretary-General Ban Ki-moon, speaking at the opening address to the International AIDS Conference.

It is not only legal barriers that are preventing people from accessing effective HIV prevention; problems also arise when prevention programmes do not contain information that will be most useful. For example, young people in Asia are generally not taught about the kinds of behaviours that put this group most at risk: unprotected sex through sex work, injecting drug use, and sex between men. Instead they focus on heterosexual transmission and reproductive health, which have a limited impact on preventing new HIV infections among young people in Asia.

The coverage of prevention of mother-to-child transmission (PMTCT) services is also very low in Asia. In East, South and South-East Asia, around 30 percent of pregnant women were offered an HIV test in 2010. This was a great improvement compared to the 18 percent of 2009, but still a very low percentage compared to other regions of the world such as Eastern Europe and Central Asia (59 percent), Eastern and Southern Africa (61 percent) and Latin America and the Caribbean (61 percent). In 2010 across East, South and South-East Asia, only 16 percent of HIV-infected pregnant women received ARVs (excluding single-dose nevirapine) to prevent mother-to-child transmission of HIV.

Due to the stigma that often surrounds those groups most at risk of HIV infection, coverage of HIV voluntary counselling and testing (VCT) services in South-East Asia remains very low. An estimated 0.1 percent of the adult population in the region received testing and counselling in 2005. Certain countries are making progress, however; testing services in India have been expanded with about 5135 testing centres now open to the public.33 Even so, far more needs to be done across Asia to ensure VCT is available to those most at risk of acquiring HIV.

Antiretroviral Treatment for HIV/AIDS and the Tuberculosis-AIDS Threat in Asia

The International AIDS-HIV charity Art reports: The availability of antiretroviral treatment more than tripled between 2003 and 2006 in Asia. Although this seems encouraging, only 39 percent of people in East, South and South-East Asia who are in need of HIV treatment are receiving it. In addition, access to HIV treatment varies widely across the region. Thailand and Cambodia have an estimated treatment coverage of 67 percent and 92 percent respectively, whilst estimated treatment coverage in Malaysia and the Philippines is 36 percent and 51 percent. [Source: Avert, International AIDS-HIV charity website]

A major barrier to treatment access is the high cost of antiretroviral drugs, as both first- and second-line drugs are still unaffordable to many governments. Cheaper HIV drugs are now produced by a number of pharmaceutical manufacturers in Asia, and together with the increasing availability of lower-cost branded ARVs, it will be easier for governments to obtain and distribute the drugs. Yet even where drugs are available, the poor state of healthcare in many Asian countries, particularly a shortage of trained doctors, is hindering governments' abilities to organise life-long treatment programmes for millions of people living with HIV.

Reuters reported in 2005: “Drug resistance combined with a deadly double infection of tuberculosis and HIV is posing a serious threat in Cambodia, Vietnam, China and the Philippines, said the World Health Organisation. The WHO said tuberculosis was the leading cause of death in HIV-AIDS patients in the Asia-Pacific region and growing resistance to a variety of drugs is fuelling a rise in cases. Tuberculosis is a bacterial disease that mostly attacks the lungs. It is an opportunistic infection that once contracted by a HIV patient sees each disease speed the progress of the other. [Source: Reuters, September 23, 2005]

People with HIV are up to 50 times more likely to develop tuberculosis (TB). In the Western Pacific, which stretches from China to Fiji, more than 1.5 million people were living with HIV/AIDS at the end of 2004 and about 120,000 people are expected to die of AIDS in 2005, said a WHO report on tuberculosis and HIV-AIDS. “HIV and TB are the leading killers among the infectious diseases today and together they form a deadly partnership,” said the report released on Friday at a WHO conference in Noumea, capital of New Caledonia in the South Pacific. “In the region, TB-HIV has not reached epidemic proportions but is already serious in some areas,” it said.

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Last updated November 2012

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