in the South-East Asia Region
HIV/AIDS
HIV/AIDS in the South-East Asia Region
WHO Library Cataloguing-in-Publication data
World Health Organization, Regional Office for South-East Asia.
HIV / AIDS in the South-East Asia Region: progress report 2010.
1. Acquired Immunodeficiency Syndrome – epidemiology – prevention and control. 2. HIV Infections – epidemiology. – prevention and control. 3. Tuberculosis – prevention and control. 4. National Health Programs. 5. Antiretroviral Therapy, Highly Active. 6. Unsafe Sex – statistics and numerical data. 7. South-East Asia.
ISBN
978-92-9022-389-4
(NLM classification: WC 503.6)
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CONTENTS Acknowledgements Foreword Acronyms EXECUTIVE SUMMARY HIV EPIDEMIOLOGIC SITUATION The Global HIV Epidemic iii iv v 1 1 1 16 16 22 25 27 27 30 32 34 39 40 43 46 48 54 52 56 60 63 70 72 75 75 84 81 79 67 ii
HIV Epidemic in the South-East Asia Region HEALTH SECTOR RESPONSE TO THE HIV EPIDEMIC Blood Safety Prevention of HIV Transmission in Most-at-Risk Populations Prevention and Control of Sexually Transmitted Infections HIV Testing and Counselling Antiretroviral Therapy HIV–TB Strategic Information COUNTRY BEST PRACTICES Bangladesh : Effective Government–NGO Collaboration Bhutan : Strong Political Commitment Democratic People’s Republic of Korea : Widespread Health Infrastructure India : Rapid and Effective Scale-up of Antiretroviral Treatment Myanmar : Successful HIV and TB Collaboration Indonesia : Novel Approach for Improved Size Estimation of Most-at-Risk Populations Maldives : Effective Use of Evidence for Programme Development Nepal : Local Partnerships to Prevent HIV Among PWID Timor-Leste : National PLHIV Network Shows the Way CHALLENGES AND FUTURE DIRECTIONS Annex Sri Lanka : Controlling STIs Through a Public Health Approach Thailand : Virtual Elimination of Perinatal HIV Transmission Prevention of HIV Transmission from Mother-to-Child
Selected New WHO Publications in 2010 References Data Notes Tables
ACKNOWLEDGEMENTS We thank the Member countries of the South-East Asia Region for providing the “Country Best Practices”. We acknowledge the assistance of staff in the World latest HIV surveillance and programme data. We are grateful to national experts from the Member countries of the Region for contributing articles in the section Health Organization country offices for their contribution in preparing this report. providing the global data. Mr Santosh Kumar entered data and prepared charts, graphs and maps. Ms Vani Kurup edited and designed the report. Many thanks are due to Michel Beusenberg, WHO and Karen Stanecki, UNAIDS for
FOREWORD This annual 2010 progress report on “HIV/AIDS in the South-East Asia Region” presents key achievements in prevention and control of HIV in the Region and highlights areas where further work is needed.
The Region is home to nearly 3.5 million people living with HIV/AIDS of whom nearly half are likely to be co-infected with TB. A large number of new HIV the agenda for national AIDS programmes. infections are still occurring each year which places HIV prevention at the top of Overall, good progress has been made in reducing heterosexual transmission of HIV through 100% condom use programmes and community-based peer led interventions. There has also been noteworthy success in ensuring safe blood transfusion services averting hundreds of thousands of infections every year. Just a few years ago, access to treatment was a dream for most people living society. with HIV in the Region. Today, more than half a million people living with HIV in the South-East Asia Region are on treatment, living longer and contributing to Despite these successes, there are important shortfalls that need urgent
attention. Countries in the South-East Asia Region have made genuine efforts in expanding HIV testing and counselling facilities yet a vast majority of infected women do not benefit from antiretrovirals resulting in a large number of mother-to-child transmission (PMTCT) of HIV programme in Thailand, children being born with HIV. Effective implementation of the prevention of documented in this report, has demonstrated that it is possible to eliminate HIV other UN organizations in targeting the elimination of perinatal transmission of HIV from the Region. Scaling up of PMTCT services will be possible only with effective collaboration between HIV programmes and the maternal and child for delivery of HIV interventions. services and by increasing the implementation capacity of the health systems Stigma, discrimination and marginalization of people living with HIV, sex among children. We call upon our Member States to join the efforts of WHO and people remain unaware of their HIV status. Two of three HIV-infected pregnant
workers, men who have sex with men, transgenders and people who inject drugs are other important hurdles in combating HIV/AIDS. Unless concerted actions not succeed in providing health services to the affected populations. Finally, meeting the Millennium Development Goals. In these times of economic sustain their commitment to fight the HIV/AIDS battle. recession, we urge national governments and all developmental partners to shortfalls in funds still exist in almost every country to achieve the targets for are taken to wipe out stigma from health care and community settings, we will
Dr Sangay Thinley, MD, MPH World Health Organization
Director, Communicable Diseases Regional Office for South-East Asia
ACRONYMS 3TC ACTG AIDS ANC ART AZT ARV BBS CCC CBO DPR Korea FSW GoB GAVI GFATM HBV HCV HIV HMIS IBBS ICTC IHC IPT MARP MSM NAC
lamivudine
antenatal clinic antiretroviral zidovudine
acquired immunodeficiency syndrome antiretroviral therapy/treatment
AIDS Clinical Trials Group
NACO NAP NASP NGO NTP NVP OST PHL NFHS
National AIDS Control Organization National AIDS Programme National Family Health Survey nevirapine National AIDS/STD Programme National Tuberculosis Programme
nongovernmental organization
biological and behavioural survey community-based organizations Community Care Centres female sex worker Democratic People’s Republic of Korea
NYSC OPD
National Youth Services Council out-patient department people living with HIV opioid substitution therapy Public Health Laboratory prevention of mother-to-child transmission people who inject drugs
Global Alliance for Vaccines and Immunization Global Fund to Fight AIDS, Tuberculosis and Malaria hepatitis B virus hepatitis C virus human immunodeficiency virus herpes simplex virus-2 Government of Bangladesh
PLHIV SACS SEAR STD STI TB TG T&C THC TRG PWID
PMTCT
State AIDS Control Society South-East Asia Region
sexually transmitted infection tuberculosis transgender testing and counselling
sexually transmitted disease
HSV-2
Health Management Information System
Integrated Biological and Behavioural Surveillance Integrated HIV Care isoniazid preventive therapy most-at-risk populations men who have sex with men Ministry of Public Health
Intergrated Counselling and Testing Centre
UNAIDS UNFPA USAID WHO YFHS UNODC
the joint United Nations Program on HIV/AIDS United Nations Population Fund United States Agency for International Development Youth Friendly Health Services World Health Organization United Nations Office on Drugs and Crime
Technical Resource Groups
Township Health Centre
MOPH
National AIDS Committee
The HIV epidemic remains a serious public health concern globally with a large number of preventable new HIV infections occurring each year and millions of living with HIV in the world. people dying prematurely of AIDS. In 2009, an estimated 33.3 million people were
HIV epidemic situation in the South-East Asia Region I
An estimated 3.5 million people were living with HIV/AIDS in the South-East living with HIV. deaths.
Asia Region in 2009. Women account for 37% of the total number of people Annually, there are an estimated 220 000 new HIV infections and 230 000 AIDS Five countries (namely India, Indonesia, Myanmar, Nepal and Thailand) account for the majority of HIV infections. No case of HIV has been reported from the Democratic People’s Republic of Korea. Bangladesh, Bhutan, Maldives, in the Region.
I I
Sri Lanka and Timor-Leste together represent less than 1% of all HIV infections I
The number of new infections every year is showing a downward trend in four of the five high HIV burden countries (namely India, Myanmar, Nepal and Thailand). In Indonesia, the HIV epidemic is still on the rise. the second most common mode of HIV transmission.
I I
The majority of HIV infections are transmitted sexually; injecting drug use is The South-East Asia Region accounts for nearly 15% of the global burden of new HIV-positive tuberculosis (TB) cases. HIV prevalence among new TB patients is 5.7%.
I
The overall HIV prevalence among the adult population is very low (0.3%) in the Region, but sex workers and their clients, men who have sex with men, HIV. transgenders and people who inject drugs are disproportionately affected by
I
In some areas, HIV prevalence has decreased among female sex workers; inject drugs, men who have sex with men and transgenders.
however, there is evidence of continuing high transmission among people who Prevalence of sexually transmitted infections is very high particularly among sex workers, men who have sex with men and transgender populations.
I
Health sector response to the HIV epidemic I
Consistent condom use is reaching high levels among sex workers; however, Coverage of a comprehensive package of HIV interventions for people who
men who have sex with men and transgenders have low rates of condom use. inject drugs continues to be low.
I
A programme for the elimination of congenital syphilis is being scaled up in many of the Region’s Member countries. Reported screening of pregnant women for syphilis is over 50% in India and Myanmar, and 80% in Sri Lanka.
I I
Resistance to ciprofloxacin (an antimicrobial to treat gonorrhoea) is very high, ranging from 75% in Thailand to 92% in Sri Lanka. Based on 2008 data, 10.5 million units of blood were collected against a total
requirement of 17 million units. About 71% blood was collected from voluntary non-renumerated donors. Overall, 0.32% of screened blood units were found to be positive for HIV antibody.
I
A large number of facilities provide testing and counselling services resulting in approximately 15.1 million people being tested in 2009 across the Region. far below optimal levels. Access to testing and counselling services for most-at-risk populations is still
I
Barely 18% of pregnant women have access to HIV testing and counselling. Of the estimated HIV-infected pregnant women, 34% received antiretroviral prophylaxis. Currently, 577 000 people with advanced HIV infection are receiving
I
antiretroviral treatment. But these numbers represent only 32% of those in 65–92% are alive and on treatment 12 months after start of therapy.
need of treatment as per latest WHO criteria. Of those started on treatment, I
Countries with HIV–TB dual epidemics have made substantial progress in patients is still low.
implementing collaborative activities; however, detection of HIV–TB coinfected Substantial progress has been made in expanding surveillance systems in the Region leading to a better understanding of the national epidemics. There is scope to improve routine programme monitoring systems to better track progress towards programme goals.
I
I
HIV drug resistance surveys completed in three countries — India, Indonesia and Thailand — indicate a low level of transmitted drug resistance.
Challenges and future priorities
Key challenges in achieving universal access to HIV prevention, care and treatment services include: continuing stigma and discrimination faced by people living with HIV and most-at-risk populations; limited capacity of health systems; still high for the future in light of these challenges are listed below. prices of antiretroviral drugs; and lack of sustained finances. The critical priorities 1. Reducing HIV transmission among most-at-risk populations. Minimizing HIV2. Reducing perinatal HIV transmission by increasing access to prevention of mother-to-child treatment services for pregnant women by integrating HIV services with related health services. people to know their status.
associated stigma and discrimination in community and health care settings.
3. Decentralizing HIV testing and counselling services further to enable more 4. Ensuring timely access to treatment and improving the quality of antiretroviral treatment. Providing treatment adherence support and close monitoring to “slow” the development of HIV drug resistance.
5. Continuing advocacy for reducing prices of antiretroviral drugs. implementation capacity for scaling-up HIV interventions. research on priority topics.
6. Investing in building health systems and human resources to increase the 7. Strengthening epidemiologic capacity at the country level and undertaking
The Global HIV Epidemic Globally, the HIV epidemic continues to remain a serious public health problem with an estimated 33.3 million (31.4–35.3 million) infected with HIV, Region-wise globally a stable trend in HIV prevalence is being noted.
People’s Republic of Korea (DPR Timor-Leste — and is home to a
Korea), India, Indonesia, Maldives,
Myanmar, Nepal, Sri Lanka, Thailand, population of 1.8 billion. Tables A1– A3 in the Annex provide selected socio-economic and health countries. information on the demographic, infrastructure profiles of each of the WHO South-East Asia Region Member
people currently living with HIV [1]. differentials exist. In recent times,
While 0.8% of the adult population is
Magnitude and Trends in HIV Infection In the South-East Asia Region the with an estimated 3.5 million
In 2009, an estimated 2.6 million infections occurred in low- and
(2.3–2.8 million) people were newly
infected with HIV. The majority of new middle-income countries. The number of new HIV infections decreased by approximately 16% from 2001 to 2009. In 2009, an estimated illnesses. people died due to AIDS related
overall adult HIV prevalence is 0.3% (3.2 million–4.0 million) PLHIV. The magnitude of HIV infection differs greatly between countries in the Indonesia, Myanmar, Nepal and countries, Bangladesh, Bhutan, Region. Five countries account for
1.8 million (1.6 million–2.1 million)
majority of the burden, namely India, Thailand. No case has been reported from DPR Korea. The remaining five Maldives, Sri Lanka and Timor-Leste, total HIV burden in the Region. The widely from <100 in Maldives to page 2 and Table 1 on page 5). have low level or concentrated epidemics; however, adult HIV Papua Province in Indonesia. estimated number of PLHIV ranges 2.4 million in India (see Figure 1 on Majority of the countries in the Region prevalence above 1% is noted in
Women account for 51% of people WHO Regions. An estimated living with HIV in the world.
living with HIV (PLHIV), although this proportion varies among the various 2.5 million (1.6 million–3.4 million)
together represent less than 1% of the
children under 15 years are currently
HIV Epidemic in the South-East Asia Region The WHO South-East Asia Region comprises 11 countries — Bangladesh, Bhutan, Democratic
Thailand, north-east India, and the During 2009, an estimated 220 000
(190 000–260 000) people were newly
Fig. 1: Estimated HIV burden in the South-East Asia Region, 2009
DPR Korea
Nepal Bhutan
% of adult population infected with HIV Myanmar
India Thailand
Bangladesh
<0.1% 0.1–0.49% 0.5–0.99% >1.0%
Sri Lanka
Maldives Indonesia
Timor Leste
Source: Country reports, national AIDS programmes, Member countries, South-East Asia Region.
infected with HIV and 230 000
(200 000–270 000) died due to AIDS related illnesses. The estimated 31%, from 320 000 in 2001 to number of new infections dropped by 220 000 in 2009, indicating that the HIV epidemic is declining in the differences in incidence exist South-East Asia Region. Country-wise (Figure 2). Thailand was the first country to record a drop in HIV late 1990s to early 2000. HIV Indonesia. incidence in the early 1990s, followed by India, Myanmar and Nepal in the incidence is still on the rise in Overall, the estimated number of PLHIV (both male and female) is shown). Within countries, HIV decreasing in the Region (data not prevalence is higher among urban than rural areas. A large household survey HIV prevalence to be 40% higher in urban than in rural areas (61% for women and 28% for men) [2]. In conducted in six states of India found
countries with a low HIV burden, such as Bangladesh, Sri Lanka and TimorLeste, HIV is mainly concentrated in large urban areas. In Timor-Leste, the sentinel surveillance [3]. In
majority of the HIV positive cases were detected in the capital city Dilli, during Myanmar, HIV prevalence among antenatal clinic attendees was 1.3% P<.001) among rural sites [4].
(104/7766) among urban surveillance
sites and much lower (0.4%; 23/5367;
Modes of Transmission
While there is much diversity in the
HIV epidemic among countries of the Region, unsafe sex and injecting drug use are the main drivers (Figure 3). Myanmar, Sri Lanka, Thailand and Timor-Leste. In Bangladesh and Indonesia injecting drug use due to injecting drug use. Sexual transmission accounts for the
majority of the cases in Bhutan, India,
epidemics are significant. Maldives
has a growing threat of HIV epidemic
Fig. 2: Estimated number of new HIV infections in the South-East Asia Region, 1990–2009 450 Estimated number of new HIV infections (in thousands) 400 350 300 250 SEAR 200 150 Thailand 100 50 0 1990 1992 1994 Myanmar Indonesia Nepal 1996 1998 2000 2002 2004 2006 2008 2009 India
Note: Number of new infections estimated by Spectrum model using surveillance data reported by national AIDS programmes, Member countries, South-East Asia Region.
Fig. 3: Distribution of reported HIV/AIDS cases by mode of transmission, South-East Asia Region, 2009 100
80 % of HIV/AIDS cases
60
40
20
0 India Thailand unsafe sex injecting drug use unsafe blood Myanmar Indonesia Nepal mother-to-child transmission others/unknown
Source: Country reports, national AIDS programmes, Member countries, South-East Asia Region.
There is also diversity in epidemics within the countries of the Region. Indonesia has two different epidemics: Papua has a heterosexual epidemic with HIV prevalence above 1% in the Indonesia, the epidemic that began general population, while in the rest of among people who inject drugs spread through the sexual networks of people who inject drugs to sex workers and their clients. In India, the northhave significant epidemics among
the global burden [5]. Five countries in also have a high TB burden (Table 1). The incidence rate of HIV-positive TB cases was the highest in Myanmar, followed by Thailand, India and 000 population in Bangladesh, Indonesia. The incidence rate of HIVMaldives, Sri Lanka and Timor-Leste. HIV-positive TB cases in the Region. Overall, HIV prevalence among TB cases is 5.7%, but it varies widely among countries. Regular HIV
the Region with the highest HIV burden
positive TB cases was below 1 per 100 India accounted for the majority of new
eastern states bordering Myanmar still people who inject drugs and new areas in the north are emerging with high in southern India, HIV is injecting drug use epidemics. However, predominantly driven by heterosexual as well as same sex risky behaviours.
surveillance among new TB patients surveillance was carried out, HIV 2010, a sentinel surveillance
has been conducted in Myanmar since 2006. In 2009, across 15 sites where in Loikaw to 26% in Monywa [4]. In Timor-Leste, showed 1.13% (0.29– 3.04%) to be positive for HIV [3]. prevalence was 9.2%, ranging from 2% conducted among 266 TB patients in
HIV–TB Coinfection
Globally, there were an estimated
1.2 million incident HIV-positive TB
cases in 2009; the WHO South-East
Asia Region accounts for nearly 15% of
Country
HIV prevalence Estimated people living with HIV Adult population infected with HIV
Prevalence of all forms of TB Number Rate per 100 000 population
HIV prevalence among new TB cases
Number
Incidence of HIV-positive TB cases
Rate per 100 000 population
HIV Among Women and Children An estimated 1.3 million
in the Region, except Bhutan and
Timor-Leste, female-to-male ratio for are among women. Of the 168
HIV infection is less than 1; in Bhutan, approximately 50% of the HIV cases in Timor-Leste, 52% are women. HIV/AIDS cases cumulatively reported Over time, the proportion of females among the reported HIV/AIDS cases
(1.2–1.6 million) women (aged 15
years and above) are currently living the Region (37%) is lower than the
with HIV in the South-East Asia Region. The proportion of women with HIV in global average (51%). In all countries
Fig. 4: Percentage of females among reported AIDS cases, South-East Asia Region, 1990–2009 50
40
% of females
30
20
10
0 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009
Source: Country reports, national AIDS programmes, Member countries, South-East Asia Region.
gradually increased in all countries, although this proportion has stabilized in the past few years (see Figure 4 on previous page). Gender inequality, male dominance, stigma, services are some of the key issues HIV in the Region. for higher vulnerability of women to The estimated number of children low literacy and barriers to health care
These include female sex workers, have sex with men (Figure 5) and HIV infection in these population men who have sex with men and general population [4,6].
people who inject drugs, men who transgenders. The following section presents the magnitude and trends of groups, e.g. in Myanmar and Thailand, people who inject drugs have 20–40 times higher HIV prevalence than the
living with HIV increased from 89 000 in 2001 to 130 000 in 2009, a 46% prevention of mother-to-child increase. Due to low coverage of the transmission (PMTCT) programme in the South-East Asia Region, a large mothers acquire HIV infection perinatally. number of babies born of HIV-positive
Female sex workers
HIV prevalence data for female sex surveillance sites from nine of 11 and DPR Korea) for 2007–2009
workers, available from 281 sentinel countries in the Region (except Bhutan showed that prevalence varied widely across the Region (Figure 6). In 33% sites, HIV prevalence among female was 1–5%, and in a quarter of the sex workers was <1%, in 39% sites it sites it was 5–20%. The highest HIV prevalence among female sex workers having HIV prevalence above 20% —
HIV Among Most-at-Risk Populations Although the overall HIV prevalence in the Region is only 0.3%, certain population groups are highly affected.
is noted in southern India with six sites
Fig. 5: HIV prevalence by population group, Myanmar and Thailand, 2009 40 Thailand Myanmar
30 % infected with HIV
20
10
0
PWID
MSM
FSW
Military recruits
ANC attendees
Sources: 2009 HIV sentinel surveillance report, National AIDS Programme, Ministry of Health, Myanmar; 2009 HIV sentinel surveillance report, National AIDS Programme, Ministry of Public Health, Thailand. PWID=people who inject drugs; MSM=men who have sex with men; FSW=female sex workers; ANC=antenatal clinic
Fig. 6: Percentage of female sex workers infected with HIV, South-East Asia Region, 2007–2010
% of sex workers infected with HIV nil 0–4.9% 5–9.9% 10–14.9% 15–19.9% > 20%
Source: Sentinel surveillance reports of national AIDS programmes, South-East Asia Region. The latest available surveillance data is used from each country: Bangladesh and Indonesia-2007; Maldives and India-2008 and Nepal, Myanmar, Sri Lanka and Thailand-2009, Timor-Leste-2010.
Namakkal in Tamil Nadu (22%); Mumbai in Maharashtra (30%);
Kolhapur in Maharashtra (26%);
Myanmar and Thailand, and remained consistently below 5% in Bangladesh, Nepal and Sri Lanka. In India, HIV prevalence decreased by a third from 10.2% in 2003 to 6.6% in 2008 at Analyses of trends among young female sex workers available from consistent sentinel surveillance sites. India and Myanmar indicate a slow
Warangal in Andhra Pradesh (27%); Bagalkot in Karnataka (34%); and Pune in Maharashtra (41%) [7]. In followed by Bali (14%) and Batam (12%) [8]. Myanmar also has significant HIV prevalence among
Indonesia the highest HIV prevalence was recorded in Tanah Papua (16%)
but steady decline in HIV prevalence Indonesia, and has remained Mumbai).
female sex workers with all five sites In Thailand, HIV prevalence among all except four of 51 sites. In Bangladesh, Maldives, Nepal and
in the past years (Figure 7). However,
showing HIV prevalence above 5% [4]. female sex workers was below 5% in Timor-Leste HIV prevalence among was undetected among female sex
HIV prevalence is increasing in Papua, consistently very high in some sites in India during the past five years (e.g. In conclusion, while HIV prevalence among female sex workers has persist. generally declined in many countries, pockets of high transmission still
female sex workers was below 5% in all sites [3,9–11]. In Sri Lanka, HIV workers in all eight sentinel sites [12]. Available trend data analysed from seven countries showed that HIV significantly decreased in India, prevalence among female sex workers
Transgenders and men who have sex with men Surveillance conducted at 88 sentinel sites in seven countries among men
Fig. 7: HIV prevalence among female sex workers aged 15–24 years, India and Myanmar, 2003–2009 50 % of female sex workers infected with HIV
40
30
20
10 India 0 2003 2004 2005 2006 2007 2008
Myanmar
2009
Sources: Sentinel surveillance reports, National AIDS Programme, Myanmar; Sentinel surveillance reports, National AIDS Control Organization, India.
who have sex with men and
transgenders showed a high HIV prevalence in this group in four and Thailand). The highest HIV countries (India, Indonesia, Myanmar prevalence was found in Mandalay (27%) in Andhra Pradesh state in (32%), Kadappa (33%) and Warangal India, Bangkok (25%), and Thiruvallur Pradesh state in India all five menwho-have-sex-with-men surveillance (22%) in Tamil Nadu, India. In Andhra sites had HIV prevalence above 10%
prevalence ranged from 14% to 34% among Warias (Bandung 14%; Surabaya 25%; Jakarta 34%); this (Bandung 2.0%; Surabaya 5.6%; Jakarta 8.1%) [13]. was four to seven times higher than among men who have sex with men
Analyses of trends show that there is who have sex with men. In fact, an
ongoing HIV transmission among men increase in HIV transmission is noted in several urban locations (Figure 8). In Bangkok, HIV prevalence among from 17% in 2003 to 25% in 2009 [6]. In Bengaluru, India HIV men who have sex with men increased prevalence showed an increasing trend — 11% in 2003 to 16% in 2009 [7]. In Nepal, however, HIV prevalence past five years [14]. among men who have sex with men
[7]. HIV prevalence was below 5% in
Nepal and Sri Lanka [12,13]. HIV was undetected among men who have sex [9,11]. with men in Bangladesh and Maldives HIV prevalence is even higher among sentinel surveillance in Mumbai showed HIV prevalence among the who have sex with men group in
the transgender population. The 2008 transgender population (16%) to be Mumbai (9.2%). In Indonesia, HIV
remained consistently below 5% in the
approximately double that in the men
People who inject drugs
HIV surveillance undertaken during 2007–2009 in 99 sentinel sites
Fig. 8: HIV prevalence among men who have sex with men, selected cities, South-East Asia Region, 2003–2009 50 2003 2005 2007 2009
% men who have sex with men infected with HIV
40
30
20
10
0
Bangkok
Phuket
Bengaluru
Yangon
Mandalay
Source: Sentinel surveillance reports, national AIDS programmes, South-East Asia Region.
Fig. 9: HIV prevalence among people who inject drugs, South-East Asia Region, 2007–2009
% of people who inject drugs infected with HIV nil 0–4.9% 5–9.9% 10–14.9% 15–19.9% > 20%
Source: Sentinel surveillance reports of national AIDS programmes, South-East Asia Region. The latest available surveillance data is used from each country: Bangladesh and Indonesia–2007; Maldives and India-2008 and Nepal, Myanmar, Sri Lanka and Thailand–2009.
showed that HIV prevalence among in 18 sites (see Figure 9 on facing
people who inject drugs varied from
Punjab. Seventeen of 50 sentinel sites in India had HIV prevalence >10 and north-eastern states. among people who inject drugs — most of these sites are in the north Analyses of trends reveal an overall decline in HIV prevalence among several old HIV epidemics have been otherwise controlled. For young people who inject drugs in India and Myanmar (Figure 10). However, remained uncontrolled over many
less than 1% in 39 sites to above 20% page). Indonesia has the most severe injecting drug use epidemics; in all both Thailand and Myanmar, HIV four sites >40% of people who inject drugs were infected with HIV [15]. In prevalence among people who inject drugs was 35%. In Bangladesh, HIV among people who inject drugs was HIV prevalence of 7%. No HIV case Lanka and Timor-Leste have epidemics. insignificant injecting drug use A wide variation in HIV prevalence was noted within countries. For example, in Myanmar, HIV prevalence among 19% in Yangon to 54% in Myitkyina. people who inject drugs ranged from In India, HIV prevalence ranged from 0% in some sites to 56% in Amritsar, undetected in 20 of 27 sites, but one neighbourhood in Dhaka city had an was detected in Maldives. Bhutan, Sri
years even in countries where HIV has example in Bangkok, HIV prevalence remained above 30% in the past 20 years although HIV is successfully state in India, the overall HIV controlled in Thailand. In Tamil Nadu prevalence has significantly declined, Chennai city (the state capital) HIV in 2008. In India, HIV prevalence among people who inject drugs in increased from 27% in 2000 to 36% some cities has been above 20% in but among people who inject drugs in
the past 10 years. In Manipur, where
Fig. 10: HIV prevalence among people who inject drugs aged 15–24 years, India and Myanmar, 2003–2009 50 % of young people who inject drugs infected with HIV
40
30 Myanmar 20
10 India 0 2003 2004 2005 2006 2007 2008 2009
Sources: Sentinel surveillance reports, National AIDS Programme, Myanmar; Sentinel surveillance reports, National AIDS Control Organization, India.
injecting drug use epidemics first
started in India, HIV prevalence was 26% in 2003 and 29% in 2008 at consistent sentinel sites. Moreover, new pockets of high HIV transmission have emerged in the northern states of India — Amritsar (56%), Bhopal (40%) in Madhya Pradesh, Ropar Nepal is the only country where are noted. In Kathmandu, HIV 2003 to 21% in 2009 [16]. (36%) in Punjab and Delhi (19%). consistent declines in HIV prevalence prevalence declined from 68% in
military recruits was 1.6% and 0.57% in Myanmar and Thailand, respectively. In Thailand, a distinct drop in HIV prevalence was noted in the early 1990s, consistent with the same time (Figure 11). In Myanmar too, HIV prevalence among young military recruits seems to have decline in the overall epidemic at the
stabilized for the past few years. HIV data among uniformed personnel is unavailable from other countries.
Antenatal clinic attendees the largest population under
HIV Among the General Population Military recruits
Antenatal clinic (ANC) attendees are surveillance in the South-East Asia to access and it is inexpensive to Region as this group is relatively easy conduct surveillance for this group. For practical convenience, surveillance in the ANC attendees group is used as a surveillance is largely carried out in proxy for HIV in the general population with some adjustments. ANC attendee India (643 sites), Myanmar (34 sites) and Thailand (67 sites). In 2009, the
Data among military recruits reflects in HIV infection among military
HIV prevalence among the young male general population. Long-term trends recruits from surveillance data are In 2009, HIV prevalence among
available from Myanmar and Thailand.
Fig. 11: HIV prevalence among military recruits, Myanmar and Thailand, 1989–2009 5 % of military recruits infected with HIV
4
3
2
Myanmar
1 Thailand 0 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009
Sources: Sentinel surveillance reports, National AIDS Programme, Myanmar; Sentinel surveillance reports, National AIDS Programme, Thailand.
average HIV prevalence in Myanmar, 0.6%, (range: 0–3.9%) respectively. Wide variations are noted within was undetected in 38% of the sites of 643 sites (134 of 643 sites) had 0–4%), 0.77% (range: 0–3.2%) and
Thailand and India was 0.96% (range:
four — chlamydia, gonorrhoea,
syphilis and trichomonas) present infection due to trichomonas was
globally in 2005, 71 million were in
the South-East Asia Region. Of these, most prevalent (38.6 million), followed by gonorrhoea (22.7 million) whereas chlamydia (6.6 million) and syphilis lower [17]. (2.9 million) infections were relatively Sexually transmitted infections are at-risk populations, particularly men due to a high turnover of partners (Figure 13).
countries. For example, in India, HIV (246 of 643 sites), while nearly 20% HIV prevalence above 1% and six sites Manipur and Nagaland in the northeast, Maharashtra, as well as 3%. had HIV prevalence above 3%. Sites in Karnataka and Andhra Pradesh in the
disproportionately high among mostamong female sex workers and their clients, and men who have sex with
south showed an HIV prevalence above Analyses of trends show that HIV is Myanmar and Thailand (Figure 12). states of India, namely Gujarat,
declining in three countries — India, Increasing trends are noted in some Orissa, Rajasthan and West Bengal.
In Indonesia, prevalence of one or (active syphilis, chlamydia or
more sexually transmitted infections gonorrhoea) ranged from 38% to 75% among direct sex workers in seven prevalence of one of the three cities. Among indirect sex workers, sexually transmitted infections was relatively lower (29–39%) [8]. The
Sexually Transmitted Infections Of the 448 million sexually transmitted infections cases (mostly
Fig. 12: HIV prevalence among antenatal clinic attendees in high HIV burden countries, South-East Asia Region, 2000–2009 % of antenatal clinic attendees infected with HIV 3
2
1 India
Myanmar Thailand
0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Sources: Sentinel surveillance reports, National AIDS Programme, Myanmar; Sentinel surveillance reports, National AIDS Control Organization, India; Sentinel surveillance reports, National AIDS Programme, Thailand.
Fig. 13: Prevalence of sexually transmitted infections, by population group, Indonesia, 2007 40 Gonorrhoea Chlamydia Syphilis
30 STI prevalence (%)
20
10
0
Direct FSW
Indirect FSW
Waria (transgender)
MSM
Source: Integrated Biological and Behavioural Survey 2007, Ministry of Health, Indonesia. FSW=female sex worker; MSM=men who have sex with men.
prevalence of any sexually transmitted infection (syphilis, gonorrhoea or chlamydia) among female sex workers in India ranged from a low of 7.6% in a high of 58% in Yevatmal District of Maharashtra [18]. Syphilis was the predominant bacterial sexually transmitted infection in most of the Prakasam District, Andhra Pradesh to
Leste; and 6% among men who have 21]. Syphilis prevalence among men who have sex with men ranged from
sex with men in Addu, Maldives [9,20, 3.5% to 18% in India, 3.2% to 5.6%
in Indonesia and 5.5–7% in Myanmar high: 25–29% in Indonesia, 17% in India and 8% in Bangladesh [11,14,18]. Chlamydia and
[4,18,22]. Syphilis prevalence data for
transgenders, where available, are also
districts across five high burden states (3.1–51%). Prevalence of gonorrhoea were generally on the lower side. The prevalence of herpes simplex virus-2 (HSV-2) antibody among female sex workers was very high and ranged 96% in Pune. from 34% in Chennai and Thane to Similarly, a very high prevalence of (0–9.3%) and chlamydia (0.9–14.2%),
gonorrhoea infections are high among men who have sex with men and transgender populations. In Indonesia, prevalence of rectal chlamydia among transgenders (23–35%) is relatively sex with men (19–22%) [14,22]. Nepal the prevalence of rectal higher than that among men who have In men who have sex with men in gonorrhoea and chlamydia was 13% and 5%, respectively and that of infections was 0.8% and 2.5%, respectively. Among the general population, urethral gonorrhoea and chlamydia
HSV–2 among men who have sex with men who have sex with men hepatitis B virus prevalence is also high: 73% with men in Bangkok; 13% among
men was noted in the Region: 15–78% in India [19]; 40% in Bangkok [20]. In among HIV-positive men who have sex men who have sex with men in Timor-
syphilis prevalence among ANC
attendees was 0.24% ranging from 0 in Maldives to 1.2% in Indonesia1. Decreasing trends in syphilis among ANC attendees were reported from several states in India and Myanmar. In many countries, overall trends in sexually transmitted infection rates
Sri Lanka, incidence of bacterial the past 10 years.
sexually transmitted infections have
remained stable at very low levels for In Thailand, the reported sexually population for many years2.
transmitted infection cases remained constant at about 20 per 100 000
have remained stable or declined. In
Universal access, country reports, 2009. Thailand Poster, National AIDS Progamme, Ministry of Public Health, Thailand. Presented at the South-East Asia Region Programme Managers Meeting, New Delhi, India, 26–28 October 2010. 1 2
The health sector response to the HIV epidemic is spear-headed by the conjunction with national and national AIDS programmes of health ministries of Member countries in international nongovernmental organizations (NGOs), the United
Good progress has been reported towards these objectives in the Region. Half the countries in the recent clients (Figure 14). region reported high levels (>80%) of
condom use by sex workers with their With regards to control of sexually transmitted infections, there is continuing evidence from research interventions for sex workers are working and have helped reduce and evaluation studies that prevention sexually transmitted infections and HIV. A comprehensive programme in Indonesia showed doubling of condom use and a steady and among 580 brothel-based sex workers significant decline in prevalence of Pre- and post-intervention crosssectional surveys in areas where Avahan interventions were
Nations and other developmental
partners. The following sections present the status and progress in the health sector response to the HIV epidemic.
Prevention of HIV Transmission in Mostat-Risk Populations Given that certain population groups, namely female sex workers and their clients, men who have sex with men, and people who inject drugs are disproportionately affected and contribute significantly to the
gonorrhoea and chlamydia infections over the period of interventions [23].
transmission of new HIV infections, prevention interventions for these populations is a priority for national a daunting task due to lack of stigma and discrimination. AIDS programmes. However, providing health services to these populations is enabling environment, as well as
implemented in Karnataka state in HIV, syphilis, gonoccocal and
India showed notable improvements in condom use and significant decline in Bangladesh, prevalence of active all sites [25]. Analyses of trends showed a reduction in sexually chlamydia infections [24]. Similarly, in syphilis decreased consistently among brothel-based female sex workers at among female sex workers in Nepal, transmitted infection rates in 22 Terai highway districts. Prevalence of gonorrhoea decreased significantly from 13.5% to 1.2% and that of chlamydia from 10% to 8.3% during use was reported during the same time (Figure 15). 2003–2009 [10]. Increased condom
Interventions for Sex Workers condom use, (ii) reducing curable counselling, care and treatment services.
Three key objectives of interventions sexually transmitted infections, and
for sex workers include (i) increasing (iii) improving access to HIV testing,
Fig. 14: Percentage of female sex workers reporting condom use with their most recent client, South-East Asia Region 100
80 % of female sex workers
60
40
20
0 Sr i 20 Lan 06 ka te an g 20 lad 07 es h M ya 20 nm 08 ar Th a 20 ila 09 nd m o 20 r-L 10 es In do 20 ne 07 sia N 20 epa 09 l In 20 dia 06
Ti
Source: Reports of behavioural surveys, national AIDS programmes, Member countries, South-East Asia Region. Note: The latest available data for each country was used.
Fig. 15: Prevalence of sexually transmitted infections and condom use among female sex workers, Terai Region, Nepal, 2003–2009 Chlamydia Syphilis Gonorrhoea Consistent condom use in last year Condom use with the last client 100 % of female sex workers using condoms
14 Sexually transmitted infections prevalence (%) 12
B
80 10 8 6 4 20 2 0 0 60
40
2003
2006
2009
Source: Integrated biological and behavioural survey among female sex workers in 22 Terai Highway Districts of Nepal 2009, National Centre for AIDS and STD Control, Nepal.
Limited data are available on access to care and treatment among sex workers.
based lubricants; and referrals to HIV and sexually transmitted infections screening and treatment. From the available information, only India seems to have relatively
Interventions for Men who Have Sex with Men 1
comprehensive operational guidelines for implementing HIV prevention with men. interventions among men to have sex The WHO, Joint United Nations
Creating an enabling environment and providing access to essential services for the men who have sex with men that interfere with HIV prevention, Region. Removal of all legal barriers aspect of an enabling environment, and Thailand) is sex between criminal sanctions against consenting same-sex adults not a population remains a challenge in the treatment and care activities is a key yet in only two countries (Indonesia criminal offence. Other countries have “homosexual behaviour” that present substantial obstacles to HIV prevention for men who have sex with men. In 2009 in India, the Delhi High relations between adults in private cannot be criminalized. Soon after were lodged. In Timor-Leste, the between adult males is legal. Court ruled that consensual same-sex that judgment, appeals in the Indian Constitution does not specify if sex Most countries in the Region have
Programme on HIV/AIDS (UNAIDS) progress report 2010” indicates a
and United Nations Children’s Fund
(UNICEF) “Towards universal access median coverage rate of 49% by HIV have sex with men in the 12 months preceding the survey in East, South and South-East Asia, which is well prevention programmes for men who
short of the 80% expected coverage coverage of men who have sex with receiving HIV prevention and
to reverse the HIV epidemic. The low men and transgender populations for treatment programmes indicates the can be reached, using the most appropriate approach to meet their need to better understand where they needs, and to accelerate the scale up interventions. The proportion of men who have sex with men reporting condom use in various south-east Asian countries remains below the use protects against HIV and the
Supreme court objecting to the ruling
and quality of HIV prevention and care
some interventions for men who have sex with men, male sex workers and transgender populations, which are Most interventions operate only in areas with few, or no targeted and appropriate agencies to primarily implemented through NGOs and community-based organizations. major urban centres, or one urban centre, leaving semi-urban and rural interventions. Lack of data, funding implement interventions outside in national plans include: peer urban centres remains a significant outreach education; promotion and
expected target. There is a wide gap actual use of condoms among men who have sex with men (Figure 16).
between the knowledge that condom
Harm Reduction Interventions for People Who Inject Drugs increasingly viewed with Harm reduction has been endorsed
globally by the United Nations and is understanding and greater acceptance in the Region. However, despite a regional expansion of harm reduction measures to address the HIV epidemic
response gap. Interventions provided distribution of condoms and water-
1
This section is adapted from “HIV/AIDS among men who have sex with men and transgender populations in South-East Asia: The current situation and national responses. WHO SEARO 2010.”
Fig. 16: Knowledge and use of condoms among men who have sex with men, Timor Leste, 2010
Used condom with casual female partner
Used condom with regular female partner
Used condom with casual male partner
Used condom with regular male partner Know that condom protects against HIV 0 20 40 60 80 100
% of men who have sex with men Source: Integrated bio-behavioral survey, National AIDS Programme, Ministry of Health, Timor-Leste, 2010.
among people who inject drugs
(PWID), the response and coverage of interventions remains insufficient to have a significant impact on the in majority of the countries in the ongoing HIV epidemics among PWID Region. A comprehensive package of HIV prevention, treatment and care address the HIV epidemic among programmes for PWID is advocated to PWID and comprises nine essential interventions. The package has the greatest beneficial impact when all interventions are delivered together nine interventions be delivered, i.e. needle and syringe programmes, opioid substitution therapy (OST),
Leste) and these sites have increased in number. In Indonesia, the site numbers increased from 159 in 2008 increased from 19 in 2008 to 40 in 2009. The number of syringes and 4 million in 2008 to 6.5 million in from 639 801 in 2007–2008 to 15 million in 2009. Myanmar to 281 in 2009 while in Myanmar sites needles distributed also increased in various countries: Bangladesh from 2009; India had a substantial rise witnessed a ten-fold increase in needle and syringe distribution between 2004 (245 000) and 2009 (5 095 301). Despite an increase in needle–syringe programme sites and needles and distributed per PWID per year) as Drugs and Crime (UNODC) and UNAIDS Technical guide: India (N = 67) and Nepal (N = 53). syringes distributed, the coverage is low (i.e. <100 needles and syringes determined by the WHO, UN Office on (N = 81), Indonesia (N = 8), Myanmar Bangladesh reported the highest distribution of needles and syringes
but it is advised that in countries with limited resources at least five of the
condoms, HIV testing and counselling, and antiretroviral treatment (ART).
Needle–Syringe Programmes The majority of countries in the syringe programmes (excluding
Region have implemented needle and Bhutan, DPR Korea, Maldives, Timor-
per PWID per year at 161. In 2009, in India, Nepal, Bangladesh and Indonesia the number of needle–syringe programme sites per 2.3 and 2.7, respectively.
common in many areas (Figure 17). To halt and reverse the ongoing HIV epidemic among PWID a sufficient challenge remains unresolved. number of needles and syringes need
1000 PWID was reported as 1.1, 1.3, The reach of needle–syringe
to be distributed, and this substantial
programmes remains highest in
Bangladesh. In 2008, the proportion of PWID accessing needle–syringe programmes was reported to be In Nepal, the proportion of PWID 44–88%, increasing to 93% in 2009. accessing needle–syringe programmes in a year was reported to be 46%, less than 1%. while in Thailand it was reported to be Information on the frequency and regularity of contact with needle–syringe programmes is not rarely documented. As in previous available and the quality of services is years the 2009 data continue to show that far too few needles and syringes are reaching the PWID in the Region. As a result needle sharing is still
Opioid Substitution Therapy — Methadone and Buprenorphine
Overall few changes have taken place sites respectively — decrease due to to be registered), Indonesia (46 and 49 sites, respectively), Maldives (1), Nepal (2 and 9 [3 methadone; 6 buprenorphine] sites, respectively). and buprenorphine. India will while Bangladesh introduced
between 2008 and 2009, with regard
to OST in the Region: India (63 and 50 specific new prerequisites for OST site Myanmar (7 and 9, sites respectively), Currently only Indonesia, Nepal and introduce methadone in late 2010, methadone in July 2010, and is displaying considerable promise. In 2009–2010, the number of PWID
Thailand allow supplies of methadone
Fig. 17: Percentage of people who inject drugs sharing injecting equipment at last injection, selected cities, South-East Asia Region 100 % of PWID sharing needles at last injection
80
60
40 Chapinawabganj
Surabaya
Manipur
Yangon
Myitkeena
Chandpur
Bandung
Rajshahi
Mumbai
Chennai
20
Jakarta
Medan
Lashio
Dhaka
Delhi
0
Bangladesh 2007
India 2006
Indonesia 2007
Myanmar 2008
Malé
Maldives 2008
Source: Reports of behavioural surveys, national AIDS programmes, Member countries, South-East Asia Region. Note: The latest available data for each country was used. PWID=people who inject drugs
Addu
accessing OST in the Region has enrolments to commence OST:
remained small and no country has witnessed a substantial increase in Bangladesh (108), India (4 800),
weeks when commencing methadone during the stabilization period. Takehome doses of OST following the process of social and economic reintegration of PWID. However, a treating doctor, can assist in the stabilization period, in agreement with
Indonesia (2000 methadone; 2000– 3000 on buprenorphine), Maldives (32), Myanmar (1000), Nepal (262 methadone; 175 buprenorphine1) and
available data show that take-home
Thailand (2200). The total number of PWID in the Region is over 500 000 and those reported to be accessing OST is less than 15 000. The 2009–2010 is <1% to 4%.
doses are not common in the Region. proportion of PWID with take-home 6% in Bali. doses of OST is 20% in Jakarta and In conclusion, despite a significant years, public policy and legislative remain a significant challenge for most countries in the Region. there is a significant reduction in opiate use, injecting practices, psychological status and social major benefits methadone and
Reports from Indonesia show that the
proportion of PWID accessing OST in
each of the countries in the Region in In Indonesia, OST is delivered through health centres, hospitals and prisons/detention centres (Figure 18). Indonesia is the only country in the Region where OST is currently delivered from prisons (N = 6). In India OST is delivered through community-based services. Myanmar is the only country in the Region where a client is required to be an inpatient and hospitalized for two
shift towards greater acceptance of
harm reduction interventions in recent problems with regard to drug use still Following the introduction of OST physical complaints and improved functioning. However, despite these
Fig. 18: Number of sites providing methadone maintenance therapy, by type of facility, 2002–2009 50 at primary health centre at hospital at prison
40
Number of sites
30
20
10
0
2002
2003
2004
2005
2006
2007
2008
2009
Source: Indonesia Poster, National AIDS Progamme, Ministry of Health, Republic of Indonesia. Presented at the South-East Asia Region Programme Managers Meeting, New Delhi, India, 26–28 October 2010. 1
Duration of buprenorphine is limited to three months only.
buprenorphine are still largely in the Region. Needle–syringe
unavailable for the majority of PWID programmes and OST have been in place in most countries for several years and despite good outcomes of small-scale programmes, these have and evaluation are required to
treatment of sexually transmitted public and private sectors. The for the treatment of sexually erythromycin, azithromycin, acyclovir.
infections by all practitioners in the commonly used antimicrobial drugs transmitted infections are penicillin, doxycycline, metronidazole and In the South-East Asia Region, private many people because they are confidentiality, and are less perceived to offer better access and stigmatizing than public sector facilities. Self-medication and direct over-the-counter purchases from infections in this Region. pharmacies is a common form of management of sexually transmitted Although sexually transmitted
not been expanded to reach effective highlight the effectiveness of various assist in tracking the progress towards reaching national HIV target indicators for PWID, and will also reduction in the Region. contribute towards advocacy efforts for a greater acceptance of harm
levels of coverage. Further monitoring harm reduction interventions. This will
providers are often more acceptable to
During 2008–2010, the Regional
Office for South East Asia (SEARO) and operational guidelines on the
supported national harm reduction
programmes by: developing clinical management of opioid dependence capacity on care and treatment of and common health problems among drug users; enhancing national staff through training; and publishing an continuing and emerging HIV HIV-positive people who inject drugs advocacy document highlighting the epidemics among people who inject drugs and the urgency to expand harm reduction interventions in community and closed settings.
infection control varies across the
Region, India, Myanmar, Sri Lanka and Thailand have implemented successful control programmes. Sri Lanka has Region (see page 63). one of the best sexually transmitted infection control programmes in the In Thailand, the 100% condom use demand condom use and access resulting in drastic reductions in recent years, however, sexually sexually transmitted infection care, sexually transmitted infection rates. In transmitted infection cases have been detected with increasing frequency among men who have sex with men improve the quality of services at in provincial hospitals. Ensuring access to sexually transmitted populations, including migrant public health sector. and young heterosexual populations. Recently, efforts have been made to sexually transmitted infection clinics infection services for marginalized workers, remains a challenge for the Enhanced syndromic case
programme enabled sex workers to
Prevention and Control of Sexually Transmitted Infections The control of sexually transmitted infections is the responsibility of the guidelines for the management of on either syndromic or etiologic management or both. These national AIDS programmes. Almost all countries in the Region have national sexually transmitted infections based guidelines aim to ensure uniform
management with minimal laboratory
tests is the cornerstone of sexually transmitted infection/reproductive tract infection management of the Indian National AIDS Control
targeted intervention programmes for most-at-risk populations. The “preferred-provider partnership” scheme was launched in 2009 to at-risk populations.
Programme. Services for the control public health facilities ranging from primary health centres to district hospitals to medical colleges.
of sexually transmitted infections are being delivered through a network of
improve service utilization of sexually transmitted infection clinics by most-
During August to October 2009, NACO organized an external mid-term review of the sexually transmitted infection control programme. The process the implementation of targeted included: a desk review, a review of intervention-sexually transmitted infection services in six states and analyses of programme data. Key to build capacity of targeted recommendations of the review were interventions for sexually transmitted infection service delivery to most-atrisk populations; establish a system implementation of 100% syphilis screening in antenatal and sexually at-risk populations, and strengthen for supportive supervision; strengthen transmitted infection clinics for mostcapacity of regional resource centres
Presently, the National AIDS Control Organization (NACO) is supporting clinics that are providing services 916 designated sexually transmitted infection/reproductive tract infection based on enhanced case management [26]. Also, NACO has strengthened infection training, reference and infection cases, monitor drug resistance to gonococci, and is strengthening the sexually seven regional sexually transmitted research centres to improve etiologic diagnoses of sexually transmitted
implement syphilis External Quality transmitted infection/reproductive
Assurance Systems. In addition, NACO tract infection service delivery through
Elimination of congenital syphilis In 2009, SEARO developed the regional guidelines for elimination of congenital syphilis. At a regional intercountry in the Region (i.e. to decrease the incidence of congenital syphilis to below 0.5 per 1000 live births in a country where more than 90% pregnant women are screened for syphilis). The elimination of congenital syphilis will contribute to the achievement of the three Millennium Development Goals on maternal and child health and on and country level. consultation held in March 2009, all countries renewed their commitment to the elimination of congenital syphilis
HIV/AIDS. The regional strategy outlines the guiding principles, key strategies and interventions to achieve the goal of elimination of congenital syphilis. The strategy also proposes initial targets and indicators both at the regional
Sri Lanka launched the national programme for elimination of congenital syphilis in late 2009. Screening pregnant and quality of maternal and newborn health services constitute the two main strategies in this programme. Rapid and communication materials on elimination of congenital syphilis have been developed. Screening of pregnant women for syphilis infection is increasing in some countries of the Region (Figure 19).
women for syphilis and treating women who are seropositive, their partners and newborns and increasing access to treponemal tests for syphilis have been made available at the district level for screening, and information, education
Indonesia revitalized the policy of screening pregnant women for syphilis in 2008 after a gap of 10 years. Antenatal syphilis screening was scaled up to cover six provinces, 12 districts and 75 health centres in 2009. During a threemonth period 4104 pregnant women were screened.
Fig. 19: Coverage of syphilis screening among antenatal clinic attendees, selected countries, South-East Asia Region, 2006–2009 100 2006 2007 2008 2009
% of pregnant women screened
80
60
40
20
0
India
Sri Lanka
Myanmar
Source: Country posters presented at South-East Asia Region Programme Manager Meeting, New Delhi, India, 26–28 October 2010.
to undertake research, conduct surveillance and monitor drug resistance.
and Thailand. Ciprofloxacin resistance ranges from 75% to 92% (Figure 20) to be high. Ciprofloxacin is used to guidelines recommend the use of for Neisseria gonorrhoeae hinders and penicillin resistance also continues treat gonorrhoea particularly by private providers although national treatment cephalosporins. The general lack of control efforts. Such data provide effective treatment. reliable antimicrobial resistance data significant insights and necessary
In Myanmar, the number of people increased from 94 000 in 2008 to 135 000 in 2009, a 44% increase
with sexually transmitted infections receiving treatment during the year
[27]. In addition to the 46 AIDS and sexually transmitted diseases (STD) teams of the Department of Health, of sexually transmitted infections. many NGOs play an important role in
implementing, prevention and control
information for standardized and costSome of the key challenges in
Gonococcal Antimicrobial Resistance Programme Available data show increasing
implementing sexually transmitted decentralized reporting centres, inadequate participation and
infection programmes include lack of laboratory capacity for diagnosis at
antimicrobial resistance to gonorrhoeal infection and treatment failure with of gonorrhoea in the Region. Antimicrobial resistance testing is drugs currently used for the treatment routinely carried out in India, Sri Lanka
compliance by the private sector, lack of regular monitoring and evaluation, interrupted supply of effective drugs available drugs. and increasing resistance to currently
Fig. 20: Percentage of Neisseria gonorrhoeae isolates resistant to quinolones, South-East Asia Region 100 92%
87% 80% 77% 75%
% of drug-resistant isolates
80
60
40
20
0
Sri Lanka 2009
Bangladesh 2008
Indonesia 2004
India 2008
Thailand 2008
Source: Country reports, South-East Asia Region.
Blood Safety Based on 2008 data, 3 456 blood annually, of a total estimated banks in the South-East Asia Region collected 10.5 million units of blood requirement of 17 million units. About 71% of the total blood is collected exist (Figure 21). Two thirds of the of blood are collected annually. from voluntary non-remunerated blood donors, but country-wise variations population of the Region resides in
part of hospital-based clinical blood transfusion services in
laboratories. Red Cross societies manage a major part of national Indonesia, Nepal and Thailand. In
many countries, blood transfusion
services lack adequate resources to update their technology. Moreover, blood banks need to increase their reach to enhance their donor base. Screening for HIV and HBV is almost universal in the South-East Asia Region; hepatitis C virus (HCV) several countries. Screening for infectious markers is of utmost the large number of carriers of decreasing (Figure 22). hepatitis B and hepatitis C. HIV screening has also been initiated in importance in this Region because of seropositivity in screened blood is In 2009, 0.32% of screened blood positive for HIV antibody.
India where more than 6 million units Bangladesh is the only country in this Region that still permits professional blood donors. Overall in the Region, 44% of blood is converted into is transfused as whole blood. components and the remaining 56% Seven countries in the Region have a national blood policy and nine blood transfusion services. In countries have nationally coordinated Myanmar, almost all blood banks are
units in the Region were found to be
Fig. 21: Percentage of voluntary blood donation, South-East Asia Region, 2004–2008 100 % of blood units donated voluntarily 2004 2006 2008
80
60
40
20
ka
nd
ar
n
te es or st e -L e or -L
h
a
a
a
0 ad gl
s
es
ta
ve
re
di
nm
ep
an
ne
la
Ko
hu
do
al
ya
B
iL
N
PR
M
Sr
M
Th
ai
an
D
Source: Country reports, South-East Asia Region. SEAR=South-East Asia Region
Fig. 22: Proportion of screened blood units positive for HIV antibody, South-East Asia Region, 2004–2008 0.7 0.6 % blood units positive for HIV 0.5 0.4 0.3 0.2 0.1 0.0 2004 2006 2008
B
es ia
es h
ka
ta n
ve s
nd
ar
a
a
Ti
m
In
re
di
nm
ep
an
la
Ko
gl ad
hu
on
al
ya
B
iL
N
In d
PR
M
Sr
M
Th
ai
Source: Country reports, South-East Asia Region. SEAR=South-East Asia Region
B
Ti m
an
D
SE
In
di
AR
al
SE
In
di
AR
si
al
HIV Testing and Counselling Continuous increase in the number of people receiving HIV testing and individuals received testing and counselling was noted throughout the Region. Approximately, 15.1 million counselling in 2009 in the Region, number of women receiving HIV Myanmar, Nepal and Thailand prevention of mother-to-child
populations. Based on sample surveys, approximately a third of the most-atamong risk groups as well as among countries. In Myanmar, coverage of calculated based on routine testing and counselling services was programme data (Figure 23). While a positive trend is noted among female men and people who inject drugs. sex workers, coverage continues to be Expectedly, a fraction (0.28%) of the age group received counselling and testing. With the expansion in services, the coverage of HIV testing among the expected to increase. A behaviour survey among young people in sexually active general population is Thailand (vocational students, median age 17 years) indicates an unchanged trend in this population (Figure 24). very low among men who have sex with general population in the reproductive risk populations in the Region received testing and counselling, with variations
nearly 50% more than in 2008. The testing and counselling far exceeded men receiving these services in India, reflecting the contribution of women tested in antenatal services under the transmission programme; whereas in Bangladesh and Indonesia (both concentrated and predominantly injecting drug use driven epidemics) more men than women were tested. During 2009, 8133 health facilities were providing HIV testing and
counselling services throughout the 100 000 population varied widely
Region. The number of facilities per among countries (Table A5). Maldives had the highest number of facilities by Thailand (1.9 per 100 000 adult in Thailand (21 tests per 1000 population), followed by India (3.5 per 100 000 population) followed population). The number of tests per 1000 adult population is the highest (16 tests per 1000 population).
Prevention of HIV Transmission from Mother-to-Child Limited progress has been made in providing access to prevention of >80%) of pregnant women had mother-to-child transmission services. Overall, a mere 18% (range: <5% to access to HIV testing and counselling in 2009. Lack of access to antenatal care services has been cited as a major barrier for expanding HIV testing and counselling among
In several countries, testing and
counselling services are provided both by the government and private/NGO exclusive provider, whereas in sectors. However, in Bhutan, Maldives and Sri Lanka, the government is the Bangladesh almost all testing and counselling services are done by charge in most countries. NGOs. In the public sector, HIV testing and counselling is provided free of Policy guidelines of all countries be targeted for most-at-risk
pregnant women. Universal access to services is improved.
HIV testing and counselling cannot be
achieved unless utilization of antenatal From 2008 to 2009, the proportion of antiretrovirals increased slightly from 28% to 34%. The percentage of HIV-
mention that testing and counselling
HIV-positive pregnant women receiving
Fig. 23: Percentage of most-at-risk populations receiving HIV testing and counselling, Myanmar, 2006–2009 20 % of most-at-risk populations receiving HIV testing and counselling 2006 2007 2008 2009
15
10
5
0
Female sex workers
Men who have sex with men
People who inject drugs
Source: 2009 Annual Progress Report, National AIDS Programme, Myanmar. Note: Numerator is number of most-at-risk populations receiving HIV testing and counselling in 2009; denominator is the estimated population size of most-at-risk populations.
Fig. 24: Percentage of young people1 receiving HIV testing and counselling in the past year, Thailand, 2004–2009 25
% of young people tested for HIV
20
Male
15 Female 10
5
0 2004 2005
2006
2007
2008
2009
Source: 2009 Behavioural Survey, Bureau of Epidemiology, Ministry of Public Health, Thailand, 2009. 1 Vocational trainees, median age 17 years.
infected pregnant women receiving
antiretrovirals varies widely from 5% in Nepal to 85% in Thailand (Figure 25). Thailand is the only country in the Region to have achieved universal
transmission services. Communitybased HIV screening by auxillary nurse midwives to identify HIV-positive cases among pregnant women who do not visit health facilities for antenatal checkups would immensely benefit states with low rate of institutional delivery. Further, testing and to round-the-clock primary health
coverage of prevention of mother-toamong women who were put on and received tripe antiretroviral on page 67.
child transmission services. Perinatal HIV transmission is almost negligible treatment early (CD4>200 cells/mm3) therapy (Figure 26). Further details on the Thailand programme are provided Over 75% of those in need for prevention of mother-to-child transmission services in the Region for universal access will depend on 11 319 (34%) of estimated HIVpositive pregnant women received strategies to increase access to prevention of mother-to-child are in India. Reaching regional targets increasing coverage in India. In 2009, antiretroviral prophylaxis. To increase coverage, NACO has planned several
counselling services will be extended centres under the “facility integrated collaboration with the National Rural Health Mission to improve access to populations living in hard-to-reach walk-in emergency labour room areas. Also, testing of every direct patient will be done using the user friendly “whole blood” finger prick testing. Finally, more convergence and securing the involvement of prevention of mother-to-child progress. transmission services through incentive-based schemes is in Ashas1 in demand generation for with the National Rural Health Mission model” in high prevalence districts in
Fig. 25: Percentage of HIV-infected pregnant women receiving antiretroviral prophylaxis, South-East Asia Region, 2009 100
% of HIV-positive pregnant women receiving antiretrovirals
80
Target
60
40
20
0
Thailand
Myanmar
India
Indonesia
Nepal
SEAR
Source: 2009 universal access country reports, South-East Asia Region. SEAR=South-East Asia Region 1
Village health women volunteers
Fig. 26: Perinatal HIV transmission rate by CD4 status and type of antiretroviral intervention, Thailand, 2009 14 12.5
12 HIV transmission rate (%) 10 8 6 4 2 0
Triple ART AZT/NVP Partial antiretrovirals
11.0
6.1
5.4 3.8
2.8 1.3
CD4<200 cells/mm3 (N=76)
CD4>200 cells/mm3 (N=321)
CD4 unknown (N=514)
Source: Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health, Thailand, 2009. ART=antiretroviral therapy; AZT=zidovudine; NVP= nevirapine
Antiretroviral Therapy The number of HIV-infected persons receiving antiretroviral therapy to 577 000 in 2009 (Figure 27). By was being provided at 1800 health facilities, a 24% increase in the 90% of facilities were in the government sector. increased ten-fold from 55 000 in 2003 December 2009, antiretroviral therapy number of facilities since 2008; nearly
coverage is 48% (range 17% in Nepal to 76% in Thailand) (Figure 28). The total estimated need for
antiretroviral therapy in the Region
based on CD4 counts 350 cells/mm3 1.2 million, respectively. Nearly 90% of the need for antiretroviral therapy is in just two countries — India and Thailand. Both countries have
and 200 cells/mm3 is 1.8 million and
demonstrated successful scale-up of of health facilities providing
Overall, 40% of all PLHIV receiving constitute 4.9% of all those on treatment (Annex, Table A7).
the antiretroviral therapy programme. antiretroviral therapy (1014) in the 2009 (see page 48).
treatment are females (range: 25% in
While Thailand has the largest number Region, India has the largest number of people on antiretroviral therapy in The Region accounts for
Indonesia to 53% in Bhutan). Children
Using the revised WHO guidelines that recommend starting antiretroviral the Region is 32% (range: 11% in therapy at CD4 count 350 cells/mm3, the overall coverage of treatment in Nepal to 61% in Thailand). Using the at CD4 200 cells/mm3, the overall
approximately 5% of all children, globally, in need of antiretroviral therapy. Access to antiretroviral therapy for children is higher in the
previous criteria for starting treatment
Region (42%) compared to the global
average (28%). Two countries — India
Fig. 27: Number of people with advanced HIV infection receiving antiretroviral treatment, by country, 2003–2009 600
500 Number of PLHIV on ART (in thousands)
400
300
200
100
0
2003
2004
2005
2006
2007
2008
2009 Thailand
Bangladesh India
Indonesia Myanmar
Nepal Sri Lanka
Source: 2009 universal access country reports, South-East Asia Region.
Fig. 28: Coverage with antiretroviral therapy, by CD4 count threshold for treatment initiation, South-East Asia Region, 2009 100 % of persons with advanced HIV infection receiving ART CD4 <200 cells/mm3 CD4 <350 cells/mm3 Target
80
60
40
20
ar
si a
ta n
ka
h
ia
d
s
0 la n In d gl ad ai Th
al di ve
al ep N
ne
nm
hu
an
do
ya
B
an
Source: Universal access country reports, 2009. ART=antiretroviral treatment; PLHIV=people living with HIV.
B
In
M
Sr
M
iL
SE
AR
es
and Thailand contribute to the largest number of children receiving antiretroviral therapy in the Region. now been rolled out in several
patients; antiretroviral therapy and cotrimoxazole preventive therapy (CPT) intensified TB case finding among for TB patients infected with HIV; and PLHIV followed by isoniazid preventive therapy (IPT) for those without TB. has been made in countries of the Towards these goals, variable progress South-East Asia Region: 14% of the notified TB cases were tested for HIV against a global average of 26%; the are in the WHO European Region (53%) and WHO Region of the highest HIV testing rates in TB cases (86%) followed by WHO African Region Americas (41%). Of the identified HIV– TB coinfected patients, 75% and 52% Asia Region Member countries; this compares to the global average of therapy (Figure 29). Barely 1000 were started on CPT and antiretroviral therapy, respectively in the South-East
Second-line antiretroviral therapy has countries in the Region. Thailand has the largest number of people on India (970 as of January 2010). second-line antiretroviral therapy (6500 as of March 2010) followed by The implementation and expansion of antiretroviral therapy programmes in the Region was accompanied by significant improvements in survival and decreases in morbidity among national programme data from six persons accessing care. Analyses of countries indicated that the overall 12-month survival rate ranges from The success of the antiretroviral
65% in Indonesia to 93% in Sri Lanka. therapy programmes in the Region has largely been a result of strong the government, civil society and agencies, as well as the global momentum to provide lifesaving collaborative efforts of the national advocacy groups, NGOs and donor therapies to those in need. Further services to facilitate early HIV programmes, with commitment from
75% on CPT and 37% on antiretroviral PLHIV benefit from IPT in the Region. In the South-East Asia Region, overall TB collaborative activities. HIV programmes are beginning to there has been good progress in HIV– implement the intensified case finding approach of TB programmes, are TB and recognizing that infection Similarly, TB programmes view interventions for HIV–TB as core antiretroviral therapy. Both the exploring IPT for those without active control in HIV care settings is urgent. activities and are linking known HIVpositive TB patients to HIV care and programmes are now building HIV–TB interventions into funding proposals, evaluation. National HIV–TB coordinating committees exist in 10 of 11 Member countries. HIV–TB activities are widely available in Region in implementing HIV–TB Thailand which continues to lead the activities. Services are being further expanded in India, Myanmar, Nepal present population access to a and in 10 provinces in Indonesia. The routine activities, and monitoring and
improvements in coverage hinge on diagnoses, strong linkages in care drug prices and health systems strengthening.
expansion of testing and counselling and treatment, further reductions in
HIV–TB Collaborative HIV–TB activities are essential to ensure that HIV-positive appropriately, and to prevent TB in HIV-positive patients. The recommended activities include: establishing mechanisms to collaborate between HIV and TB programmes; infection control in TB patients are identified and treated
health care settings; HIV testing of TB
Fig. 29: Coverage of HIV–TB collaborative activities, South-East Asia Region versus global achievements, 2009 100 South-East Asia Region Global 75% 75%
80
Percentage
60
52% 37% 26%
40
20
14%
0
% of notified TB patients tested for HIV
% of identified HIV-TB patients started on CPT
% of identified HIV-positive TB patients started on ART
Source: Global Tuberculosis Control WHO Report, 2010.
comprehensive package of HIV–TB services is estimated to be 700 million. Cross-referrals between the HIV and TB programmes have been strengthened, and the TB countries revised to include recording and reporting systems in information on HIV–TB coinfection. However, screening of TB cases for HIV infection, and vice versa, proportion of PLHIV offered preventive
therapy and TB cases co-affected with HIV receiving antiretroviral therapy remain insufficient. There is also an urgent need to scale up respiratory facilities to prevent the nosocomial others. More details about HIV–TB box below. infection control measures in health transmission of TB among PLHIV and collaborative activities in Myanmar are given on page 57 and for India in the
HIV–TB collaborative activities in India After successfully pilot testing the HIV–TB cross-referral mechanism in Maharashtra, HIV–TB joint activities were first rolled out in six high burden states in 2004. Under the revised 2009 intensified package of HIV–TB collaborative the years, cross-referrals have progressively improved and a consistently increasing number of HIV infected TB activities is currently being implemented in 17 states and it is planned to cover the entire country by 2012. During patients have been diagnosed. In 2005, 54 000 patients were cross-referred and 10 000 HIV–TB coinfected patients of 27 900 HIV–TB coinfected patients. Technical oversight for the programme is provided by a national technical the implementation of HIV–TB collaborative activities. were identified. In 2009, there were 7 80 000 cross-referrals between the two programmes resulting in the diagnosis working group, comprising key officials from NACO and the Central TB Division. Similarly, working groups at the state level and coordination committees at the state and district levels also conduct regular meetings to address issues in
Strategic Information Surveillance of HIV, Sexually Behaviours Transmitted Infections and Risk The most important surveillance questions for countries with I
Surveillance activities in the Region
have expanded substantially to include more geographic areas and population groups (Figure 30). Most elements of second generation surveillance systems are in place in the majority of Member countries of the Region. With increased surveillance activities there is richer data and a better understanding of the national epidemics. Moreover, national AIDS programmes are taking greater ownership of surveillance activities for data collection, analyses and use. During 2008–2010, several countries including India, Indonesia, Myanmar, Nepal and Timor-Leste carried out estimations among most-at-risk mapping and updated national size populations in their countries. This will provide better data for measuring coverage of interventions. In recent the national level in using HIV estimates and projections tools. In 2009–2010, Bangladesh, India, Myanmar, Nepal and Sri Lanka conducted national level exercises to years, much capacity has been built at
concentrated epidemics are:
Where are new infections likely to and which sub populations)? Are the risk markers for HIV stable)?
emerge (which geographical areas
I
changing (increasing/decreasing/ How many people are living with
I
HIV/AIDS and what is their profile?
Answering these questions through appropriate surveillance activities helps in planning, targeting and monitoring prevention programmes, as well planning and monitoring care and treatment for those who are infected. surveillance activities in the Region over the past five years (Table 2). Significant progress has been made in
Country
Mapping for most-at-risk populations
HIV sero surveillance (most-at-risk population)
STI surveillance (most-at-risk population)
Behavioural surveillance (most-at-risk population)
HIV/AIDS case reporting
HIV sero surveillance (general population)
STI case reporting (general population)
make HIV projections using the
Estimations and Projection Package model.
Implementation of HIV Drug Prevention
and Spectrum model, while Indonesia and Thailand used the Asia Epidemic Routine reporting of HIV/ AIDS and remains incomplete in countries (except Maldives, Sri Lanka and
Resistance Surveillance and In the past five years, national HIV
sexually transmitted infection cases Thailand). In countries with a high HIV facility-based antenatal clinic sentinel surveillance among antenatal clinic attendees is well established and general population. However, for
drug resistance activities have been HIV burden countries. HIV Working Indonesia, Myanmar and Thailand. In India, two surveys to assess
initiated with WHO support in the high Groups have been established in India,
burden (India, Myanmar and Thailand)
transmitted HIV-drug resistance were completed in Mumbai and Kakinada antenatal clinics, respectively. Both surveys revealed <5% transmitted at testing and counselling centres and HIV-drug resistance in the populations at these sites. Further, two surveys to assess acquired HIV-drug resistance among patients on antiretroviral therapy were implemented at antiretroviral treatment centres in
provides trends in HIV infection in the “concentrated” epidemics, it is most important to conduct surveillance Region (except Bhutan and among populations engaging in highrisk behaviours. All countries in the DPR Korea) have conducted serological and/or behavioural surveillance among populations with high-risk behaviours at one or more locations. In 2010, Timor-Leste conducted its
Chennai and Mumbai in 2008 with the technical assistance of WHO–SEARO. The survey was completed in 2009 and the analysis is ongoing. In Indonesia, the first HIV-drug resistance threshold survey for clinics in Jakarta in 2007. The transmitted resistance was conducted among people who inject drugs at five completed survey results indicate <5% transmitted HIV-drug resistance in this population. Surveys to assess acquired HIV-drug resistance were implemented among patients hospital in Jakarta. receiving first-line antiretroviral
first sentinel sero surveillance among antenatal clinic attendees, sexually transmitted infections patients and TB patients, and an Integrated Biological and Behavioural Surveillance (IBBS) among female sex workers and men who have sex with men groups. More at-risk populations for logistic IBBS is that it offers logistic same time.
countries are increasingly integrating efficiency. The main advantage of an convenience for collecting both
bio-behavioural surveys among most-
therapy at a large infectious disease In Thailand, three threshold surveys assessing transmitted HIV-drug resistance have been completed — blood banks (2005), testing and counselling centre clients (2005), and sentinel surveillance of commercial been planned for 2010–2011. sex workers (2007). In Myanmar, pilot activities for HIV-drug resistance have
biological and behavioural data at the Information on HIV incidence is generally lacking in the Region. Thailand is the only country that conducts regular laboratory-based HIV incidence surveillance among female sex workers and women attending antenatal clinics.
Fig. 30: Location of surveillance sites, by population group, South-East Asia Region, 2009
people who inject drugs men who have sex with men female sex workers antenatal clinic attendees other most-at-risk populations
Source: Surveillance country reports. Each dot represents one surveillance site.
The collection and analyses of “early warning indicators” was piloted in future. While most other countries based data abstraction, Thailand analyses data from a national HIV almost 30 000 patients receiving these indicators, which include Indonesia in 2008 and is planned in several pilot sites in India in the near collect these indicators through paperpatient-care database representing antiretroviral treatment through the prescribing practices, appointment national programme. In each setting, keeping and drug supply continuity,
Monitoring and evaluation are often recommended ingredients of the
cited as weak elements of the health sector that need strengthening. The monitoring and evaluation package evaluation unit, key performance indicators, establishment of a infrastructure, standard data flow, data analyses, use and
should include: a national monitoring
and evaluation plan, a monitoring and technical working group, adequate budget, dedicated staff, adequate collection forms, channels for data dissemination, and quality assurance. While most countries reported having a national monitoring and evaluation framework for health sector the framework have not been
are really a reflection of the provision of high-quality first-line antiretroviral services. Evaluation of these factors interventions to improve service delivery can thus serve not only to benefits of affordable first-line need. as well as site- and programme-based prevent the emergence of HIV drug antiretroviral treatment to those in Laboratories in India and Thailand have been assessed by a WHOresistance accreditation. After Institute of Health and Siriraj Headquarters team for HIV-drug evaluation, two laboratories (National Hospital) in Thailand and two in India (National AIDS Research Institute, Pune and Tuberculosis Research Centre, Chennai) gained WHO accreditation as national HIV-drug resistance reference laboratories.
interventions, all essential elements of implemented in the countries. Weak weak health systems in countries. National AIDS programmes are for monitoring and evaluation by Global Fund to Fight AIDS, report) and other sources. monitoring and evaluation of the HIV
resistance, but also to maximize the
programme, is in part, a reflection of making efforts to strengthen systems mobilizing resources through the Tuberculosis and Malaria (GFATM; mentioned as Global Fund in this
Research
Research continues to remain a low priority for most countries. Few countries have set national research priorities. Moreover, the available and policies. research is not disseminated quickly or used to improve local programmes India’s NACO provides an impressive research for evidence-based
Programme Monitoring and Evaluation An efficient monitoring and evaluation system is the cornerstone for providing universal access to measuring a country’s progress in prevention, care and treatment services by 2010 and achieving the by 2015).
example of promoting and facilitating programme and policy development. NACO has constituted a “Technical Resource Group” on research and development of an appropriate research agenda for translating development primarily to guide the
Millennium Development Goals (i.e. to “halt and reverse the spread of HIV”
knowledge into programme and policy. Also a “Network of Indian Institutions for HIV/AIDS Research” was formed with the responsibility to undertake multicentric research activities in Ethics Committee for Research was
young researchers (up to 35 years) to pursue research in the field of HIV/AIDS while doing their MPhil/MD/PhD under experienced academicians and researchers. Thailand has conducted important research particularly in the area of operations research. Similarly, guiding policy development. Indonesia has a strong technical care and treatment, vaccine trials and research group at the national level
interdisciplines. In addition, the NACO constituted with the responsibility to privacy protection and participant ensure that the process of research is conducted ethically, responsibly, with scheme was initiated to encourage non-exploitation. A research fellowship
Key issues in strategic information in the Region I I I I I I I I I
Underreporting of HIV and AIDS cases. Weak AIDS mortality surveillance. Low priority given to routine surveillance of sexually transmitted infections. No country, except Thailand, conducts incidence surveillance. Not enough attention to data quality and analyses.
Fragmentation of monitoring and evaluation systems in some countries leading to inefficiency in collecting and reporting information. Weak health systems with limited staff and infrastructure. Low priority and poor resource allocation for research. inadequate linkages across interventions and among departments.
Developing research protocols — WHO–NACO training workshop
To generate evidence for policy and programme development for the next five-year HIV strategic plan, the National AIDS Control Organization (NACO) of India in conjunction with WHO-SEARO organized a workshop in New Delhi, India from 22–26 June 2010. A total of 19 participants working in the HIV treatment programme and research institutes from various parts of country attended the five-day workshop. Participants included a mix of physicians, paediatricians,
statisticians, social scientists and epidemiologists. Participants were nominated for this workshop with the understanding that they would be fully involved in the research implementation. The training used a “learning by doing” approach with a significant proportion of the training being conducted in group work under the guidance of mentors. The workshop started with the identification of research gaps and priority research questions and moved to other topics including:
elements of a research protocol; types of research studies; sample size and sampling design; quantitative and qualitative data collection and overview of data analyses; ethics and project management including budget and timeline. Following research proposals will be implemented over the next three years using Global Fund monies. Interim findings from the studies will contribute to the national strategic planning scheduled in 2012. theory lectures in the morning hours, participants worked in three separate teams, each under the guidance of a mentor to draft sections of the protocol. At the end of the workshop, three multicentric research protocols were prepared. These
Effective Government–NGO Collaboration
I I I I
First case reported Estimated PLHIV risk groups MSM: <1% FSW: <1%
Quick Facts
1989
Adult HIV prevalence <0.1% PWID: 1.2%
7000
HIV prevalence among most-at-
E
arly and continued
implementation of HIV
(Hijra); and just above 1% among prevalence among PWID was 7%.
most-at-risk populations (MARPs), guided by data from regular HIV at bay.
prevention programmes among
people who inject drugs (PWID), only in one neighbourhood in Dhaka HIV C (HCV) and active syphilis — have Surrogate markers of risk — hepatitis declined in many sites and population declined among Dhaka PWID (Figure 31), suggesting that safer injecting practices are being adopted, and sites among female sex workers (FSWs). groups. HCV prevalence and incidence I I
Early national response to HIV threat Expanded surveillance system Sound and comprehensive set of policies, guidelines and services to most-at-risk populations and use of epidemiologic data
Unique Features
surveillance and behavioural surveys, have largely helped Bangladesh keep HIV prevalence in Bangladesh
continues to remain at a very low level — less than 0.1% in the general population; below 1% among female and male sex workers, men who have
I
to guide programme and policy strategic frameworks targeting
active syphilis rates declined in many
sex with men (MSM) and transgenders
Prepared by Shamim Rabbani, Director, HIV Program & Team Leader – IDU Intervention, PADAKHEP, Bangladesh
Fig. 31: HIV incidence rate among people who inject drugs (n=561), Dhaka, Bangladesh, 1999–2007 1.6 Incidence rate (per 100 persons)
1.2
0.8
0.4
0.0
1999
2000
2001
2002
2004
2005
2006
2007
Source: Azim et al. Twenty years of HIV in Bangladesh: Experiences and way forward, World Bank and UNAIDS, 2009.
Early national response
A very important factor was the early implementation of HIV prevention interventions have been cited interventions among the MARPs — internationally as best practices. FSWs, PWID and MSM. These early Analysis of data modelling the impact of early PWID interventions in Dhaka showed beneficial effects in delaying the epidemic.
NGO initiatives and
collaboration between the Government and NGOs The interventions for prevention of HIV/AIDS among vulnerable populations in Bangladesh was Later a strong partnership was initially started and led by NGOs. developed between the GoB, NGOs, civil society and donors. Success in controlling HIV can be attributed to the government, NGOs, research etc. functional collaboration, programme participation and ownership between institutes, and educational institutes, NGOs are significantly involved in HIV have also been playing a key role in projects. A number of community-
The Government of Bangladesh (GoB) acted early in responding to the HIV epidemic, by forming the National high-profile advisory body has the President as Chief Patron and is Family Welfare. The NAC is AIDS Committee (NAC) in 1985. This chaired by the Minister of Health and responsible for formulating major programme implementation and mobilizing resources. A NAC policies and strategies, supervising Technical Committee (TC–NAC) of the NAC and National AIDS/STD Programme (NASP).
prevention in Bangladesh. Some NGOs managing the implementation of large based organizations have also been set up to provide services. Care and the network of positive people
experts provides technical advice to
support services for people living with
HIV (PLHIV) are available only through
established in the country. In fact networks. The provision of
once persons are identified as HIVpositive they are referred to these antiretrovirals (ARVs) is also managed by the network of positive people. With support from GoB, the NGOs have set up a sexually transmitted working in the field of HIV/AIDS. Effective interactions among the NASP are formulated with 17
detoxification, long term drug others.
treatment and rehabilitation, capacity building of ex-drug users, among
Sound national planning and policies Bangladesh was the first country in policy on HIV/AIDS and sexually Issues”. It was developed and 1st National Strategic Plan
infections (STI)/AIDS network with
more than 230 member organizations
the South-East Asia Region to develop and adopt a comprehensive national transmitted diseases —“National Policy on HIV/AIDS and STD Related approved by the cabinet in 1997. The 1997–2002 was formulated and adopted through consultation and
across the country. All efforts are made to maintain strict anonymity and confidentiality. Blood samples and information are collected from populations of highest epidemiologic interest, i.e. male and female sex workers, PWID, MSM, hijras, and male groups likely to be clients of sex workers, such as rickshaw pullers, transport workers, dock workers, male STI patients. To improve surveillance design, a pilot of “Respondent Driven Sampling” methodology was done in 2007. Some additional data to inform programme decisions were collected by other methods, such as a GIS mapping of 17 brothels and nearby police stations, NGOs and clinics; workshops to take stock of relevant areas of knowledge; and several surveys, research and evaluation studies.
different ministries to support the ministries and focal points working together. Partnership between the Global Fund (Round 2 and 6) and the involvement of 104 NGOs in programmes. Comprehensive GoB and NGOs has increased through HIV/AIDS Intervention Services, with HIV/AIDS prevention in three major interventions are targeted at the most vulnerable and bridge groups in the population. These groups include FSWs and their male clients, PWID, The intervention packages include peer education, health education/ MSM, hijras and transport workers. condom promotion, STI management, counselling, resting/recreation facility, community awareness and local level advocacy. Essential harm reduction service packages are also being implemented in the country that includes needle–syringe exchange,
involved all stakeholders (including
ministries, NGOs, private sector, civil practice. The 2nd National Strategic Plan was developed for 2004–2010. Protocol for safe blood transfusion was formulated in 1997.
society and others), in line with global
Conclusion
Bangladesh demonstrates an example of government and non-government collaboration for addressing the worked well due to strong HIV/AIDS problem. In Bangladesh,
Surveillance, research, monitoring and evaluation
Bangladesh began HIV (and syphilis) serological surveillance and (separate) behavioural surveys in 1988, and has expanded this surveillance and the sample sizes over the years. Since 1998, eight rounds of sero surveillance and six rounds of behavioural surveys have been completed at sentinel sites
this Government–NGO collaboration commitment on both sides to combat HIV/AIDS in Bangladesh. While the partnership has worked well so far, services in target populations by different service providers. there is a need for continuing close
coordination to avoid duplication of
Strong Political Commitment
I I I I
First case reported in 1993 Estimated PLHIV: <1000 population: <5% Adult HIV prevalence: 0.1% HIV prevalence in most-at-risk
Quick Facts
I I I
Visionary royal leadership Strong political will forces Community participation
Unique Features
only 0.02%, even though the first HIV Bhutan tackled the HIV epidemic through the unique leadership of the Kings of Bhutan and government policies in HIV control that facilitated the development of Bhutan’s robust HIV prevention programme. HIV is considered a national priority by the
case was reported nearly 17 years ago.
B
hutan remains a low HIV
prevalence country with less
thus helps maintain political
than 0.1% adult prevalence of
consciousness to HIV prevention. This strong political commitment demystified the HIV problem, enabled prevent HIV infection, and mitigated the stigma and discrimination for the community to respond effectively to people living with HIV (PLHIV) and their families. Working with the communities through multi-sectoral task forces identify actions that could be synergized for the social good. (MSTFs) provided the opportunity to
through multi-sectoral task
National Assembly of the country and
Prepared by Gampo Dorji, Deputy Chief Program Officer, National AIDS Control Programme, Department of Public Health, Royal Government of Bhutan
Setting up the national response framework In 1993, immediately after the first AIDS Committee was formed, comprising representatives from
Following these initiatives, strategies for free and universal access to HIV prevention and care services were HIV education among other HIV prevention. strengthened and mainstreaming of organizations was intensified. This was a huge leap in public health for
future NGO for people infected and affected with HIV.
report of HIV infection, the National different sectors under the Director General of the Ministry of Social Service. The National AIDS Committee AIDS Commission in February 2004 to advise the Government on HIV policies. The Commission formulated conclusive policies, such as provision of free antiretrovirals (ARVs), greater involvement of PLHIV, and multisectoral duties in the biennial meetings. was strengthened to form the National
The Queen — an icon of HIV prevention Good leadership is the cornerstone of any public health intervention. Her Majesty, the Queen Ashi Sangay the position as the UNFPA Choden Wangchuck is the icon of HIV prevention in Bhutan. She assumed Ambassador for Bhutan in 1999.
Mainstreaming HIV/STI prevention The National Strategy for HIV/sexually transmitted infection (STI) prevention Royal Edict. HIV prevention moved disease model” to incorporate fundamental issues of rights and poverty, and improve livelihoods through the maximum feasible is based on the principles of the 2004 from the concept of an “ill health and empowerment to address its link with participation of the community. The mainstreaming of HIV education through institutional teaching started in 2008, with nine vocational training institutes, one army training centre, senior schools and 747 non-formal based HIV curriculum.
Since then, she has constantly worked and reproductive health. Her Majesty routinely visits the different sections of the communities, and holds numerous public gatherings and discourses on HIV prevention. The and rural masses are repeatedly reached across the country.
for public health education campaigns
focusing on HIV prevention, and sexual
The unique leadership of the Kings of Bhutan The ultimate demonstration of the of the Kings of Bhutan. The Royal 24, 2004 by the Fourth King, His Majesty Jigme Singye Wangchuck
armed forces, school children, out-of-
school children, monastic institutions
concern and commitment for the HIV Decree on HIV prevention, dated May calls for citizens to participate in HIV prevention and respect the rights of the roles of the organizational and
epidemic is reflected in the initiatives
The World AIDS Day has always been observed under the auspices of Her urgency to avert a serious HIV Majesty reminding the nation of the epidemic. The Queen has reached out to the people more than any media encouraging cross-sectoral campaign leading to mass awareness, participation, and being a role model for all the sections of the Bhutanese sectoral participation at the district formation of MSTFs for HIV prevention. society. Her Majesty mobilized multiand the grassroots levels through the
education centres integrating life-skill The Ministry of Labour and Human
HIV infected and affected people. The Royal Edict (also in 2004) broadened individual-level participation for HIV heir to the throne in 2005, deeply proclaimed to the nation that:
Resources introduced HIV education The armed forces mobilized women volunteers among family camps to intensify HIV prevention through condom promotion and health
booths at youth employment counters.
prevention. The Fifth King, His Majesty Jigme Gesar Namgyel Wangchuck and concerned about the HIV epidemic, “HIV/AIDS is no exception. The youth will use their strength of character to reject undesirable activities; their their will to prevent its spread.” The deeper appeal to the youths to look forward to HIV free lives. Today, the one of the key targets in HIV prevention. compassion to aid those afflicted; and youthful image of the King, promotes “youth in-and-out-of-school” group is
education. In the hospitality sector, hotels and lodges in urban settings karaoke bars in Thimphu and participated in condom promotion. All Phuntsholing, the two biggest urban cities in the country, introduced workplace HIV education during entertainment hours in 2010. In line and empower them to take control,
Social mobilization — multisectoral task forces In Bhutan, social mobilization was patronage. In 1999–2000, two capital city) and Phuntsholing
with the Royal Edict, to engage PLHIV the National AIDS Control Programme successfully mobilized the first peer association of PLHIV in 2009, named Lhaksam. It is expected to grow into a
formally initiated under Her Majesty’s demonstration sites — Thimphu (the (commercial hub at the Indo-Bhutan border) — were piloted to engage a
multi-sectoral framework for HIV
prevention. The aim was to engage partners from formal and informal sectors at the local level as equal demonstration projects were partners of the health sector. The two successful and provided “renewed strength and clarity within the process of decentralization towards 2002, the MSTF approach was expanded to all 20 districts of the prevention and care for HIV/AIDS”. In country, and remains the key strategy for population based HIV prevention. platform for HIV prevention for the general population in the district. the district administration. The They function under the governors The MSTFs have become an effective
HIV prevention at grassroots level The MSTF approach enabled the engagement of the communities at the block (geog; a cluster of communities) level. Through an integrated approach, HIV prevention. The Gup, who is the elected head of the block, acts as the chair of the geog MSTF . Over 50% of MSTFs since 2005. HIV/AIDS messages are propagated during enhanced through outreach of the 206 blocks have established geog religious and festive events in the blocks are increasingly participating in
communities. Condom distribution is community volunteers and the existing rural setting. In 2008, 75.4% reported easy access to condoms and 73.6% development committees regularly the geog, and plan and monitor communities. implementation in the villages and In conclusion, Bhutan’s success to used condoms during extramarital sex in the previous six months. The block review the HIV prevention activities of network of village health workers in the
(Dzongdags) or the executive head of MSTFs coordinate different players at the local level and ensure sectoral participation in the prevention of HIV/AIDS. Since 2004, the district
MSTFs have been implementing the HIV prevention programme through an annual workplan. The PLHIV are are actively engaged in HIV also represented as members of the MSTFs in four districts. Sex workers prevention in Phuntsholing. Women groups in the armed forces and civilians also formed effective alliances to engage in condom
remain a low HIV prevalence state can be attributed to the unique leadership of the royals and the strong political HIV epidemic. The strong leadership enabled the community to respond effectively to protect from the HIV virus, and mitigate stigma and their families. discrimination faced by PLHIV and will that prevailed since the start of the role has demystified the HIV problem,
promotion activities, family planning programmes, and prevention of in the communities. domestic- and gender-based violence
Widespread Health Infrastructure
I I I
No HIV case reported in national population expatriates 28 HIV-positive cases among Vulnerability and risk factors exist but undefined
Quick Facts
T
o date, no HIV infection has been detected in any of the citizens of the Democratic
most-at-risk populations has not been done. However, several factors that could contribute to an epidemic of include low awareness about HIV prevention, cross-border travel STIs and HIV in the future exist. These between DPR Korea and China, poor and management of STIs and HIV.
People’s Republic of Korea (DPR
Korea). Cumulatively, 28 foreigners, who tested positive from 1998 to 2008, have been deported back to their countries. Currently, there is little epidemiological information on HIV, and risk behaviours. Mapping of sexually transmitted infections (STIs)
I I
Widespread health care infrastructure
Unique Features
Government commitment to universal access to services
quality of blood transfusion services
and limited services for the diagnosis
National response
free medical care and services,
Recognizing the increasing number of HIV cases in neighbouring countries, the Government of DPR Korea has AIDS Committee was established in from governmental institutions, organizations. Nationally and nongovernmental organizations, taken several measures. The National 1988 and comprises representatives academic institutions and social provincially, the HIV programme a wide range of communicable government has committed to operates through a network of Anti disease control programmes. The stepping up prevention activities and The National Strategic Plan on providing care, support and treatment for those infected and affected by HIV. HIV/AIDS Prevention and Control— DPR Korea (2008–2012) calls for Plan aims to improve HIV/AIDS awareness among the general population. intersectoral coordination to prevent the spread of HIV in the country. The
including prevention and curative
services. The Government “maintains a commitment to the universality of against a backdrop of severe and protracted hardships.” DPR Korea received a funding of US$ 4.3 million from the Global Alliance for Vaccines and Immunization (GAVI) Health System Strengthening project in the 2007– capacity in health management health equipment and clinical laboratory services. 2011. This will help in strengthening systems and support health service delivery, including infrastructure, services, including a complete set of entitlements for children and women,
Epidemic Health Stations that manage
A national Health Management
Information System (HMIS) is being put in place to improve disease indicators. It will identify disadvantaged groups for the surveillance and standard health programme or targeted interventions. Opportunities are also seen in STI transmission, and use the introducing syphilis screening among indicators to measure the risk in HIV transmission. Condom use can be well as through community-based actions. promoted through the reproductive health programme in the hospitals as
Opportunities to prevent HIV spread The well organized and widespread health care system represents a strong basis for preventing a potential spread of HIV infection. DPR Korea than 800 general and specialized county levels, and about 1 000 also has an extensive network of more hospitals at the central, provincial and hospitals and 6 500 polyclinics at Ri (rural county) and Dong (urban at the community level. The county) levels, with an estimated 50 000 section level doctors working fundamental principles of the national health policies include universal and
pregnant women to reduce the risk of
The strong network of communityElderly Association, trade unions, women’s association and the Cross offer opportunities for support.
based peoples’ committees, Korean
Family Planning Association, Korean International Federation of the Red community-based prevention, early detection, treatment, care and
Rapid and Effective Scale-up of Antiretroviral Treatment
I I I I
First case reported in 1986
Quick Facts
Estimated PLHIV: 2.3 million Adult HIV prevalence: 0.3% population: HIV prevalence in most-at-risk PWID: 9.2% (range 0–56%) MSM: 7.3% (range 0–41%) FSW: 4.9% (range 0–41%)
I
ndia’s national antiretroviral
treatment (ART) programme has
To accommodate the growing programme has scaled up
the lives of people living with HIV (PLHIV). Since its launch in April there has been a gradual but
had a major impact on enhancing
numbers of PLHIV, the national ART considerably and as of March 2010 272 fully functional ART centres. 322 561 people are receiving ART at Analysis of available data shows that nearly 89% of PLHIV who initiated ART were alive and on treatment after 12 months of starting treatment. The remaining 11% had either reportedly died or were lost to follow-up. I I I I
Government commitment guidelines for scale-up
Unique Features
2004, with eight government hospitals located in six high prevalence states, sustained increase in the number of PLHIV registered for ART and those seeking treatment (Figure 32).
Sound technical and operational Global Fund grant for ART ART delivery drugs Use of existing tertiary and
secondary health facilities for Production of affordable ARV Participation of NGOs and network of positive people
I I
Prepared by Damodar Bachani, Director-Professor & Deputy Director General, National AIDS Control Organization, India
Fig. 32: Number of people living with HIV on treatment and antiretroviral treatment centres, India, 2004–2010 400 Number of ART centres Number of PLHIV on ART Number of PLHIV on ART (in thousands) Number of ART centres 300 300 400
200
200
100
100
0
2004
2005
2006
2007
2008
2009
2010
0
Source: National AIDS Control Organization, Annual report 2009–2010. Note: Year data refer to the month of March.
ART delivery through a threetier health infrastructure facilities supported under the ART services are being provided
hospitals. Support under the
programme includes additional nurses, laboratory technicians,
personnel (doctors, counsellors, pharmacists, data managers and care coordinators) based on patient load. supplied directly to ART centres. Equipment and kits for CD4 count and ARV drugs are procured centrally and for the treatment of opportunistic are designated as Centres of Funds are provided for drugs required infections. Of the 272 ART centres, 10 Excellence. Besides routine functions provide second-line and alternative services, impart training, conduct research work and mentor ART seven Regional Paediatric Centres have been set up in large children first-line ART, as well as tertiary level centres linked to them. In addition, hospitals of the country for providing tertiary care, second-line paediatric of ART, the Centres of Excellence also
through a three-tier system of health programme with clearly laid down structures, functions, operational, reporting in standard formats for monitoring. technical and financial guidelines, and
(i) ART centres
The ART programme identified
suitable locations for setting up ART services based on the prevalence of HIV, numbers of PLHIV identified and centres are established in medical the capacity of existing institutions to deliver ART services. Most of the ART colleges and district hospitals in the government sector. In high volume districts, some ART centres are also functioning in the subdistrict and area
ART, training, research and mentoring of paediatric care and treatment services at ART centres.
as per schedule. CCCs are linked with ART centres and undertake various functions including counselling for ART preparedness, drug adherence, outreach services for follow up; and social support services.
Guidelines for ART in adults and
adolescents – March 2007, updated May 2008; Technical guidelines for October 2009. These are also revised regularly on the Resource Group.
April 2009; Operational guidelines for ART centres – March 2007, updated second-line ART roll out in children – available on the National AIDS Control Organization (NACO) website and are recommendations of the Technical
(ii) Link ART Centres
The ART programme set up Link ART Centres to make treatment services of ARV drugs to the PLHIV. These Centres are located mainly at more accessible and facilitate delivery district/subdistrict level hospitals and Community Health Centres close to the patient’s residence to improve ART services, it was observed that main constraints in access to ART accessibility. During the scaling up of distance, travel time and costs are the services and adherence to treatment. are provided on a monthly schedule, one of the reasons for poor drug adherence, lost to follow up and As the treatment is life-long and drugs PLHIV faced inconvenience which was missed cases. These Centres are
nutrition and prevention; treatment of opportunistic infections; referral and
Capacity building
The ART programme developed
standard curriculum and training for capacity building. To ensure
modules for all categories of human uniform standards of services and training is provided to various training modules and tools at
resources involved in the programme adherence to operational guidelines and treatment protocols, induction personnel using standard curriculum, identified institutions. Various training programmes organized under include: I I I I I I I
Technical Resource Group
The programme constituted four ART, paediatric care, laboratory technical aspects of care and treatment. These TRGs meet and operational or technical progress and give valuable
Technical Resource Groups (TRGs) on services and CCCs to oversee the periodically to review, discuss and guidelines. The TRGs review the suggestions and recommendations on various technical and operational Meetings of TRGs are held and issues for discussion. issues relating to the programme. periodically with clearly drawn agenda
recommend any changes in strategies
located at the Integrated Counseling and Testing centres (ICTC) which further helped in linkages between ICTC and ART services. Currently, country. there are 325 Link ART Centres in the
National AIDS Control Programme- III Orientation of medical colleges/ Training of ART centre medical officers: 12 days
district hospital faculty: five days
(iii) Community Care Centres
Training of CCC/Link ART centre medical officers : four days Training of counsellors: 12 days Training of ART centre data managers: three days
Community Care Centres (CCC) were a comprehensive package of care, support and treatment services. At
Supply chain management for ARV drugs The programme has an effective most vital components of drug
set up with the mandate of providing present there are 287 CCCs that play a critical role in providing treatment, located in and run by the care and support to PLHIV. These are nongovernmental sector with the main objective of providing psycho-social allow better community and family responses towards PLHIV through and those who miss visits to ART support, ensuring drug adherence and providing home-based care. The CCCs
Training of laboratory technicians for CD4 count: two days process): three days. Training of pharmacists (under
supply chain management. One of the adherence is continuity of drug supply to the centres. Monitoring is done centrally for all ARV drugs based on monthly consumption and stocks at month drug stock. In the event of a shortage, drugs are re-located to drugs and CD4 kits is done by a dedicated supply chain team appointed at NACO.
Operational guidelines and modules The programme produced several guidelines to provide normative help in standardized delivery of services using a public health guidance to users for ART delivery to approach. Key guidelines include:
the centres. As per guidelines, all ART centres must have a minimum threeensure that there are no stock-outs.
family counselling. The CCC also helps in tracing patients lost to follow-up centres for collecting their ARV drugs
The supply chain management of ARV
Monitoring, evaluation and research A set of standard Monitoring and
Supervision and periodic review meetings The programme grouped various states into regions for close monitoring, mentoring and supervision of ART centres. Regional coordinators are appointed to supervise the programme in their regions. The Regional coordinator
Evaluation Tools and Formats have been developed and distributed to each ART centre for standardized standard list of indicators for recording and reporting from different centres. This ensures reporting on a monitoring progress and comparison of performance across centres. Also formats for reporting of patients on second-line and alternative first-line treatment have been developed. Additions are made to the monthly
visits ART centres at least once in two monthly reports to NACO. A monthly meeting of Regional coordinators is held at NACO to review the various issues pointed out by them. In
months and sends regular weekly and
reporting format at the ART centre to get more information on most-at-risk populations, CD4 counts and socioeconomic status of the patients.
addition, consultants (care, support
and treatment) have been appointed visit centres based on their monthly coordinators, Indian Network for
at most State AIDS Control Societies reports, and feedback from Regional
(SACS). NACO and SACS officials also
Based on identified programme gaps, multi-centric operational research projects are undertaken and their of the programme. findings used in redefining strategies
People Living with HIV (INP+), NGOs, among others. Currently there are 10 of the country. Regional coordinators in various parts
Challenges in care, support and treatment of PLHIV Currently, the rapid scale up of ART services in India is supported by the Global Fund. However, as the number of PLHIV on ART further increase and the number of persons requiring second-line ART also increase, the costs of providing ARV drugs to an estimated 6 00 000 persons would be massive. For the availability of such enormous funding, the current policy of providing free mainly through government supported hospitals, there will be need to internalize services within the existing system for long-term sustainability. supported by the states or domestic budget. It will also be challenging to services to all PLHIV needs to be examined. Though ART services are provided Additional human resources covered under the programme may have to be ensure services to the large migrant and moving population as these tend to be irregular in treatment and maintain sub-optimal drug adherence. However, on NGOs and the network of positive people are strengths of the Indian national HIV control programme. the positive side, government commitment, production of affordable ARV drugs offered by the Indian pharmaceutical manufacturers, as well as participation of
Novel Approach for Improved Size Estimation of Most-at-Risk Populations
I I I I
First case reported in 1987 Estimated PLHIV: 190 000 population: Adult HIV prevalence: 0.2% HIV prevalence in most-at-risk PWID: 50% (range 43–56%) MSM: 3.5% (range 2–8%) FSW: 6% (range 2–17%) Waria: 19% (range 14–34%)
Quick Facts
understanding the epidemic potential of an area, estimating the burden of disease, and setting appropriate diverse as Indonesia requires epidemic. A country as large and population size estimates at the and resource allocation. priorities in response to the HIV/AIDS
P
opulation size estimations of most-at-risk populations (MARPs) are key to:
only six provinces. Estimation improved considerably with the increase in number of data available for use. In 2009, more and better data generated of most-at-risk populations available institutions, led to an improved estimation process. from NGOs, Ministry of Health, other I I
at the districts level and mapping data
Estimation is decentralized to the district level districts Recent mapping data made available from a large number of Evidence-based assumptions used from behaviour surveys village in the country Availability of village potential survey (Podes) data from every
Unique Features
I I
provincial and district/municipality
levels for proper programme planning Since 2002, Indonesia started MARP estimations at the national level, however with very limited data from
Complete data on key statistics from all areas in Indonesia were also available from the 2008 Village Potential survey was modeled using a multinumber of high-risk districts. Statistics Survey. Data from the village variable regression model to predict the
Prepared by Muhammad Noor Farid and Pandu Riono, Faculty of Public Health, University of Indonesia
The unique features in the new estimation process were: I I
to 306 districts in 2009. Men who
Establishment of a Technical Working Group Engaging NGOs and other validation of basic data institutions for collection and Calculation of estimation and Group confirmation and revision of initial results by the Technical Working Consensus on the results at the province and national level by engaging with key stakeholders.
have sex with men (MSM) mapping in 2006 and 178 districts in 2009.
estimated using Poisson Regression method, with the district mapping data as the predictors. The model data as the outcome and the Podes built for each subpopulation in Group the dummy variable in each 1 at the national level with the district
data were reported from 30 districts Sero-surveillance data for 2007 and 2009 were obtained from 23 of 33 covered eight provinces. provinces. IBBS data from 2007 data covered 11 provinces while 2009 data The 2008 Village Potential Statistics were available from all districts in estimation were a percentage of karaokes, theatre, as well as Indonesia. The variables of Village Potential Statistics data used in the urban villages and villages with sexual predominance of drug abuse, and transaction sites, pubs/discotheques/ illegal drug trading. Since the Podes were available for all districts, these data were used as predictors in the population of 15–49 years olds in each district was also used as a predictor. model for estimating the population
as the observation and the province as subpopulation model. The final model of each subpopulation was used to estimate the subpopulation size in the district with no mapping data, since the predictors were available for all districts. For Group 2, the multiplier method was used to estimate the subpopulation size. The data inputs for this method were the estimates of IBBS data. IBBS data were not subpopulation size of Group 1 and the available from all districts, and for the ones which did not have IBBS data, behaviour indicators were assumed using the data from the similar
I
I
The data used in the estimation data, integrated biological and
process were from various sources,
i.e. mapping data, sero-surveillance behavioural surveillance (IBBS) data and Village Potential Statistics. Mapping data were obtained from the local health offices, National AIDS who inject drugs (PWID), districts Direct female sex worker (FSW) Committee, national NGOs, and local institutions. For mapping of people 2006 to 182 (out of 483) in 2009. providing data increased from 45 in mapping data availability increased 2009. Indirect FSW mapping data reported from only 81 districts in
size in the districts with no data. The
district. For Group 3, the estimation
For subpopulation estimations, the population was divided into four groups for MARP estimations, i.e. Group 1: FSW, Waria, MSM and PWID; Group 2: clients of FSW, sex partners of FSW clients, and sex partners of general population of Papua. For PWID; Group 3: prisoners; Group 4: Group 1, the subpopulation size was
was based on the register data from the general population in Papua.
the Ministry of Justice and for Group 4 it was based on the 2006 IBBS among The 2009 survey showed improved Importantly, these estimates are monitoring.
from 209 districts in 2006 to 332 in 2006 increased to 314 districts in
population size estimations of MARP . available for each district, which will facilitate district level planning and
2009. Waria mapping data reporting
increased from 146 districts in 2006
Subpopulation
Median
Population size High
Low
Effective Use of Evidence for Programme Development
I I I I
First case reported in 1991 Estimated PLHIV: <100 population: <0.1% Adult HIV prevalence: <0.1% HIV prevalence in most-at-risk
Quick Facts
T
he Government of Maldives
recognized the central role of
The first BBS was conducted in 2008 with technical support from UN first BBS — monitoring the partners. The strategy utilized by this populations at greatest risk — is sound method for identifying considered the most epidemiologically emerging epidemics and responding conduct the BBS were based on the highest risk, i.e. urban areas where commercial sex and drug use are to behavioural risks among the most I I I
and took the initiative to develop national guidelines for second
surveillance in response to HIV
Strong governmental commitment Fund
Unique Features
generation surveillance in 2005. The availability of funds from the Global Fund to fight against AIDS, TB and to conduct the first biological and One of the biggest challenges in HIV has been the cultural and behavioural survey (BBS) in 2008. crafting intervention programmes for religious beliefs among policy makers and opinion leaders which placed the country in a state of denial. This first BBS provided evidence that the there is complacency. country’s risk is evolving and an impending epidemic can occur if Malaria made it possible for Maldives
Financial support from Global Technical support from United Nations partners
vulnerable groups. Sites prioritized to
likely to exist. The population groups included in the survey were: female FSW, men who have sex with men (MSM), people who inject drugs (PWID) and youth. sex workers (FSWs), male clients of
The BBS found that HIV prevalence
was undetected except in one resort worker. The prevalence of ulcerative
Prepared by Ms Mariyam Waheeda, Assistant Public Health Program Officer CCHDC Communicable Disease Control Division-Prevention Programme TB/HIV, Maldives
syphilis was 1.2% in resort workers. BBS uncovered an alarming set of overlapping risk behaviours and the low self-risk perception, the interface among the most-at-risk
Likewise, hepatitis B and C were also
behaviours, sexual behaviours, perception. The BBS provided
found among the subpopulations. The
number of partners (casual, regular etc.), usage of condoms and risk baseline data for evidence-based programme planning, as well as monitoring and evaluation. BBS the development of a Behavior of specific target groups. The findings have also been used to guide Change Communication Strategy that addresses the communication needs information gathered from the study is also being used extensively for policies to create an enabling advocacy to identify gaps, set targets and mobilize resources; as well as for environment for an effective response. In view of the evidence generated by the BBS, the Ministry of Health is problem of HIV and STI and country’s HIV response. committed to address the growing acknowledges that surveillance must remain at the forefront of the
populations. The BBS also highlighted existence of a knowledge–practice gap, low condom use and unsterile needle and syringe sharing among and poor uptake of voluntary counselling and testing services. PWID, poor health-seeking behaviour
How the survey findings were used To date the 2008 BBS is the most comprehensive and recent data available on HIV in Maldives (Figure knowledge/ evidence on the risk awareness on health seeking behaviour patterns, knowledge and 33). The BBS has generated a body of
Fig. 33: Sexual and injecting risk behaviours among people who inject drugs, Addu and Malé, 2008 Addu Malé
Shared needle/syringe, last injection Unprotected sex with non-regular partner Unprotected sex when selling sex Unprotected sex when buying sex 0 20 40
60
80
100
% of people who inject drugs Source: 2008 bio-behavioural survey, National AIDS Programme, Maldives
Successful HIV and TB Collaboration
I I I I
First case reported in 1988 240 000
Quick Facts
Estimated number of PLHIV: Adult HIV prevalence: 0.6% population: HIV prevalence in most-at-risk PWID: 35% (range 19–54%) MSM: 22% (range 13–32%) FSW: 11% (range 7–17%)
W
ith a TB incidence of
171 cases per 100 000
Centres (THC), the district hospitals, its Department of Health and the World Health Organization. I
estimated 240 000 people living with HIV (PLHIV), Myanmar has a high burden of HIV–TB coinfection. The 2009 seroprevalence survey showed 2% to 26% across sites.
persons per year and an
Collaboration between the various stakeholders permitted the implementation of the full spectrum of WHO recommended HIV–TB collaborative activities in several townships of Myanmar. HIV, TB and HIV–TB patients all benefitted from the inter-programme collaboration. Provider-initiated HIV testing of TB of a substantial number of HIV-
Strong coordination between all levels
Unique Features
TB and HIV/AIDS programme at Rigorous follow-up and intensive monitoring Support by PLHIV network
I I
9.2% sero-positivity rate among newly diagnosed TB patients, ranging from To address issues related to HIV and Myanmar set up a high level HIV–TB against HIV–TB. These included the NGOs, national TB and HIV control programmes, the Township Health
TB coinfection, the Ministry of Health, coordinating body placing in synergy the various actors involved in the fight civil society with the PLHIV networks,
patients permitted the identification infected patients and linked them to a comprehensive HIV care programme. of HIV–TB coinfected patients was favourable. Once ART was provided, the outcome
Prepared by Dr Moe Zaw, Assistant Director (TB), Department of Health, Myanmar and Dr Philippe Clevenbergh, Head, The Union, Myanmar.
Fig. 34: Number of patients enrolled in the joint HIV–TB programme, Mandalay, May 2005–September 2009 Adult TB patients registered 11841
Number of TB patients HIV tested 8428 (71%)
HIV positive 2812 (33%)
HIV negative 5616 (67%)
Spouse/partner/children tested 759 HIV positive 454 (99 children, 351 spouses, 4 sexual partners)
HIV positive 305 (164 children, 141 spouses)
Total positive 3266
Number enrolled: 1866 (1583 TB patients) (58 children, 221 spouses, 4 sexual partners)
Sources: National TB Control Programme, National AIDS Programme, Ministry of Health, Myanmar.
Integrated HIV Care Programme In 2005, the pilot — Integrated HIV was launched in five townships of Care (IHC) programme for tuberculosis patients and their family members — Mandalay city. It has since expanded population of 2 262 671 people and about 5000 TB cases per year. In 2009, in Mandalay, of the 2991 (95%) were offered HIV test, 2610 was also offered to 499 spouses/
Stakeholders and responsibilities All HIV–TB activities are implemented in and by the public sector, but with collaboration between the various stakeholders.
to five additional townships covering a
National Tuberculosis Programme (NTP) is the entry point to the IHC programme and offers: providerinitiated HIV testing and counselling to all adult TB patients and spouses/ of HIV–TB coinfected patients to therapy (CPT) before enrolment; proportion receiving CPT and divisional/district HIV outpatient children of coinfected patients; referral department; co-trimoxazole preventive recording and reporting of the number of adult TB patients tested for HIV, antiretroviral therapy (ART), and proportion enrolled in the HIV outpatient department; defaulter
adult TB patients registered, 2830 (87%) were tested for HIV; 803 (31%) were diagnosed HIV-positive. HIV test 263 (61%) were HIV-positive. Nearly 78% (832) patients were enrolled in enrollment of TB patients from neighbouring townships too. children and of the 430 (86%) tested, the programme, of whom 65% were
put on ART. The programme permits
tracing through the township health distribution and health education HIV-infected patients.
services; HIV prevention by condom material; and active TB screening for National AIDS Programme (NAP)
patients referred from the various
entry points or to admitted patients. outpatient department (OPD). The hospital social workers provide treatment adherence counselling before starting ART and help in defaulter tracing.
Medical officers and nurses of various
medical units man their respective HIV
coordinates the national response to stigma and provides educational sessions for the general population
the HIV/AIDS epidemic. It addresses and training of health workers. The
sessions to all HIV-infected patients
central or local NAP is responsible for topics: HIV testing and counselling, performance of HIV test, drug
training public health staff on specific adherence counselling; HIV testing and counselling and sexually transmitted diseases/infections (STD/STI) screening, and treatment in STD clinics; as well as TB screening and PLHIV. It ensures joint supervision, monitoring and evaluation with the National Tuberculosis Programme (NTP) and the Union. The NAP
Health Laboratory (PHL) provide support for haematology,
Hospital laboratories and the Public
biochemistry, hepatitis serology and CD4 count. The PHL in Mandalay is HIV tests performed in Upper Myanmar. responsible for quality control of rapid
isoniazid preventive therapy is (IPT) for
People living with HIV/AIDS are
organized into self-help groups, one the integrated HIV programme are actively encouraged to join their participation in support group counselling, referral services and
per township. All patients enrolled in respective township self-help group for meetings. PLHIV provide community health education sessions and peer defaulter retrieval. counselling for testing and adherence, home-based care and participate in
supports PLHIV self-help groups and organizes defaulter tracing through these peer support groups. NAP also provides drug adherence counselling its investigators. sessions and defaulter tracing through Township health centres (THCs) provide their respective townships. THC also provides CPT to all HIV–TB infected patients in the medical units, while
TB treatment to all patients residing in
The Union (i.e. the International Union Against Tuberculosis and Lung Disease) is responsible for procurement and delivery of
waiting enrolment. It distributes health information and education materials, is provided at the township level. In and free condoms. The enrolment form Mandalay, HIV test for TB patients and chronic care of HIV-positive people on level. Treatment of latent TB infection is provided at the THC in the seven townships of Mandalay district. Medical Units (HIV inpatient and ART are decentralized at the township
antiretroviral and opportunistic infections drugs to the public and financial overview of the hospitals, as well as for the technical programme. It supports rapid HIV tests for TB patients and family opportunistic infections, and members, first- and second-line ART, laboratory follow-up including CD4 of all drugs provided by the IHC prevention, diagnosis and treatment of count. The store staff maintain records programme and replenish the substocks in adult and paediatric medical units. They provide a monthly report
outpatient departments) in the public
hospitals are general internal medicine units delivering specialized HIV care to
on stocks of all drugs in the central HIV OPDs and data collection and recording are provided through IHC
store. Additional manpower to run the facilitators and data-entry operators.
consultation (flow of patients, weight and height, patients’ files, next workers for drug adherence counselling, drug adherence appointment date, referral to social counselling), and systematically screen all attendees for TB symptoms using the five questions assessment from TB OPD. WHO. TB suspects are referred to the Patient appointments are recorded in a diary. The list of patients missing their appointment is produced at the midwives, peer volunteers and social workers from hospitals and STD clinics. end of each consultation. A defaulter
Activities
The IHC programme has
implemented all WHO-recommended HIV–TB activities — intensive case patients, intensive TB screening finding for TB disease and HIV the HIV OPDs. findings of HIV infection among TB among HIV patients, intensive case infection among spouses and children, and infection control procedures in All registered adult TB patients are systematically screened for HIV coinfection using a provider-initiated children of HIV–TB patients are also advised to get tested. opt-out strategy, and the spouses and
tracing system is organized with THC
Health information and education materials, and free condoms are HIV OPDs. distributed in the THC, TB OPDs and A specific HIV OPD is devoted to HIV– HIV-infected patients are screened for
Test results are obtained on the same day using two rapid HIV tests. At the THC, a HIV testing and counselling on HIV-infected patients and their register is maintained. Another “HIV
TB coinfected patients. In other OPDs, TB symptoms, in particular cough; TB suspects are promptly referred for TB evaluation and treatment. All patients are requested to wear a facial mask distributed by the volunteers at the mask and cover their mouth while lights further decrease the risk of transmission of TB. Active assessment of TB disease is beginning of each OPD. Wall posters coughing. Environmental measures, such as fans, air extractors, and UV
positive” register collects information outcome in the HIV programme. The NTP is responsible for the delivery of Co-trimoxazole preventive therapy is
TB treatment, as well as recording and reporting of TB treatment outcomes. patients while awaiting enrolment in refers the HIV–TB patients from the township to the district hospital HIV the spot. initiated among all HIV–TB coinfected the HIV OPD. The TB key staff person OPD. In the ART programme, HIV–TB
encourage patients to wear the facial
performed using sputum microscopy, tuberculosis (in Mandalay). IPT is provided in eight of the 10 townships This collaborative model should
chest X-ray and sputum culture for M.
patients are prioritized and enrolled on Clinical services are delivered at HIV OPDs co-manned by NGO medical doctors, peer volunteers and government employees (medical
after verbal assessment of well-being. rapidly be expanded to all the areas activities would be scaled up to 24 townships by 2015.
providing ART. With the GFATM round IX support, the HIV–TB collaborative
officers, nurses, pharmacists, social
workers). Peer volunteers organize the
Local Partnerships to Prevent HIV Among PWID
I I I I
First case reported in 1988 Estimated PLHIV: 64 000 population: MSM: <5% FSW: <5% Adult HIV prevalence: 0.4% PWID: 3–21% HIV prevalence in most-at-risk
Quick Facts
N
epal was among the first
countries in Asia to adopt
Western parts of the country (Nepal local level led to the need for unity local, district and national levels. organizations developed strong Affairs, Ministry of Health and
the early 1990s. Drugs consumption is a serious concern in the country C. The HIV epidemic is concentrated among the most-at-risk populations (MARPs), which include people who inject drugs (PWID), men who have sex with men (MSM), female sex was 21% in Kathmandu, 3% in
harm reduction approaches in
IBBS 2009). Working with PWID at the even to engage in advocacy and work closely with the Government at the network, Recovering Nepal, these While working with the main national partnerships and enhanced working relations with the Ministry of Home Population, especially through the National Centre for AIDS and STD Board. Control and HIV/AIDS STI Control I
High-level advocacy for harm reduction by numerous stakeholders society Active participation by civil Community-based delivery of services
Unique Features
due to the spread of HIV and hepatitis
I I
workers (FSWs) and labour migrants. Pokhara and 8% in Eastern and
The infection prevalence among PWID
Prepared by Anan Pun, Executive Director, Recovering Nepal
Fig. 35: HIV prevalence among people who inject drugs, Nepal, 2002–2009 80
% PWID infected with HIV
60
40
20
Kathmandu
0
Eastern Terai Pokhara 2003 2005 2007 2009
Source: Integrated Biological and Behavioural Survey among PWID, National Centre for AIDS and STD Control, Ministry of Health, Nepal.
The overall HIV prevalence in Nepal has begun to stabilize and HIV prevalence among PWID has declined significantly from 68% in 2002 to 21% in 2009 in Kathmandu, the capital city. The NGOs and civil society groups have played an important role in combating HIV in PWID and other most-at-risk groups through harmonization and coordination of organizations in Nepal organized founded in 2001. This national
Reduction Initiative is considered to society organizations were able to reach most PWID in the targeted is to strengthen the drug users support groups and build their
be most instrumental in the declining
HIV trends noted among PWID as civil districts. The purpose of this initiative capacity in carrying harm reduction level, with the primary beneficiaries and drug-led HIV. This programme and treatment among drug users through the support of ‘drop-inmobilization of drug users and
efforts. A large number of civil society themselves through Recovering Nepal network of PWID and drug service combat HIV among PWID through capacity development support, programmes. advocacy initiatives, information communication and small grant organizations is supporting more than 146 partners spread across Nepal to
activities and programmes at the local being organizations working on drugs delivered a package for HIV prevention centres’, extensive outreach and peer community-based drug treatment services by the local community It is through the closer working based organizations (CBOs) in Nepal. relationship among the civil societies in Nepal that these gains have been observed. The Nepal Government has
Of these, the Partnership support fund’s Community-based Harm
Partnership support fund is a small grant programme to support communitybased harm reduction projects in 18 districts in Nepal through Recovering partners in 2009 with the ultimate objective to reach out to unreached Nepal. The initiative supported 43 partners in the network in 2008 and 37 populations and create an enabling environment for harm reduction services to provide service to existing drug users, the fund has created an enabling harm reduction services to PWID. environment for harm reduction services covering 12 districts in 2008 and through a new model of community-based harm reduction approach. Initiated 11 districts in 2009. It provides needle–syringe exchange and community-based
started recognizing and appreciating the participation and contribution of civil society organizations in the epidemic. national response to the HIV/AIDS Harassment by law enforcement
The Conference examined and
provided a platform for: creating an understanding of the HIV/AIDS situation in Nepal; familiarization with the ongoing HIV/AIDS and harm delivering HIV; and health that target drug users. reduction plans and programmes; the extent and quality of experiences in programmes and activities in Nepal The active civil society and
agencies can further marginalize
PWID in society and compel many
drug users to hide and shun seeking health services. Challenges of social limited services to drug users still exist. However, there have been HIV among the MARPs especially of the civil society in Nepal. stigma attached to HIV coupled with positive changes in the fight against among PWID due to the engagement In 2009, a second National Harm
Government participation helped elected officials, government regulators and the media to play a significant role in highlighting drug
users’ challenges, healthcare options and laws, rules and even perceptions been possible to spread and build a consensus on how current, pending and perceptions impact drug users’ civic space in the country. that influence day-to-day lives of drug users and the prevention of HIV. It has and future laws, regulations, policies lives in Nepal while still expanding the There is also a strong consensus
Reduction Conference was organized forth issues surrounding the
through the network, its members and the Government to discuss and bring of accessible and quality health protection of human rights, provision services as well as comprehensive departure from the previous harm reduction services to drug users and PLHIV in Nepal. This was a clear conference where the Government possibly due to concerns about declined involvement in discussions anticipated confrontations with CBOs that advocate and work with drug users. The approach has now changed with an acknowledgement of the need to work together taking precedence.
among the local organizations working with PWID on the need to work more human rights and public health comprehensively towards promoting a approach to drug use and HIV/AIDS. Focus should not only be on HIV prevention and treatment but include care, among other health problems related to illicit drugs use. hepatitis C prevention, treatment and
Controlling STIs through a Public Health Approach
I I I I
First case reported in 1987 3000
Quick Facts
Estimated number of PLHIV: Adult HIV prevalence: <0.1% population: MSM: <1% FSW: <1% PWID: <1% HIV prevalence in most-at-risk
I I I I I
Standardized national guidelines Standard package of care Effective defaulter tracing Open referral system services Large scale up of quality
Unique Features
infections (STIs) during the past improved quality of care,
decade. This was possible due to strengthened preventive measures, and the well-established network of
S
ri Lanka was successful in of sexually transmitted
maintaining a low prevalence
with men (MSM) and people who inject drugs (PWID) in close collaboration with the local STD clinic staff, and refer the target population regularly to STD clinics for care services.
sexually transmitted diseases (STD) in the capital, Colombo.
The continuous sexually transmitted infections (STI) reporting system permits the evaluation of STI maintained within the government indicators and trends over time. A rate of gonococcal infections also decreased from more than 7% in the same period, while infectious STD programme for over five decades decline in bacterial STIs was observed in the past 10 years (Figure 36). The
clinics with the central clinic and the
National Reference Laboratory located Since 2000, patients seeking care at the STD clinics increased following better infrastructure and improved awareness activities carried out by STD staff with the involvement of other sectors, such as education, labour, youth, military and nongovernmental organizations
2004 to less than 2% in 2009. During syphilis rate continued to be less than 2%, there was a gradual increase in viral STIs, such as herpes and viral warts.
(NGOs). NGOs work with female sex workers (FSWs), men who have sex
Prepared by Chandrika Wickramasuriya, Consultant Venereologist, National STD/AIDS Control Programme, Sri Lanka
Fig. 36: Incidence rate of sexually transmitted infections, Sri Lanka, 2000–2009
12 Incidence per 100 000 population 10 8 6 4 2 0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Non gonococcal infections Infectious syphilis
Gonorrhoea
Genital herpes Genital warts
Source: STI surveillance reports, Ministry of Healthcare and Nutrition, Sri Lanka
Well-organized screening,
education and counselling
settings, and their close link with STI services play an important part in STIs. prevention of syphilis as well as other Antenatal VDRL screening for syphilis was low until a few years back. With
In Sri Lanka, asymptomatic patients
attend STD clinics to get screened for common STIs. Here they also receive condoms). This early care-seeking behaviour probably indicates the out and the confidence of people health education and counselling (for HIV testing, risk reduction and use of
was started in 1952, but the coverage the availability of testing in the private sector 92% of antenatal women were with positive test results are directed to STD clinics to confirm the diagnosis. The pre employment medical examination for prospective employment and for confirmation of service in the state sector, provides another opportunity for large scale performed in 2008 for pre screened for syphilis in 2007. Women
impact of awareness activities carried regarding the STD clinics. A repeat their sexual exposures, which gives screening is also offered depending on further opportunity for education and counselling during subsequent visits. male patients and 48% of newly registered female patients who did not have a STI. During 2009, 53% of newly registered attended the government STD clinics The availability of large-scale syphilis screening programmes, in different
state employees, those seeking foreign
screening for syphilis at STD clinics. employment, 11 were confirmed
Of the 46 471 syphilis-screening tests cases of syphilis. The low prevalence (0.02%) rate of syphilis among the
pre employment category can be
considered as a proxy to indicate the syphilis in all large-scale screening programmes are directed to STD treatment for other STIs at STD partners managed accordingly. The state sector organization,
and the National Youth Services
syphilis rate in the general population. Those testing positive on screening for clinics for confirmation. If syphilis is clinics, and are provided with health
Council (NYSC). Currently, 50 YFHS centres are available in the country and NYSC has a network of centres activities are carried out in the Sri spread throughout the country. Peer
educator led HIV and STI prevention Lankan army. There are 14 workplacebased HIV/STI prevention projects implemented by the private sector.
confirmed they undergo screening and education and counselling, and their
Standardized national guidelines National guidelines are used to provide standardized care at all STD clinics. Syndromic management of STIs (2001) and the Elimination of National guidelines on management of sexually transmitted infections (2000), congenital syphilis (2009) are being followed at all STD clinics. The STI treatment for general practitioners (2005) was developed to assure
National Blood Transfusion Service, is responsible for blood safety in the country. It screens all donated blood units for syphilis, hepatitis B and C, malaria and HIV. The units of blood tested for transfusion transmitted infections in 2008 and 2009 were Education and behaviour change
320 000 and 310 000, respectively. communication activities are carried
out throughout the country with multisectoral participation. STI prevention are implemented by NGOs in collaboration with the national FSWs, MSM and PWID for risk activities for most-at-risk populations programme. NGOs carry out targeted interventions for female sex workers reduction. Clients of sex workers, a proportion of male STD clinic educational programmes on 34 prisons. hard to reach group is addressed at
standards of care in general practice.
Standard package of care
All symptomatic patients attending of care, which includes treatment, HIV testing and risk reduction,
STD clinics receive a standard package health education and counselling for promotion and provision of condoms, and contact management. Patients repeat culture (test of cure) after treatment in clinics where culture diagnosed with gonorrhoea undergo a facilities are available. In all clinics
the STD clinic as it constitutes a large attendees. Ongoing peer educator led STIs/HIV/AIDS are being conducted in External migrants are educated on STIs and HIV by incorporating the topics to a 13-day pre-departure training programme. (In 2008, about 250 000 and in 2009 about 300 000 women going for unskilled labour.) In school, youth are reached through school youth are reached through integration of STIs/HIV/AIDS to the national school curriculum. Out-ofYouth Friendly Health Services (YFHS) people migrated, of whom 50% were
patients treated for trichomoniasis clinics. At all STD clinics an
undergo repeat wet smear. Serological experienced medical officer reviews are made to trace defaulters with STI defaults on attendance, extra efforts are made to find her for for the baby and the mother. positive test results and with active
follow up for syphilis is done at all STD records of all patients daily. Attempts infections. If a pregnant woman with treatment in view of the implications
Effective defaulter tracing
Contact tracing is mainly based on the patient referral method. The provider referral method is not practically feasible and cost effective as
Open referral system
Sri Lanka has a free and open referral system: i.e. a person with a STI related problem and their contacts can attend the STD clinic of their choice; availability of STI services in the private sector; and the presence of a good public and private health accessibility to STD services). partnership (which also increases the However, limited facilities for health education and counselling, condom in the private sector is offset by the state sector. promotion and partner management availability of the option for referral to
information on sexual contacts are not readily given by the patients and even if they did, the information mostly the effectiveness of contact was found to be incorrect. Therefore, management is heavily influenced by the role played by the patients in directing their contacts to STD clinics. In each clinic public health staff is defaulters when appropriate, educating about and promoting executing community outreach activities among the general responsible for tracing contacts and condoms to STD clinic attendees, and population and most-at-risk groups.
Large scale up of quality services While services have been scaled up so that there is at least one STD clinic in a district, where patients may access also been taken to ensure the quality of care at each clinic. All staff at the clinic before being appointed to the peripheral clinics. Further, the Post Graduate Institute of Medicine MD in Venereology courses to train laboratory services includes an internal quality assessment external quality assessment Laboratory. STD clinics are trained at the central services within a few hours, steps have
Free condom distribution
Condoms are provided free of charge to all STD clinic attendees and NGOs carry out condom promotional available for purchase, stigma activities. While condoms are freely attached to condoms reduces its population. Condoms are also greater acceptance and usage in the available at a very low cost through public health staff at the field level way of dual protection against condoms, respectively were where they promote the condom as a HIV/STIs and pregnancy. In 2008 and 2009, 487 972 and 13 10 832 distributed by the NSCAP to STD
conducts Diploma in Venereology and specialists in prevention and care of STI/HIV/AIDS. Quality assurance of programme for STD clinics and an programme for the National Reference Though the impact of each of the above public health preventive successful control of STIs in Sri Lanka. components cannot be calculated, the overall approach may have lead to
clinics, NGOs and armed forces. The Family Health Bureau, which is the has distributed 15 00 000 and respectively. government institution implementing 65 00 000 during 2008 and 2009, family planning services in Sri Lanka,
Virtual Elimination of Perinatal HIV Transmission
I I I I
First case reported in 1984 610 000
Quick Facts
Estimated number of PLHIV: Adult HIV prevalence: 1.4% population: FSW: 3% PWID: 35% HIV prevalence in most-at-risk MSM: 6–25%
I I I
Strong commitment and leadership development
Unique Features
W
ith the dedication of public health workers around the country, a strong health
and implementation. The programme, since its implementation has led to reduction in perinatal HIV transmission rates, decrease in from HIV infection.
infrastructure as well as the strong Ministry of Public Health leaders, into an effective HIV prevention
Evidence-based programme Strong infrastructure of deliveries antenatal care services and high coverage of institutional
leadership and commitment of the robust scientific evidence was turned programme that saved the lives of thousands of children in Thailand. preventing mother-to-child HIV antenatal care programme
reported paediatric AIDS cases and
has saved more than 20 000 children In the late 80s and early 90s, the mode of HIV transmission was
Thailand was the first resource-limited country to integrate interventions for transmission into its existing strong infrastructure in early 2000. The development of the prevention of programme included research to
HIV/AIDS epidemic emerged as a
major problem in Thailand. The major heterosexual intercourse from mosttheir male clients and from male clients to the general female at-risk female sex workers (FSWs) to population. With this ‘male-to-general female population’ transmission, the number of women getting infected their children increased. and consequently transmitting HIV to
mother-to-child transmission (PMTCT) identify an appropriate and affordable antiretroviral regimen, field-testing
Prepared by Tanarak Plipat, Medical Officer, Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health
Fig. 37: Number of reported AIDS cases among children (0–4 years), Thailand, 1991–2009 1400 1200 Number of children with AIDS 1000 800 600 400 200 0 91 95 99 01 03 93 97 19 19 19 20 20 05 07 20 19 19 20 20 09
Testing and counselling + formula
Zidovudine short course
Zidovudine 28 weeks + single-dose nevirapine
Source: Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health, Thailand.
The Ministry of Public Health (MOPH) tried to integrate HIV testing and care services when it noticed an counselling into the routine antenatal alarming increase in HIV infection among pregnant women in 1991. Nurses were trained and voluntary HIV testing and counselling units were set up in the MOPH hospitals. In these early years, no interventions were
available for pregnant women. HIV mainly done to identify infected women so that strict precautions
testing among pregnant women was could be taken during labour. In 1993, the MOPH recommended that all HIVinfected women be discouraged from breastfeeding and allocated funds to born to HIV-positive mothers.
The data from the Thai HIV sentinel surveillance showed that HIV prevalence among pregnant women who attend public antenatal clinics increased from 0% in December 1990 to 1.78% in June 1994 and peaked at 2.29% in 1995, resulting in a large number of children acquiring HIV infection perinatally.
purchase infant formula for all infants
Zidovudine trials: The major breakthrough in ‘prevention of mother-to-child HIV transmission’ occurred in 1994 when the results of the AIDS Clinical Trials Group (ACTG) Protocol 076 became available. The study demonstrated that, in babies for 6 weeks, could lower the risk for perinatal HIV-1 transmission from 25.5% to 8.3%. This regimen was prophylaxis has become the primary focus of strategies to prevent mother-to-child HIV transmission. However, quickly adopted as the standard of care in the US and Western Europe and the use of perinatal antiretroviral drug because of the complexity and cost of the ACTG 076 regimen, it has not been implemented in Thailand. Instead, the MOPH collaborated in partnerships to plan and conduct two phase III clinical trials to study the efficacy of shorter courses of AZT. One of the short course AZT trials from Bangkok reported 50% efficacy compared to that of the rates were 4.1% when using a longer course of AZT and 10.5% when using a shorter course of AZT. placebo in a non-breastfeeding population in early 1998. The other study showed that the perinatal HIV transmission In 1997, the MOPH decided to conduct a pilot project to assess programme feasibility, effectiveness, and regimen were reported. The perinatal HIV transmission rates were low (7.7% and 9.6%) in both regions. the absence of breastfeeding, zidovudine (AZT) given orally during pregnancy, intravenously during labor, and orally to
acceptability to prevent mother-to-child HIV transmission in two regions (region 7 and region 10). In both regions, high proportions of pregnant women received voluntary counselling and testing for HIV and a short course AZT
National implementation of PMTCT In December 1999, the MOPH
from Perinatal HIV Prevention Trial 2 study, MOPH changed the regimen to be as follows Antenatal and intrapartum ARV to infant
This year (2010), Thai MOPH has updated its national PMTCT guidelines to use triple drugs (AZT + 3TC + lopinavir/ritonavir (LPV/r)) among all HIV-infected pregnant women. The updated guidelines also included couple counselling in the pregnant women. prevention package to be offered to The success in implementation of the PMTCT programme can be measured by routine programme monitoring testing and counselling rate, and coverage for prophylaxis and indicators in the critical areas from antenatal care attendance rate, HIV treatment. Currently, Thailand has and counselling for all pregnant
recommendation of antiretroviral 300 mg AZT, 150 mg 3TC and 200 mg NVP twice per day starting at 28 weeks through delivery
convened an expert panel to review existing data and develop national 2000, the MOPH announced and began supporting nationwide programme. The programme components included: (i) the guidelines for preventing mother-tochild HIV transmission. In January
integration of a PMTCT programme
a single dose of 2 mg/kg NVP and 2 mg/kg AZT every 6 hours – for 1 week if the mother received antiretroviral medications more than 4 weeks or
into the existing maternal-child health establishment of confidential
voluntary HIV testing and counselling units at all health care facilities; (ii) counselling to all pregnant women; (iii) oral zidovudine (AZT) (300 mg gestation until labour and 300 mg syrup to all infants born to HIV confidential voluntary HIV testing and twice a day) starting from 34 weeks’ every three hours during labour to all HIV seropositive women; (iv) oral AZT seropositive women; (v) infant formula months of age; (vi) HIV antibody testing to all children born to to substitute for breastfeeding until 12 seropositive women at age of 12 mothers and children.
– for 6 weeks if the mother received antiretroviral medications less than 4 weeks
In 2004, the MOPH added an optional require treatment (i.e. mothers who This treatment is the combination therapy as follows Antenatal Intrapartum
antiretroviral regimen for mothers who have CD4 counts >200 cell/mm2, or who have an AIDS defining condition).
achieved universal coverage for testing women and above 90% of women are receiving ARV prophylaxis and almost all the babies born to HIV-positive HIV transmission rate to 3%. mothers are receiving ART. This has resulted in a reduction of perinatal
300 mg AZT twice per day starting at 28 weeks
months and 18 months; and (vii)
proper medical care and treatment for National antiretroviral regimen for PMTCT use in Thailand has been updated in 2004. Based on the results
ARV to infant
300 mg AZT and 200 mg nevirapine (NVP) at the onset of labor and 300 mg AZT every 3 hours thereafter
In conclusion
Starting from research to identify an appropriate and affordable antiretroviral prophylaxis regimen for pregnant women, to field testing and implementing the programme to achieve universal coverage, Thailand saving lives of many children.
a single dose of 2 mg/kg NVP and 2 mg/kg AZT every 6 hours – for 1 week if the mother received AZT for more than 4 weeks or – for 6 weeks if the mother received AZT for less than 4 weeks
has demonstrated strong leadership in combating perinatal HIV transmission
National PLHIV Network Shows the Way
I I I I
First case reported in 2001 <1000
Quick Facts
Estimated number of PLHIV: Adult HIV prevalence: 0.1% population: FSW: 2.7% MSM: 1.3% HIV prevalence in most-at-risk
T
imor-Leste is still a low HIV recent evidence that sexual
prevalence country but there is
Timor-Leste faces many challenges in such as stigma and discrimination; in the emergence of a growing population group with significant disposable income; proximity to Indonesia which has a concentrated health care services. fast economic growth rates resulting
confronting the threat of HIV and STIs I I I
transmission outside the context of predicted. The 2009 Sentinel
sex work and male-to-male sex (the
Evidence based responses Appropriate strategy and programming national response
Unique Features
traditional epicentres), is higher than Surveillance and Integrated Biological and Behavioural Surveillance showed that the HIV prevalence was 0.68% among pregnant women, 2.58% (STI) patients, 1.13% among TB
Involvement of the PLHIV in
epidemic; illegal migration and crossborder exchange; and poor access to Since 2005 Timor-Leste has successfully developed and implemented a national strategy to combat HIV/AIDS/STIs. Major progress has been made in prevention among most-at-risk populations implementation of an effective (MARPs), access to antiretroviral therapy (ART) and STI management, sentinel surveillance system, strong endorsement at the political level, and
among sexually transmitted infections patients, 2.76% among female sex workers (FSWs) and 1.33% among As of June 2010, 198 people, men who have sex with men (MSM). including 14 children under the age of with 83% living in the capital Dili; 47% of all HIV-positive cases are female. five years, were confirmed HIV-positive
Prepared by Sr. Narciso Fernandes, National HIV/AIDS Program Manager, Ministry of Health, Timor-Leste and Amber Kimbro , HIV Technical Officer, WHO – Timor-Leste
effective partnership between the programme implementation.
government and community sectors in One of the unique features of the Estrela+, a national network of
The actions of Estrela+ are assisting the country in responding appropriately to HIV. Estrela+ has recently established an HIV Networking Group that includes health personnel involved in treatment at the National Hospital. Several members on providing pre- and post-test of Estrela+ have attended testing and counselling training and are focused counselling for people attending HIV
approach across sectors in relation to few nations in the world that could have been expected to have maintained as strong a focus on
strategy and programming. There are
programme in Timor-Leste is that of positive people that has been actively epidemic. It currently has 59 active members from eight of the 13 supported through a variety of Solidarity and Progressio (an districts in Timor-Leste. They are channels, such as the Ministry of international agency providing Health, and the Ministry of Social development advisors). Estrela+ has recently undertaken the process for of Justice. formal registration with the Ministry assisting the Ministry of Health (MOH) in appropriately responding to the HIV
programme implementation as has occurred given the country’s social and political upheavals. Timor-Leste 2011–2016 in place that provides a and harmonization of funding from different sources to maximize its effectiveness and efficiency. With has a National HIV and STI Strategy clear direction for ensuring alignment
services and follow up counselling to workshop along with a local NGO, Fundasoun Timor Harii and the Scarlet Alliance.
individuals and families. Members of
Estrela+ helped facilitate an advocacy
commitment from all partners TimorLeste is well placed to strengthen the existing response to HIV, meet new minimizing HIV transmission in challenges and achieve the goals of Timor-Leste, and ensure high quality of treatment and care for PLHIV.
In Timor-Leste, overall there is broad consensus on the basic principles of partnership, evidence based responses and a human rights
Story of Estrela+ 2000, Antonio1, 32 years of age, also positive for HIV. He did not believe his initial test results so he took another it does not matter now; the result is still the same. In 2003, Maria1, now aged 35, tested positive for HIV, as did her husband and eventually one of her children. In HIV test in 2006, which again came back with a positive result. He had been in Indonesia at the university when he
tested positive and is not sure if it was the result of injecting drugs or from unprotected sex. But, according to him, Maria and her husband felt isolated and alone; they were the first few diagnosed with HIV in the country. Through a few other Timorese who were also HIV-positive. They decided that they needed to establish a support group for people like them and in 2004 “Esperanca” was born. Esperanca means ‘hope’ in Portuguese. The group was officially established as Estrela+ in 2009.
connections with local NGOs working on HIV, such as Timor Aid and Church World Services, they were introduced to
Estrela+ has overcome many challenges since its initiation but at the same time many opportunities have also come their way. In August 2009, two members were invited to attend the International Congress on AIDS in Asia and the One member of the group has been selected to be a permanent member of APN+, the Asia Pacific Network of people living with HIV/AIDS, and participates in regional meetings. Pacific in Bali. They were able to connect with members of Bali Plus and other HIV positive networks. Additionally, in July 2010, two members were provided with scholarships to attend the International AIDS Conference in Vienna.
Although they still envision a long and bumpy road ahead, Maria and Jose are proud of their efforts to bring HIV to to finally be able to stand up proud and not be afraid. 1
the forefront in Timor-Leste. Antonio, as the first PLHIV to disclose his status publicly, feels empowered and relieved
Countries in the South-East Asia Region have made substantial in a slow decline in new HIV progress in their response to the HIV infections. Still, much remains to be done. An estimated 220 000 individuals were newly infected with remain unacceptably high among populations engaging in high-risk HIV in 2009. HIV transmission rates behaviours, namely sex workers, men who have sex with men and people infected pregnant women do not receive prophylactic antiretrovirals who inject drugs. Two of three HIVresulting in a large number of children being born with HIV each year. The more than half do not receive will require overcoming many challenges. majority of the HIV-infected people are unaware of their HIV status and treatment. Addressing these issues epidemic in the past decade resulting
sanctions against this group in many the most discriminated and
countries. The transgender population is highly vulnerable to HIV; it is one of stigmatized populations. Although there is government support in Member countries to engage with and populations, the law enforcement health services. agencies are often not adequately provide services to these marginalized sensitized resulting in poor access to
Weak Health Systems
While effective interventions for the prevention and control of HIV have been successfully implemented in not achieve the level of coverage some areas in the Region, these could needed to make an impact because of weak health systems. There has been acknowledgement for the need to strengthen health systems, but in reality little progress has been made. The current weaknesses and gaps in the health system are largely due to underinvestment in health systems. District and subdistrict health facilities usually lack adequate nonexistent. equipments and commodities and referral mechanisms are usually
Key Challenges Stigma and Discrimination stigma in communities and HIV prevention and control efforts are being undermined by HIV associated discriminatory practices in health care settings. Unfavourable laws, policies, and cultural and social norms that increase the vulnerability of marginalized groups to HIV infection
Insufficient Health Workforce skilled staff in the majority of
There continues to be a shortage of Member countries with many health facilities having vacant positions. programmes face enormous National and subnational HIV control challenges in recruiting skilled and
still exist. Sex work and drug use are largely hidden due to criminal
illegal in most countries. The men who have sex with men population remains
competent staff due to inadequate good staff is equally challenging. constant transfers and frequent changing political environment, change of leadership due to the undermines the implementation Moreover, unfilled staff positions,
incentives. Motivating and retaining
of data, as a result of expanded have sex with men, transgender
information systems, vital information on most-at-risk populations (men who persons, and clients of sex workers Surveillance sites for most-at-risk the epidemics and data on HIV
including migrants) is still inadequate. populations are not enough in number to capture the geographic diversity of services is usually incomplete and scale up interventions and a gap untimely. Very little investment has exists in synthesis and analyses of data leading to underutilization of programmatic reforms and resources dedicated to HIV available information for policy and improvements. In general, staff and information systems are limited; and surveillance, monitoring and evaluation as well as research. available staff have limited training in
capacity of national and subnational the number of health care workers insufficient, but they lack the care services as well as the
HIV control programmes. Not only are necessary technical training to provide HIV/AIDS prevention, treatment and managerial skills to plan, prioritize and monitor HIV programmes.
been made on operational research to
High Prices of Antiretroviral Drugs Although the price of first-line antiretrovirals has dropped considerably over the years, these variations in drug prices among drugs continue to be unaffordable to countries in the Region. The revision guidelines in 2010, would lead to a proportionately increase country expenditures for first-line drugs.
the governments. There are also large of WHO global antiretroviral treatment substantial increase in the number of PLHIV needing treatment; and this will Second-line treatment prices are very high, which presents a significant would progress on to second-line challenge for universal access because treatment. The prices of laboratory be reduced, to lower the financial and care. people currently on first-line treatment diagnostics and supplies also need to burden of countries as more people start accessing HIV/AIDS treatment
Lack of Sustainable Financing In most Member countries in the scaled-up response to the HIV Region government funding of HIV epidemic. Sustainable financing programmes is too low to develop a strategies are essential to enable Heavy reliance on international
countries to develop and implement funding is very common with many for implementing even essential services, such as blood safety. It is
long term responses to the epidemic. countries dependent on donor funds important to understand that donor they have filled critical gaps and several countries with limited resources, these monies usually and service coverage cannot be meet universal access and the
funds are of limited duration and have unpredictable continuity. Also, though greatly boosted national responses in support “few pieces” of the national scaled-up to the extent required to
Data Gaps in Interventions for Most-at-Risk Populations While the Member countries of the
response. Expansion of interventions
Region in recent years generated lots
Millennium Development Goals, unless there are substantial increases in domestic and international funding.
4. Ensuring timely access to treatment centres.
treatment by effective linkages
between testing, counselling and 5. Continuing advocacy for reduced 6. Improving the quality of prices of antiretroviral drugs. antiretroviral treatment while improving access. Ensuring monitoring to “slow” the resistance. development of HIV drug 7. Investing in building health capacity for scaling-up HIV supervision and better adherence support and close
Future Directions
Given the setting of a concentrated epidemic and the above listed challenges, critical priorities for countries and development partners
in the coming years are listed below. populations with the highest transmission of HIV, i.e. sex have sex with men, the who inject drugs.
1. Reducing HIV transmission among workers and their clients, men who transgender population and people 2. Removing barriers to access to populations by repealing settings.
systems and human resources to increase the implementation interventions. Integrating effective management of HIV programmes into strong health systems.
health services for most-at-risk discriminatory laws and reducing stigma in communities and health
8. Decentralizing HIV testing and counselling services to enable more people to know their status. building epidemiologic capacity (both institutional and human) within countries, to carry out and research activities. relevant surveillance, monitoring Undertaking research on priority topics to achieve targets for care and treatment. universal access to HIV prevention,
3. Reducing perinatal HIV
transmission by increasing access to prevention of mother-to-child with related services such as transmission services for pregnant women. Integrating HIV services maternal and reproductive health services to achieve high coverage of programmes for preventing mother-to-child transmission.
9. Filling in information gaps by
Selected New WHO Publications in 2010 WHO-SEARO publications HIV/AIDS among men who have sex with men and transgender populations in South-East Asia: The current situation and national responses
HIV/AIDS among men who have sex with men and transgender population s in South-East Asia THE CURRENTSITUATION AND NA TIONALRESPONSES
There are an estimated 4–5 million men who have sex with men; among the transgender population, the number is less clear. Many of them are involved in high-risk sexual behaviours that put them at risk for HIV infection, resulting in a high and increasing HIV prevalence in several countries of the Region. Control of HIV infections among these populations is an urgent public health priority. The countries reviewed are Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. This report highlights the need for improved advocacy efforts and a greater national response to save the lives of these populations who are at risk for HIV infection.
Report on people who inject drugs in the South-East Asia Region
This report highlights the need to advocate for greater efforts and resources to be channelled into harm reduction interventions in the South-East Asia Region. The report reviews the national responses of Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal and Thailand in terms of efforts to reduce the HIV prevalence among people who inject drugs. Data show that such harm reduction measures have a limited reach and are not sufficiently scaled up to match the size of the problem in the Region.
A strategy to halt and reverse the HIV epidemic among people who inject drugs in Asia and the Pacific 2010–2015
This document is a road map to ensure that the HIV and hepatitis epidemics among people who use drugs and their sexual partners in the Asia Pacific region will be halted. The strategy is designed to formulate a regional framework, identify issues and priorities and provide guidance to countries in the Region for developing national strategic responses over the next six years. It shows the important link between halting the HIV epidemic and health and development, and will help countries achieve United Nations Millennium Development Goal 6.
Priority HIV and sexual health interventions in the health sector for men who have sex with men and transgender people in the Asia-Pacific Region
This publication is meant for public health decision-makers, national AIDS programme managers, health-care providers, managers of community-based organizations, civil society, people living with and affected by HIV and international development partners. It identifies the priority interventions required by the health sector to meet the HIV and sexual health needs of men who have sex with men and transgenders. This document highlights how national health sector partners can strengthen their response to HIV among men who have sex with men and transgenders.
Toolkit for monitoring and evaluation of interventions for sex workers
This toolkit aims to demonstrate how a small number of recommended indicators can provide critical information to guide interventions. These tools can be used at different levels of management to track the progress of a programme and focus efforts on achieving targets. Special attention is paid to how data can be used by on-site managers to help them make periodic decisions. The intended audience for this toolkit includes project directors or project managers of sites, monitoring and evaluation officers from nongovernmental organizations, state/provincial health officers and national monitoring and evaluation officers.
WHO-Headquarters publications Priority interventions: HIV/AIDS prevention, treatment and care in the health sector Priority Interventions HIV/AIDS prevention, treatment and care in the health sector 2010
This document brings together key WHO guidance and references for the health sector response to HIV/AIDS. The complete set of WHO-recommended priority health sector interventions is described to strengthen an effective and comprehensive health sector response to HIV/AIDS. In addition, it summarizes key policy and technical recommendations developed by WHO and its partners; guides the selection and prioritization of interventions for HIV prevention, treatment and care; directs leaders to key WHO resources and references containing the best available information on the overall health sector response to HIV/AIDS and on the priority health sector interventions with the aim of promoting and supporting rational decision-making in designing and delivering HIV-related services.
These Guidelines are a revision of the 2006 guidelines and present significant evidence and experience on when to initiate ART and what drug regimens to use. WHO’s new guidance on ART for adults and adolescents provides evidence that rates of death, morbidity and HIV and TB transmission are all reduced by starting treatment earlier. The 2010 guidelines recommend: Earlier diagnosis and treatment of HIV in the interest of a prolonged and healthier life; greater use of more patient-friendly treatment regimens; and expanded laboratory testing to improve the quality of HIV treatment and care while recognizing that access to laboratory tests should not be a prerequisite for treatment.
2010 Guidelines: Antiretroviral treatment for HIV infection in adults and adolescents
2010 Guidelines: Antiretroviral drugs for treating pregnant women and preventing HIV infections in infants
These new WHO guidelines on PMTCT and infant feeding practices provide the basis for more effective PMTCT interventions in resource-limited settings, and eliminate the number of new paediatric HIV infections. For the first time, the eradication of mother-to-child transmission of HIV (MTCT) is considered a realistic public health goal. The Guidelines recommend earlier antiretroviral therapy (ART) for a larger group of HIV-positive pregnant women, longer provision of antiretroviral (ARV) prophylaxis for HIV-positive pregnant women, and provision of ARV prophylaxis to the mother or child to reduce the risk of HIV transmission during the breastfeeding period. For the first time, WHO also recommends ARVs while breastfeeding.
Antiretroviral therapy for HIV infection in infants and children: Towards universal access. Recommendations for a public health approach: 2010 revision
These guidelines address the diagnosis of HIV infection and consider ART in different situations, e.g. where infants and children are coinfected with HIV and TB, or have been exposed to ARVs, either for PMTCT or because of breastfeeding from an HIV-infected mother on ART. These guidelines also address the importance of nutrition in the HIV-infected child and of recognizing the severity of malnutrition, especially in relation to the provision of ART. A section on ART in adolescents briefly outlines key issues related to treatment and care for this age group. This publication is intended for treatment advisory boards, national AIDS programme managers and other senior policy-makers who are involved in the planning of national and international HIV care strategies for infants and children in resource-limited countries.
Guidelines on HIV and infant feeding 2010: Principles and recommendations for infant feeding in the context of HIV and a summary of evidence The 2010 recommendations are consistent with the previous guidance, i.e. they recognize the important impact of ARVs during the breastfeeding period, and recommend that national authorities in each country decide which infant feeding practice should be promoted. Where national authorities promote breastfeeding and ARVs, mothers known to be HIV-infected are now recommended to breastfeed their infants until at least 12 months of age. Guidance is given on what to do in case of a delay in ARV roll-out.
WHO recommendations on the diagnosis of HIV infection in infants and children
To enable antiretroviral (ARV) prophylaxis to be given to infants as soon as possible after birth, all infants should have their HIV exposure status known at birth. As not all mothers are given HIV tests, very few HIVexposed infants are identified and very few infants are known to be gaining access to early diagnosis, the necessary prerequisite to ‘timely’ initiation of antiretroviral therapy (ART). Currently, only an estimated 15% of HIV-exposed infants needing testing are tested in the first two months of life.
Recently published data confirming dramatic survival benefits for infants started on ART as early as possible after the diagnosis of HIV, prompted a review of the WHO paediatric treatment guidelines.
Many opportunities to diagnose HIV infection in infants and children are missed within the health system, such as at facilities providing services for antenatal care, prevention of mother-to-child transmission (PMTCT) of HIV, immunization, nutrition, inpatient admissions and within programmes for other vulnerable children. Very few HIV-infected infants are started on antiretroviral therapy, and those who do receive it, are started when they are already very sick, largely due to a delay in HIV testing. This policy brief advocates expanded access to HIV testing and counselling for infants and children and presents ways to address the unique challenges for policy-makers, programme managers and health-care providers. The brief aims to outline key issues that should be addressed within national policy guidance to support country programming. It is designed to be used by country programmes and technical working groups for developing policy and practice guidelines relevant to HIV testing for children.
Policy requirements for HIV and counselling of infants and young children in health facilities
PMTCT strategic vision 2010-2015: Preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals
This publication elaborates WHO’s ongoing commitment to the United Nations General Assembly Special Session (UNGASS) goals and global and country support to scale up access to prevention of mother-to-child transmission (PMTCT) of HIV services and integrate these services to maternal, newborn and child health programmes. The objective is strengthening of support for PMTCT within the context of the Millennium Development Goals (MDGs) and reflects an important part of WHO’s health sector response to HIV/AIDS and will contribute directly to the new Outcome framework of the Joint United Nations Programme on HIV/AIDS (UNAIDS).
Delivering HIV test results and messages for re-testing and counselling in adults
This new WHO publication complements the WHO/UNAIDS Guidance on provider-initiated HIV testing and counselling in health facilities. The document states that re-testing should be recommended to people with ongoing risk of HIV infection and to those who recall an incident of risk in the previous three months. The document aims to help HIV policy-makers, programme and site managers, trainers, and testing and counselling providers in all settings to detect HIV earlier among people with recent exposure to, or ongoing risk for HIV; it will promote earlier referral of HIV-positive people to prevention, care, treatment, including PMTCT services.
Priority research questions for TB/HIV in HIV-prevalent and resource-limited settings
This publication presents priority questions, which reflect a wide range of research needs in basic, epidemiology, clinical, and operational research. Concomitant to increasing the scientific interest of the research community towards these questions, enhancing fund allocation by national governments of resource constrained settings is very crucial. It is believed the priority research questions identified in this document would provide guidance on what needs urgent scientific interest and funding to address the dual TB and HIV epidemic.
This comprehensive research agenda, released by WHO and partners, can help significantly advance global responses to HIV among women, girls and children. It includes 20 specific recommendations to expand upon and improve responses to the HIV-related challenges facing women and children worldwide.
Asking the right questions: advancing an HIV research agenda for women and children Consensus statement
It focuses on key gaps in clinical and programmatic knowledge that hinder access to effective HIV prevention, treatment and care for women and children, and was released to coincide with International Women’s Day.
Guidelines for using HIV testing technologies in surveillance: selection, evaluation and implementation: UNAIDS/WHO working group on global HIV/AIDS/STI surveillance
Serosurveillance is an important component of most HIV surveillance activities and an understanding of current HIV testing technologies is important. These technical guidelines are for HIV surveillance coordinators and other health professionals involved in HIV testing for surveillance purposes in developing countries. They are part of a series of operational guidelines for second generation HIV surveillance systems. The guidelines describe the specimens used in HIV testing, testing strategies in surveillance, selection and evaluation of HIV testing technologies, and laboratory quality assurance and safety.
References 1. 2010 Report on the global AIDS epidemic. Geneva, UNAIDS, 2010. 2. National Health and Family Survey-3, 2006. Government of India. Timor-Leste, 2010. Myanmar, 2009. 3. HIV sentinel surveillance—5 districts in Timor-Leste. Ministry of Health, 4. Report of the HIV sentinel sero-surveillance survey. Ministry of Health, 5. Global tuberculosis control: epidemiology, strategy financing. Geneva, World 7. HIV sentinel surveillance report. National AIDS Control Organization, Ministry 8. Integrated biological-behavioural surveillance (IBBS) among most-at-risk-groups (MARG), Indonesia. Surveillance highlights: Female sex workers. Ministry of Health, Indonesia, 2007. Health and Family, Republic of Maldives, 2008. Nepal, 2009. 9. 2008 Biological and behavioural survey (BBS) on HIV and AIDS. Ministry of 10. Integrated biological and behavioral surveillance survey (IBBS) among female 11. National AIDS/STD Programme. Sentinel surveillance, 2007. Ministry of 12. HIV serological surveillance. Ministry of Healthcare and Nutrition, Sri Lanka, 13. Integrated biological and behavioural survey (IBBS) among men who have sex 14. Integrated biological/behavioral surveillance among most-at-risk-groups 15. Integrated biological/behavioral surveillance among most-at-risk-groups Ministry of Health, Indonesia, 2008. with men 2009. Family Health International, Nepal, 2008. (MARG) in Indonesia: surveillance highlights Fact sheets: men who have sex with men and warias/transgender. Ministry of Health, Indonesia, 2008. (MARG) in Indonesia: surveillance highlight. Fact sheets: injecting drug users. drug users in Kathmandu. Family Health International, Nepal, 2009. health sector: Progress report 2010. WHO-UNAIDS-UNICEF . 2009. Health, Bangladesh, 2007. sex workers in 22 Terai highway districts of Nepal. Family Health International, of Health and Family Welfare, India, 2009. 6. HIV sentinel surveillance. Ministry of Public Health, Thailand, 2009. Health Organization, 2010. (http://www.nfhsindia.org/nfhs3.html, accessed 4 November 2010).
16. Integrated biological and behavioral surveillance survey (IBBS) among injecting 17. Towards universal access. Scaling up priority HIV/AIDS interventions in the 18. Integrated behavioural and biological assessment Round 1 (2005–2007): 19. Brahmam GN, et al. and IBBA Study Team. Sexual practices, HIV and S45–S57. men in four high prevalence states of India. AIDS, 2008, 22 Suppl 5, national interim summary report. Family Health International, India, 2008. sexually transmitted infections among self-identified men who have sex with
20. McNicholl J, et al. Prevalence of sexually transmitted infections (STI) in a Paper presented at: The Fourth IAS Conference on HIV Pathogenesis, #CDB198. Treatment and Prevention; July 22–25 2007; Sydney, Australia. Abstract
cohort study of men who have sex with men (MSM) in Bangkok, Thailand.
21. Integrated biological-behavioral surveillance (IBBS), Ministry of Health, Timor22. Morineau G, et al. Sexual risk taking, STI and HIV prevalence among men 23. Bollen LJ, et al. Addressing the high prevalence of gonorrhoea and comprehensive intervention. Sexually Transmitted Infections 2010;86(1):61–5. Leste 2010. who have sex with men in six Indonesian cities. AIDS and Behaviour, 2009. chlamydia among female sex workers in Indonesia: results of an enhanced,
24. Ramesh BM, et al. Changes in risk behaviours and prevalence of sexually sex workers in five districts in Karnataka state, south India. Sexually Transmitted Infections 2010;86 Suppl 1:i17–24. Bangladesh, 2008. General of Health Services, Ministry of Health and Family Welfare, and Family Welfare, India 2010. Health, Myanmar, 2010.
transmitted infections following HIV preventive interventions among female
25. Behavioural surveillance survey: technical report 2006–2007. Directorate 26. Annual report 2009–2010. Department of AIDS Control. Ministry of Health 27. National strategic plan for HIV & AIDS in Myanmar: Progress report. Ministry of
Tables
Total
Total <15 years
Male <15 years
Female <15 years
Total 15 years and above
Male 15 years and above
Female 15 years and above
Bangladesh Bhutan India DPR Korea Maldives Nepal Indonesia
Population in urban areas 2010 35% 60% 28%
Adult literacy rate (% aged 15 and above) (2005–2008)a 53 55
Gross national income per capita (PPP 2008, US$) 5 607 1 587
Human Development Index (rank) 129 NA 119 NA
Myanmar
Sri Lanka Thailand Timor-Leste
14% 34% 28%
19%
34%
40%
44%
30%
NA 98 92 63
3 337 1 596 5 408 3 957
NA
92 91 94 58
107 138 91 92 132
108
4 886 8 001
1 201
NA
5 303
120
Number of administrative units Regions/Provinces/ Districts of local States administrative units
Number of health facilities Public Private Total
Per capita expenditure on health (US$)a
Government expenditure on health as % of total government expenditurea
Estimated number of PWID
Number of needle– syringe programme sites per
Number of Number of syringes/needles syringes/needles distributed per PWID per year
Number of OST sites
Number of PWID currently enrolled on OST
Number of PWID currently enrolled on buprenorphine
Country Bhutan India Bangladesh
Number of tests 26 278 NA
Population (15 years plus) 113 664 000 497 000
Number of tests per 1000 adult population 0.2 NA NA
Total Number of facilities for T&C 105 NA NA
Number of facilities per 100 000 adult population 0.09 NA NA
DPR Korea Indonesia Maldives Nepal Myanmar Sri Lanka Thailand Timor-Leste
13 494 372
NA
160 765
840 306 000
18 914 000
270 301 59 609 1 099 657 NA –
374
170 488 000
16.1 0.9
5 089 565 350 179 1 014 47 8
0.61 0.33 3.51 0.94 0.94 0.30 1.89
37 084 000 19 141 000 15 455 000 53 510 000 646 000
228 000
1.6 7.3 3.1 NA
20.6
NA
NA
NA
Country
Number of pregnant women who were tested
Percentage of pregnant women tested for HIV
Number of HIVinfected pregnant women receiving ART
Estimated number of HIV-infected pregnant women
% HIV-infected pregnant women who received ART
Country
Total
Number of adults and children with advanced HIV infection who are currently receiving ART Adult male Adult female
% of PLHIV on ART Based on CD4 200 Based on CD4 350
Children
% of children living with HIV on ART Low estimate
High estimate
Data Notes The results presented in this report are primarily based on national surveillance and progress reports of the national AIDS programmes of the Member countries. Survey results based on inadequate sample size (as per national protocols) were data from consistent (continuing) sites. excluded. Trends in HIV prevalence and risk behaviours were presented based on Surveillance data presented by national AIDS programmes are subject to
important limitations. First, the geographic coverage of biological and behavioural surveillance for most-at-risk populations is limited to a few large cities or major urban areas. Given the large size of countries in the Region and the epidemiologic diversity, a few surveys in the large urban areas may not be representative of the national situation. Despite the limitations, these surveys are useful in assessing trends in HIV prevalence in different population groups. Second, data on risky possible, that some respondents may report desirable behaviours (social condom use at last sex with a client. The high rates of condom use are desirability bias). For example, in Myanmar 96% female sex workers reported inconsistent with high HIV infection in this population, indicating a possible social majority of prevention interventions are implemented by nongovernmental unavailable. Moreover, there is limited reporting by the private sector in all organizations but unified reporting from all implementing agencies is usually countries. Thus, data on curative interventions, particularly, treatment of sexually transmitted infections and antiretroviral treatment may be incomplete and underestimated due to non-reporting by the private sector. On the contrary, sometimes reported service data may be overestimated due to double counting of the target population. For example, when two nongovernmental organizations provide services to a specific population in the same geographic area, there is a likelihood of the population being counted in the records of both nongovernmental agencies. Double counting can also occur when an individual utilizes services from more than one agency; for example, an individual may go for HIV testing to more than one health facility. .
behaviors is collected from respondents based on self-reported behaviours. It is
desirability bias among reported behaviours by female sex workers. Thirdly, a large
This progress report presents the current status of
HIV/AIDS in the South-East Asia Region based on latest
surveillance and programme data reported by Member countries. The report highlights the progress made in challenges and future priorities. Unique programmatic achievements of each Member country are elaborated in this report would be useful to a wide audience including field of HIV/AIDS. prevention and control of HIV in the Region and lists under the Country Best Practices section. The information HIV programme managers in the Region and around the world, donors, policy makers as well as researchers in the