HIV/AIDS in the South-East Asia Region Progress towards MDG 6A, 2012
in the South-East Asia Region Progress towards MDG 6A, 2012
HIV/AIDS
WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia. HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012 1. HIV Infections – epidemiology – prevention and control. 2. Acquired Immunodeficiency Syndrome – epidemiology – prevention and control. 3. Antiretroviral Therapy, Highly Active. 4. Drug Resistance. ISBN 978-92-9022-438-9 (NLM classification: WC 503.6)
© World Health Organization 2013 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from Bookshop, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: bookshop@searo.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization. Printed in India
Contents
Foreword.............................................................................................................v Acronyms...........................................................................................................vii Executive summary.............................................................................................ix Introduction.....................................................................................................xiii MDG 6 at a glance.................................................................................... xiii Global scenario.......................................................................................... xv Status of the HIV epidemic in the South-East Asia Region........................... xvi 1. Progress towards MDG 6(a)....................................................................... 1 1. MDG 6(a): Have halted by 2015 and begun to reverse the spread of HIV/AIDS (reversing and halting the epidemic).................................... 1 - - - - - 2. HIV among antenatal attendees................................................... 5 Reducing the sexual transmission of HIV among populations at high risk...................................................................................... 8 HIV reduction among MSM......................................................... 9 HIV reduction among female sex workers.................................. 11 HIV among injecting drug users ................................................ 12
Goal 6(a), Target 6.2: Proportion of population aged 15–24 years with comprehensive and correct knowledge of HIV/AIDS.................. 15 - Comprehensive knowledge among key affected populations..... 17 Condom use among MSM......................................................... 20 Sex workers and condom use.................................................... 21 Control of sexually transmitted infections in HIV prevention...... 27 The STI burden among MSM, FSW subpopulations................... 28 Reducing new infections among children by preventing mother-to-child transmission of HIV.......................................... 30 MDG (G6.Target 6(a), 16.2) Condom use at last high-risk sex............. 19 - - - - -
3.
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2.
Progress towards MDG 6 (b) Universal access to treatment for HIV/AIDS............................................................................ 35 1. 2. 3. 4. 5. 6. Universal access targets MDG 6(b) T6(b): Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it................ 35 HIV testing and counseling................................................................ 42 New models of testing are used to expand testing services................. 44 Retention of persons on ART............................................................. 45 Drug resistance to antiretroviral drugs................................................ 47 HIV/TB collaboration to reduce AIDS deaths..................................... 47
3.
Challenges and the way forward.............................................................. 51 1. Challenges......................................................................................... 52 - - - - 2. 3. Continuing stigma and discrimination........................................ 52 Limited capacity of health systems............................................. 52 Sustainable financing................................................................. 53 Antiretroviral drugs.................................................................... 53
HIV as a chronic disease and ageing.................................................. 54 The way forward............................................................................... 54
4.
The MDGs beyond 2015.......................................................................... 55
References........................................................................................................ 57
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HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Foreword
In the past decade, the Millennium Development Goals (MDGs) have set the agenda for global development, and the health-related MDGs have seen crucial progress. This is particularly true of the HIV-related components of MDG 6, which are: • to halt and begin to reverse the spread of HIV/AIDS by 2015; and • to achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it. There have been intense, dedicated efforts, initiatives and innovations across Member States in the WHO South-East Asia Region to meet these goals, and the impact of these efforts are now visible. Governments are also investing more on the AIDS response in Member States. Indonesia, Sri Lanka and Thailand have financed over 40% of domestic funds for the national AIDS response. India has committed to allocate 90% of domestic funds for HIV/AIDS in the coming years. Consequently, due to the concerted efforts of Member States, with support from the World Health Organization and development partners, the HIV epidemic is declining in the Region and has stabilized in many countries. Four countries with high HIV burden (India, Myanmar, Nepal and Thailand) have reduced new HIV infections by more than 50% since 2000. Particularly heartening is the rapid decline seen in India with more than 57% reduction of new infections from 2000 to 2011. This has greatly contributed to the large drop in the number of new infections in the Region. Nepal has also drastically reduced new HIV infections by 91%. However, in Bangladesh, Bhutan, Indonesia, and Sri Lanka the epidemic is on the rise with more than 25% increase since 2000. An estimated 211 000 people in the Region were newly infected in 2011, a 35% decrease from 2001. People living with HIV remained stable at an estimated 3.46 million (2.6–4.0 million). With improved availability and accessibility to treatment, deaths due to AIDS have dropped by 14% since 2005.
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More people survived on antiretroviral treatment (ART), with survival for those on one year of treatment ranging from 70 to 91%, and after 2 years, at 62–92%, in 2011. Resistance to antiretroviral drugs is still low in the Region. Countries have demonstrated successful scale-up of ART programmes with 840 000 people accessing treatment. ART coverage for prevention of mother-to-child transmission (PMTCT) in the Region has increased from 32% in 2009 to 39.7% in 2011. Thailand has reached the universal access targets of providing ART prophylaxis for pregnant women. However, much remains to be done in order to sustain the achievements and many areas continue to be of concern. High-risk sexual behaviour and injecting drug use continue to fuel the epidemic, and young people below the age of 25 years are particularly vulnerable. Adding to their vulnerability is the fact that HIV awareness has declined over the years, so that they may not even be aware of the risk. Only two out of five young people had correct and comprehensive knowledge of HIV, and myths on HIV transmission are still prevalent among young people. Much more needs to be done for scaling up access to prevention, treatment and care. Less than half of all persons with HIV (46%) have access to life saving treatment with ART. No country in South-East Asia Region has reached the universal coverage treatment targets, although Thailand is on track with 70% ART coverage. Only one in five people know their HIV status and one in four pregnant women have access to HIV testing. Less than 50% key affected populations of female sex workers, men who have sex with men (MSM) and people who inject drugs (PWID) are reached by prevention interventions. Harm reduction programmes for injecting drug users are inadequate. Impeding effective scaling up of HIV/AIDS programmes to ensure all people have access to prevention, treatment and care, is large-scale stigma and discrimination of people living with HIV, and key affected populations such as sex workers, men who have sex with men, transgender populations and people who inject drugs. Often they are criminalized, further decreasing their ability to access health care that they need. We have come a long way in meeting the MDG for HIV/AIDS, but need to follow a coordinated effort with involvement of all sections of the society if we are to reach the goal by 2015.
Dr Samlee Plianbangchang Regional Director
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Acronyms 3TC ACTG AIDS ANC ART ARV AZT BCC BBS CBO CCC CPT FSW GAVI GoB GFATM HBV HCV HIV HMIS HRP HSV-2 HTC IBBS ICTC IDU IEC IHC IPT KAP MARP MDG lamivudine AIDS Clinical Trials Group acquired immunodeficiency syndrome antenatal clinic anretroviral therapy/treatment anretroviral zidovudine behavioural change communication biological and behavioural survey community-based organizations Community Care Centres co-trimoxasole preventive therapy female sex worker Global Alliance for Vaccines and Immunization Government of Bangladesh Global Fund to Fight AIDS, Tuberculosis and Malaria Hepatitis B virus Hepatitis C virus human immunodeficiency virus health management information system harm reduction programmes Herpes simplex virus-2 HIV testing and counselling integrated biological and behavioural surveillance integrated counselling and testing centre injecting drug user(s) information, education and communication integrated HIV care isoniazid preventive therapy key affected populations most-at-risk populations Millennium Development Goal
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MOPH MSM MTCT NAC NACO NAP NASP NFHS NGO NSP NTP NVP NYSC OPD OST PHL PLHIV PMTCT PWID SACS SEAR STD STI T&C TB TG THC TRG TRIPS UNAIDS UNFPA UNODC USAID VCT WHO YFHS YKAP
ministry of public health men who have sex with men mother-to-child transmission National AIDS Committee National AIDS Control Organization National AIDS Programme National AIDS/STD Programme National Family Health Survey nongovernmental organization needle syringe programme National Tuberculosis Programme nevirapine National Youth Services Council outpatient department oral substitution therapy public health laboratory people living with HIV prevention of mother-to-child transmission people who inject drugs State AIDS Control Society South-East Asia Region sexually transmitted diseases sexually transmitted infection testing and counselling tuberculosis transgender Township Health Centre Technical Resource Groups Trade-Related Intellectual Property Rights Joint United Nations Programme on HIV/AIDS United Nations Population Fund United Nations Office on Drugs and Crime United States Agency for International Development voluntary counselling and testing World Health Organization Youth Friendly Health Services young key affected population
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HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Executive summary
In the South-East Asia Region (SEAR), an estimated 211 000 (112 0000301 000) people were newly infected with HIV, 35% fewer than in 2001. The HIV epidemic is declining in the SEAR and has stabilized in many countries. Four high HIV burden countries (India, Myanmar, Nepal and Thailand) have reduced new HIV infections by more than 50% since 2000. • Notably the epidemic has rapidly declined in India with more than 57% reduction of new infections from 2000 to 2011 and it has greatly contributed to the large drop in the new infections in the Region. Nepal has drastically reduced new HIV infections by 91%. • In Bangladesh, Bhutan, Indonesia and Sri Lanka the epidemic is on the rise with more than 25% increase since 2000. • Incidence among young people in high burden countries follow a similar pattern. In Nepal new infections are falling rapidly among young people than in adults. • Adult prevalence is stable at 0.3% regionally but subregional epidemics with high rates occur in India, Indonesia and Thailand.
• People living with HIV (PLHIV) remained stable at an estimated 3.46 million (2.6–4.0 million). About 37% of PLHIV were women. • An estimated 135 000 (118 000 –156 000) children were living with HIV and 16 000 were newly infected in 2011. • An estimated 230 000 (160 000 – 320 000) people died in 2011 due to AIDS. With improved availability and accessibility to treatment AIDS deaths have dropped by 14% since 2005. • Sexual and injecting drug use continue to drive the HIV epidemic. HIV prevalence is declining among female sex workers (FSW) but high rates were seen among people who inject drugs (PWID), men who have sex with men (MSM), particularly among transgender populations. –– One in 3 injecting drug users in Indonesia and 1 in 10 sex workers in Myanmar were infected with HIV.
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–– A rising epidemic of HIV among MSM is noted in Indonesia. Thailand has a sustained epidemic, one in five (20%) MSM were infected with HIV. • The STI burden is still high among key affected populations. High rates of active syphilis, chlamydia and gonorrhoea were found particularly among MSM • Young people were more vulnerable to HIV particularly young key affected population (below 25 years) –– About 12% young injectors in Indonesia, 12% young MSM in Thailand and 9% of young sex workers in Myanmar were infected with HIV.
• Less than 50% key affected populations of FSW, MSM ad PWID are reached by prevention interventions. • Harm reduction programmes for injecting drug users are inadequate. –– Bangladesh and India met international standards of providing 200 needles distributed /person/ year, Indonesia and Thailand provide less than 10 needles for a drug user for a year. • Stigma and discrimination continue to be an impediment to effective programme scale up for key affected populations and PLHIV. • Criminalization of people who use drugs, sex workers and men who have sex with men are the most commonly identified. Punitive laws and policies still exist in almost all countries. • Stigma in communities, health-care settings, and among law enforcement were identified as obstacles to service access and uptake. • Positive outcomes are seen, India and Nepal repealed the discriminative laws and recognized same-sex behaviour as natural. • Less than half the persons with HIV (46%) are getting life-saving treatment with ART. No country in the South-East Asia Region has reached the universal coverage treatment targets. Thailand is on track with 70% ART coverage.
–– HIV awareness has declined over the years. Only two out of five young people had correct and comprehensive knowledge on HIV, myths on HIV transmission is still prevalent among young people. • The majority of men fail to use condoms at high-risk sex. Condom use is reaching the universal coverage targets (80%) among female sex workers but coverage is low among men who have sex with men and people who inject drugs. • Only one in five people know their HIV status and one in four pregnant women have access to HIV testing. Scaling up of testing is essential for accessing prevention, treatment and care to achieve universal access coverage.
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HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
• Only 39% children in need have access to ART, in the Region. • More people survived on ART, survival at one year ranged 70-91%, and after 24 months 62-92% in 2011. Resistance to antiretroviral drugs is still low in the Region. • Two out of five pregnant women are getting ARV prophylaxis for preventing HIV transmission to the baby. –– ART coverage for prevention of mother-to-child transmission (PMTCT) in the SEAR increased from 32% in 2009 to 39.7% in 2011. –– The coverage for using most effective antiretroviral regimen (non nevirapine based) was 16%. –– Thailand, has reached the universal access targets of providing ART prophylaxis for pregnant women.
• HIV TB co-infection is declining in SEAR in high HIV/TB burden countries (India, Myanmar, Nepal, Thailand) except in Indonesia, but still unacceptably high, ranged <1 to 77%. • Over 80% people with HIV/TB coinfection received co-trimoxasole preventive therapy, while only three out of five (59%) with HIV/TB coinfection received ART in 2011. • Governments are investing more on AIDS response in Member States. –– Indonesia, Sri Lanka and Thailand had financed over 40% of domestic funds for the AIDS response. India has committed to allocate 90% of domestic funds in the coming years.
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Introduction
The Millennium Development Goal (MDG) 6 is one of the health-related MDGs and relates to combating HIV/ AIDS, malaria and tuberculosis. The HIV-related targets of Goal 6 include: • to halt and begin to reverse the spread of HIV/AIDS by 2015; and • to achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it.
(UN) Assembly in 1990 that set up the MDG. Member States of the Region joined in the renewal of their commitments in 2011 at the Sixtyfifth UN General Assembly to intensify efforts to eliminate HIV/AIDS and the new goals of eliminating new paediatric infections, halving TB deaths among HIV-positive people, placing 15 million people on antiretroviral therapy (ART) and intensifying prevention efforts by 2015.1 In response, WHO developed a Global Health Sector Strategy on HIV 2011–2015 to guide and support Member States to reach these goals, which was unanimously adopted by the Sixty-fourth World Health Assembly.2 Following this, the WHO South-East Asia Region developed a Regional Health Sector Strategy on HIV 2011-2015 to guide the health sector response to HIV epidemics to achieve universal access to prevention, treatment and care3. Based on the new Global HIV Strategy it focuses on priorities most relevant to the Region with concentrated epidemics in key affected populations: sex workers (SW); men who have sex with men (MSM); transgenders; people who inject drugs (PWID); and young people.
MDG 6 at a glance Almost 30 years into the HIV /AIDS epidemic since it was first reported in 1984 in the South-East Asia Region, and 20 years into the global efforts to combat HIV/AIDS with the declaration on MDG, the progress to achieve the MDG 6 in the South-East Asia Region has been overwhelming. The Region has begun to reverse the epidemic. The global and regional commitments are reflected in the many declarations and initiatives particularly over the past 10 years to accelerate and improve the scaling up of preventive and treatment services since the first United Nations
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Achieving zero transmission and zero new infections of HIV by 2015 seems possible in the light of the new research evidence for ARV treatment as prevention can reduce HIV transmission by 96% in uninfected partners of serodiscordant couples – HPTN 052 trial, along with scaling up services, continued commitment and resources4, 5. While the progress in the SouthEast Asia Region towards reaching the goal of reversing the epidemic has been impressive, it is still lagging in some major areas. The number of people on treatment has rapidly increased over the past few years in almost all countries of the Region, however it is still falling behind in terms of the global coverage. It is behind schedule with regard to achieving some prevention indicators, and improving comprehensive knowledge and condom use among young people.
strategy: (i) to reduce the incidence of HIV in young people (15-24 years) by 50%; (ii) reduce new HIV infections in children by 90%; (iii) reduce HIVrelated deaths by 25%; and (iv) reduce tuberculosis-related deaths among HIVpositives by 50%. The interventions promoted by the strategy will contribute to attaining the Millennium Development Goals (MDGs), in particular MDGs 4, 5 and 6 (i.e. reducing Child Mortality, Improving Maternal and Child Health and Combating HIV, Malaria and other Diseases) and achieving universal access to prevention, treatment and care. Indicators have been defined for each of the two targets [6(a) and 6(b)] to measure the progress towards achieving the MDG 6. Indicators that measure the progress towards achieving the MDG 6(a) of halting and reversing the epidemic by 2015 are: (i) HIV prevalence among young people 15-24 years; (ii) proportion of population aged 15-24 years with comprehensive and correct knowledge on HIV/AIDS; and (iii) condom use for high-risk sex.
The Region is yet to ensure that all infected pregnant mothers are given preventive treatment to save babies from HIV. Nor has it managed to extend basic prevention and care services to most-atrisk populations sufficiently and rapidly, with large numbers of sex workers, However in the context of the people who inject drugs (PWID) and men who have sex with men (MSM) concentrated epidemics prevailing in the South-East Asia Region, WHO’s thrust remaining deprived in this respect. is to support prevention interventions WHO collaborates with UN agencies that target the key affected populations and other partners in the AIDS response. (KAP): sex workers (including male and Getting to “zero” is the cornerstone of female sex workers); men who have sex WHO strategy to ensure that people with men (MSM); and people who inject living with HIV receive treatment; prevent drugs (PWID). Thus measuring reduction people living with HIV from dying of in HIV prevalence, incidence (new tuberculosis; and prevent mothers from infections) and change in risk behaviours dying and babies from becoming infected among the key affected populations and with HIV. more specifically among the young is critical for evaluating the effectiveness of This report will assess the progress the response and is discussed in Chapter made towards achieving the MDG 6, one. through the Regional Health Sector HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
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MDG 6(b): Achieve, by 2010, universal access to treatment for all those who need it by 2015. This goal will be measured through: proportion of people with advanced HIV infection with access to antiretroviral drugs. However the WHO new treatment guidelines encourage early initiation of ART to increase the survival rate, as well as to prevent further HIV transmission at the community level. Therefore, availability and accessibility to quality services are discussed under Goal 6(b) - Chapter 2 in this report. Finally the challenges, and the way forward and beyond 2015 are discussed in Chapter 3. New HIV infections are falling worldwide and HIV prevention has been effective, and virtual elimination of mother-to-child transmission seems possible by 2015. More than 8 million people were on HIV treatment globally by the end of 2011, and more people are surviving due to effective treatment. Yet, prevention of HIV by 50% through sex and drug use is lagging behind. Even now, for one person put on treatment three people are getting infected.6
worldwide, which has helped in reducing AIDS-related deaths, while increasing the survival of people living with HIV.6, 7 While 0.8% of the adult population is infected with HIV worldwide, regionwise differentials exist, from a low HIV prevalence of 0.1% in the Western Pacific Region to a high of 4.7% in the African Region. HIV prevalence in the SouthEast Asia Region is 0.3%. In recent years, globally a stable rate in HIV prevalence has been noted.6, 7 As a consequence of expanded treatment, AIDS-related deaths are decreasing, and growing numbers of PLHIV are living longer and more productive lives. The number of people dying of AIDS-related causes fell to 1.7 million [1.5 million–1.9 million] in 2011, 24% down from a peak of 2.2 million [2.1 million–2.5 million] in the mid2000s. An estimated 230 000 [200 000– 270 000] children less than 15 years died from AIDS-related causes in 2011, 20% less than in 2005.6,7 New infections are declining globally, led by sub-Saharan Africa, but trends in some other regions are worrisome. Much has been achieved globally – fewer people are dying from AIDSrelated illnesses and the rate of new HIV infections has fallen by nearly 20% in the past 10 years, the majority being in the African Region. In 2011, there were 2.5 million [2.2 million–2.8 million] new HIV infections, down by 21% from the peak of the global epidemic in 1997and 20% fewer than the 3.25 million people who were newly infected in 2001.This decline in HIV incidence leveled off in 2005-2006; since then, the global rate of new HIV infections appears to be stable, although the global reduction
Global scenario The number of people living with HIV (PLHIV) continues to rise, due to lifeprolonging treatment. At the end of 2011 an estimated 34.0 million (31.4 million to 35.9 million) people were living with HIV. Globally, this translates to an increase of 17% from 2001, including 3.3 million [3 100 000–3 800 000] children less than 15 years of age. This reflects continued new infections and significant scaling up of antiretroviral therapy (ART)
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in the rate of new HIV infections hides regional variations. The sharpest declines in the numbers of people acquiring HIV infection since 2001 have occurred in the Caribbean (42%) and sub-Saharan Africa (25%). There has been an increase in the rate of new HIV infections in Eastern Europe, Central Asia and the Middle East.6, 7, 8 During the past decade, many national epidemics have changed dramatically. In 39 countries the incidence of HIV infection among adults fell by more than 25%, from 2001 to 2011, and 23 of these were in sub-Saharan Africa. Similarly, 25 countries have seen a 50% or greater drop in new HIV infections since 2001, In India, the rate of new HIV infections fell by more than 57% and in South Africa by more than one third; both countries have the largest number of PLHIV. There has been an increase in the rate of new HIV infections in Eastern Europe, Central Asia and the Middle East.6, 7, 8, 9 An estimated 330 000 [280 000 – 380 000] children were newly infected with HIV in 2011, 41% fewer than the peak of 560 000 [500 000 – 630 000] new infections annually in 2002 – 2003. Half of all reductions in new infections in the past two years were among newborns showing that elimination of new infections in children is possible. Globally, the rate of new infections is still high, outstripping advances made in providing life-saving treatment to people living with HIV. There are five people newly infected with HIV for every two people newly put on treatment.6, 7
Status of the HIV epidemic in SEAR In 2011, there were an estimated 3.4 million [3.0 million–3.9 million] PLHIV in the Region; this figure remained stable for the past five to six years. (Figure 1). Overall, the estimated adult HIV prevalence in the South-East Asia Region remains at 0.3%; however there are extensive subregional differentials (range <0.1% to >1.3%).6, 7 Five countries in the Region account for the majority of the HIV burden: India, Indonesia, Myanmar, Nepal and Thailand. India with its large population bears the second-highest burden of HIV in the world. As no case has been reported from the Democratic People’s Republic of Korea, the remaining five countries, Bangladesh, Bhutan, Maldives, Sri Lanka and Timor-Leste, together represent less than 1% of the total HIV burden in the Region. The estimated number of PLHIV ranges widely, from <100 in the Maldives to 2.1 million in India. There were 230 000 [160 000– 320 000] estimated annual deaths due to AIDS-related illnesses in 2011, which is a 12% – 14% drop from 260 000 (240 000 – 280 000) in 2005 due to improved access to life-saving ART for PLHIV, especially over the past few years (Figure 2). India has averted over 150 000 deaths due to AIDS-related causes with the scaling up of free ART since 2004 in the country.6, 7, 9 Women and children are more vulnerable to HIV in the Region In Asia more women are getting infected, the majority from their spouses or intimate partners.10 High rates of HIV among wives (32%) and intimate partners
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HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Figure 1: Number of people living with HIV and new infections among PLHIV (WHO South-East Asia Region), 1999–2011 4 000 000 3 500 000 3 000 000 2 500 000
Number
2 000 000 1 500 000 1 000 000 500 000 0
People living with HIV
New HIV infections
Source: Estimations and Projections from Spectrum/AEM model outputs of data from National Programmes & UNAIDS 2012
Figure 2: Treatment coverage with antiretroviral therapy and survival of PLHIV in the South-East Asia Region, 1999–2011 900 000 800 000 700 000 600 000 500 000 400 000 300 000 200 000 100 000 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
ART
Deaths
Source: Estimations and projections from Spectrum/AEM model outputs using data from National programmes in SEAR & UNAIDS 2012
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(57%) of people who inject drugs were found in a study in Nepal and HIV transmission from infected husbands to wives was mainly (89%) through unprotected sex. It was also evident that 57% of the HIV transmission from infected men to their intimate partners was through unprotected sex.11 The AEM (Asian Epidemic Model) estimates that 32% new infections in Thailand between 2012-2016 will be through intimate partners.10 In the South-East Asia Region women comprised 37% of the adults living with HIV in 2011, a percentage that is lower than the global average of 49% (46-51%).6,7 Gender inequality, male dominance, stigma, low literacy levels, migration and barriers to accessing healthcare services are some of the key issues that account for the higher vulnerability of women to HIV in the Region.
The estimated number of children living with HIV increased from 89 000 in 2001 to 135 000 ( 118 000 -156 000) in 2011— an estimated increase of 46% due to increased survival rate of children on life-saving ART, or increased acquisition of infection from infected mothers due to low coverage of prevention of motherto-child transmission (PMTCT) services in the Region. Approximately 16 000 babies were newly infected in 2011. An estimated 12 000 [6800–18 000] children died in 2011.6, 7 Globally, it is estimated that 23% of all PLHIV are under the age of 25 yrs and over 40% of new infections occur among youth aged 15-24 years.12 In the SouthEast Asia Region, young people below 25 years account for approximately 13% of all HIV infections among adults. The estimated number of young people with HIV in high- burden countries continues to decline except in Indonesia. Among
Figure 3: Men and women living with HIV, in the South-East Asia Region, 2000–2010 4 000 000 Total
3 000 000 Number (in thous ands )
Males
2 000 000 Females
1 000 000
2000
2002
2004
2006
2008
2010
Source: Estimates generated by Spectrum model using surveillance data reported by national AIDS programmes
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HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
low prevalence countries Bhutan has During 2011, an estimated 211 000 shown a slight increase over the years. (112 000 - 301 000) people were (Figure 4). newly infected with HIV, a substantial 35% decrease from 320 000 in 2001, A significant finding of the Report indicating that the HIV epidemic is of the Commission on AIDS in Asia declining in the Region or has stabilized in 2008 is that in Asia 95% of new in many countries. However a slight infections of young people occur in increase in the number of people newly young-key-affected-populations (YKAP) infected in 2011 is noted, from 210 000 such as young sex workers, young men people that were infected in 2010.6, 7, 8 having unprotected sex with men, and young people injecting drugs.10 The progress among high-burden The illegal nature of their behaviour countries towards reducing new together with widespread social stigma infections is reflected in Figure 5. and discrimination drives the KAP underground, thereby making them hard A sharp decline in new HIV infections to reach with preventive interventions. is now seen in four of the five highThe legal age requiring consent from burden countries since the peak parents also acts as a barrier for them to reached in early 1990–2000, while access these essential services. the epidemic in Indonesia is still rising. New HIV infections are declining and the epidemic has begun to reverse in the South-East Region. As stated before country-wise differences in the burden of new infections exist. Of the nine countries
Figure 4: Proportion of young people (15–24 years of age) among people living with HIV, by sex, in the South-East Asia Region, 2011 45% 40% 35% 30%
Number
25% 20% 15% 10% 5% 0%
Male (15-24)
Female (15-24)
Source: UNAIDS Estimates and Projections; Global AIDS Response Progress Country Reports, 2012
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Figure 5: Estimated number of new HIV infections in the South-East Asia Region, in the five high-burden countries, 1990–2011 450 400 350 300 250 200 150 100 50 0
E s timated number of new HIV infections (in thous ands )
SEAR
India Thailand Indonesia Myanmar Nepal 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2011
Source: Estimations and projections by Spectrum /AEM model using data from National AIDS Programmes of member countries South- East Asia Region, UNAIDS 2012
in the Region with trend data, four of the five high-burden countries (India, Thailand, Myanmar and Nepal) have already achieved their targets of reducing the number of new HIV infections by 25% between 2001 and 2015 and reversing the epidemic. In Indonesia the epidemic is still on the rise with more than 25% increase since 2001.6, 7 Thailand was the first country to record a drop in HIV incidence in the early 1990s, followed by India, Myanmar and Nepal in the late 1990s to early 2000s. Between 2001-2011 Nepal reduced new HIV infections drastically by 91%, and may reach the “zero new infections” target by 2013. Three countries that account for a large number of people living with HIV in the Region – India, Myanmar, and Thailand – reduced new HIV infections by more than 50%. Notably the epidemic has rapidly declined in India with more than 57%
reduction of new infections from 2000 to 2011 that has contributed greatly to the large drop in new infections in the Region. Maldives had static progress with comparatively low numbers of new HIV cases. However the epidemic increased significantly by more than 25% in Bangladesh, Bhutan and Sri Lanka from 2001 to 2011 despite experiencing a low HIV prevalence over the years. The Democratic People’s republic of Korea remains the only country in the Region that has still not reported any HIV infection.6, 7 The rising HIV incidence in Indonesia is a concern with transmission dynamics changing in the country. The main mode of transmission has shifted away from injecting drug use to heterosexual sex over time in most parts of the country. Heterosexual transmission has risen from 38.5% (in 2006) to 76% (2011), while infection from injecting drug use
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HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Figure 6: Mode of transmission of HIV in Indonesia, 2006-2011 90 80 70 60 76.3
54.42
% AIDS cases
50 40 30 20 10 0 PWID Heterosexual MSM 2006 Perinatal 2011 16.3 4.91 4.7 0.2 0.2 blood transfusion 0.2 0.2 unknown 38.5
2.2
2.2
Source: Ministry of Health, Indonesia
has dropped from 54% to 16% during the same period. (Figure 6) The picture is different in the Papua province in Indonesia, where a low-level generalized epidemic is seen (with a high HIV prevalence of over 2% in the general population) more than 90% infections are through heterosexual transmission.13
Many countries experience dual or mixed epidemics driven by unsafe sex and injecting drug use. Nevertheless more than 90% HIV infection is acquired through the sexual route in the majority while unsafe injections account for the infections with a wide variation across the Member States.
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Chapter 1
Progress towards MDG 6(a)
1. MDG 6(a): Have halted by 2015 and begun to reverse the spread of HIV/AIDS (reversing and halting the epidemic) As it is evident that the epidemic has begun to reverse in high-burden states a sustained response and continued commitment are critical to sustain the gains. To halt and reverse the HIV epidemic, more emphasis is now given to reducing new infections and preventing transmission through unsafe sex and injecting drugs that are the key drivers of the epidemic in this Region. The progress towards reaching the MDG6(a) is assessed through the following three target indicators: 6.1 HIV prevalence among young people 15–24 years, including reduction in HIV prevalence among the key affected populations. 6.2 Proportion of the population aged 15–24 years having comprehensive and correct knowledge of HIV/AIDS. 6.3 Condom use at last high-risk sex.
Target 6.1: HIV prevalence among the population aged 15-24 years HIV prevalence is the proportion of the population infected with HIV within a particular time period, and is not a good marker of effective HIV control compared to HIV incidence. New infections reflect recent risk behaviours and are a better measure of effectiveness of interventions than prevalence that reflects past behaviours. The reduction in HIV prevalence may be due to falling new infections with effective interventions or due to increased deaths. On the other hand increases in HIV prevalence may not necessarily be due to rising new infections in the post-ART era but due to increased survival of people living with HIV with effective treatment. HIV prevalence among adults is ideally measured through household surveys. Due to concentrated epidemics that are prevailing in the Region, regular HIV prevalence surveys to monitor the epidemic are generally conducted among the key affected populations (FSW, MSM, PWID) and other vulnerable or bridge populations (long-distance truck drivers, migrants, prisoners, and service personnel, etc.). Alternately, HIV prevalence among
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
1
Figure 7: Estimated adult prevalence in high-burden countries, South-East Asia Region, 1990–2011 3
2
P e rc entag e
Thailand 1
Myanmar Nepal India Indonesia 0 1990 1995 2000 2005 2006 2007 2008 2009 2010 2011
India
Indonesia
Myanamar
Nepal
Thailand
Source: Estimations and Projections from Spectrum and AEM Models using data from National AIDS Programmes: UNAIDS
pregnant women attending antenatal in Indonesia where the prevalence care (ANC) is measured as a proxy for continues to rise (Figure 7). the general population. The magnitude of HIV infection As direct measurement of HIV differs greatly between countries in the prevalence in the general population is not Region range (0-1.4%). In majority of available national adult HIV prevalence countries, the estimated adult prevalence is estimated through estimation and was below 1% in 2011 except in projection models using epidemiological Thailand where the estimated adult HIV (HIV surveillance data) and demographic prevalence was 1.4%. From the trend data from all Member States. data, four high-burden countries (India, Myanmar, Nepal and Thailand) have already begun to reverse the epidemic Trend reversal in prevalence of HIV with the adult HIV prevalence showing a continues as shown by the estimated declining trend [Figures 7 and 7(a)]. prevalence. The estimated adult prevalence in the South-East Asia Region continued to decline from 0.38% in 2001 to 0.31% in 2011.The trend data indicate that the HIV epidemic has declined or stabilized in most countries in the Region except Among the low prevalence countries, the adult HIV prevalence has remained stable below 0.1% in Bangladesh, Maldives and Sri Lanka over the years, denoting that the epidemic was static, while in Bhutan a slight increase was seen.
2
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Figure 7(a): Estimated adult HIV prevalence in high-burden countries, 2000–2011 2 1.8 1.6 1.4
Adult HIV Prevalence
1.2 1 0.8 0.6 0.4 0.2 0 Indonesia India Myanmar Nepal Thailand
2000
2005
2011
Source: Estimations and Projections 2012 UNAIDS, Country Global AIDS Response Progress Reports
However contrary to this a rising trend of new infections in Bangladesh, Bhutan and Sri Lanka in recent years suggests that the epidemic is on the rise in these low-prevalent states [Figure 7(b)].
Alarmingly in Indonesia the epidemic continues unabated; the HIV prevalence increased from 0.1% in 2001 to 0.3% in 2011 among adults.6 Even within countries, there are marked differences and the national prevalence masks the high-prevalence areas within states. The estimated adult prevalence is above 1% The analysis of epidemic patterns in north-east India and in the Papua among different risk populations from province of Indonesia. the 2010-2011 HIV sentinel surveillance data helps explain the trends as similar For example in India the estimated declining trends are noted at national level adult HIV prevalence at national level has among the general population, female continued its steady decline from 0.41 sex workers and MSM, while it is stable in 2000 through 0.35% in 2006, 0.28% among PWID. In high prevalent states
in 2010, and to 0.27 in 2011.The statewise HIV prevalence in 2011 confirms a clear declining trend in estimated adult HIV prevalence in all high-prevalence states. Manipur recorded the highest estimated prevalence of 1.2% while Andhra Pradesh, Nagaland, Karnataka, Maharashtra and Tamil Nadu recorded <0.75 prevalence. States of Mizoram and Goa also had high HIV prevalence above national level, which however showed, a declining trend (Figure 8).9
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
3
Figure 7b: Estimated adult HIV prevalence in low-burden countries, South-East Asia Region, 2000–2011 0.35
0.3
0.25
Adult prevalence
0.2
0.15
0.1
0.05
0 Bangladesh Bhutan Maldives Sri Lanka
2000
2005
2007
2009
2011
Source: Estimations and Projections from Spectrum and AEM Models using data from National AIDS Programmes, UNAIDS 2012
Figure 8: State-wise adult HIV prevalence in selected high-burden states in India, 2003–2011 2.5
2.0
P e rc e n ta g e
1.5
1.0
0.5
0.0 2003 2004 2005 2006 2007 2008-09 2010-11
Andhra Pradesh Mizoram
Karnataka Nagaland
Maharastra Tamil Nadu
Manipur
Source: HIV Sentinel Surveillance 2010–2011 – A Technical Brief, National AIDS Control Organization
4
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
HIV among FSW declined significantly. those that receive a large number of However pockets of rising epidemics tourists, and provinces bordering the among MSM and PWID were seen.14 eastern seaboard and Gulf of Thailand including Phuket, Cholburi, Trad and The low- prevalence states in Samut Songkram.15 India like Chandigarh, Odisha, Kerala, Jharkhand, Uttarakhand, Delhi, Punjab, In Indonesia, the Papua province has Arunachal Pradesh and Meghalaya show a high estimated adult HIV prevalence, rising trends in adult HIV prevalence nearly over 4%, while the national in the last four to five years. The rising prevalence is less than 1% (Figure 9). trends of HIV among PWID and the large The biggest challenges to addressing population of PWID in these states may the epidemic across Papua are the daunting problems of communication explain the reason for the rising trend. and transportation as well as the The possible role of migration in seriously limited health and community fuelling the epidemic in these states infrastructure.13 is also collaborated with the evidence from the recent round of HIV sentinel Men are affected more than women, surveillance.14 Low levels of HIV among but the number of women infected the high-risk population in these states, with HIV is rising. large volume of out-migration from rural areas to high-prevalent states, higher Overall, men have a high HIV ANC HIV prevalence in rural areas prevalence compared with women. than urban areas together with higher The estimated adult prevalence among prevalence among pregnant women with women and men in Indonesia is shown migrant spouses, are the likely reasons. in (Figure10). Nevertheless the trend data among male migrants are not adequate to make valid conclusions. HIV among antenatal attendees The estimated HIV prevalence among young population has also followed the adult pattern in India; it fell from 0.3% in 2000 to 0.11 in 2011.9 The evidence indicates that the long- standing focused prevention interventions have had a clear impact in the high-burden states, however more attention needs to be paid to the low-prevalence states, as well as to border and rural areas where new pockets of HIV might emerge. HIV infection among pregnant women shows a steady decline in high-burden countries, but pockets of high-prevalence areas are seen.
HIV prevalence among women attending antenatal clinics is taken as a proxy for HIV infection in the general population. Limited data available from high-burden countries where regular surveillance is conducted among In Thailand the estimated HIV antenatal clinic attendees (ANC) supports prevalence is higher in urban than the evidence that the adult prevalence is rural areas. The spread of HIV in some declining in these countries. provinces of Thailand is still severe, over A declining trend in HIV among 2%, among pregnant women, especially pregnant women is seen in three high-
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
5
Figure 9: Adult HIV prevalence in Indonesia in Papua and non-Papua areas 12.00%
10.00%
8.00%
Year 2011 6.00%
4.12% 4.00%
2.00%
0.38% 0.00%
0.33% 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 2021 2023 2023
Papua 15-49 Source: AEM Model, Indonesia 2009
National 15-49
Non-Papua 15-49
Figure 10: HIV prevalence among adult males and females aged 15–49 in Papua province, Indonesia 12.00%
10.00%
8.00%
Year 2011
6.00%
4.56% 4.00%
4.12% 3.63%
2.00%
0.00%
1995
1997
1999
2001
2003
2005
2007
2009
2011
2013
2015
2017
2019
2021
Males 15-49 Source: AEM Model Indonesia 2009
All 15-49
Females 15-49
6
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
2025
2025
burden countries (India, Myanmar and Thailand). The proportion of pregnant women infected with HIV declined from 0.6% in 2009 (range: 0–3.9%) to 0.40% in 2010-11 in India, 14 from 0.77%(range:0–3.2%) in 2010 to 0.6% in 2011 in Thailand16 and from 0.96% in 2010 (range: 0–4%) to 0.9% in 2011 in Myanmar.17 It is worth noting that for the first time the ANC HIV prevalence has been below 1% in all states in India with a national prevalence of 0.40% (Figure 11). This further strengthens the evidence that the epidemic is declining in India. However considerable differences continue to exist in prevalence rates across different geographical locations within states. For example, while highprevalent states recorded a decline, low-
prevalence states of Gujarat, Odisha, and Chhattisgarh recorded a higher prevalence than the national average. In addition high rates were found among rural pregnant women and those with migrant spouses in India according to the latest surveillance round.14 HIV prevalence among young antenatal women is considered as a better surrogate for the prevalence and incidence among young populations as it reflects more recent infections. The data from HIV sentinel surveillance over the years has revealed that HIV prevalence among young pregnant women declined from 2.15% in 2000 to 0.64% in 2011 in Myanmar; from 1.46% in 2000 to 0.43% in 2011 in Thailand; and from 1% in 2003 to 0.40% in 2011 in India (Figure 12).
Figure 11: HIV prevalence among pregnant women attending ANC clinics in India, 2010–2011
Tripura Chandigarh Himachal pradesh Megahlaya Jammu and Kashmir Assam Sikkim Kerala West Bengal Bihar Haryana Uttarpradesh Arunachal Pradesh Uttarkhand Punjab Delhi Madya Pradeash Goa Rajastan Tamilnadu India Mizoram Maharashtra Chhattisgarh Odisha Jahrkhand Gujarat Nagaland Karnataka AndhraPradesh Manipur
0 0
0.04
0.05 0.06 0.09 0.09 0.13 0.13 0.17 0.19 0.21 0.21
0.3 0.26 0.3 0.32 0.33
0.38 0.38 0.4 0.4 0.42 0.43 0.43 0.45 0.46
0.66 0.69
0.76 0.78 0.8 0.9
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Source: Sentinel surveillance report 2010-2011, National AIDS Control Organization, India
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
7
Figure 12: HIV prevalence among young pregnant women aged 15–24 years in high burden countries 3
% of antenatal clinic attendees infected with HIV
2
1
Myanmar Thailand India 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Source: Sentinel surveillance reports, national AIDS programmes
Reducing the sexual transmission of HIV among populations at high risk Unsafe injecting drug use and sex are driving the epidemic in many countries in the Region. A pattern is observed in Asia where, HIV that was initially concentrated among the key drivers (FSW, MSM, TG and PWID) got transferred to their clients or partners who act as the bridge population. They in turn infect their intimate partners, thereby allowing the infection to enter the general population.10 Monitoring the trends in HIV prevalence and risk behaviours among the key affected populations and other vulnerable populations gives a better clue as to where the epidemic is heading
(the trajectory of the epidemic). HIV services are not yet reaching all key populations at higher risk of infection, such as sex workers, people who inject drugs and men who have sex with men. The number of people newly infected is therefore not declining sufficiently in areas where the epidemic is concentrated among key populations at higher risk. Preventing new infections among these populations is a key strategy to control the HIV epidemic. As prevention efforts gain momentum, fewer sex workers are getting infected but infection is not declining rapidly enough among MSM and PWID; and more action is needed to halve the HIV transmissions by 2015.
8
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
HIV reduction among MSM The MSM epidemic is on the decline in some countries and on the increase in others. The review of the reported data indicates that considerable variation exists in the incidence of HIV epidemic among MSM in the Region. The national prevalence rates among MSM ranged from 0–20% across countries in the Region in 2011 but hide wide subnational variations. Alarmingly high HIV prevalence rates among MSM are still observed notably in Indonesia 8%13, 18, Myanmar 7.8%17, and Thailand 20%.16 A declining trend is seen in the national HIV prevalence rates among MSM in Myanmar, India and Nepal. In Myanmar the HIV prevalence fell from 29% in 2005 to 7.8% in 2011. The prevalence rate among MSM halved in India between 2003 to 2011 from 8.47% to 4.43% at national level, 14 and in Nepal 4% MSM were infected in 2011.19 While the MSM-driven epidemics are declining in both countries, emerging pockets of HIV are being observed subnationally. Thailand is experiencing a sustained epidemic with high prevalence above 19% for the past five years while in Indonesia a rising epidemic is being seen among the MSM with an increase from 6% in 2007 to 9.8% in 2011.15, 16, 18 Sri Lanka20 and Bangladesh21 have insignificant epidemics with HIV rates below 1%, while Maldives22 has not reported HIV among MSM yet. Very high rates of HIV are seen among MSM living in cities and locations. For example in India between 10% to 15% MSM living in Manipur, Nagaland, Andhra Pradesh and Chhattisgarh were infected, while 9 out of 23 states have shown greater than 5% HIV prevalence
including four low-prevalence states. Delhi, Gujarat, Madhya Pradesh, Odisha and West Bengal had an HIV prevalence above the national rate of 4.4%.14 Similarly 31% MSM in Bangkok and 10% in Phuket were having HIV while the national rate was 20% in Thailand.16 In Indonesia, cities of Jakarta, Bandung and Surabaya had 9-17% HIV prevalence among MSM, while in Malang it was a low 2.5%13, 23 (Figure 13). Young MSM are more vulnerable and it is noteworthy that a substantial proportion of them, 12% of young MSM below 25 years in Thailand, 6% in Indonesia and 6% in Myanmar, were infected with HIV according to the data reported in 2011, suggestive of a serious epidemic. The rates could be much higher as surveys generally fail to recruit young people below 18 years due to ethical reasons. The limited data also show very high HIV infection rates among transgenders (TG), for example 8.8% TG in India and 34% transgenders in Jakarta (Indonesia) were found to be infected with HIV. While HIV infection was not reported among MSM in Bangladesh during the past few years, 1.7% transgenders were found to be infected with HIV in the recent surveillance round in 2011.14, 18, 21 The analysis of data on reported cases of HIV/AIDS shows that the HIV transmission through male-to-male sex is on the rise in the Region. In Indonesia according to the estimations and projections, the majority of new infections (32%) will be through male-to- male sex between 2011 and 2015 (Figure 14). The AIDS in ASIA (2008) Report warns that by 2015 more than 50% of new infections in Asia will occur through male-to-male sex, and urges national governments to take urgent action.10 9
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Figure13: HIV prevalence among men who have sex with men in selected cities, South-East Asia Region, 2005–2011 40 35 30 25 Percent
20 15 10 5 0 Bangkok Phuket Delhi Andra Pradesh India Yangon Mandalay Jakarta Bandung Kathmandu Nepal
Thailand
Myanmar
Indonesia
2005
2007
2009
2010
2011
Source: Sentinel surveillance reports, National AIDS programmes,
Figure 14: Proportion of new infections, by route of transmission, in Indonesia (2015) 120 000 100 000 80 000 32% 60 000 2% 40 000 20 000 25% 2% 4% 26%
9%
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
2016
2018
2020
2022
2024
2011-2015 Husband->wife Needle sharing Waria sex Wife->husband Sex work Casual sex Male–male sex
Source: Asian epidemic model, Ministry of Health, Indonesia
10
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
With well-designed and well-run HIV HIV reduction among female sex prevention programmes targeting FSW, workers The HIV prevalence among female sex workers is declining; however infection among male sex workers and some types of sex workers continues to be high.
A steady decline of HIV infection among female sex workers is seen across countries in the South-East Asia Region, ranging from 0% to 9% in 2011 with low rates in Bangladesh (0.25%), Bhutan (2%), India (2.67%), Nepal (2%), Sri Lanka (0.2%) and in Thailand (1.82%). (Figure 15) The rates in Indonesia and Myanmar were still high at 7% and 9%, respectively, in 2011.14, 16-21, 24 However, new information from surveys has thrown light on the wide disparities among Disparity is seen among types of sex people infected with HIV in males and work (direct or indirect, institutional, young sex workers. Figure15: Trends in HIV prevalence among sex workers in selected high-burden countries, 2000–2011 40
an impressive decline in HIV infection among female sex workers is seen in almost all countries in the Region. HIV infection halved in Myanmar between 2008 and 2011 from 18.4% to 9.4%. A declining trend was observed from 2005, yet the overall HIV prevalence among FSW remains at a high level in Indonesia for the past few years. Male sex workers appeared to be more vulnerable to HIV as they had higher rates of HIV infection than the female sex workers in Thailand (18% vs 1.82%); Indonesia (18.3% vs 7%); Bhutan (5% vs 2%); and Nepal (5.19 % vs 1.69%) in 2011, indicating that the interventions have not been adequately focused to reach the male sex workers.13, 16, 19, 24
35
30 25
20
15 11.4 10
5
2.67
2.2
2.2
0
India FSW
Indonesia FSW
Mynmar FSW
Nepal FSW
Thailand FSW
2005
2006
2007
2008
2009
2010
2011
Source: Sentinel surveillance reports, national AIDS programmes
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
11
hotel /venue- based, street-based etc.) and locations. In Indonesia direct sex workers were found to be infected more than the indirect sex workers. The prevalence among direct sex workers remained high (over 10%) for the past four years compared with a declining epidemic among indirect sex workers with low prevalence (3%) in 2011. Sex workers operating in large cities such as Denpasar (16%) and Batang (20%) had higher HIV than in rural areas like Surabaya (2%) in Indonesia. In India, sex workers in Andhra Pradesh, Karnataka, and Maharashtra were the most affected with HIV prevalence being above 5%. This means more innovative approaches through peer led interventions are required to reach these populations.14, 18 Alarmingly, quite a number of women are now starting to sell sex at a young age according to the behavioural surveillance surveys. Seventeen percent of FSW surveyed entered sex work at less than 15 years in India and 47%-63% of FSW started sex work between 15-24 years in Myanmar, while in Maldives FSW entered sex work at a median age of 17-19 years. A substantial proportion of young sex workers below 25 years were infected with HIV, in Indonesia (8%) and Myanmar (9%) according to the reported data in 2011.15, 17, 22 The decline in prevalence among young sex workers in Myanmar has slowed in recent years and seems to have stabilized. It is only slightly lower than the national average and raises concern. Generally the young sex workers have more clients and have low negotiating power for condom use and are likely to be sexually abused. The age-specific information education and communication (IEC) and behavioural change communication
(BCC) programmes addressing the specific needs of young KAP are urgently needed to prevent HIV infection among these vulnerable populations.
HIV among injecting drug users (PWID) Uncontrolled HIV epidemics among injecting drug users (PWID) prevail and women PWID are at more risk of HIV. Countries are on track to achieve the goal of 50% reduction of new HIV infections among PWID. HIV prevalence among PWID has declined over the years in countries facing injecting drug use epidemics; it is still stabilized at unacceptable high levels among PWID in Indonesia (36.4%), Myanmar (22%), India (7.4%) and Thailand (22%). A significant reduction has been observed in the prevalence of HIV among PWID in Kathmandu, Nepal from 68% in 2003 through 20.7% in 2009 to 6.3% in 2011. The data reported in 2011 indicate that the national HIV prevalence among PWID varied in the range of 1% - 36.4% in 2011 across Member States.13, 14, 16, 17 (Figure 16) At the subnational level substantial differences were seen. The rise in HIV epidemics among PWID observed in some states in India (Punjab Chandigarh, Mizoram, Haryana and Bihar) is a cause for grave concern. A 24% reduction in HIV prevalence from 2007-2011 among PWID in Medan city in Indonesia is overshadowed by the increasing rates observed among new injectors in Jakarta from 33% to 44% during the same period.13, 14
12
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Figure 16: Trends in HIV prevalence among PWID in selected cities in the South-East Asia Region 2000–2011 80 70 % of injecting drug users infected with HIV 60 50 40 30 20 10 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 Kathmandu Nepal Dhaka Bangladesh 2009 2010 2011 Chennai India Lashio Myanmar
Jakarta Indonesia
Bangkok Thailand
Source: Sentinel surveillance data reported by national AIDS programmes. Sample size for each site was adequate as per national protocols. Dashed line indicates no data available for that period.
There is a dearth of information on female injectors even in countries with a high PWID problem such as Indonesia, Myanmar and Nepal. Generally it is known that women injectors are more vulnerable to HIV as they are likely to engage in sex work to buy drugs for themselves or for their drug taking partners. However it is difficult to make valid conclusions due to lack of data. In Thailand more women PWID were infected with the virus (31%) compared with men (24%) in 2011.16 The increase in HIV prevalence among young PWID less than 25 years of age as seen in Thailand (8%), Myanmar (14%) and in Indonesia (12%) raises concern.13, 16, 17 Alarmingly quite a number of young men and women start injecting drugs early, by the age of 17 years. For example 6-21% PWID in India
started injecting at 17-18 years25 (Figure 17). It is obvious that the young injectors are highly vulnerable to HIV and urgent attention is needed for targeting the young IDU with harm-reduction interventions. Moreover the legal age of consent for oral substitution therapy is a barrier for the young PWID to access harm reduction programmes (HRP) as well as HIV testing and counselling services. The HIV prevention interventions for KAP are showing mixed results; the epidemics have begun to decline or stabilize, but there is no room for complacency. Sustained and concerted efforts in scaling up of prevention interventions to reach more people at risk of HIV are vital.
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
13
Figure 17: Young people’s age of entry for commercial sex and injecting drug use
Age of entry into risk behaviours… 23–34% of PWID in India started injecting at 22–25 years Mean age when PWID 6-21% of PWID in India started injecting started injecting drugs in Myanmar is 20–26 years at 17–18 years 10–14 years 17% of FSWs surveyed in India entered sex work at <15 years 15–19 years FSWs entered sex work in Maldives at a median age of 17-19 years 47-63% of FSW in Myanmar entered sex work between 14–24 years Source: National Behavioural Surveillance Reports ; Global AIDS Response Progress Reports- Country Reports (2012) ; UNGASS Progress Reports (2010).
20–24 years
>25 yr
In conclusion HIV prevalence among the MSM and PWID remains at a high level and is a matter of concern. Rigorous scaling up of prevention programmes is critical. Successful harm reduction programmes have resulted in bringing down HIV infection among injecting drug users in the Region, i.e. Nepal where introducing needle syringe programmes in 2005 reduced HIV prevalence among PWID from 48% in 2005 to 12.5% in 2007 and to 5.35% in 2011.19 The MSM are diverse (gay, bisexuals, transgenders, male sex workers or general MSM) and largely invisible. Additionally, continuing social stigma and criminalization of same-sex behaviours in most countries prevent them from divulging their identity and
attending prevention and care services. The Majority of young MSM meet their partners through websites, chat rooms and reaching young MSM with education messages through electronic media, SMS & internet is timely. Urgent attention is needed to scaling up HRP especially for young PWID, and to address the laws and social stigma that are barriers for effective prevention interventions for MSM and PWID. As prevention efforts gain momentum, fewer sex workers are getting infected but infection is not declining rapidly enough among MSM and PWID. Thus more action is needed to halve the HIV transmissions by 2015.
14
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
2. Goal 6(a), Target 6.2: Proportion of population aged 15–24 years with comprehensive and correct knowledge of HIV/AIDS
population-based surveys. According to the reported data contained in the Global AIDS Response Progress Reports, comprehensive knowledge among youth aged 15-24 ranged from 13.9% to 47.5% in the South-East Asia Region far below the global target of 95% by 2010. (Figure 18) In India comprehensive knowledge among youth surveyed in three states in 2009 showed a wide Correct and comprehensive knowledge variation from 11% in Karnataka to 45% on methods of HIV transmission and in Tamil Nadu.25 prevention is a key factor in preventing However, the recent behavioural HIV transmission, reducing stigma towards people living with HIV (PLHIV) surveys carried out among vulnerable and increasing access to services. populations indicate that comprehensive Comprehensive knowledge is defined knowledge declined among young in all as a person’s ability to correctly identify the populations surveyed in Thailand three methods of HIV prevention and over the past two years and new army reject at least two misconceptions about recruits had less than 30% comprehensive knowledge.16 HIV transmission. The five components that make up the indicator to measure comprehensive knowledge and correct knowledge on HIV prevention: (i) the risk of HIV transmission can be reduced by having sex with only one uninfected partner who has no other partner; (ii) a person can reduce the risk of getting HIV by using a condom every time he/she has sex; (iii) a healthy-looking person can have HIV; (iv) it is an incorrect belief that a person can get HIV from mosquito bites; and (v) a person cannot get HIV from sharing food with someone who is infected. Most young people lack comprehensive knowledge of HIV, but now know specific ways to prevent its spread. Large gap exists in the knowledge, and disparity is seen by gender and age. Overall, young men had a higher knowledge on HIV than young women in Bangladesh, Nepal and Timor-Leste while in Indonesia and Myanmar there was no gender imbalance, rather women had a slightly better knowledge (Figure 19). Though the overall comprehensive knowledge as measured by the five components that make up the indicator is low, knowledge on methods to avoid HIV transmission is generally widespread among young people. According to the country reported data the proportion of young people who knew that HIV/AIDS can be prevented by using condoms ranged from about 50% to almost 90% (Figure 20).
Though some progress has been made over the years, comprehensive and correct knowledge on HIV among young people is unacceptably low in Unfortunately misconceptions on most countries in the Region according methods of HIV transmission are still high to the latest available data from among youth despite various educational
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
15
Figure 18: Proportion of population aged 15–24 years with comprehensive and correct knowledge on HIV/AIDS, 2005–2010 100 90 80 70
Percentage
60 50 40 30 20 10 0
Bangladesh
Bhutan
DPR Korea
Thailand
Timor-Leste
India
Indonesia
Maldives
Myanmar
2005
2010
Source: Global AIDS Response Country Progress Reports 2012, UNGASS country reports, national behavior surveillance reports
Figure 19: Percentage of young women and men aged 15–24 years with comprehensive and correct knowledge on HIV/AIDS, South-East Asia, 2007–2011 100 90 80 70
Target
Percentage
60 50 40 30 20 10 0 Bangladesh Indonesia Myanmar Nepal
Males
Females
Both sexes
Source: Global AIDS response Country Reports 2012, UNGASS reports 2010
16
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Global
Nepal
SEAR
Figure 20: Proportion of women and men aged 15–24 years with correct knowledge on condom use as a method of HIV prevention in selected countries 100 90 80 70
Target
Percentage
60 50 40 30 20 10 0 Bangladesh Indonesia Myanmar Nepal
Males
Females
Both sexes
Source: Global AIDS Response Country Reports 2012, UNGASS Country Reports, National Behavior Surveillance Reports
programmes carried through mass media, peers and curriculum in schools. Over half the youth still believe that a person can get infected by sharing food or/and through mosquito bites. Less than 50% (range 26% in Maldives to 60% in Myanmar) had rejected misconceptions on HIV transmission. Widespread incorrect beliefs can lead to increase in stigma and discrimination towards PLHIV.
ways of preventing sexual transmission and reject major misconception about HIV transmission except in Myanmar (78%) (Figure 21). The comprehensive knowledge on HIV among all the key affected populations declined between 2007-2011 in Indonesia to a very low level of 44% among IDU, 16% among sex workers and 26% among MSM. Yet the knowledge of condom as a protective method was high—over 80% among all groups (Figure 22).23 Delaying sex until marriage, limiting number of sexual partners or having a faithful, single partner and using condoms at high-risk sex are the expected behavioural change among young people with adequate HIV knowledge.The age at first sex among the youth in the region ranged 23-26 years, while less than 20% had more than one sexual partner. Generally women marry at an early age
Comprehensive knowledge among key affected populations Increasing the knowledge among KAP is a key strategy of national governments for changing their risk behaviours. Comprehensive knowledge among the young, key affected populations in highburden countries varied considerably. Female sex workers appeared to be less knowledgeable as only two out of five FSW (less than 40%) were able to identify
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
17
Figure 21: Percentage of key affected populations aged 15–24 years with comprehensive and correct knowledge on HIV/AIDS, South-East Asia, 2007–2009 100 90 80 70
Percentage
60 50 40 30 20 10 0 FSW MSM IDU
Indonesia 2007
Myanmar 2007-9
Nepal 2011
Thailand 2009
Source: UNGASS Country Reports 2010, Universal Access 2011 and Global AIDS Response Progress Reports 2012
Figure 22: Trends in comprehensive knowledge on HIV/AIDS among KAP in Indonesia, 2007–2011 60.00% 52.20% 50.00% 40.30% 40.00% 44%
30.00%
25.30%
26%
20.00% 16% 10.00%
0.00% 2007 2011
IDU
MSM
FSW
Source: Integrated Bio-behavioural Surveillance Reports, National AIDS Commission, Indonesia
18
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
than men as was seen in Bangladesh; over 32% women were married by 15 years, and 66% by 18 years, though the legal age at marriage is 18 years. Men tend to marry much later; only 5% were married by 18 years exposing them to premarital sex and posing risk to their wives.21 The majority of youth get HIV information messages, through peers, internet and electronic media, while information through health services is low, due to unavailability of youthfriendly services. Also, age acts as a barrier to attend the formal health/sexually transmitted infection (STI) services. Youth-friendly, age-appropriate preventive messages need to be made available to the target groups. More innovative methods such as use of internet (popular websites such as Facebook, Youtube) and mobile phones (SMS messages) to deliver youth friendly messages may be tried out to reach the young people, in addition to a formal curriculum- based lifeskill education on HIV/reproductive health in-school adolescents.
This information is collected through community or general population surveys (Demographic Health Surveys or multiple indicator surveys) generally from women. The most recent data show that there is a large gap in condom use among men and women worldwide with an average of 29% and 23% among men and women respectively.1 Many countries with concentrated epidemics in the Region do not collect regular data on HIV among general population as they are not relevant in an epidemic scenario. The reported data for Global AIDS Response Progress Report revealed that in the South-East Asia Region on average less than 50% of men used condoms at their last higher-risk sexual encounter, however considerable variation is seen (ranged 1.2% in Bhutan-74% in India) (Figure 23)14, 25 Few women reported having multiple partners or using condoms with their spouses or intimate partners during surveys. This further collaborates the finding that the majority of women living with HIV were infected by their spouses or intimate partners. The limited data show that in the Region the majority of young people fail to use condoms during sex for many reasons even if the risk of getting HIV through such action is perceived. The level of condom use particularly among the young in the Region is unacceptably low, even in countries with a high burden of HIV and a large youth population. In Timor-Leste, out of a substantial number of young women who had multiple partners, a mere 2% admitted using condoms at last high-risk sex.26
3. MDG (G6.Target 6(a), 16.2) Condom use at last high-risk sex Condom use to prevent HIV is still dangerously low in many developing countries, especially among women and young people Protection against HIV and sexually transmitted diseases is afforded by correct and consistent use of condoms particularly at higher-risk sex (at commercial sex and with non-regular partners). It is important that condoms are used at all sex encounters.
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
19
Figure 23: Condom use at last high-risk sex among men 15-49 years in the South-East Asia Region, 2008–2011 80 70 60 54.5 74
Percentage
50 40 30 20 10 5.5 9.6 32.7 26.5
Bangladesh 2008
Bhutan 2008
Indonesia
India
Myanmar
Nepal
Sri lanka
Thailand
Source: Global AIDS Response Country Reports 2012. UNGASS country reports, National behavioral surveillance reports
Women are thus at risk of getting infected through casual sex with boyfriends, married men, intimate partners or spouses. In Thailand the increase in incidence of mixing of sexual partners without using condoms may have contributed to the increased risk for STIs and unwanted pregnancy among youth, as the highest number of STI cases were reported among the 15-24year age group, and the number of teenage deliveries per 1000 girls aged 15-19 years had increased from 33.7% in 1989 to 50.1% in 2010.16
The use of condoms at anal sex among MSM ranged from a low 29% in Bangladesh to over 60% in all the countries as reported in 2011. Myanmar and Thailand have reached the universal coverage of over 80% men using condoms at last anal sex with a male partner. There was no disparity in condom use between the young MSM and those older than 25 years (Figure 24).
The limited data show that condom use among transgenders continues to be unacceptably low and varied considerably with type of sex such as, anal, oral, receptive or insertive. Despite the reported high level of condom use at Condom use among MSM last sex, inconsistent use at all encounters An increasing trend in condom use could be a reason for high level of HIV among MSM is seen in the South-East seen among MSM and transgenders. Asia Region.
20
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Timor-Leste
0
Figure 24: Percentage of men who have sex with men using condoms during last anal sex, South-East Asia Region (2008–2011) 100 85 85 85 78 75 75 76 66 61 61 61 60 60 64 58
82 80
84
% of MSM using condom
40 29
37
23 20
0 Myanmar Nepal Thailand Timor-Leste Sri Lanka Indonesia Bangladesh
Condom use in last anal sex all
<25 years
>25 years
Source: Monitoring and reporting on the health sector response to HIV and AIDS 2008-2010; Reports of behavioural surveys, national AIDS programmes.
Sex workers and condom use Reaching the FSW, MSM with interventions to reduce sexual transmission remains low: Reaching the target of 80% coverage to reduce 50% HIV infection through sexual transmission by 2015 is a challenge Overall, condom use among female sex workers has increased over the years (range 28% in Indonesia-96% Thailand. Myanmar, Thailand and Sri Lanka have reached the universal coverage target (80%). However, it is worthy of note that over half of male sex workers had failed to use condoms with their partners at the last sexual encounter, and as a result were reported to have a higher HIV prevalence than FSW. The limited data show that age did not make much difference in the level of condom use among sex workers as young sex workers also had a similar coverage
(Figure 25). However comparisons and valid conclusions cannot be made due to small numbers of young sex workers recruited for the behavioural surveys. Despite the high level of reported condom use it was evident that many young sex workers were getting infected as stated earlier. Behavioural surveys have shown that sex workers use condoms less frequently with their live-in or stable partners and also during anal sex. A substantial proportion of sex workers in Indonesia and Myanmar were subjected to coercive sex by clients without using condoms.13, 16, 17, 20 The minimal prevention interventions delivered to KAP to reduce HIV transmission include education on HIV transmission and prevention, promotion and provision of condoms, diagnosis and treatment of sexually-transmitted infections (STIs) and HIV testing and counselling etc.
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
21
Figure 25: Percentage of sex workers reporting condom use with their most recent client, South-East Asia Region, 2011 120 Condom use has reached universal access targets 80% coverage among FSW in most countries 96 96 87 89 83 67 60 60 49 40 38 33 36 49 62 96 94 88 96 95 90
100
% of s ex workers
80
20
0
Male sex workers
Female sex workers Thailand 2010 Indonesia 2009
<25 years Sri Lanka 2006-7 Bangladesh 2010
>25 years Nepal 2008
Myanmar 2008 Timor-Leste 2010
Source: Universal access country reports, Global AIDS response country reports, National behavioral surveillance reports
Despite the scaling-up efforts the reported prevention coverage remains low among the key affected populations (assessed through behavioural surveys, whether the respondents received condoms and knew where to go for an HIV test).6, 7 Large disparities among countries in reaching the sex workers and MSM Coverage with the minimum package of interventions for female sex workers ranged from 7.5% in Bangladesh to 80% in India (Figure 26). Though Thailand‘s success story of implementing a 100% condom use programme (CUP) among brothel-based sex workers had a major impact in bringing down the HIV epidemic in the early
nineties, the present coverage of 56.9% is inadequate to prevent resurgence of HIV among sex workers in the country. Indonesia is lagging behind the target with unacceptably low coverage of 20% i.e. with only one in five sex workers receiving an intervention. Wide gaps also are seen in coverage by location and type of sex work according to the data provided by countries. Generally those in rural and border areas are not reached compared with those in urban cities, as seen in India. 27 Non-national (migrant) sex workers as well as sex workers operating independently from their homes through mobiles etc. (indirect sex workers) are less likely to be reached compared to the traditional brothel-and street-based sex workers.16, 21
22
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Figure 26: Coverage with prevention interventions for FSW and MSM in selected countries in the South-East Asia Region, 2011 100 90 80 70 60 50 40 30 20 10 0 Bangladesh India Indonesia Myanmar Nepal Thailand
FSW
MSM
Source: Global Response Progress Reports 2012, *India programme coverage data
Myanmar success story in HIV prevention among sex workers Myanmar is closing in on the universal targets for providing HIV prevention interventions for 76% sex workers. Of the estimated 60 000 sex workers 50 000 were reached in 2011. More sex workers are using condoms (95%) and have been tested for HIV (71%). As a result, HIV infection among FSW declined to 9.4% in 2011 from 18% in 2008. Of the estimated new infections, 23% were among sex workers and 35% of financial resources available for prevention were allocated to target sex workers with an average of US$ 89 spent per sex worker. The success is due to proper targeting of resources, collaboration and commitment on the part of a range of partners including government, international and local NGOs, as well as the community, in the implementation of the programme, and continuous flow of resources from donor through the Global Fund.
The MSM who were reached with services ranged from 9% in Bangladesh to 77% in Nepal. Notably, the coverage was low even in countries with high rates of HIV among MSM. Indonesia and Thailand reached only 23% and 49% respectively of the MSM with interventions that reduce HIV. According to the AIDS in Asia Report 2008, over 50% infections will occur among MSM in Asia by 2020 if no action is taken.10 Reducing new infections through drug use is more challenging. Harm reduction efforts for PWID are still not adequate; majority do not get sterile needles and syringes and a mere few get substitution therapy (OST) to overcome drug addiction. A comprehensive harm reduction package (HRP) for PWID including nine elements is recommended by WHO/UNODC for achieving the goal of reducing 50% new HIV infections among PWID by 2015.28 There is increased emphasis on ongoing advocacy efforts to
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
23
provide at least five of the nine interventions— needle syringe programmes (NSP); oral substitution therapy (OST); condom promotion; HIV counselling and testing; and providing antiretroviral therapy. However, the coverage and scale-up of these interventions remain a challenge in the Region. Bhutan, Democratic People’s Republic of Korea, Maldives, Timor-Leste and Sri Lanka do not have needle syringe programmes (NSPs) as yet in their countries. Importantly where NSPs exist, the locations for scaled-up prevention services are not based on evidence (high HIV infections) where the emerging epidemics are, and thus are not available, and inaccessible to the majority of PWID. More needles are distributed and the sites dispensing needles have also increased, however coverage is severely inadequate to reverse the epidemic driven by injecting drug use.
Countries in the region with high levels of injecting drug use have increased the number of distributing sites coupled with an increased number of syringes/ needles being distributed by NSPs. While the number of NSP sites doubled from 350 in 2009, around 70 million needles and syringes were distributed to PWID in 2011, a threefold increase from 30 million in 2009. However, there was wide variation across countries (Figure 27). It appears that PWID are not getting adequate supply of sterile needles to maintain safe injecting behaviour thus preventing new HIV infections (Figure 28). The uptake reached the internationally recommended target of a minimum of 200 syringes distributed to each PWID for a year in only two countries, Bangladesh and India, at 264 and 306 syringes/ PWID/year. The number of syringes distributed per/PWID/year ranged from 7 in Indonesia to 306 in India, respectively.
Figure 27: Number of syringes/needles distributed by needle and syringe programmes (NSP) among countries in the South-East Asia Region, 2008–2011 50 000 000
40 000 000
30 000 000
20 000 000
10 000 000
0 2008 2009 2010 2011
Bangladesh
India
Indonesia
Myanmar
Nepal
Thailand
Source: Universal access country reports, global AIDs response country pogress reports 2012
24
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
The control of injecting-drug-use (IDU) driven epidemics is a challenge especially in Indonesia and Thailand where the coverage is extremely low at 7 and 10 needles/PWID/year) while the proportion of HIV-infected PWID in both countries is still very high. Governments are recognizing drug use as a health issue. Support for harm reduction programmes is improving. Coverage of oral substitution therapy (OST) in the Region is too low to have an impact on the HIV epidemic among PWID in terms of OST sites and number of people on treatment, even in countries that provide OST such as Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal and Thailand. Although many governments have endorsed the need for OST, implementation has been delayed due to many social, cultural, political and programmatic reasons. Sri Lanka,
Bhutan and Timor-Leste do not provide OST to drug users yet. However Bhutan and Sri Lanka are currently advocating introduction of HRP/OST with the support of the Global Fund and UN partners. The legal age of 18 to start therapy; the need to be hospitalized to initiate therapy (induction period); and non-availability of take-home doses, are some of the barriers that exist in countries for implementation of OST. Unsafe injecting practices among IDUs A low supply of needles and reduced access to services lead to unsafe injecting practices among PWID such as reuse or sharing needles, which increases the risk of acquiring HIV. The reported safe injecting practices among PWID (defined as using a sterile needle/syringe at last injection) is increasing over the years and was high
Figure 28: Proportion of PWID reached by needle-syringe programmes in the South-East Asia Region, 2008–2011 350 300 250 200 150 100 50 0 Bangladesh Myanmar India Nepal Indonesia Thailand
High coverage >200 needles per IDU per year
Medium coverage 100-200 needles per IDU per year
Low coverage <100 needles per IDU per year
2008
2010
2011
Source: global AIDs Response Progress Reports, 2012, Universal access country reports
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
25
among the PWID, reaching the universal access target of 80% in many countries; in Nepal it was 95%, in Myanmar it was 81%; in Indonesia it was 87%, while in Thailand it was 78% in 2011. A similar pattern was observed among the young injectors. Despite having a strong needle exchange programme that reached reaching the international standards, and distributing over 200/needles/IDU per year, only 34% PWID reported safe injecting practices in Bangladesh.13,16,17,21
HIV testing populations
among
Key
affected
Many key affected populations know their HIV status; injecting drug users have reached the target of 80% HIV testing in high- burden states.
Owing to increased emphasis on promoting HIV testing, many KAP are aware of their HIV status enabling them to seek services that reinforce safe sexual/ drug-taking behaviours, if negative, and Nevertheless more women (77%) seeking treatment and care services, if reported using sterile equipment at last found to be positive. injection than men (32%) in Bangladesh The coverage of HIV testing ranged while it was the reverse in Thailand, having from 9%-79% among FSW, 29%-92% more men (77%) vs women (56%) using 16, 21 among MSM, and 4%-91% among PWID sterile equipment at last injection. More insight into the injecting frequency, with a better coverage in high-burden networking among PWID, accessibility to countries (Figure 29). NSP and drug availability, etc. are needed The 2011 behavioural survey results to make valid conclusions. indicated that over 90% of key affected Figure 29: Key affected persons who received an HIV test in the last 12 months and who know their results: in South-East Asia Region, 2011
100%
92% 79%
92%
75%
71% 66% 55%
50%
50% 44% 41%
48% 42% 33% 27% 29% 21% 14%
25% 9% 4%
9%
0% Sex workers People who inject drugs Men who have sex with men
Bangladesh
Indonesia
Myanmar
Nepal
Sri Lanka
Thailand
Timor-Leste
Source: Global AIDS Response Progress Country Reports 2012, Country Surveillance Reports, South-East Asia Region, Indonesia, 2011: IBBS, Myanmar FSW 2009, PWID 2005
26
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
populations in Indonesia had been tested and were aware of their HIV status—a sharp increase from 29% in 2007. Female sex workers had the highest uptake of HIV testing in the Region (over 50%) and Myanmar, Indonesia and Timor-Leste are on the track to reach the 80% universal coverage target. The overall regional coverage was low (less than 40%) among MSM and lowest among PWID.
the Region to effect an impact on the growing epidemic among PWID.
Control of sexually transmitted infections in HIV prevention STIs are slowly declining with wide disparities across countries and among populations; nevertheless the burden of STIs is still high in the Region. However, the focus on STI control has not been adequate in the South-East Asia Region.
A likely reason for the low uptake of HIV testing among PWID could be due to the fact that drug users are still incarcerated and not accessible to services in the Member States. The HRP Identifying and treating sexuallyand ART care services are not available transmitted infections (STIs) rapidly is in prison settings except in Indonesia. highly effective in controlling HIV since A review of country reports reveals the presence of other STIs synergistically that most interventions operate only in increases the risk of HIV. Moreover they major urban cities and there is hardly share the same methods of transmission. any coverage among the semi-urban and Successful STI control among other rural populations. Steps are being taken preventive measures may also have by countries to strengthen the linkage largely contributed to the decline in HIV of community organizations with health prevalence in India, Myanmar, Sri Lanka services at district level and through and Thailand. Women benefit more as capacity building of community-based the STI preventive and control measures organizations (CBOs), nongovernmental reduce the chances of infertility and organizations (NGOs) and self-help adverse pregnancy outcomes such as stillbirths, and perinatal and congenital groups. infections in the baby. In conclusion HIV prevalence The STI services while addressing isamong the MSM and PWID still remains sues specific to STIs, provide an opportuat a high-level and is a cause for concern. Successful harm reduction pogrammes nity to offer HIV testing and counselling have resulted in bringing down the HIV and link those who are positive to HIV incidence among injecting drug users, care and treatment services. The burden i.e. Nepal where introducing needle- of STIs, (particularly syphilis, chalmydia syringe programmes in 2005 reduced and gonorrhoea) is still unacceptably high the HIV prevalence among PWID from in the Region especially among the most48% in 2005 to 12.5% in 2007, and to at-risk populations. Syphilis is the most 5.35% in 2011.29 However the overall commonly reported STI in the Region. coverage of oral substitution therapy The change in the proportion of preg(OST) is severely inadequate and Needle- nant women infected with syphilis serves syringe programmes are suboptimal in as an early warning of changing HIV risk behaviour in the general population.
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
27
Currently, syphilis among pregnant women is low (range 0.07%-0.46%) in the Region and a declining trend is seen in Sri Lanka, Thailand, Myanmar and India as a result of reaching the population widely with various interventions that have proven to be effective, as well as due to the commitment and collaboration of national STI/AIDS control and maternal and child health programmes.14, 16, 17, 20 (Figure 30) The spread of infection that is being observed in the rural population in some countries is a concern. In Myanmar similar rates of syphilis were seen in young pregnant women in rural and urban areas. A mix of components tailored for different populations and implemented in different settings has been effective in reducing the STIs. Syndromic management of common STIs (genital ulcer and urethral discharge syndromes) at the patients, first contact with the health services is the preferred method in STI management in
most countries with limited laboratory facilities to diagnose STIs. Enhanced syndromic management with minimal laboratory support is the method used in India and the drugs are provided in pre-packed, colour-coded kits for easy dispensing by health-care workers.27 Thailand and Sri Lanka manage STIs based on laboratory diagnosis with a network of dedicated STI clinics with laboratory support, and have been able to reduce STIs significantly over the years. Rapid simple diagnostic tests are now available that can be used in the field without skilled technicians. The tests provide results immediately or within a short period of time. This has improved STI diagnosis and management especially in the community settings.
The STI burden among MSM, FSW subpopulations The rates of bacterial STIs such as gonorrhaoea and active syphilis serve to
Figure 30: Trends of syphilis rates among ANC attendees in selected countries in the South-east Asia Region, 1991-2010 5 4.5 4 3.5
% positive
3 2.5 2 1.5 1 0.5 0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Thailand
India
Myanmar
Sri lanka
Source: Global AIDS Response Progress Country Reports 2012, Country Surveillance Reports, South-East Asia Region, Annual Reports National AIDS Programmes
28
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
2011
evaluate whether the programmes for STI/HIV prevention are effective. The key affected populations have unacceptably high STIs in many Member States despite long-standing control programmes. High rates of syphilis are observed among MSM (ranged 1%-17%) and in FSW (0%-10%) in the Region despite scaling up of interventions to reduce sexual transmission (Figure 31). The rising epidemics of rectal gonorrhoea and chlamydia are seen among the MSM, for example in Indonesia and Nepal, largely among male sex workers and transgender people. In Indonesia 33%-43% of MSM and TG were infected with one or more STIs (chlamydial and gonorrhoea), a substantial increase from 29% to 34% among MSM in three cities surveyed in 2007.23 Similarly, high rates of rectal gonorrhoea (12.5%) and chlamydial infection (5%) were seen among the MSM population, with a relatively high prevalence among
MSWs: 18.5% rectal gonorrhoea and 11% chlamydial infection, respectively, in Kathmandu valley in Nepal. Notably, two out of three MSM (66.7%) with urethral gonorrhea, two out of 10 MSM (20%) with urethral chlamydial infection and one out of six MSM (16.7%) with untreated syphilis were HIV-positive in Kathmandu, indicating a potential relationship between such STIs and HIV.29 The high rates of STI/HIV can be due to unprotected anal sex among MSM, as more than 70% MSM in Indonesia fail to use condoms consistently with their male partners, while the condom use at last sex was 60%.29 This indicates that services have failed to reach the MSM populations. Lack of clear understanding about the need to use condoms at all high-risk sexual encounters to protect against STI/HIV or difficulty in getting enough condoms, etc. are common reasons for the low use of condoms.
Figure 31: Active syphilis rates among sex workers, men who have sex with men in selected countries, South East Asia region, 2011 20 18 16 14 12 10 8 6 4 2 0 % of SW positive for syphilis Bangladesh Thailand Indonesia Srilanka % of MSM positive for syphilis Myanmar Timor-Leste Nepal 3.8 3.9 2.4 0.7 0.5 2.5 1.5 1.5 9.8 8.6 7.1 11.7 18
Source: Global AIDS Progress Report, 2012
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
29
The gains of reversing the HIV epidemic such as through promoting safer injecting practices among IDUs in Nepal and 100% condom use among FSW in Thailand will be lost if timely attention is not given to the emerging new HIV epidemics among MSM. This demands increasing the quality and coverage of services for KAP especially the MSM. Innovative methods are being used by Member States to reach the KAP to provide STI care. Providing periodic presumptive treatment as a temporary measure for MSM and FSW (to treat KAP at regular intervals of three months irrespective of having STI symptoms), and referring them to STI services has been the approach in Indonesia. Many countries try to serve these hard-to-reach and hidden populations through mobile clinics as in India and Indonesia. “Preferred provider partnership” is an innovative method used in India where general practitioners preferred by KAP are chosen and given an incentive to provide a package of services to the KAP free of charge.27
An estimated 57 000 pregnant women were living with HIV, while an estimated 48 000 children were newly infected in 2011in the South-East Asia Region. It is estimated that over 90% children living with HIV were infected through transmission of HIV from infected mothers during pregnancy, at childbirth or from breast-feeding. A small fraction of children get infected through unprotected sex at an early age, through blood or through child abuse. The risk of motherto-child transmission of HIV can be reduced to a very low level with the new treatment approaches (to less than 5% or even lower in breastfeeding populations from a risk of 35%, and to less than 2% in non-breastfeeding populations from a background risk of 25%).32
The WHO PMTCT guidelines for the treatment of HIV-infected pregnant women and exposed infants, updated in 2010, include recommendations for ARV prophylaxis to prevent MTCT including during breastfeeding, on the optimal time to initiate ART in pregnant women who need treatment, and on safe feeding The recent initiative in the Region practices for HIV-exposed infants.33 to eliminate congenital syphilis and new paediatric HIV infections by 2015 The WHO Regional Health Sector has further strengthened the efforts to Strategy on HIV, developed in 2010, reduce STIs/HIV among adolescents, targets reduction at new HIV infections particularly girls.30 in children by 90% to achieve the goal of elimination of new paediatric infection by 2015. This will be realized through Reducing new infections among several programme targets. MDG 6(a) preventing HIV among young people; children by preventing motherzero unmet needs for family planning to-child transmission of HIV among women living with HIV (goal 5); Programmes for prevention of mother- over 90% pregnant women access ANC to-child transmission of HIV (PMTCT) and skilled care at birth (goal 5); 90% know support the attainment of several their HIV status and 90% HIV-positive Millennium Development Goals mothers and exposed infants receive (MDGs). MDG 6: preventing new HIV effective ART to reduce mother-to-child infections in children, MDG 4: reducing transmission (MTCT); and 90% eligible child mortality, and MDG 5: reducing HIV-positive pregnant women retain on maternal mortality.31 30
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
ART at 12 months and 90% infected children receive ART [goal 6(b)].3 Two out of three HIV-infected pregnant women do not receive ART prophylaxis to prevent mother-to-child transmission; access to HIV testing and counselling for pregnant women is still low in the South-East Asia Region.
from 18% in 2009. Among the highburden countries, ANC HIV testing coverage was highest in Thailand at 100%, and ranged from 21% in India, 25.4% in Myanmar, 16.6% in Nepal, to a low 0.4% in Indonesia (Figure 33). Of the 10 million pregnant women who reported receiving an HIV test in the Region in 2011, about 22 350 (0.23 %) were found to be HIV-positive, the majority of them in India. This accounts for about half of the estimated pregnant mothers who need ART. Many pregnant women who need treatment for their own health or and to prevent MTCT are thus unaware of their HIV status.
entry point to PMTCT and is generally offered to pregnant women at antenatal care settings. The number of pregnant women accessing ANC care has improved over the years due to concerted and coordinated efforts by governments. More than half the estimated pregnant women were accessing ANC care at least once according to national surveys and over 80% in three high-burden countries, Indonesia, Myanmar and Thailand, while two high-burden countries like India (75%) and Nepal (58%) are still lagging behind with a gap of unmet need ranging from 25% to 40%. However, less than 50% pregnant women attend ANC regularly in the two countries, while the number attending once (first visit) is high.34 On average, in 2011, nearly 39 million pregnant women were enrolled for ANC at the first visit and of these only about 10 000 000 were tested for HIV (Figure 32). This amounts to a bare 25% of the estimated number of pregnant women who had access to HTC (range <1% to 100%) in 2011, a slight increase
Ideally HIV-infected pregnant women who do not need treatment (high CD4 count) should be identified early at 14 weeks of pregnancy to offer prophylactic ART to prevent MTCT. Progress has been limited in scaling up HIV testing and counselling (HTC) services for pregnant women and many pregnant women Coverage of ART prophylaxis is low are unaware of their HIV status. and many pregnant women are not HIV testing and counselling is an receiving ART for PMTCT
For pregnant women who do not need ART for their own health, initiation of ART to prevent MTCT is recommended early at 14 weeks with either Zidovudine (AZT) (Option A) or triple ARV (Option B). The 2010 updated WHO PMTCT guidelines also recommend that ART during breast-feeding should be continued in resource-poor settings if women decide to breast-feed, together with improved feeding practices. The 2012 Programmatic Update to the PMTCT guideline additionally proposes Option B+, where in a single, universal regimen is provided to all HIV-positive pregnant women for life regardless of their immune status/CD4 count. 35 Progress has also been limited in providing ARV prophylaxis to prevent MTCT. Most countries have now revised the PMTCT guidelines to include the most efficient regimens, and continue ART during labour and breastfeeding.
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
31
Figure 32: Status of ANC coverage with HIV testing and ART coverage among pregnant women in high-burden countries in the South-East Asia Region, 2011 100000000 10000000 1000000 70 100000 60 50 40 30 100 20 10 1 India Indonesia Myanmar Nepal Thailand Estimated number of pregnant women Number of pregnant women tested for HIV Number received ART for PMTCT PMTCT coverage %
100 90 80
10000 1000
10 0 Number of women attending ANC Number of HIV positive pregnant women detected Estimated number of HIV infected pregnant women
Source: Global AIDS Response Progress Reports, 2012, annual report 2012 and HIV estimates 2012 National AIDS control Organization, India. Denominators used are global PMTCT estimates
Figure 33: Percentage of pregnant women who received HIV counselling and testing in high-burden countries of the South-East Asia Region, 2009–2010 100 99.8 100
82 80
Target
% HIV-infected pregnant women
60
40 30 19 21 21 18 21 17 9 0 Thailand India Myanmar Nepal Indonesia All countries 11 0.5 0.2 0.4 20 18 19
20
2009
2010
2011
Source: Global AIDS Response Progress Reports 2012, Universal Access Country Reports
32
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
PMTCT coverage
Number
Bangladesh is yet to revise the PMTCT However children born to HIVguidelines to provide effective preventive positive mothers in the Region still have interventions for the mother-baby pair. a low survival rate due to late diagnosis and treatment. The MTCT rates estimated Based on the data reported by through statistic models indicate high countries in the Region, from 2010 to transmission rates except in Thailand 2011, the proportion of HIV-positive where the PMTCT programme is pregnant women receiving ARVs considered the best practice. The MTCT improved in almost all countries. The rates ranged from 12.6% in Myanmar, regional PMTCT coverage with most 39.6% in Nepal, and 3% in Thailand effective regimens (non-Nevirapine- (Figure 35). based regimens) increased 8 folds from 2% in 2008 to 16% (11%-23%) in 2011, Urgent action is necessary to a slight increase from 14% coverage in improve ANC attendance and expansion 2010 (Figure 34). India continues to of HIV counselling and testing for provide Nevirapine-based regimens to pregnant women attending ANC to offer the mother-baby pair at delivery, and early ART. Adaptation of new treatment the regional PMTCT coverage including guidelines for resource-poor countries Nevirapine-based regimens was 39.7% that recommend early ART initiation and (range 9%-91%) in 2011, an increase proper infant-feeding practices, together from 32% in 2010. Thailand had the with new initiatives such as testing highest coverage (91%) based on and treatment of all pregnant women reported data, followed by Myanmar irrespective of their immune status (80%) with a range 60-95%, India 34% (CD4 cell counts B+ approach) with (on Nevirapine- based regimen) and expansion of HIV testing services, and Nepal 16% with a range of 7%-29%. Of integration into primary health care and the high-burden countries, Indonesia maternal and child health care services had the lowest coverage of 13% (range will improve survival of the mother-baby 8%-23%). The PMTCT coverage has pair. improved in majority of the low- burden The recent expression of high-level countries since 2010, from 12% to 41% in Bangladesh and from 4-9% in Sri Lanka political commitment by governments while Bhutan had a slight drop from 27% to reach zero new infections among children through strengthening in 2010 to 24% in 2011. PMTCT programmes in the Region Babies exposed to HIV (born to is commendable. The Government HIV-positive mothers) are given ART of Myanmar has pledged strong prophylaxis treatment to reduce early commitment to scale up PMTCT services mother-to-child transmission (MTCT). to eliminate paediatric HIV by 2015. A The ART coverage for exposed babies policy decision by the Government of ranged widely from 3% to 99% in Indonesia to adopt option B+ (testing Member States in 2011. Nevertheless and treating of all HIV-positive pregnant Thailand, Myanmar and India have been women with ART irrespective of CD4 able to provide prophylaxis ART to a large level) is another positive move. number of babies with the expansion of PMTCT programmes over the years.
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
33
Figure 34: Percentage of HIV-infected pregnant women receiving antiretroviral prophylaxis, South-East Asia Region, 2010-2011 100.0% 90.0% 80.0% 70.0%
Target
Percentage
60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Thailand Myanmar India Nepal Indonesia SEAR
2005 2007 2009 2010 2011 Source: Universal Access Country Reports 2010, Global AIDS Progress Reports, 2012
Figure 35: PMTCT Outcome in high burden countries in the South-East Asia Region 2011 120%
100%
80%
60%
40%
20%
0% India Indonesia Myanmar Nepal Thailand
% pregnant women given ART % infants born to Hiv positive mothers givn ARV Px % HIV exposed infants received a HIV test % Infants tested HIV positive MTCT rate modelled Source: GARP country reports 2012 and modelled data
34
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Chapter 2
Progress towards MDG 6 (b) Universal access to treatment for HIV/AIDS
1. Universal access targets MDG 6(b) T6(b): Achieve, by 2010, universal access to treatment for HIV/ AIDS for all those who need it. Indicator 6(b): Proportion of people (adult and children) who are eligible for treatment receiving it. Antiretroviral treatment has expanded globally and people live longer and enjoy a productive life. The global expansion of access to HIV treatment ranks among the great recent achievements in public health. At the end of 2011, worldwide an estimated 8 million people in lowand middle-income countries were receiving ART—a 25-fold increase since 2002 and an increase from 6.6 million in 2010. About 54% people living with HIV (PLHIV), who were eligible for ART, were receiving it at the end of 2011, up from 49% in 2010.6,7 Several countries (including resource-limited ones) have reached or are close to achieving “universal
access” to ART defined as coverage of at least 80% of the population in need. In the developing region, among the middle-and low-income countries, 10 countries including three with generalized epidemics (Bostwana, Namibia and Rwanda) have already attained universal access to treatment.6, 7, 8 The Asia-Pacific countries are committed to achieve the target of 1.1 million people on ART by 2015 from baseline in 2011.6, 7, 8 There has been considerable progress in the South-East Asia in providing ART to those in need in terms of numbers and coverage. All Member States except the Democratic People’s Republic of Korea with no reported cases of HIV/AIDS provide ART to eligible adults and children. Although Member States are yet to achieve the universal target of 80% coverage, an increase of PLHIV receiving ART is seen in almost all countries. Still, countries have a long way to go to reach the universal access target of providing ART to all eligible people by 2015. At the end of 2011 available data showed that overall 840 000 eligible people were receiving ART, an increase from 717 000 in 2010, thus representing an additional 100 000
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
35
people or a 17% increase since 2010. This amounts to a dramatic 15-fold increase from 2003 when scaling up of treatment began in the Region (Figure 36). The total estimated need for ART in the Region based on a CD4 count of 350 cells/mm3 increased from 1.8 million in 2009 to 2 million in 2011, including over 85 000 children. About 137 000 people were reported to have started newly on ARV treatment in 2011. About 46% of eligible people (at a 350 CD4 count) were receiving antiretroviral treatment in the South-East Asia Region in 2011, up from the 39% in 2010 and 9% in 2003 (Figure 37). This means that in 2011 more than half the people in need did not access treatment: possibly unaware that they were infected with HIV, or fear of stigma
and discrimination may have prevented those who knew that they were infected with HIV to attend health-care settings. However the regional ART coverage of 46% lags behind the global average of 54% PLHIV that received treatment in 2011.6, 8 Considerable variation is seen across countries in ART coverage. Thailand is the only country close to reaching the 100% universal access target with a 71% coverage for ART. However the treatment is initiated at a very low CD4 count (average 100), thus patients’ survival rate is low in Thailand. As per the revised WHO guidelines that recommend starting of ART early at a CD4 count of 350 cells/mm3, the overall coverage of treatment across countries in the SouthEast Asian Region ranged from 21% in Sri Lanka to 71% in Thailand.
Figure 36: Scale-up of the ART programme in the South-East Asia Region, 2003–2011: Number and proportion of people receiving ART in theSouth-East Asia region, 2003–2011 90% 80% 70% 60% 50% 40% 1800000 1600000 1400000 1200000
840412 717000 577000 46% 39% 32% 28% 25% 442600
1000000 800000 600000 400000 200000 0
30% 20% 10% 0% 2003 2004 2005 2006
330000 83000 7% 140000 210000 12% 16% 2007
55000 5%
2008
2009
2010
2011
ART coverage
Number receiving ART
Source: Global AIDS Response Progress Country Reports 2012, Universal access progress country reports
36
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Figure 37: Percentage of persons with advanced HIV infection receiving antiretroviral treatment, by country, in the South-East Asia Region, 2008–2011
100 90 80 70 60 50 40 30 20 10 0 Thailand India Myanmar Bangladesh 2008 Bhutan Indonesia Nepal Maldives Sri Lanka All countries
2009
2010
2011
Source: Global AIDS Response Progress Country Reports 2012, Universal access reports
India and Thailand have the largest number of adults and children on treatment (nearly 500 000) in India and (225 272) in Thailand (Figure 38). Almost 90% of ART need in the Region is in these two countries. Both countries have demonstrated successful scale-up of their ART programmes. Thailand has the largest number of health facilities providing ART (943) in the Region, while India has the largest number of people on ART. India accounts for 6% of the total population receiving ART globally with a national coverage of 43%, an increase from 27% in 2010. Thailand accounts for 4% of those receiving ART globally with coverage of 71%, an increase from 67% in the previous year. The number of people receiving treatment in highand-low burden countries are shown in figures 39 and 40.
Most people are getting treatment from the public sector though the private sector is also providing treatment to a considerable number of PLHIV. In India (about 35 000) and Thailand (45 000) PLHIV are taking ART from the private sector while special clinics are providing ART to migrant populations in Thailand. In Myanmar the majority of patients get ART from the nongovernmental sector, free of charge. However as the data are not reported to governments the number of PLHIV receiving ART in the private sector are estimates of the ART drugs dispensed by pharmacies*. Adherence to treatment guidelines by clinicians, proper monitoring of patient’s compliance and adherence to treatment to prevent drug resistance, and the quality of care are some of the issues in providing treatment in the private sector. 27, 16.17 (*Not included in the analysis of coverage as the denominators are not known)
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
37
Figure 38: Number of people with advanced HIV infection receiving antiretroviral therapy, in high-burden countries, 2003–2011 900 000 800 000 700 000 600 000 500 000 400 000 300 000 200 000 100 000 0 India Indonesia Myanmar Nepal Thailand
2005
2007
2011
2015 target
Source: Global AIDS Response Progress Country Reports 2012, Universal access progress country reports Note ;India figures are from reported data, may change from the published reports due to reporting period.
Figure 39: Number of people with advanced HIV infection receiving antiretroviral therapy, in high-burden countries, 2003–2010 600 000
500 000
Number (in thousands)
400 000
300 000
200 000
100 000
0
India
Indonesia
Myanmar
Nepal
Thailand
2003 2008
2004 2009
2005 2010
2006 2011
2007
Source: Global AIDS Response Progress Country Reports 2012, Universal access country reports, HIV Estimation 2012 NACO India
38
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Figure 40: Number of people with advanced HIV infection receiving antiretroviral therapy, by low-prevalence countries, 2003–2011 500 450 400
Number (in thousands)
350 300 250 200 150 100 50 0 Bangladesh Bhutan Maldives Sri Lanka Timor-Leste
2003 2008
2004 2009
2005 2010
2006 2011
2007
Source: Global AIDS Response Progress Country Reports 2012, Universal access progress country reports
Access to ART is not yet equitable. Migrant populations and those in border and rural areas have limited access to ART in the majority of countries, due to lack of facilities in the rough terrain and in border areas. In Thailand the non-Thai migrants are not yet eligible for free ART from the government ART sites.16 Treatment access is also much too low in settings where the epidemic is concentrated among marginalized populations such as sex workers, people who inject drugs, men who have sex with men, and transgender. However reliable data are not available on the number of KAP receiving ART across the Member States. Still disparities are seen among women and children in treatment access.
Men have greater access to treatment than women, however more women are now receiving ART in the Region. (Figure 41) This has been due to the scaling up of programmes for preventing mother-to-child transmission (PMTCT) in the Region. Overall, 42% PLHIV receiving treatment were women in 2011, notably in high-burden countries, in contrast to 39% women in 2010. In Maldives all those receiving treatment were men. Some countries have taken innovative steps to minimize the gender disparity and to improve equity in access to services. Opening special clinics especially in the rural and hard-to-access areas, which are managed exclusively by women health-care workers and changing in the opening hours to suit women are the novel approaches currently being piloted in Bangladesh.
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
39
Figure 41: Proportion of women and men on ART in the South-East Asia region, 2011 100 90 80 70
Percentage
60 50 40 30 20 10 0
Bangladesh
Bhutan
India
Indonesia
Thailand
Male
Female
Source: Global AIDS Response Progress Country Reports 2012, Universal access reports
According to UNAIDS/WHO estimates about 33 600 children under 15 years out of an estimated 85 000 in need of treatment, were receiving ART Many children with HIV have still not at end of 2011 in the Region with an been diagnosed and are not receiving estimated coverage of 39% (low estimate ART. Only two out of three children 27%- high estimate 60%) remaining the same as in 2010. received ART in 2011. Many infected children are not provided with life-saving ART as reflected by the low coverage. It is estimated that over 90% children living with HIV were infected through transmission of HIV from their mothers during pregnancy, at childbirth or from breast-feeding. A few get infected through unprotected sex at an early age or through child abuse. About 5% children will still get infected even if the infected pregnant women are provided ART, if the babies are breastfed. The new approaches of treating pregnant mothers early, continuing treatment during breastfeeding and with safe feeding practices, have substantially reduced the risk of MTCT. Babies are provided prophylactic ART during the early postpartum period of six weeks to reduce the risk of early mother- to-child transmission. Considerable variation occurs within countries. India and Thailand contribute to the largest number of children receiving ART while Myanmar and Nepal scaled up the treatment services considerably in 2011, and the ART coverage ranged from 12%-70%. Thailand has the highest coverage (70%) and has progressed well with continued commitment and improved facilities (Figure 42). The ART coverage for children (younger than 15 years) in need of treatment in 2011 (39%) was considerably lower than the 46% coverage for adults. Lack of testing facilities for early diagnosis of HIV among exposed babies is one of the reasons for the low coverage.
40
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Timor-Leste
Myanmar
Nepal
Sri Lanka
Figure 42: Children receiving ART in high-burden countries 30 000
20 000
Number 10 000
0 India Thailand Myanmar Indonesia Nepal
2010
2011
Source: Global AIDS Response Progress Country Reports 2012, Universal access progress reports
Facilities for early infant diagnosis before 18 months of age is available in all the five high- burden countries yet the coverage is significantly low, for example in India 4%, Myanmar, 4.8%, and Nepal 2.3%, while only Thailand had a high coverage of 73%.
Several initiatives are in place to increase ART provision in the Region.
The new WHO guidelines (2010) present a public health approach for resourcelimited settings to increase the number of people eligible for treatment, improve the quality and tolerability to treatment As stated earlier a greater number regimens and bring down morbidity and of HIV-exposed babies are now getting mortality due to tuberculosis, a common ART prophylaxis treatment to reduce opportunistic infection among HIVearly mother-to-child transmission positive people. (PMTCT); the coverage ranged widely With the new recommendation to from 2% to 99% in 2011. Nevertheless initiate ART at CD4 count of 350 (2010), India, Myanmar and Thailand have been able to provide ART to a large number more PLHIV are eligible for ART. This in of exposed babies with the expansion of turn will increase the demand for testing PMTCT programmes. Children born to facilities, improved diagnostics that are HIV-positive mothers in the Region still simple, low cost and give results early, have a low survival rate as the condition ART drugs, and health-care facilities for is detected late and the children are in-patient care, etc. This will have many implications to national governments denied the benefits of life-saving ART. with limited resources: funds, manpower
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
41
and infrastructure. The new evidence of ART as a strong HIV prevention tool led to the recommendation of treatment as prevention (TasP) by WHO in 2012.35 The TasP is considered in zero-discordant couples, pregnant women living with HIV and key populations at risk (SW, IDU and MSM). Owing to this ART needs will increase considerably, so will the cost. Another proposed approach (Treatment plus) with initiation of ART at a higher CD4 count, and ultimately, to treat all people diagnosed with HIV (“test and treat strategy”) will add more burden to governments in future.35 Steps have been taken to test more people to initiate early ART.
convenience for clients including health facilities, community-based locations and work-places and through outreach services that may be stationary or mobile. This is with a view to reach people, especially the marginalized populations (KAP) who generally do not visit the formal health-care services. The HIV testing services are easily available and accessible to people. More facilities are now available for people to have an HIV test with an increase in the number of centres from nearly 10 300 in 2010 to 12 725 in 2011 in the Region. However out of the large number of health facilities still a low proportion are providing HTC with wide variations across Member States (less than 1% - 68%). With regard to HIV testing, India and Thailand take the lead in providing HTC through a large number (41% and 68% respectively) of health facilities. More private facilities and community centres (NGO) are now providing voluntary counselling and testing in addition to the public sector. For example in India, over 5000 facility-integrated counselling and testing centres (ICTC) in the government, 964 in the private sector and 4533 stand-alone centres provide HIV testing, while Bangladesh has more nongovernmental organization-based VCT facilities. Provider-initiated testing and counselling services are offered mainly through public health facilities in Sri Lanka and Timor-Leste. More people have been getting tested for HIV over the years. Nearly 20 million HIV tests were done in 2011, an increase from 6 million in 2007 and 16 million in 2010. The majority of tests were done in high-burden countries.
2. HIV testing and counseling More facilities are providing HIV testing and counselling for people to know their HIV status to initiate early ART, however a large gap remains with only one in five men and women knowing their HIV status. Also, the number of people in the key affected populations accessing services is still low. The HIV testing and counselling (HTC) services are an entry point to ART. Early initiation of ART will not only improve or increase survival, it will reduce the incidence of TB and TB deaths among PLHIV, and prevent HIV transmission to their partners. The HTC services can be initiated by person or client (client-initiated HIV testing and counselling) or by the provider (provider-initiated HIV testing and counselling). The HIV testing services are offered in a variety of settings to optimize
42
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
Overall it is evident that more women have been tested in India, Thailand, Myanmar and Nepal, which may reflect the high uptake of testing by pregnant women and sex workers due to the scaling up of prevention of mother-to-child transmission initiatives and longstanding interventions for promotion of HIV testing for sex-worker populations. Men do not have the opportunity for testing as they do not have regular contact with health services. On the other hand, women have contact with maternal and child health-care services and are offered HIV testing to prevent mother-to-child transmission of HIV. In 2011 approximately 10 000 000 pregnant women were offered HIV testing and counseling services, majority in India (over 800, 000 tests). Myanmar and Thailand where strong PMTCT programmes are in place more women are tested than men. In Indonesia more
men have been tested while testing among high-risk populations has improved over the years as stated earlier according to behavioural surveys. However many people are still not aware of their HIV status among the general population. A large gap exists despite these efforts. The majority of people have not had an HIV test and only one in five persons, (barely 20%) were aware of their HIV status, according to the population surveys conducted in the Region. In addition very few young people knew about their HIV status. To achieve the global targets of placing more people on ART the governments are intensifying campaigns to promote the uptake of testing among all. Integration of HIV testing into health facilities is a vital step to scale up HIV testing to fill the large gap of unmet need of HIV testing among the general population.
Figure 43: Number of women and men who received HIV testing andcounselling services through any method or setting in the past12 months and know their results, 2007–2011 100 000 000 10 000 000 1 000 000 100 000 10 000 1 000 100 10 1 Bangladesh India Indonesia Myanmar Nepal Thailand
2007 2008 2009 2010 2011 Source: Global AIDS Response Progress Country Reports 2012, Universal access reports
South-East Asia Region
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
43
3. New models of testing are used to expand testing services.
the same day. Newer tests are available that can be done by patients at home (self-testing). These tests afford privacy and confidentiality and are convenient A large audience can be reached through for the patient. mobile clinics. In Indonesia conducting More laboratory facilities for CD4 mobile VCT, was apparently successful in testing and viral load assays are needed providing VCT to pregnant women and to asses patients, ART eligibility for India has set up a large number of mobile initiation of therapy as well as to monitor integrated counselling and testing clinics treatment efficacy, and developing of (ICTC) in hard-to-reach areas. These drug resistance to ART. Preferably the consist of a van with a room to conduct results need to be made available without counselling and general examination and delay in order to avoid loosing patients a space for collecting and testing blood between counselling and testing, and for samples, which can operate at flexible starting treatment. hours. The country has been successful While almost all the ART facilities that in reaching a large clientele of over 10 000 000 through multiple services: dispense ART to patients in the Region combined client-initiated and provider- regularly monitor treatment based on CD4 initiated testing (for pregnant women at tests, the number of ART facilities with antenatal care and at delivery) through CD4 testing is highly inadequate ranging stand-alone VCT, facility-integrated and from a single site to 943 in Thailand. The mobile ICTC. Opening special clinics ART centres with facilities to conduct viral especially in rural and hard-to-access load assays to detect treatment failure areas, managed exclusively by women and diagnose HIV in babies and young health-care workers and changing the children early are severely lacking across opening hours to suit women, and the Region, except in India and Thailand. encouraging more women to attend Introducing point-of-care diagnostics for the services, are the novel approaches HIV testing, CD4 and viral load assays are the options being considered by some piloted in Bangladesh. Member States like India, Indonesia and Nepal, to overcome the delay in Delay in test results is a drawback to diagnosis of HIV and patient attrition link the patient to treatment services; between counselling and pre-ART care. loss of patients between counselling However the high cost of tests has been a and initiation of treatment can be drawback. Domestic production of CD4 prevented by using new technologies. tests is an option considered by India to New technologies such as point- overcome the high cost of tests. of-care-diagnostics for HIV testing are More facilities are available to available to carry out tests in the field using dispense ART. The facilities for providing direct blood samples (DBS) obtained from a finger-prick method and are being ART have also been scaled up in the used in India. They are easy to carry out Region in both the public and private without skilled laboratory technicians, sectors. The ART was being provided at with minimal patient discomfort and 2500 health facilities in 2011, an 18% give results within a short period or on increase since 2009. Nearly 90% facilities
44
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
As the current vertical ART service were in the government sector but more private facilities are also providing ART delivery is cost intensive, its functional at present (Figure 44) integration into general health-care delivery system, is being considered. Access to ART is not equitable, as Piloting of cost-effective service delivery majority of the facilities providing ART models for standardizing care in healthare in urban areas. The PLHIV living care settings: mobilizing KAPs through in rural, high-terrain and border areas outreach services to access ART services, where cross-border mobility and risk of and capacity building of health-care HIV infection are high, face poor access providers in the general health care as few facilities dispense ART. system who are presently not HIV care, To overcome these barriers patient are the key activities for integration of incentives or a monthly transportation ART services into health care system. cost are provided by some governments Many PLHIV are now continuing to PLHIV to visit ART centres combined treatment and surviving longer. with regular monthly visits to districtlevel ART centres by specialized staff or through mobile clinics. India has taken 4. Retention of persons on the initiative to provide preventive care ART services to mobile populations at both transit and resident countries including When more people are on ART for life, close follow-up is necessary to make sure provision of ART. that they adhere to the prescribed drugs Figure 44: Number of health facilities that offer ART, by country, South-East Asia Region, 2008–2011 1200 1100
Number of health facilities that offer ART
1000 900 800 700 600 500 400 300 200 100 0 Bangladesh Bhutan India 2008 Indonesia 2009 2010 Myanmar 2011 Nepal Sri Lanka Thailand
Source: Global AIDS Response Progress Country Reports 2012, Universal Access Reports
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
45
to keep the HIV virus at a low level. The proportion of people still living and continuing ART (retention on ART) over 12, 24 and 60 months reflects the longterm success of the ART programmes and the quality of services. The high survival rates are reported in majority of countries in the South-East Asia region. The analysis of national programme data from six countries on retention of PLHIV on ART indicated that the overall 12month survival rate was high, ranging from 67%-89% (Figure 45). It is observed that the maximum attrition occurs during the first year on treatment and slows down thereafter. The limited information confirms that at 24 months a large number of people were still continuing treatment in majority of countries ranging from 87%-91%. At 60 months about 67%94% of people were still continuing the
prescribed drugs, largely (over 90%) in Myanmar and Thailand. This means that the ART services have to provide the necessary ART drugs without any interruption or without stockouts. In 2011 the low-burden countries such Bangladesh, Maldives and Sri Lanka reported high stock-out rates (83%-100%) despite few facilities that provided ART to PLHIV. However, it appears that there was no interruption to treatment as the patients were prescribed a different treatment combination or drugs were procured from other sources as a temporary measure. Indonesia and Thailand reported very low stock-out rates below 3% while Bhutan, India, Myanmar and Nepal did not have interruption to ARV supply. National governments must pay more attention to more efficient procurement processes such as centralized bulk procurement and efficient supply chain management to avoid stock-outs and minimize costs.
Figure 45: Percentage of adults and children with HIV who are still alive and known to be on treatment 12, 24 and 60 months after initiation of ART, 2011 Bangladesh 100 90 80 70 Percentage retention on ART
Indonesia
Myanmar
Sri Lanka
Thailand
60 50 40 30 20 10 0 % people at the initiation of ART
Source: Global AIDS Response Progress Reports, 2012
% of people still alive after 12 months initiation of ART
% of people still alive after 24 months initiation of ART
% of people still alive after 60 months initiation of ART
46
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
5. Drug resistance to antiretroviral drugs As more people start antiretroviral therapy, concerns are growing about the possible increase in HIV drug resistance. Fortunately the observed level of drug resistance is low in the Region according to the drug resistance surveillance surveys among people newly infected with HIV and among people receiving antiretroviral therapy. However reluctance to use new guidelines and prescription of inappropriate regimens by clinicians especially in private care, limited drug combinations, poor adherence to treatment, drug stockouts, and errors in dispensing, are causes of concern for developing drug resistance. Only three countries (like India, Indonesia and Thailand) have so far conducted initial drug resistance surveys. Use of early warning indicators to detect and minimize events associated with the development of resistance, such as poor adherence, stock-outs, prescription of inappropriate regimens and errors in dispensing are not optimal in the Region. Therefore countries have to design a smarter combination therapy, and set the standard for treatment programmes through rationally designed and simplified treatment options that can help avoid developing of drug resistance.
People with HIV are 20-30 times (Stop TB partnership) more likely to get tuberculosis (TB), which remains one of the leading causes of death among PLHIV despite being preventable and curable. If given early, ART reduces new TB infections and prolong survival of people with HIV.37 The South-East Asia Region has the highest TB burden in the world, and account for 15% of the global HIV/TB burden. Five countries of the Region are among the 22 high TB-burden countries in the world: Bangladesh, India, Indonesia, Myanmar and Thailand. Among these, four countries – India, Indonesia, Myanmar and Thailand – have a high burden of TB and HIV. While Nepal is not among the countries with the highest TB burden, the number living with HIV is still high and there is a threat of TB burden rising in the country.37 Worldwide 8.7 million developed TB in 2011 and 1.1 million (13%) of these were living with HIV/TB In the South-East Asia Region, nearly 5 000 000 people were living with TB and approximately 140 000 of the estimated 3 500 000 people who newly developed TB were HIV-positive in 2011. The estimated rate of new HIV infections among TB patients has dropped from 10 to 7.7 per 100, 000 population (range 6.4-9.1) with the majority being in India, Myanmar, Indonesia, Nepal and Thailand.37 Collaborative HIV/TB activities between national TB and HIV programmes are vital to prevent diagnose and treat TB among PLHIV, and HIV among those with TB to achieve the goal of reducing TB-related deaths. Better collaboration between the TB and HIV programmes in the Region
6. HIV/TB collaboration to reduce AIDS deaths The world had reached the MDG target of halting and reversing the TB epidemic, but HIV/TB coinfection is a challenge for reducing TB deaths by 50% by 2015.
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
47
Figure 46: Coverage of HIV/TB collaborative activities in selected high-burden countries (where data are available) in the South-East Asia Region, 2011 100% 80% Percentage
100%
100% 89%
100%
91%92% 75%
80% 74%
60% 46%
59%
59%59%
42% 32% 36% 20% 15%
40% 20% 0% 1% 1% 3%
6.5% 4%
7.2%
% of notified TB patients tested for HIV
% of tested TB patients HIV positive
% of Identified HIV-positive TB patients started on CPT
% of identified HIV positive - TB patients started on ART
Bangladesh
India
Indonesia
Myanmar
Thailand
SEAR
Source: World Health Organization. Global Tuberculosis Control Report, 2012; GARP reports 2012
aims to reduce the burden of HIV among with HIV/TB coinfection through testing people with TB and burden of TB among and counselling in 2011.(37) the PLHIV. In the South-East Asia Region around The number of TB patients identified 440 000 PLHIV attending HIV care and to be HIV-positive and enrolled on ART treatment services were assessed for has grown steadily in the Region as well TB during their last visit, of whom the as globally. In 2011 globally 40% of TB largest number was in India in 201137. patients had a documented HIV test India and Myanmar have assessed and result in 2011 while on average 32% recorded the TB status of almost all HIV of TB patients knew their HIV status in patients enrolled for HIV care at the last the South East Asia Region. This was an visit. The HIV-associated TB deaths can improvement from 19% in 2009. The be prevented by offering co-trimoxasole levels of testing were especially low in preventive therapy (CPT) to PLHIV. An Indonesia and Myanmar. This means approximate 89% (75%-100%) of PLHIV the two out of three people with TB in were provided with co-trimoxasole the Region are not aware that they are preventive therapy (CPT) to prevent infected with HIV. The stigma associated deaths from TB in SEAR, compared with with HIV prevents people with TB 87% in 2010 and 79% worldwide. Of attending HIV care services for an HIV the 6 countries that provided data in test, and clinicians in TB clinics are still 2011, Bangladesh, India, Indonesia and reluctant to offer HIV testing (known Myanmar had over 90% CPT coverage. as provider-initiated counselling and It is recommended that ART be protesting) to TB patients under their care. About 7.2% of TB patients were detected vided to all people living with HIV who have active TB irrespective of their im-
48
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
mune status (CD4 cell count).38 About 59% of TB patients living with HIV received ART in the Region in 2011, and the ART coverage was slightly up from 57% in 2010. Bangladesh, Myanmar and Sri Lanka reached over 80% ART coverage while the three high-burden countries, India (43%), Indonesia (59%) and Thailand (59%) remained with a low coverage despite intensifying crossreferrals for HIV testing of TB patients. The regional average is better than the global coverage of 48% on CPT and 40% on ART. Nearly 440 000 PLHIV were assessed for TB, which is a small fraction of the large number of estimated PLHIV. About (59%) of those diagnosed with HIV/TB coinfection were provided with ART though it varied widely across the Region, highest being in Myanmar.
effect of IPT prior to introducing the drug as a preventive measure. It is heartening to note that TB/HIV collaborative activities are progressing steadily in the Region. India and Thailand have fully integrated nationwide implementation of TB/HIV collaborative activities while scaling up of the services is being carried out in other countries. Nepal does not have strong TB/HIV collaborative activities yet.
According to the new estimates new TB infections and deaths are declining globally as well as in the Region. The number of HIV-associated TB deaths was 430 000 globally in 2011, it declined by 13% in the last two years due to a sharp increase of people with HIV/ TB coinfection accessing ART (a 45% 37 Myanmar and Sri Lanka are the increase from 2009–2011). only countries that provide PLHIV with The global target of halving TB/HIV daily isoniazid treatment to prevent TB deaths by 2015 can be realized, but infection. However, only 368 people were only if services are scaled up through provided isoniazid prophylaxis treatment concerted and joint efforts to detect HIV/ (IPT) in 2011. India is contemplating a TB coinfected people early and offer study to assess drug toxicity and preventive treatment, for both TB and HIV.
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
49
Chapter 3
Challenges and the way forward
Significant progress has been made in the South-East Asia Region in responding to HIV/AIDS as it is evident from the reduction in new infections in the four high-burden countries. Thailand achieved success in treatment scale-up and in reducing MTCT to less than 3%, high-level strong political commitments were made by Indonesia and Myanmar to prevent mother-to-child transmission; and discriminating laws towards “same sex” were repealed in India and Nepal. However there is more to do, to reach the 2015 targets. The analysis made by UNAIDS (business model) highlights that the Asia-Pacific region is unlikely to reach the MDG targets by 2015. The number living with HIV in the South-East Asia Region is a huge 3.46 million, and new infections are still rising. Three out of five pregnant women are not getting prophylaxis treatment to prevent mother-to-child transmission and 16 000 children are getting infected each year. Not a single country has reached the universal access targets for treatment with ART, and less than half of adults, and 2 out of 3 children who require treatment are getting it. As many as 230 000 adults and children die of HIV/AIDS each year without access to life-saving ART. The resurgence of the epidemic
in the Region is a major concern as unacceptably high HIV transmission still occurs among key populations. Migrants, access to prevention and care services is an issue in countries with cross-border migration. Barriers to access information and services due to age limits make young people more vulnerable to HIV. Overcoming these issues is a challenge with declining donor funds and limited national funds. Achieving prevention goals requires systematically implementing a comprehensive package of basic services, including greater efforts in reaching key populations at higher risk of HIV infection. Treatment services need to be made available and accessible to all people with equity, including women and children, to accomplish the vision of zero deaths by 2015 and beyond. New directions and opportunities continue to emerge with regard to achieving the MDG goals. These include more efficient and effective treatment and prevention approaches, technologies, contribution by civil society to service delivery, decentralization and integration of services and synergizing health systems.
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1. Challenges The Key challenges in achieving universal access to HIV prevention, care and treatment services include (i) continuing stigma and discrimination against people living with HIV and key affected populations; (ii) limited capacity of health systems, including lack of trained human resources; inadequate supplies of equipment, drugs and poor logistics; limited laboratory capacity; weak monitoring systems; (iii) ensuring a continuing focus on and political commitment to HIV; and (iv) declining finances in the face of the global economic crisis and competing health priorities.
among health-care workers and ensuring health-care worker rights. Laws and regulations are still an obstacle for KAP in accessing health care. Criminalization of people who use drugs, sex workers and men who have sex with men are most commonly seen. All countries have identified at least two punitive laws that block the response, while arrest and detaining sex workers, and compulsory detention of drug users are still common. However there are positive moves that, in India, Indonesia and Thailand have put in place programmes to ensure that law enforcement does not act as an obstacle to HIV treatment and prevention. India and Nepal have recognized same-sex activity between two consenting adults as natural and a human right. The Supreme Court direction for government to issue, amend or scrap all discriminatory laws against lesbians, gays, bisexuals, transgenders and to introduce same-sex marriage law in Nepal has led to less violence and supportive attitudes on the part of media, and political and social groups. Providing treatment with equity is a challenge, especially for the key affected populations, people with HIV living in rural areas or in conflict zones, and national and non-national migrants.
Continuing stigma and discrimination Stigma and discrimination towards people living with HIV and key populations, criminalization of sexual and drug taking behaviours, gender inequity and violence against women and girls are barriers to HIV prevention, but still continue to occur in the Region. Stigma in communities, health-care settings, and in law enforcement were identified as obstacles to service access and uptake. In Myanmar, for example, about 18% people living with HIV were verbally insulted and 10% were physically assaulted as result of their HIV status, according to surveys collected through the People Living with HIV Stigma Index. In Nepal, about 12% people living with HIV reported losing a job or income on the basis of their HIV status. In Bangladesh about 50% of women reported violence by their intimate partners.
Limited capacity of health systems
Scaling-up of treatment and prevention demands a large health workforce of skilled staff. National governments are already overburdened with limited funds, poor logistics, and untrained Stigma and discrimination of PLHIV staff, which results in poor programme at public health-care institutions should coverage. Linkages between prevention be overcome by increasing awareness and care services are highly inadequate
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to provide a continuum of care to those in need. Moreover, frequent changes in leadership, either at the political or policy level, affect not only implementation of the national response but also planning, prioritizing and monitoring the response due to poor managerial skills. While health system strengthening is acknowledged by governments as an area that needs attention, few countries have taken adequate actions to address the gaps and secure funds. Recruiting skilled staff, continuing training and retaining those on the job are big challenges in the public sector. Task-shifting, task-sharing and community involvement in service delivery are some activities that have been successfully carried out by some countries like India to overcome the challenges.
countries in the Region continue to rely significantly on external funding including the Global Fund for HIV/AIDS for scaling up the response or even providing essential services. This is not sustainable especially with the new funding model of the Global Fund, which will likely result in reduced funding in many countries.
Antiretroviral drugs
Antiretroviral drugs (ARVs) continue to be unaffordable for governments although drug prices have dropped considerably over the years. With the initiation of ART at a CD4 level of 350, the treatment needs rise annually by nearly 1 million. The provision of antiretroviral drugs to a large number of ART-eligible persons is a big challenge to governments. As stated earlier with the new treatment approaches in 2012—treatment as Sustainable financing prevention (TasP)* and Treatment Plus In a scenario of declining donor funds, (Treatment+)** approach, the ART sustaining the achievements made needs will further increase in the Region. over the years is a big challenge for In addition to first-line drugs, more governments. Investing for AIDS is a shared responsibility of national people have moved on to second-line governments as well as development drugs that are more costly for governpartners who need to expand services to ments. Introducing new technology and achieve the Millennium Development new point-of-care diagnostics for early Goals (MDGs). With the support of diagnosis of HIV, assessing CD4 counts PEPFAR, the Global Fund and domestic and the viral load to initiate treatment programmes, Member States in the early, and monitoring the effectiveness Region spent over U S $ 1 billion for of treatment will cost governments a substantial amount. Reduction in prices AIDS response in 2011. of other supplies such as drugs for the Three countries, Indonesia, Sri Lanka treatment of opportunistic infections, and Thailand financed over 40% of their and diagnostics, etc. are also needed to AIDS response from domestic resources reduce the burden as more people are in 2011.The Government of India plans put on ART. to contribute at least 90% of the funding The Trade-Related Intellectual for Phase IV of its National AIDS Control Programme in 2012. Thailand spent over Property Rights (TRIPS) agreement and 78% domestic funds for AIDS response the WHO drug prequalification schemes mainly for care and treatment. Many have controlled the prices of generic drugs to a certain extent, but much more needs to be done. HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012 53
2. HIV as a chronic disease and ageing With HIV programmes expanding rapidly, people with HIV (PLHIV) are living longer, and and are developing non-HIV-related chronic conditions similar to the rest of the population. The PLHIV often have high rates of noncommunicable diseases. Providing chronic care for people living with HIV over their lifetimes is now an additional burden for countries.
for eliminating mother-to-child transmission of HIV, and preserving the health of women and children. (3) Enabling people to know their HIV status to avail treatment and care services through decentralization of HIV testing and counselling services and use of innovative models of testing and effective linkages among testing, counselling and treatment services. (4) Improving access to and quality of treatment, through implementation of the five pillars of Treatment 2.0 that use combination of efforts to bring down treatment costs, make treatment regimens simpler and smarter, reduce the burden on health systems and improve the quality of life for people living with HIV. There is also the need for innovation in service delivery through decentralization and its integration into primary health care and relevant systems, and for community mobilization. (5) Providing support for treatment adherence and ensuring close monitoring to “slow” the development of HIV drug resistance. (6) Continuing advocacy to reduce the prices of antiretroviral drugs through the use of international treaties and instruments, such as flexibilities in the Trade-related Aspects of International Property Rights (TRIPs). (7) Supporting the strengthening of health systems to increase the capacity for implementing and scaling up HIV interventions.
3. The way forward Given the setting of a concentrated epidemic and the above-listed challenges, critical priorities for countries and development partners in the coming years are as follows. (1) Designing of structural interventions to reduce the stigma and discrimination in community and health-care settings, especially for key populations at higher risk; and address legal barriers by repealing discriminative laws that hinder access to prevention interventions. Innovative approaches need to be considered for reducing new infections such as strategic use of ARV- prioritized scale-up of “treatment as prevention” for key populations irrespective of immune status. (2) Increasing the coverage of, and access to HIV prevention, treatment and care services for women and children. This can be done through integrated and linked responses with sexual and reproductive, and maternal and child health services
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Chapter 4
The MDGs beyond 2015
The progress made so far clearly shows that countries are unlikely to reach the 2015 MDG 6 targets. Thus sustained action, policies and programmes backed by high-level commitment and adequate resources (financial and human) are critical to achieve the MDG 6 targets, beyond 2015. Investing in new initiatives such as strategic use of ARV and treatment 6.0 would help to prioritize and scale up HIV interventions, efficiently and effectively. As for every person newly put on treatment three people are getting infected, treatment and prevention efforts, funding and commitments should be balanced. The WHO Global Health Sector Strategy on HIV/AIDS 20112015, and the Regional Health Sector Strategy on HIV 2011-2015 will guide countries in planning their national strategies to align with local situations with maximum investment. Countries need to move towards sustainable financing of the AIDS response through domestic sources while advocating for external funds. Investment cases that demonstrate returns on investing in
AIDS programmes is critical to sustain the response and for post-2015 discussions. AIDS response has moved away from a life-threatening illness to a chronic disease, and chronic care of PLHIV have to be tackled within the existing systems with coordinated efforts and by managing the noncommunicable diseases. Health and sustainable development: The development agenda post 2015 is being debated and health is seen as a contributor to achieve sustainable development goals, as a potential beneficiary and as a way of measuring the progress of sustainable development policy. The social determinants of health such as equity, poverty and human rights issues are interlinked with AIDS response. In setting new development goals and targets one needs to consider the challenge of framing an overarching goal and target that is relevant to all countries, that acknowledges health as a global concern, that appeals to both politicians and the public, and is measurable.
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References 1. United Nations. The Millenium Development Goal global report 2012. New York: UN, 2012 - http://mdgs.un.org/ unsd/mdg/Resources/Static/Products/Progress2012/ English2012.pdf - accessed 08 April 2013. 2. World Health Organization. Global health sector strategy, on HIV/ AIDS.2011-2015. Geneva: WHO, 2011 - http://www.who.int./hiv/pub/hiv_strategy/en/ - accessed 08 April 2013. 3. World Health Organization, Regional Office for South East Asia. Regional health sector strategy on HIV, 20112015. New Delhi: WHO SEARO, 2011. 4. Joint United Nations Programme on HIV/AIDS. HIV in Asia and Pacific: getting to zero. Geneva: UNAIDS. 2011. 5. World Health Organization. Antiretroviral treatment as prevention (TASP) of HIV and TB Programmatic update. Geneva: WHO, 2012 - http://www.who.int/hiv/ pub/mtct/programmatic_update_tasp/en/ - accessed 09 April 2013. 6. Joint United Nations Programme on HIV/AIDS. Report on the global AIDS epidemic. Geneva: UNAIDS, 2012 – http://www.who.int/hiv/pub/global_report2010/en/ accessed 09 April 2013. 7. Joint United Nations Programme on HIV/AIDS. Together we will end AIDS. Geneva: UNAIDS, 2012 - http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2012/JC2296_UNAIDS_TogetherReport_2012_en.pdf - accessed 09 April 2013. 8. Joint United Nations Programme on HIV/AIDS. UNAIDS world AIDS day report results 2012. Geneva: UNAIDS, 2012 http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2012/gr2012/JC243 accessed 09 April 2013. 9. National Institute of Medical Statistics. Technical report India HIV estimates. New Delhi: National AIDS control Organization, 2012. HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
57
10. Independent Commissions on AIDS in Asia. Redefining AIDS in Asia: crafting an effective response. New Delhi: Oxford University Press, 2008. 11. The hidden truth Nepal: a study of HIV vulnerability, risk factors and prevalence among the wives and intimate partners of men who inject drugs Kathmandu, NEPAL. June, 2011. Supported by Ministry of Foreign Affairs, the Netherlands Mainline Foundation, Netherlands Nai Zindagi, Pakistan Youth Vision, Nepal. http://www.aidsdatahub.org/dmdocuments/The_hidden_truth.pdf - accessed 11 April 2013. 12. Joint United Nations Programme on HIV/AIDS. Global report on the AIDS epidemic. Geneva: UNAIDS, 2010. 13. Indonesian National AIDS Commission. Republic of Indonesia country report on the follow up to the declaration of commitment on HIV/AIDS (UNGASS): reporting period 2010-2011. Indonesian National AIDS Commission 2012. 14. National AIDS control Organization. HIV Sentinel Surveillance 2010 -11: a technical brief. New Delhi: Department of AIDS Control, 2012. 15. India, Ministry of Public health. HIV sentinel surveillance 2010. Bangkok: Bureau of Epidemiology, 2010. 16. Thailand, Ministry of Public Health. Global AIDS response progress report. Bangkok: Bureau of Epidemiology, 2011. 17. Myanmar, Ministry of Health. Global AIDS response progress report. Yangon: National AIDS Programme, 2011. 18. Indonesia, Ministry of health. Global AIDS response progress report. Jakarta: Indonesian National AIDS Commission 2011. 19. Nepal, Ministry of Health and Population. Global AIDS response progress report. Kathmandu: National Centre for AIDS and Control, 2011., 20. Sri Lanka, Ministry of Health. Global AIDS response progress report. Colombo: National STD/AIDS Control Programme, 2011. 21. Bangladesh, Ministry of Health. Global AIDS response progress report. Dhaka: National AIDS/STD Programme, 2011. 22. Republic of Maldives. Global AIDS response progress report. Male: National AIDS Programme, 2011. 23. Indonesia, Ministry of Health. Integrated biological and behavioural surveillance among MARP . Jakarta: National AIDS commission, 2011. 24. Royal Government of Bhutan, Ministry of Health. Global AIDS response progress report. Thimphu: MOH, 2011. 25. India, Ministry of Health and Family Welfare. Integrated biological and behavioural surveillance 2009 India in four states. New Delhi, MOHFW, 2009. 26 Timor-Leste, Ministry of Health. Global AIDS response progress report. Deli: MOH, 2011. 58
HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012
27. National AIDS Control Organization. Annual progress report 2012. New Delhi: Department of AIDS Control, 2012. 28. World health Organaization. WHO/UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment, and care for injecting drug users. Geneva: WHO, 2009 - http://www.unodc.org/documents/hiv-aids/idu_target_setting_guide.pdf - accessed 11 April 2013. 29. UNAIDS. Integrated biological and behavioural surveillance (IBBS) survey among Injecting Drug Users (IDUs) in Pokhara Valley, Nepal - Round V - 2011. USAID, ASHA - http://ns4439.ukserverhosting.net/en/bhutanreference-library/item/24022-integrated-biological-and-behavioural-surveillance-ibbs-survey-among-injecting-drug-users-idus-in-pokhara-valleynepal-round-v-2011-usaid-asha-2011 - accessed 11 April 2013. 30. UNAIDS. Elimination of new HIV paediatric infection and congenital syphilis in Asia Pacific 2011-2015: conceptual framework, monitoring and evaluation guide. UNAIDS - - accessed 11 April 2013. 31. Economic and Social Commission for Asia and Asia Pacific. Asia-Pacific regional MDG report 2011/12. ESCAP - http://www.unescap.org/pdd/calendar/CSN-MDG-NewDelhi-Nov-2011/MDG-Report2011-12.pdf - accessed 11 April 2013. 32. World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: towards universal access, recommendations for a public health approach (2006 revision). WHO, 2006 - http://www.who.int/hiv/pub/mtct/antiretroviral/en/ - accessed 11 April 2013. 33. World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: recommendations for a public health approach (2010 version). Geneva: WHO, 2010 - http://www. who.int/hiv/pub/mtct/antiretroviral2010/en/index.html - accessed 11 April 2013. 34. World Health Organization. World health statistics 2012. Geneva: WHO, 2012. http://www.who.int/gho/publications/world_health_statistics/EN_ WHS2012_Part1.pdf - accessed 11 April 2013. 35. World Health Organization. Use of antiretroviral drugs for treating regnant women and preventing HIV infection in infants, programmatic update. Geneva: WHO, 2012 - http://whqlibdoc.who.int/hq/2012/WHO_HIV_2012 - accessed 11 April 2013. 36. World Health Organization. Antiretroviral therapy for HIV infection in adults and adolescents: recommendations for a public health approach. 2010 revision. Geneva: WHO, 2010 - http://whqlibdoc.who.int/ publications/2010/9789241599764_eng.pdf - accessed 11 April 2013. 37. World Health Organization. Global tuberculosis report 2012. Geneva: WHO, 2012 - http://www.who.int/tb/publications/global_report/en/ - accessed 11 April 2013. HIV/AIDS in the South-East Asia Region: Progress towards MDG 6A, 2012 59
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 States. Data are complemented by research findings as appropriate. The report highlights the progress made in prevention and control of HIV in the Region with an overview of strategic information systems and lists the challenges and future priorities. The information in this report would be useful to a wide audience including HIV programme managers in the Region and around the world, policy-makers and other stakeholders as well as researchers, in the field of HIV/AIDS.
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