Winter, an added health hazard in Afghan camps.

WHO News Sex and drugs fuel simmering AIDS crisis in Asia and Pacific Countries in the Asia-Pacific region are being urged to combat the social exclusion of sex workers and of injecting drug users in order to prevent an explosive epidemic of HIV/ AIDS in a region which accounts for 60% of the world’s population. A new report by WHO, HIV/AIDS in Asia and the Pacific Region, says the epidemic is being driven mainly by sex work and drug abuse — both of which are illegal and clandestine activities in just about all the countries throughout the region. But efforts to focus prevention on these groups are failing, the report says, because those spreading the infection are largely out of reach on the fringes of society or on the wrong side of the law. Dr Neff Walker, an epidemiologist with UNAIDS, believes there is an urgent need to ensure that sex workers and injecting drug users have access to HIV prevention pro- grammes. ‘‘We have to learn how to build bridges so that we can work with these populations,’’ he told the Bulletin. The report, issued in August, says HIV prevalence rates remain low in most Asia- Pacific countries — due in part to social norms that discourage women from both premarital and extramarital sex. But it warns that there are now ‘‘major public health concerns’’ about the future growth potential of HIV/AIDS in the world’s most populous region. In Nepal, north-east India and Delhi, and in some provinces of southern China, at least 50% of injecting drug users, the report says, are now HIV positive, vs ‘‘a negligible number about a decade ago’’, according to Walker. Similar rates of infec- tion have been reported among sex workers in some areas of Cambodia, Myanmar, and Thailand, and in some cities in India. In Asia, most commercial sex takes place without condoms, according to WHO’s Western Pacific regional office. And needle exchange programmes are difficult to implement as long as drug-taking remains illegal. The report — produced jointly by WHO’s South-East Asia and Western Pacific regional offices — urges countries to follow the example of Thailand and Cambodia in implementing a 100% condom policy throughout the sex industry. In Thailand, where prostitution remains illegal, this has led to a dramatic fall in infection rates among sex workers — from 33% in 1994 to 20% by 2000. WHO also calls on countries to ‘‘aggressively implement’’ HIV prevention programmes for injecting drug users, including the provision of clean needles to ensure safe injection practices. Another report, Sex work in Asia, soon to be launched also by WHO’s South-East Asia and Western Pacific regional offices, says changing social and economic trends — including increased labour mobility, eco- nomic hardship, migration, and changing sexual attitudes — have led to an increase in prostitution in many countries throughout the region. In some countries, commercial sex is already big business: in Indonesia, Malaysia, the Philippines, and Thailand, the sex industry now accounts for an estimated 2%–14% of gross domestic product (GDP). To make matters worse, the report says, prostitution is now spreading beyond the traditional ‘‘red light’’ areas to suburbs, highways, and international borders, where it is less visible — posing additional challenges for HIV prevention efforts. The report, due to be published in October, was presented in August at a meeting in Hanoi, Viet Nam, on condom promotion in Asia. It says most sex workers are unable to insist on condom use, especially if they are young, victims of trafficking, or migrants. It is estimated that over 500 000 people in the Asia-Pacific region died from AIDS- related illnesses in 2000— 17% of the global annual number of deaths from AIDS — and that the annual death toll will rise in the coming years to about 800 000 in the region. Most of the deaths are expected to occur in China (see Box on next page), India Myanmar, and Thailand. An estimated 6 million people in the Asia-Pacific region are living with HIV/AIDS. n Sheila Davey, Geneva, Switzerland On-the-spot report Winter, an added health hazard in Afghan camps Humanitarian workers and displaced people are racing against time to build about 6000 mud brick shelters here in the Maslakh camp for displaced persons, which is just outside Herat, a city of 800 000 inhabitants in western Afghanistan. Across the country, others are bracing themselves for the possible consequences of the tragic events in the United States and the attack on Mr Ahmed Shah Massoud, military leader of the anti-Taliban alliance. At this writing (12 September), they have less than eight weeks before winter brings snow and freezing winds to rake the valley. Another 4000 shacks need repairs, and new displaced people continue to arrive at a rate of Sex workers — as in this Phnom Penh, Cambodia, brothel — are central to Asia’s growing HIV/AIDS crisis. U N A ID S/ Sh eh za d N oo ra ni 1000 # World Health Organization 2001 Bulletin of the World Health Organization, 2001, 79 (10) around 300 a day — more than 8500 in August. At the same time, all international UN staff, and many NGO workers, are being evacuated. Even if construction goals are met, winter is going to be tough for the thousands that have come to this camp to flee drought and conflict in their home provinces. Take the eight members of the Saadat family, who arrived inMaslakh fiveweeks ago, having lost their harvest for the third year in a row. In the warm nights, half the family members sleep outside their 4-square-metre room, but winter will see them all crammed inside, day and night, along with the fire smoke, dust and any infections that happen along. Health workers have been fighting high levels of diarrhoea and dehydration all summer. The Herat hospital paediatric ward is full of cholera patients from outlying districts. So far there have only been two confirmed cases of cholera in the camp itself, but the emergency health task force coordi- nated by WHO is on high alert. ‘‘In these kinds of crowded conditions, the attack rate can be as high as 5%. That would mean about 7500 cases inMaslakh,’’ says Dr Lindel Cherry, medical co-ordinator for Me´decins Sans Frontie`res. But with winter coming, attention is turning to respiratory tract infections, especially in children, many of whom are undernourished. In such overcrowded and impoverished conditions what starts as a cold can become a killer, saysDrMojibullah Wahdati, WHO officer for Herat. There is also a risk of tuberculosis, particularly among women, who are often more confined. Previous WHO studies in camps for displaced persons in Afghanistan have shown that as many as 3% of the population will contract tuberculosis every year. Last winter, a wave of unusually cold weather saw temperatures fall to -25 oC and more than 150 people died in one week, says Wahdati. ‘‘We need to be able to support the [displaced persons’] health clinics in treating patients quickly and properly this winter, and be ready to help with fuel supplies and other materials to protect against the cold,’’ says Wahdati. But funds are desperately short. WHO’s appeal for donations for health activities in Afghanistan this year has garnered less than 10% of needed funds. Humanitarian organizations are also trying to slow the accumulation of people in the Herat camps by providing aid in their places of origin. But they expect another substantial influx of displaced persons here in Herat just before the snows close the road. ‘‘They will try and stay in their homes, but at the last minute if they see they do not have enough food, they will come here. We need to be prepared,’’ says Wahdati. n Hilary Bower,WHO, Geneva, Switzerland China openly anticipates surge in HIV/AIDS China, home to a fifth of the world’s population, could be on the brink of a huge HIV/AIDS epidemic. The government says about 600 000 people were living with HIV/AIDS by the end of 2000 and numbers of reported HIV infections during the first half of 2001 were 67% higher than for the same period in 2000. China’s National Center for AIDS Prevention and Control (NCAIDS) has reportedly warned that, on current trends, as many as 10 million people could be infected by 2010. HIV infection among injecting drug users is on the increase and spreading in China, according to a new WHO report, HIV/AIDS in Asia and the Pacific Region (see main text), and now accounts for over 70% of all HIV infections so far reported in China. Most users report regular sharing of needles. Alarm bells have also been triggered by Chinese health ministry data suggesting a dramatic upsurge in reported cases of sexually transmitted infections (STIs) — up from 5800 in 1985 to over 836 000 in 1999— and by the high prevalence, reported in the WHO report, of STIs among sex workers and other high-risk groups. TheWHO report says that a recent, as yet unpublished, study commissioned by WHO’s Western Pacific regional office, revealed that 86% of female sex workers in Kunming, Yunnan province, and 17% of truck drivers in Tongling, Anhui province, were infected with at least one STI. A second WHO report, Sex Work in Asia, says there has been a ‘‘huge resurgence’’ of sex work in China (and Viet Nam) — fuelled by market- oriented policies and bymigration. However, condom use is believed to be low. Chinese surveillance data show that about one in ten sex workers report consistent condom use, while almost half say they never use condoms. Although only 0.5% of HIV infections have been linked to blood transfusions so far, the Chinese health ministry said in August that an estimated 30 000–50 000 cases have been caused by illegal plasma collection. According to press statements made by Chinese health officials, blood stations in Henan province pooled the blood of paid donors—mostly poor farmers— to obtain plasma, and then transfused the remaining depleted blood back to the individual sellers, along with HIV in many cases. Meanwhile, according to recent press reports, unsafe injection practices and excessive use of injections are being blamed for the spread of hepatitis B and possible transmission of HIV. In August, the Chinese government announced a US$ 11 million-a-year programme to improve blood safety and a US$ 12 million-a-year education programme to combat the spread of the virus through intravenous drug use and blood transfusions. SD An Afghan doctor tells an elderly resident of the Maslakh displaced persons’ camp, near the town of Herat, how to prepare for the coming winter. W H O /H ila ry Bo w er 1001Bulletin of the World Health Organization, 2001, 79 (10) WHO News