A comprehensive study of the AIDS epidemic in Asian countries, what drives it, who is most at risk, how intervention programmes must be designed and resources allocated.

Redefining AIDS in Asia: Crafting an effective response, a report of the Commission on AIDS in Asia, released in March 2008, was drafted by a commission headed by C Rangarajan, Chair, Economic Advisory Council to the Prime Minister of India. The Commission’s mandate was to analyse the developmental consequences of the AIDS epidemic in the region. If Asia is to achieve the Millennium Development Goal of reversing the spread of HIV by 2015, it requires a concerted plan of action.

According to UNAIDS and WHO estimates, 4.9 million (range 3.7 million-6.7 million) people were living with HIV in Asia in 2007. Some 440,000 (210,000-1.0 million) became newly infected and 300,000 (250,000-470,000) died from AIDS-related illnesses in that year. AIDS currently accounts for more deaths annually among 15-44-year-old adults than do tuberculosis and other diseases.

The report states that epidemics across countries in Asia are similar in that they are centred around: unprotected paid sex, the sharing of contaminated needles and syringes by injecting drug users, and unprotected sex between men. It recommends that interventions be evaluated for their impact (on HIV prevention and transmission) and cost. High-impact interventions, regardless of their cost, should be promoted as a priority. Additional resources should be mobilised for low-impact interventions such as sexually transmitted infections-related programmes and condom promotion for the general population; measures to strengthen health systems, social and health sector infrastructure; and women’s empowerment programmes.

Driving forces and groups most at risk

Men who buy sex are the single most powerful driving force in Asia’s HIV epidemics. Since most of these men are married or will get married, millions of ‘low-risk’ women who only have sex with their husbands are exposed to HIV. However, effective means of preventing HIV infections in the female partners of these men have yet to be developed.

Up to 10 million Asian women sell sex and at least 75 million men buy it regularly. Male-male sex and drug injecting add another 20 million men at high risk of HIV infection. A portion of those men also pass HIV on to women with whom they regularly have sex, so several million more women are also at risk.

Because relatively few women in Asia have sex with more than one partner, HIV epidemics in Asia are unlikely to sustain themselves in the general population independently of commercial sex, drug injecting, and sex between men. Prevention efforts to reduce HIV transmission in these most-at-risk populations will bring the epidemics under control.

In Asia, men who buy sex from women far outnumber drug injectors and men who have sex with men. High client turnover can create a critical mass of infections sparking the rapid spread of HIV within the sex trade. Programmes for increasing condom use with sex workers will do more than any other intervention to control HIV infections in Asia.

Drug injectors are another important at-risk group. Countries with relatively low prevalence among this group should focus on reducing drug injecting, promoting the use of sterile equipment, and encouraging safe sex between drug users and their sexual partners. Unfortunately, few such programmes are found in Asian countries.

Sex between men accounts for an increasing share of new infections in Asia. Because of social taboos and discrimination, many men who have sex with men may be married. Many have high numbers of male partners and low condom use. This has led to a rapid rise in HIV prevalence among this group.

The proportion of women with HIV in Asia has risen from 19 per cent in 2000 to 24 per cent in 2007. Most of them got infected through sex with partners who were infected during paid sex or through injecting drugs. The most sensible way to prevent HIV infection among women is to prevent their partners from becoming infected. But there are few attempts to provide these programmes.

The Asian epidemics

The Commission uses the Asian Epidemic Model with country-specific data on the size and behaviours of the groups most at risk of infection to develop country-specific models and focus prevention efforts. It notes that no country in Asia has experienced the spread of HIV as a ‘generalised’ epidemic where it is thought necessary to target the entire sexually active population with prevention efforts. Nowhere in Asia has HIV spread independently of drug injecting, sex between men, and/or commercial sex. International classifications of ‘low-level’, ‘concentrated’, and ‘generalised’ epidemics do not express the dynamics of Asia’s epidemics. The report therefore recommends developing a new classification according to predominant risk behaviours and their relative contribution to new infections. Till then, the Commission has presented four epidemic scenarios for Asia: latent, expanding, maturing, and declining epidemics.

Impact of HIV

A great deal of the epidemic’s damage is concentrated in poor families with no cushion against the consequences of AIDS-related illness, or the support of social schemes. Children abandon education to care for parents; wives caring for HIV-infected husbands are ostracised, and widows are forced to leave their homes and land. Women and children in Asia bear a disproportionate impact of the epidemic. By 2015, AIDS will have caused a further 6 million households in Asia to fall below the poverty line at the current rate of response. Every death from AIDS represents the loss of income of almost USD 5000— the equivalent of nearly 14 years of income for people earning USD 1 per day at current prices.

Resources

An analysis of current resources available for Asia shows that only USD 1.2 billion of the USD 6.4 billion needed every year is available. Despite the increase in external funding to countries for fighting their HIV epidemics, domestic spending in Asia has increased at a slower rate than in other regions. On the other hand, external funding can have a negative impact on national AIDS programmes as external funders may target areas outside the countries’ own priorities.

The Commission classifies HIV interventions into four categories, according to their effectiveness and cost: high-cost/high-impact, low-cost/high-impact, low-cost/low-impact, high-cost/low-impact. Governments should prioritise programmes with a high impact, whether they are low-cost or high-cost. The Commission recommends a standard of expenditure for a priority response in Asia: from USD 0.50 per capita to USD 1.00 per capita depending upon the stage of the epidemic in each country. The Commission concludes that USD 1 investment in appropriate prevention can save up to USD 8 in treatment costs for expanding epidemic countries.

Interventions

The Commission states that interventions for preventing HIV among sex workers and their clients can prevent 7,000 times more new infections than can universal precautions—for the same amount of money spent. Other programmes that are known to be highly effective, and should be prioritised, are the prevention of mother-to-child transmission, focused counselling and testing, and antiretroviral treatment programmes.

The Commission proposes a focused prevention package that is affordable for most countries in Asia. Between 2008 and 2020, this package is expected to reduce cumulative infections by five million, the number of people living with HIV in 2020 by 3.1 million, and the number of AIDS-related deaths by 40 per cent.

Recommendations

The Commission has the following recommendations:

Leadership

• AIDS programmes should be implemented through efficient governance structures backed by political leadership and the business community and with community involvement.
• National AIDS Commissions should focus on policy-making, coordination, monitoring, and evaluation, separate from the technical role of the national programme.
• Country Coordinating Mechanisms under the Global Fund have an important role in government and civil society organisations’ prevention and treatment programmes. 
• Countries should strengthen their epidemiological and behavioural information systems and HIV policies and programmes must be guided by country-owned HIV and AIDS estimations and projections.

Environment

• Governments should remove legislative, policy, and other barriers to strengthening access to services for groups most at risk. Donors must remove conditionalities preventing the support of organisations working with sex worker organisations.
• Governments should repeal laws enshrining HIV-related discrimination, especially those that regulate the labour market, the workplace, access to insurance, healthcare, educational and social services, and inheritance rights. Watchdog bodies should monitor HIV-related discrimination in healthcare settings, in workplaces and educational institutions, and in the wider society.
• Governments should ensure that correctional institutions provide prisoners with HIV information and essential prevention services.
• People living with HIV should be supported in their efforts to organise themselves as HIV advocates, educators and activists.

Resources

1. If countries committed resources of USD 0.50–USD 1.00 per capita, HIV epidemics in Asia could be reversed, 40 per cent of AIDS-related deaths could be averted (through the provision of antiretroviral therapy), and 80 per cent of women and orphans could be provided with social security protection and livelihood support.
2. Additional resources should be mobilised for activities such as: prevention and treatment of sexually transmitted infections, and condom promotion and provision for the general population; health systems strengthening measures, such as blood safety and universal precaution systems; sex education for school students; strengthening social and health sector infrastructure, and women’s empowerment programmes.
3. Governments should reduce dependency on external financial support and invest more in their national HIV response.

Interventions

1. Interventions with the quickest, largest, and most sustainable effect must be given priority. High-impact interventions, such as prevention focused on populations at risk and antiretroviral treatment should constitute the core of the HIV response.
2. Governments must ensure free antiretroviral therapy for all who need it and a comprehensive package of first and second-line antiretroviral drugs should be integrated into the general health care systems.
3. Treatment and impact mitigation programmes should be integrated into existing national social security systems.
4. Impact mitigation programmes should have at least four components: income support programmes for affected households; support for families caring for children orphaned by AIDS; care for AIDS-affected people incorporated into social security schemes; and laws to guarantee inheritance rights for both women and men.

Community involvement

1. Community and civil society organisations should be involved at all stages of policy, programme design, implementation, monitoring, and evaluation.
2. Regional inter-governmental organisations, like ASEAN and SAARC, should assume a stronger role in negotiations on antiretroviral drug prices, and regular monitoring of the AIDS response in member countries in high-level political forums.
3. The UN should continue to advocate for greater financial and political commitment from countries, based on its comparative advantage in this area.
4. UNAIDS should support a strategy for Asia’s HIV epidemics and responses, and ensure that UN agencies provide support to realise this strategy at country and regional levels.

Strategies and programme implementation
Prevention

1. Prevention programmes must focus on interventions that have been shown to work and reduce the maximum number of new HIV infections. These include harm-reduction programmes for drug injectors and promoting condom use during paid sex including with men who buy sex, and providing men who have sex with men, condoms, water-based lubricants and access to services for sexually transmitted infections, and supporting local advocacy. More research is needed on how to improve interventions to protect wives of men who buy sex, inject drugs or have sex with other men.
2. Programmes accentuating AIDS-related stigma should be avoided. These include ‘crack-downs’ on red-light areas and arrest of sex workers, large-scale arrests of young drug users under the ‘war on drugs’ programmes, and mandatory testing for HIV.
3. Prevention programmes such as school sex education, HIV media campaigns and post-exposure prophylaxis for healthcare workers exposed to infection must be incorporated into the relevant sectoral programmes to ensure long-term sustainability.

Treatment and care
Governments must reduce the cost of antiretroviral drugs through strategies such as pooled procurement, compulsory licensing and parallel importation. They must make drugs available in sufficient quantities and ensure equitable access to treatment by subsidising “hidden costs”, and maintain treatment adherence through support systems or groups. Governments should also strengthen the linkages between HIV and tuberculosis diagnosis and treatment to boost service delivery under both programmes.

Impact mitigation
Impact mitigation programmes must serve the needs of affected households through income-generation and livelihood security for affected women, and cash transfers and education subsidies for foster families to children orphaned by AIDS. Governments should review insurance regulations so that people infected with HIV have equitable access to life and health insurance coverage.

Organisational issues

1. A unit within the national AIDS infrastructure should guide, monitor and evaluate responses, collating data, assessing their quality, building epidemiological models, and using them to determine the cost-effectiveness of various options.
2. Funding flows to community projects must be streamlined through public-private partnerships.
3. Capacity building should be done of organisations representing most-at-risk populations and people living with HIV.
4. Service delivery mechanisms should include both focused and integrated approaches: For example, prevention services for most-at-risk populations should be entrusted to community-based and other civil society organisations, with support from government or other institutions. Programmes for preventing mother-to- child transmission of HIV, HIV counselling, testing, and treatment and care should be integrated into healthcare systems.

A critique of the report is available at: http://infochangeindia.org/hivonline/debates_24.php

The complete report is available at:
http://data.unaids.org/pub/Report/2008/20080326_report_commission_aids_en.pdf

InfoChange News & Features, July 2008