Can Asian Countries halt and reverse the AIDS epidemic by 2015?

JVR Prasada Rao

Special Advisor to UNAIDS Executive Director International Epidemiological Association Meeting, Colombo May 24, 2010 May 24, 2010

There is an increased understanding of the Asian epidemics

   The principal modes of HIV transmission   HIV is generally concentrated among certain populations. Infections appear first among IDUs, SWs and Clients, and MSM, but then it spreads to wives and children The driving forces of Asian epidemics  sharing of needles during Injecting Drug Use – kick-starts and accelerates the epidemic   unprotected Commercial sex – gives it range and power Sexual networking among Asian men markedly higher than women Projections into the future based on various scenarios UNAIDS May 24, 2010 2

The HIV epidemic in Asia appears to be slowing down overall

UNAIDS May 24, 2010

Adults and children living with HIV 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 1988 1990 1992 1994 1996 1998 2000 Year 2002 2004 2006 2008 2010 Adults & Children S & SE Asia Adults & Children East Asia Source: 2009 AIDS Epidemic Update. UNAIDS, WHO, 2009

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However, new infections in different countries and their sub-regions differ

Indonesia Cambodia

200,000 150,000 100,000 50,000 0 19 85 75,000 50,000 25,000 0 1985 400,000 19 90 19 95 300,000 20 00

Myanmar

200,000 20 05 1990 100,000 20 10 20 15 20 20 1995 0 2000 20 05 2005 2010 20 06 2015 Clients Lo-risk male 2020 20 07 Sex workers Lo-risk female 20,000 15,000 10,000 5,000 0 19 85 19 90 19 95 20 00 20 05 20 10 20 15 ..based on how effectively prevention targets new infections 20 08 MSM Children 20 09 IDU 20 10 20 20 UNAIDS May 24, 2010

Source: Commission on AIDS in Asia 2008

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For the first time the CAA estimated the large numbers of people at risk of HIV infection in Asia

Asian Population : 3.3 billion 10 million Women sell sex

75 million

4 million Men who inject drugs Men in Asia visit sex workers

(2-20% of adult men)

Men who have sex with men

Men

50 million

Women married to men who visit sex workers

Women

1 million

infants and children UNAIDS May 24, 2010 5

A causal model showing linkages among factors that influence HIV transmission in intimate partners relationships

UNAIDS April 30, 2020 6

“People on the Move” in Asia’s fastest growing economies China, India, Indonesia, Malaysia, Thailand, and Vietnam

   Asia was host to 26.3 million migrants , or about 13.8 per cent of the world's total migrant stock, in 2005 (University of Sussex and the World Bank)  Malaysia and Thailand are expected to absorb large numbers of foreign workers considering the economic growth prospects Asia an important source of international migration, sending 54.2 million migrants abroad or 28.4 per cent of the world's total (ibid)  By 2030, India and China are projected to account for global workforce (World Migration Report 2008) 40 per cent of the  Sri Lanka, Philippines and Indonesia contribute a large female work force working abroad Gendered dimension of migration – the numbers of women migrating from the six countries will continue to rise - particularly as domestic workers, care givers, service employees, moving across borders and within the country UNAIDS May 24,2010

Source: AIDS 2031. UNAID, 2009

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This migration and mobility exposes migrants to HIV risk .. particularly internal rural-urban migration

• Commercial sex work is concentrated in areas of circular migrants – more Clients • Large numbers of rural female migrants moving to urban areas engage in the entertainment industry – more FSWs • Expands the of migrants, both the men and the women

triangular

sexual networks • Lack of access to health services, particularly those living outside their countries UNAIDS May 24, 2010 8

Mobile men can be more vulnerable to HIV infection

Percentage of

non-mobile

/

mobile

men paying for sex in the past 12 months (FHI 2006) 33% 33% 32% 21% 15% 9% China 4% Cambodia Indonesia 2% Viet Nam 9 UNAIDS May 24, 2010

The epidemic data show this emerging dynamic of HIV spread - about 200,000 more Asian women are living with HIV in 2008 compared to 2001

UNAIDS May 24,2010

Regional Trends in People living with HIV 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 1,200 180 1,300 290 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Women S&SE Asia Adults & Children S&SE Asia Year Women East Asia Adults & Children East Asia Source: 2009 AIDS Epidemic Update. UNAIDS, WHO, 2009

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People are still dying of

AIDS

in Asia – an estimated 330,000 deaths in 2008 HIV-related Deaths of Adults and Children 350 300 250 200 150 100 50 1988 1990 1992 1994 1996 1998 2000 Year Deaths Adults & Children S & SE Asia 2002 2004 2006 2008 2010 Deaths Adults & Children East Asia

UNAIDS May 24, 2010

Source: 2009 AIDS Epidemic Update. UNAIDS, WHO, 2009

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The Asia Commission projections suggest that we are at a cusp in the epidemic progression…

1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 19 85 19 90 Clients Lo-risk male 19 95 20 00 Sex workers Lo-risk female 20 05 MSM Children 20 10 20 15 IDU 20 20 where a resurgent epidemic … 1,200,000 1,000,000 800,000 600,000 400,000 can be avoided if prevention and treatment reach universal coverage 200,000 0 19 85 19 90 19 95 20 00 20 05 20 10 20 15 20 20 Clients Sex workers MSM IDU Lo-risk male Lo-risk female Children UNAIDS May 24, 2010

Source: Commission on AIDS in Asia 2008

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Better information but the response is lagging

• Response is a mixed picture country to country and provinces within the same country ( in India and China ).

• There are excellent prevention efforts, but not to scale.

• Babies are still getting infected - PM TCT coverage in the region is very low ( 25%) • If reducing the new infections to half by 2015 is the goal, many countries need to act fast.

UNAIDS May 24, 2010 13

HIV prevalence among IDUs in Bangkok, 2000-2009 60 50 40 % 30 20 10 0 HIV prevalence among MSM in Thailand, 2003-2007

UNAIDS May 24, 2010

Source: Bureau of Epidemiology, Thailand Ministry of Public Health

Thailand's early successes in reducing sex work-related infections, have given way to increasing infections among IDUs and MSM 14

100 % 80

HIV prevention coverage among IDUs, 2005-2009

60 40 20 0

UNAIDS May 24, 2010

2005 2007 2009 Source: UNGASS country progress report_2006, 2008 & 2010

* Calculated median value 2009 data is provisional 15

HIV prevention coverage among MSM 2005-2009 100 % 80 60 40 20 0

UNAIDS May 24, 2010

2005 2007 2009 Source: UNGASS country progress report_2006, 2008 & 2010

* Calculated median value 2009 data is provisional 16

100

PMTCT coverage, 2006-2009

80 60 40 20 0

UNAIDS May 24, 2010

2006 2007 2008 2009 Source: UNGASS country progress report_2006, 2008 & 2010

2009 data is provisional 17

Enabling environment and unseen challenges

• Political leaders in Asia must be credited for seeing the danger of a looming epidemic and acting early ...

• But, the political rhetoric is often not translated into measurable programme outputs which have an IMPACT on the epidemic. • Disturbing trend of reversal of earlier gains – new legislations in countries like Cambodia which enhance stigma. New conservatism around issues like sex work, male to male sex … • Impact mitigation is the missing piece. No effective measure to mitigate the effects of stigma and discrimination. No earmarked funding.

UNAIDS May 24, 2010 18

No country spends enough

3 2 Cambodia 1 Sri Lanka 0 China Pakistan Philippines 0.00% India Vietnam Nepal 0.50% Myanmar HIV prevalence (%) 1.00% Thailand 1.50% With a normative value of $1 per capita, 9 countries still fell short on resource commitment to AIDS programmes The region needs $ 3.2 bn for reversing the epidemic, but availability hovers around $ 1.2 bn.

UNAIDS May 24, 2010

Source :Commission on AIDS in Asia 2008

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Sources

of AIDS funding, selected countries Afghanistan (2008-2009) Cambodia (2008) China (2009) Fiji (2008) India (2007-2012) Indonesia (2008) Lao PDR (2008-2009) Malaysia (2009) Mongolia (2009) Nepal (2007) Pakistan (2009) Thailand (2009) Vietnam (2008) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Public International Private

UNAIDS May 24, 2010

Source: UNGASS country progress report 2010

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Percent distribution of AIDS spending per key area, selected countries

Afghanistan (2008-2009) Bangladesh ( 2007-2009) Cambodia (2008) India (2009) Indonesia (2008) Lao PDR (2008-2009) Malaysia (2009) Mongolia (2009) Nepal (2007) Pakistan (2009) Thailand (2009) Vietnam (2008) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Prevention Care and treatment Others

UNAIDS May 24, 2010

Source: UNGASS country progress report 2010

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The brighter side

• Countries understand the need for information and are starting to generate more data and fill data gaps.

• Behavioral surveys are identifying and characterising the risk factors.

• Successful interventions which can bring down new infections effectively have been demonstrated. • Stronger health system support for treatment and PMTCT programmes is resulting in fast scale up. Treatment coverage increased impressively to 565,000 • Good scale up in resources - GF and PEPFAR and BGMF as new donors have added much needed resources.

• Social environment changing in countries like India and Nepal with a proactive judiciary leading the way to social reforms.

UNAIDS May 24,2010 22

Strategic information systems are improving across the region and risk factors better understood

UNAIDS May 24, 2010

100% 80% 60% 40% 20% 0%

8 countries 4 countries 12 countries

No survey At least 2 populations among FSW, IDU, MSM All 3 populations 24 countries % of countries with HIV prevalence surveys among populations at higher risk, in the last 2 years (2009)

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HIV prevention coverage is improving across most the region % 100 80 60 40 20 0

UNAIDS May 24, 2010

2005 2007 2009 Source: UNGASS country progress report_2006, 2008 & 2010

* Calculated median value 2009 data is provisional 24

ART coverage is scaling up fast in many countries

ART coverage among adults and children, 2006-2009 UNAIDS May 24, 2010

Source: UNGASS country progress report_2006, 2008 & 2010

* Only for adults 2009 data is provisional 25

The MARPs agenda- opening the doors for social sector reform

• Acceleration of gender and HIV activities in the region

 By the end of 2009, 3 countries had gender reviews of their NSPs and 2 policies for systematic inclusion of gender. 4 more countries currently working on them.

 Regional Report on Intimate Partner Transmission of HIV was launched at 9 th ICAAP based on analysis in 13 countries UNAIDS May 24, 2010 26

•

The MARPs Agenda – opening the doors for social sector reform .. ( cont’d )

UNAIDS Agenda for Women and Girls to be promoted in 2010 to support engendering of new National Strategic AIDS Plans and Global Fund Grants. • Social environment changing in countries like India and Nepal with a proactive judiciary leading the way to social reforms.

• Establishment or improvement of remedial instruments and legal reform, and agencies where PLHIV can seek redress and legal services. UNAIDS May 24, 2010 27

Empowerment of positive people

• Strong networking of PLHAs in most Asian countries and linking with Regional body APN+ • Representation on NACs and CCMs at national level.

• Core funding for organizational development to APN+ from UNAIDS • Involvement in development of strategies for prevention of Intimate Partner Transmission • HIV Bill in India to guarantee the rights of positive people • Stigma Index roll out commenced in 2008 with PLHIV groups involvement.  Five countries completed the index and are disseminating findings (Sri Lanka, Bangladesh, China, Myanmar and Thailand).

 Seven more countries (Cambodia, Fiji, Malaysia, Pakistan, Philippines, PNG and Viet Nam) implementing index through PLHIV networks with universities support. UNAIDS May 24, 2010 28

Global Fund Round 6 & 8 HIV spending in Asian countries: Priority areas Round 6 Round 8 Migrants/ Mobile populations 1% MARPs 24% PMTCT 2% VCT 46% MARPs 59% PMTCT 2% Mass Media 0% Condom Social marketing 0% VCT 13% STI treatment 6% Blood safety 2% 0% Youth 1% Youth 17% Migrants/Mobi le populations 17% Blood safety 9% Workplace intervention 0% STI treatment 1% Mass Media 0%

UNAIDS May 24, 2010 29

Global Fund Round 9 HIV spending in 6 Asian countries: Priority areas

Workplace intervention 0% Youth 0% Blood safety 0% STI treatment 2% Condom Social marketing 3%

Migrants/Mobile populations 10% VCT 5% PMTCT 7%

Mass Media 0%

MARPs 73%

UNAIDS May 24, 2010

Source: Global Fund Round 9 budget tracking_2010 MARPs Prevention 27% Treatment & Care 46%

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UNAIDS April 30, 2020

Why is this the right time to act?

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Countries with highest prevalence in Asia show good progress on MDG 6 targets for HIV and TB, but less progress on infant and maternal targets MDGs 4 & 5 Country MDG Goal 4 MDG Goal 5 MDG Goal 6 Under-5 mortality Maternal mortality Antenatal care At least once birth by skilled professional HIV prevalence TB incidence TB prevalence China India Indonesia Myanmar Thailand Vietnam Early achiever

UNAIDS May 24, 2010

On track Slow Regressing/No progress Source: UNESCAP, ADB & UNDP_ Achieving the millennium development goals in an era of global uncertainty_2010

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With 2015 MDG targets approaching, HIV and AIDS interventions should be integrated into Health Systems strengthening

UNAIDS May 24, 2010

Source: UNESCAP, ADB & UNDP_ Achieving the millennium development goals in an era of global uncertainty_2010

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UN is reinforcing its role

• AIDS affords an opportunity for the UN system to deliver as ONE • The one programme where this has been successfully done was the AIDS programme where the secretariat and the 10 Co-Sponsors work together in a joint programme to provide support to countries.

• This needs to be intensified, taking advantage of the Outcome Frame Work of UNAIDS and the Division of Labour between agencies.

UNAIDS May 24, 2010 34

What needs to be done in Asia and the Pacific?

•

In the next 5 years

 provide earlier. , • Understand the characteristics of the epidemic and tailor the response.

• AIDS should get to the top of the agenda for activists and social reformers It provides a platform for civil society no other movement was able to • Focus on programmes that produce impact and results, and don’t waste money on low impact interventions.

• Coverage and scale up is the Mantra - Attempt and attain more than 80% coverage of populations who need prevention and treatment services.

In the long term

, impact mitigation is the key  special focus on orphans and women.   AIDS related stigma and discrimination should be wiped out.

CAA estimated that for the entire Asia they are not going to cost more than $ 300 m per year.

UNAIDS May 24, 2\010 35

Thank you!

Acknowledgements • UNAIDS RST • HIV and AIDS Data Hub for Asia and the Pacific www.aidsdatahub.org

UNAIDS May 24, 2010 36