(December 2004) While Asia has rarely been in the spotlight in the global response to AIDS, this region and Eastern Europe are the two areas of the world with the most rapid growth in new HIV infections.

UNAIDS estimates that more than 7 million Asians are living with HIV; most became infected while injecting drugs with dirty needles or while buying or selling sex without condoms. Indeed, the interaction between unsafe drug injection and unprotected commercial sex accounts for much of the sharp rise in new infections in Asia, the world’s most populous region.

National surveillance data from some countries show that the epidemic is growing rapidly (see Figure 1). For instance, the rise in HIV infections among injecting drug users in the Chinese province of Guangxi has been followed by a subsequent rise in HIV among sex workers. Jakarta and Hanoi have experienced a similar pattern of infection.

But why does HIV rise among sex workers a few years after it has begun to rise among drug injectors?

Figure 1
Rising HIV infection among injecting drug users, followed by rising infection among sex workers

Source: Monitoring the AIDS Pandemic Network, “AIDS in Asia: Face the Facts,” accessed online at www.mapnetwork.org/docs/MAP_AIDSinAsia2004.pdf on Nov. 30, 2004.

Sharing needles is an efficient way to spread HIV. Therefore, HIV prevalence among drug injectors tends to be high. In many places in Asia, half of all injectors have HIV. And while many in the health community had believed that drug injectors were not very sexually active, new data suggest the opposite is true.

Substantial proportions of male injectors in many Asian countries visit sex workers—more than 80 percent of male injectors in Surabaya, and more than 50 percent in Hanoi and central Bangladesh. Most of these male injectors do not use condoms. In some countries, including Vietnam and parts of China, a high proportion of female sex workers are also drug injectors.

To prevent the sharp rises in infection, injectors need access to clean needles. In addition, condom use needs to become the norm in commercial sex.

Asian Examples Prove the Epidemic Can Be Beaten

While the data from Asia highlight areas of great concern, signs of progress are also evident in the region. Asian countries that have faced the facts and that have taken action provide some of the best examples of effective prevention in the world.

The success of the “100 percent condom-use” campaign in Thailand is already famous. Because condom-use rates in commercial sex in Thailand are so high, even the spread of HIV among drug injectors there has not fuelled a sexual epidemic. In fact, in Bangkok, most injecting drug users opt for condoms when visiting sex workers.

Thailand’s neighbour, Cambodia, has seen similar success with a programme that has encouraged young people to avoid risky behaviors. Through public information campaigns, Cambodia’s programme has also tackled stigmatization of those infected with HIV; and it has actively encouraged men to use condoms when buying sex. Rapid rises in condom use in commercial sex in Cambodia have been accompanied by a significant decrease in HIV infection among sex workers. HIV prevalence has also fallen among their clients.

Bangladesh has also has confronted the threat of HIV transmission among drug injectors. HIV prevention for drug injectors is usually the most difficult step to tackle politically, although this step is among the easiest and most effective.

One Bangladeshi city has a harm reduction programme that provides clean needles and sexual health services for 88 percent of its drug injectors. Those drug injectors who lacked access to the programme were far more likely to share needles and had more unprotected sex than those who did have access. And those who lacked access were also less likely to seek appropriate treatment when they had a sexually transmitted infection (STI).

Most importantly, Bangladesh had the foresight to allow a nongovernmental organization to set up the programme before HIV was detected in this population. And the programme has helped to keep prevalence low, with no positive cases yet found in surveillance among drug injectors in the area. By contrast, in India, Indonesia, Myanmar, Thailand, and Vietnam, HIV infection among injecting drug users has risen in just a few years from near zero percent to 50 percent or more.

Asian Programs Provide Valuable Lessons

As these examples show, Asia has not only the opportunity to take on the AIDS epidemic, but the proven ability to beat it. Countries that are beating the epidemic have provided three lessons:

  • Policymakers and program planners must tailor their response to the behaviors that are spreading the epidemic. In Asia, these behaviors are drug injection, commercial sex, and sex between men. Countries that have succeeded have been pragmatic, not judgemental.
  • Services that directly reduce the risk of HIV transmission are essential. Programs must move beyond leaflets and banners to providing easy access to condoms, lubricant, clean needles, and screening and treatment of STIs.
  • While it is not necessary to provide these services to everyone, the services should be made available to the great majority of the population engaging in high-risk behavior. Twenty years into the HIV epidemic, small demonstration projects are not the answer.

There has been a lot of discussion about “access,” and especially about access to treatment for people living with HIV. Asia is in a rather fortunate position. In many countries, the number of people in immediate need of antiretroviral therapy is still relatively limited because the epidemics are relatively recent. Thus, the countries of the region can aim to achieve high coverage for treatment while building up the systems that will be needed to reach more people in the future.

However, as data from Indonesia show (see Figure 2), the greater challenge in the region is still to provide wide-scale access to prevention services. Estimates of only those at highest risk in Indonesia show that roughly one-half million people are in daily need of prevention services—including condoms, clean needles, and screening and treatment for STIs. This figure dwarfs the 8,500 men and women in the country who need antiretrovirals.

Figure 2
Treatment is critical, and HIV prevention services remain a major priority in Indonesia

Source: Monitoring the AIDS Pandemic Network, “AIDS in Asia: Face the Facts,” accessed online at www.mapnetwork.org/docs/MAP_AIDSinAsia2004.pdf on Nov. 30, 2004.

Karen Stanecki is Senior Adviser on Demographics and Related Data at UNAIDS’ Department of Social Mobilization and Information as well as part of the expert team on epidemiology at UNAIDS. In addition, she is currently chair of the Monitoring the AIDS Pandemic Network.