Immediately before the Sixth International Conference on AIDS in Asia and the Pacific (ICAAP), in Melbourne, Australia, independent experts supported by UNAIDS met from 30 September to 2 October as the MAP (Monitoring the AIDS Pandemic) group, chaired by Karen Stanecki of the USA. Their draft report was released on 4 October 2001, the day before the official opening of ICAAP. It highlights rapid HIV increases in a number of populations, some of which threaten to become widespread epidemics in the world’s most heavily populated countries.
UNAIDS Director, Dr Peter Piot, is worried by the apparent lack of political commitment to tackle the problem in many countries in the region and has promised to give it increased priority in the years to come. In the first issue of the ICAAP conference newsletter, and from conference platforms, he has repeatedly criticised the level of government engagement with the UN General Assembly Special Session on AIDS, which no Asian head of government attended. A UNAIDS briefing reports that “some 6.4 million people in Asia carry the virus and determined steps are needed to prevent a massive increase in their numbers.”
The MAP Review
Three countries – Cambodia, Myanmar and Thailand – already have widespread HIV epidemics affecting more than one per cent of their adult populations. The same applies to several populous Indian states, for example, Andhra Pradesh, Maharashtra and Tamil Nadu, each with more than 55 million people. Cambodia and Thailand have reversed the growth of the epidemic, although sustaining this will not be easy. These are among the few positive developments reported by MAP in what is otherwise grim reading. Generally, the picture is of fast-moving epidemics with mobile populations – some movement being international, some within countries – at particularly high risk.
Sex and Mobility
Rapid increases in HIV among sex workers in Indonesia are associated with very high levels of mobility between cities and islands both on the part of sex workers and their clients. STDs are common and condom use is unusual. Refugee flows after unrest in several regions has increased HIV risks for the population.
The neighbouring Philippines continues to have very low levels of HIV. High rates of other STDs and low levels of condom use among sex workers must, according to the experts, cast doubt on how long this can continue without more successful efforts to change behaviour. Similar concerns are expressed in relation to Bangladesh (see below).
Harm Reduction and Drug Use
HIV is increasing among injecting drug users in China, Indonesia, Iran, Nepal and Vietnam, among other countries. Indonesia has a continuing escalation in injecting drug use as such, accompanied by HIV and other medical problems. In Iran, drug users in prison have higher rates of HIV than drug users in clinics: there is probably transmission within the prisons. The Iranian government is setting up methadone programmes and promoting harm reduction and voluntary HIV counselling and testing (with 75,000 tests so far) on a strictly confidential basis. Nepal has average rates of 40 per cent across 19 centres, rising to 50 per cent in Kathmandu in 1998. In Vietnam, levels of HIV in other cities have overtaken those established in Ho Chi Minh City, rising to 60 per cent and more. More than 20 per cent of male injecting drug users in Hanoi and Da Nang reported paying for sex in the past year; the majority in both cities did not use condoms in those contacts.
Men who have sex with men, some gay-identified, some of them in traditional transvestite roles, are increasingly affected by HIV in Cambodia, Japan, Malaysia, Thailand and other countries.
Overlapping Epidemics
In Thailand, the circulation of different subtypes of HIV points to linkages between epidemics among injecting drug users, heterosexuals, and men who have sex with men. This contrasts strongly with patterns seen with HIV and hepatitis B in Europe and North America, where segregation has been more usual. For example, in Northern Thailand, “subtype E” (see HIV type O and viral diversity) is dominant among men who have sex with men and injecting drug users as well as among heterosexuals.
Injecting and needle-sharing are common in Bangladesh, where substantial overlaps have also been identified between injectors, men having sex with men and men having sex with female sex workers, pointing to a high risk of epidemics across multiple populations once HIV reaches a “critical mass” in the country.
The Challenge of Treatment and Care
With the millions of HIV positive people living in the region, UNAIDS head Dr Peter Piot has observed that there is already a serious care and treatment issue to be faced. Speaking at a Community Forum before the main ICAAP conference opened, Dr Piot said there could be fewer “excuses” for failing to provide antiretroviral therapy in Asia than there were in Africa, given that in many Asian countries, the existing healthcare systems were far stronger than they are in Africa.
An Australian Upsurge
Melbourne itself has problems with a 41 per cent upsurge in HIV diagnoses in Victoria during the year 2000 compared to 1999, which has continued through 2001. This pattern, so far not seen in other Australian states, set part of the agenda for the annual meeting of the Australian Society for HIV Medicine (ASHM), which began immediately before ICAAP in the same venue including some shared sessions.
Unlike some of the other scenarios listed above, this does not appear to represent the beginning of something much larger, but rather a shift from a low, stable rate of infections to a higher but also – for the time being – stable rate. As in Britain, antiretroviral treatment has saved lives and led to a greatly increased number of people living with the virus, most of whom are gay men. The community response to the upsurge, presented at ASHM, includes outreach programmes to “sex on premises venues” and a series of publicity campaigns for gay men and injecting drug users.
The perils of statistics were illustrated by one ASHM presenter who made great play of published figures implying that all of the rise in 2000 was accounted for by one Melbourne clinic. Unfortunately, it emerged in a later session that the report quoted was in error. In fact, the rise had been spread across multiple centres and even different categories of people at risk. The proportion known to be newly infected, based on previous negative tests, has remained steady. Whatever had caused this rise, it was a great deal more than a change in one clinic’s relationship to the communities it serves.
Further reports from ASHM and ICAAP will appear on this site during the next week. ICAAP webcasts are promised in due course on the official conference website.