My Background

1. The HIV Epidemics in Asia and the PacificOhio Leadership ConferenceApril 15, 2008Thu Vuong MBA, MPH CandidateOhio State University

2. My Background • Former Senior Program Officer, IDU Interventions, FHI Vietnam • Chair, Vietnam Harm Reduction Technical Working Group, 2005-2006 • Trained Drug Addiction Treatment Counselor • MBA, 2003 • MPH Candidate June 08, HSMP, OSU

3. Outline • Epidemiology of HIV in Asia • What works in HIV prevention: Why is Asia different? • US government support and policies regarding HIV prevention, care, and treatment in developing countries • Country case study: Vietnam • The future: Continuing challenges

4. Adults and children estimated to be living with HIV as of end 2005 Eastern Europe & Central Asia 1.6 million [990 000 – 2.3 million] Western & Central Europe 720 000 [570 000 – 890 000] North America 1.2 million [650 000 – 1.8 million] East Asia 870,000 [440 000 – 1.4 million] North Africa & Middle East 510 000 [230 000 – 1.4 million] Caribbean 300 000 [200 000 – 510 000] South & South-East Asia 7.4 million [4.5 – 11.0 million] Sub-Saharan Africa 25.8 million [23.8 – 27.9 million] Latin America 1.8 million [1.4– 2.4 million] Oceania 74 000 [45 000 – 120 000] Total: 40.3 (36.7 – 45.3) million Source: UNAIDS

5. 1989 1994 1999 2003 Asian epidemics show great diversity and have become more serious over time4.8 million PLHAs in 2007 (UNAIDS) < 0.05% 0.05 - 0.1% 0.10 - 0.5% 0.50 - 1.0% > 1.0%

6. Stages of the HIV Epidemic by UN/WHO classification • Low Grade • Prevalence of HIV is consistently below 5% in any “high risk groups” and below 1% in the “general population” • Concentrated • Prevalence of HIV has surpassed 5% on a consistent basis in one or more “high risk groups” but remains below 1% in the “general population” • Generalized • Prevalence of HIV has surpassed 1% in the “general population” Source: UNAIDS

7. HIV Epidemic Summary in Asia-Pacific Region • Three countries in Asia have generalizedepidemics: • Cambodia (1.6%), Thailand (1.4%), and Myanmar (1.3%) • Rapidly expanding concentrated epidemics include India, Indonesia, Nepal, Vietnam and several provinces in China • One country in the Pacific now is also on the verge of a generalized epidemic – Papua New Guinea • Possibility for an ‘African-style’ epidemic

8. HIV Epidemic Summary in Asia-Pacific Region (cont’d) • But even within one country, there is significant variation in epidemic spread • India, China

9. Adult HIV prevalence among African countries in 2005 Source: UNAIDS/WHO 2006 Report on the global AIDS epidemic

10. Adult HIV prevalence among Asian countries in 2005 Note: * <0.1 Source: UNAIDS/WHO 2006 Report on the global AIDS epidemic

11. What's the big deal with HIV in Asia? • With a few exceptions, Asia epidemics will not reach the high levels seen in the highest prevalence in sub-Saharan African countries • So what’s the big deal? • Even a low-grade epidemic in Asia means millions of people (60% of world population – 4 billion)

12. Every percentage point in Asia adds a huge number to the global epidemic Total=15.5 million 1% increase in adult HIV prevalence in SS Africa=2.9 million

13. What drives the spread of HIV in Asia?

14. Factors that drive the spread of HIV • Major behavioral factors • Unsafe blood transfusion • Needle sharing • Multiple heterosexual partners engaging in unprotected sexual intercourse • Multiple homosexual partners engaging in unprotected anal sex • Commercial sex • Major co-factors • Presence of other STI • Non-circumcision

15. Socio-economic factors that may affect HIV epidemic spread • Poverty • Higher levels of commercial sex • Higher levels of drug use • Less access to quality health care • Travel/Migration • Long-distance truck drivers, seafarers… • Men living without their families; Higher use of sex workers • Female migrants

16. Social and cultural factors in Asia promoting or inhibiting HIV spread? • A tolerance for men, strict prohibition for women • Loosening sexual norms in Asia • Increasing age at marriage producing large pool of unmarried youth • Gender inequality • Reduces employment opportunities, promoting sex work • Limits negotiating ability in relationships

17. “It’s very difficult to speak about ‘the Asian epidemic’. Whatever we come up with, we always find a big exception in Asia.” (Dr. Peter Piot, UNAIDS Executive Director)

18. So what explains the variations between countries? • Levels of risk • Frequency of needle sharing, sexual activity • Sizes of at-risk populations, especially drug users, sex workers and clients of sex workers • Linkages among at-risk sub-populations • Behavior change in response to prevention • Timing of HIV introduction into the high-risk groups • Biological factors such as STI and circumcision

19. HIV prevalence among IDUs far outstrips sex worker prevalence in most places (Source: National surveillance reports)

20. If HIV infection is highest among IDUs, why is it claimed that commercial sex is the main driver of HIV epidemics in Asia? • Absolute numbers • IDU more likely to be infected • More HIV infections overall will be transmitted sexually

21. Dynamics of Asian HIV/AIDS epidemics FSW MSM IDUs Clients Low or no risk males Low or no risk females Early infections focused in at-risk groups: Clients & FSW, IDU and MSM. These groups strongly linked behaviorally Newborns

22. IDUs visit sex workersPercent of injectors visiting sex workers last year Sources: National surveillance systems. *Bangladesh values are for the last month.

23. Impediments to HIV Prevention in Low Prevalence/Emerging Epidemic Countries Low Prevalence = Low priority = We’re different - “Risk behavior does not happen here so there’s no need to respond” = Lack of capacity = Tendency to focus on politically popular but epidemiologically inefficient groups, e.g. general population = Vicious circle of lack of data → no response → lack of data….

24. Low prevalence among whom? • Asian countries have overall low HIV prevalenceHigher prevalence in higher risk populationsNeed to focus on these higher risk populations

25. SOUTH & SOUTH-EAST ASIAEstimated number of injecting drug users (IDUs) HIV prevalence among IDUs (mid est.1998/2005) IRAN: 206,000 AFGHANISTAN: 34,080 0.5% unknown BHUTAN: unknown NEPAL: 41,000 PAKISTAN: 462,000 Up to 60% unknown LAOS: 8,000 INDIA: 1,294,000 unknown MYANMAR: 195,000 68.4% Up to 79.5% THAILAND: 57,000 VIET NAM: 128,000 BANGLADESH: 98,000 64% 2.6% 54% MALDIVES unknown PHILIPPINES:17,000 MALAYSIA: 19,500 1% SRI LANKA: 28,241 35.5% unknown SINGAPORE: 15,000 1.7% INDONESIA: 580,000 47%

26. Factors that increase HIV transmission associated with IDU • Sharing and re-using injecting equipment (due to lack of clean needles & syringes or fear of arrest and beatings by the police) • Professional injectors and shooting galleries • Sexual behaviour of IDUs • Selling sex to buy drugs • Women IDUs selling sex to buy drugs • Male IDUs selling male-male sex to buy drugs • Drug injectors buying sex • Imprisonmentor drug treatment centers (Source: SHARAN Archives. 2000)

27. A B D C IDU “Mixing” in Prisons A IDU Network HIV -ve C IDU Network HIV -ve B IDU Network HIV +ve D IDU Network HIV -ve PRISON A IDU Network HIV +ve D IDU Network HIV +ve B IDU Network HIV +ve C IDU Network HIV +ve

28. Epidemics among FSW often follow IDU epidemics

29. Essential HIV prevention package: weighting varies by country • Confront stigma and discrimination • National leadership, mass media, education • Prevent sexual transmission • Condoms and social marketing for FSW, clients, MSM • Reducing number of sexual partners • Delaying sexual debut • Prevention of IDU transmission • Harm reduction programs including substitution therapy • Peer counseling • Voluntary counseling and testing • Confidentiality and consent

30. Essential HIV prevention package: weighting varies by country • Prevention of MTCT • Antenatal screening • Focus on HIV prevention among youth • Peer counseling, mass media campaigns, school education • Integrate prevention into treatment services • Treatment of STIs • Workplace programs • Ensuring safety of blood supply • Transfusion screening • Preventing HIV transmission in healthcare settings • Universal precautions

31. Example of a full HIV prevention, care, and treatment program: Vietnam

32. HIV/AIDS in Viet Nam • Initially largely driven by injection drug use and, to a lesser extent, by sex work • Moved into general population with husband-to-wife-to-child transmission, through the sexual networks of drug users and clients of sex workers • Women now account for one-third of all new infections

33. How the US government supports HIV programs in developing countries • Two major US government agencies: USAID, CDC • These agencies can provide funding directly to ministries of health • They can also provide them through technical organizations and universities • FHI and UNC are two that are very active in HIV and other diseases internationally

34. US government policies regarding HIV prevention: myths and realities • The PEPFAR initiative has brought tremendous resources to HIV treatment in addition to prevention and care • 15 focus countries; $15 billion for 5 years • President Bush has just requested a doubling of this amount • Contrary to the belief of many, PEPFAR fully supports condom promotion to FSW, their clients, and MSM

35. US government policies regarding HIV prevention: myths and realities (cont'd) • 20% of prevention funding must go to abstinence programming (some countries receive a waiver, e.g. Vietnam) • No funding can be used to support the purchase or distribution of syringes or needles for IDUs • Partners must sign a pledge that they do not support the legalization of prostitution nor will funds be used for this. • In 2005, DKT International is challenging this in court because they refused to certify its opposition to prostitution

36. FHI HIV Program focus in Vietnam • Prevention interventions to address behaviors at the core of the epidemic – drug use, commercial sex work and sex among men (i.e., IDUs, FSWs and their clients, and MSM) • Care and treatment interventions at district level to provide treatment, care and support for people living with HIV/AIDS (PLWHA) • Integrated bio-behavioral surveillance to understand the direction of the epidemic, behavior change, and estimates of HIV infection

37. Interventions for IDU: strategic approaches • Peer outreach to shooting locations and drop-in center services • Drug addiction treatment counseling with relapse prevention • Substitution treatment: Methadone substitution treatment planned for 3 sites for 2008

38. Strategic approaches to reaching clients of FSW • Reaching at-risk men at entertainment establishment (beer houses, bars, restaurants, coffee houses) with “Live Like a Real Man" messages • A dedicated hotline with experienced counselors • Strong linkages with the mass media component

39. Strategic approaches for FSW • Peer outreach to FSW based on mapping of commercial sex • Condom distribution • Drop-in centers with integrated services (VCT, STI, counseling, edu-tainment, referrals)

40. Interventions for MSM: strategic approaches • Peer outreach to discos, bars, and locations where men meet for sex • Drop-in center for edu-tainment and peer discussions • Internet intervention

41. Drug "rehabilitation centers": a unique challenge in Vietnam • Government of Vietnam (GoV) began addressing drug “problem” 10 years ago with a “social evils” perception. • Main strategy was placement in drug rehabilitation centers (known as 06 Centers – “labor and education”) • Mandatory detoxification • Rehabilitation through lectures on drug use, risk of HIV transmission • Vocational training

42. Drug "rehabilitation centers": a unique challenge in Vietnam • By 2006, 83 rehabilitation centers were in operation, with up to 57,000 residents • GoV noticed high rates of relapse (>90%) from 2 year rehabilitation period and so increased the length of time to up to 5 years • Spiraling costs of 06 centers and high HIV rates (up to 50% HIV+) forced willingness to view alternative approaches • With PEPFAR support, FHI and others are "rehabilitating" the rehabilitation centers

44. Knowing what we (Asia) do, why are HIV programs still failing? • Focus and misdirection • Capacity for quality programming • Coverage • Political will

45. Why do we fail?: Focus and misdirection • Global and national program misdirection • African paradigms in Asian settings – ABC • USG restrictions on harm reduction (needles and syringes) • Social order and social evil campaigns

46. Why do we fail?: Capacity • National program capacity • Understaffed, overburdened, lacking some skills sets • NGO and community capacity • Great development capacity • Little experience with HIV & marginalized groups • International support capacity • Limited technical staffing and consultant base, largely from outside

47. Why fail?: lack of size estimation/ coverage data • Most countries do not yet have size estimates of critical groups: • Sex workers, clients, IDU, MSM • Difficult to know: • what each group’s role is in the epidemic • what coverage goals should be to make a difference

48. Why do we fail? Political will • Countries successful against HIV have • Leadership from the top • Grass roots efforts working upward • Societal mobilization • But many Asian leaders (& their replacements): • do not acknowledge risk – HIV/AIDS is not really an Asian problem • do not understand their epidemics – infection will restrict itself to high-risk groups • do not support work with marginalized groups

49. Asia – Boom or Bust? • The next sub-Saharan Africa? No • 3-5% possible in some countries? Yes • Can we stop it? Yes, by • Focusing in the right places, with the right prevention services, and for the right people • Mobilizing the resources to go to scale; The time for “boutique” pilot projects is long past • Building country capacity to respond in the most effective manner

50. Thank You Slide • Robert Ali, University of Adelaide, Australia • Stephen Mills, FHI Vietnam • Tobi Saidel, FHI India • Dimitri Prybylski, FHI Bangkok • Tran Vu Hoang, FHI Vietnam • Tim Brown, University of Hawaii, Hawaii, USA • Fritz Van Grievsen, US-CDC, Bangkok • Philippe Girault, FHI Bangkok