AN HIV RESPONSE AND UNFOLDING REALITIES

Asia can pride itself on being home to some of the world's most dynamic economies and rapidly changing societies. It has distinguished itself in the past by confronting health challenges in a pragmatic fashion, that is, in its responses to outbreaks of SARS and H5N1 avian influenza. The same pragmatic approach is needed if Asian countries are to gain the upper hand over HIV epidemics.1

According to UNAIDS and WHO estimates, 4.9 million (the lower and upper estimates are 3.7 million and 6.7 million respectively) people were living with HIV in Asia in 2007, including the 440,000 (210,000-1.0 million) people who became newly infected in that year. Approximately 300,000 (250,000-470,000) people died from AIDS-related illn.esses in 2007.2

Overall, an estimated 9 million Asians have been infected with HIV since it first appeared in the region more than 20 years ago. Approximately 2.6 million men, more than 950,000 women—many of them in their 20s and 30s—and almost 330,000 children have died of AIDS-related diseases.

AIDS will cause a total loss of 180 million years of healthy and productive life in Asia between 2002 and 2020—more than any other disease (see Chapter 3).3

Despite the progress made on prevention and treatment in many countries in Asia and the declining trend of new HIV infections in some, AIDS currently accounts for more deaths annually among 15-44 year-old adults than does tuberculosis and other diseases.4

The likely trajectories of the HIV epidemics in Asia have been the subject of much speculation. At one extreme, dire warnings have been given that the populous countries of the region could see their epidemics spin out of control and approach the scale and intensity of those raging in parts of Africa. At the other end, complacency seems to prevail, and it is argued that social norms and mores in Asian societies will hold HIV in check, even with minimal prevention efforts.

As our understanding of HIV epidemics in Asia improves, it becomes clear that neither of those scenarios fit the actual picture, and they may actually lead to further confusion.

Indecisive or misdirected HIV responses have been one outcome of this confusion. The importance of focusing resources on effective programmes has sometimes been neglected. Another consequence has been the failure to recognize the socioeconomic impact epidemics a're having on households and communities in Asia.

Overall, Asia's response has neither matched nor kept pace with the unfolding realities of HIV epidemics.

THE COMMISSION ON AIDS IN ASIA: A FRESH PERSPECTIVE

It was this realization that led to the creation of an independent Commission on AIDS in Asia. This body was asked to review the scientific evidence surrounding the spread of HIV in Asia, assess the medium- and long-term impact of AIDS on Asian societies, and propose practical HIV responses that can have the maximum effect on Asia's HIV epidemics.

Since its establishment in June 2006, the Commission on AIDS in Asia has collected a mass of data and evidence, which has formed the basis of its Findings and Recommendations. The Commission's work has included:

•    reviewing over 5,000 papers and commissioning almost 30 new studies in the areas of epidemiology, socioeconomic impact and resource allocation, the role of civil society, the status of different national responses, and best practices;

•    engaging more than 30 specialists to examine and propose new and innovative ways to address the epidemics in Asia;

•    convening sub-regional workshops and country missions where the Commission heard testimonies on the HIV situation and responses from Government and civil society representatives.

WHAT MAKES ASIAN EPIDEMICS UNIQUE?

Chapter 2 is central to the Report. It examines the epidemiology of HIV in Asia in some detail and outlines the policy implications of these findings. Crucially, it emphasizes the need for HIV responses that focus on those population groups that are most-at-risk of getting infected with HIV and most likely to transmit the virus to others.

Although HIV epidemics vary considerably from country to country in the Asian region, they share important characteristics, and are centred mainly around:

•    unprotected paid sex,

•    the sharing of contaminated needles and syringes, and

•    unprotected sex between men.

It shows, in particular, that men who buy sex are the single-most powerful driving force in Asia's HIV epidemics. Since most men who buy sex are either married or will get married, significant numbers of ostensibly `low-risk' women who only have sex with their husbands are exposed to HIV. In several Asian countries currently, as many as 25-40 per cent of new HIV infections are among spouses and girlfriends of men who got infected during paid sex, injecting drugs, or having sex with other men. Effective means of preventing HIV infections in female partners of most-at-risk men have yet to be developed in Asia, but such prevention is clearly a crucial piece of the puzzle.

The Commission estimates that up to 10 million Asian women sell sex and at least 75 million men buy it regularly. The fact that HIV circulates freely among those commercial sex networks means that millions of women who are or will be married to current or past male clients of sex workers are potentially at risk of HIV infection.

Male-male sex and drug injections add another 20 million or so to the number of men at high risk of HIV infection once the virus enters those networks. A portion of those men, particularly injectors, may pass HIV on to the women they have sex with regularly, which means that several million more women are then also at risk.

But because relatively few women in Asia have sex with more than one partner, the chain of HIV infection tends to end once wives and girlfriends become infected. Some might transmit HIV to their unborn children, but the probability of those women passing HIV to another man is generally very small.

HOW CAN ASIAN COUNTRIES PREVENT THE SPREAD OF THEIR HIV EPIDEMICS?

HIV epidemics in Asia are highly unlikely to sustain themselves in the 'general population' independently of commercial sex, drug injecting, and sex between men. The most effective way to protect women who, ostensibly, should be at low risk of HIV infection is by preventing their husbands and boyfriends from getting infected. And, most important, prevention efforts that drastically reduce HIV transmission among and between these most-at-risk groups of people will bring the epidemics under control.

The basic components of such programmes are known and have been shown to be effective in various countries around the world, including in Asia. The technical and institutional design of such programmes is not a significant obstacle. Nor are the financial costs a major hurdle, as the analysis in Chapter 3 confirms. And yet, as Chapter 5 shows, only a handful of countries in Asia have introduced such programmes.

The main constraint, it seems, is the lack of effective political leadership in bringing about a change in social attitudes. Asia's HIV epidemics are centred primarily on behaviours which 'polite' society frowns upon, yet which are widely disseminated throughout the population-at-large. As many as one in five Asian men have purchased sex at some point in their lives. Other directly affected groups—such as sex workers, injecting drug users, and men who have sex with men—are often socially stigmatized and harassed.

Admittedly, some Governments find it uncomfortable devoting resources to help people protect themselves from the health consequences of behaving in a manner that is illegal or that society scorns. This is why mature and far-sighted political leadership is so important for establishing and championing the policies and priorities for programmes that can reverse HIV epidemics.

A strictly service-delivery approach to HIV, however, is not enough. The scourge of stigma must be overcome and an 'enabling environment' must be created if HIV interventions are to make a difference. Changes in social policy, the mobilization of opinion leaders at all levels, the cooperation of law enforcement personnel, and the involvement of communities are all essential to the creation of such an environment.

Countries need to carefully re-assess their epidemics and risk profiles on a regular basis to determine which prevention interventions should be prioritized. Because of the broad commonalities in the way HIV spreads in Asia, the question 'what should we be doing' will always be guided by the stage each country's epidemic has reached, as discussed in Chapter 2.

As Chapter 3 argues, Governments also have a material interest in ensuring that effective HIV prevention is in place. Prevention can. reduce the number of people who will need to be provided with treatment and care in the future, and can also reduce the potential impact of the epidemic on individuals, families, and societies as well, sparing millions of lives. The key point is that preventing an HIV infection costs a lot less than treating, caring for, and providing livelihood assistance to a person who is infected.

WHAT SHOULD ASIAN COUNTRIES DO TO CARE FOR PEOPLE LIVING WITH HIV AND THEIR FAMILIES AND MITIGATE THE IMPACT OF THE EPIDEMIC?

Chapters 4 and 5 examine some of the social, economic, and cultural factors that promote risky behaviours and that tend to undermine effective prevention, treatment, and impact mitigation programmes. Chapter 4 is particularly concerned with what might be called the 'social drivers' of HIV.), for example, poverty, income and gender inequality, inadequate education, the stigmatization of groups most at risk, and so on. Chapter 5 looks at different national responses to the epidemics in the Asian region. rIbgether, the chapters suggest how these areas must be addressed in order to achieve large-scale and effective provision of HIV prevention, treatment, and care services.

Even those Governments that provide only rudimentary health services have pledged to ensure widespread access to treatment and care for HIV-positive persons. That is an expensive undertaking. Although the cost of most commonly used antiretroviral drugs has fallen dramatically in recent years, such drugs are still far more costly than prevention services. Second-line drugs5 are much more expensive.

In the short- to medium-term, the demand for treatment will remain considerable. In the longer-term, irrespective of the success of prevention efforts, much more can be done to reduce the costs of treatment and care. For example, Governments should negotiate price reductions more forcefully and make more effective use of the flexibilities inscribed in international trade agreements (such as compulsory licensing)—all of which can reduce the costs of antiretroviral and other pharmaceutical drugs. Partnerships with civil society, as examined in Chapter 5, could boost those efforts.

Chapter 6 discusses the key roles that community organizations must play in this respect. In general, a 'top-down' solution can never be fully effective unless accompanied by strong community involvement. But although everyone agrees in principle with the notion of community involvement, clarity is needed about which communities need to be involved and how Governments and international organizations can best aid this process.

With regard to the treatment of those already infected, although most Governments meet a significant share of treatment costs, it is sometimes forgotten that many other costs associated with chronic illnesses an-d death of adults of working age are borne mainly by their families. These impacts are disproportionately felt by the poor, who are least able to afford them. There is an urgent need for Governments to provide access to treatment and stronger social and economic protection for these households—and especially for women and children who disproportionately bear the impact of the epidemic.

Ultimately, those welfare obligations will be reduced as access to antiretroviral treatment increases and more and more people affected by AIDS remain productive, employed, and care for their families. The costs of treatment will be more than offset by the benefits of keeping people healthy and productive. Investing in a solid and sustainable treatment programme is one of the effective ways of mitigating the impact of the epidemic on people living with HIV and their families.

MAKING A DIFFERENCE: A CALL FOR STRONG AND MATURE LEADERSHIP

The Commission recognizes that Asian Governments are increasingly responsive to the global nature of infectious diseases. The recent outbreaks of SARS and avian influenza have underscored the fact that pragmatic methods based on sound science are the most effective ways of dealing with infectious disease and other public health challenges.

After reviewing and analysing scientific and other evidence of Asia's experiences with HIV, the Commission has compiled a detailed set of recommendations which is presented in Chapter 7.

The Commission believes that Governments in Asia have the information, the institutions, and the resources to considerably reduce new HIV infections. The unique nature of Asian epidemics, the currently low prevalence, the strength of public and private systems, and economic prosperity in the region create an opportunity unavailable in many parts of the world. If Governments in Asia deploy their financial and human resources prudently, and strengthen partnerships with non-Government and community sectors, they will be able to halt and reverse the epidemic within the time-frame set in global declarations on Universal Access and achievement of the Millennium Development Goals (MDGs). All these recommendations are pragmatic, feasible, and affordable.

The most important ingredients for success are the Governments' leadership and commitment in mounting effective prevention and care efforts, together with the involvement of affected communities and other civil society entities. If the Governments of Asia choose to meet these challenges and put in place the steps outlined in this Report, the battle against HIV in Asia can be won.

1 The countries surveyed are provided in Annex 1 to this Report.

2 UNAIDS/WHO (2007), 2007 AIDS Epidemic Update, Geneva: UNAIDS.

3 This estimate is based on the number of disability-adjusted life years (DALYs) and potential years of life lost due to premature death. DALYs measure the equivalent years of 'healthy' life lost due to poor health or disability, and potential years of life lost due to premature death. One DALY equalszne lost year of 'healthy' life.

4 Based on estimates derived from the Asian Epidemic Model, 2007.

5 'Second line' drugs are required when patients develop resistance to the original drugs used.