Asia and The Pacific

Lessons Learned
Countries such as Thailand, Cambodia and some Indian states were widely recognised for their effective and focused HIV responses, especially their campaigns encouraging 100 percent condom use in sex work settings. In Tamil Nadu, India, a programme targeting sex workers introduced in 1995 under a tripartite agreement between government, community organisations and funding agencies has resulted in a dramatic increase in condom use among female sex workers and truckers.

In Malaysia, the government allowed the introduction of harm reduction programmes in 2005, and by 2008, there were more than 22,000 drug users on opioid substitution therapy, more than one million needles distributed, and a methadone programme introduced in prisons. In China, Vietnam and Indonesia, the response has recently begun to gather pace and has shown moderate success. Harm reduction programmes for injecting drug users (IDUs) are gradually expanding in the region; however, men who have sex with men (MSM) have been largely overlooked.

Thailand has rapidly growing rates of HIV incidence among MSM in a cohort from Bangkok. One thousand HIV-negative MSM were recruited and tested for HIV every four months. To date, in the on-going study, the annual HIV incidence in the group is estimated at 5.1 percent. 

In Bangladesh, information on HIV prevention was integrated into the school education curriculum, taking into the account the local cultural and religious context. Papua New Guinea faces a generalised HIV epidemic, which is expanding rapidly in a context of weak health infrastructure, insufficient political The Avahan initiative was launched in India by the Bill & Melinda Gates Foundation in 2003, with the objective of increasing access to HIV prevention in six states with India’s highest HIV prevalence rates. Working with the national, local and district governments and major non-governmental organisations, Avahan provides funding and technical support to distribute condoms, provide screening and treatment for sexually transmitted infections, and expand peer outreach within communities of high-risk groups.

Challenges and Opportunities
An independent commission on AIDS in Asia made recommendations that emphasised the urgent need to focus on populations most at risk and called on political leaders to acquire a complete understanding of the dynamics of the epidemic in their countries, and to invest in evidence-based interventions.

They also highlighted that law enforcement activities criminalising drug use, sex work and homosexuality continue to obstruct HIV service provision. In Thailand and Myanmar, for example, drug users continue to face incarceration and even death at the hands of law enforcement officers. In Cambodia and China, sex workers face violence and human rights violations. Sex between men remains illegal in most of Asia and is therefore driven underground.

Some examples of progress are emerging: in India, for instance, the Minister of Health expressed support for changing the Indian Penal Code, which criminalises homosexuality. However, it is clear that a stronger commitment from political leadership is needed to ensure equal access to HIV services for these groups.

Other priorities in the region include expanding the provision of treatment and care, including access to affordable second-line drugs; maintaining treatment adherence; strengthening linkages with TB and HCV programmes; and integrating HIV services with services for maternal and reproductive health. The expansion of HIV testing and counselling is key, with the need for the right balance between protecting the individual’s right to confidentiality on the one hand, and facilitating access to services on the other.

The need for reliable data on the populations affected by HIV and their access to services should also be a focus. Greater investment is needed not only in generating data to evaluate and improve programmes, but in building capacity to analyse and use data from different sources. The extensive work undertaken by the commission on AIDS in Asia to review existing evidence and make recommendations will serve as the basis for expanding the response to the epidemic in the region, and for assessing progress at future conferences on AIDS.

Asia and the Pacific
• Number of people living with HIV: 5 million in Asia, 74,000 in the Pacific
• AIDS-related deaths (2007): 380,000 in Asia, 1,000 in the Pacific
• New infections (2007): 380,000 in Asia, 13,000 in the Pacific
• Populations most at risk: sex workers, IDUs, MSM

Eastern Europe and Central Asia

This region includes one of the fastest-growing HIV epidemics, particularly in the Russian Federation and Ukraine, and is concentrated primarily among IDUs, with significant overlap between injecting drug use and sex work. While political attention and resources allocated to HIV are growing, the policy and programmatic response – including government efforts to include civil society groups in decision-making – has been uncoordinated and inconsistent.

Lessons Learned
In the Russian Federation, domestic resources allocated to the HIV response have increased 57- fold from 2005 to 2007 (up to 10.7 billion roubles or US$445 million in total), based on Russia’s 2008 Country Progress Report.

In Uzbekistan, IDU “trust points”, which offer needle and syringe programmes and substitution therapy, are slowly being scaled up. In Moldova, harm reduction interventions are being expanded in prison settings. Ukraine has the highest estimated HIV prevalence in the region, with very high infection levels among IDUs. The Ukrainian government has demonstrated strong political commitment to address the epidemic, and access to substitution therapy and antiretroviral therapy for injecting drug users is slowly scaling up.

The first pilot substitution therapy project was introduced in Ukraine in 2004 and had expanded to 11 sites by 2007. A national operational plan to scale up opioid substitution therapy in Ukraine between 2007 and 2011 is being finalised.

Also in the Ukraine, the number of people receiving ART expanded from 137 in 2004 to nearly 8,000 people in 2007 after stewardship of a grant from the Global Fund was transferred from the Ministry of Health to the HIV/AIDS Alliance, a non governmental organisation, due to problems with grant management by the government recipient.

The Alliance, working in close collaboration with the Ministry of Health, the Ukrainian AIDS Centre and the All-Ukrainian Network of People Living with HIV/AIDS, has demonstrated how a multidisciplinary approach with shared responsibility is successful in scaling up service delivery at a national level.

Challenges and Opportunities
Universal access to HIV prevention, treatment and care in Eastern Europe and Central Asia will not be achieved unless policy and legislative changes take place that decriminalise homosexuality and sex work, and increase evidence-based infections, drawing attention to the probability of an under-estimation of the burden of disease, especially among MSM, sex
workers and prisoners.

There should be the integration of HIV prevention and care within overall health systems, strengthening and service quality assurance measures in these countries, including greater cooperation between civil society organisations and government agencies in policy and decision-making processes – meaningful civil society in this region, particularly PLHIV, remains low. The issues in this region have been complicated in some countries by rapid economic growth and less reliance on the Global Fund and other external donors; however, this could jeopardise the continuity of existing grants and programmes.

The overall access to these services for IDUs remains unacceptably low. Although access to prevention and treatment services for IDUs is expanding, many projects are still in the pilot phase. Consistent access to NSPs remains limited, and some countries, including the Russian Federation, still do not provide OST. Data on the epidemic among MSM remains very limited, although evidence suggests that the epidemic among this population may be substantially larger than official figures estimate. The Ukrainian HIV surveillance system, for example, only reported 159 HIV transmissions from sex between men since reporting began, even though there are an estimated 40,000 MSM living with HIV in the country.

The region has made better progress in PMTCT, with coverage at 71 percent in 2007. Access to antiretroviral therapy is also increasing, although coverage was only 17 percent in 2007, and drug prices remain high. Co-infection with TB and hepatitis B and C is highly
prevalent in the region. There is also support for improved HIV surveillance and monitoring, including a desegregation of service indicators by sex and by risk group, and monitoring of treatment outcomes and drug resistance.

Middle East and North Africa

There is no single HIV epidemic in this region, and the response has been shaped by diverse sociopolitical and epidemiological contexts. The regional response is described in three overlapping categories: a “comprehensive” response in countries such as Djibouti, Iran, Morocco, Somalia and Sudan; an “adaptive and potentially effective” response in countries such as Jordan, Lebanon, Tunisia and Yemen; and responses “limited” either by political constraints (such as Egypt and the Libyan Arab Jamahiriya), or by war or post-war contexts (Afghanistan, Iraq, Occupied Palestinian Territories).

Middle East and North Africa
• People living with HIV: 380,000
• AIDS-related deaths (2007): 27,000
• New infections (2007): 40,000
• Populations most at risk: sex workers, IDUs, MSM

Conclusions

Several overarching themes must be addressed in the scale-up of national HIV responses, including:

1. Advance Universal Human Rights
There is the need to address basic human rights for women and girls, gay and other MSM, IDUs and sex workers in country-level AIDS planning. National governments must acknowledge the needs of the groups most affected by HIV, expand their access to health services, and most importantly, remove legal and policy barriers to scale up by decriminalising sex work and homosexuality, taking concrete measures to address the root causes of gender inequality, and embracing the implementation of effective harm reduction strategies for IDUs, including NSPs and OST. Governments must also build more meaningful collaboration with civil society groups, especially groups representing people living with HIV, in the development, implementation and monitoring of programmes.

2. Invest In Strategic Health Information And Improve Accountability
There is the need for more robust data to understand the burden and trends of the epidemic, to inform programme development, and to measure outcomes. The lack of data regarding populations at high risk of HIV, especially MSM, is evident. The health needs of these groups will continue to be neglected unless countries commit to knowing the size of populations at risk, monitoring disease trends, and tracking their access to services. Data needs to be interpreted with caution: coverage of treatment services was measured only against the number of people who know their HIV status and are enrolled in public services – overlooking the many who are not yet diagnosed.

The international community must play its part to ensure that accurate, complete data are being collected and reported by countries. Civil society organisations are increasingly willing to build their own capacity to monitor progress and hold governments and international agencies accountable.