1.  **Introduction**

The Kuala Lumpur Monitoring the AIDS Pandemic (MAP) Network Symposium,
*The Status and Trends of the HIV/AIDS/STD Epidemics in Asia and the
Pacific* was held on 19-21 October 1999. This was an official satellite
symposium of the 5th International Congress on AIDS in Asia and the
Pacific.

The three-day MAP Network symposium held in Kuala Lumpur was the sixth
symposium formally organized by this global network formed in December
1996. It was part of a continuing series of regional and global symposia
that have been organized to understand the trajectory of the HIV/AIDS
epidemics. Starting with *The Status and Trends of the HIV/AIDS
Epidemics in Africa Symposium* that was held in Kampala, Uganda in
December 1995, a team of internationally recognized technical
specialists in epidemiology, modeling, economics, demography, public
health, and international development was formed to monitor the dynamics
of the HIV/AIDS pandemic and various regional epidemics. By collecting,
analyzing and disseminating information on HIV/AIDS, this team of
experts, which has grown rapidly over the course of three years into a
global network, seeks to assist governments, organizations and the world
at large to respond more actively and effectively to the challenges
posed by the HIV/AIDS pandemic.

The MAP symposium in Kuala Lumpur brought together 40 global and
regional experts, including MAP members and some specially invited
participants, to achieve the following objectives:

-   To present and share information on the status and trends of the
    HIV/AIDS epidemics in Asia and the Pacific and analyze this
    information in a global context;

-   To review the epidemiological and behavioral patterns among the
    HIV/AIDS epidemics affecting the different populations in the
    region;

-   To identify specific data needs for monitoring and estimating the
    HIV/AIDS epidemics in the region; and

-   To produce and disseminate a consensus report on the current status
    of the HIV/AIDS epidemics in Asia and on the current and projected
    trends for these epidemics in the region.

Because a large percentage of the world's population resides in the
Asia-Pacific region, the symposium held in Kuala Lumpur was important in
enabling MAP to focus strategically on the evolving HIV/AIDS epidemics
in the Asian and Pacific region countries, fuse current knowledge,
identify gaps therein and determine topical and geographical areas for
action.

The symposium began by first reviewing the recommendations made during
the Manila MAP symposium, 21-23 October 1997, to determine the progress
made to-date. From then on, the team concentrated on the situation in
the overall region and the Western Pacific and Southeast-Asian
subregions, presented country-specific epidemic profiles on Bangladesh,
Cambodia, China, Japan, India, Indonesia, Pakistan, the Philippines, and
Vietnam.

This provisional report, coauthored by the Kuala Lumpur MAP Symposium
participants and produced in some 24 hours, reflects a consensus of the
analysis, projections and recommendations brought forward during the
symposium. Its aim is to provide information that can be used by
international as well as local bodies to briefly review the most
important aspects of the history of the HIV/AIDS epidemics in the
Asia-Pacific region to date, recognize the current status of and trends
within these epidemics, and take immediate action to affect the course
of these epidemics in the future.

2\. The Status and Trends of HIV/AIDS Epidemics in Asia and the Pacific

With a population of nearly 3.5 billionrepresenting nearly sixty
percent of the world\'s populationthe Asia-Pacific region has the
potential to influence greatly the course and overall impact of the
global HIV/AIDS pandemic. For the purpose of this report, this region
stretches from and includes Pakistan on the west, to Japan and island
nations in the Pacific, and from China in the north, to countries
forming Oceania to the south. The general HIV/AIDS trends and HIV
prevalence levels in this region were described in the MAP report that
was prepared prior to the 4^th^ International Congress on AIDS in Asia
and the Pacific in Manila in 1997. This MAP report, prepared for the
5^th^ International Congress on AIDS in Asia and the Pacific in Kuala
Lumpur, Malaysia, in October 1999, updates the status and trends of
HIV/AIDS epidemics in the region.

## **Epidemic patterns and trends**

HIV epidemics in the region are diverse, localized, and have different
trends over time. The spread of HIV in this region began in the
early-to-mid 1980s. Early infections could be traced to sexual contacts
with infected persons residing outside the region, as well as some
apparent further spread within the region itself. By the late 1980s,
however, it became evident that the transmission of HIV was increasing
among several populations, in some cases with great velocity, and that
two sets of factors strongly influenced the course of the emerging
epidemics in this region: patterns in sex work and sexual networking and
patterns of injecting drug use (IDU).

As of 1999, this region had close to 60 percent of the world's adult
(15-49 years of age) population and about 20 percent of the estimated
adult HIV infections.[^1] Several HIV epidemics in this region began
about 10 years ago and HIV disease, including AIDS, is now increasing
markedly and the associated needs for care are rising steeply. The
estimated adult HIV prevalence in the region varies from almost zero
(DPR Korea) to one per several thousand in most countries in the region,
up to 2 to 3 percent in Cambodia, Myanmar, Thailand, and in several
major states in India.

HIV infections were first introduced into several Asian-Pacific
countries/cities such as Australia, New Zealand, Japan, Malaysia,
Singapore, and Hong Kong, during the early 1980s by men who have sex
with men (MSM), who acquired their infections in major cities of North
America and Europe. Relatively extensive spread of HIV occurred in the
MSM sexual networks in these Asian-Pacific countries/cities. These focal
epidemics peaked during the mid-to-late 1980s, but HIV incidence
continues in MSM populations in the region, albeit at much lower levels
during the 1990s. HIV infection has probably also been introduced to
other "hidden" populations of MSM in many other Asian-Pacific countries,
but data on such introductions and possible spread has not been
collected in most of these countries.

Many intense focal HIV epidemics have been documented in Asian-Pacific
countries among their IDU populations beginning around the late 1980s.
Such epidemic spread, which can lead to infection levels of over 50
percent within a year or two, have occurred in Australia, Thailand, in
northeast India, several provinces of China, Malaysia, Myanmar, Vietnam,
and most recently, Nepal. Although HIV can spread rapidly among IDUs who
share contaminated injecting equipment, and from them to their sexual
partners, these epidemics have so far resulted only in limited spread of
HIV to the heterosexual population at large.

As with all other sexually transmitted infections (STI), the major
driving force of the HIV pandemic is heterosexual transmission. This is
because there are huge numbers of heterosexuals, whose sexual behaviors
place them at significant risk of HIV, compared to the much smaller
numbers of IDU and MSM who may be at high risk of HIV. Extensive
heterosexual spread of HIV resulting in HIV prevalence levels of from
2-3 percent of the total 15- to 49-year-old population have been
documented in Cambodia, Myanmar, Thailand, and in several states in
India, but have not yet been observed in other countries in the region.

It is becoming increasingly clear that the intensity of HIV epidemics
associated with sex work, affecting both female sex workers (FSWs) and
their clients, is primarily determined by the daily or weekly number of
sex partners (clients) per sex worker, the frequency of use of
commercial sex by men, and other factors, such as the rate of regular
condom use in commercial sex. Outside of the highest heterosexual risk
groups (FSWs and their clients), the pattern, prevalence, and frequency
of heterosexual risk behaviors may be insufficient to sustain any
further significant HIV transmission within the general population at
large. However, risk behavior is not limited to sex workers and their
clients, and the magnitude of the epidemics will be determined by the
size of the larger (sub-) populations at risk.

Over the past decade, epidemiological studies have also shown that HIV
epidemics in MSM, IDU, and heterosexual populations mayin large
partdevelop rather independently of each other. An example for this may
be the two concurrent HIV epidemics of different HIV subtypes in
Thailand occurring in MSM, IDU and heterosexuals. This is probably due
to the rather tenuous social-sexual bridges between IDU and MSM
populations and other heterosexually active adults for a variety of
reasons, including social isolation of IDU and MSM populations and their
sexual partners, and/or the stigmatization to which they are subjected.
However, the presence of HIV in any of these risk groups can serve as
the spark or "bridge" to ignite an epidemic in another risk behavior
group, but any subsequent epidemic spread in that group will depend on
the pattern and prevalence of the group's HIV risk behaviors.

From a regional perspective, the magnitude and short-term trends of HIV
epidemics are largely dependent on the extent of ongoing epidemics in a
few countries: Cambodia, India, Myanmar, Thailand and, because of their
population size, Indonesia and China. With a population of 1 billion and
multiple epidemic foci, India has a complex epidemic, involving focal
outbreaks among injecting drug users and extensive HIV spread among
female sex workers and their clients in several regions.

## **Mapping the epidemics**

If the HIV epidemics were analyzed on a country-by-country basis, as if
HIV epidemics respected national geopolitical boundaries, many countries
in the Asian-Pacific regionstillshow comparably low prevalence
(proportion of adults living with HIV/AIDS) and low incidence
(proportion of adults newly infected each year). Such is the case for
the industrialized countries within the region. Australia and New
Zealand experienced sudden epidemics in MSM with a peak of incidence in
the mid-1980s, followed by a rapid decline. The spread among IDUs in
these two countries has been and remains limited (less than 2 percent
among the IDU population), due to effective prevention programs that
were started early. Heterosexual transmission also remains at low levels
(the prevalence of HIV among pregnant women is lower than 1 per 10,000)
in these countries. In Japan, where an initial dramatic outbreak of HIV
infection among people with hemophilia was brought under control in the
mid-1980s, other modes of transmission seem to contribute to a limited
HIV burden in the country today.

In some of the developing countries in the region, HIV prevalence has
also remained very low (less than 0.1 percent) in the total 15- to
49-year-old population, despite comparably high levels of sexually
transmitted infections in segments of this population. In the
Philippines, HIV surveillance has found only a few cases of HIV
infection among female sex workers, male STI clinic patients and MSM.
Similarly, only a small number of AIDS cases and low levels of HIV
infection have been reported from Indonesia to date.

Less reassuring would be the estimated and projected trends in India.
There, a sharp increase in the estimated number of HIV infections from a
few thousand in the early 1990s to a working estimate of about 3.5
million people living with HIV/AIDS in mid 1998, in a context of a
severe gap of knowledge about prevailing sexual risk-taking behaviors,
creates great uncertainty about the future course and impact of the
epidemics. HIV prevalence among sex workers in India varies widely from
state to state, with high HIV prevalence in western and southern India
and low levels of HIV in eastern and northern India. HIV prevalence
among sex workers tested in Mumbai (formerly Bombay) rose from 1 to 51
percent between 1987 and 1993. Prevalence among sex workers in Calcutta
was consistently low at about one percent until 1994, but there are
suggestions that it might be rising. In Mumbai, HIV prevalence increased
from two to three percent in STI clinic attendees before 1990 to 36
percent in 1994.

Cambodia, Myanmar, and Vietnam, as well, have seen substantial spread of
HIV, mainly driven by intravenous drug use and sex work. While
substantial heterosexual epidemics have been observed with comparably
high levels of HIV in pregnant women in Cambodia (Phnom Penh: from no
evidence of infection in 1992 to 3 percent in 1995 and 1996) and parts
of Myanmar (around 4 percent in Kawthaung and Tachileik in 1997), in
Vietnam the epidemic is still concentrated in IDUs (over 45 percent in
Ho Chi Minh City, and more than 80 percent in Da Nang) and sex workers
(up to 16 percent in 1998 in the border town An Giang). Also in
countries such as China, Malaysia and Nepal, HIV has spread
substantially in IDU populations. However, the still comparably low
levels of HIV in other population groups in these countries offer
opportunities for early prevention.

## **Large-scale epidemics ahead?**

Are HIV epidemics likely to expand abruptly in India, or in other
countries in Asia and the Pacific? To answer this question, possible
clues can be drawn from past history in several countries, including
Thailand, Myanmar and Cambodia. In Thailand, information was available
on IDU, needle sharing practices and sex work in the country when, in
the mid-1980s, HIV had not begun to spread in epidemic form. The
epidemics that were predicted but insufficiently prevented did occur
later in this decade, infecting an estimated 800,000 women, men and
newborns by 1999. HIV rates in army recruits rose to around 4 percent in
1993 with peak levels in the northern provinces about threefold the
national average. As a result of a most committed and effective
prevention strategy, infection levels then peaked and started to
gradually decline. Similarly, prevalence rates in pregnant women reached
over 2 percent in 1995 nationwide, have decreased gradually over the
past several years and in 1998 was about 1.5 percent.

In Myanmar, rates of HIV infection in IDUs, sex workers and pregnant
women are similar to those found in Thailand. Consistent with an
East-West gradient of HIV prevalence in Myanmar, the epicenter of the
epidemics appears to lie in the eastern part of the country. The
analysis of geographical differentials in HIV infection rates and trends
over time underscores both the deepening severity of the epidemics and
the potential for national, aggregate data to mask important
sub-national epidemic trends. In Cambodia, HIV spread rapidly in the
early 1990s, reaching high levels in sex workers (about 40 percent HIV
prevalence), and from 2 to 3 percent of the 15- to 49-year-old
population. The evolution of the epidemic in this country illustrates
the potential for HIV to spread fast and widely when patterns of
commercial sex involve high mobility, a high sexual partner exchange
rate, and low condom use.

Empirical evidence thus exists showing that sudden and sharp increases
in HIV incidence can and have occurred in Asia. However, the lack of
quantitative and qualitative epidemiological, behavioral and social
information on the nature of and linkages between sexual networks in any
of these countries makes it difficult to predict the future course of
HIV epidemics even in countries that would intuitively appear vulnerable
to rapid spread. These countries include, in particular, Malaysia, Nepal
and Vietnam, where rapid increases of HIV incidence in various
vulnerable populations are being noted. There is an urgent need to
collect and analyze systematically the information needed for the dual
purpose of projecting epidemic trends and targeting prevention toward
factors that seem to influence the vulnerability of the population to
the furtherand possibly rapidspread of HIV.

The potential for continued spread of HIV/AIDS in Asia and the Pacific
is real and requires determined and sustained prevention efforts.
Several countries have already experienced intense HIV epidemics in
certain population groups or, in some cases, in the population at large.
In these countries, including India, Thailand, Myanmar and Cambodia, the
individual impact of HIV has begun to be felt as AIDS has imposed new
demands on the health care systems. It is essential that countries
reinforce their prevention and care efforts in order to enhance their
response to the existing HIV/AIDS challenge. In addition, countries
should make every effort to collect and analyze the information needed
to assess and monitor the evolving potential for large-scale HIV
epidemics.

Recognizing the threat of emerging or fast-growing epidemics in certain
populations is essential to an early and effective response. To
acknowledge the possibility that, in other populations, rapid and
extensive spread of HIV may not occur is equally crucial as policy- and
decision-makers may, on the basis of this information, orient efforts
and resources towards people who are most at risk.

*HIV/AIDS in China*

China, because of its size and rapid changes in social and sexual
behaviors during the past decade, potentially represents a major focus
of the HIV epidemic in the Asia-Pacific region. During the last few
years, China has rapidly and impressively developed an HIV surveillance
system. The following is a report of the HIV distribution, trends, and
prevalence in China as of 1999, based on their HIV surveillance
findings.

![](media/image1.wmf){width="5.997222222222222in"
height="5.1930555555555555in"}During 1998, close to 100 HIV sentinel
sites were operational in 30 provinces in China. There were 36 sites for
STI patients, 22 for female sex workers (FSW), 19 for injecting drug
users (IDU), 7 for long distance truck drivers, 12 for blood donors, and
1 for antenatal women. This represents an almost doubling of the
sentinel sites that were operational in 1997.

The availability of HIV/AIDS data indicates that HIV spread among
currently-affected IDU populations is continuing to increase and is
spreading to more IDU groups in many other provinces. In 1998, over half
of the 19 IDU sentinel sites detected HIV infection and HIV prevalence
rates ranged from 10 to 80 percent in the Provinces of Yunnan, Xinjiang,
Guangxi, and Sichuan.

![](media/image2.wmf){width="5.99375in" height="4.080555555555556in"}

There is increasing public health concern that such high prevalence
rates among IDU groups in these provinces will ignite extensive spread
of HIV among FSW and their male clients. Indeed, over the last few
years, HIV infections have been increasingly detected in FSW sentinel
sites.

Although HIV infections have been detected among FSW and STI patients in
these provinces, the number of HIV infections that are not directly
associated with IDU is still limited. There is currently no evidence of
substantial spread of HIV within the heterosexual general population
following a so-called self-sustaining epidemic. However, some behavioral
surveillance data have been collected from IDU and FSW groups in China.
These data show that the levels of heterosexual and IDU risk behaviors
continue to be very high among these HIV/risk behavior groups. A very
large proportion of FSW report that they never use condoms and a
relatively large proportion of IDU groups continue to share injection
equipment. These data need to be monitored closely and prevention
programs need to be scaled up in order to limit further spread of HIV.

There are limited, but adequate HIV data to provide reasonable working
estimates of HIV prevalence in China, and the official estimate
developed by the Chinese AIDS program ranges between 300,000 to 500,000
with a working estimate of 400,000 as of the end of 1998 appears
reasonable. However, projection are difficult given the lack of data and
the large size of the country's population. Further spread of HIV within
the population at highest risk, in particular IDUs, has to be expected.
The still unclear potential for an extensive spread of HIV outside these
populations will determine the course of the epidemic in the longer
term.

As extensive spread of HIV among injecting drug populations continues to
be the major HIV/AIDS problem in China, there is a need to aggressively
institute harm reduction programs. However, such programs will not be
successful until the police and security forces in China can accept such
programs. The findings of high levels of heterosexual risk behaviors in
some areas of China, especially among the "mobile working population"
should be addressed with specific behavior change programs before HIV
prevalence rates are detectable by sentinel surveillance.

![](media/image3.wmf){width="5.404166666666667in"
height="3.7395833333333335in"}

![](media/image4.wmf){width="5.404166666666667in"
height="3.7395833333333335in"}

China still has a window of opportunity to assure that extensive
heterosexual transmission of HIV will not occur. The epidemiological
findings from Thailand and more recently from India, where extensive
heterosexual spread of HIV has been documented, show that there is
generally a 3-5 year lag after HIV prevalence reaches about 5 percent in
FSW before there is any measurable HIV prevalence in antenatal females.

Regardless of whether the overall epidemic potential for extensive
heterosexual spread of HIV in China is large or small, the only prudent
public health course of action is to promote and aggressively implement
a "100% condom use program" for commercial and casual sex settings
before HIV prevalence reaches levels of a few percent among FSW and
their clients. School education programs addressing sexual health and
HIV/AIDS should also be an essential part of the program that will lay
the ground for success of a long term strategy in response to HIV/AIDS.

# **HIV/AIDS in India**

With a population of one billion, the HIV epidemics in India will have a
major impact on the overall spread of HIV in Asia and the Pacific and
worldwide. Most of the Indian states have a population greater than a
majority of the countries in Africa. The spread of HIV within the
country is -- at least -- as diverse as the societal patterns between
its different regions, states, and metropolitan areas. Both tracking the
epidemic and implementing effective programs pose a serious challenge to
the authorities and communities at all levels. Although HIV prevalence
is low in a majority of states, the numbers of HIV infections overall
are high. The epidemics vary from states with heterosexually transmitted
infections predominating in Maharashtra and Tamil Nadu to infections
concentrated among injecting drug users (IDU) and their partners in
Manipur.

Between 1994 and 1997, HIV prevalence among STI Clinic attendees in
Maharashtra state increased from 6 to 36 percent and prevalence among
IDU in Manipur increased from 25 to 61 percent. However, there were
insufficient numbers of sentinel surveillance sites to get an adequate
picture of the overall HIV situation. There was non-participation of
some states, inadequate representation of various risk groups, no
representation of the rural population, and a scattered schedule of
rounds of collection. In order to obtain better HIV prevalence for
India, the National AIDS Control Organization instituted a National
Sentinel Surveillance program. States were given guidelines on the
selection of sentinel surveillance sites to adequately represent the
various population subgroups and a regularly scheduled timing for
surveillance was instituted.

In 1998, the number of sentinel surveillance sites increased from 55 to
180: 83 STI, 89 ANC and 8 IDU. HIV prevalence data were collected twice
in 1998, February -- March and August -- October. This was the first
ever national surveillance survey and all states and Union Territories
participated. Starting with 1999, sentinel surveillance data will only
be collected once a year, from August to October.

![](media/image5.png){width="0.7444444444444445in"
height="0.3111111111111111in"}The 1998 Sentinel Surveillance from
antenatal clinics in 7 metro cities in the country shows HIV infection
over 2 percent in Mumbai, more than 1 percent in Hyderabad, Bangalore,
and below 1 percent in Calcutta, Ahmedabad and Delhi. Levels outside
these major urban agglomerations are lower in general, and no infection
was found in a number of rural sentinel sites.

![](media/image6.wmf)

Based on the analysis of existing sentinel surveillance data, the states
and Union Territories can be broadly classified into three groups in
accordance with proposed UNAIDS/WHO typology for patterns of the HIV
epidemics as part of the UNAIDS/WHO package on Second Generation HIV
Surveillance (UNAIDS/WHO, 1999):

Group I: includes states like Maharashtra, Tamil Nadu, Karnataka, Andhra
Pradesh and Manipur where the HIV infection is 1 percent or more in
antenatal women.

Group II: includes states like Gujarat, Goa, Kerala, West Bengal and
Nagaland, where HIV infection is 5 percent or more among high risk
groups but infection rates are below 1 percent in antenatal women.

Group III: includes the remaining states where HIV infection in any of
the high risk groups is still less than 5 percent.

# India: Strengthened surveillance allows for improved estimation of HIV/AIDS {#india-strengthened-surveillance-allows-for-improved-estimation-of-hivaids .Style1}

Tracking and understanding the spread of HIV in India is a major
challenge. India is home to more people than the African continent as a
whole, and many of the Indian states have larger population sizes than
most countries in the world. The social structures of Indian society are
not uniform, and HIV is largely concentrated in sup-populations at high
risk for HIV infection. Levels and patterns of HIV spread differ
substantially from sub-region to sub-region, and reliable data on HIV
prevalence used to be rather patchy. Consequently, estimates on HIV/AIDS
for India included a large range of uncertainty and ranged between 2 or
3 and 5 million for people living with HIV/AIDS (PLWHA) in previous
years.

The National AIDS Control Organization (NACO) has undertaken major
efforts in improving the HIV surveillance system. In 1998 NACO increased
the number of sentinel sites from 55 to 180, which now cover all states
and include rural areas in 18 sites. The surveillance groups include
women attending antenatal care clinics, injecting drug users, sex
workers, and STI patients.

In October 1998 NACO convened a group of national and international
experts to review the results of the first round of the expanded HIV
sentinel surveillance with the goal of producing state-specific and
national estimates on HIV/AIDS. The group took into consideration the
HIV prevalence rates obtained through the two rounds of sentinel
surveillance in 1998, and agreed on transparent assumptions of HIV
prevalence for different populations based on surveillance findings and
specific studies, as well as urban-rural and sex differentials. The
assumptions as well as the results of this exercise were presented and
discussed during the MAP meeting in Kuala Lumpur 19-21 October 1999.
While acknowledging the limitations of any of such calculations, the MAP
members agreed on the approach and the assumptions in general, given the
difficulties described above. The new calculations give greater
confidence in the assessment of the magnitude of the epidemic in India,
and a working estimate of about 3.5 million people living with HIV and
AIDS in mid 1998 lies well within the range of previous estimates.

The national program and the MAP members agreed that there is still a
range of uncertainty around this working estimate, and minor changes in
some of the assumptions could result in substantial differences in total
estimates of those living with HIV/AIDS, given the sheer size of India's
population. However, this range will probably narrow over time, as more
and more consistent data become available through a further expanded
sentinel surveillance system. NACO will also increase the efforts to
improve the data collection on high-risk populations, such as men having
sex with men, injecting drug users, and sex workers. In addition,
behavioral studies such as the population-based study in Tamil Nadu will
also greatly contribute to a better understanding of the frequency of
risk behavior and, thus, the potentials for spread of HIV. NACO plans to
repeat this estimation exercise based on the 1999 sentinel surveillance
data in early 2000. A working group of expert epidemiologists, including
representatives from state AIDS programs, will help to ensure a better
understanding of the epidemics and improved estimates. Even more
importantly, though, this process will undoubtedly support the efforts
to decentralize India's HIV/AIDS program and strengthen states' capacity
to respond to the epidemic in an appropriate manner.

![](media/image5.png){width="0.7444444444444445in"
height="0.3111111111111111in"}

+--------+--------------+-----------+-----------------+---------------+
| # **   |              |           |                 |               |
| HIV PE |              |           |                 |               |
| NETRAT |              |           |                 |               |
| ION IN |              |           |                 |               |
| TO ASI |              |           |                 |               |
| AN AND |              |           |                 |               |
|  THE P |              |           |                 |               |
| ACIFIC |              |           |                 |               |
|  COUNT |              |           |                 |               |
| RIES** |              |           |                 |               |
+--------+--------------+-----------+-----------------+---------------+
| ##     | **CURRENT    |           | **MAIN          | **PROJECTED   |
|  **COU | HIV EPIDEMIC |           | POPULATIONS     | HIV EPIDEMIC  |
| NTRY** | TRENDS**     |           | AFFECTED**      | TRENDS**      |
|        |              |           |                 |               |
|        | **HIV        |           |                 | **(3-5        |
|        | Incidence    |           |                 | YEARS)**      |
|        | HIV          |           |                 |               |
|        | Prevalence** |           |                 |               |
+--------+--------------+-----------+-----------------+---------------+
|        | ###          |           |                 |               |
|        |              |           |                 |               |
|        | ### Countr   |           |                 |               |
|        | ies with epi |           |                 |               |
|        | demic spread |           |                 |               |
+--------+--------------+-----------+-----------------+---------------+
| Aus    | Low and      | Low and   | MSM             | Decline       |
| tralia | decreasing   | stable    |                 |               |
+--------+--------------+-----------+-----------------+---------------+
| Ca     | High and     | High and  | Individuals     | Sustained     |
| mbodia | increasing   | i         | with high and   | upward trend  |
|        | rapidly      | ncreasing | moderate risk   |               |
|        |              |           | heterosexual    |               |
|        |              |           | behavior        |               |
+--------+--------------+-----------+-----------------+---------------+
| China  | Low except   | Low and   | IDU             | Increasing    |
|        | in Yunnan    | i         |                 |               |
|        |              | ncreasing |                 |               |
+--------+--------------+-----------+-----------------+---------------+
| India  | Moderate and | Still low | Individuals     | Increasing    |
|        | increasing   | but       | with high-risk  |               |
|        | (significant | i         | heterosexual    |               |
|        | regional     | ncreasing | behavior and    |               |
|        | variation)   | (si       | IDUs            |               |
|        |              | gnificant |                 |               |
|        |              | regional  |                 |               |
|        |              | v         |                 |               |
|        |              | ariation) |                 |               |
+--------+--------------+-----------+-----------------+---------------+
| Ma     | Moderate and | Low and   | Principally     | Slowly        |
| laysia | increasing   | i         | IDUs but        | increasing    |
|        |              | ncreasing | increasing      |               |
|        |              |           | among           |               |
|        |              |           | individuals     |               |
|        |              |           | with high-risk  |               |
|        |              |           | sexual behavior |               |
+--------+--------------+-----------+-----------------+---------------+
| M      | High and     | High and  | Individuals     | Increasing    |
| yanmar | increasing   | i         | with high-risk  |               |
|        |              | ncreasing | heterosexual    |               |
|        |              |           | behavior, IDUs  |               |
|        |              |           | and their       |               |
|        |              |           | spouses         |               |
+--------+--------------+-----------+-----------------+---------------+
| New    | Low and      | Low and   | MSM and IDU     | Decline       |
| Z      | decreasing   | stable    |                 |               |
| ealand |              |           |                 |               |
+--------+--------------+-----------+-----------------+---------------+
| Papua  | Moderate and | Low but   | Individuals     | Slowly        |
| New    | increasing   | i         | with high-risk  | increasing    |
| Guinea |              | ncreasing | heterosexual    |               |
|        |              |           | behavior        |               |
+--------+--------------+-----------+-----------------+---------------+
| Th     | Moderate and | High but  | IDUs and        | Tending to    |
| ailand | stabilizing  | st        | individuals     | stabilize     |
|        | in specific  | abilizing | with high and   |               |
|        | groups       |           | moderate-risk   |               |
|        |              |           | heterosexual    |               |
|        |              |           | behavior        |               |
+--------+--------------+-----------+-----------------+---------------+
| V      | Moderate and | Still low | Principally     | Increasing    |
| ietnam | increasing   | but       | IDUs but        |               |
|        |              | i         | increasing      |               |
|        |              | ncreasing | among           |               |
|        |              |           | individuals     |               |
|        |              |           | with high-risk  |               |
|        |              |           | sexual behavior |               |
+--------+--------------+-----------+-----------------+---------------+
|        | ##           |           |                 |               |
|        |  **Countries |           |                 |               |
|        |  with low tr |           |                 |               |
|        | ansmission** |           |                 |               |
+--------+--------------+-----------+-----------------+---------------+
| Bang   | Low          | Low       | Individuals     | Slowly        |
| ladesh |              |           | with high-risk  | increasing    |
|        |              |           | heterosexual    |               |
|        |              |           | behavior        |               |
+--------+--------------+-----------+-----------------+---------------+
| Hong   | Low          | Low       | IDU, MSM        | Slowly        |
| Kong   |              |           |                 | increasing    |
+--------+--------------+-----------+-----------------+---------------+
| Ind    | Low          | Low       | MSM, Bisexual   | Slowly        |
| onesia |              |           | and high-risk   | increasing    |
|        |              |           | heterosexual    |               |
|        |              |           | behavior        |               |
+--------+--------------+-----------+-----------------+---------------+
| Japan  | Low          | Low       | Previously      | Slowly        |
|        |              |           | blood product   | increasing    |
|        |              |           | related,        |               |
|        |              |           | currently       |               |
|        |              |           | sexual          |               |
+--------+--------------+-----------+-----------------+---------------+
| Nepal  | Low except   | Low       | Individuals     | Slowly        |
|        | in IDU       | except in | with high-risk  | increasing    |
|        |              | IDUs      | heterosexual    |               |
|        |              |           | behavior and    |               |
|        |              |           | IDUs            |               |
+--------+--------------+-----------+-----------------+---------------+
| Phili  | Low          | Low       | Individuals     | Slowly        |
| ppines |              |           | with high-risk  | increasing    |
|        |              |           | heterosexual    |               |
|        |              |           | behavior        |               |
+--------+--------------+-----------+-----------------+---------------+
| Sin    | Low          | Low       | MSM, IDUs       | Slowly        |
| gapore |              |           |                 | increasing    |
+--------+--------------+-----------+-----------------+---------------+
| Sri    | Low          | Low       | Individuals     | Slowly        |
| Lanka  |              |           | with high-risk  | increasing    |
|        |              |           | heterosexual    |               |
|        |              |           | behavior and    |               |
|        |              |           | MSM             |               |
+--------+--------------+-----------+-----------------+---------------+

The following countries in the region have minimal spread of HIV
infection: Bhutan, Brunei, DPR Korea, Macao, Mongolia, Pacific Island
countries and areas, Republic of Korea.

3\. Most vulnerable populations

*Mobile Populations and the Spread of HIV in Asia*

As countries in Asia become more developed economically, population
mobility increases. Environmental degradation and the search for more
viable economic opportunities steadily feeds rural-to-urban population
migration in several countries. Many communities, once thriving, are no
longer able to support their greater numbers of people, forcing them
into migrant work or jobs depending upon the mobility of others. The
desire for economic growth, the need for more jobs and expanding
infrastructure are fueling the mobility of more and more individuals,
businesses and whole societies in ways non-existent in Asia 20 years
ago. At the same time, epidemics of HIV transcend international borders
and move through risk groups in greater numbers and with greater
frequency.

The fluidity in international markets and especially the lack of
economic stability in Asia has erupted into non-stop movement within
countries and among countries, mirrored in growing prevalence of HIV.
The epidemics themselves are more fluid, passing infection through
truckers, traders, contract laborers, sailors, fishermen, traveling
salesmen and their sexual partners, many of whom are sex workers, who
can increase the spread of HIV in communities exponentially through
sexual networks. In Bangladesh, for example, migrant workers originate
from the Gulf States, India, Malaysia, Myanmar, Nepal and Singapore,
while sailors passing through the country's prime port of Chittagong
also consist of Chinese, Croatians, Greeks, Ghanaians, Indonesians,
Koreans, Pakistanis, Poles, Russians, Slovenians, Sri Lankans and
Ukrainians.

About 100 foreign ships and more than 2,000 sailors per month dock in
Chittagong, along with some 12,000 long-distance truck drivers and more
than 1,000 local sailors, who transit Bangladesh's principal port city.
Compounding these numbers are resident populations of nearly 3,500 dock
workers and more than 26,000 rickshaw pullers. One recent study found
that nearly 42,000 men access sex workers every week in Chittagong, with
each sex worker averaging between nine and 15 partners per week. This
activity totals an estimated minimum of \$7 million per year from the
sex trade in Chittagong, and given the economic constraints in
Bangladesh, there is a guaranteed influx of young women into this
business.

Chittagong sex workers rarely request condom use since condoms are known
locally as useful only for family planning purposes. Thus, Chittagong,
as a port city with a highly transient population, exemplifies a locale
ripe for potential explosive growth in HIV infection, similar to many
other Asian border towns and cities. In these towns, the congruence of
personal anonymity, quick interactions at drinking establishments and
transit hotels, and the general lack of social and legal controls
promote risk behaviors, making both transient and resident populations
highly vulnerable to sexually transmitted infections, including HIV.

India, China, Thailand, Cambodia, to name only a few, have highly mobile
populations within their borders, moving from state to state (or
province to province) and rural to urban areas. In China, permanent and
temporary migrants may total as many as 120 million people.

# **Cross-Border Risk Areas**

Asian settlements with significant cross-border activity include Poipet
and Aranyapratet in Thailand and Cambodia respectively; Raxaul and
Birgunj in Nepal and India; and, Bauvet and Moch Bai in Cambodia and
Vietnam. These crossings are frequented by populations changing
residence, including economic refugees, as well as migrant workers, who
may traverse back and forth continually. Examples of cross-border
populations include seafaring populations between Merauke, Indonesia,
and Mahachai, Thailand, and populations crossing rivers, such as from
Mae Sai, Thailand to Taichilek, Myanmar, and Huay Sai, Laos, to Chiang
Kong, Thailand. Finally, some border locations have significant land and
sea traffic, such as from Tao Tong, Cambodia, to Klong Yai, Thailand.

Border-crossing groups frequently include sex workers, with foreign sex
workers in high demand in many places because they are considered, at
times erroneously, to be infection-free. Of increasing concern is the
illegal international trafficking of women and girls specifically for
the sex trade. Beyond issues of basic human rights are those of public
health: many of these girls return home to Nepal from India infected
with HIV. On the other hand, sex workers living with HIV in Myanmar
cross the borders into China and Thailand and infect members of local
communities in these neighboring countries.

Analysis of the distribution of HIV in parts of Asia has suggested that
busy land border crossings and international fishing ports have higher
STI and HIV rates than other locations. In Indonesia, a high percentage
of seaport workers has been found to be infected with STIs. One recent
Indonesian study determined that between 40 and 90 percent of the
seaport workers and truck drivers in the study had commercial sex in the
previous year, averaging once or twice a month. Because of the high
volume of transit and the atmosphere of risk, ports and border towns can
produce explosive pockets of HIV. In Vietnam, some provinces bordering
Chinese and Cambodian provinces, where intensive HIV epidemics exist
across the border, show the highest HIV prevalence in the country.
Pockets such as these can quickly spread HIV across countries and
regions when infected individuals work and settle in a wide variety of
locations or bring their infection home, as evidenced in sub-Saharan
Africa.

# **Challenges in Reaching Mobile Populations**

Other risk-taking populations that are highly mobile include the
military, who work in a daily environment of readiness for combat, high
stress and rigid control, which combined with peer pressure to perform,
a need for stress release and loneliness away from home, promote
risk-taking behavior while off duty. While members of the military are
more systematically being exposed, albeit briefly in most cases, to HIV
prevention programs, most other highly mobile populations are not. Most
individuals are not aware of their personal risk for HIV infection
because they are not resident anywhere long enough to receive targeted
behavior change communication messages and essential prevention
education. While this factor makes these groups difficult to reach by
prevention programs, there is an urgent need to access mobile
populations who are more vulnerable to HIV and can diffuse the virus
unknowingly across a wide geographic area. Moreover, these individuals
need diagnosis and treatment as well as provision of care.

Reaching mobile populations is difficult for a variety of reasons,
including wide variance in language, yet the need is acute. Windows of
opportunity for prevention messages of only a few days or weeks in one
site can save not only the lives of individuals, but the lives of many
others, including members of their families. Recent HIV prevention
interventions with truck drivers in Tamil Nadu, India, resulted in an
overall reduction in their number of partners and a substantial increase
in their use of condoms.

In Pakistan's Sindh province, where HIV infections number the highest in
the country, the percentage of immigrant workers is substantial,
documenting just one example of a country facing an emerging epidemic
being fueled by mobile population influx. However, a recent organized
situational response to population mobility and the HIV pandemic shows
what can be done to help protect populations through international
cooperation: The Nepal-India border project at Raxaul-Birgunj accesses
mobile populations through well-coordinated NGO and private sector
business collaboration, providing HIV prevention interventions, STI
diagnosis and treatment, and access to affordable condoms for all,
including community residents at high risk of HIV/STI.

More programs such as the one at Raxaul-Birgunj are needed urgently in
areas with high population mobility, both at border crossings and other
high-transit locations in Asian countries. While intensive ethnographic
and behavioral survey efforts would be ideal to determine specific
risk-taking characteristics and effective communication messages for
diverse populations, rapid assessments can enable an adequate design and
launching of solid programs. Given the crucial role mobile populations
play in bridging HIV infection from high- to seemingly low-risk
populations all along their pathways, they may prove to be one of the
most critically important and cost-effective groups to reach with
interventions over the long term, preventing the spread of HIV infection
in general populations throughout Asia.

# **Sex Work and HIV Transmission in Asia and the Pacific**

In the Asia/Pacific Region, sex workers are particularly vulnerable to
HIV as well as other STIs and represent the most significant core group
for transmission to the rest of the population through their clients.
The critical factors influencing the rate of spread from sex workers
include the number of clients per day and the proportion of men in a
society who regularly visit sex workers. In nations with high levels of
both of these factors and where sex is not protected by condoms, HIV
epidemics spread very rapidly. In Cambodia, HIV infection among sex
workers has risen to well over 50 percent in many areas. Similarly, in
India, where the sex trade is large, in some cities nearly half the sex
workers are infected. Even in Papua New Guinea, where formal brothels
and red light districts do not exist, HIV levels among urban floating
sex workers reached 16 percent in 1998.

In China, even though HIV infection is reportedly less than 0.1 percent
of sex workers, the total sex worker population − male and female -- is
estimated to be between three and four million. Neighboring Vietnam is
facing a more advanced HIV epidemic, with surveillance data showing that
nearly 2.5 percent of sex workers are infected, although in some areas
the percentage is much higher.

When HIV prevalence reaches higher levels among sex workers, its spread
to client groups becomes easier as more men are exposed to HIV. Regular
clients of sex workers in turn infect other sex workers, and this cycle
can lead to higher rates of infection among both groups in the absence
of condom use. Thus, comprehensive targeted interventions for sex
workers carried out when levels are low are essential to success in
diminishing the spread of HIV. Unfortunately, few nations have moved
quickly to accomplish this. Even when such programs have been
implemented early, they rarely have been large enough to have the impact
needed to affect an HIV epidemic in an entire nation.

Sex work is highly varied, and both the types and intensity of risks
associated with it vary accordingly. In the brothels in parts of South
and South East Asia, female workers are generally highly controlled and
financially pressured under the threat of violence or eviction. Without
the cooperation of persons having power over these women, safer sex
strategies − for example, 100 percent condom use − are highly likely to
fail. In Thailand and Cambodia, much of the success in obtaining high
rates of condom use has come from involving brothel owners and
encouraging them to establish condom-only establishments.

While sex workers who are independent and working on their own can be
difficult to reach, they may sometimes have greater control over their
own decision-making and learn to promote condom use with their clients.
Naturally, the most effective programs are those which intervene with
both the sex workers themselves and their clients.

Since sex workers often carry a high STI burden, programs that provide
user-friendly STI services to sex workers -- often involving them in the
design and management -- are also important. A major example of this is
the Sonagachi project of Calcutta, which originally started as a
research project in the early 1990s. It has since grown into a respected
organization operated by sex workers themselves. The project provides
STI treatment, health services, and a wide range of other services such
as literacy classes to sex workers. While populations of sex workers in
other areas of India such as Mumbai and Pune are experiencing extremely
high rates of HIV prevalence, the Sonagachi project has been able to
keep HIV prevalence at approximately 5 percent and to reduce syphilis
prevalence. However, since HIV has firmly entered the population, the
project remains challenged to increase condom use and to mobilize the
women even more to protect themselves.

For most people, the condom represents a barrier to intimacy, and many
sex workers continue to take high risks with steady partners even while
practicing safer sex with their clients. This gap in prevention behavior
needs intervention attention. Monitoring the levels of reported condom
use among sex workers with both their clients as well as their
non-paying partners is thus critical.

Sex work continues to be illegal in most countries, and therefore it is
often hidden and clandestine, making prevention interventions difficult.
Attention by public health organizations can also bring attention by law
enforcement organizations leading to arrests and forcing sex workers
even further underground where they are less reachable. The most
effective interventions are those which work together with law
enforcement agencies so that they do not undermine prevention efforts.
In a recent address about the seriousness of HIV in Cambodia, Prime
Minister Hun Sen expressed his support for the 100 percent condom in
brothels project saying that condoms must be promoted with sex workers
whether prostitution is legal or illegal in countries.

# **Men who have sex with men**

As in all societies around the world, men having sex with men (MSM)
constitute a measurable part of the population in Asian countries.
However, structure and patterns of MSM groups are widely unknown and MSM
feel marginalized and stigmatized. Men who have sex with men represent a
diverse group that is not easily identifiable for intervention, let
alone surveillance purposes. Yet they represent one of the highest risk
groups because of the transmission probabilities associated with anal
intercourse.

Governments need to build collaborative relationships with
non-governmental organizations (NGOs), which are often better at
understanding networks of men who have sex with men and provide safe
spaces for services. MSM constitute an ill-defined group, and include
men who both sell and buy sex as well as those who exclusively practice
homosexual behavior and others who are bisexual. Many of these men are
married, and all socioeconomic classes are represented in this group. In
some settings, biological males who maintain a transvestite lifestyle,
or a transgendered identity, may also be part of the MSM community.

While MSM are usually not covered in national HIV surveillance systems
in the region, examples exist that show both the importance and
feasibility of such surveys. In Bangladesh, based on the collaboration
between one NGO and surveillance investigators, MSM have become an
important part of the sentinel surveillance system, carrying out their
own behavioral surveys. In 1998, survey results showed 12 percent
syphilis (TPHA+) and 0.2 percent HIV in a sample of 401 MSM from Dhaka.
Behavioral surveillance revealed new and valuable information for the
development and refinement of targeted interventions.

In addition to self-identified MSM, other males included in the sample
also were asked about male-to-male sex. As shown below, the majority of
MSM engage in anal sex and suffer from anal STIs. This figure separates
male sex workers from other MSM, transgender males, and males who most
often are considered heterosexual. MSM accessing health care can
sometimes encounter problems from disapproving or discriminating health
practitioners. In the Dhaka MSM sample, most men sought treatment
quickly, but those of lower socioeconomic status preferred traditional
practitioners and medicine shops. Transgender males had greater problems
accessing care. The number and types of partners also varies
considerably among MSM. The figure below shows the median number of
partners last month and last year among the full sample of MSM, those
who were male sex workers (MSW), and MSM who were not sex workers.
Although a few MSM sex workers had some female partners, the non-sex
worker component of the sample had the majority of the female partners.

#### Proportion Practicing Anal Sex and Anal STIs among MSM

> ![](media/image7.wmf){width="4.989583333333333in"
> height="2.7118055555555554in"}**Dhaka, 1998.**

**Median Number of Partners (Male and All) among all MSM, Male Sex
Workers (MSW) and non-MSW Last Month and Last Year. Dhaka, 1998.**

![](media/image8.wmf){width="4.989583333333333in"
height="3.7395833333333335in"}

The study showed that condom use varied by type of partner, as did
whether sex was bought or sold. The highest risk sub-group, MSW, used
condoms for 26 percent of sex acts during the prior week with their
clients. Overall, only 8 percent of the entire MSM sample used condoms
consistently the last time they had sex.

In India, the West Bengal Sexual Health Project has included MSM in
their recently established behavioral surveillance system to monitor
progress toward risk reduction in this group. The first wave, completed
in 1999, indicated substantial risk among men: 25 percent reported
insertive or receptive anal sex with a male sex worker in the past year,
71 percent with a non-regular partner, and 50 percent with a long-term
partner. Condom use was highest with their most recent sex worker
partners (79 percent), followed by other non-regular partners (72
percent), and, finally, long-term partners (59 percent). In the future,
behavioral surveillance in West Bengal will be conducted at regular
intervals in order to determine trends among MSM as well as other risk
groups in the state.

Very few countries have carried out studies indicating the levels of HIV
or other STIs among MSM. These are important to indicate disease burden
in this group, as well as for policy and advocacy purposes to initiate
prevention interventions. Many of the existing studies have taken place
among male sex workers, as opposed to non-sex work MSM. The Thai
Ministry of Health conducts HIV surveillance among male sex workers in
selected provinces in addition to ANC clinic attendees, female sex
workers, and IDUs. In 1997, 14.8 percent of male sex workers in Chiang
Mai tested HIV-positive.

In all surveillance and monitoring studies including MSM, design and
implementation requires the active participation of target group members
and the organizations that serve them. This not only guarantees that
data are more valid and accurate, it also facilitates the design of
effective HIV prevention interventions targeted for MSM.

#  

***HIV Epidemics Among Injecting Drug Users (IDUs) in Asia and the
Pacific***

The Asia and Pacific region has been significantly affected by
drug-related HIV epidemics compared with other regions of the developing
world. In most countries in South and South East Asia, injecting drug
users (IDUs) are the first community to be affected by HIV. Typically,
HIV epidemics among IDUs reach very high levels of infection within one
year of diffusion into this population. Users in Asian and Pacific
countries are rapidly switching from non-injecting drugs to injecting
drugs, forcing previously undetectable levels of HIV to skyrocket in
these groups. Examples include some provinces in China, New Delhi,
India, and Kathmandu, Nepal, reporting HIV prevalence rates of 80
percent or more, 45 percent, and 45 percent respectively among IDUs.
Other Asian countries and locations such as Myanmar, Northeastern India,
and Vietnam have reported HIV infection levels as high as 80-90 percent
in this group.

The table below shows the estimated number of IDUs, HIV prevalence, and
the types and coverage of prevention programs in selected countries in
Asia and the Pacific. epidemics still unfolding

-   cov and enabling environment

+-------------+-------------+-------------+-------------+-------------+
| #           | **Estimated | **HIV       | **Types of  | *           |
| **Country** | number of   | prevalence  | harm        | *Percentage |
|             | drug        | among       | reduction   | of IDUs     |
|             | injectors** | IDUs**      | programs**  | covered by  |
|             |             |             |             | prevention  |
|             |             |             |             | programs**  |
+-------------+-------------+-------------+-------------+-------------+
| Bangladesh  | 25,000      | 0-2.5%      | Needle      | Low         |
|             |             |             | exchange    |             |
+-------------+-------------+-------------+-------------+-------------+
| China       | 1,000,000   | 0.4-86%     | Peer        | Low         |
|             |             |             | education   |             |
+-------------+-------------+-------------+-------------+-------------+
| India       | \> 100,000  | 1-80%       | Needle      | Low         |
|             |             |             | exchange,   |             |
|             |             |             | s           |             |
|             |             |             | ubstitution |             |
+-------------+-------------+-------------+-------------+-------------+
| Japan       | Not         | .03%        | Not         | Not         |
|             | available   |             | available   | available   |
+-------------+-------------+-------------+-------------+-------------+
| Malaysia    | Not         | 30-40%      | Peer        | Low         |
|             | available   |             | education   |             |
+-------------+-------------+-------------+-------------+-------------+
| Myanmar     | Not         | 34-90%      | None        | Low         |
|             | available   |             |             |             |
+-------------+-------------+-------------+-------------+-------------+
| Nepal       | 28,000      | 45%         | Needle      | Low         |
|             |             | (Kathmandu) | exchange,   |             |
|             |             |             | s           |             |
|             |             |             | ubstitution |             |
+-------------+-------------+-------------+-------------+-------------+
| Pakistan    | Few hundred | 0-11%       | Needle      | Low         |
|             | thousand    |             | exchange    |             |
+-------------+-------------+-------------+-------------+-------------+
| Philippines | Several     | \<1%        | Peer        | Low         |
|             | thousand    |             | education   |             |
+-------------+-------------+-------------+-------------+-------------+
| Thailand    | 60,000      | 30-40%      | Needle      | Low         |
|             |             |             | exchange,   |             |
|             |             |             | drug        |             |
|             |             |             | treatment   |             |
+-------------+-------------+-------------+-------------+-------------+
| Vietnam     | 130,000     | 37-46%      | Peer        | Low         |
|             |             |             | education,  |             |
|             |             |             | Bleach,     |             |
|             |             |             | pilot       |             |
|             |             |             | needle      |             |
|             |             |             | exchange    |             |
+-------------+-------------+-------------+-------------+-------------+

Unfortunately, the response to drug-related HIV epidemics has been
unsatisfactory. Most countries in Asia and the Pacific have depended
largely on using traditional legal measures, abstinence-based messages,
and correctional efforts with little or no proven efficacy. An example
is Malaysia, where demand reduction using legal means has not eliminated
an emerging IDU-related HIV epidemic. The table above shows that most
countries in the Asia and Pacific region do not have comprehensive HIV
prevention programs for IDUs, such as peer education and needle
exchange.

Even where intervention programs exist, there is little access to the
IDU community. In most countries, coverage of IDUs by any kind of HIV
prevention program is 10 percent or less. A recent example is the rapid
increase of HIV infection among IDUs in Kathmandu, Nepal, where the HIV
prevalence has risen from 0 percent to 45 percent, despite a pioneering
needle exchange program, which is the first of its kind in the country.

These lessons should inform countries yet to experience growing HIV
infection among drug users. Of the 26 countries reporting HIV prevalence
to the World Health Organization from the Asia and Pacific region, 19
have reported drug-related HIV epidemics, including nine countries with
significant levels of HIV. Nepal was one of two countries where HIV has
gone up because of low access to the IDU community by prevention
programs. In Pakistan, a country with low levels of HIV infection, a
recent study in Lahore revealed an 89 percent prevalence of hepatitis C
among IDUs, indicating high rates of needle sharing. Despite the growing
recognition of inadequate programs, successful and sustainable HIV
prevention among injecting drug users remains an enigma. Thus, there is
a need for much greater research and prevention outreach to the IDU
community, including participation in the design of studies and
interventions related to HIV prevention that will prove more effective
over time.

In summary, the following six points would better inform HIV prevention
programs for IDUs in the Asia and Pacific region:

-   Most countries in the Asia and Pacific region have recognized HIV
    epidemics among IDUs, yet there has been little response until after
    high prevalence of HIV has been reported.

```{=html}
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```
-   Only two countries in the region initiated harm reduction early, but
    did not ensure adequate programmatic coverage.

```{=html}
<!-- -->
```
-   Drug-related HIV epidemics are still unfolding in Asia and the
    Pacific.

```{=html}
<!-- -->
```
-   Denial of drug-related HIV epidemics continues in some countries.

```{=html}
<!-- -->
```
-   Denial of the contribution injecting drug-related HIV epidemics can
    make to HIV epidemics in the general population continues in many
    countries.

-   There is an urgent need for better designed HIV prevention
    interventions for IDUs, including the critical elements of
    comprehensive intervention, broad coverage and the creation of
    enabling environments.

    **4. HIV risk behavioral surveillance: Tracking and monitoring
    behavioral trends**

Behavioral surveillance surveys have emerged as a critical component of
an integrated surveillance package for countries. Adding to the
contributions of HIV and STI surveillance, behavioral surveillance
consists of the systematic monitoring of risk behaviors in key groups
which affect epidemic spread. Why is this necessary? Changing risk
behaviors -- specifically increasing condom use and reducing the number
of sex partners - remains a key strategy to reduce the spread of HIV,
and behavioral surveillance provides the tool to monitor whether
interventions as a whole are reaching this goal.

Furthermore, where HIV is still low, behavioral surveillance helps to
pinpoint which population groups are most vulnerable to HIV infection
and where HIV may appear in the future if prevention interventions are
not initiated. This early warning is particularly important in Asia
where many countries are fortunately still experiencing low rates of HIV
infection. Behavioral surveillance data can also be used for policy
purposes -- for politicians, religious and community leaders, and
non-government organizations -- to indicate that behaviors are putting
people at risk for HIV even though it is not yet visible.

Behavioral surveillance consists of repeated cross-sectional surveys of
sub-population groups in relatively large geographic areas such as large
metropolitan areas or a province or state. As such, the results are
meant to describe broad-based behavioral trends from these large
geographic areas rather than small project areas where specific
interventions are located. For the evaluation and monitoring of
individual projects, other types of behavioral research -- both
quantitative and qualitative - are necessary which complement behavioral
surveillance. Nevertheless, it indicates whether interventions as a
whole combined with other environmental influences are producing
behavioral change. If results indicate that behavioral change is not
occurring, then this is a signal that existing intervention strategies
need to be adjusted and re-configured.

As with HIV surveillance, behavioral surveillance necessitates careful
planning in its design and implementation. Behavioral surveillance
depends on the reliable and valid collection of sensitive self-reported
behaviors such as sexual intercourse, condom use, and injecting
drug-using practices. It requires careful scientific attention to such
design aspects as choice of groups to include, mapping of the sample
universes, sampling, questionnaire design and administration, and
analysis.

Furthermore, since the mapping and surveying of critical highest-risk
population groups such as sex workers, injecting drug users, and men who
have sex with men are important for behavioral surveillance, the active
involvement of the target group members themselves and the organizations
which serve them is indispensable.

# **Behavioral surveillance in Asia: Improvements, but still notable gaps**

In Asia, the tracking of behavior in key risk groups has improved in
several countries with the implementation of systematic behavioral
surveillance surveys conducted on a regular basis. To cite several
examples, Thailand, Cambodia, Vietnam, Nepal, the Philippines, and
Bangladesh have initiated systematic behavioral surveillance surveys in
the past five years. In larger countries such as China, India, and
Indonesia, several provincial and state-level behavioral surveillance
surveys have been initiated to provide more regional estimates.

In Thailand, where some of the earliest behavioral surveillance began
and indicated that condom use among sex workers and their clients has
reached 90 percent or more levels, the challenge will be to maintain
these levels. "Relapse" to unsafe sexual behaviors has been documented
in Western countries among men who have sex with men populations, and it
is likely that long-term maintenance of condom use among sex workers and
their clients in Thailand will confront similar challenges.

Behavioral surveillance in Cambodia was initiated in 1997 by the
National AIDS Program among the following population groups: female sex
workers, beer promotion women (who also operate as indirect sex
workers), working women, military/police, motorcycle taxi drivers, and
male vocational students. These groups were chosen to represent a
diverse cross-section of population sub-groups important to track
behavioral trends. Results between 1996-1998 indicate that all three
male groups reduced their HIV risk. In 1996, 58 percent of
military/police, 42 percent of motorcycle taxi drivers, and 27 percent
of vocational students reported visiting a sex worker in the past month.
By 1998, this was reduced to 36 percent, 34 percent, and 18 percent,
respectively. Likewise, condom use increased among all the groups with
their sex worker partners. The sex worker samples corroborated these
results with 16 percent of them reporting consistent condom use in 1996,
increasing to 42 percent in 1996 and 54 percent in 1997.

In the Southern state of Tamil Nadu in India where HIV rates are among
the highest in the country, a behavioral surveillance project there by
the AIDS Prevention and Control (APAC) Project has been monitoring
behavioral trends since 1996 in several urban areas of the state.
Population groups included in the survey are female sex workers, truck
drivers/helpers, male factory workers, and female factory workers. Among
other risk reduction findings, the survey has found two important
trends: reductions in non-regular sex partnerships and increases in
condom use among non-regular sex partners. Non-regular sex partnerships
declined from 48 percent in 1996 to 32 percent in 1998 among
truckers/helpers, 15 percent to 9 percent among male factory workers,
and 3 percent to 1 percent among female factory workers. More in-depth
analysis revealed that among the male groups, most of the reduction was
among the men's paid partners, not their casual partners.

Furthermore, as the figure below indicates, condom use among all the
groups with their non-regular sex partners increased as well. Sex
workers increased condom use with their clients from 56 percent in 1996
to 80 percent in 1998, truckers/helpers from 44 percent to 66 percent,
male factory workers from 17 percent to 50 percent, and female factory
workers from 20 percent to 26 percent (low sample sizes in the latter
group makes the estimates unstable.)

![](media/image2.wmf)

Behavioral surveillance may sometimes indicate that strategic changes
are necessary. In Indonesia, HIV prevention interventions have been
under way for several years to increase condom use between sex workers
and their clients. But amidst low HIV risk perception and social,
political, and economic disruption during the past few years in
Indonesia, behavioral change has been difficult to realize. Behavioral
surveillance in Jakarta, Surabaya, and Manado from 1996 to 1998
indicates that condom use between sex workers and their clients remains
to a great extent still very low and unchanged, despite substantial
interventions during the past few years.

In 1998 Bangladesh undertook expanded HIV, syphilis and behavioral
surveillance. This initial wave showed striking differences in risk
behaviors, corroborated by the levels of syphilis found among brothel
and street-based sex workers, MSM, IDUs in two cities, and long-distance
truckers. The sampling frame included a full proportional random sample
of all 18 registered brothels (n=1,147) and cluster samples among the
other groups, for a total of 3329 respondents.

The findings indicated a serious problem of needle sharing in both Dhaka
and Rajshahi. Fewer than 5 percent of men in both samples injected
safely over the past week. Brothel-based sex workers averaged more
clients per week than street-based women (9 vs.16), but the street-based
women experienced far more violence. Street-based women reported 56
percent group hire sex the previous week, as compared with 18 percent of
brothel women. Anal sex and anal STI symptoms were common among men who
have sex with men, and 25 percent of brothel women reported anal sex the
previous week. Reported condom use in the past week ranged between 2
percent and 42 percent, depending on gender and on whether the partner
was a client or lover. Overall, condom use was highest among street
based sex workers at 28 percent. About half of the truckers revealed
they had non-marital sex the previous month, over 80 percent of which
was commercial. About 12 percent of truckers had sex with both males (or
hijras) and females over the past year.

Despite the above accomplishments, there remain considerable gaps in
monitoring behavioral trends among several important target groups in
Asia, notably injecting drug users and men who have sex with men. These
gaps in behavioral surveillance reflect a lack of prevention
interventions. However, given the vulnerabilities of these groups, they
require special attention, both in the design and implementation of
programs, as well as behavioral surveillance to monitor the success of
these programs.

## 

##### Community prevalence of sexually transmitted infections in Tamil Nadu

The emerging HIV epidemic in India has made STI control one of the most
important strategies since early diagnosis and prompt, appropriate
treatment of STI have a vital role to play in the prevention of HIV
transmission. There is a dearth of community-based data on STI, and
estimates are highly variable. In this background, the AIDS Prevention
and Control (APAC) Project of Voluntary Health Services in Tamil Nadu
commissioned a study to obtain the prevalence of seven major STIs and
five syndromes. A consortium of institutions was formed with expertise
in epidemiology, biostatistics, microbiology, social work, and
management.

Using a multi-stage sampling design, 1,981 adults (15-45 years) were
randomly selected from 1,114 households in 90 clusters distributed in
three districts of Tamil Nadu. During a 45-day period, 90 medical camps
were held and all members in the community were invited to obtain basic
medical care. Before the commencement of medical camps, social workers
visited the selected households 3 or 4 times and motivated the study
population to participate in the research. During the medical camp, the
study population was identified by the social workers that obtained
their informed consent and accompanied them to the interview, medical
examination, and specimen collection. Specimens collected were blood,
urine, vaginal smears, cervical smears, and urethral swabs, and care was
taken by laboratory experts to label and transport them to a central
laboratory. In total, 8,791 specimens were collected and 18,349 tests
were done.

Overall, the community prevalence of STIs was 9.7 percent. Including Hbs
Ag and HIV, the prevalence was 15.8 percent. The prevalence of HIV was
1.8 percent. Thirty-two percent of the women and 72 percent of the men
who were diagnosed with STIs had no significant genital/urinary symptoms
on clinical examination.

![](media/image3.wmf){width="2.5819444444444444in"
height="2.1041666666666665in"}Syndrome Percentage

Vaginal discharge (W) 41.50

Genital Ulcers (W) 2.70

Scrotal swelling (M) 2.10

PID (W) 0.60

Urethral discharge (M) 0.20

Genital ulcers (M) 0.10

(W=women M=men)

# **5. Recommendations from the MAP Symposium in Kuala Lumpur, Malaysia, 19-21 October 1999**

1.  Recognizing the fundamental principles of human rights is critical
    in mounting an effective response to the HIV/AIDS pandemic. Most
    populations in Asia and the Pacific at high risk for HIV infection
    are marginalized. They may practice activities considered illegal,
    making the provision of effective prevention and care services for
    these groups very challenging. Yet it is precisely these populations
    -- including injecting drug users (IDUs), sex workers and men who
    have sex with men (MSM) -- who need HIV services the most.

> Better understanding of the extent and distribution of these
> populations is essential for planning and providing the comprehensive
> prevention and care services they deserve. Effective service delivery
> requires not only a non-discriminating and non-stigmatizing approach,
> but also the participation of community members in planning,
> implementing, and evaluating surveillance and initiatives to ensure
> their success and the overall sustainability of programs.

2.  MAP recognizes that mobile populations in the Asia-Pacific region
    are one of the groups most vulnerable to infection, as HIV is not
    confined by state or national borders. Mobility includes
    cross-border and within-country movements of workers (farm workers,
    truck drivers, fishermen), traders and refugees within and between
    countries and between rural and urban areas. Sex workers are often
    highly mobile as well. Specific programs need to be developed for
    effective surveillance of these populations to provide guidance for
    prevention and care services. Although such programs may be
    difficult to start due to the need for multi-sectoral and
    international cooperation, it is essential to initiate these
    programs even if they are only of limited scope initially.

3.  Confidentiality is key in all activities related to HIV/AIDS
    surveillance, prevention, and care. For HIV and AIDS case reporting,
    confidentiality is absolutely essential to ensure confidence in the
    system and the protection of individual human rights. For HIV
    sentinel surveillance, the use of unlinked anonymous studies is
    preferred, but where they are not possible, confidentiality is
    crucial for enabling participation and data validity. Access to
    confidential, voluntary HIV counseling and testing is becoming an
    increasingly important part of effective HIV/AIDS programming around
    the world. Confidentiality is also crucial for effective case
    finding and providing adequate care and support for people living
    with HIV/AIDS.

4.  Building on the achievements of existing surveillance systems and
    their various improvements over the last five years, most countries
    in Asia and the Pacific need to develop comprehensive surveillance
    packages. Described by UNAIDS and the World Health Organization in
    their recent publication on second generation surveillance,
    guidelines for such packages focus on the following elements:
    improved HIV sentinel surveillance, behavioral surveillance,
    surveillance of sexually transmitted infections (STIs), and HIV/AIDS
    case reporting. MAP encourages countries to examine the elements of
    second generation surveillance and determine the feasibility for
    national and local implementation.

5.  A key element of second generation surveillance is the use of
    behavioral surveillance to better monitor HIV epidemics among
    selected population groups. Behavioral surveillance includes both
    qualitative aspects (mapping of risk groups, assessment of networks)
    and quantitative aspects (following key behavioral variables over
    time to monitor trends). Such behavioral information is needed to
    better understand the HIV epidemics, indicate the potential for the
    spread of HIV, and help guide effective prevention programs,
    contributing to monitoring and evaluation.

6.  The close association between the transmission of STIs and HIV means
    that STI surveillance, prevention and treatment programs should be
    integrated with their corresponding HIV programs. Further, STIs
    themselves are markers for unprotected sex, signaling that STI data
    forms an important part of overall behavioral and epidemiologic
    surveillance.

7.  MAP recommends that greater emphasis be placed on the need for
    quality in surveillance data. For HIV sentinel surveillance, more
    attention needs to focus on selecting representative sentinel sites
    and using appropriate data collection methods to reduce
    participation and selection biases. In this regard, the quality of
    sites may be even more important than the quantity of sites.
    Moreover, multiple data sources should be used wherever possible to
    provide a "triangulation" of results for greater validity and more
    precision. It is particularly important to use data sources in
    addition to traditional surveillance data, such as qualitative and
    quantitative data from community groups, non-governmental
    organizations, and the private sector. The quality of policy and
    program decisions can only be as good as the data upon which they
    are based.

8.  National estimates of HIV prevalence may be valuable for advocacy,
    facilitation of political support and program planning. Producing
    useful estimates, however, is only feasible with good data. Good
    data overall are more important than HIV prevalence estimates as
    such. The process of creating estimates is more important than the
    final numbers, since the process itself improves the understanding
    of the HIV epidemics. This process should be both participatory and
    consensual, involving national and local experts as well as
    representatives of the affected communities. Only by using such an
    informed mechanism can a sense of ownership of the resulting
    estimates be ensured.

[^1]: For comparison, sub-Saharan Africa has less than 9 percent of the
    global adult population and more than two thirds of the global total
    of adult HIV infections, and countries in North America and Western
    Europe have about 12% of the global adult population but less than 5
    percent of the estimated global total of adult HIV infections
    (UNAIDS/WHO, 1999).