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Risk and vulnerability: do socioeconomic factors influence the risk of acquiring HIV in Asia?

Greener, Roberta; Sarkar, Swarupb

doi: 10.1097/01.aids.0000390084.37812.30

HIV epidemics in Asia have been mainly concentrated among certain population groups such as injecting drug users, sex workers and their clients and men who have sex with men (MSM). HIV risk has also been associated with labour migrants and their partners. Many of the people at risk through these behaviours are very poor, and this raises the question that poverty and social deprivation may be underlying factors that drive the adoption of risk behaviours and can be regarded as ‘determinants’ of vulnerability to HIV infection in Asia. The study presents some observations of the socioeconomic pattern of HIV spread in Asia, using country-level and household-level data. The discussion then draws tentative conclusions about what is known concerning the mechanisms influencing the risk of HIV acquisition in Asia and what they might imply for programme design and policy. In summary, the data presented here do not support the hypothesis that HIV epidemics in Asia are primarily driven by poverty and social deprivation, though sex inequality and education for women and girls are strongly associated factors. There is clearly a multidimensional relationship between the risk of HIV infection and a host of underlying social and cultural factors that confound any attempt at a single explanation for the HIV epidemic in Asia or elsewhere. There is an undeniable need for further research through multicountry studies and better analysis of existing household data, as well as through further investigation of the quantitative relationship between the barriers to HIV services and the risk of infection. The key message for policy is to seek a broad balance between a focus on prevention and treatment for the higher-risk behaviours without losing sight of the importance of programmes that address vulnerability and behavioural change among the sexually active adult population. The implication of these findings for the allocation of resources for downstream factors such as risk behaviours as well as upstream development factors is briefly discussed.

aJoint United Nations Programme on HIV/AIDS, UNAIDS, Switzerland

bAsia Unit at the Global Fund for AIDS, Tuberculosis and Malaria, Geneva, Switzerland.

Correspondence to Robert Greener, Senior Economics Advisor, Joint United Nations Programme on HIV/AIDS, 20 Avenue Appia, CH-1211, Geneva 27, Switzerland. Tel: +41 22 791 4493; fax: +41 22 791 4187; e-mail:

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In most areas of public health, there is a strong association between poverty and health status – wealthier countries and wealthier individuals enjoy better health as measured by a variety of indicators such as life expectancy. It is, therefore, not surprising that many people have expected HIV to follow this pattern, even describing it as a ‘disease of poverty’ [1].

To date, the HIV epidemics in Asia have mostly been concentrated among injecting drug users, sex workers and their clients and men who have sex with men (MSM) [2]. HIV transmission has also been associated with labour migration, both within and across borders [2]. Many of the people at risk through these factors are very poor, suggesting that poverty and social deprivation may be underlying factors that lead to risk behaviours and constitute social ‘determinants’ of vulnerability to HIV infection in Asia.

Indeed, there is a view that AIDS drives a ‘vicious circle’, caused by its ‘downstream’ impacts, which increase poverty and social deprivation, and the ‘upstream’ effects of social deprivation, which potentially increases the societal vulnerability to HIV infection [3].

The potential downstream impacts of AIDS on individuals and households arise from the microeconomic impacts of AIDS. These are likely to be proportionately greater for poor households, and AIDS can be expected to increase both poverty and income inequality in areas of high HIV prevalence [4].

The economic impact at higher levels of aggregation (such as on the gross national income – GNI) or macroeconomic impact is inferred from modelling work rather than empirical measurement. Most such studies apply to high-prevalence African countries, but one Asian study argued that there may be significant impact in some Asian countries (as high as 0.5% of per-capita GNI annually) [5], though this conclusion is not supported by other studies [6].

A possible dynamic for upstream effects is that poverty and food insecurity give rise to the adoption of risky behaviours, particularly among women who may engage in transactional sex. In addition, the economic dependence of many women on their partners is also thought to increase their risk, because it makes it difficult for them to insist on safer sex, even within stable partnerships.

It is important to understand the socioeconomic factors that influence the transmission of HIV, because policy makers have often been unresponsive to the important issues related to HIV that are identified with behaviours like drug use or commercial sex considered to be socially undesirable. Unfortunately, evidence of these upstream effects is inconclusive and has primarily been investigated in the African context [7]. The evidence is not yet adequate to bring an understanding of the degree or dynamic in the Asian context. In general, the view that poverty is a principal driving force behind the epidemic is not well supported either at national or at household level. The purpose of this study is to investigate the current evidence for these upstream effects and to examine their policy implications.

The study presents some observations of the socioeconomic pattern of HIV spread in Asia, using data at both higher and lower levels of aggregation. The choice of socioeconomic variables is restricted to those that have been measured together with HIV prevalence. The discussion draws tentative conclusions about what is known concerning the mechanisms influencing the risk of HIV acquisition in Asia and what they might imply for programme design and policy.

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The socioeconomic pattern of HIV spread in Asia

Country level pattern of HIV

The regions of south, south-east and east Asia encompass considerable economic and cultural diversity, in the levels of HIV population prevalence and in the dynamics of spread of HIV. At the national level, there is no discernable correlation in low-income and middle-income countries between per-capita GNI and the prevalence of HIV (see Fig. 1, which omits high-income countries such as Japan, Korea and Singapore). The poverty level, measured by the percentage of people earning an income less than $1 per day, is also uncorrelated with HIV prevalence, though the highest HIV prevalence is found in the country with least poverty (Thailand) and a much lower prevalence in the country with the highest poverty rate (India).

The relationship between HIV and sex inequality (represented here by the Gender Development Index – GDI, which includes measures of sex parity) is very weakly positive (i.e. there is slightly higher HIV prevalence where there is less sex inequality), but is not statistically significant. Income inequality, as measured by the Gini coefficient, is similarly uncorrelated with HIV at the national level, in contrast to the association found in sub-Saharan Africa [3].

The most striking country level pattern can be seen in the association between HIV prevalence and the proportion of men who report visiting sex workers (see Fig. 2). There is clearly a positive association between countries, though it would be more meaningful if it were possible to divide India into the separate states, as India is known to have many clustered epidemics.

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Household level pattern of HIV

Given the diversity in national population and economic structure, there is a limit on the amount of information that can be gleaned from cross-country scatter plots. Household level data are now becoming available from the two countries that have conducted a Demographic and Health Survey (DHS+), which include an HIV test. Figure 3 shows the distribution of HIV prevalence broken down by quintiles of wealth, derived from a measurement of assets for these two countries, India and Cambodia [8,9] (Figs 4 and 5).

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Poverty and HIV in India and Cambodia

In India (2005–2006), the HIV prevalence was higher among men than among women. For both men and women, the highest HIV prevalence was found in the fourth wealth quintile, that is, among households with wealth levels higher than the median value, whereas the lowest prevalence was found in the highest wealth quintile. For women, the prevalence rose steadily from the lowest wealth quintile up to the fourth, whereas for men, there was also high prevalence among the lowest wealth quintile. In addition, the difference between urban and rural prevalence in India was not found to be large – for women, rural prevalence is about three quarters of the urban prevalence and for men almost 90% of urban prevalence.

In Cambodia (2005), there was higher HIV prevalence among women than among men, except in the wealthiest quintile. For both men and women, there is a clear positive association between the wealth index and the HIV prevalence. This difference may be to a large extent explained by the difference between urban and rural prevalence rates, which are less than 40% of urban rates for women and about a quarter of urban rates for men.

Although the lowest wealth quintile in both cases had slightly higher prevalence than the second quintile and the highest wealth quintile had lower prevalence than the fourth quintile for men in India, the HIV prevalence generally increased with the wealth quintile for both men and women, particularly in the middle three quintiles. For India and Cambodia, therefore, wealth and HIV infection were found to be positively associated at household level, as has been found in most sub-Saharan African countries [10]. The situation in other Asian countries may be different, but can only be fully investigated once DHS+ type surveys are available.

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Education and HIV

Household-level studies in sub-Saharan Africa find that HIV prevalence tends to be higher among men and women with higher levels of education [10]. Multivariate analysis that controls for confounding with household wealth and other factors has, however, shown that education predicts health independently of income and is generally protective [11]. In sub-Saharan Africa, this predictive effect applies also to HIV.

Household evidence in the DHS surveys from India and Cambodia is mixed concerning the bivariate association between education level and HIV prevalence. In India, women with less than 5 years of education had the highest prevalence (somewhat higher than those with no education at all), and showed declining levels for higher levels of education. Men showed a generally similar pattern, though the highest prevalence was among those with no education. This strongly suggests that education is protective in India for both men and women.

In Cambodia, the pattern was sex-specific. For women, the highest prevalence was among uneducated women and the lowest among those with secondary or higher education. For men, the pattern was reversed – more educated men had higher HIV prevalence. This result may not be confirmed by multivariate analysis, but the pattern suggests that education in Cambodia has a protective effect for women, if not for men. The difference in this association between women and men warrants further investigation, in particular through multivariate analysis of existing data.

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Sex, marital status and HIV

Social norms in many Asian countries permit men to exhibit high-risk behaviour such as visiting sex workers and to dominate sexual decision-making within the household. The data show that men have a much higher engagement in sex outside marriage – between 5 and 20% of Asian men are clients of sex workers, who constitute only between 0.2 and 0.8% of women [12]. A study from Cambodia has shown ‘that HIV infections acquired during paid sex are on the decline, but HIV infections in pregnant women have stayed stable – as men continue to transmit HIV to their wives and partners' [13].

In Thailand, although overall incidence is falling steadily, women's HIV prevalence is still rising, despite the fact that most of them do not exhibit ‘risky behaviours’. A United Nations Development Programme (UNDP) report from 2004 stated that as many as half of the new adult infections are occurring among women who were infected by their regular partners [14].

This pattern suggests that married women, despite exhibiting minimal risky behaviour, are at risk because their partners are current or former clients of sex workers and form a ‘bridge’ for the spread of HIV into the general population. If true, marriage itself might be regarded as a risk factor, especially wherein women are neither able to negotiate safe sex nor to control the extramarital sex of their partners.

The DHS+ surveys from India and Cambodia both show higher HIV prevalence among married women (and men) than among those who are unmarried (though this would be expected if premarital sexual activity were low). However, both surveys also show that HIV prevalence was markedly higher for both men and women who had once been married, but were now either divorced, separated or widowed. Although this is a comparatively small group, it suggests either that the risk in both countries would seem to increase considerably after marriages break up (if HIV was acquired after the break-up) or that there is a tendency for marriages to break up if one or other partner is HIV-positive.

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Mobility and HIV

Evidence from many Asian countries suggests that people who move in search of work are at higher risk of HIV infection. There are a variety of ‘push’ and ‘pull’ factors that drive migration. One of these is a fall in rural–urban terms of trade, making it more difficult to obtain a livelihood in rural areas [15,16], which has been identified as a factor leading rural women to seek sex work in the cities. Although this may be a significant factor in south-east Asia, household-level data from the India Family Health Survey (FHS) did not confirm a positive relationship between HIV prevalence and the frequency and duration of travel away from home by men. The result showed no increase in vulnerability for long-term migrants and in fact seemed to show that the vulnerability of those who left for short periods was less than average.

There are wide differences in the levels of industrial development and employment opportunities between neighbouring countries that lead to economic migration. A major destination for migrant workers in south and south-east Asia are the countries of the Gulf Cooperation Council (GCC). The International Labour Organization (ILO) estimates that in 2000, Asian migrant workers made up 40–70% of the labour force in the countries of the GCC [17,18].

There has been little research linking the vulnerability of migrant workers to HIV. One of the few available studies suggests that intercountry migrants face increased vulnerability to HIV: long periods away from home; limited access to information and services and limited rights to organize and negotiate [19]. In the Philippines and Sri Lanka, 60–80% of those seeking work abroad are women.

Several countries report that a large proportion of HIV-positive people are former migrant workers. For example, about 70% of the reported people living with HIV (PLHIV) in one province in Pakistan [North West Frontier Province (NWFP)] were deportees from the Middle East; 33% of the new infections in the Philippines were among overseas Filipino workers (December 2006); and 41% of PLHIV in Bangladesh were returned migrant workers (2002) [20].

The report of the commission on AIDS in Asia (2008) has suggested that a strategy that targeted those among the migrant population who visit sex workers may be more efficient than addressing the overall migrant population.

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Stigma, discrimination and HIV

Although not normally regarded as risk factors for the acquisition of HIV, stigma and discrimination directed against sex workers, injecting drug users and MSM are significant barriers that deter access to counselling and testing, and other prevention and treatment services. Stigma, therefore, adds to a social environment that complicates the delivery of prevention and treatment services.

A study by Asia Pacific Network of People Living with HIV/AIDS (APN+) in the Asia and Pacific region showed that healthcare settings were most frequently identified by respondents as places where they have experienced both stigma and discrimination. In Thailand, 40% of respondents complained of breaches of confidentiality within the health system [21]. A study in China showed that some HIV-positive people refuse HIV information and avoid healthcare professions because of stigma. The same study cited also indicates that HIV-positive women are more likely to experience stigma and discrimination in India, Indonesia, Philippines and Thailand [22].

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Barriers to access of services aimed at most-at-risk populations

Although socioeconomic factors such as poverty, education and sex have been discussed in literature as potential determinants of HIV, the role of the immediate environment as a barrier to HIV prevention services is not sufficiently discussed [23]. For example, harassment by police, violence, timing of services and attitude of the service providers have been identified to be determinants of poor utilization of prevention services and, therefore, potentially higher HIV incidence [24]. The commission on AIDS in Asia advocated that these issues should be compulsorily addressed in risk reduction programmes. Some recent programmes such as Avahan (funded by the Bill and Melinda Gates Foundation) in India have incorporated them in their large-scale prevention settings [24].

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Most adult HIV prevention programmes in Asia and elsewhere focus upon condom use, the use of unsafe needles for injection, reducing the number of concurrent partners and STI treatment. It is clear in the Asian context that there needs to be a strong focus on higher risk behaviours such as sex work and injecting drug use (IDU), but these approaches have been criticized on the grounds that they do not pay sufficient attention to the broader social and economic determinants of these high-risk behaviours and may lack effectiveness as a result [25]. The evidence presented above does not yet seem sufficiently strong to support this view, but there are glaring gaps in our understanding of the relationship between social and economic factors and HIV prevalence. The current reality is that the bulk of prevention resources are not allocated to sex workers or most-at-risk populations, despite the centrality of these populations in the Asian epidemic. They currently receive a budget amounting to less than 20% of the total resources allocated [26].

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Poverty and HIV

Although there does not appear to be a direct causal link between poverty and the risk of acquiring HIV, the household-level evidence from DHS surveys is currently limited to two countries, and there is as yet no published literature that has conducted a multivariate analysis of these data to search for causal effects associated with household wealth or education.

In both India and Cambodia, there was high HIV prevalence (though not the highest in the population) among the poorest households, where the impacts of AIDS illness will be felt most strongly in the absence of effective social protection or social health insurance systems. It seems clear that AIDS is an additional factor that strengthens the urgent need to build effective social safety nets throughout the Asian region.

The DHS+ reports do not support the hypothesis that the highest vulnerability is found among women living in the poorest households. The contrary appears to be true – that there is generally higher vulnerability for households that have a higher wealth index (with the exception of the wealthiest households, and men in the poorest households). This evidence clearly supports the hypothesis that vulnerability to HIV infection is associated with people living in wealthier, probably urban households.

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Paid sex and HIV

Work done by Tim Brown through his modelling of Asian Epidemic Model [12] has established the role of paid sex as a key determinant of the Asian HIV epidemic. His work, discussed at length in the report of the commission on AIDS in Asia and elsewhere, has established beyond doubt the interrelationship between IDU, MSM and sex work. He concluded that the HIV prevalence in an Asian country would be largely determined by the percentage of the adult male population who are clients of sex workers. Although IDU can accelerate the epidemic and HIV among MSM remains a parallel epidemic, male clients and their partners who are mostly monogamous constitute the majority of the infected population [27].

The findings in both India and Cambodia are consistent with this relationship between HIV and the proportion of men who are clients of sex workers – this is a risk behaviour that is likely to be more prevalent among men who have more disposable income. This empirical finding is strongly suggestive that sex work is the most important driver of HIV infection in the region.

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Education and HIV

Education has been a major focus in many Asian countries in recent decades, and the evidence shown here indicates that the level of education is very likely to be associated with reduced risk of HIV infection, though this cannot be clearly established in the case of Cambodia without multivariate analysis. The case was, however, particularly clear for women, who showed lower HIV prevalence with higher levels of education in both India and Cambodia, even without controlling for the effect of household wealth. This gives a strong indication that the strengthening of education systems targeted at girls is almost certainly a vital enabling factor for HIV prevention in the region.

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Sex inequality and HIV

The household-level evidence confirms higher infection rates among married women. It would seem clear that HIV programmes must continue to target this group, for example, through antenatal clinics. Important examples might be women who have husbands with occupations that require travel (merchants, soldiers, seafarers, migrant workers, truck drivers and mobile construction workers).

The vulnerability of young women needs to be reduced by measures to improve access to schooling and education in sexuality and reproductive health. In conjunction with improved property and inheritance rights for women, these measures will reduce women's economic dependence on men.

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Mobility and HIV

The evidence shows that HIV risk and consequent infection among migrant and mobile workers is largely restricted to those among them who are clients of sex workers. Although the vulnerability of migrant workers can be addressed in the long term by providing better prevention education in both the donor and recipient countries, the risk behaviour is best addressed in the short term in a sex-work setting or by targeting potential clients. Although there have been successful examples of client intervention both outside and within sex-work settings, the evaluations of typical migrant programmes, with the exception of truck drivers, have not been well designed (STI 2010). It is encouraging to note that south and south-east Asian Ministers of Health attending the World Health Assembly in 2007 in Geneva agreed to collaborate with regard to all areas of health risk and to cooperate with the receiving countries (in this case, the Gulf Cooperation Countries) regarding the repatriation of infected workers.

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Stigma, discrimination and HIV

There is considerable evidence that stigma is an obstacle to accessing health services, but both stigma and associated discrimination reflect deeper social attitudes and are not amenable to quick-fix measures. A sustained campaign is needed, including political advocacy with leaders (religious, social and political), social activism, legal reform, information campaigns and human rights activism.

Discrimination at the programme level can be reduced by designing services to protect patient confidentiality and avoid harassment by public authorities. The expansion of antiretroviral therapy (ART) programmes can also reduce stigma as people on treatment regain health and normal social function.

There is clearly a multidimensional relationship between the risk of HIV infection and a host of underlying social and cultural factors that confound any attempt at a single explanation for the HIV epidemic in Asia or elsewhere. The key message for policy is to seek a broad balance between a focus on prevention and treatment for the higher-risk behaviours without losing sight of the importance of programmes that address vulnerability and behavioural change among the sexually active adult population.

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Policy implications for prioritization and financing

The debate about risk and vulnerability (upstream and downstream factors) often centres around resource allocation and financing. In a resource-constrained environment, there is competing demand to finance wider issues of vulnerability reduction such as girls’ education as well as addressing the immediate risk behaviour of sex workers and their clients. The Commission on AIDS in Asia (2008), while noting this controversy, has recommended that the AIDS budget in a resource-constrained setting should prioritize the primary risk behaviour while providing catalytic budgets to other Ministries and sectors for long-term development issues such as girls' education and social security for catastrophic health expenditures. These latter factors must be addressed on a long-term basis and through larger and more broad-based funding from a variety of sectors and should not solely depend on AIDS budgets [6].

On the other hand, social factors, including reduction in stigma must be a part of prevention interventions within activities meant to reduce transmission among sex workers, injection drug users, MSM and their partners. These activities, often called ‘enablers’, are required to create an enabling environment for these groups by removing barriers to access to services. Some of these include the timing of services (for example, evening rather than daytime for sex workers), community ownership (for example, MSM, IDU or sex workers running their own clinics), removing disincentives caused by police harassment or violence and addressing other hindrances (for example, crèches to look after children of sex workers while they attend clinics or those of IDUs in detoxification services).

Finally, more systematic research needs to be carried out on the collection and multivariate analysis of existing as well as new data at household level from cross-sectional surveys or case–control studies in community settings. In addition, the social and economic impacts of the epidemic have been primarily studied by modelling or theory than by empirical surveys or measurement. As a result, comparatively little is known about the mechanisms or duration of the income and expenditure impacts resulting from AIDS at household level in Asia. Clearly, empirical research in this area would be helpful for the design of programmes and policies to address the impact of the epidemic.

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The views expressed in this paper are those of the authors and do not necessarily represent the position of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Conflicts of Interest: None.

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HIV; inequality; poverty; vulnerability

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