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AIDS in Asia amid competing priorities: a review of national responses to HIV

Rao, Prasada JVRa; Mboi, Nafsiahb; Phoolcharoen, Wiputc; Sarkar, Swarupd; Carael, Michele

doi: 10.1097/01.aids.0000390088.60682.6f

Introduction: The paper reviews progress in addressing the HIV epidemic and questions whether at the midway mark to the conclusion of the Millennium Development Goal set for 2015, the goal number 6 of halting and reversing the HIV epidemic will be reached.

Methods: Fourteen 2008 United Nations General Assembly Special Session on HIV/AIDS country progress reports and 18 country reports on Universal Access 2009 were analyzed. Data on national HIV strategic plans was also provided by 18 countries that participated in the regional training on costed national strategic plans 15–16 September, in Bangkok in 2008.

Results: Four countries with substantial populations in Asia are on track to achieve Millennium Development Goal 6. Elsewhere, elements of a potentially effective response are being introduced, but the degree of urgency and scale needed to curb the epidemics are not yet evident. Most national programmes still lack key planning components for the operation and financing of the response. Only 13 national strategic plans explicitly address the three key populations at higher risk for HIV. One third of the countries that have designed plans for effective interventions have not costed them.

Discussion: Early successes in controlling HIV epidemics in Asia may not be sustainable in the future. There is an urgent need to make prevention scale-up as robust as treatment scale-up and to focus programmes on high impact prevention, which directly contributes to reduction of new HIV infection. A necessary objective is to convince policy makers that the emergency posed by HIV continues.

aUNAIDS Regional Support Team, Bangkok, Thailand

bNational AIDS Commission, Indonesia

cPolicy Research and Development Institute Foundation, Bangkok, Thailand

dThe Global Fund, Geneva, Switzerland

eHIV and AIDS Data Hub for Asia-Pacific, Bangkok, Thailand.

Correspondence to Dr Michel Carael, 124 chemin des Gentianes, Sergy, F-01630, France. E-mail:

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The HIV responses in Asia have evolved within the context of several important recent global developments in treatment and prevention. Firstly, several international initiatives have guided countries' attempts to enhance their HIV responses, such as the Millennium Development Goals (MDGs), including halting and reversing the HIV epidemic by 2015 [1], the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) Declaration of Commitment in mid-2001 [2], the ‘3 by 5' treatment initiative [3], and an additional push to achieve universal access to HIV prevention, treatment and care services [4]. Secondly, successful efforts to lower the prices of antiretroviral therapy (ART) made HIV treatment an increasingly affordable component of national HIV responses. Thirdly, there was an increase in donor funding for HIV programmes. Fourthly, a mass of evidence has been presented by the Commission on AIDS in Asia – an independent body of experts – that strongly advocated for high impact prevention and treatment programmes to become the core of country-level responses through which funds can be gainfully utilized [5,6].

Without doubt, each of these was positive development. However, recently there have also been further obstacles to the response. For instance, the current economic crisis is a direct threat to AIDS funding; the notion of ‘AIDS exceptionalism’ is under attack from many quarters, including selected donors and advocates of health system development [7,8]; the myth of overspending on HIV at the expense of other diseases has reemerged owing to the increased competition for funds [9]; public health emergencies like the H1N1 outbreak and new global health threats, such as global warming, are all vying for monetary and political attention. But the AIDS epidemic will not go away by itself [10]. In this paper, after analyzing the HIV epidemiology and the most important aspects of the current national responses to HIV in Asia, we discuss the implications for the future.

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To assess the progress of national responses, we reviewed 14 2008 UNGASS country progress reports in Asia [11], 18 2009 country reports on universal access in 2008 [12] and data on 18 countries participating in the regional training on costed national HIV strategic plans in Asia held in Bangkok in 2009 [13]. The National AIDS Spending Assessment resource tracking methodology was carried out in five countries in Asia by 2009 [14]. In addition, we have reviewed short surveys of AIDS spending available in five countries (Table 1).

Table 1

Table 1

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HIV epidemiology: early success in controlling the epidemic may not be sustainable

The region shows great diversity in the way the HIV prevalence is evolving. Broadly grouped into the categories higher (>1%), moderate and low HIV prevalence:

  1. Higher prevalence countries, where HIV prevalence has started to decline. These include the well documented successes in Cambodia and Thailand, but also new evidence of stabilization in Myanmar, Nepal and the southern high-prevalence states of India [15]. In these countries, high HIV prevalence rates prompted comparatively timely and comprehensive responses – for example, raising condom use in sex work settings to levels higher than 80% – which contributed to containing and reversing the epidemic [5,15].
  2. Moderate prevalence countries, where the HIV epidemic continues to expand. These include China, Indonesia, Malaysia, Vietnam and the lower-prevalence states of India. In these areas, sex work-related risk is moderate. There have been prevention efforts in sex work and injecting drug use, but insufficient to reverse the epidemic [5,15]. It also includes countries with currently low HIV prevalence – such as Pakistan and Bangladesh – where the epidemic is low because it has only started recently, but where high levels of risk behaviour exist, such as needle sharing among injecting drug users (IDUs) [5,15].
  3. In other Asian countries, such as Sri Lanka, Maldives, Bhutan, Lao, and the Philippines, the epidemic remains low because of isolation, because risk is low and/or risk factors for HIV sexual transmission such as male noncircumcision are absent [5,15].

At present, new infections are distributed among a number of different population groups rather than being concentrated in any one. Substantial numbers of new infections are occurring in sex workers and their clients, men who have sex with men (MSM), IDUs and as a result of husband-to-wife transmission. All modes of transmission are of concern and all must be addressed by effective regional responses [11].

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Current HIV responses

In recent years, many countries in Asia have taken important steps towards strengthening their HIV national responses:

  1. In Indonesia, HIV surveillance and data collection at the district level now document behavioural risks and disease burdens.
  2. By including civil society in its HIV policies and making safer sex work a priority, the Philippines has paved the way for a more focused HIV programme.
  3. China is fostering collaboration between its health authorities and law enforcement agencies in order to introduce harm reduction programmes for IDUs.
  4. Despite its rudimentary public health system, Lao has expanded its ART programme to the point where it now reaches more than 40% of people in need of treatment.
  5. In India, homosexuality/same sex relations have been decriminalized and, in Nepal, same rights of homosexuals and transgender as other citizens have been recognized.
  6. Harm reduction programmes are being implemented at larger scale in some countries such as China, Malaysia, Bangladesh, and Nepal: progress in coverage is evident.

These are important signs of progress. Unfortunately, these positive elements are not always embedded in HIV strategies that seek to be comprehensive and coherent.

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Political commitment is still critically needed

Strong political commitment and leadership proved to be decisive in Thailand's response in the 1990s to dramatically increase condom use among sex workers and clients, and provided vital impetus to HIV programmes in countries like Cambodia, China, India, and Indonesia [5,6]. In those and other countries, far-sighted politicians have built awareness among their constituencies, lobbied for HIV-related legislation, pushed for more HIV resources, and have tried to hold their governments accountable for their countries’ HIV responses. This political openness is particularly important in Asia, where the epidemic is driven by stigma and discrimination. Political leaders can create an enabling environment for addressing these issues by facilitating the involvement of civil society and community groups, mobilizing public opinion or earmarking resources for such activities. Political commitment is also important for instilling and maintaining the sense of urgency required to mobilize a response.

This type of political commitment has been variable over time in Asia. For instance, in some countries, strong advocacy and activism have persuaded leaders to take action, but generally this is still lacking [16]. Political leadership in the Philippines and Thailand appears to have lost momentum over the last decade, especially with regards to harm reduction programmes for IDU's, whereas it has increased considerably in Cambodia, China, India and Malaysia [6,15].

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Policy and legal environment needs to be more supportive

The current trend in Asia is to adopt national HIV response strategies that are informed by the specific characteristics of the local epidemic – even when such choices might seem politically difficult. Malaysia – a country with a prominent Muslim society – exemplified this tendency with its decision in 2005 to support harm reduction. China, Nepal, and Indonesia are also part of this trend, and now make harm reduction services available to IDUs. This shift is needed, though not yet universally realized. In China, for example, needle exchange and methadone substitution are not available in the same locality; substitution therapy in Nepal is very limited; and Vietnam's harm reduction programme is still in its initial phases. In Indonesia, a reverse in politics has occurred with the new narcotics law that force users of illegal substances to go to drug rehabilitation centres prior to being sentenced [17].

Sex work is licensed only in Singapore and the Philippines and decriminalization of sex workers is limited to a few countries; sex work is still illegal in 18 out of 26 countries in the region [17]. Advocacy to amend or relax harmful laws remains weak. Similarly, there is low quality and coverage of services and programmes for MSM. This is associated with the social stigma attached to male-to-male sex and the widespread criminalization of this behaviour: sex between two men is criminalized in 15 countries in Asia, posing serious obstacles to effective HIV service provision [18–20].

Discrimination remains against populations at higher risk and depending of the population at risk is embedded in laws, policies, or the operational guidelines of law enforcement agencies in most countries. Reports of harassment are common across the region [18] and, in many countries, these populations experience a corresponding lack of access to appropriate HIV programmes [19]. Without cooperation between law enforcement agencies and the judiciary, the criminalization of these risk behaviours can effectively neutralize otherwise supportive HIV policies. In addition, only three countries – Cambodia, the Philippines and Vietnam – have introduced laws that specifically seek to protect the rights of people living with HIV [17]. China's HIV regulations include statements to protect their rights. Another five countries have announced similar policies.

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HIV strategic plans still lack essential planning components

The quality of HIV programmes and strategic plans varies significantly [13]. Some countries lack the strategic information necessary to create an informed response, whereas others have based their response on limited interpretations of the data. In some national plans, resource allocation does not match the priorities highlighted. Overall, most plans lack key planning components for the operation, management, and financing of the response (Fig. 1).

Fig. 1

Fig. 1

In some places, a patchwork of interventions of varying quality and coverage has emerged. In other cases, although HIV strategies appeared to be comprehensive, the necessary resources and capacity have been spread too thin leading to disappointing outcomes.

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Investing in community engagement

National HIV responses tend to be strengthened when community-based and nongovernmental organizations (NGOs) participate in programme planning and implementation. Cambodia, India, and the Philippines are among the countries that have offered tangible evidence for this proposition. In many other countries, communities are able to exert some influence, but their participation is often nominal. Inclusive and community-driven education and outreach systems as well as the capacity to translate findings into policymaking still pose challenges in many countries, but are evident in Bangladesh, India, Cambodia, and Vietnam.

The need to gain community support increases with a degree of marginalization. Populations such as young people can easily be reached through broad programmes like mass media and condom distribution. Truck drivers, uniformed services and other occupational groups require counselling and services, as could be provided through outreach conducted by NGOs or networks. Sex workers, IDUs and MSM tend to be at higher risk, the most marginalized and targets for stigma and discrimination. They are best-empowered and reached through peer outreach and services run through community organizations and groups that improve access to, and utilization of, services [20].

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Monitoring coverage and quality of HIV programmes

Even when populations at higher risk are identified as a priority for HIV prevention, governments must ensure that an effective approach is adopted. In many cases, efforts to mobilize strong leadership and resources are later undermined if the interventions fail to reduce HIV risk and transmission in the targeted groups.

Recent reviews of programmes implemented in different Asian countries reveal considerable room for improving services for most-at-risk populations [19,20]. Currently, only four of the 11 countries in Asia with HIV epidemics among IDUs are providing both needle exchange and drug substitution services through government-funded outlets, and only two of those involve peer outreach programmes. Only five countries have introduced peer education programmes for sex workers, and only two have launched nationwide information and education campaigns that target sex workers' clients. Few countries were devoting significant resources to interventions for MSM, although momentum is now building with more evidence showing increasing HIV prevalence among MSM in the region [19].

Almost all countries in Asia have national strategic plans that recognize specific high-risk behaviours, but only 13 of those plans address the three population groups at higher risk for HIV. Meanwhile, none of the plans contain all of the effective intervention elements that should be included in a focused response.

HIV data collection has improved in several Asian countries over the last decade, and 12 countries now have second-generation HIV surveillance among at least three population groups at higher risk [19]. However, the push for such surveillance still tends to come more from external donors than national agencies. Although several international agencies provide country level HIV projections, only six countries have generated their own projections. Another six countries have information that makes it possible to prioritize and focus interventions at the subnational level.

Although clear progress can be seen in the frequency of data collection – with many more countries reporting on UNGASS progress indicators in 2008 – more than half were unable to assess their coverage of targeted populations and/or estimate sizes of target populations [13]. Monitoring of prevention for key populations needs to happen through a systematic and planned approach, with close involvement of the people themselves, and in permanent connection with programme planners and implementers.

Coverage ranks high among the several yardsticks for measuring the effectiveness of HIV programmes. Since the late 1990s, despite significant gains in resource availability, coverage of HIV services for sex workers, IDUs and MSM has remained low (Fig. 2). Across Asia, about 50% of sex workers were being reached by HIV prevention services in 2008, whereas only 30% IDUs and about 25% of MSM had access to prevention services. Of 14 low and middle-income countries in Asia reporting progress against UNGASS indicators in 2007, 12 have reported HIV prevalence and behavioural data on all three most-at-risk populations in the last 2 years, four countries reported on at least one, and eight countries did not have any data [13].

Fig. 2

Fig. 2

The quality and the validity of the coverage data of the UNGASS progress reports vary considerably, with some countries using the populations at risk attending services or reached by peer educators as equivalent to the size estimation of the subpopulation. Some other countries use HIV-reported cases as denominators for specific populations at risk such as IDUs [17]. This is why comparisons between countries need to be cautious and figures should be analyzed over time.

With regard to commercial sex, in addition to progress made at the national level in Cambodia, Mongolia, and Thailand, significant local-level progress has been made in other places implemented by NGOs such as Sonagachi in Kolkata, India; the Avahan project in India's six highest HIV-prevalence states, including Ashodaya project; and the Shakti project in Dhaka, Bangladesh. These three programmes have focused on empowerment approaches where planning and implementation of interventions are led by female sex workers (FSWs) and have shown high coverage and high condom use [21]. Reported condom use by direct FSWs has considerably increased in recent years to reach a median of 80% in 2008, but much less has been achieved among IDUs and MSM (Fig. 3).

Fig. 3

Fig. 3

Meanwhile, about eight out of 10 pregnant women in the region are not being reached by the prevention of mother-to-child transmission services (PMTCT). Countries where women attend antenatal clinics on a large scale should theoretically have made good progress in providing PMTCT, as has been demonstrated in Thailand [22]. However, even in these countries, such as China and Indonesia, the uptake of PMTCT has barely reached 10–20%.

Lowered prices for antiretroviral drugs and increased external financial support for their provision has helped change the HIV treatment landscape in many Asian countries [23]. Four countries have used these opportunities to expand HIV testing, treatment, and care provision. Despite the comparatively small number of adults in need of antiretroviral treatment in Asia overall, only about 36% of them are receiving it, with large disparities between countries. Moreover, the specific needs of HIV positive children in terms of providing paediatric formulations of ART are not yet recognized in the region.

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Financing the AIDS response

One of the major changes in the last decade has been the vast increase in financial resources now available to Asian countries for fighting their HIV epidemics; much of it available via the Global Fund to fight AIDS, tuberculosis, and malaria and the World Bank, as well as bilateral funding agencies. Implementing strategic plans calls for strong management and adequate resources; yet, among countries that have designed plans for effective interventions, for example, only 65% have broadly costed those plans (see Fig. 1). Cambodia is a prime example of how adequate operational planning and financing can enable a rapid scale-up. Despite both economic and infrastructural obstacles, the country saw a significant improvement of its testing and treatment services owing to exceptional political commitment [5].

An estimated US$ 1.2 billion was spent on AIDS in Asia in 2007 [5]. However, about US$ 5.1 billion is required for a comprehensive response [23]. Domestic spending on HIV-related programmes in Asia has increased at a far slower rate than in other regions [23,24]. The percentage of total HIV expenditure funded out of national budgets has in fact decreased in the 14 surveyed countries, from 60% in 1996 to 40% in 2004 [5,6]. There were two notable exceptions to this trend: China, where domestic funding now accounts for almost 80% of total AIDS expenditure, and India, where domestic funding reached almost 65% in 2009. In the other surveyed countries, the ratio of domestic to external funding has remained the same or decreased [14].

The increase in external funds available for HIV programmes makes it easier for countries to fund their HIV responses, but medium-term to long-term sustainability of some programmes may be compromised if HIV loses its prominent position on the international agenda. At the very least, funding should match the priorities and patterns of the HIV epidemic, with at least 60% of spending of the budget on HIV prevention [5,25]. For example, in Thailand – where the government funds 80% of the HIV budget – there was a marked bias towards treatment for several years; only more recently, HIV prevention efforts have been revitalized [22]. However, when disaggregating HIV prevention programme activities, it is striking that in many countries, the epidemiologically-informed priorities – such as the population groups where most of the new HIV infections are occurring – are not taken into account and thus money is not being spent on the most effective interventions for targets groups. The HIV prevention budget often goes to ‘soft’ programmes, such as general awareness for the population at large, and not into high impact HIV prevention (Fig. 4).

Fig. 4

Fig. 4

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Data reported by countries about their progress towards the implementation of the UNGASS Declaration of commitment or about their progress towards Universal Access have suffered from various biases mainly owing to different interpretation of denominators. Some countries have used as denominators, the reported number of HIV cases or the number of people attending facilities and not the estimated number of people of specific categories in need of services. These variations sometimes make comparisons difficult. Data quality, data gaps, and data reliability in Asia are all serious issues that limit a proper assessment of national responses to HIV [26].

National HIV responses in Asia have evolved amid shifting government priorities, changing perceptions of the epidemic, and the emergence of a range of HIV stakeholders and partners. As a result, unity of purpose, policy clarity, and harmonized action have suffered in many countries: the response to HIV has either lagged behind or faltered for long periods of time. The degree of urgency, coherence, and scale needed to curb the epidemics is not yet evident.

The continuing low coverage of HIV programmes for populations at higher risk in all countries in Asia, and the persistence of high-risk behaviours have meant that prevention has not been effective. Asia could prevent more than half of projected new HIV infections by bringing proven strategies to scale and by developing programmes based on evidence from epidemiological data on the progression of the epidemic [23]. Ambitious coverage targets have been set by countries in Asia [24]. However, financing the fight will become much more difficult, owing to the international economic crisis and other priorities in public health [9].

Given the broad diversity of HIV dynamics and responses in the region, it is difficult to make generalizations for the region as a whole. Still, increasing intensity of effort in the following three areas must be achieved in order to attain universal access to HIV interventions – or, at the very least, to dramatically scale up current efforts:

  1. Make prevention scale-up as robust as was treatment scale-up [27,28].
  2. Focus on high impact prevention, which will directly contribute to reduction of new HIV infections.
  3. Long-term planning with sustainable national capacity for implementing scale-up, including adequate financial support.

Although the world's wealthiest countries have recently renewed their financial commitments for infectious diseases, the pledge was still far below the current needs [29]. The impact of the economic crisis on income inequalities may soon generate more HIV risks and vulnerabilities such as migration or increased illicit drug use as well as loss or redirection of funding. It is expected that the crisis will most affect HIV prevention efforts among marginalized groups [29].

Looking to the future, a long-term AIDS response will need to go far beyond 2015 – that is, well after the MDG 6 deadline. This will require a new AIDS exceptionalism for the following reasons:

  1. Accountability is lagging. All stakeholders, including civil society, must be accountable for the billions of dollars being spent on AIDS. No other health programme has attracted such large-scale international and domestic funding. Notably, accountability is often not scrutinized to the same extent as other government programmes.
  2. Momentum has been achieved. AIDS has provided an opportunity for a wide range of social sector reforms:decriminalization of sex work, drug use, sex between men, impact mitigation for orphans and children, sexual and reproductive health reform, social insurance for health, among others. No other health programme provided such a platform and such an opportunity for political leaders and social reformers to create a constituency for themselves by advocating on issues, which were ignored for decades.
  3. Social activism is wavering. Without activism, AIDS programmes will silently die out and the investment will disappear into a myriad of programmes with limited effectiveness. This is especially important in countries with low and concentrated HIV epidemics [5,6].
  4. AIDS is exceptional for United Nation system reform. There is no better example of system-wide coherence, as has been achieved in the AIDS response which has made a living example of the United Nation delivering as one common, unified force. United Nation can continue to prove its relevance as a joint programme for AIDS in the long term.

During the last 20 years, resources for HIV in Asia have increased dramatically. The new economic crisis may jeopardize sectors funded by international development partners, especially the scaling-up of HIV prevention programmes. The current situation should be taken as an opportunity to underline the importance of sustained domestic funding for AIDS programmes, to offset the risks and uncertainties associated with external funding, and to refocus programme activities to those which have been demonstrated to be most cost-effective. As we enter the final half of the MDG timeline, this evidence must be acted upon in order for the MDGs to be deemed a success in Asia in 2015.

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We thank Peter Ghys, Amala Reddy, Rifat Atun and the HIV and AIDS data Hub for Asia-Pacific team for contributions and useful comments on the manuscript.

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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Asia; coverage; exceptionalism; financing; HIV; national response

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