may 24, 2010 jvr prasada rao special advisor to unaids executive director international...

May 24, 2010

JVR Prasada RaoSpecial Advisor to UNAIDS Executive DirectorInternational Epidemiological Association Meeting, Colombo

May 24, 2010

Can Asian Countries halt and reverse Can Asian Countries halt and reverse the AIDS epidemic by 2015?the AIDS epidemic by 2015?

2May 24, 2010

There is an increased understanding of There is an increased understanding of the Asian epidemicsthe Asian epidemics

The principal modes of HIV transmission HIV is generally concentrated among certain populations. Infections appear first among IDUs, SWs and Clients, and MSM, but

then it spreads to wives and children The driving forces of Asian epidemics

sharing of needles during Injecting Drug Use – kick-starts and accelerates the epidemic

unprotected Commercial sex – gives it range and power Sexual networking among Asian men markedly higher than women

Projections into the future based on various scenarios

UNAIDS

3May 24, 2010UNAIDS

The HIV epidemic in Asia The HIV epidemic in Asia appears to be slowing down overallappears to be slowing down overall

Adults and children living with HIV

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

# H

IV+

in T

ho

usa

nd

s

Year

Adults & Children S & SE Asia Adults & Children East Asia

Source: 2009 AIDS Epidemic Update. UNAIDS, WHO, 2009

4May 24, 2010UNAIDS

However, new infections However, new infections in different countries and their sub-regions differin different countries and their sub-regions differ

Indonesia

0

50,000

100,000

150,000

200,000

New

infe

ctio

ns in y

ear

Cambodia

0

5,000

10,000

15,000

20,000

New

infe

ctio

ns in

yea

r

0

100,000

200,000

300,000

400,000

Clients Sex workers MSM IDU

Lo-risk male Lo-risk female Children

Myanmar

0

25,000

50,000

75,000

Ne

w in

fectio

ns in

ye

ar ..based on how effectively

prevention targets new infections

Source: Commission on AIDS in Asia 2008

5May 24, 2010UNAIDS

For the first time the CAA For the first time the CAA estimated the large numbers of people at risk of estimated the large numbers of people at risk of HIV infection in AsiaHIV infection in Asia

Asian Population: 3.3 billion

WomenMen

75 million Men in Asia visit

sex workers

(2-20% of adult men)

50 million Women married to men who visit

sex workers

4 millionMen who

inject drugs

16 millionMen who have sex with men

10 millionWomen sell sex

1 million infants and

children

6April 19, 2023UNAIDS

A causal model showing linkages A causal model showing linkages among factors that influence HIV transmission among factors that influence HIV transmission in intimate partners relationshipsin intimate partners relationships

7May 24,2010UNAIDS

“ “People on the Move” in Asia’s fastest growing economies - People on the Move” in Asia’s fastest growing economies - China, India, Indonesia, Malaysia, Thailand, and VietnamChina, India, Indonesia, Malaysia, Thailand, and Vietnam

Asia was host to 26.3 million migrants, or about 13.8 per cent of the world's total migrant stock, in 2005 (University of Sussex and the World Bank) Malaysia and Thailand are expected to absorb large numbers of foreign

workers considering the economic growth prospects Asia an important source of international migration, sending 54.2 million

migrants abroad or 28.4 per cent of the world's total (ibid) By 2030, India and China are projected to account for 40 per cent of the

global workforce (World Migration Report 2008) Sri Lanka, Philippines and Indonesia contribute a large female work force

working abroad Gendered dimension of migration – the numbers of women migrating from

the six countries will continue to rise - particularly as domestic workers, care givers, service employees, moving across borders and within the country

Source: AIDS 2031. UNAID, 2009

8May 24, 2010UNAIDS

This migration and mobility This migration and mobility exposes migrants to HIV risk .. particularly exposes migrants to HIV risk .. particularly internal rural-urban migrationinternal rural-urban migration• Commercial sex work is concentrated in

areas of circular migrants – more Clients• Large numbers of rural female migrants

moving to urban areas engage in the entertainment industry – more FSWs

• Expands the triangular sexual networks of migrants, both the men and the women

• Lack of access to health services, particularly those living outside their countries

http://www.asiatravelpics.de/cd1/400/IMG0049.html

9May 24, 2010UNAIDS

Mobile men can be more Mobile men can be more vulnerable to HIV infectionvulnerable to HIV infection

Percentage of non-mobilenon-mobile / mobilemobile men paying for sex in the past 12 months (FHI 2006)

China Cambodia Indonesia Viet Nam

9%

15%

4%2%

33% 33%

21%

32%

10May 24,2010UNAIDS

The epidemic data show this emerging The epidemic data show this emerging dynamic of HIV spread - about 200,000 more Asian dynamic of HIV spread - about 200,000 more Asian women are living with HIV in 2008 compared to 2001women are living with HIV in 2008 compared to 2001

Regional Trends in People living with HIV

180 290

1,200 1,300

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

# H

IV +

in

Th

ou

san

ds

YearWomen S&SE Asia Women East AsiaAdults & Children S&SE Asia Adults & Children East Asia


11May 24, 2010UNAIDS

People are still dying of People are still dying of AIDSAIDS in Asia – in Asia – an estimated 330,000 deaths in 2008 an estimated 330,000 deaths in 2008

HIV-related Deaths of Adults and Children

-

50

100

150

200

250

300

350

1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

# D

ea

ths

in

Th

ou

sa

nd

s

Year

Deaths Adults & Children S & SE Asia Deaths Adults & Children East Asia



The Asia Commission projections suggest that we The Asia Commission projections suggest that we are at a cusp in the epidemic progression…are at a cusp in the epidemic progression…

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

New

infe

ctio

ns in

yea

r

Clients Sex workers MSM IDU

Lo-risk male Lo-risk female Children

where a resurgent epidemic …

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

New

infe

ctio

ns in

yea

r

Clients Sex workers MSM IDU Lo-risk male Lo-risk female Children

can be avoided if prevention and treatment reach universal coverage

Source: Commission on AIDS in Asia 2008


Better information but the response Better information but the response is laggingis lagging

• Response is a mixed picture country to country and provinces within the same country ( in India and China ).

• There are excellent prevention efforts, but not to scale.

• Babies are still getting infected - PM TCT coverage in the region is very low ( 25%)

• If reducing the new infections to half by 2015 is the goal, many countries need to act fast.


HIV prevalence among IDUs in Bangkok, 2000-2009

HIV prevalence among MSM in Thailand, 2003-2007

Source: Bureau of Epidemiology, Thailand Ministry of Public Health

Thailand's early successes in reducing sex work-related infections, have given way to increasing infections among IDUs and MSM

15May 24, 2010

UNAIDS

HIV prevention coverage among IDUs, HIV prevention coverage among IDUs, 2005-20092005-2009

* Calculated median value

Source: UNGASS country progress report_2006, 2008 & 2010

2009 data is provisional


HIV prevention coverage among MSM HIV prevention coverage among MSM 2005-20092005-2009





PMTCT coverage, 2006-2009PMTCT coverage, 2006-2009




Enabling environment and unseen Enabling environment and unseen challengeschallenges

• Political leaders in Asia must be credited for seeing the danger of a looming epidemic and acting early ...

• But, the political rhetoric is often not translated into measurable programme outputs which have an IMPACT on the epidemic.

• Disturbing trend of reversal of earlier gains – new legislations in countries like Cambodia which enhance stigma. New conservatism around issues like sex work, male to male sex …

• Impact mitigation is the missing piece. No effective measure to mitigate the effects of stigma and discrimination. No earmarked funding.


No country spends enoughNo country spends enough

Vietnam

Thailand

Sri LankaBangladesh Pakistan

Nepal MyanmarChina IndiaIndonesia

Cambodia

Philippines0

1

2

3

0.00% 0.50% 1.00% 1.50%

HIV prevalence (%)

reso

urce

per

cap

ita (

$)

With a normative value of $1 per capita, 9 countries still fell short on resource commitment to AIDS programmes

The region needs $ 3.2 bn for reversing the epidemic, The region needs $ 3.2 bn for reversing the epidemic, but availability hovers around $ 1.2 bn.but availability hovers around $ 1.2 bn.

Source :Commission on AIDS in Asia 2008


SourcesSources of AIDS funding, selected countries of AIDS funding, selected countries

Source: UNGASS country progress report 2010


Percent distribution of Percent distribution of AIDS spending per key area, selected countriesAIDS spending per key area, selected countries

Source: UNGASS country progress report 2010

22May 24,2010UNAIDS

The brighter side The brighter side • Countries understand the need for information and are starting

to generate more data and fill data gaps.• Behavioral surveys are identifying and characterising the risk

factors.• Successful interventions which can bring down new infections

effectively have been demonstrated. • Stronger health system support for treatment and PMTCT

programmes is resulting in fast scale up. Treatment coverage increased impressively to 565,000

• Good scale up in resources - GF and PEPFAR and BGMF as new donors have added much needed resources.

• Social environment changing in countries like India and Nepal with a proactive judiciary leading the way to social reforms.


Strategic information systems are improving across Strategic information systems are improving across the region and risk factors better understoodthe region and risk factors better understood

% of countries with HIV prevalence surveys among populations at higher risk, in the last 2 years (2009)


HIV prevention coverage is improving HIV prevention coverage is improving across most the regionacross most the region





ART coverage is scaling up fast ART coverage is scaling up fast in many countriesin many countries

ART coverage among adults and children, 2006-2009

Source: UNGASS country progress report_2006, 2008 & 20102009 data is provisional

* Only for adults


The MARPs agenda- opening the doors The MARPs agenda- opening the doors for social sector reform for social sector reform

• Acceleration of gender and HIV activities in the region By the end of 2009, 3 countries had gender reviews of their

NSPs and 2 policies for systematic inclusion of gender. 4 more countries currently working on them.

Regional Report on Intimate Partner Transmission of HIV was launched at 9th ICAAP based on analysis in 13 countries


The MARPs Agenda – opening the doors for The MARPs Agenda – opening the doors for social sector reform .. ( cont’d )social sector reform .. ( cont’d )

• UNAIDS Agenda for Women and Girls to be promoted in 2010 to support engendering of new National Strategic AIDS Plans and Global Fund Grants.

• Social environment changing in countries like India and Nepal with a proactive judiciary leading the way to social reforms.

• Establishment or improvement of remedial instruments and legal reform, and agencies where PLHIV can seek redress and legal services.


Empowerment of positive peopleEmpowerment of positive people

• Strong networking of PLHAs in most Asian countries and linking with Regional body APN+

• Representation on NACs and CCMs at national level.• Core funding for organizational development to APN+ from

UNAIDS• Involvement in development of strategies for prevention of Intimate

Partner Transmission • HIV Bill in India to guarantee the rights of positive people• Stigma Index roll out commenced in 2008 with PLHIV groups

involvement. Five countries completed the index and are disseminating

findings (Sri Lanka, Bangladesh, China, Myanmar and Thailand). Seven more countries (Cambodia, Fiji, Malaysia, Pakistan,

Philippines, PNG and Viet Nam) implementing index through PLHIV networks with universities support.


Global Fund Round 6 & 8 HIV spending in Global Fund Round 6 & 8 HIV spending in Asian countries: Priority areasAsian countries: Priority areas


Global Fund Round 9 HIV spending in Global Fund Round 9 HIV spending in 6 Asian countries: Priority areas6 Asian countries: Priority areas

Source: Global Fund Round 9 budget tracking_2010

Treatment &

31April 19, 2023UNAIDS

Why is this the right Why is this the right time to act?time to act?

32

Country MDG Goal 4 MDG Goal 5 MDG Goal 6

Under-5 mortality

Maternal mortality

Antenatal care

At least once birth by skilled

professional

HIV prevalence

TB incidence

TB prevalence

China

India

Indonesia

Myanmar

Thailand

Vietnam

May 24, 2010UNAIDS

Countries with highest prevalence in Asia show Countries with highest prevalence in Asia show good progress on MDG 6 targets for HIV and TB, good progress on MDG 6 targets for HIV and TB, but less progress on infant and maternal targets MDGs 4 & 5but less progress on infant and maternal targets MDGs 4 & 5

Early achiever On track Slow Regressing/No progress

Source: UNESCAP, ADB & UNDP_ Achieving the millennium development goals in an era of global uncertainty_2010


Source: UNESCAP, ADB & UNDP_ Achieving the millennium development goals in an era of global uncertainty_2010

With 2015 MDG targets approaching, With 2015 MDG targets approaching, HIV and AIDS interventions should be integrated into HIV and AIDS interventions should be integrated into Health Systems strengtheningHealth Systems strengthening


UN is reinforcing its roleUN is reinforcing its role

• AIDS affords an opportunity for the UN system to deliver as ONE

• The one programme where this has been successfully done was the AIDS programme where the secretariat and the 10 Co-Sponsors work together in a joint programme to provide support to countries.

• This needs to be intensified, taking advantage of the Outcome Frame Work of UNAIDS and the Division of Labour between agencies.

35May 24, 2\010UNAIDS

What needs to be done in Asia and the Pacific?What needs to be done in Asia and the Pacific? In the next 5 years,• Understand the characteristics of the epidemic and tailor the response.• AIDS should get to the top of the agenda for activists and social reformers

It provides a platform for civil society no other movement was able to provide earlier.

• Focus on programmes that produce impact and results, and don’t waste money on low impact interventions.

• Coverage and scale up is the Mantra - Attempt and attain more than 80% coverage of populations who need prevention and treatment services.

In the long term,• impact mitigation is the key

special focus on orphans and women. AIDS related stigma and discrimination should be wiped out. CAA estimated that for the entire Asia they are not going to cost more

than $ 300 m per year.


Thank you!Thank you!

Acknowledgements

• UNAIDS RST• HIV and AIDS Data Hub for Asia and the

Pacific www.aidsdatahub.org

may 24, 2010 jvr prasada rao special advisor to unaids executive director international...

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