by Susan J. Blumenthal, M.D. and Kathleen Tran, M.Sc.
Yesterday's signing into law of the reauthorization and expansion of the President's Emergency Plan for AIDS Relief (PEPFAR) and the upcoming International AIDS Conference in Mexico City provide an opportune time to re-examine the current landscape of the global AIDS epidemic. It is no secret that HIV/AIDS has profoundly affected Sub-Saharan Africa -- the major focus of PEPFAR's lifesaving programs -- over the past two decades. In some countries in this region, life expectancy has declined to 38 years of age. A much lesser known fact is that the prevalence of HIV/AIDS is now also rising in Asia at unprecedented rates. Consider that in the early 1980s, HIV was virtually unknown in Asian countries -- China's first indigenous case of HIV was reported in the Yunnan province in 1989. Since then, HIV has spread at an alarming pace across the entire region. UNAIDS recently reported that in 2007, approximately 446,000 Asian and Pacific Islanders were newly infected with HIV, bringing the total number of people living with HIV/AIDS in the region to nearly 5 million. In the same period, more than 300,000 people living in the region died from AIDS-related illnesses.
With roughly sixty percent of the world's estimated 6.7 billion people living in Asia, even a small percentage of infected people can make Asia the next flashpoint for the global AIDS epidemic. The humanitarian, economic, and national security implications of an uncontrolled HIV epidemic in Asia could be staggering.
To better understand AIDS in Asia, several characteristics of the epidemic there should be noted. As compared to Sub-Saharan Africa where the HIV/AIDS epidemic is widely generalized in the population, in Asia it can be pictured as multiple concentrated epidemics involving specific vulnerable populations. In China, where there are currently 700,000 people living with HIV, injection drug users, commercial sex workers, and men who have sex with men comprise more than half of the country's HIV-positive population. Ethnic minorities in the southern and western parts of the country are also disproportionately affected. In Vietnam, where the number of people living with HIV more than doubled between 2000 and 2005, commercial sex workr and injection drug use are major drivers of the epidemic. In Thailand, despite prevention campaigns that dramatically reduced the number of new HIV infections in the 1990s, HIV prevalence among men who have sex with men rose from 17 to 28% between 2003 and 2008.
While HIV prevalence is currently concentrated among vulnerable groups in Asia, there is a serious risk that the epidemic will also spread beyond them to the general population. For example, societal norms and expectations may motivate some men who have sex with men to live "dualities of existence," marrying women and having children. A significant percentage of intravenous drug users and men who buy sex from women are also married with children. This explains in part why female partners of infected men now comprise a growing proportion of HIV-positive individuals in Asia, and why the rate of mother-to-child transmission in this region of our world is also on the rise.
Stigma related to HIV/AIDS and to the vulnerable groups most affected is one of public health's greatest enemies when it comes to stemming the spread and impact of the disease in Asia and around the world. It leads to the abandonment of people living with HIV by their loved ones, bringing devastating social consequences to those who are already suffering. Stigma also keeps the healthy from recognizing behaviors and practices that put them at risk of transmission. And it keeps HIV-positive persons from seeking lifesaving treatment services and from disclosing their status to sexual partners, thereby secretly fueling the epidemic onwards.
Furthermore, the emergence of the AIDS epidemic in Asia, as in other regions, must be considered within a broader social context. The impact of poverty fuels the epidemic, with economic hardship driving the sex and drug industries and fueling gender inequalities in addition to pushing people to migrate between different parts of Asia in search of better economic opportunities. Poverty also impedes the growth of solid public health infrastructure, rendering efforts to prevent the spread and impact of the disease very difficult.
There are several key elements of a more comprehensive, coordinated and concerted national and international response to the emerging AIDS epidemic in Asia. First of all, strong political leadership is essential in developing an effective response to the HIV/AIDS epidemic in every country. While the national response to HIV/AIDS has varied considerably among countries, only a few Heads of State of Asian nations have provided significant leadership on this issue. Asian governments must strengthen their commitment to combating the HIV/AIDS epidemic by mobilizing their leadership and agencies to respond, increasing resource allocation for HIV prevention and treatment, establishing HIV committees in their legislative bodies, and implementing evidence-based interventions such as syringe exchange programs and drug substitution therapy. HIV education, public awareness campaigns and dedicated resources from the government are critical in fighting this disease and are essential to overcoming the stigma and discrimination that further compound the suffering of those living with HIV/AIDS.
Fortunately, over the past decade, despite numerous challenges, a range of programs to combat the HIV/AIDS epidemic has been developed in several Asian countries. In China for instance, advances have been made in expanding availability of condoms and increasing the number of methadone clinics for injection drug users -- though stigma and fear of retribution still keep many people from accessing these services. In Cambodia, Thailand, and the Indian province of Tamil Nadu, prevention campaigns have helped reduce the incidence of HIV among commercial sex workers. In the Lao People's Democratic Republic, prioritizing access to lifesaving anti-retroviral therapy (ART) has expanded the reach of these drugs to more than 40% of those in need. These successes, however, have not been enjoyed evenly across all of Asia and the Pacific--when considering the region as a whole, only a quarter of HIV-positive individuals in need of ART are receiving it. A great deal of work remains to be done across the entire region to promote public awareness and understanding of the epidemic, to reduce stigma and fear, and to expand access to science-based prevention and treatment services.
Support for HIV/AIDS programs in Asia is importantly coming from civil society and non-governmental organizations. Several NGOs have already mobilized to help fight HIV/AIDS on this new frontier of the epidemic. In the late 1990s for instance, when little attention was being paid to the looming HIV/AIDS crisis in Asia, amfAR, The Foundation for AIDS Research, understood the need for the broader introduction of HIV/AIDS therapeutics in the region. In 2001, it established an initiative called Therapeutics Research, Education, and AIDS Training in Asia (TREAT Asia). TREAT Asia is a network of clinics, hospitals, and research institutions working with civil society to ensure the safe and effective delivery of HIV/AIDS treatments throughout Asia and the Pacific. It has made important strides in strengthening HIV/AIDS care and treatment through education and training programs in the region
In the coming years, Asian nations must target the marginalized, vulnerable groups that are suffering most heavily from the burden of HIV/AIDS. For a variety of cultural and political reasons, health authorities are often resistant to discussing certain modes of HIV transmission. For instance, sex between males still remains illegal in as many as 50% of Asian nations, and it is often not publicly acknowledged or discussed. Governments, NGOs and others must deepen their understanding of the epidemics' characteristics and landscape within their countries to accelerate efforts to effectively address those who are most at risk.
Community involvement is also essential in reaching vulnerable populations. Past experience has shown that community-based interventions such as the use of support groups for sex workers, peer outreach to injection drug users, and hotlines to address the concerns of men who have sex with men can be effective strategies to provide HIV-related support and prevention messages to groups who may be overlooked by government programs. Advocacy and activism by community leaders and civil society are also essential in motivating political leadership to combat HIV/AIDS.
As in other parts of the world, Asian nations must address HIV/AIDS not solely as a health problem, but as a wider socioeconomic problem that must be confronted from multiple vantage points. Governments often relegate the task of eradicating HIV/AIDS to their Ministries of Health, ignoring that HIV/AIDS is a much broader issue requiring coordinated involvement from multiple sectors of society. In the coming years, mounting an effective response to HIV/AIDS will require greater collaboration and coordination within and across relevant governmental agencies, private sector organizations, and a broad range of other stakeholders.
There is an ancient Chinese proverb saying, "It is better to light a candle than to curse the darkness." This is the attitude that should be adopted in addressing the newest frontier in the global AIDS epidemic. PEPFAR and other governmental, foundation and private sector initiatives should be expanded to focus greater attention on Asian nations, given that HIV/AIDS represents an enormous challenge not just in Sub-Saharan Africa but in numerous countries throughout Asia and the Pacific as well. In a time when U.S. engagements around the world have been too often associated with military intervention by the international community, fighting to improve the health of people globally is one of the most significant ways in which the United States can serve as a beacon of light and hope worldwide--while addressing one of the most pressing humanitarian and public health challenges of our time.
Susan J. Blumenthal, M.D., M.P.A. is Senior Policy and Medical Advisor at amfAR, The Foundation for AIDS Research. She is also a Clinical Professor at Georgetown and Tufts University Schools of Medicine. For more than 20 years, Dr. Blumenthal served in health leadership positions in the Federal government, including as Assistant Surgeon General of the United States and the first Deputy Assistant Secretary of Women's Health in the U.S. Department of Health and Human Services, as Chief of the Behavioral Medicine and Basic Prevention Research Branch at the National Institutes of Health, and as a White House Advisor on health issues. Dr. Blumenthal has received numerous awards including honorary doctorates for her important contributions to improving health in the United States and globally. Her work has included a focus on HIV/AIDS since the beginning of the epidemic in the early 1980s.
Kathleen Tran, M.Sc., is an M.D. candidate at the University of Pennsylvania School of Medicine and a Health Policy Fellow at amfAR, The Foundation for AIDS Research in Washington, D.C. She earned two Masters degrees from Oxford University as a Rhodes Scholar. She is also the recipient of a Paul and Daisy Soros Fellowship for New Americans.