HIV prevalance in Aisa

07 ASIAASIAAIDS epidemic update Regional Summary UNAIDS/08.09E / JC1527E (English original, March 2008) © Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) 2008. All rights reserved. Publications jointly produced by UNAIDS and WHO can be obtained from the UNAIDS Content Management Team. Requests for permission to reproduce or translate UNAIDS publications—whether for sale or for noncommercial distribution—should also be addressed to the Information Centre at the address below, or by fax, at +41 22 791 4835, or e-mail: publicationpermissions@unaids.org. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of UNAIDS or WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specifi c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by UNAIDS or WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by UNAIDS and WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall UNAIDS and WHO be liable for damages arising from its use. UNAIDS 20 avenue Appia CH-1211 Geneva 27 Switzerland T (+41) 22 791 36 66 F (+41) 22 791 48 35 distribution@unaids.org www.unaids.org WHO Library Cataloguing-in-Publication Data Asia : AIDS epidemic update : regional summary. “UNAIDS/08.09E / JC1527E”. 1. HIV infections - prevention and control. 2.HIV infections - epidemiology. 3.Acquired immunodefi ciency syndrome - epidemiology. 4.Disease outbreaks. 5.Asia. I.UNAIDS. II.World Health Organization. ISBN 978 92 9 173665 2 (NLM classifi cation: WC 503.4) ASIA AIDS epidemic update Regional Summary 1 2 0 0 7 A I D S E P I D E M I C U P D A T E | A S I A ASIA China Although HIV infections have been reported in each of China’s provinces, most of the people living with HIV in China are believed to be in Henan, Guangdong, Guangxi, Xinjiang and Yunnan provinces (Ministry of Health China, 2006). In Yunnan province, HIV surveillance at antenatal service sites found that 0.3% [0.21%– 0.31%] of pregnant women were infected with HIV, although prevalence was as high as 1.6% in some counties (Zhang, Hu & Hesketh, 2006). A little less than half the estimated 700 000 [390 000–1.1 million] people living with HIV in China in 2006 are believed to have been infected while injecting drugs with contaminated equipment, while a similar proportion acquired the virus during unprotected sex (Ministry of Health China, 2006; Lu et al., 2006). Once HIV enters injecting drug user networks, it tends to spread rapidly—especially where HIV knowledge is poor and non-sterile injecting equipment is frequently used. In rural parts of Guangxi province, a study begun in 2002 measured a baseline prevalence of one in four (25%) injecting drug users. After tracking new infections over the next year, they found annual HIV incidence of 3.1% among the 702 injecting drug users who participated in the study (Liu W et al., 2006). Similar situations occur in other provinces, such as Guangxi, Sichuan, Source: Xiao Y et al. (2006). Expansion of HIV/AIDS in China: lessons from Yunnan Province. Social Science & Medicine, 64(3):665–675. Epub 2006 Nov 14. 10%–39%<10% >_ 40%HIV prevalence No data 1992–1994 1995–1996 1997–1999 2004 HIV prevalence among injecting drug users in Yunnan province, China, 1992–2004 Figure 1 2 A S I A | 2 0 0 7 A I D S E P I D E M I C U P D A T E Xinjiang and Yunnan where high HIV prevalence has been found among injecting drug users (Choi, Cheung & Chen, 2006). In Sichuan province, HIV prevalence in injecting drug users in a city in the south-west rose from 11% in 2002 to 18% in 2004 (Zhang et al., 2006). More than half (58%) of the injecting drug users surveyed at eight drug rehabilitation centres in Yunnan province said that they used non-sterile injecting equipment (Hesketh et al., 2006), as did 39% of those enrolled in detoxification centres in another part of the province (Christian et al., 2006). In the latter study, one in five (20%) of the injecting drug users did not know that the use of non-sterile needles carries a very high risk of HIV transmission, almost two thirds (64%) of them had had unprotected paid sex in the previous month, and almost half (45%) had never bought a condom. Yet, more than half (57%) of the injecting drug users, most of whom were men, believed that they were at slight or no risk of acquiring HIV (Christian et al., 2006). Harm reduction efforts, although still partial and scattered, are beginning to show positive results. China has set up more than 700 needle exchange sites. At the six sites that reported rates of the use of non-sterile needles in a national survey in 2005, 12%–56% of injecting drug users said they still used non-sterile needles, compared to the 27%–79% who had been doing so when the projects began in the early 2000s (Wu et al., 2006). In a similar project in Hunan province, reported use of non-sterile needles declined from 43% to 23% and levels of HIV awareness and knowledge increased fourfold to 80% between 2003 and 2005 (Chen Y et al., 2006). These positive develop- ments underline the need to further improve and expand harm reduction programmes in China, with special attention to the rising number of female injecting drug users who use non-sterile equipment (Zhang & Wu, 2002), and to the ways in which gender dynamics influence HIV risk (Choi, Cheung & Chen, 2006) (see box). The overlap of injecting drug use and sex work is an important aspect of China’s HIV epidemic. An increasing number of women are injecting drug users in China and, in some places, as many as half of those who do so also sell sex (see box). Many male injecting drug users also buy sex, DOUBLE JEOPARDY: GENDER AND HIV RISK AMONG INJECTING DRUG USERS The majority of injecting drug users in China, as elsewhere in the world, are male. But because women who inject drugs are often also involved in commercial sex, women may be at greater risk of acquiring HIV. Up to 30%–40% of injecting drug users in some Chinese studies were women (Phariss & Thomson, 2004; Jia et al., 2003), and a substantial proportion of them also sold sex (Choi et al., 2007; Li et al., 2006). In a city in the south-west of Sichuan province in 2003–2004, more than half (57%) of the surveyed female injecting drug users sold sex. As a consequence, the female drug users were more likely to be infected with sexually transmitted diseases, compared with their male counterparts. They were also more likely to borrow used needles from their sex partners, compared with male injecting drug users (Choi, Cheung & Chen, 2006). In Anhui province, 39% of female injecting drug users said that they had used non-sterile injecting equipment in the previous month—more than double the 18% of male users who said that they had done likewise. More than half (56%) of the women had also sold sex in the previous year, just over half of whom (53%) said they used condoms “most of the time” when doing so. And yet three quarters (78%) of the female injecting drug users claimed that they were “certain” that they would not be infected with HIV (Liu H et al., 2006). Furthermore, the context in which women use drugs and sell sex (the latter usually to finance the former) often increases the risks of HIV infection. Where sex work is criminalized and sex workers are harassed by the authorities, clients are more difficult to obtain, and this can compromise the women’s abilities to insist on safe sex (Choi, Cheung & Chen, 2006). In another Sichuan province study, fewer than one third of female injecting drug users who sold sex reported consistent condom use with their clients (He et al., 2003). Harm reduction and other prevention programmes need to take into account such gender differences and inequalities in HIV risk. 3 2 0 0 7 A I D S E P I D E M I C U P D A T E | A S I A often without using condoms. In the Yunnan study conducted at rehabilitation centres, only one third (36%) of the sexually active injecting drug users (most of them men) said that they had ever used a condom (Hesketh et al., 2006). Although the use of contaminated drug injecting equipment is still the main mode of HIV trans- mission in Yunnan province, the proportion of reported HIV infections attributed to sexual transmission more than doubled between 1996 and 2004, from 5.3% to 12% (Lu et al., 2005). Injecting drug use has also been shown to be one of the key factors associated with HIV infection among sex workers in the same province, 21% of whom tested HIV-positive in one recent study (Wang et al., 2006a). Reported cases of sexually transmitted infec- tions such as syphilis have greatly increased since the 1980s. In the mid-1980s, a mere 194 cases of syphilis were officially reported coun- trywide; by 2005, that number had risen to 113 000, according to a recent national surveil- lance exercise. Researchers estimate that 0.5% of pregnant women, 0.8% of sex workers and 15% of men who have sex with men nationally are infected with syphilis (Chen Z-Q et al., 2006). The rapid social and economic changes in China are contributing to this trend. Strict policing in the second half of the 20th century helped to limit sex work, and drove it underground. However, economic and social reforms since the 1980s have been accompanied by widening income gaps and a more liberal cultural climate (Nolan, 2003), which has facilitated a resurgence of sex work (Gill et al., 1996). A skewed national gender ratio (the male/ female ratio was estimated at 117:100 in 2000) (Guilmoto, 2005) and an increase in migration are also believed to be contributing to the demand for sex work (Tucker et al., 2005). Research among men who moved from rural areas to Beijing, Nanjing and Shanghai, found that one in 10 (10%) had bought sex and one in five (20%) had a history of sexually transmitted infections (Wang et al., 2006b). Several other studies have highlighted the sexual risky behaviours among some groups of migrants (Yang & Xia, 2006; Smith & Yang, 2005). A 2003 survey in the south-west of China found that temporary migrants were at least five times more likely than non-migrants to have sex with a non- regular partner and seven times more likely to have commercial sex. Female temporary migrants were 14 times more likely to have sex with a non-regular partner than non-migrant women and 80 times more likely to sell sex (Yang & Xia, 2006). This places them at higher risk of exposure to HIV and other sexually transmitted infections. Meanwhile, low levels of HIV and reproduc- tive health knowledge, clients’ reluctance to use condoms and the illegal status of sex work in China place female sex workers at high risk of exposure to HIV. In a study among sex workers in Hong Kong Special Administrative Region, a minority (43%) of the women used condoms consistently with clients (in the previous three months), and a similar percentage (42%) of the women were found to be infected with at least one sexually transmitted infection (Choi, 2006). Consistent condom use with clients is reported to be especially low among women working in the lower echelons of the sex trade (on the streets, or in parks, salons or inns)—under 20%, compared with 57% among sex workers operating out of expensive hotels, according to another study (Parish & Suiming, 2006). Indeed, sexual risk- taking seems to be the norm among male clients. Only one third (36%) of the almost 1000 sex worker clients participating in a recent study in Sichuan province said they had used a condom the last time they paid for sex; 6% of them had had a sexually transmitted infection in the previous six months (Wan & Zhang, 2006). Though still few in number, condom promotion projects that target sex workers and their clients are yielding results. Started in 2003, a 100% condom use programme set up in barbershops (which sometimes double as commercial sex sites) in the city of Liuzhou (in Guangxi province) led to an increase in condom use among sex workers from 48% to 80% and a decline in gonorrhoea cases from 8.6% to 2.2% within two years (Li, 2006). In Wuhan, the capital of the eastern Hubei province, condom use levels increased from 33%, when a similar project was started in 2002, to 69% a year later, and the proportion of sex workers infected with Chlamydia was halved, to 15% (Wei et al., 2006). Reports from similar projects in Guangxi, Hainan, Hubei, Hunan and Jiangsu Harm reduction efforts, although still partial and scattered, are beginning to show positive results in China. 4 A S I A | 2 0 0 7 A I D S E P I D E M I C U P D A T E provinces also show positive outcomes (WHO, 2004). If sufficient in number and quality, such projects could prove vital in China’s efforts to reverse its epidemic. The spread of HIV among men who have sex with men has received relatively little attention in China, although as many as 7% of HIV infec- tions could be attributable to unsafe sex between men, according to some estimates (Lu et al., 2006). Studies have found HIV prevalence among men who have sex with men ranging from 1.5% in Shanghai (Choi et al., 2007), 1.7% in the south (Tao et al., 2004; Zhu et al., 2005), and 3.1%–4.6% in Beijing (Choi et al., 2003; Ma et al., 2006). Several studies indicate patterns of behaviour that could lead to wider exposure to HIV in and beyond networks of men who have sex with men. Most of the participants in the Shanghai study (cited above) were knowledgeable about HIV transmission, with 52% believing that they were at low risk and 38% believing that they were at no risk of becoming infected. Yet more than half (57%) of the men interviewed had had unprotected anal sex with other men in the previous six months, and 13% had had unpro- tected sex with both men and women. A total of 14% of the men were infected with syphilis (Choi et al., 2007). Very high levels of sexual risky behaviours have been found in a Beijing study, where two thirds (68%) of men who have sex with men said that they had had unprotected sex with other men in the previous six months. HIV prevalence among them was 4.6% (Ma et al., 2006). Another study in the same city revealed slightly lower levels of HIV infection (3.2%), but equally widespread sexual risk-taking behaviour among men who have sex with men, a significant proportion of whom (29%) also had sex with women. Fewer than one quarter (21%–24%) of the men used condoms consistently with regular male partners, fewer than half (35%–42%) did so with non-regular male partners, and only one third (33%) did so with their female partners (Ruan et al., 2007). In Guangzhou city, in the southern province of Guangdong, findings were similar, with 55% of surveyed men saying they had had unprotected sex with other men, and with syphilis prevalence of 11%. Since one quarter (26%) of the men were married and almost one third (32%) of the men had regular female partners, the potential for sexually transmitted infections to spread beyond their male sexual networks exists (He et al., 2006), as it does in Beijing and Shenyang, where studies found that 28% and 36%, respectively, of surveyed men who have sex with men also had recent female sexual partners (Choi et al., 2004; Gu et al., 2004). Such study findings underscore the need for prevention programmes that strengthen the social networks of men who have sex with men in China, and promote safer sex within them. Other factors complicate China’s AIDS response, including capacity constraints, low levels of civil society involvement and substantial HIV-related stigma. Of the almost 4000 nurses surveyed in Guangxi, Sichuan and Yunnan in 2005, for example, almost one in five (18%) said patients with HIV should be isolated and nearly half (45%) said that they preferred not to work in AIDS wards. In another study, 43% of the 1100 surveyed health-care providers supported mandatory HIV tests for all persons using hospital facilities (Sun et al., 2006). Overall, though, China has stepped up its response to the HIV epidemic in recent years. Free HIV testing is available at more than 3000 sites in all 31 provinces (Wu et al., 2007), and an estimated 30 000 patients were receiving antiretroviral treatment at the end of 2006 (Wu et al., 2007). However, research suggests that the response would benefit considerably from stronger coordination between and across relevant agencies and actors, and from a more concerted focus on most-at-risk groups (Gill, Huang & Lu, 2007). In addition, improved co-management of HIV and tubercu- losis needs to be a priority and should include improved laboratory diagnosis, earlier commence- ment of antiretroviral treatment, stronger adherence strategies and better community awareness. Field studies are reporting significant levels of coinfections of HIV and tuberculosis. In a rural study in 2003–2005, nearly one quarter (22%) of persons with HIV also had tuberculosis. Death rates among them were high, largely due to low tuberculosis treatment completion rates (Dahmane et al., 2006). Overall, although high levels of risky behaviour have been documented in some provinces of China, and prevalence of HIV and other sexually transmitted infections are increasing in some population groups, it is difficult to generalize on the basis of that information. China’s HIV epidemic is heterogeneous and is evolving at different rates in different regions. 5 2 0 0 7 A I D S E P I D E M I C U P D A T E | A S I A India New, more accurate estimates indicate that approximately 2.5 million (2 million–3.1 million) people in India were living with HIV in 2006, and that adult national HIV prevalence was 0.36%. Although the proportion of people living with HIV is lower than previously estimated, India’s epidemic continues to be substantial in terms of absolute numbers. These latest estimates are based on an expanded surveillance system, improved data (including a countrywide, population-based HIV survey carried out in 2005–2006), as well as the use of more robust and enhanced methodology. The estimates confirm earlier population-based HIV data which suggested that state-level and national prevalence estimates based on sentinel surveillance might have been overestimated. Research in Guntur district in the southern state of Andhra Pradesh had found that HIV preva- lence in a population-based study was about half as high as those based on sentinel surveillance (Dandona L et al., 2006). Among almost 100 000 adults (aged 15–49 years) tested for HIV in the most recent national population-based survey (NFHS-3, 2007), reported prevalence was 0.28% (0.23–0.33%). India’s epidemic is highly varied across states and regions, and diverse trends are evident in different parts of this huge country. Even in the four southern states (Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu) where the large majority of people living with HIV in India are believed to reside, HIV prevalence varies, and the epidemic tends to be concentrated in certain districts (NACO, 2005a; World Bank, 2005). Reported adult HI