Hiv Harm Reduction

UNDERSTANDING AND RESPONDING TO AIDS IN ASIA KNOWING OUR EPIDEMICS – UNDERSTANDING

David Wilson GAMET The World Bank

25 July 2008

HETEROGENEITY OF HIV (1-1) qGlobal HIV epidemics far more heterogeneous than initially recognized

GLOBAL HIV INFECTIONS BY SIZE AND SOURCE Gen pop heterosexual ID

SW MS

ID SW IDU MS

Gen pop heterose

HETEROGENEITY OF HIV IN AFRICA

0-0.1% 1-5% 3-7% 15-35%

HIV PREVALENCE IN THREE CITIES

5 4 0 4 5 3 0 3 5 2 0 2 5 1 0 1 5 05 0

Manzini, Swaziland

Kampala, Uganda Dakar, Senegal

8 6

8 8

9 0

9 2

9 4

9 6

9 8

0 0

0 2

0 4

AFRICA’S HYPER-EPIDEMICS (1-3) qGrowing understanding of Africa’s unique generalized hyper-epidemics qDifferences in NUMBERS of sexual partners alone CANNOT account for Africa’s hyper-epidemics

HOUSEHOLD HIV PREVALENCE IN FRANCISTOWN, BOTSWANA 8 0 6 0 4 0 2 0 0 1519

2024

25303529Male 34 Female 39

4044

4549

AFRICA’S HYPER-EPIDEMICS (2-3) qAt least two factors critical in hyperepidemics? qAcute infection and concurrent sexual partnerships qUncircumcised men

HIV TRANSMISSION RISKS

Half of transmission in first 1-5 months Wawer et al, 2005

CONCURRENT PARTNERSHIPS Female Male GLOBALLY Percentage of 15-49 year olds reporting > 1 regular partner in last year

6 0 5 0 4 0 3 0 2 0 1 0

Asia

0

Singapore Sri Lanka

Africa

Thailand

Philippines

Kenya Tanzania

Zambia

Cote D'Ivoire

Lesotho

Sources: Cassell et al, 2005

15-24 YR OLD SOUTH AFRICANS REPORTING 2+ SEX PARTNERS IN 2005

AFRICA’S HYPER-EPIDEMICS (3-3) qMeta-analyses - circumcised men 60% less likely to get HIV qEcological studies - circumcision major factor in variations in Africa and Asia’s HIV epidemic qThree randomized trials - circumcision reduced HIV transmission by 60-70% in South Africa, Kenya, Uganda

MALE CIRCUMCISION AND POPULATIONBASED HIV PREVALENCE IN AFRICA

High (>80%) male circumcision

Low (<20%) male circumcision

MALE CIRCUMCISION AND HIV Bangladesh Pakistan Philippines Indonesia

0 0 0.1 0.1

High (>80%) male circumcision

0.1

Low (<20%) male circumcision

Fiji China

0.30

Vietnam

0.60

PNG India

0.91 1.2

Burma Thailand

1.5

2.6

Cambodia

0

1

2

3

IMPLICATIONS (1-1) qConcurrent sexual partnerships and limited male circumcision - the perfect storm responsible for Africa’s unique hyperepidemics?

CONCENTRATED EPIDEMICS (1-1) qGrowing understanding of Asia’s concentrated epidemics qSexual networking patterns suggest generalized heterosexual epidemics highly unlikely in Asia – but significant

GENERALIZED AND CONCENTRATED EPIDEMICS(1-1)

CONCENTRATED EPIDEMICS MATTER (1-1) qConcentrated epidemics important given size of injecting drug use and sex work populations, we face large concentrated epidemics

ASIA (1-9) qAsian epidemics initiated by sex if: qMen uncircumcised qMany men visit sex workers (> 10%) qSex workers have many clients (> 20 weekly) qThus, first wave of epidemics in Asia Thailand, Cambodia, India (outside North East) – largely ignited by sex

HIV PREVALENCE BY PERCENTAGE OF MEN VISITING SEX WORKERS, ASIA

HIV PREVALENCE BY AVERAGE NUMBER OF CLIENTS PER SEX WORKER PER WEEK, ASIAN CITIES

ASIA (2-9) qElsewhere in second wave Asian epidemics, injecting drug use sparks sexual transmission, sex work the engine that maintains it qAsian data shows how injecting drug use fuels HIV in sex work, fundamentally amplifying epidemic potential qIndonesia, Central Asia, Pakistan, Bangladesh, Afghanistan, Iran – lands of opportunity. Effective IDU programs can radically curtail sexual epidemics

HIV INITIATORS IN ASIA

Initiated by sex Initiated by IDU Limited sexual or IDU transmission

HIV PREVALENCE AMONG SEX WORKERS IN CENTRAL ASIA

HIV PREVALENCE AMONG SEX WORKERS IN HAIPHONG, VIETNAM

HIV HIGHER IN FSW WHO INJECT DRUGS IN VIETNAM

IDU IGNITING HIV INFECTION AMONG SEX WORKERS IN ASIA

7 0 6 0 5 0 4 0 3 0 2 0 1 0 0

1994

1995

1 996

1 997

1998

1999

Guangxi, IDU

Guangxi, sex workers

Hanoi, sex workers

Jakarta, IDU

2 000

2 2 001 002 Hanoi, IDU

2003

Jakarta Sex workers

IDU IGNITING A DORMANT EPIDEMIC IN JAKARTA Sexual infections originating from IDU

108,29 6 48

48

100,00 0

5 0

80,00 0

4 0

4 1

3 0

60,00 0 40,00 0

2 0

16 35,85 0

20,00 0

2,04 9

0

1 98 15 98 6 1 98 7 1 98 8 1 98 9 1 99 0 1 99 1 1 99 2 1 99 3 1 99 4 1 99 5 1 99 16 99 7 1 99 18 99 9 2 00 0 2 00 1 2 00 2 2 00 23 00 4 2 00 5 2 00 6 2 00 7 2 00 8 2 00 9 2 01 0

Cumulative HIV infections

6 0

HIV infections if nothing changes HIV infections without IDU epidemic

HIV infections in IDUs if nothing changes IDU HIV prevalence

1 0 0

HIV

120,00 0

ESTIMATED HIV PREVALENCE AMONG MOST-AT-RISK POPULATIONS, 2006 45.0 0 40.0 0

41.0 7

35.0 0 30.0 0 Percen

25.0 0 20.0 0 15.0 0

13.7 2

13.4 6

10.0 0 5 .00 -

4 .00 IDU Partner of IDU FS W

5 .39

2 1 0 .69 0 .20 .90 .29 Client of FSW Partner of MSMTransvestite Client of Prisoner FSW Client Transvestite

Source: Ministry of Health, Indonesia

ESTIMATED NUMBER OF MOST-AT-RISK POPULATIONS IN INDONESIA, 2006 3,500,00 0

3,136,61 5

3,000,00 0 2,500,00 0 2,000,00 0

1,820,81 0

1,500,00 0 1,000,00 0 500,00 0 -

766,39 0 219,13 0

222,98 5

93,34 5 IDU Partner of IDU FS W

96,21 83,06 27,90 0 5 5 Client of Partner of MSM Transvestite Client of Prisoner FSW FSW client Transvestite

INDONESIA’S DYNAMIC EPIDEMIC: EVOLVING SOURCES OF INFECTION, 1990-2020 1 00% 90 % 80 %

Proporsi Infeksi Baru

70 % 60 % 50 % 40 % 30 % 20 % 10 % 0 %

1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 989 990 991 992 993 994 995 996 997 998 999 000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020

Clien t

ID U

MS W

MS M

FSW

Low-risk men

Lowrisk

ASIA(3-9) qHIV rising among Bangladesh IDU, especially in Central region 6 5 4

4

4

4. 9

3 2 1

1. 4

1. 7

2

0 Round II

Round III

Round IV

Central

SE D

0 0

Round V

NW F1

0. 6 Round VI

ASIA(4-9) qRemarkable concentration – and heterogeneity 1 0 8

8. 9

6

4

4 2 0

1. 4 Round IV Round V Round VI

ASIA(5-9) qRates among other Bangladesh groups 5 4 3 2 1 0

0. 2

0. 0 6 0 .01 S W Central

0. 4

0. 4

0

HIJRA S

NE

N

MS M

ASIA(6-9) qBut Bangladesh rates won’t stay zero unless injecting is kept safe 70

FEMALE IDU

60 50 40 30 20 10 0 % sex

% main

Clients per

worker

income sex

month

work

10 9 8 7 6 5 4 3 2 1 0

HIV AMONG FEMALE IDU 7. 1 4. 9

1. 3

0

Male IDU Central A1

Female IDU Central A2

Central A

ASIA(7-9) qSignificant infection among MSM in Asia – especially MSW and transgender

ASIA MSM HIV PREVALENCE

ASIA(8-9) qYet, unlike IDU, nowhere have MSM ignited heterosexual epidemics

ASIA(9-9) qHIV in Asia largely initiated by IDU qHIV in Asia sustained by SW qHIV in Asia augmented by MSM qHIV in Asia amplified by prisons/drug centres qHIV in Asia preventable – 99.8% of Asians don’t have HIV qHIV in the Papuas the exception

FORMER SOVIET UNION (1-3) qFormer Soviet Union has world’s fastest growing HIV epidemic, as Russian data show REPORTED HIV CASES IN RUSSIA, 1987-2005 40000 0 30000 0 20000 0 10000 0 0

1

1

1

1

1

1

1

2

2

2

FORMER SOVIET UNION (2-3)

qMore than Asia, former Soviet Union’s HIV epidemics initiated AND sustained by injecting drug use

PERCENTAGE KNOWN HIV INFECTIONS FROM INJECTING DRUG USE

FORMER SOVIET UNION (3-3)

qWhy does injecting drug use play greater role in former Soviet Union than Asia - significantly less sex work per capita

ASIA SW per 1,000 people

FS U

CAN WE REDUCE HIV? YES – EVIDENCE FROM MANY COUNTRIES (1-1)

GENERALIZED EPIDEMICS CONCENTRATED EPIDEMICS Africa Asia qUganda qThailand qKenya qCambodia qZimbabwe qSouth India qUrban Ethiopia qUrban Rwanda qUrban Malawi qUrban Zambia qUrban Burkina Faso qUrban Cote D’Ivoire Caribbean qHaiti qBarbados qBahamas

BEHAVIOR CHANGE AND DECLINING HIV 10 0 8 0 6 0 4 0 2 0 0

8 9 9 0 Condom use

9 9 9 1 2 3 Percent visiting SW

9 9 4HIV in 5

conscripts

9 9 6HIV in 7

9 8

pregnant women

100

BEHAVIOR CHANGE AND HIV TRENDS IN CAMBODIA

80 60 40 20 0 1997

SW condom use

Police condom use

1998

Police visiting SW

1999 SW HIV prevalence

2 Police HIV 001 prevalence

HIV PREVALENCE IN INDIAN 2 1. 5

1. 7

1. 6

1. 5

1. 2

1 0. 5 0

0. 2

0. 2

0. 3

0. 3

2000

2001

2002

2003

South

North

1. 1

0. 3 2004

BUT THIS SUCCESS IS PARTIAL (1-1) qHIV remains unacceptably high even in “success stories” – 7 – 20% in “successful” African countries and 1% in Thailand qAnd HIV transmission and behavioral risk are rebounding in Uganda and

0 1 2 3 4 5 6 7 8 9 10 11

Prevalence(%)

Crude Prevalence by Sex - Masaka Rural Cohort HIV PREVALENCE IN MASAKA, UGANDA

Proportion of Respondents

1990 1991

1992

1993

1994

1995

1996

1997 1998

1999

Survey Round/Year

Males - New Villages Males - Original Villages

2000

2001

2002

2003

2004

2005

Females - New Villages Females - Original Villages

0

.02

.04

.06

.08

PROPORTION IN MASAKA, UGANDA REPORTING 2+ Proportion of Resp 2+ Casuals in Past Year CASUAL SEX PARTNERS IN with LAST YEAR By Age of Respondent

1997

1999

2000 2001 Year of Survey 13-19 25-34

2003 20-24 35+

2004

2005

MEN VISITING SEX WORKERS IN URBAN THAILAND

CONDOM USE IN SEX WORK IN THAILAND

HIV PREVALENCE AMONG PREGNANT WOMEN IN THAILAND

MAINTAINING THE FOCUS IN ASIA (1-1) qHIV – a classic example of public health program we must preserve SYPHILIS INCIDENCE IN CHINA 8 6 4 2

5

0

0 3

1

0

9 8

6

9

9 4

2

9

9 0

8

6

8

0 8

P er hu nd re d th ou sa nd

1 0

HIV REVITALIZED INFECTIOUS DISEASE EPIDEMIOLOGY IN ASIA (1-1)

qHIV re-established infectious disease epidemiology globally and gave Asia the platform to successfully tackle SARS and Avian Influenza

HIV HAS INVIGORATED CIVIL SOCIETY (1-1) qHIV has transformed civil society more than any other disease it has enabled vulnerable groups – whether sex workers in India or gay men in China – to demand and increasingly receive a greater

WHAT’S UNIQUE ABOUT HIV? (1-3)

CAUSES OF MORTALITY IN AFRICA, 2000

WHAT’S UNIQUE ABOUT HIV? (2-3)

CAUSES OF DEATH AMONG ADULTS AGED 15-44 IN THAILAND,2002

WHAT’S UNIQUE ABOUT HIV? (3-3) q No other fatal disease preferentially strikes young adults in couples - robbing society of breadwinners, parents and families and creating million of orphans worldwide q In contrast, malaria and tobacco selectively strike the very young and the very old – no malaria or tobacco orphans q HIV’s lethal synergy with TB and other infectious childhood diseases is reversing a century of progress in sanitation and health

KEY LESSONS IN ASIA (1-1) qDo the right thing qDo it right qAnd do enough of it

DOING THE RIGHT THING AS INDONESIA’S EPIDEMIC SHIFTS

Sources: Beyrer, 2006

DOING THE RIGHT THING IN AN EVOLVING EPIDEMIC IN THAILAND

A CHANGING EPIDEMIC, WITH EARLY SUCCESS AND POTENTIAL FUTURE FAILURES IN ASIA

COST PER DALY GAINED FOR DIFFERENT INTERVENTIONS IN ASIA

AND DOING IT RIGHT IN YUNNAN, CHINA? .

Methadone detoxification

4 9

IEC materials

11

HIV counseling

5 6

3

Free condoms Free STI treatment

0.5 One person

Free needles

0.3 0

1 0

2 0

3 0

4 0

5 6 0 Percent 0

7 0

8 0

9 0

10 0

OR JAKARTA, INDONESIA, WHERE YOUTH ARE HAVING MORE DRUGS AND ALCOHOL THAN SEX Multiple partners last year

0.8 0.2

Had sex in the last year

Female Male

4 6 5

Ever had sex

9 0.5

Injected drugs

3 6

Tried illegal drugs

34 4

Drunk alcohol

30

0

5

10

15

20 Percent

25

30

35

40

AND DOING ENOUGH OF IT EVERYWHERE?

CONCLUSION (1-1) qIn this vast region, encompassing 60% of humanity from the Mediterranean to the Pacific, with its complex, heterogeneous, variegated and evolving epidemics among vulnerable groups, we rely even more than elsewhere on surveillance and research to ensure our responses are intelligent, informed, reflective, prioritized, differentiated and focused

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