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BEYOND BEYOND 2000 2000 Responding to HIV/AIDS in the new millenium Responding to HIV/AIDS in the new millenium Heidi J. Larson Jai P. Narain © World Health Organization 2001 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for South-East Asia, application should be made to the Regional Office for South-East Asia, World Health House, Indraprastha Estate, New Delhi 110 002, India. 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 the Secretariat of the World Health Organization concerning the legal status of any coun- try, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The views expressed in this publication are those of the author and do not neces- sarily reflect the decisions or stated policy of the World Health Organization; how- ever they focus on issues that have been recognized by the Organization and Member States as being of high priority. Contents ACKNOWLEDGEMENTS ......................................................................................xx FOREWORD ..............................................................................................................xx 1. Introduction........................................................................................xx 2. HIV/AIDS in South-East Asia – An Overview......................xx 2.1 The global context ............................................................................xx 2.2 Patterns of transmission....................................................................xx 3. Vulnerability Across Asia ..............................................................xx 3.1 Young people......................................................................................xx 3.2 The status of women in the context of HIV/AIDS ........................xx 3.3 Sex and HIV/AIDS ............................................................................xx 3.4 The challenge of culture....................................................................xx 3.5 Drugs and HIV/AIDS........................................................................xx 3.6 Migration and HIV/AIDS ................................................................xx 4. Health and Socio Economic Implications of HIV/AIDS....xx 4.1 The economics of HIV/AIDS............................................................xx 4.2 Tuberculosis and HIV/AIDS ............................................................xx 4.3 The impact on children ....................................................................xx 4.4 Stigma and Discrimination ..............................................................xx 5. What Have We have Learned?......................................................xx 5.1 Political mobilization is critical ........................................................xx 5.2 Communities must act......................................................................xx 6. Beyond 2000 – Strategies for the New Millennium............xx CONCLUSION ..........................................................................................................xx iii Acknowledgements Several persons have helped us in preparing this document. Tim Brown and Daniel Tarantola provided valuable technical inputs; Binod Mahanty and Karen Reynolds gave considerable editorial assistance; Jay Dowle designed its attractive cover and both Saroj Jha and Purushottam Shrestha provided useful technical and editorial suggestions. We gratefully acknowledge the contributions made by them. Heidi J. Larson Jai P. Narain 15 May 2001 Foreword “Beyond 2000 – Responding to HIV/AIDS in the New Millennium” unfolds the story of AIDS in WHO’s South-East Asia Region. The document focuses on how the epidemic has moved from a handful of HIV infections reported only from Thailand, in 1985, to over five million by early 2001. An extensively referenced account is also presented of the pattern of transmission, the vulnerabilities of differ- ent population groups and documented evidence of the socio-economic and health implications of HIV/AIDS in the Region. As we step into the new millennium, it is appropriate to reflect on the progress made so far and to learn from the past as we plan for the future. A number of lessons have been learnt over the last 15 years. The most important is that the control of AIDS calls for intensified multisec- toral action backed by strong political support and community par- ticipation. The key role of the health sector is also well recognized as crucial to stemming the tide of the epidemic—an epidemic that is sweeping across Asia at a faster pace than anywhere else in the world. Strategies for the new millennium as proposed in the document describe the approaches that countries of the Region must take if they are serious about slowing down the relentless spread of HIV infection, providing care and support for those infected and affected and alleviating the social and economic impacts of the epidemic. Accelerated efforts are clearly needed to build on what we now know works, to heighten and sustain national responses to the HIV/AIDS epidemic, and to bring about the necessary changes required, in policy as well as practice, without stigma or discrimination. Dr Uton Muchtar Rafei Regional Director WHO South-East Asia Region Acronyms AIDS Acquired Immunodeficiency Syndrome ANE Asia and Near East CSW Commercial Sex Worker DOTS Directly Observed Treatment, Short-course HIV Human Immunodeficiency Virus IVDU Intravenous Drug User NGO Nongovernmental Organization PWA People With AIDS SEARO South-East Asia Regional Office STD Sexually Transmitted Disease STI Sexually Transmitted Infection UNAIDS Joint United Nations Programme on HIV/AIDS UNICEF United Nations Children’s Fund UNFPA United Nations Population Fund WHO World Health Organization vi CHAPTER 1 Introduction The rapid changes sweeping across the world today are having a profound impact on our lives. These changes have irrevocably made us part of the global village, with all that this implies and entails. We are no longer immune to the consequences of the actions of other people and other nations. Nor can we find solutions to our problems in isolation. Dr Uton Muchtar Rafei, Regional Director, WHO South-East Asia Region Introduction 3 he story of AIDS is the story of an illness that is posing one of the biggest global challenges in the history of public Thealth. Three decades into the epidemic, there is still no vaccine and no “cure” for AIDS, the Acquired Immunodeficiency Syndrome. There is considerably more information available on how the Human Immunodeficiency Virus (HIV) which leads to AIDS, is spread, a wealth of “lessons learned” in implementing prevention strategies, and increased understanding about what constitutes effective treatment and care. The social and economic conditions that facilitate the spread of HIV are also well understood. Despite all we know, risk behaviour and risk environments persist and HIV continues to spread among individuals and across national and regional borders, the latest frontier being Asia1. With nearly six million people already infected in WHO’s South-East Asia Region, the potential health and socio-economic impacts of AIDS in the new millennium is cause for serious con- cern. There is a compelling need to chalk out well-designed and effective strategies that will halt the spread of HIV and reduce the impacts of the epidemic in the region. The challenges that face us are enormous. To address these, a more holistic approach to HIV/AIDS prevention and care is urgently called for. The HIV/AIDS epidemic is deeply entrenched in several Asian countries in numbers that are escalating fast.1 2 While Africa remains the worst hit region in the world, the rate of increase in the numbers of HIV infections is even higher in Asia. With more than 60 percent of the world’s population, the Asian region needs prompt concerted action to avert the potential social and economic consequences of a more widespread epidemic. While community-based responses to HIV and AIDS are still acknowledged as being the most effective means to change behaviour, supportive social, political and economic environments are also crucial to sustaining action at a community level. And, it is not just the socio-economic and political stage set at a national level that matter; policies and agreements made at an inter-coun- try and regional levels are critical to an effective response. AIDS has not only crossed geographic borders around the world and within Asia, but the epidemic has also challenged traditional cultural boundaries. Effective prevention involves 1 NOTE: While “Asia” is used throughout the text, the key countries addressed are those covered by the WHO South East Asia Regional Office(SEARO): Bangladesh, Bhutan, DPRKorea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. 3 addressing traditional “taboo” areas in many cultures. Discussing sensitive issues around sexuality – critical to effective AIDS educa- tion – requires a change of traditional “cultures of silence” so that people can more openly talk about sex. Due to the early association of HIV and AIDS with commercial sex, drugs and men having sex with men, the disease has also

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