Click on figure for the latest pictographic image of the estimated annual number of new HIV infections worldwide (2003), and by region, 1988 to 2003 (pdf, 2 MB)

View Spread of HIV in Asia & Pacific (figure) and read the latest report on the AIDS Epidemic Update in Asia and the Pacific 30

China and India: large epidemics

HIV prevalence in both countries is very low: 0.1% (range: 0.1–0.2%) in China and between 0.4% and 1.3% in India. But a closer focus reveals that both have extremely serious epidemics in a number of provinces, territories and states.

In China, 10 million people may be infected with HIV by 2010 unless effective action is taken. The virus has spread to all 31 provinces, autonomous regions and municipalities, yet each area has its own distinctive epidemic pattern. In some, injecting drug use is fuelling HIV spread. Among injecting drug users, HIV prevalence is 35–80% in Xinjiang, and 20% in Guangdong. In other areas, such as Anhui, Henan, and Shandong, HIV gained a foothold in the early 1990s among rural people who were selling blood plasma to supplement their meagre farm incomes. Infection levels of 10–20% have been found, rising to 60% in certain communities. As a result, many people have already died of AIDS .

India has the largest number of people living with HIV outside South Africa—estimated at 4.6 million in 2002. Most infections are acquired sexually, but a small proportion is acquired through injecting drug use. Injecting drug use dominates in Manipur and Nagaland in the north-east of the country, bordering Myanmar and close to the Golden Triangle. In this area, HIV infection levels of 60–75% have been found among injecting drug users using non-sterile injecting equipment.

In the southern states of Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu, HIV is transmitted mainly through heterosexual sex, and is largely linked to sex work. Indeed, according to selected surveys, more than half of sex workers have become infected with HIV . In all four states, infection levels among pregnant women in sentinel antenatal clinics have remained roughly stable at over 1%, suggesting that a significant number of sex workers’ clients may have passed on HIV to their wives (see Fig. 2).

Figure 2

In India, knowledge about HIV is still scant and incomplete. In a 2001 national behavioural study of nearly 85000 people, only 75% of respondents had heard of AIDS and awareness was particularly low among rural women in Bihar, Gujarat and West Bengal. Less than 33% of all respondents had heard of sexually transmitted infections and only 21% were aware of the links between sexually transmitted infections and HIV .

HIV transmission through sex between men is also a major cause for concern in many areas of India. Recent research shows that many men who have sex with men also have sex with women. In 2002, behavioural surveillance in five cities among men who have sex with men found that 27% reported being married, or living with a female sexual partner. In a study conducted in a poor area of Chennai in 2001, 7% of men who have sex with men were HIV -positive. Attention currently focuses on areas with high recorded prevalence, but there is concern about what might be happening in the vast areas of India for which there are little data.

Risk behaviour on the rise

Elsewhere in South Asia, behavioural information suggests that conditions are ripe for HIV to spread. For example, in Bangladesh, national adult prevalence is less than 0.1%, but there are significant levels of risky behaviour. Large numbers of men continue to buy sex in greater proportions than elsewhere in the region. Moreover, most of these men do not use condoms in their commercial sex encounters and female sex workers report the lowest condom use in the region.

Among injecting drug users, 71% of those who do not participate in needle-exchange programmes use non-sterile injecting equipment, compared with 50% of attendees in central Bangladesh programmes, and 25% in north-west Bangladesh programmes. Drug use in south-east Bangladesh appears to be on the rise (Dhaka, 2003). Surveys show that only about 65% of young people, fewer than 20% of married women, and just 33% of married men have even heard of AIDS .

In Pakistan, 2001 country-level studies of populations more likely to be exposed to HIV revealed very low prevalence. Pakistan has an estimated adult HIV prevalence of 0.1%. It also has about three million heroin users, many of whom started injecting drugs in the 1990s. The first outbreak of HIV infection among injecting drug users happened in 2003. In Larkana, a small rice-growing town in Sindh province, 10% of 175 injecting drug users tested HIV -positive. A behavioural survey in Quetta found that a high proportion of respondents used non-sterile injecting equipment; and over half of them said they visited sex workers. Few had heard of AIDS , and even fewer had ever used a condom.

In South-East Asia, three countries in particular—Cambodia, Myanmar and Thailand—are experiencing particularly serious epidemics. Cambodia’s national HIV prevalence is around 3%—the highest recorded in Asia. Data suggest that there have been some dramatic changes in the shape of Cambodia’s epidemic. For instance, infection among brothel-based sex workers fell from 43% in 1998 to 29% in 2002 (see Fig. 3).

Figure 3

There have also been sustained declines in prevalence among their customers, who include urban policemen, military conscripts and motorcycle taxi riders. This is believed to be due to increased condom use, as well as fewer visits to sex workers. However, the picture is incomplete: little has been done to monitor the epidemic among drug users, or men who have sex with men, even though HIV prevalence among male sex workers in the capital was above 15% when last measured in 2000 (Girault et al., 2004).

in Black and White or Map Data Table

Figure 4. HIV seroprevalence among prostitutes in Cambodia. View also HIV seroprevalence among pregnant women in Cambodia.

Thailand: progress is lagging

In Thailand, the number of new infections has fallen from a peak of around 140000 a year in 1991, to around 21000 in 2003. This remarkable achievement came about mainly because men used condoms more, and also reduced their use of brothels. However, Thailand’s epidemic has been changing over the years (see Fig. 5). There is mounting evidence that HIV is now spreading largely among the spouses and partners of clients of sex workers and among marginalized sections of the population, such as injecting drug users and migrants.

Figure 5

Despite Thailand’s indisputable success, coverage of prevention activities is inadequate. This is especially the case among men who have sex with men, and injecting drug users; their infection levels remain high. In Bangkok, over 15% of men who have sex with men who were tested in a 2003 study were HIV -positive, and 21% had not used a condom with their last casual partner.

Many young Thai men avoid brothels because they are afraid of contracting HIV . However, the drop in commercial sex patronage appears to have been accompanied by an increase in extramarital and casual sex. Young Thai women also appear more likely to engage in premarital sexual relationships than earlier generations (VanLandingham and Trujillo, 2002). In Chiang Rai province, a study among vocational students revealed that only 7% of males surveyed said they had ever bought sex, but that almost half the students (male and female) were sexually active. Behavioural surveillance between 1996 and 2002 shows a clear rise in the proportion of secondary-school students who are sexually active. It also shows consistently low levels of condom use.

in Black and White or Map Data Table

Figure 6. HIV seroprevalence among prostitutes in Thailand. View also HIV seroprevalence among pregnant women in Thailand.

One of the newest epidemics in the region is in Viet Nam. National prevalence is still well below 1%, but, in many provinces, sentinel surveillance has revealed HIV levels of 20% among injecting drug users. Although HIV prevalence among injecting drug users increased significantly in some provinces in the late 1990s, recent outbreaks are now occurring in other provinces such as Can Tho, Hue, Nam Dinh, Thai Nguyen, and Thanh Hoa. Use of contaminated drug injecting equipment is believed to be responsible for two-thirds of HIV infections, but unsafe sex is also a concern in Viet Nam. In major cities in 2002, prevalence levels of 8–24% were reported among sex workers.

in Black and White or Map Data Table

Figure 7. HIV seroprevalence among prostitutes in Vietnam. View also HIV seroprevalence among pregnant women in Vietnam.

Indonesia’s epidemic is currently unevenly distributed across this archipelago nation of 210 million people; six of the 31 provinces are particularly badly affected. The country’s epidemic is also driven largely by the use of contaminated needles and syringes for drug injection. HIV prevalence among its 125000–196000 injecting drug users has increased threefold—from 16% to 48% between 1999 and 2003. In 2002 and 2003, HIV prevalence ranged from 66% to 93% among injecting drug users attending testing sites in the capital city, Jakarta. Indonesia’s drug users are regularly arrested and sent to jail. In early 2003, 25% of inmates in Jakarta’s Cipinang prison were HIV -positive.

Among Indonesia’s more than 200 000 female sex workers, HIV prevalence varies widely. In many areas, recent serosurveillance shows that HIV infection in this population group is still rare. But some areas of the country have recorded sharp rises in the past year or two, with reported levels as high as 8–17%. Among transgender sex workers, known as waria, data show a sharp increase in HIV prevalence—from 0.3% in 1995 to nearly 22% in 2002 in Jakarta. There is strong evidence that various sexual and injecting-drug-user networks in Indonesia overlap significantly, thus creating an ideal environment for HIV to spread.

Oceania

In Australia, following a long-term decline, the annual number of new HIV diagnoses has gradually increased over a five-year period, from around 650 cases in 1998 to around 800 in 2002. HIV transmission continues to occur mainly through sexual contact between men. Among men diagnosed with newly acquired HIV infection between 1997 and 2002, more than 85% were found to have had a history of sex with another man. Relatively small percentages of newly acquired infections were attributed to a history of injecting drug use (3.4%), or heterosexual contact (8.5%). Similarly, the principal form of HIV transmission in New Zealand continues to be sexual contact between men.

Papua New Guinea, which shares an island with one of Indonesia’s worst-affected provinces, Irian Jaya, has the highest prevalence of HIV infection in Oceania. Prevalence is over 1% among pregnant women in the capital, Port Moresby, and in Goroka and Lae. Papua New Guinea’s epidemic appears largely heterosexually driven. High levels of other sexually transmitted infections indicate behavioural patterns that would also facilitate HIV transmission beyond sex workers and their clients.

In other islands in Oceania, HIV infection levels are still very low, but levels of sexually transmitted infections are high. A person with a sexually transmitted infection faces a higher risk of contracting and transmitting HIV during sexual encounters. In Vanuatu, pregnant women have chronically high levels of some sexually transmitted infections: 28% have Chlamydia and 22% have Trichomonas infection. Some 6% of pregnant women are infected with gonorrhoea, and 13% with syphilis. About 40% of the women had more than one sexually transmitted infection. Similarly, in Samoa, 31% of pregnant women had Chlamydia and 21% had Trichomonas infection. Overall, 43% of pregnant women had at least one sexually transmitted infection.

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The excerpted text and figures integrated herein were mainly from the:

• 2004 Report on the global AIDS epidemic (July 2004) © UNAIDS/WHO
  Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO)
• US Bureau of Census: HIV/AIDS Surveillance
• Center for Disease Control and Prevention (CDC): Divisions of HIV/AIDS Prevention

unless indicated, otherwise.

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