Aids

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AIDS Summary

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Aids

Asia contains 60 percent of the world's population and almost 20 percent of the adults with HIV infections—some 6 million of the estimated 34.4 million worldwide at the end of the twentieth century. But the epidemic is relatively new to the region. It was first detected in the early to mid-1980s, the earliest cases of infection reflecting sexual contacts with infected persons from outside the region. By 2000, there were an estimated 6 million infections; national experiences were diverse as to sources, levels, and prospects. Estimated HIV prevalences ranged from near zero in the Democratic People's Republic of (North) Korea to one per several thousand in most countries and as high as 2–3 percent in Cambodia, Myanmar (Burma), Thailand, and some states of India.

Today, all the governments of the region have HIV/AIDS task forces and action plans to deal with the threat, though these commitments are relatively recent and the translation into real programs remains variable. In Thailand, action by both the Thai government and the private sector has been aggressive and notably effective since 1987. Other governments generally have expended less in resources and have less to show for their efforts.

Drivers of the Asian Epidemic

Across much of the region, the spread of HIV is driven by sex work and associated sexual networking and by patterns of use of injected drugs. There are external, visitor-driven, and internal dimensions to each of these. The initial patterns were focal epidemics of some intensity involving men having sex with men (MSM) and intravenous drug users (IDU). Rates of infection due to MSM have since declined, while rates of infection due to IDU have not. Whether in each national population there is breakout to the general population is mainly a function of patterns of heterosexual sex in sexual networks. The pattern and magnitude of the heterosexual epidemic in each society reflect the social structures and behaviors characteristic of each, particularly the prevalence of men having multiple partners, including sex workers.

Demographic and Social Impacts

In Eastern and Southern Africa, AIDS is among the top ten causes of death, and AIDS deaths have substantially diminished the rate of population growth. The demographic impacts are much weaker thus far in Asia, though population growth rates have already been reduced slightly in Myanmar, Cambodia, and Thailand, and it is estimated that those three countries have each lost three years of life expectancy. One key to understanding the social impact is the fact that HIV infection disproportionately strikes the adult population rather than children or elderly people, resulting in the loss of economically productive members of households and of society as a whole. The repercussion is a dramatic loss of quality of life or even of life chances among infants and children, due to orphanhood and diminished household incomes. A full accounting of impacts must consider lost productivity and economic progress, the private (that is, family) and public costs of medicines and care, and the social costs of weakened families and other institutions.

Prospects for Behavior Change and Control

Projections of the spread of HIV infections and cases of AIDS vary dramatically by country and with what is assumed about the national epidemic patterns. The future of HIV in Asia hinges on what occurs in certain critical countries, among them China, India, Thailand, Myanmar, and Cambodia. The Monitoring the AIDS Pandemic or MAP network lists five countries in which HIV prevalence is increasing and another ten in which it is slowly increasing. This leaves only two countries in decline (Australia and New Zealand), and one, Thailand, which is tending to stabilize.

In Asia, many women and children are HIV-infected. Here, a one-year-old HIV-infected girl plays in her bed at Phaya Thai Baby's Home, a facility for HIV-infected children in Bangkok, Thailand. (AFP/CORBIS)

The case of Thailand is illuminating. In the mid-1980s, there was worrying evidence from IDU data and data on sex work, and by 1993 the HIV rate among army recruits (virtually a representative sample of young adult males) was at 4 percent (much higher in the north, due both to the greater poverty there as well as the prevailing sexual behaviors, which encourage the spread of infection). Infection levels then peaked and have been declining as a direct consequence of imaginative programs. Some of these have brought messages about the dangers of infection and the protection afforded by condoms directly into the brothels. Levels of condom use in brothels have risen dramatically. Similarly, HIV prevalence among pregnant women peaked at about 2 percent in 1995. Whether the same positive experience can be shared by other Asian countries depends on their government and private-sector efforts and policies.

Myanmar, Cambodia, and Vietnam are showing the patterns and levels once witnessed in Thailand. Their epidemics have thus far been driven by intravenous drug use and sex work, though Cambodia has high infection levels among pregnant women as well. These countries illustrate the potential for HIV to spread quickly. In China, Malaysia, and Nepal, HIV has spread among IDU populations but apparently not yet outside those groups. Cambodia has begun to show hopeful signs. Government and nongovernmental institutions are in place, and campaigns are underway. Condom use in brothels rose between 1997 and 1999, as did HIV prevalence among young sex workers.

China is viewed as a potential focus of rapid epidemic spread. There is now in place an extensive sentinel or monitoring system, by 1999 covering nearly a hundred sites in thirty provinces and focused on female sex workers, intravenous drug users, long-distance truck drivers, blood donors, and antenatal women. Recent returns from this system indicate rising infection rates for IDU and female sex workers. Overall, reported sexually transmitted infections reached 836 thousand in 1999. The government estimates that there are 3 million drug users in China and that needle sharing is common. There are a similar number of sex workers, half of whom report never using condoms. The working estimates of HIV infections in China were 400,000 at the end of 1998, 600,000 in 2000, and probably over 1 million by late 2001. There is enormous potential for pandemic and massive numbers of infections.

India displays a diverse set of experiences across its states and metropolitan areas, from very low HIV prevalences to as high as 2 percent of adults in the state of Tamil Nadu and the city of Mumbai (Bombay), from epidemics driven by heterosexual transmission (Tamil Nadu, Maharashtra) to epidemics driven by intravenous drug users (Maniput). A surveillance system was put in place only recently, and the 1999 estimate of 3.5 million HIV infections certainly will be revised as new data are examined.

Considering the diversity of national patterns and mixture of experiences for subgroups within countries, overall projections are difficult. The United Nations' AIDS coordinating agency or UNAIDS produces such projections, and these were incorporated into the United Nations' 1998 round of population projections. Among the twenty-nine largest countries with HIV prevalences of 2 percent or greater, three are in Asia: India, Thailand, and Cambodia.

Observations

Unlike many other diseases, with HIV/AIDS, behavioral knowledge and behavioral change are intimately connected. The HIV/AIDS epidemic is behaviorally driven and linked to intimate areas of personal life. The knowledge-gathering needed to deal with HIV/AIDS is akin to an X ray of the social corpus, with the HIV virus taking the role of radioisotopes, revealing aspects not usually seen. There is revealing new knowledge of marriage, family, and sexual systems, and even national polities are being placed under a scrutiny that exposes political interests and underlying values.

The attention now being given throughout Asia to heretofore off-limits behavior is generating pressure for change. Before the HIV/AIDS pandemic has become history, it is likely that important social changes will occur or will be accelerated because of it: in gender relations (such as wives' changed expectations of their husbands, and more openness within unions about marital and sexual relationships), in family-based care and in the role of governments and private agencies in supplementing it, in the relationships between parents and their young adult children, in the role of public or private reproductive health services to young unmarried people, and in the status of marginalized population groups such as sex workers and drug users.