The Nature of Asia’s HIV Epidemics

Programme and Policy Implications Tim Brown Member, Commission on AIDS in Asia

Leading the AIDS Response in Asia: Recommendations from the Commission on AIDS in Asia

XVII International AIDS Conference August 5, 2008 Commission on AIDS in Asia – Projections and Implications 1

The Commission’s charge

•

Take a fresh look at HIV in Asia:

– Review socio-economic dimensions of HIV – Assess epidemic dynamics in the region – Provide Asia-specific recommendations for effective strategies Commission on AIDS in Asia – Projections and Implications 2

Guiding principle: making sound policy requires good epidemic understanding •

Commission’s charge required knowing:

– What do Asian epidemics look like?

– What drives them and how does this vary?

– How do Asian epidemics evolve and how do response needs change over time?

– What are the policy and programme implications of an understanding?

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Where is the risk in Asia that fuels HIV?

Asian Population: 3.1 billion 10 million Women sell sex

75 million

10 million Men who inject drugs Men in Asia visit sex workers (2-20% of adult men) 10 million Men who have sex with men 50 million

Women married to men who visit sex workers

Men

Infants and children

Women

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Sex work gives epidemics their reach… but varies substantially by country Country Thailand Cambodia Japan Hong Kong Bangladesh China Philippines Singapore % clients 22% / 10% 13% 11% 11-14% 10% 9% 7% 7.6% Number 4 / 1.8 million 0.5 million 3.2 million 0.15 million 4.0 million 34.0 million 1.6 million 0.1 million Year 1990/1997 2000 1999 early 2000s 2006 2000 2000 early 1990s 3 to 20% of adult males visit sex workers Commission on AIDS in Asia – Projections and Implications 5

To account for local variations, the Commission generated a set of models • • • Made specific models to understand where epidemic was going in each country Use these Asia-appropriate models to conduct analytic comparisons of: – – – Effectiveness of different prevention approaches Cost-effectiveness of programs Different prevention alternatives After review, chose Asian Epidemic Model Commission on AIDS in Asia – Projections and Implications 6

AEM takes behavioral inputs, translates them to HIV infections & compares against actual trends

Sizes & behavioral trends in clients, sex workers, injecting drug users, men who have sex with men, population at large

Injecting drug users Female sex workers AEM Calculation Engine Adult males Adult females

Probabilities of transmission and start years Observed HIV trends (white lines)

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Process for preparing country models

• • • • Collect data from published and unpublished sources – Over 4,500 papers and extensive data sets Extract behavior & HIV/STI trends by country Fit AEM to observed HIV in country Validate the model by comparison with – – – Observed prevalence trends Reported HIV, AIDS and M/F ratios if available Other country-specific projection work Commission on AIDS in Asia – Projections and Implications 8

Four patterns were seen in the region • • • • Cluster 1 – higher risk with prevention success – Thailand, Cambodia, Myanmar, Tamil Nadu and high prevalence Indian states Cluster 2 – moderate risk with limited success – China, Indonesia, Malaysia, Nepal, Vietnam and low prevalence states of India Cluster 3 – currently low HIV, higher risk and potential – Bangladesh and Pakistan Cluster 4 – lower risk and/or successful prevention – Hong Kong, Japan, Lao PDR, the Philippines, Republic of Korea, Singapore, Sri Lanka Commission on AIDS in Asia – Projections and Implications 9

Regional patterns in the epidemic

5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 1985 1990 Cluster 1 1995 Cluster 2 2000 Cluster 3 2005 Cluster 4 2010 Commission on AIDS in Asia – Projections and Implications 10

The overall regional epidemic has slowed, but will soon accelerate again 20,000,000 15,000,000 10,000,000 Late 2007: • 5.1 million living with HIV • 376,000 new infections • 418,000 deaths 5,000,000 0 1985 1990 1995 2000 2005 2010 Cumulative HIV Current HIV 2015 2020 New HIV Commission on AIDS in Asia – Projections and Implications 11

New infections in the regional epidemic

1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 1985 1990 1995 2000 2005 2010 2015 2020 Clients Lo-risk male Sex workers Lo-risk female MSM Children IDU Commission on AIDS in Asia – Projections and Implications 12

Why this pattern? The result of mixed prevention successes and failures • • For sex workers and clients – – – – Early prevention successes in higher risk countries Limited prevention success in moderate risk Coverage 34% on a regional basis But failure to address husband-to-wife transmission For IDUs and MSM – – – A legacy of abysmal failure < 2% coverage for IDUs, < 5% coverage for MSM New infections will be climbing rapidly for MSM Commission on AIDS in Asia – Projections and Implications 13

Today – all transmission modes in play

400,000 300,000 200,000 100,000 0 Clients Lo-risk male 2005 2006 Sex workers Lo-risk female 2007 MSM 2008 Children 2009 IDU 2010 Commission on AIDS in Asia – Projections and Implications 14

Casual sex does not drive Asian epidemics 800,000 600,000 400,000 200,000 0 1985 At-risk populations 1990 1995 Husband-wife 2000 2005 Mother-to-child 2010 Casual sex Commission on AIDS in Asia – Projections and Implications 15

At-risk population focused efforts have more impact & are more cost-effective 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Interventions focused on sex workers and their clients Interventions focused on men who have sex with men Harm reduction interventions for injecting drug users Prevention of spousal transmission through VCT/PMTCT Mainstream youth interventions General workplace intervention and condom marketing Health care settings (blood safety, safe injection, universal precautions) % or resources required % of infections averted Figure 3.9: Comparison of prevention interventions, according to distribution of resources and percentage of new infections averted, 2007-2020 Source: Redefining AIDS in Asia: Crafting and Effective Response Commission on AIDS in Asia – Projections and Implications 16

Prioritisation of resources: Averting new infections

Cost of Interventions Low-cost, High-impact

(prevention among most at-risk populations)

High-cost, High-impact

(antiretroviral treatment and prevention of mother to-child transmission)

Low-cost, Low-impact

(general awareness programmes through mass media and other channels)

High-cost, Low-impact

(universal precautions and injection safety) Commission on AIDS in Asia – Projections and Implications 17

Cost of a Priority Response – high impact

Interventions

High-impact prevention Treatment by ART Impact mitigation Programme Management Creation of an Enabling Environment

Total Total Cost (millions USD) $1,338 $761 $321 $363 $359 $3,143 % of total 43% 24% 10% 12% 11% 100% Average total cost per capita ranges from $0.50 to $1.70, depending on the stage of the epidemic.

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Commission prevention recommendations • • • • Prioritize the most effective interventions Focus on high impact interventions to reverse the epidemic and lessen impacts Leverage other resources to address other drivers and impediments Increase local investments in responses – Return on investment is high Commission on AIDS in Asia – Projections and Implications 19

But new infections in every country differ

Indonesia Cambodia

200,000 150,000 100,000 50,000 0 19 85 75,000 50,000 25,000 0 1985 400,000 20,000 15,000 10,000 5,000 0 19 85 19 90 19 95 300,000 20 00

Myanmar

200,000 20 05 20 10 20 15 20 20 19 90 19 95 20 00 20 05 20 10 20 15 20 20 100,000 ..and effective prevention targets new infections 1990 1995 0 2000 20 05 2005 2010 20 06 2015 Clients Lo-risk male 2020 20 07 Sex workers Lo-risk female 20 08 MSM Children 20 09 IDU 20 10 Commission on AIDS in Asia – Projections and Implications 20

Countries must assess situation and prioritize accordingly • • Requires comprehensive strategic analysis capacity – Today data collected, but not guiding programs for maximum impact Each country needs an analysis unit linked into program and policy decisions – Able to pull data together to determine what’s driving the local epidemic today – – Strongly linked to decision making Adapts the response as the epidemic evolves Commission on AIDS in Asia – Projections and Implications 21

What can such programs mean for the regional epidemic?

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If we make the right choices

1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 19 85 19 90 Clients Lo-risk male 19 95 20 00 Sex workers Lo-risk female 20 05 MSM Children 20 10 20 15 IDU 20 20 Commission on AIDS in Asia – Projections and Implications 23

..but ART will keep overall prevalence stable 20,000,000 15,000,000 10,000,000 5,000,000 0 1985 1990 1995 2000 2005 2010 Cumulative HIV Current HIV 2015 2020 New HIV Commission on AIDS in Asia – Projections and Implications 24

So, which will it be?

A resurgent epidemic?

1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 19 85 19 90 Clients Lo-risk male 19 95 20 00 Sex workers Lo-risk female 20 05 MSM Children 20 10 20 15 IDU 20 20 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 19 85 19 90 Clients Lo-risk male 19 95 20 00 Sex workers Lo-risk female 20 05 MSM Children 20 10 20 15 IDU 20 20 Or a contained one?

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The choice is ours

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Supplementary slides for follow-on discussions

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Causes of death 15-44 year olds in Asia Year 2005 2010 2015 2020

TB 292.1

IHD 164.1

Diabetes 25.9

Cancer 318.6

AIDS Old WHO 366.4

AIDS Comm ission 383.9

197.9

160.3

140.9

155.6

29.2

30.9

318.1

307.2

516.6

882.8

346.4

319.2

90.3

152.8

30.1

301.2

1207.4

369.2

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Important things to understand about Asian epidemics

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Key findings on Asian epidemic dynamics • • • • • Sex work is the key driver of Asian epidemics with female infections primarily from husbands who are clients MSM epidemic proceeds in parallel and can contribute substantially to total prevalence Both risk and HIV are disseminated throughout the “general population” Asian epidemics will not go “generalized”, i.e., be driven by boyfriend-girlfriend sex But… – large number of current & past clients, MSM, IDU, and FSW creates potential for HIV to reach a few percent Commission on AIDS in Asia – Projections and Implications 30

So most current infections remain in the “general population” from risk in the past 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 1995 Client 2000 FSW 2005 IDU 2010 MSM 2015 2020 General male 2025 2030 General female “Lo-risk” general population MSM/IDUs Currently active in SW Commission on AIDS in Asia – Projections and Implications 31

Injecting drug users kick start Asian epidemics, but clients drive them 280,000 240,000 200,000 160,000 120,000 80,000 40,000 0 Injecting drug users 19 95 20 00 Clients Female sex workers Clients 20 05 20 10 Injecting drug users Men having sex with men Client wives Men having sex with men 20 15 20 20 Currently lo-risk men Currently lo-risk women Commission on AIDS in Asia – Projections and Implications 32

The way Asian epidemics evolve Expanding Maturing 560,000 480,000 400,000 320,000 240,000 160,000 80,000 0 Latent 1995 2000 2005 Sex work Sex between men 2010 2015 Husband-wife sex Injecting drug use 2020 2025 Casual sex 2030 Commission on AIDS in Asia – Projections and Implications 33

When HIV in sex work is addressed other groups become quite important 200,000 150,000 Declining 100,000 50,000 0 1995 2000 2005 Sex work Sex between men 2010 2015 Husband-wife sex Injecting drug use 2020 2025 Casual sex 2030 Commission on AIDS in Asia – Projections and Implications 34

The most effective components of the response vary by epidemic stage The source of most new infections shows where to focus for impact

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Programs for injecting drug users and sex work have maximum impact in latent stage 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 1995 2000 2005 2010 2015 2020 Injecting drug user program Injecting drug user + sex work program No intervention Commission on AIDS in Asia – Projections and Implications 36

During expanding stage programs for sex work have maximum impact 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 1995 2000 2005 2010 2015 2020 Sex work program Sex work + husband-wife program Sex work + husband-wife + injecting drug user program Sex work + husband-wife + injecting drug user + men having sex with men No intervention Commission on AIDS in Asia – Projections and Implications 37

In declining phase, programs for men having sex with men and injecting drug users most effective 1,000,000 800,000 600,000 400,000 200,000 0 1995 2000 2005 2010 2015 2020 Men having sex with men program Men having sex with men + injecting drug use program Men having sex with men + injecting drug use + husband-wife program No intervention (sustain program for sex work) Commission on AIDS in Asia – Projections and Implications 38

So prevention in Asia should stay focused in nature but adapt over time • • Programs needed for most at-risk populations: – sex workers & clients, MSM, IDUs, husband-wife But balance changes over time: – Latent epidemics • Focus on IDUs buys time for sex work prevention • But, must prepare for sex work epidemic – Expanding epidemics • Focus most resources on sex workers and clients – Declining epidemics • Sustain sex work programs to avoid resurgence • • Expand programs for MSM and IDU Expand to address husband-wife transmission Commission on AIDS in Asia – Projections and Implications 39

Asian epidemics follow similar patterns…

FSW Clients Low or no risk males MSM • New infections strongly focused in a few behaviorally linked at-risk groups • - IDUs, clients and FSW, MSM And then spread to their lower-risk partners Low or no risk females IDUs …but the details vary from country to country Commission on AIDS in Asia – Projections and Implications 40

• • • • • • • • • Membership of the Commission Chakravarthi Rangarajan – Chair, Economic Advisory Council to Prime Minister of India Nerissa Corazon Soon-Ruiz – Congressional Representative for Cebu, Philippines Rajat Kumar Gupta – Global Fund for AIDS, Tuberculosis and Malaria Tim Brown – Senior Fellow, East-West Center Tadashi Yamamoto – President, Japan Center for International Exchange Wu Zunyou – Director NCAIDS, China Mahumuda Islam – Professor of Sociology, Dhaka University Frika Chia Iskandar – Coordinator, Women’s Working Group APN+ JVR Prasada Rao – Director UNAIDS RST and former Director of NACO in India Commission on AIDS in Asia – Projections and Implications 41

The Commission on AIDS in Asia

• • • June 2006, UNAIDS creates Commission as independent body Purpose: – With fresh eyes, review HIV epidemic in Asia and the responses to it – – Analyze course and impacts of the epidemic Provide region-specific recommendations to improve: • Prevention, • • Treatment and care, and Impact mitigation Report was launched last week at the UN Commission on AIDS in Asia – Projections and Implications 42