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Situation of HIV Epidemic in Asia and the Health Sector Response

Situation of HIV Epidemic in Asia and the Health Sector Response. Presentation by : Dr. Partha Haldar Country Office for India, World Health Organization New Delhi, India. Scheme of the presentation. Description of the epidemic What is the burden of the HIV epidemic in Asia?

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Situation of HIV Epidemic in Asia and the Health Sector Response

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  1. Situation of HIV Epidemic in Asia and the Health Sector Response Presentation by: Dr. Partha Haldar Country Office for India, World Health Organization New Delhi, India

  2. Scheme of the presentation • Description of the epidemic • What is the burden of the HIV epidemic in Asia? • Prevalence, Incidence, Women, Children • In different MARPs • What is the transmission dynamics of HIV in Asia? • What are the Vulnerabilities? • MARPs (type, size, behaviour) • STIs (type, popl grp affected) • Health sector response to the epidemic • Prevention, • Care, support and treatment

  3. EA EA EA Countries in Asia: South-East Asia & South Asia

  4. Percentages and denominators !!Better to remember, what you are dealing with • HIV Epidemic in Asia started around 1990s • Overall adult HIV prevalence in Asia is around 0.3% compared to 4.9% in Sub Saharan Africa (SSA) • National adult HIV prevalence in most of the Asian countries are actually low (<1%) • (Ban, Mal, SL, <0.1%; Bh, TL, 0.1%; Ino, 0.2%; In, 0.3%, Np, 0.4%; Myr, 0.6%; Th 1.4%) • However, large population sizes (60% of world popln) means even with low prevalence, large number of people are infected • Thus, around 4.9 million people are living with HIV in Asia compared to 22.5 million in SSA Source: WHO 2009, WHO 2010; UNAIDS Global Report 2010

  5. HIV situation, South & South-East Asia, 2001 and 2009 Source: WHO, UNAIDS, Global Report 2010

  6. HIV in Asia- a comparison of 2001 vs 2009 Source: WHO, UNAIDS, Global Report 2010

  7. What is this burden as a proportion of the global HIV burden? - Second highest HIV burden in the world after SSA - Accounting for 15% of people living with HIV globally

  8. Of the total HIV burden in Asia: India 60% India and Thailand 70% First seven countries almost 95% Select countries account for major portions of the HIV Burden in Asia People living with HIV in select countries in Asia Source: WHO, UNAIDS, Global Report 2010, (Note: China, between 0.24 to 0.47 million)

  9. Even within the countries, the burden is concentrated • National epidemics are mainly concentrated • E.g. in India, more than half (56%) is in high prevalence states • In China, five provinces account for 53%

  10. “Overall”, the HIV epidemic in Asia is, stable • An estimated 4.9 million people were living with HIV in 2009 • Overall, it is stable around this figure Source: WHO, UNAIDS, Global Report 2010, (Note: China, between 0.24 to 0.47 million)

  11. HIV prevalence, select Asian countries Source: HIV prevalence curves generated by Spectrum using surveillance data reported by Ministries of Health, SEAR countries WHO,

  12. The epidemic is stable or declining in most of the countries • Most national HIV epidemics appear to have stabilized • No country in the region has a generalized epidemic • Thailand: only country in this region which has prevalence close to 1% (stabilized) • Cambodia: adult prevalence decreased from 1.2% (yr 2001) to 0.5% (yr 2009) • India: sustained decline from 0.41% (yr 2000) to 0.31% (yr 2009)

  13. But, there are historically low prevalence countries that are now showing an increase • HIV prevalence is increasing in low-prevalence countries: • Bangladesh • Pakistan (mainly IDU driven) • Indonesia • Philippines

  14. HIV prevalence varies within countries • E.g. in India, (national adult HIV prevalence 0.31%) • Within the country, Manipur 1.40%, followed by Andhra Pradesh (0.90%), Mizoram (0.81%), Nagaland (0.78%), Karnataka (0.63%) and Maharashtra (0.55%). • Besides, Goa, Chandigarh, Gujarat, Punjab and Tamil Nadu have > (0.31%), • Delhi, Orissa, West Bengal, Chhattisgarh & Puducherry have shown estimated adult HIV prevalence of 0.28-0.30%. • All other states/UTs have lower levels of HIV.

  15. In India, declining in historic HP states Source: National AIDS Control Organization, India (HIV Estimations, 2010); Note: Mizoram is not classified as HP state

  16. However, increasing in historic LP states in India Source: National AIDS Control Organization, India (HIV Estimations, 2010)

  17. HIV incidence in Asia (“overall trend”) • An estimated 360,000 people were newly infected in 2009 (450,000 in 2001), a 20% reduction over eight years • Overall incidence shows a declining trend Source: WHO, UNAIDS, Global Report 2010, (Note: China, between 0.24 to 0.47 million)

  18. Incidence rates vary by countries Source: WHO, 2010: Number of new infections estimated by Spectrum model using surveillance data reported by national AIDS programmes, Member countries, South-East Asia Region.

  19. HIV Incidence in Asia (contd.) • Between 2001 and 2009, incidence fell by more than 25% in: • India (60%), Nepal and Thailand • However, the epidemic remained stable during this time in: • Malaysia and Sri Lanka • During this period, incidence increased by 25% in: • Bangladesh and Philippines (otherwise low % level)

  20. HIV incidence vary within countries E.g. in India: • Of the estimated 120,000 new infections in 2009, • six high prevalence states account for only 39% of the cases, • while otherwise low prevalence states of Orissa, Bihar, West Bengal, Uttar Pradesh, Rajasthan, Madhya Pradesh and Gujarat account for 41% of new infections

  21. HIV burden in Women (SEA) 37% Global average =51% Proportion of females among reported AIDS cases, South-East Asia Region, 1990–2009 Source: WHO, 2010:

  22. HIV burden in Women (contd.) • An estimated 1.3 million women (aged >15 yrs) are living with HIV in SEA • Except Bhutan and Timor-Leste, F:M ratio < 1 • Proportion of women with HIV has increased over period of time • Reasons for higher vulnerability of women: barrier (access) to health care; stigma, gender inequality,

  23. HIV burden in Children (S&SEA) • Prevalence: • Estimated no of children (<15 yrs) living with HIV increased from 140,000 (yr 2005) to 160,000 ( yr 2009) • Incidence: • Estimated number of children (<15 yrs) getting newly infected with HIV 22,000 (yr 2009) from 26,000 (yr 1999) • 15% decline • Reason: increasing access to PMTCT of HIV  drop in number of children getting infected • AIDS related deaths among children declined from 18,000 (yr 2004) to 15,000 (yr 2009)

  24. AIDS related mortality Number of deaths have largely stabilized Source: WHO, UNAIDS, Global Report 2010, (Note: China, between 0.24 to 0.47 million)

  25. AIDS related mortality • Number of deaths have stabilized • Estimated AIDS related deaths 300,000 (yr 2009) compared to 250,000 in 2001 • Variations exist by countries • Almost 50% of these deaths occurred in India (estimated 172,000) • The trend of annual AIDS deaths in India is showing a steady decline since the roll out of free ART programme in 2004.

  26. Both the measures are important Prevalence reflects the load/burden at a point in time Affected by both new infections and mortality Needed to determine care and treatment needs Incidence reflects the rate of spread or progress of HIV epidemic Better measure to understand the epidemiology and to assess the impact of preventive interventions Although incidence is a preferred measure, it is difficult to obtain. What are the methods to get HIV prevalence? What are the available data sources? What are the methods to get HIV incidence? What special softwares are used? Which is better? Which is feasible? Significance of prevalence and incidence

  27. Message, till now… • HIV prevalence in Asia: overall declining • HIV incidence in Asia: overall declining • Magnitude differs greatly between countries • Some showing decline (India, Thailand, Nepal) • Some showing increase (Bangladesh, Philippines, Indonesia, Pakistan) • Burden is concentrated in specific geographical areas within the countries

  28. Routes of transmission

  29. Distribution of reported HIV/ AIDS cases by mode of transmission, selected South-East Asian Countries • Unsafe sex and injecting drug use are the main risk behaviors driving the HIV epidemic in South-East Asia Source: National AIDS programme, Ministry of Health, SEAR countries, 2007

  30. Concentrated nature of the epidemic Most At Risk Population (MARPs) also known as High Risk Group (HRG) population

  31. Concentrated nature of the epidemic • Although the overall HIV prevalence is around 0.3%, certain population groups are highly infected • These include: • Female Sex Workers (FSW) • Injecting Drug Users (IDU) • Men who have Sex with Men (MSM), & TG

  32. HIV prevalence by population group, Myanmar and Thailand, 2009 - Wide variations, - 10-40 times higher than general population Source: National AIDS Program,2009 HIV sentinel surveillance report

  33. HIV prevalence by population group, India 2008-09, Annual HIV Sentinel Surveillance Source: 2008-2009 HIV sentinel surveillance, National AIDS Control Organization, India

  34. HIV prevalence by population group, Viet Nam, 2001-2006 Highest HIV prevalence was found in IDU, SW compared with other sentinel groups Source: 2001-2006 sentinel surveillance, MOH, Viet Nam

  35. HIV prevalence by population group, Lao PDR, HSS 2004

  36. Percentage of female sex workers infected with HIV, South-East Asia Region, 2007–2010 Of 281 sentinel sites for FSW, in 33% sites, HIV prev was <1%, 39% sites it was 1-5%, 25% sites it was 5-20%; highest is noted in Southern India Source: WHO SEAR Office

  37. HIV prevalence in FSW, 2010 • Indonesia: Tanah Papua (16%), Bali (14%), and Batam (12%) • Myanmar: all five sites >5% • Thailand: allof 51 sites had <5%, except four sites • <5% in Bangladesh, Maldives, Nepal and TimorLeste • No HIV detected in FSW in Sri Lanka

  38. Trend of HIV prevalence among FSW, SEA, 2000-2008 Source: WHO SEAR Office

  39. HIV trends among FSW, India, 2003-2007 Source: HIV sentine surveillance, National AIDS Control Organization, India

  40. MSM

  41. Trend ? Trend ? HIV prevalence among men who have sex with men, selected cities, South-East Asia Region, 2003–2009 Source: Sentinel surveillance reports, national AIDS programmes, South-East Asia Region.

  42. Rising trend in all the South Indian states Source: HIV sentine surveillance, National AIDS Control Organization, India

  43. HIV transmission among MSM is ongoing • Myanmar 29%, India 7.3%, Indonesia 5%, • Thailand, (around 28-31%) • China: rising prevalence among MSM in Shandong, Jiangsu provinces and Beijing

  44. IDU

  45. HIV in IDU • Estimated 4.5 million people in Asia inject drugs • More than half of them are in China • Other large numbers are in India, Vietnam and Pakistan • On an average, HIV prev = 16% (with variations) • Myanmar= 19-38%, Thailand = 30-50%, Vietnam = 32-58%, China= 7-13%, India = 0-56%

  46. HIV prevalence among injecting drug users, South-East Asia, 2007-2009 New spots, worry, fuel, explode epidemic Mostly known areas; need control and CST

  47. In India, • Decline in Manipur, Nagaland • Rise in Meghalaya, Mizoram, WB, Mumbai, Kerala and Delhi • New spots: in Amritsar and Ropar (Punjab), Chandigarh, Delhi and Orissa

  48. Variations with in the country

  49. HIV among general population

  50. HIV prevalence among military recruits,Myanmar and Thailand, 1989–2009 Source: Sentinel Surveillance Reports,National AIDS Programmes, South-East Asia Region.

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