1 Where have we failed? Findings of the Commission on AIDS in Asia Tim Brown East-West Center Modes of Transmission in the Philippines Stakeholders’ meeting.

1

Where have we failed?Findings of the Commission on AIDS in Asia

Tim BrownEast-West Center

Modes of Transmission in the Philippines Stakeholders’ meetingManila, the Philippines

November 27, 2009

2

The Commission on AIDS in Asia

• An independent body created by UNAIDS• Purpose:

– With fresh eyes, review HIV epidemic in Asia and responses to it

– Analyze course and impacts of the epidemic– Provide region-specific recommendations to

improve:• Prevention,

• Treatment and care, and

• Impact mitigation

3

The Commission found a slowing regional epidemic that was about to resurge

0

5,000,000

10,000,000

15,000,000

20,000,000

1985 1990 1995 2000 2005 2010 2015 2020

Cumulative HIV Current HIV New HIV

4

The pattern of new infections was evolving

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1985

1990

1995

2000

2005

2010

2015

2020

New

infe

ctio

ns in

yea

r

Clients Sex workers MSM IDU

Lo-risk male Lo-risk female Children

5

This pattern results from a mixture of prevention successes and failures

• For sex workers and clients– Early prevention success in higher risk, high prevalence

countries – near universal coverage– Limited prevention success in moderate & lower-risk countries– Coverage 34% on a regional basis– New infections fell, but moderate risk country contribution is now

growing

• For IDU & MSM– A legacy of abysmal failure– < 2% coverage for IDUs, < 5% coverage for MSM– New infections climbing rapidly for MSM– Sustained high prevalence among IDU

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Today – all transmission modes in play

0

100,000

200,000

300,000

400,000

2005

2006

2007

2008

2009

2010

New

infe

ctio

ns in

yea

r

Clients Sex workers MSM IDU

Lo-risk male Lo-risk female Children

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But new infections in every country differ

0

100,000

200,000

300,000

400,000

2005

2006

2007

2008

2009

2010

Clients Sex workers MSM IDU

Lo-risk male Lo-risk female Children

Indonesia

0

50,000

100,000

150,000

200,000

1985

1990

1995

2000

2005

2010

2015

2020

New

infe

ctio

ns in

yea

r

Cambodia

0

5,000

10,000

15,000

20,000

1985

1990

1995

2000

2005

2010

2015

2020

New

infe

ctio

ns in

yea

r

Burma

0

25,000

50,000

75,000

1985

1990

1995

2000

2005

2010

2015

2020

Ne

w in

fect

ion

s in

ye

ar

Japan

0

5,000

10,000

15,000

20,000

1985

1990

1995

2000

2005

2010

2015

2020

Ne

w in

fect

ions

in y

ea

r

8

…and to focus, a country needs to know where its new infections are occurring

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…so countries need to assess their own situation and act on it

• Collate local knowledge of– The sizes of key populations:

• IDU, MSM, sex workers & clients

– Their levels of risk behavior– Their HIV and STI prevalence

• Estimate new infections by population

• Select programs for max impact using this

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The Commission also reviewed what worked in HIV prevention

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Effective efforts addressed new infections with high coverage, e.g., Thai sex work

• Response start: 1991• Data collected 1990-91

– Most men getting infected were clients of sex workers

– STIs enhancing HIV

• Prevention targeted:– Condom promotion in

sex work– STI treatment

Proportion new infections by population in Thailand

0.0

0.2

0.4

0.6

0.8

1.0

1988 1990 1995

IDU MSMClient from FSW Husband from wifeFSW from client Wife from husbandCasual sex

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..but if prevention coverage was low in a population, countries saw major failures

17.3

28.330.7

0

5

10

15

20

25

30

35

2003 2005 2007

HIV prevalence among MSM in Bangkok (Wipas 2008)

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At-risk population focused efforts have more impact & are more cost-effective

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Interventionsfocused on sex

workers andtheir clients

Interventionsfocused on men

who have sexwith men

Harm reductioninterventions for

injecting drugusers

Prevention ofspousal

transmissionthrough

VCT/PMTCT

Mainstreamyouth

interventions

Generalworkplace

intervention andcondom

marketing

Health caresettings (blood

safety, safeinjection,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, 2007-2020Source: Redefining AIDS in Asia: Crafting and Effective Response

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Early harm reduction efforts with IDUs prevent many downstream infections

0

20

40

60

80

100

120

2005 2010 2015 2020 2025 2030

New

HIV

infe

ction

s av

erte

d ('0

00s)

ChildrenMSMMSWLow-risk womenLow-risk menClientsFSWIDU

• 192,000 IDU infections

• 60,000 FSW infections

• 460,000 client infections

• 200,000 infections in low-risk adult populations

• 50,000 infections in MSM

• 30,000 infections in children

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But in too many countries, prevention efforts are proving less than effective

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Emerging epidemics in different populations

0

20

40

60

80

1988

1993

1998

Per

cen

t H

IV+

Rangoon, Burma Guangxi, China

Bangkok, Thailand Hanoi, Vietnam

Jakarta, Indonesia

0

20

40

60

80

100

120

1985

1990

1995

2000

2005

Rep

ort

ed H

IV in

fect

ion

s

0

10

20

30

40

1995

2000

2005

Per

cen

t H

IV+

0

2

4

6

8

10

Round

II

Round

III

Round

IV

Round

V

Round

VI

Round

VII

Per

cen

t H

IV+ Central A (M)

Central A (F)

Central E

SE D

NW F1

Among MSM, e.g., Hong Kong Among FSW, e.g., Indonesia

Among IDU, e.g., Bangladesh Elsewhere IDU stays high

Indo

nesi

a U

NG

AS

S r

epo

rt

SP

P,

Hon

g K

ong

HS

S,

Ban

glad

esh

HS

S d

ata

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Why are efforts failing? Coverage

10 8

38

2 3

20

0

20

40

60

80

100

MSM IDU FSW

East-Asia and Pacific Southeast Asia

Source: Stover and Fahnestock 2006

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…and why is coverage so low?

• Resource constraints

• Inappropriate targeting of resources

• Limited community engagement– Awareness issues– Lack of ownership– No resources allocated for communities

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We need to do better!!!

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How do we improve our responses?

1. Build capacity to:– Identify the sources of new infections – Evaluate prevention coverage & impact

2. Direct prevention to those sources 3. Achieve high coverage in populations with

high incidence4. Mobilize and resource communities and

partners to engage the epidemic5. Act early in an epidemic