TORONTO, August 14, 2006 — South Asia's HIV and AIDS epidemic can be expected to grow rapidly unless the eight countries in the region, especially India, can saturate high-risk groups such as sex workers and their clients, injecting drug users, and men having sex with men with better HIV prevention measures, according to a new World Bank report launched at the 16th International AIDS Conference in Toronto, Canada.
Contributing regional risk factors include widespread stigma and discrimination, poverty and inequality, illiteracy, the low social status of women, trafficking of women into commercial sex, porous borders, widespread migration, high levels of mobility, cultural restrictions on discussing sex, high rates of sexually transmitted infections, and limited condom use.
The report says halting the spread of the epidemic will depend on a two-pronged approach: first, establishing effective prevention programs for groups at increased risk of HIV infection such as sex workers and their clients, injection drug users, and men who have sex with men; and, second, resolving the social and economic drivers of the epidemic such as poverty, stigma, and sex trafficking of women.
"Reaching and involving people at risk of HIV is the greatest challenge in South Asia because they're frequently marginalized within their own communities because of what they do, and are therefore difficult to involve and reach with conventional prevention measures," says Julian Schweitzer, Director for Human Development in the World Bank's South Asia regional team. "But our experience shows that where governments, civil society, and other partners make a concerted effort to work closely, including these at-risk groups, you can achieve positive results with specially tailored programs that reduce people's HIV risks."
Epidemics differ across South Asia
South Asia's women increasingly vulnerable to HIV infection: a young mother with HIV waits to see the doctor with her young son
The first set of AIDS cases appeared in the region during the early 1980s, and by the end of the decade, national health authorities of most countries had received reports of AIDS cases. Despite similar times of HIV introduction, epidemics in the various countries have played out in remarkably different ways.
India could even be considered a continent in itself, with individual states and even smaller geographic pockets with unique epidemic patterns, requiring different HIV responses. Indeed, a major lesson from South Asia and also from Sub-Saharan Africa—a region with approximately half the population of India alone—is the need to understand how HIV transmission patterns can be remarkably different both between and within regions and countries. This lesson has received insufficient emphasis globally.
Focusing mainly on five countries in the region for which there is adequate data—Bangladesh, India, Nepal, Pakistan, and Sri Lanka—the new report conclude that countries must tailor their HIV prevention programs to suit their own local conditions rather than rely on generic global or regional approaches which have failed to make a difference in individual countries.
In Nepal, for example, over 30% of the budget of the National Centre for AIDS and STD Control has been spent on prevention, care, and treatment activities for the general population, and only 6% on harm reduction programs for injecting drug users, although injection drug use is a major driver of the HIV epidemic in Nepal.
In India, most NGOs have focused their HIV prevention work on migrant men rather than on the one million sex workers who are considered an extremely vulnerable group for HIV transmission. Moreover, South Asia's most severe epidemic is in parts of India, particularly in a cluster of Southern and Western States, including Tamil Nadu, Karnataka, Andhra Pradesh, Goa, and Maharashtra where sex work is the critical driver of HIV transmission.
Country priorities going forward
A woman comforts her HIV-positive husband at a hospital in India
In addition to comparing the different factors driving HIV epidemics across the region, the new report also offers a number of policy measures for each of the countries in South Asia, based on a rigorous, evidence-based review of HIV policy and programming in the region.
India: The future size of India's HIV epidemic will depend above all on the effectiveness of prevention programs for sex workers and clients, MSM (men having sex with men), and their sexual partners, together with injecting drug users and their sexual partners, the latter particularly in northeastern India. Throughout the country, tackling stigma and discrimination towards vulnerable and often marginalized people engaging in high risk behaviors, and those living with HIV, remains vital. In certain high-prevalence states, districts, and blocks/tahsils/talukas, tailoring strategies to tackle the increasing numbers in rural areas is also a priority. HIV prevention and treatment have potential reciprocal benefits: HIV prevention makes treatment more affordable, and treatment creates important opportunities for enhanced HIV prevention.
Nepal: The future size of Nepal's HIV epidemic will depend above all on the scope, coverage and effectiveness of programs for sex workers and clients, as well as IDUs and their sexual partners. Cross-border migration, especially involving women migrating (or trafficked) into sex work, particularly to Mumbai, increases HIV transmission. The national response should also address the further risk of sex between men. Nepal's continuing internal civil strife poses a formidable challenge, but also increases the importance of NGOs and community-based organizations (CBOs) working in this area. Tackling stigma and discrimination are a priority, as elsewhere in the region, and efforts to reduce trafficking are critically important.
Pakistan and Bangladesh: The current HIV epidemics in both countries occur mainly within networks of injecting drug users with evidence of the epidemic increasingly spreading among men having sex with men and hijras (transgendered men). Effective prevention programs among these communities may avert a wider epidemic. The potential spread of HIV from injecting drug users to networks of male and female sex workers will increase the severity of the epidemic and narrow a major window of opportunity for prevention. In Bangladesh, levels of risk are high, with potential for a substantial epidemic if there is significant spread among injecting drug user networks and their sexual partners. HIV infection among sex workers in both countries remains at a low level, and intensive programs for them and their clients, including a major focus on sex workers who inject drugs or whose sexual partners inject drugs, can prevent the epidemics from escalating.
Sri Lanka: The HIV epidemic remains at a low level, even among groups engaged in high-risk behaviors, in Sri Lanka. Early, effective, affordable programs for sex workers and clients, and men having sex with men and their other sexual partners, together with programs to detect any growth in injection drug use can ensure that HIV remains at very low levels. The country has an opportunity that it must not lose.
Afghanistan: The evidence suggests increasing HIV transmission among some clusters of Afghanistan's injecting drug users. Injecting drug users returning from Iran, which has a significant problem of injecting drug use, are at high risk. The country must act urgently to limit HIV infection in this high-risk sub-population.
Bhutanand the Maldives: Despite limited data, and for very different reasons, these disparate countries may have low HIV prevalence and relatively small numbers of injecting drug users, sex workers, and clients. Recent observations suggest, however, that injecting drug use may be growing in the Maldives.
Regional cooperation on HIV and AIDS also vital
The report says some of the major challenges in South Asia require regional and cross-border programmatic cooperation. For example, working on HIV prevention with injecting drug users in Afghanistan and Pakistan would benefit from coordination with similar initiatives in Iran and Central Asia.
"Preventing HIV infection among sex workers in Nepal would certainly be more effective if they were coordinated with efforts in India focusing on migration and sex worker trafficking, especially to Mumbai," says Doctor Mariam Claeson, co-author of the new report and theWorld Bank HIV/AIDS coordinator for the South Asia region. "Another compelling example of why we need greater regional cooperation is the cross-border drug trade and sexual networks between the highest prevalence districts in northeastern India, parts of Bangladesh, and Myanmar, which underscores the role of migration, and clearly calls for countries to worktogether more closely toprevent HIV from becoming widely established in the region's general population."
The World Bank has supported efforts to fight AIDS in South Asia since the first National AIDS Control Project for India in 1992, and has committed US$380 million to support national programs to date. The main components of these projects include: surveillance, monitoring and evaluation, targeted interventions for vulnerable sub-populations, blood safety, stigma reduction among the general population, and institutional development for a multi-sectoral response.