“HIV and Gender in the Asia Pacific Region”​ where are we and what needs to be done ?

Sanjeev Neupane

Asia and the pacific region is home to around 15% (5.2 million out of 37 million) of total people living with HIV around the world. It is one of the hardest hit region by HIV after Africa. However, the HIV epidemic is not similar across all the countries of the Asia and pacific region. However, there are some similar characteristics in HIV epidemic across all countries of the Asia Pacific region. The HIV in this region is concentrated in some selected key populations and is not generalized unlike in countries of Africa. The key population that largely carry the burden of HIV in the Asia Pacific region are sex workers and their clients, men having sex with men, people who inject drugs and transgenders. WHO has estimated that MSM are 28 times higher; injecting drug users are 22 times higher and sex workers and transgenders are at 13 times higher risk of acquiring HIV infection than the general population. As the HIV epidemic in Asia is largely driven by the key populations we can guess how the HIV epidemic would have exploded in absence of any interventions in key population in Asia. Due the investment in HIV programme and hard efforts from civil societies; government and donors the HIV epidemic has been brought to control. From 2010 to 2017 the new HIV infections have declined by 14% in Asia but in recent years the progress has been slowed down. In particular; Philippines and Pakistan are facing rapidly expanding epidemics.
India has the highest estimated number of people living with HIV in the Asia (2.1 million which accounts for 40% of total people living with HIV in Asia). Another country in Asia with the highest estimated number of people living with HIV is Indonesia with 630 thousand estimated PLHIV; Myanmar has 220 thousand; Thailand has 440 thousand; Vietnam has 250 thousand; Pakistan has 150 thousand; Malaysia has 87 thousand; Philippines has 68 thousand; PNG has 48 thousand and Nepal has 31 thousand estimated number of people living with HIV. There are 5.2 million people estimated to be living with HIV in Asia among which 1.9 million are women. Out of estimated 5.2 million PLHIV in Asia; 2.7 million people are receiving Anti-retroviral therapy which is expanding but still behind the goals.
Men having sex with men (MSM) is one of the important key population that is largely driving the HIV epidemic in this region. Bangkok in Thailand; Yangoon in Myanmar; Yogyakarta in Indonesia have HIV prevalence between 20% and 29% among MSM. Besides high HIV prevalence in this population; another major problem is the shifting of epidemic to the young MSM. Around 50% of all MSM of this region are less than 25 years of age and the existing HIV prevention and testing programs have very less focus on Young MSM. People Who Inject Drugs (PWID) is another important key population driving the HIV epidemic in the region. In countries like Afghanistan, Myanmar, Pakistan and Vietnam 20-65% of all new infections are among Injecting drug users. The major problem with this key population (PWID) in the Asia and pacific is that 50% of the PWID who are living with HIV don’t know their status and only 18% are accessing antiretroviral treatment. Although Harm Reduction programs are largely accepted and implemented in the countries of Asia; eleven countries in the region still have compulsory detention centres for PWID. The recent extra judicial killings of drug user suspects by police and arms vigilante groups in Philippines has further made the situation worse for drug users and is a worst form of human rights violations. Transgender is another key population driving the HIV epidemic in Asia. Transgenders in Asia and Pacific are often stigmatized, isolated and ostracized from family and society. The social exclusion and lack of employment opportunities force them into the sex business. The low bargaining power, lack of education and offer of more money from clients for sex without condom puts them in risk of practicing unsafe sex without using condoms. The prevalence of HIV among transgender is particularly high in some cities such as 49% in Delhi and 42% in Mumbai of India and 37% in Phnon Penh of Cambodia. Female sex workers are another key population in which the epidemic is concentrated. When the epidemic began in Asia; it was largely concentrated among female sex workers and their clients. Due to the wide implementation of 100% condom use program the epidemic has been brought under control in this key population but prevalence is still more than 5% in this key population in some countries. The highest reported prevalence of HIV among female sex workers in Asia and pacific is Papua New Guinea with 17.8% prevalence.
 Gender based violence and intimate partner violence in Asia Pacific Region
Gender based violence and Intimate partner violence can increase the risk of HIV transmission. Globally studies have shown that the intimate partner violence can increase the risk of HIV infection by 50%. In Asia between 15-65% of women experience violence by their intimate partner during their lifetime. In Thailand FSW who experience physical or sexual violence are 31% more likely to report an STI symptom. Globally, women exposed to Intimate Partner Violence (IPV) from husbands exposed to HIV through regular unprotected multiple sex partners have a 7 times higher HIV risk compared with women not exposed to intimate partner violence and whose husband did not have multiple sex partners.
There are difference in the laws and policies across the 38 countries of Asia Pacific region in the way they see and treat people living with HIV and key population at risk of HIV. Thirty-seven countries of the Asia and Pacific criminalize some aspects of sex work; eleven countries have compulsory detention centres for people who inject drugs; fifteen countries have death penalty for drug related offenses; seventeen countries criminalize same sex relations and ten countries impose some form of restrictions on the entry, stay and residence of people living with HIV based on their HIV status.
Conclusion: 
Asia and Pacific region is the hardest hit region by HIV after Africa. Although the new infections in this region are on decline the progress is not yet satisfactory. Some countries like Pakistan and Philippines have new infections on the rise. Female sex workers and their clients; transgenders, men having sex with men and people who inject drugs are the main drivers of the epidemic in this region. The existing gender gap; low socioeconomic status of women; low bargaining power of women and punitive laws and restrictions towards people living with HIV and key population at risk makes the situation worse for these population in this region. The different discriminatory practices and policies in the region increase the vulnerability of girls and women to HIV in this region. Some bold measures are needed to fight the existing gender gaps and discriminatory practices in this region. Without this the HIV epidemic curve of Asia Pacific region cant be bent down.

Sanjeev Neupane, Technical Specialist for Global Fund Programs in Nepal at Save the Children US

10th IAS Conference on HIV Science (IAS 2019), Mexico

Involvement of people living with diseases in the NCD response