India

The exact number of people living in the world’s second-largest and probably most varied country is a highly contentious subject. UNAIDS gives wider margins of uncertainty than it does for nearly any other country, estimating that though the best guess is something near five million people, it could be as low as 2.2 million or as high as 8.5 million. We have explained above why India’s patchy surveillance system and largely private health care makes assessing accurate figures particularly difficult.

In parts of north-east India, widespread injecting drug use helped establish an early entry-point for HIV. In Manipur in 1988 the prevalence of HIV was hardly detectable. Just four years later, HIV prevalence had risen to over 70% among injecting drug users and has stayed at this level ever since, and prevalence in pregnant women has risen from 1% to 5% in the cities, though prevalence in the state as a whole is around 1.5% and is higher in Maharashtra and Andhra Pradesh (2.5%). Typically, the majority of injecting drug users are men who will eventually pass HIV to their wives, girlfriends or other sexual partners through unprotected sex.

UNAIDS comments that “there are signs that injecting drug use is playing a bigger role in India’s epidemics than previously thought.” In Chennai in the high-prevalence state of Tamil Nadu, for instance, 64% of injecting drug users had HIV by 2003. Nearly half of them lived with a wife or regular sex partner.

A different pattern has been seen in southern and western states. By the mid- 1990s, a quarter or more of sex workers in cities such as New Delhi, Hyderabad, Madurai, Pune, Tirupati, and Vellore tested positive for HIV. By 1997 the prevalence of HIV among sex workers in Mumbai had reached 71%, despite long-established HIV prevention programmes. In 1996, 14% of truck drivers in Tamil Nadu reported recent unprotected sex with a sex worker.

We have already mentioned that a considerable number of men appear to have sex with men in India and though this taboo area is little researched, a few studies do give a glimpse into the gay element to India’s epidemics. A study of 6,661 MSMs contacted through parks and cruising areas in Andhra Pradesh in central India showed that the vast majority of them (87%) had had unprotected anal sex, nearly half had had it in the last two weeks, and 20% in their last sexual encounter. Although 85% had heard of AIDS and 70% knew condoms could prevent it, nearly a quarter of them had never even heard of condoms. Forty-one per cent of the men were currently married (though, intriguingly, 2.3% said ‘to a man’), and that half of them had had sex with a woman in the last three months, most of it without condoms.

Countrywide, awareness of HIV/AIDS is high, with roughly three-quarters of adult Indians (aged 15–49) aware that correct and consistent condom use can prevent sexual transmission of HIV. But, in general, awareness and knowledge of HIV/AIDS remain low in rural areas and particularly among women.

Behavioural studies in India suggest that prevention efforts directed at specific populations (such as female sex workers and injecting drug users) are paying dividends in some states, in the form of higher HIV/AIDS knowledge levels and condom use. However, HIV prevalence among these key groups continues to increase in some states, underlining the need for well-planned and sustained interventions on a large scale.

Thailand

Around 510,000 people were believed to be living with HIV/AIDS at the end of 2004, or 1.5% of the adult population, though as in India there is a considerable margin of uncertainty as to the actual figures, with low and high limits of 310,000 and one million. This is due concentrated epidemics occurring among two of the most marginalised groups in Thai society – injecting drug users and migrant workers, largely from Myanmar. However in general HIV prevalence continues to edge lower.

The main route of transmission is heterosexual sex. It is currently thought that more than half of all new cases are occurring through transmission within marriage. Thailand, with its ‘100% condom campaign’ in 1992, is one of the few countries to have made a real difference to its HIV epidemic with a comprehensive campaign. But sexual mores in Thailand are changing, and a campaign targeting sex workers and their clients is of less relevance in a society adopting more ‘westernised’ sexual behaviour, including sex before marriage between teenagers. One study released in advance of the Bangkok World AIDS Conference found only 25% of Thai teenagers used condoms. HIV rates among pregnant women are about 2%, particularly in the southern provinces.

About 20% of infections continue to occur through injecting drug use, which was very important in the early establishment of HIV in Thailand, compared with about 5% a decade ago. Median HIV prevalence among IDUs varies from 31% to 51% and despite a strong activist movement among drug users which sprang up in the wake of a rash of extra-judicial killings in 2002/3, needle exchange is still illegal. In contrast to the pattern seen with blood-borne infections in North America and Western Europe, where sexual transmission and injecting drug use transmission seem to be remarkably separate, there has been a shift in Thailand from a dominance of subtype B virus among IDUs to a dominance of 'subtype E', matching the strain that is most commonly transmitted through sex.

Recent reports suggest that the main modes of transmission may be changing. Whereas most HIV transmission in the 1990s occurred through commercial sex, half the new HIV infections now appear to be occurring among the wives and sexual partners of men who were infected several years ago. There are also indications that unsafe sexual behaviour is on the increase among young people in Thailand.

As in much of the rest of Asia, the contribution of gay men to the epidemic is under-researched; one survey in Bangkok found that 17% of gay men had sex there, rising to 25% among men who met men in ‘informal settings’ like parks.

Myanmar (previously Burma)

This oppressed and impoverished country has become the latest candidate for the development of a severe generalised epidemic of HIV in Asia.

UNAIDS range estimates in July 2004 suggested that between 170 000 to 610 000 people are infected, the high end equivalent to 2.2% prevalence among adults. In September 2004, the government revised its own point estimate upwards to 340 000, doubling its published 2002 figure.

Myanmar’s former status as the world’s number one producer of opiates (Afghanistan has now taken over) meant that there was an early epidemic among injecting drug users, and 45 to 80 per cent of IDUs have tested positive for HIV in sentinel surveillance every year between 1992 and 2003.

Genetic typing of HIV shows that with the exception of one outbreak in China, virtually all the strains of HIV now circulating in Asia -- from Manipur, India, all the way to Vietnam, from mid-China all the way down to Indonesia, come from Myanmar, with research teams showing that these various HIV strains can be tracked along four major routes, all originating in the country.

By 2003, 12 out of 29 sentinel sites for pregnant women were recording HIV prevalence above 2%, with figures of 5% and 7.5% in two sites. HIV among sex workers rose from 5% in 1992 to 31% in 2003. And the proportion of men and women attending STI clinics was, respectively, 6% and 9% in 2003.

Myanmar has not been helped by its oppressive military government: in August 2005 The Global Fund withdrew $35.7 million worth of funding from the country because severe travel restrictions imposed on aid workers meant that, in the Fund’s view, they could not mount an effective programme.

Cambodia

Cambodia has about 170,000 people living with HIV/AIDS, and this 2.6% prevalence rate is the highest in Asia. However this is lower than previous estimates, and Cambodia has followed Thailand in a very active programme of HIV prevention which has had some success despite the lack of resources available within the country.

It has been the norm in Cambodia for men to engage in premarital and extramarital sex, particularly with women who are paid. There is some evidence that condom use among men using sex workers has increased dramatically in recent years and there are encouraging signs of a decline in HIV rates among pregnant women - from 3.2% in 1997 to 2.3% at the end of 2000. The proportion of men under 24 visiting sex workers in 2003 was 8% - three years previously it had been 19% - and male teenagers are about nine times more likely to use condoms than older men, suggesting prevention programmes are on target.

It has been reported that consistent condom use among direct female sex workers has increased by 86% from 42% in 1997 to 78% in 1999. Among indirect sex workers (known as beer girls) consistent condom use increased by 300% from 9.6% to 46% over the same period.

HIV prevalence among men who have sex with men in Cambodia is estimated at 14%.

Cambodia has reported stabilising levels of infection, along with decreasing levels of high-risk behaviour. HIV prevalence among pregnant women in major urban areas declined slightly from 3.2% in 1996 to 2.8% in 2002. Prevalence among sex workers declined from 42% in 1998 to 29% in 2002, according to the latest surveillance data, with the decline most pronounced among sex workers under 20.

China

China still has a low HIV prevalence of about 0.1% and UNAIDS estimates that there are about 830,000 people with HIV in this, the world’s most populous country. However, it also says that unless effective responses rapidly take hold, a total of ten million Chinese will have acquired HIV by the end of this decade. HIV was originally concentrated among injecting drug users in peripheral provinces such as Yunnan and Xinjiang and later erupted into Henan province in mid-China via the selling of infected blood. It has now spread to all 31 provinces. HIV prevalence among Yunnan drug injectors is 21%.

There are also signs of heterosexually transmitted HIV epidemics spreading in at least three provinces (Yunnan, Guangxi and Guangdong) where HIV prevalence in 2000 was as high as 11% among sentinel sex worker populations. Many sex workers inject drugs and in Sichuan province only 40% reported using condoms with clients.

The onward sexual transmission of HIV by people who became infected when they sold their blood to collecting centres that ignored basic blood-donation safety procedures poses a massive challenge, as does the need to provide them with treatment and care.

As in much of the rest of Asia the contribution of men who have sex with men is unknown. A rare survey in Beijing found prevalence of 2% among gay men.

Unlike India, there are still very low rates of HIV awareness in parts of China. However there are signs that China’s strong centralised government is now waking up to its potential HIV problem. Condom distribution schemes have taken off in cities like Guandong.

Japan

There are an estimated 12,000 people living with HIV/ AIDS, or 0.02% of the adult population. However annual incidence has doubled since 1992 and has risen by 2,000 since 2002. There has been a marked shift in the proportion of transmission due to homosexual sex, which has risen to more than double the proportion due to heterosexual sex; until 1999 the proportions were equal.

Indonesia

Another vast and varied country, Indonesia is still a low-prevalence area for HIV but in the last few years has seen an explosive epidemic happening among injecting drug users. Rates among IDUs in the capital, Jakarta, rose from 8% in 1998 to 48% in 2001 and have stayed at that level, but even in far-flung areas like Kalimantan (Borneo) some surveys have shown that the majority of IDUs are now infected.

For the situation in Irian Jaya (western New Guinea), see Papua New Guinea in the Australasia and the Pacific section.

Low-prevalence countries

Several highly populous countries in Asia still have low HIV prevalence and, as UNAIDS comments, have the opportunity to keep it that way with imaginative HIV prevention projects. An example is Bangladesh where needle-exchange programmes in cities like Dhaka have not only shown a decrease in needle reuse among participants but a ‘spin-off’ in the form of lower rates of unprotected sex too. Malaysia has just inaugurated needle-exchange – despite protests from conservative Islamists – and as its epidemic is still largely restricted to IDUs it stands a chance of staying a low-prevalence country. Pakistan and the Philippines face regular predictions of the eruption of HIV but so far have shown little sign of encroaching HIV prevalence even in high-risk groups like sex workers. In the Philippines the official number of cases of HIV stands at 2,200. UNAIDS estimates that 10,000 HIV-positive people lived in the country in 2003, but even so this is only just over 0.1% of the population. Risk behaviour points to a potential for an epidemic in some of these countries, but so far outreach campaigns seem to have contained HIV with, for instance, the rate of condom use among freelance sex workers in the Philippines increasing from 65 % in 1997 to 72% in 2000 and 80% in 2002. Pakistan saw its first outbreak of HIV among IDUs in 2004 but so far this does not seem to have spread to the rest of the population.