If Some Countries In Asia Pacific Can Be On Track To End AIDS Then Why Cannot All?

Not just richer nations like New Zealand are meeting some of the 2025 HIV-related targets but also low- and middle-income countries like Nepal, Cambodia and Thailand in Asia and the Pacific region.

"2025 AIDS-related targets are ambitious but not wishful thinking: We know this, because nine countries have already achieved HIV testing and treatment targets. Four countries from Asia Pacific are treating more than 80% of people living with HIV (Cambodia, Nepal, New Zealand, Thailand). Nepal is also among the 4 countries globally that has reduced the new infections by more than 75% (compared to 2010) and can potentially reach the 90% target by 2030,” said Eamonn Murphy, UNAIDS Regional Director for Eastern Europe and Central Asia, and Asia and the Pacific region.

“Other countries can learn from their approaches. 18 countries have eliminated mother to child transmission of HIV globally – and 4 of these countries are in Asia Pacific region: Malaysia, Thailand, Maldives and Sri Lanka,” he added.

"Why should I get diagnosed if I cannot access treatment"?

A sex worker had told us 20+ years back when there was no lifesaving antiretroviral therapy. She was referring to the devastating impact of HIV positive diagnosis on one's life but no way to access treatment and live normal lives (back then). But even after 20+ years, though treatment is available to a lot many people today, but may be, not accessible to all. So are prevention services which remain inaccessible or not-available because of which new infections continue to occur.

There are several countries in Asia Pacific which did not even reach half of people living with HIV with lifesaving antiretroviral therapy in 2023. Afghanistan provided the treatment to only 9% of people living with HIV, Pakistan to 15%, Fiji to 28%, Indonesia to 31%, Mongolia to 39%, Iran to 43%, Philippines to 43% and Bangladesh provided the therapy to 49% of people with HIV in 2023.

On the other hand, there are countries like Nepal that successfully provided antiretroviral therapy to 82% of people living with HIV, Thailand did so to 82%, Cambodia to 89% and New Zealand provided the treatment to over 90% of people with HIV.

Know-Do gap in Asia Pacific

“Why is it that despite services being available, people get diagnosed for HIV and disappear in the shadows?” asks Eamonn Murphy.

If we are to keep people with HIV healthy and stop the spread of infection, there is no doubt that we have to keep all people with HIV virally suppressed – and – make the full cascade of HIV prevention options are available and accessible for everyone.

In other words, if people are not diagnosed with HIV, or diagnosed with HIV but not put on treatment, or not virally suppressed, we will not only fail to avoid unnecessary human suffering (and untimely deaths) but also fail to stop the infection spread.

Same holds true for glaring gaps in making HIV prevention accessible and available. These missed opportunities are not acceptable if we are to end AIDS. More importantly, these gaps are responsible for threatening to undo the progress we have made in HIV response.

UNAIDS’ Eamonn Murphy says that when a range of countries of different socio-economic and health systems can do better, then why cannot the rest of the nations. “So, no excuse that it cannot be done.” He is right: Cambodia for example, has ensured that 99.9% of those who know their HIV positive status are on treatment, Bhutan has 99% of those diagnosed on treatment, New Zealand has 97%, China 93%, Japan 93%, Thailand 91% and Nepal has 87% of those diagnosed on the therapy.

Whereas Afghanistan has been able to provide treatment to only 34% of those diagnosed. No wonder that number of new HIV infections are alarmingly higher in Afghanistan. Same goes true for countries where gaps are between those diagnosed and those on treatment. Some of the nations in Asia Pacific also join this list with Afghanistan: 52% of those diagnosed in Fiji were put on therapy, 67% in Pakistan, 68% in Malaysia and 68% in Philippines.

The regional average in Asia Pacific is 86% of those diagnosed are on treatment.

Guess what? We know major reasons that fail us in HIV responses!

Key populations and people living with HIV remain criminalised in some countries in Asia Pacific. Legal barriers to HIV response remain in 39 countries in the region. These include:

• 38 countries that criminalise some aspect of sex work
• 17 countries that criminalise same-sex relations
• 28 countries have laws that do not allow for possession of a certain limited amount of drugs for personal use
•  20 countries criminalise the transmission of, non-disclosure of, or exposure to HIV transmission
• 14 countries restrict the entry, stay and residence of people living with HIV.

“It is the countries that need to show leadership on HIV and not criminalise or penalise the people. For people, from key populations or those among the people living with HIV, these are real reasons why they may remain fearful and hidden,” said Eamonn Murphy. “This is why we are seeing rising infections."

Social justice and human rights are bedrock to end AIDS

Social justice and human rights are fundamental to address the needs of key populations and people living with HIV. But realities on the ground speak differently:

•  38% of gay men and other men who have sex with men avoided seeking healthcare due to stigma in Yangon, Myanmar
• 14% of female sex workers in Cambodia experienced physical and/or sexual violence in the past 12 months
• 71% of women who use drugs in Malaysia have unmet need for reproductive healthcare due to stigma and discrimination
•  25% of young people living with HIV (18-24 years) in Thailand experienced HIV-related discrimination in healthcare settings
• 9% of people living with HIV in Iran experienced stigma and discrimination in community settings, and
• 4.5% of people living with HIV in Vietnam reported seeking redress for violations of their rights.

30-80-60 targets

If we are to deliver on HIV prevention and treatment service targets, we have to expand community-led or key-population led responses. This means that by 2025, at least:

• 30% of testing and treatment services must be delivered by community-led or key population-led organisations
• 80% of service delivery for HIV prevention programmes for key populations to be delivered by community-led or key population-led organisations
•  60% of the programmes that support achievement of societal enablers to be delivered by community-led or key population-led organisations.

Out of 39 countries in Asia Pacific, only 16 allow that HIV services can be provided by community-led or key population-led organisations, 17 allow registration of key population-led organisations, 17 register organisations led by people living with HIV, 10 report requirements for community-led organisations or key population-led organisations for delivering HIV services, and 17 allow services to key populations can be provided by community-led organisations.

Inequalities drive the AIDS epidemic

“Inequalities between countries, inequalities of key populations, even inequalities between the key populations, impacted the different levels of service access in Asia Pacific region,” said Eamonn. “We must confront these disparities – not just in service deliveries but all the disparities that exist in socioeconomics, political and legal systems that leave communities and people behind.”

Nepal despite its challenges is emerging as a pole star to guide AIDS responses in the region

Nepal is among the 4 countries globally that has reduced new HIV infections by more than 75% (compared to 2010).

Dr Rajesh Sambhajirao Pandav, WHO Representative to Nepal, said that: "#PuttingPeopleFirst, means serving and engaging priority populations in HIV responses, particularly by countering stigma and discrimination many of these populations face, including in healthcare settings. This focus is an essential aspect of addressing their physical and mental health needs. Priority populations encompass individuals with diverse intersectional identities, such as children, adolescents, adults of all ages, including pregnant and breastfeeding women and people with different gender, racial, cultural and religious identities. Men and boys are less likely to use health services and consequently experience poorer health outcomes in some settings. Other vulnerable populations may include people with disabilities, migrants, mobile populations, and people affected by conflict."

He added: "Amongst the vulnerable, five key populations - men who have sex with men, people who inject drugs, sex workers, transgender and gender-diverse people, and people in prisons and other closed settings - are disproportionately affected by HIV compared with general population in all parts of the world."

"People living with HIV have wide-ranging health needs. People living with advanced HIV disease require specialized care, including inpatient care. Ageing with HIV may bring different health issues to the forefront at different life stages, and access to a comprehensive package of services remains important throughout the life-course. Strengthening primary healthcare and public health systems is the only way to ensure that people living with HIV and key and vulnerable populations can lead healthy and productive lives through access to high-quality people-centred health services,” said Dr Pandav.

"#PuttingPeopleFirst to me, represents adopting a "person-centred," "whole of society," and "life-course approach" to promoting holistic long-term health and wellbeing. This will ensure that priority populations, and their families receive comprehensive care ranging from prevention, diagnosis, treatment and palliative care without any stigma and discrimination," he said.

Rollout of Pre-Exposure Prophylaxis (PrEP) in Asia Pacific

Pre-Exposure Prophylaxis (PrEP) is a medicine for HIV negative people which protects them from getting infected with HIV through sexual route. It was approved by US FDA in 2012. Even after 12 years now, its rollout globally is very low.

PrEP use in the region of Asia and the Pacific is only 2.5% of the 2025 target. A little over 204,000 PrEP users were reported in 2023 in Asia Pacific which is a fraction of the 2025 target of having over 8.2 million PrEP users. Only few countries in the region have rolled PrEP in the recent years, such as Thailand and Australia. Pakistan had launched PrEP in June 2022 and Papua New Guinea had started PrEP rollout in 2023 but both countries did not report PrEP data to the Global AIDS Monitoring tool 2024.

When 150,000 new HIV infections took place in Asia Pacific in 2023, it becomes critically important to ensure all HIV combination prevention options (including PrEP) are accessible to everyone – everywhere – especially to those who could be at a higher risk of HIV, such as key populations. Countries like Thailand have also demonstrated the key role key populations-led HIV and health services play in reaching the unreached people in need.

Bobby Ramakant – CNS (Citizen News Service)

(Bobby Ramakant is a World Health Organization (WHO) Director General’s WNTD Awardee 2008 and serves as Health Editor at CNS (Citizen News Service). He is on the board of Global Antimicrobial Resistance Media Alliance (GAMA) and Asia Pacific Media Alliance for Health and Development (APCAT Media). Follow him on Twitter @BobbyRamakant).

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