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Asia-Pacific: Falling behind in the fight against HIV/AIDS
Asia-Pacific has shown important leadership on HIV/AIDS and has made solid progress towards controlling the epidemic in the region. In this op-ed, however, the authors draw attention to recent indicators suggesting that Asia has fallen behind in the fight against HIV/AIDS in key areas compared to other regions of the world. After summarising some of the obstacles to achieving epidemic control, such as widespread stigma and discrimination, the authors offer possible solutions for how the region can close gaps in HIV testing and treatment.

As the world reflects on its progress in the now over 35-year fight against the human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), it is time for Asia-Pacific to both acknowledge its successes and to ask how we have fallen behind in controlling this persistent public health threat.

Asia-Pacific’s leadership in HIV research and policy

In the 1990s, physicians in Asia-Pacific began to see increasing numbers of patients with HIV, but had little local evidence to guide their clinical decisions. Much of the science on HIV was emerging from the U.S., and the world’s attention was focused on the massive epidemic of HIV in sub-Saharan Africa. In order to gather sufficient Asian patient data on experiences with HIV and antiretroviral treatments, individual researchers would need to collaborate.

The Foundation for AIDS Research (amfAR) TREAT Asia program was founded in 2001 as a platform for a new network of clinician-researchers who contributed their clinic data to aggregated databases of HIV patient outcomes.1 Managed and analysed by the National Centre in HIV Epidemiology and Clinical Research at the University of New South Wales, Australia (now the Kirby Institute), these databases became a key source of cross-regional HIV epidemiology data, which now includes patient data from 21 sites in 12 countries.2 The Kirby Institute had separately been developing a cutting-edge HIV clinical trial research program to test the newest antiretroviral drugs and management strategies in patients in the region, as well as across the world.

Both programs continue their work around HIV and co-infections today, with a growing focus on the goal of hepatitis B and C elimination.3

The region has also demonstrated its leadership capacity by instituting or supporting policies to prevent and treat HIV. In 1991, Thailand implemented the “100% Condom Programme,” focused on supporting female sex workers, which led to marked decreases in new HIV and other sexually transmitted infections. The country began recommending universal lifelong treatment for all pregnant women with HIV in 2015, before the policy was adopted by the World Health Organization (WHO).

In October 2018, Malaysia joined Thailand as the second country in the region and only the 12th in the world to be validated by the WHO for having met their criteria for eliminating mother-to-child transmission of HIV.4 Pre-exposure prophylaxis (PrEP) using the combination of tenofovir disoproxil fumarate and emtricitabine is slowly being scaled up across the region as a way for individuals to protect themselves from infection.5 In addition, the massive global scale-up of antiretroviral therapy could only have been possible through the impact of generic drug production in India on driving down the costs of medicines.

It is therefore difficult to understand why only 53 percent of the 5.2 million people living with HIV in Asia-Pacific are being treated with these medicines. HIV treatment coverage is now higher in the Caribbean (57 percent) and Latin America (61 percent), which have much smaller epidemics (2.1 million combined), as well as in East and Southern Africa (66 percent), which has the largest global epidemic (19.6 million).6

Controlling the HIV epidemic in Asia-Pacific will require more than just medicines. These are some of the key reasons why the region has fallen behind in our efforts to lift the burden of HIV within our communities.

Many people with HIV have not yet been diagnosed

The Joint United Nations Programme on HIV and AIDS (UNAIDS) has established a “treatment cascade” that helps countries track their progress in reaching three critical milestones:

  1. 90 percent of all people with HIV are diagnosed using an HIV antibody test and know their HIV status;
  2. 90 percent of all people with HIV are on treatment with antiretroviral medicines; and
  3. 90 percent of all people with HIV have evidence of treatment success using an HIV viral load test, which shows they have suppressed the HIV virus level in their blood.

Without reaching the first milestone, health programs cannot hope to achieve the second and third milestone (Figure 1). While Asia-Pacific countries have made substantial strides in diagnosing people who have HIV, individuals who have never been tested have proven to be the most challenging to reach. These may be people who do not perceive themselves to be at risk, or who fear the consequences of knowing they have HIV. A particularly challenging group to engage through traditional health promotion strategies is young adults. For example, failure to develop effective targeted interventions for youth has led to new infections rising by 170 percent since 2010 in the Philippines in this age group (15-24 years).

Stigma and discrimination deter people from getting tested and seeking care

Key reasons for the fear of being diagnosed are the stigma and discrimination associated with HIV and population groups known to be at high risk of having HIV, including men who have sex with men and people who use drugs. Although the risk of acquiring HIV in Asia-Pacific is highest among current or former members of key population groups and their partners, the virus itself does not discriminate. In fact, in the largest regional epidemic in India, 42 percent of the 2.1 million people living with HIV are female.

Unlike most other viruses, and until we find a cure, HIV requires lifelong management, making it a chronic disease as much as it is an infection. The potential for also having to deal with lifelong stigma can be a greater burden than the health consequences of uncontrolled HIV.7

A particularly concerning finding that has been confirmed in multiple studies and surveys in the region is that stigma and discrimination are frequently experienced by people seeking HIV testing and care within healthcare settings.8 The discriminatory attitudes of administrative staff, nurses, and physicians may reflect personal judgements against their patients’ lifestyle, gender identity, or having HIV itself. There is no amount of outreach or peer support that can overcome the knowledge that you are not wanted by the very people who are supposed to help you access HIV testing and care. We should appreciate that healthcare providers themselves may need expert guidance and training to help them better understand and respect their patients with HIV.

Insufficient resources being dedicated to solving these problems

Inadequate financial investment is another reason why Asia has fallen behind in its control of the HIV epidemic. UNAIDS estimates that in 2017, US$3.7 billion was available for HIV-related program costs, of which 78 percent were domestic resources.

External donors are giving smaller amounts to the region, with the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) now supporting only 7.3 percent of overall regional resources and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) representing 4.1 percent (Figure 3). However, with US$4.9 billion needed by 2020 for Asia-Pacific to reach its resource target for addressing HIV, renewed funding commitments by national governments are crucial.

What can we do to achieve HIV epidemic control in the Asia-Pacific?

To reach the UNAIDS 90-90-90 targets, we need to diagnose about 816,000 more people with HIV and start 1.5 million more people on antiretroviral treatment. Many of these individuals are young people who respond better to their peers than to “traditional” public health approaches.

Media-savvy young people are at higher risk for HIV and can be more effective advocates of prevention messages. In order to engage them, we should be actively creating leadership roles for youth in the HIV response. Their involvement can be essential to developing programs that reach those most in need of HIV testing.

To encourage people to remain in care and on treatment after diagnosis, we must hold ourselves accountable to a higher standard for how we treat people living with HIV and be honest with ourselves about the stigma and discrimination they face.

The Asia-Pacific region has the human, technical, and financial resources to relieve the suffering HIV is causing in our communities and meet global public health targets. We may have fallen behind, but it is now time to catch up.

References:

  1. For more information: www.treatasia.org
  2. Reference: A Decade of Combination Antiretroviral Treatment in Asia: The TREAT Asia HIV Observational Database Cohort. AIDS Res Hum Retroviruses. 2016 Aug;32(8):772-81. doi: 10.1089/AID.2015.0294. https://www.ncbi.nlm.nih.gov/pubmed/27030657
  3. For more information: https://kirby.unsw.edu.au/research/hepatitis
  4. Reference: http://www.who.int/reproductivehealth/congenital-syphilis/emtct-validation-malaysia/en/
  5. For more information: Action for AIDS Singapore, http://afa.org.sg/portfolio-item/prep-answered/
  6. All epidemiology data are from UNAIDS based on 2017 data. See report: Joint United Nations Programme on HIV/AIDS (UNAIDS). Miles to go: Closing gaps, breaking barriers, righting injustices. http://www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdf
  7. For more information: Ho LP, Goh ECL. How HIV patients construct livable identities in a shame-based culture: the case of Singapore. Int J Qual Stud Health Well-being. 2017 Dec;12(1):1333899. https://www.ncbi.nlm.nih.gov/pubmed/28641480
  8. For more information: Philbin MM, Hirsch JS, Wilson PA, Ly AT, Giang LM, Parker RG. Structural barriers to HIV prevention among men who have sex with men (MSM) in Vietnam: Diversity, stigma, and healthcare access. PLoS One. 2018 Apr 3;13(4):e0195000. https://www.ncbi.nlm.nih.gov/pubmed/29614104
  9. From amfAR infographic “Funding gaps could put Asia further behind on HIV/AIDS,” June 2018. Available at https://www.amfar.org/TREAT-Asia-Infographics/
  10. From amfAR infographic “Funding gaps could put Asia further behind on HIV/AIDS,” June 2018. Available at https://www.amfar.org/TREAT-Asia-Infographics/

Dr. Annette Sohn is the director of the TREAT Asia program in Bangkok and vice president for global initiatives at amfAR.

 

 

 

Dr. Ng Oon Tek is a senior consultant at Tan Tock Seng Hospital and the National Centre for Infectious Diseases in Singapore.

 

 

 

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