HIV in Asia
August 2019—The Asia-Pacific region is home to nearly 60% of the world’s population1 and more HIV-positive people than any region outside sub-Saharan Africa.2 At the time that TREAT Asia was founded in 2001, there was a high prevalence of HIV in certain localities and among key population groups, including men who have sex with men, people who inject drugs, and sex workers. At the same time there was poor access to available treatment overall, and especially for members of these marginalized populations. While substantial progress has since been made to develop comprehensive local, national, and regional responses to combat HIV, troubling trends in recent years suggest that efforts need to be re-invigorated, stepped up, and better targeted to reach people most at risk.
UNAIDS reported that in 2018, there were an estimated 310,000 new HIV infections in the Asia-Pacific, bringing the total number living with HIV/AIDS in the region to 5.9 million.2 In 2018, approximately 200,000 people died from AIDS-related illnesses in the region,2 a 24% decline in deaths since 2010, but in some countries—including Afghanistan, Bangladesh, Indonesia, Pakistan, and the Philippines—AIDS-related deaths have increased.3
Access to antiretroviral therapy (ART) in the region increased from 17% in 2010 to 54% in 2018, when approximately 3.2 million people had access to ART. However, this falls below the treatment access levels globally (62%). Large numbers of people living with HIV in the Asia-Pacific, including 22% of HIV-positive children under age 15, still do not have access to ART. Only 56% of HIV-positive pregnant women in Asia have access to the antiretroviral medicines needed to prevent mother-to-child transmission (PMTCT) of HIV. In fact, the Asia Pacific region lags well behind East and southern Africa in terms of ART and PMTCT coverage.4
People Most at Risk
HIV rates among key populations in Asia and the Pacific—people who inject drugs (PWID), men who have sex with men (MSM), transgender people, and sex workers—are far higher than among the general population. UNAIDS reports that in 2018, key populations and their sexual partners accounted for more than 78% of new HIV infections in the region.2 Efforts to reach key populations with prevention, treatment, and care services vary widely. From 2016 to 2018 less than half of key populations living with HIV in Bangladesh, Malaysia, Pakistan, the Philippines, and Sri Lanka knew their status.3 Other groups with increased vulnerability to HIV include migrant workers and women. Children and adolescents also lag behind adults in treatment rates, and often have higher death rates from HIV/AIDS-related causes.
MSM
The sharp rise in the number of new HIV infections among MSM in the region has continued, and sexual activity between men remains stigmatized and often hidden. HIV prevalence among MSM was 5% or higher in 10 of the 24 countries that reported these data to UNAIDS in 2019. The countries reporting the highest rates are Indonesia (25.8%), Malaysia (21.6%), and Australia (18.3%).4 Rates among younger men (aged 15 to 24 years) are especially high and increasing.3 Male-male sex remains illegal in a number of countries in the region and prevention programs for MSM remain limited. About 30% of all new infections in Asia are in MSM.3 Unless the course of the HIV epidemic among MSM is changed, new infection rates among this population will surpass those among every other high-risk group in the region. Scale-up of HIV programs targeting MSM and reduction of the stigma and discrimination they frequently encounter are essential.
Transgender People
There is limited data on transgender people in Asia, but certain cities have reported high HIV prevalence in this risk population. Reported country rates of HIV in transgender people include 24.8% in Indonesia, 11% in Thailand, 10.9% in Malaysia, 8.5% in Nepal, 5.9% in Cambodia, and 5.5% in Pakistan.4 Such data suggests substantial need for transgender-specific health services in order for them to access prevention and treatment interventions.
People Who Inject Drugs
A large proportion of the world’s population who inject drugs live in the Asia-Pacific and are at increased risk of HIV and hepatitis C infection. Many countries in the region still lack effective harm reduction programs, though some have taken steps in recent years to expand access to syringe exchange, overdose prevention, and opioid substitution therapy. In many countries drug laws often conflict with HIV prevention strategies, and the financial resources available for harm reduction programs are still far below what is needed. Overall HIV prevalence among people who inject drugs in the Asia-Pacific is 12.3%,3 with much higher rates in some countries, including the Philippines (29%), Indonesia (28.8%), Pakistan (21%), Thailand (20.5%), and Myanmar (19%).4
Sex Workers
HIV prevalence among sex workers is over 5% in several countries in the region, with the highest reported rate in Papua New Guinea (17.8%).4 The rate is even higher in some urban areas. However, high condom use among female sex workers correlates with declining HIV rates in this population. There are significant efforts underway to study and implement PrEP programs for female sex workers in the region.
Migrant Workers
Economic upheaval over the past several decades has resulted in increased population mobility and environmental degradation, encouraging people to move to cities in search of better employment opportunities. Sexual transmission of HIV is exacerbated by this mobility, with migrant workers spending long periods of time away from home and potentially engaging in high-risk behaviors. Throughout the region, HIV continues to spread along trucking routes; among traveling sailors, fishermen, and migrant workers; and within the sex industry, which is itself fueled by economic disparity.
Women
As elsewhere in the developing world, sex-based socioeconomic disparities play a significant role in the spread of HIV. Even when women know or suspect that their partners are HIV-positive or are having sex with multiple partners, they often have little power to insist on condom use. As a result of these and other factors, women accounted for 37% of adults with HIV in Asia in 2018—up from 19% in 1990.4
Children and Adolescents
AIDS-related deaths among children and adolescents have fallen since 2010, but too many young people living with are still not on treatment or are not virally suppressed. In 2018, there were 110,000 children age 14 and younger in Asia and the Pacific living with HIV.4
Programs to prevent mother-to-child-transmission have had varied success throughout the region, ranging from elimination of MTCT in Thailand and Malaysia to a 10% coverage rate for HIV-positive pregnant women in Pakistan.4 Approximately 56% of HIV-positive pregnant women in the Asia-Pacific are receiving ART to prevent infection in their babies, compared to 92% of HIV-positive pregnant women in East and Southern Africa.4 The overall regional rate of MTCT remains comparatively high, at 21%, and in 2018 only 34% of HIV-exposed infants received early infant diagnosis—although there is wide variation throughout the region.3 Many HIV-positive women remain reluctant to seek antiretroviral therapy or to bottle-feed their infants for fear of arousing suspicion regarding HIV status and confronting associated stigma and discrimination. Access to pediatric HIV treatment remains limited; in 2018 only 78% of HIV-positive children in the region were receiving antiretroviral treatment.2 Successful transition of infected adolescents from pediatric to adult HIV care remains a challenge, and adolescence is a particularly perilous time for youth who have been HIV positive since birth.
While there were 12,000 new infections in children 14 years of age and younger in 2018, 26% of new HIV infections in the Asia-Pacific region occurred in young people aged 15-24 years. Currently the Asia-Pacific has about 120,000 adolescents aged 10-19 years living with HIV.4 Adolescents from key populations, in particular young men who have sex with men, make up a large percentage of the increase in new infections in this age group.3
National HIV Data
While the overall prevalence of HIV in most Asian countries remains low, there are expanding HIV epidemics among certain populations and in certain countries. In Afghanistan, Bangladesh, Pakistan, and the Philippines, for example, rates of new infections have increased steeply since 2010.3
• In China in 2018, 860,000 people knew they were HIV positive, 720,000 were on treatment, and 680,000 had suppressed viral loads.4 Among gay men the HIV prevalence is 6.9%; among people who inject drugs it is 5.9%, and among sex workers it is 0.2%.3
• In India, 1.7 million people knew they were HIV positive in 2017, and 1.2 million were on treatment.4 Among MSM the HIV prevalence is 2.7%, among sex workers it is 1.6%, among PWID it is 6.3%, and among transgender people it is 3.1%. While the number of people on antiretroviral therapy has increased greatly, a high percentage of people with HIV do not get tested or access treatment until their disease has progressed to dangerous levels.3
• Indonesia, the world’s fourth most populous country,5 had 46,000 new infections in 2018, compared to 63,000 in 2010. According to UNAIDS, in 2018 only 51% of people living with HIV were aware of their status, and only 17% of the 640,000 people living with HIV/AIDS were receiving antiretroviral therapy. Around a quarter of MSM, transgender people, and PWID were estimated to be HIV positive. There were 3,500 new infections among children, down from 3,700 in 2015 but still more than the 3,300 reported in 2010. This is despite an increase in the rate of pregnant women living with HIV accessing antiretroviral medicines, from 3% in 2010 to 15% in 2018. Early infant diagnosis is also extremely low, at 1.2%. AIDS-related deaths increased from 24,000 in 2010 to 38,000 in 2018.3
• In Malaysia, 86% of people living with HIV have been diagnosed, but only 48% are on treatment. New infections increased from 5,400 in 2010 to 5,600 in 2018. There are fewer than 100 new infections per year among children and there is a 94% treatment coverage rate among children. The percentage of pregnant women living with HIV accessing antiretroviral treatment is more than 95%. In October 2018 Malaysia became the second country in the region to be certified by the World Health Organization as having eliminated mother-to-child transmission of both HIV and syphilis (following Thailand’s certification in 2016). HIV prevalence among MSM is 21.6%, in PWID it is 13.5%, in transgender people it is 10.9%, and among sex workers, it is 6.3%.3
• In Myanmar in 2018, 240,000 people were living with HIV. There has been a 31% decrease in new infections in recent years, from 16,000 in 2010 down to 11,000 in 2018. About 6.4% of MSM are HIV positive; and of these, 52.4% know their status. About 5.6% of sex workers are HIV positive and 44.6% of them know their status. The prevalence of HIV among PWID is 19%.3
• Pakistan saw a 57% overall increase in new infections from 2010 to 2018 (from 14,000 to 22,000), including a 38% increase among young people aged 15-24 years. During this time period, the number of people living with HIV more than doubled, from 67,000 in 2010 to 160,000 in 2018. AIDS-related deaths almost quintupled, increasing from 1,400 to 6,400. Only 10% of people living with HIV are on treatment. The HIV prevalence among PWID is 21%.3,4
• In the Philippines in 2018, new HIV diagnoses were reported to be 195% higher than in 2010 (4,400 to 13,000), an alarming rate of increase. The vast majority of new infections were among MSM, particularly young men. About 4.9% of MSM are living with HIV; about 1.7% of transgender people are HIV-positive; about 0.6% of sex workers have HIV; and about 29% of PWID have HIV. While 44% of people living with HIV are on treatment; only 20% of children living with HIV are on treatment and only 22% of women aged 15 and up living with HIV are on treatment. Just 18% of pregnant women with HIV are accessing antiretroviral medicine; the rate of early infant diagnosis is just 3.6%. Since 2010, new HIV infections among young people (aged 15-24 years) increased by 197%.3,4
• In Thailand, a country with a history of successful prevention efforts, HIV prevalence among adults aged 15-49 is 1.1%. There were 480,000 people living with HIV in 2018, compared with 580,000 in 2010. Between 2010 and 2018, there was a 60% decrease in annual new infections. Prevalence among people who inject drugs (PWID) is 20.5% and among MSM it is 11%.4 But in Bangkok MSM HIV prevalence is more than 28%.6 In Thailand, more than 95% of people living with HIV have been diagnosed, and 72% of HIV-positive people are on treatment.4
• In Vietnam, the estimated number of people living with HIV has increased from 220,000 in 2010 to 230,000 in 2018. However, there was a 64% decrease in new infections between 2010 and 2018, from 16,000 to 5,700. About 65% of people living with HIV are on treatment. Among key populations, 10.8% of MSM are living with HIV and 23.3% are on treatment; 11% of PWID are HIV positive and 53.4% are on treatment; and 3.6% of sex workers are living with HIV and 21.3% are on treatment.3
Mounting an Effective Response
Evidence from successful interventions in the region shows that prevention efforts targeting those at greatest risk are essential to stem the spread of HIV. Above all, to be effective in Asia, prevention messages will have to both acknowledge and challenge cultural stereotypes and expectations that often prevent frank discussion of issues surrounding sex and drug use. Communities face persistent challenges to overcoming the stigma that surrounds the disease and creates barriers to prevention and care, and those that are most affected must be central to developing an effective response. Laws that criminalize key populations must be changed, as well as discriminatory practices such as those that allow employers to screen their workers for HIV.
Mounting an effective response to the epidemic in Asia and the Pacific will require increasing the level of resources committed to HIV/AIDS programs, using those resources where they are most needed, and balancing the need for continued prevention efforts with the growing demand for HIV treatment. It also requires continued and increased political commitment, involvement of communities in the design and delivery of interventions, and the application of newer technologies and interventions such as rapid testing and PrEP. Better collection and use of strategic information, including surveillance and program data, is necessary to ensure that effective interventions are focused where, when, and on whom they are needed. As HIV clinical and treatment outcomes of those infected with HIV improve, addressing the chronic care needs of people living with HIV and AIDS, including coinfections, comorbidities, and mental health concerns, becomes increasingly important.
1Worldometers. World Population by Region. Accessed August 2019
2UNAIDS. Fact Sheet—Global AIDS Update 2019. Published July 2019. Accessed August 2019.
3UNAIDS. UNAIDS Data 2019. Published July 2019. Accessed August 2019. Pages 137-207.
4UNAIDS. AIDSinfo. Updated July 2019. Accessed August 2019.
5Worldometers. Countries in the world by population (2019). Accessed August 2019
6UNAIDS. Prevention Gap Report 2016, page 130. Accessed August 2019.