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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”



Risk and Vulnerability

There are three factors that appear to play a crucial role in HIV transmission in the Asia and Pacific region: female sex work, substance use, and mobility. Female sex workers and their clients have been a major factor in the heterosexual transmission of HIV in Thailand, Cambodia and parts of India and Myanmar. Separate but explosive epidemics have been seen in some IDU populations in Thailand, Myanmar, Manipur (India), and Malaysia. And mobile populations, particularly at national borders are at higher risk of HIV acquisition due to the fact of being away from home, community and the anonymity and loneliness of travelling. The following three sections focus on the monitoring of the HIV epidemic in these vulnerable populations.

Female Sex Work in the Asia-Pacific Region

The numbers of commercial sex workers

Female sex workers operate in all countries in the region, but it is important to know how large the sex-worker population may be to adequately interpret surveillance results. It is believed that in some countries, rapid increases in the absolute numbers of sex workers have resulted from significant political, social or economic changes. The number of female sex workers in countries can range from a few thousand to a few hundred thousand. Thailand, for example, has approximately 80,000-100,000 female sex workers--an estimate that only recently has gained consensus. In most countries, however, validated estimates of the numbers of sex workers are almost non-existent. Without such numbers, interpretation of surveillance results, policy commitment, planning, intervention designing, and resource allocation are extremely difficult.

How many sex workers?

Most estimates of the numbers of female sex workers are either restricted to a subset of licensed commercial sex establishments or ad hoc unvalidated "guesstimates." In Dhaka, Bangladesh, estimates of the number of sex workers frequently quoted range from 3,000 to 100,000. It is impossible to anticipate the scale of services and funds and nature of interventions needed without more meaningful numbers.

One promising direct estimation method being used in Thailand, Laos, Nepal and Taiwan developed by the Thai Red Cross and the East-West Center is the method of comprehensive geographic mapping of sex work sites and types. In Thailand, this method has now been adopted by the Ministry of Public Health for their annual survey of sex work. In several areas, the method has detected up to 50 percent more sites than estimates by using the conventional method of referral by STD patients. In other countries, population estimates have been generated through innovative applications of capture-recapture techniques. In Dhaka, CARE Bangladesh recruited and trained sex workers to assist in "capturing" street sex workers throughout the city by handing out different colored cards for 24 hours on two different days within a fortnight.


All estimates need regular updating and validation but these two approaches are worthy of replication in other settings. Neither method can work without the trust and involvement of sex workers themselves.


The nature of sex work and the profile of sex workers vary enormously within and between countries. There are female and male sex workers, and those that work full-time, part-time or seasonally. Sex workers may operate in variety of settings such as brothels, bars, massage parlors, street corners, restaurants, etc. Sex workers operating in government-registered establishments exist in a few countries such as the Philippines, in contrast to the free-lance sex workers in most countries of this region. There are also commercial sex areas that are highly organized, such as in Indonesia as opposed to those with bonded or sex workers imprisoned in underground settings. There are women in brothels who cannot refuse sex with customers and those in massage parlours or bars who have more freedom of decision.

For surveillance purposes, sex work can be characterized by work conditions, methods of recruitment, number of clients per week, price, how clients are contacted, where sex takes place, types of clients, existence of employers or agents. Despite these diversities, some types of sex workers are more visible and/or more easily brought to the attention of government or public health officials. These are usually the sex workers who are the subjects of epidemiological studies presented without acknowledging the fact that they represent only a subset of all sex workers. Without a clear understanding of these diversities, effective surveillance cannot be designed or implemented.


Sex workers and HIV

Frequency of exposure to HIV infection through sexual intercourse is the key factor for transmission of HIV among sex workers. In many countries, a significant proportion of sex workers is infected with HIV. The rates might vary from less than 1 percent to 40 percent or higher in some settings.

Even where HIV infection has not yet spread extensively, STD infection is often very high among sex workers. For example, in one brothel area in Bangladesh, 95 percent of 466 sex workers tested positive to antibodies for genital herpes virus and 60 percent for syphilis, although HIV was not detected among any of them. With the progression of the epidemic, HIV tends to increase where other STDs are present.

HIV, STD, and behavioral surveillance

Systematic, continuous and quality sentinel surveillance of HIV and STD will provide not only the indications of an emerging epidemic but its progress over time as well. This will benefit policy formulation, planning and resource allocation. For sex workers, confidentiality, community participation and protection against stigmatization should be integral components of surveillance activities. STD services should also be provided as part of the surveillance package. However, if serosurveillance is to be used for monitoring success of intervention programs, it must be accompanied with behavioral surveillance because HIV prevalence may not decline for several years despite successful interventions. Behavioral surveillance results can also be used to direct the detailed design of prevention activities with special emphasis on specific sub-groups within sex worker populations.

Improving surveillance of HIV/AIDS among sex workers

There is no doubt that commercial sex played or is playing a crucial role in the heterosexual transmission dynamic in Thailand, Cambodia, Myanmar and large parts of India. It remains to be seen whether similar experiences will be repeated in countries which at present have little evidence of extensive HIV infection among sex workers. The following are issues and suggested recommendations based on these observations in the region:

  • Surveillance of sex workers can place an emphasis on sex workers as the 'cause' of an HIV epidemic and can, therefore, result in a backlash producing greater discrimination and more support for prohibitive policies leading to an increase in the vulnerability of this population to HIV. Thus, surveillance should be accompanied by clear policies on non-discrimination and supportive prevention interventions.
  • In many areas of Asia, the high prevalence of HIV detected from surveillance activities has not been translated into resources for programs targeting this group. Even when resources are allocated, funding is often not utilized or restricted to awareness programs that necessarily do not necessarily change behavior.
  • Future efforts in surveillance should attempt to document the distribution and characteristics of the female and male sex workers. Such information would lead to a recognition of the biases inherent in the continued use of 'captured' groups of sex workers for epidemiological and behavioral surveillance. It would also permit a more meaningful measurement of the variations of condom use and the rates of partner exchange between and within types of sex work.
  • Better estimates of the numbers of sex workers are also needed. These should also take into account the types of sex work and the diverse settings that influence the negotiating power of sex workers for condom use. Current estimates using geographic, capture-recapture or ad hoc approaches need to be validated.
  • Focalized surveillance, if possible, is likely to be more useful for intervention design and to permit a more careful analysis of the behaviors and sexual networks of sex workers so that more informed decision-making regarding interventions can occur.
  • More attention is also needed on the types of indicators to be measured in the behavioral surveillance of sex workers and potential male clients as well as other methodological issues such as reducing selection bias and increasing the truthfulness of responses.

Substance Use: Patterns and Impact on HIV Transmission

There are many aspects to the nexus of drug use and HIV infection, but globally and in Asia, the direct contribution of HIV transmission by the reuse of contaminated injecting equipment among people injecting illicit drugs, and the indirect contribution of sexual and vertical transmission from this core group far outweigh other aspects. In most of Asia, people who choose to use drugs that are not socially sanctioned are treated as entirely outside society, enemies even of the social structure. What does this mean for HIV/AIDS and drug use? For the majority of injecting drug users (IDUs), it means that lip-service is paid to the principles supposedly learned through the course of the epidemic: in relation to IDUs and the risks of HIV transmission, issues such as human rights, peer education, community participation, and legal and social change are unachievable fictions.


Patterns of use of illicit drugs are becoming globalized and 'standardized.' What were fairly simple equations have largely gone, to be replaced by complex global production and distribution networks, diversified marketing, new and emerging markets--a highly dynamic and thriving scene. Drug control efforts are almost always not one pace, but two, three or even more behind the market. Racism and colonialism continue to be fundamental determing aspects of the global drug trade, both licit and illicit, as they have been for centuries.

Amphetamines are flooding into Thailand and beyond from China and Myanmar. Developing countries are all becoming major illicit drug consumers. New producers are springing up--Opium production has started again within the borders of China and in Afghanistan opium production has risen rapidly to hold second rank globally among illicit opium producers. The transition from little use of a certain drug in a particular community, to its widespread availability and use orally or nasally, and then to its injection--followed by epidemics of HIV--can be extremely rapid, as is exemplified by recent history. This pattern has been so common and so predictable that we must recognize it as the norm, even if we do not fully understand the dynamics of the process. Shifts from smoking or inhaling opium to injecting heroin as a result of 'crackdowns,' increasing price or decreasing purity of available drug have been seen in many countries. Furthermore, cocaine injecting, if it becomes prevalent in the region, is problematic because of the greater frequency of injecting and the increased social and personal disorganization of the user. This places a further barrier in the way of achieving safer injecting behavior.

We must also recognize the role misguided attempts to control drug use have played in accelerating these processes. The rise in heroin use in India, Thailand, Hong Kong and Laos all date from the institution of anti-opium laws. Prisons in some ways are exemplars of the impact of current policies at national levels: even where there has been successful behavior change in the community, this has not happened in prisons.


Impact on HIV transmitted through injections

The diffusion of HIV among IDUs in South East Asia has been well described. Epidemics that can literally be called explosive have been documented among IDUs in Thailand, Myanmar, Malaysia, Vietnam and China, with prevalences reaching 60 to 90 percent within a few months of the appearance of the first case, and often forming epicentres for wider diffusion of the HIV epidemic. Prevalences of 60 percent or more have been described among young IDUs within their first two years of injecting. Several communities in Asia have now had HIV among IDUs for so long that they are now in the grip of multiple ongoing epidemics; of drug use and its consequences, injecting drug use, resulting HIV infection among IDUs, their sexual partners and their children, AIDS and tuberculosis. The tragedy is that these epidemics are totally predictable and preventable, and we know exactly how to prevent them. The scientific evidence on this point is unassailable.

The Need for Harm Reduction

The principles of harm reduction are increasingly being applied to stem the emerging epidemic of HIV among injecting drug users in Asia and the Pacific, through a range of different programs including:

  • needle and syringe exchange programs (NSEPs)
  • methadone maintenance therapy
  • sale of clean injecting equipment through pharmacies and other outlets
  • peer support and outreach programs.

Of these, NSEPs are becoming accepted as an important, relatively inexpensive tool to prevent the spread of HIV among injecting drug users, and there is a growing body of evidence to support their effectiveness. For example, a 1993 review by the Institute for Health Policy Studies in the U.S. showed NSEPs were associated with decreases in sharing of injecting equipment. Recently, an ecological association was demonstrated between the presence of NSEPs in a city and a flat or declining trend in HIV seroprevalence among IDUs as compared with increasing trends for cities without NSEPs.

Although NSEPs have been available since the late 1980s in countries such as Australia and Canada, their introduction to users in Asia has occurred more recently. Asian examples include, among others, the programs run by the Lifesaving and Lifegiving Society in Khatmandu, Nepal, and the Shalom Project in Manipur in northern India. NSEPs in and of themselves do not guarantee reduced incidence, since for this to happen, the need for sharing injecting equipment must be eliminated or substantially reduced.

In some cities in Canada, for example, the prevalence of HIV remained stable in IDUs following the introduction of NSEPs in the late 1980s, but prevalence rates have recently risen dramatically. Reasons for this are unclear, but probably include a shift in the pattern of drug use from heroin injection to cocaine-injecting together with limitations of service provision at NSEP sites. This shows that NSEPs must do more than just provide clean injecting equipment; they must provide IDUs with access to the other elements of harm reduction such as peer counseling and education, provision of condoms and safe sex information, social support, and referral to medical care and/or drug treatment services (i.e., methadone maintenance). Indeed, it is not so much the NSEP itself that can prevent HIV infection amongst IDUs, but the supportive legal and social environment in which NSEPs can exist and flourish. The creation of this environment is an integral part of the development of a harm reduction approach and it requires one major conceptual step-- admission of IDUs to the human race.


There are certain places in Asia that now have uncontrolled epidemics of HIV infection that began as explosive epidemics among IDUs, taking the community from one with no HIV infection to one with a large pool of sexually active infected people in a matter of months. These include epidemics that could have been prevented by timely and relatively inexpensive interventions at an early stage, if, and only if, the conceptual leap had been taken that people who inject drugs are human and worth caring about. Education and advocacy is needed on a much larger scale to influence those authorities concerned nationally and internationally with drug control and drug demand reduction. Efforts should be made to involve them more as partners in prevention of HIV among IDUs, building on the memorandum of understanding between UNAIDS and the United Nations Drug Control Program (UNDCP), for instance, at program level, and empowering and assisting NGOs and communities to advocate and influence national policy and the practices of public security and police.

Globally, there are relatively few programs and very few countries that have as a prime concern the prevention of HIV infection among IDUs. There are far more programs and policies that are oriented toward drug demand reduction, with the prevention of HIV among drug users or in association with drug use tacked on as a subsidiary aim.

Direction for Enhanced Surveillance and Monitoring in IDUs

Most of the information about HIV risk among IDUs comes from captive treatment or incarcerated populations, which are often not representative of the wider community of drug users. Increased investigation of risks and HIV dynamics in these so-called 'hidden populations' is necessary. A detailed understanding of transmission from core groups of IDUs to their sexual partners and children is urgently needed in Asia to demonstrate the central role IDUs can play in national epidemics and to increase the justification for early and intense action.

In addition, better enumeration or estimation of populations at risk (i.e., those currently injecting drugs, or sex partners of IDUs) and populations coming to be at risk, and a better understanding of the dynamics of drug consumption and social organization of drug use are all necessary for targeting interventions effectively.

Incidence data, in particular, are also necessary from a range of sources to counter the potential for misunderstandings about the interpretation of available prevalence data. Potential sources for incidence data may include drug rehabilitation centers and prisons where recidivism is high and testing is mandatory (as in many Asian countries). While simple conceptually, obtaining these data may be difficult since it may require substantial negotiations with the appropriate authorities.

Finally, a process for categorization and analysis of laws relating to drug use, country by country, and their impact (potential or real) on both drug use and HIV transmission among IDUs is necessary to develop appropriate interventions. Prevention programs should be specifically aimed at reducing transmission of HIV among IDUs based on harm reduction principles. Evidence-based interventions should be the focal point to prevent HIV transmission among IDUs in Asia. In evaluating programs for their effect in decreasing HIV transmission, there is an absolute need for epidemiologically sound outcomes, especially incidence data, and a need for appropriate analysis of the factors underlying trends in risks or transmission.

Mobility, HIV and the Clustering of the HIV Epidemic in Asia

Population Mobility in Asia

Populations in Asia are moving across land and sea borders in increasing numbers. International trade and commerce supports this growth in population mobility, which is also facilitated by the growing number of international highways and construction of new bridges. As in Africa, truckers on international land routes move vast quantities of goods between mainland countries. For example, at one international border between India and Nepal, more than 3,000 trucks cross daily. Also occurring in Asia are high levels of maritime trade, and seamen on fishing vessels travel widely in the region, enabling the transmission of HIV to populations in areas where the virus was formerly unknown.

State of Knowledge

In Africa, mobility has been demonstrated to be an independent risk factor for the spread of HIV. Therefore, extremely mobile population groups such as travelers, fishermen, traders and migrant workers tend to have high HIV prevalence. In Asia, evidence exists showing a similar association between population mobility and vulnerability to HIV. Prevalence of HIV among travelers and fishermen in Thailand and India is higher than in the general population, approximating rates found in male STD patients.

The fact of being away from home, family and community, and the anonymity and loneliness of traveling are factors that increase vulnerability to HIV acquisition. Since opportunities for casual sex may occur frequently en route, itinerant people may adopt high-risk behavior that otherwise might not occur. Current evidence indicates that the environment in well-traveled border crossing areas and international fishing ports in several Asian countries fosters more risk-taking behavior than in other trade towns.

Crossing land or sea borders often requires overnight stays, leaving the individual with idle time and opportunities to visit drinking and gambling establishments and brothels. HIV surveillance data for female sex workers, male STD clinic patients and young males in four countries in the region--Thailand, Myanmar, Cambodia and Vietnam--show a clustering of high prevalence sites around international borders and ports. The map (not included at the present time) shows the distribution of higher and lower HIV prevalence by sentinel site, with clustering of HIV infection along the Thai-Myanmar, Thai-Cambodia, Cambodia-Vietnam and Vietnam-China borders.

Opportunities for Prevention

HIV prevention interventions targeted to border crossing areas could take advantage of the idle time of travelers waiting for border clearance. Such interventions could include those focused on behavior change, provision of sexually transmitted infection (STI) services and access to affordable condoms. Structural interventions, including advocating for policy change to improve the process of border crossing and shorten the waiting time, might help reduce opportunities for high risk-behavior.

Recent cross-border interventions have documented that their effectiveness relies on their service provision on both sides of the border. Those that involve communities passing through and residing at border sites as well as NGOs/PVOs with the ability to work transnationally supported by local governments offer more opportunities for success. Private sector businesses and institutions, such as transport and shipping companies as well as corporations, have a vested interest in ensuring safer environments for their labor force passing through or residing in cross-border areas and offer the potential for collaboration and resource support.

The behavioral and epidemiological patterns found among mobile populations in cross-border areas are poorly known. Investigative study, including ethnographic research, is needed to provide better understanding of the risk environments populations encounter as they pass through or reside in these areas. Border crossings in Indochina and South Asia require urgent prevention and care interventions.

Interventions to reduce the vulnerability of populations traversing cross-border areas are urgently needed because mobile groups can serve as "bridges" between high-risk and low-risk populations, thereby creating the potential for a widespread diffusion of HIV. Well-traveled border towns and ports are also gateways and catchment areas for many different types of travelers passing through them and are, therefore, appropriate and convenient sites for intervention.