The Asia and Pacific region was home to an estimated 5.9 million people living with HIV in 2018. China, India and Indonesia account for almost three-quarters of the total number of people living with HIV in the region.

It is increasingly clear that the Asia and Pacific region is falling behind Africa in its HIV response. In 2018, 69% of people living with HIV in this region were aware of their status. Among those diagnosed with HIV, 78% were on treatment of which 91% were virally suppressed. In terms of treatment coverage this equates to 54% of all people living with HIV being on treatment and just 49% being virally suppressed.

The epidemic is largely characterised by concentrated and growing epidemics in key populations in a variety of countries, particularly clients of sex workers and other sexual partners of key populations, and men who have sex with men (sometimes referred to as MSM). Low national prevalence masks much higher prevalence among these groups and in specific locations, particularly urban areas.

In 2018, 310,000 people became infected with HIV in the region. Although new infections declined by 14% between 2010 and 2017, progress has slowed in recent years and new infections are on the rise in some countries. In particular, Philippines and Pakistan are facing rapidly expanding HIV epidemics. Philippines is experiencing the steepest rise, with new infections up by 170% on 2010 levels, and Pakistan 29%. The political turmoil in the country under President Duterte, where extrajudicial killings for people who use drugs have been sanctioned and condom use discouraged, suggests this worrying trend is likely to continue.

Key affected populations in Asia and the Pacific

Men who have sex with men (MSM)

The HIV epidemic among men who have sex with men (sometimes referred to as MSM) is growing. In 2017, prevalence among this group – particularly young men - was higher than 5% in 10 countries and new infections are increasing. Sexual activity between men remains illegal in a number of countries and is widely stigmatised.

HIV prevalence among men who have sex with men is particularly high in urban areas. Cities such as Bangkok in Thailand, Yangon in Myanmar and Yogyakarta in Indonesia have estimated HIV prevalence rates of between 20% and 29%.

Across the region it has been found that men who have sex with men are becoming infected by HIV at a young age. One study carried out in Bangkok found HIV incidence among those aged 18 to 21 was more than double the incidence among men over 30. Around half of all men who have sex with men in the region are under 25. However, HIV prevention and testing services were reaching fewer young men who have sex with men and they reported lower condom use than their older counterparts.

A further example of the HIV epidemic among men who have sex with men in a high-income country within the region is in Australia. While prevalence here has declined overall, it rose among men who have sex with men, with 16.5% of men who have sex with men living with HIV. This rise is despite an increase in access to antiretroviral treatment.

People who inject drugs (PWID)

One third of all people who inject drugs (sometimes referred to as PWID) live in Asia and the Pacific.

In 2015, between 20 and 65% of all new adult infections in Afghanistan, Myanmar, Pakistan and Vietnam were among people who inject drugs. Yet half of the people who inject drugs who are HIV positive are unaware of their status and only 18% are accessing antiretroviral treatment.

Although the need for harm reduction is increasingly accepted across the region, a largely punitive policy and legal environment continues to fuel the HIV epidemic among drug users. Eleven countries in the region still operate compulsory detention centres, and incarcerated over 455,000 people who use drugs in 2014.

China, Singapore, Malaysia, Indonesia and Vietnam continue to execute people who use drugs in high numbers. While the Philippines abolished the death penalty for all crimes in 2006, an estimated 7,000 extrajudicial killings of alleged ‘drug suspects’ by police and armed vigilante groups were carried out between June 2016 and January 2017 alone.

Transgender people

HIV remains a critical concern for many transgender populations across Asia. There is particularly high prevalence among transgender people in Delhi (49%) and Mumbai (42%) in India, and Phnom Penh (37%) in Cambodia for example. In many of these cities, prevalence is much higher among transgender people in comparison to men who have sex with men.

Transgender people in many Asian and Pacific countries are very often isolated. This has serious knock on effects for obtaining both health-related information and developing health policies and programmes that effectively support this key affected population. This social exclusion, coupled with a lack of employment opportunities, means that many transgender people in the region engage in sex work. One study estimated that the proportion of transgender people who sell sex to be 90% in India, 84% in Malaysia and 81% in Indonesia.

Stigma, discrimination and legal barriers remain a major obstacle for providing and accessing services for transgender people in Asia. It also means that data on transgender access to HIV treatment and testing services is scarce.

Sex workers

When the HIV epidemic began in Asia and the Pacific, it was heavily concentrated among sex workers and their clients. Significant progress in reducing new infections among female sex workers across the region has been made since then, particularly in Cambodia, India, Myanmar and Thailand. This is linked to the broad implementation of ‘100% Condom Use’ programmes in Thailand, Cambodia, Philippines, Vietnam, China, Myanmar, Mongolia and Laos, aimed at sex workers and their clients.

Despite this, HIV prevalence among sex workers is over 5% in several countries and female sex workers are 29 times to be living with HIV compared to other women of reproductive age in the region. Clients of sex workers remain the largest population at risk of HIV infection in the region, with data suggesting the proportion of men buying sex in the previous year ranges from 0.5% to 15%, depending on the country.

The highest reported national prevalence among female sex workers is in Papua New Guinea where 17.8% are living with HIV. Prevalence is even higher in some cities, even when national trends have declined. For example, in Yangon, Myanmar, 24.6% of female sex workers were estimated to be living with HIV in 2015.

Data on male and transgender sex workers is scarce, but where available shows high prevalence. For example, 18% of surveyed male sex workers in Indonesia and Thailand tested positive, as did 31% of transgender (waria) sex workers in Jakarta, Indonesia. This underscores both the need for better data regarding male and transgender sex workers, and for HIV programming that addresses the needs of female, male and transgender sex workers.

Migrant workers

Economic upheaval in the region over several decades has resulted in increased population mobility, encouraging people to move to cities in search of employment. Sexual transmission of HIV is exacerbated by this, with people spending long periods of time away from home and engaging in high-risk behaviours. Throughout the region, new HIV infections continue to be concentrated along trucking routes, among sailors, fishermen and other migrant workers.

HIV prevention programmes in Asia and the Pacific

In 2017, there were an estimated 280,000 new HIV infections in the region. Overall, the region is making progress in reducing new infections with a 14% decline between 2010 and 2017.

Some countries have seen a much steeper decrease over this period such as Thailand (50% decrease) Vietnam (34% decrease) and Myanmar (26% decrease) but in Philippines infections have increased by 170% and by 29% in Pakistan.

There were 10,000 new HIV infections among children in the region in 2017, a 33% decline since 2010.  HIV prevention programmes have played an important role in reducing HIV incidence, some of which are outlined below.

Condom availability and use

Condom programmes have been the cornerstone of prevention in Asia and the Pacific since its HIV response began. Condom use varies greatly across different areas and populations. In 2017, condom use among men who have sex with men is reported to be 95% in Nepal, 82% in India and Thailand, and 81% in Indonesia - and among sex workers 91% in India, 93% in Sri Lanka and 81% in Thailand.

However, condom promotion programmes for people who use drugs are not as developed: India reports the highest rates for the region at 77%.

Overall, two-thirds of men who have sex with men report using condoms the last time they had anal sex, but this figure is lower for men who have sex with men in cities and urbanised areas, where under half of men who have sex with men reported doing so.

HIV education and approach to sex education

Major barriers exist to the implementation of effective HIV and comprehensive sexuality education in schools in Asia and the Pacific. In 2012, UNESCO found 20 countries in the region had national HIV laws or policies, of which 13 explicitly mentioned the role of education.

However, only Cambodia, China, Indonesia, Nepal, Papua New Guinea and Vietnam included a detailed description of sexuality education in their policy frameworks. As a result, less than half of young people in most countries in the region are thought to have comprehensive knowledge of HIV.

Prevention of mother-to-child transmission (PMTCT)

Prevention of mother to child transmission (PMTCT) has been significantly scaled-up across Asia and the Pacific. The period between 2009 and 2015 saw a decline of 30% in new HIV infections among children.

In 2015, among pregnant women who attended an antenatal appointment or had a facility-based delivery, 100% were tested for HIV in Thailand, 85% in Myanmar and 41% in India. As a result, more than 55% of HIV-positive pregnant women were unaware of their status in all countries except Thailand in 2015. Bangladesh, Indonesia, Nepal, Sri Lanka and East Timor have now prioritised HIV testing for pregnant women in high prevalence areas.  

In June 2016, Thailand became the first country in the region to eliminate mother-to-child transmission of HIV and syphilis after reducing transmission rates to less than 2%, and providing antiretroviral treatment (ART) to more than 95% of pregnant women.

ART coverage has also greatly increased in Myanmar, and stood at 77% in 2015, compared to 39% in 2010. PMTCT ART coverage remains low in other countries and has shown some improvement only in Nepal. Indonesia lags far behind, at less than 10% in 2015. Overall, 48% of pregnant women in the region are receiving ART through PMTCT services.

In October 2018, Malaysia was certified by the World Health Organization (WHO) Western Pacific Region as having eliminated mother-to-child transmission of HIV (and syphilis). The country started antenatal HIV screening in 1998 which is provided free of charge, and nearly all women have access to health services.

Antiretroviral treatment availability in Asia and the Pacific

Around 2.7 million people living with HIV in the region were accessing antiretroviral treatment (ART) in 2017, up from 900,000 in 2010.  

Most countries have expanded HIV treatment guidelines to include all those living with HIV regardless of CD4 count, which indicates the level of HIV in someone’s body. This move is partly driven by the notion of ‘treatment as prevention’ because individuals who are virally suppressed – the result of effective, continual treatment and monitoring – are unable to transmit HIV to others.

As the total number of people living with HIV in the region has increased, so there is an increase in treatment coverage from 19% in 2010 to an estimated 53% in 2017.  Similar growth over the next period would likely fall short of the UNAIDS target of 81% of all people living with HIV on treatment by 2020.

Children and younger adolescents (0-14 years) who are living with HIV are considerably less likely to be receiving treatment than adults, with treatment coverage among this age group at 40%.

Some countries in the region are struggling to provide antiretroviral treatment. In 2017, only 8% of people needing treatment in Pakistan were receiving it. India also has very low treatment coverage: approximately 16% among men who have sex with men and 18% among people who inject drugs were estimated to be on ART in 2012/2013.

Myanmar reports that approximately 29% of female sex workers living with HIV were accessing HIV treatment, as were 47% of gay men and other men who have sex with men living with HIV. However, in Thailand, at the end of 2017, 72% of people needing treatment were receiving it. The stark contrast across the region highlights the differences in national responses and funding for HIV treatment.

There are high retention rates for treatment, with 95% of people still accessing treatment after 12 months in Singapore, and 90% Afghanistan, Cambodia and Sri Lanka. Lower levels of retention, ranging from 63% to 84%, were reported by New Zealand, Bangladesh, Mongolia, Philippines, Malaysia and Myanmar.

Adherence rates among adolescents and young people (12-24 years) are also high, estimated at 84%, significantly higher than in the higher-income areas of North America and Central Europe, where adherence among this age group ranges between 50 and 60%.

In 2016, just over half (52%) of people accessing ART in the region also had access to routine viral load testing. The estimated percentage of people living with HIV who achieved viral suppression increased from 34% in 2015 to 45% in 2017.

The emergence of HIV drug resistance is of deep concern when scaling up ART. However, routine HIV drug resistance testing is not recommended for people starting ART in the region, leading to limited data on this issue. A systematic review of studies in the region published between 2000 and 2011 found that most reported relatively low levels of drug resistance. However, a separate review of a range of low- and middle-income countries reported an annual increase in the odds of pre-treatment HIV drug resistance of 11% in Asia.

HIV and tuberculosis (TB) in Asia and the Pacific

Nine out of the world’s 22 ‘high burden’ tuberculosis (TB) countries are in the Asia and Pacific region which is home to more than half of all people living with TB globally. Many countries are also facing alarming epidemics of multi-drug resistant TB.

TB and HIV control programmes have improved, but joined-up programmes still need to be strengthened in countries with a high TB burden. Routine testing of people with TB for HIV is not universally implemented, compromising people’s health and hampering accurate data collection. In 2013, less than half of all TB cases were tested for HIV, although testing rates vary greatly between countries.

However, the region has responded well to treating TB - TB-related deaths fell by around 40% between 1990 and 2014. In 2016, there were 42,000 TB-related deaths among people living with HIV as compared with 62,000 in 2014.

Barriers to the HIV response in Asia and the Pacific

Legal, cultural and socio-economic barriers

Scaling-up prevention, treatment and care services for key affected populations is crucial. However, many punitive laws are preventing services reaching and being accessed by these population groups.

HIV restrictions on entry, stay and residence are still very prominent across the region, with 11 countries including Malaysia and Papua New Guinea still enforcing HIV restriction laws. China and Mongolia lifted travel bans on people living with HIV in 2012, an important steps towards reducing stigma and discrimination.

Numerous other punitive laws are hindering the HIV response in the region. For example, although the need for harm reduction is increasingly accepted, a largely punitive policy and legal environment continues to fuel the HIV epidemic among drug users.

Same-sex activities are criminalised in 18 countries including Bangladesh, Pakistan and Malaysia. Ultimately, this means that many men who have sex with men and people who are lesbian, gay, bisexual or trans (LGBT) in these countries find accessing prevention and treatment services very difficult.

In 2013, New Zealand became the first country in the region to legalise same-sex marriage. Transgender identity and transgender rights have been increasingly accepted at a national level in Pakistan and India, where in 2009 and 2010 respectively, a third gender was formally recognised.

Nepal is an example of a country that has enhanced and strengthened the rights of many key populations, amending discriminatory laws and creating a more favourable environment for people to access HIV services and treatment.

Stigma and discrimination

Stigma and discrimination still poses a major barrier in places like Fiji, where more than half (59%) of female sex workers reported avoiding health-care services due to stigma and discrimination. In Lao People’s Democratic Republic and Thailand, by contrast, only 2% and 11% of female sex workers, respectively, reported similar trepidation. Three quarters (75%) of gay men and other men who have sex with the men in Lao People’s Democratic Republic and about one third (36%) of their peers in Fiji said that stigma and discrimination deterred them from visiting healthcare facilities.

Stigma and discrimination have a huge impact on key affected populations, especially transgender communities who face daily prejudice and discrimination.

In 2016, in-depth interviews with 30 transgender people and members of the hijra community in India found all had experienced traumatic experiences in relation to their gender identity. Very few received any family support, and due to family rejection at an early age many had either migrated to different states or lived away from their family. A large number faced gender-based violence.

Some could not complete their education due to stigma in the educational system. Participants also reported two types of stigma within healthcare settings: firstly from healthcare providers, and secondly from self-stigma associated with their appearance and gender expression.