Low coverage, poor information and little mainstreaming
Over a period of 27 years, HIV has killed an estimated 25 million people across the world. There are now some 33 million people living with HIV. Even while it has produced an unprecedented response globally, HIV remains an immense public health challenge, threatening development efforts and national security. While almost 67% of this burden is borne by Africa, all other regions have been affected, including Asia. For example, there were an estimated 4.9 million people living with HIV in Asia in 2007. Just under half a million of these became newly infected in 2007.
People who inject drugs
HIV epidemics in Asia are diverse. But they disproportionately affect people who inject drugs, people who are sex workers and their clients and men who have sex with men. There are concentrated epidemics among drug users in China, Indonesia, Malaysia, Myanmar and Viet Nam. The spread of HIV among drug users has led to exceptionally high HIV prevalence levels, for example as high as 56.1% among Indonesian women who inject drugs, and 52.2% among Indonesian men who inject drugs. HIV prevalence rates among people who inject drugs are significantly higher than prevalence rates in the overall population. In the most affected countries incidence rates among this population group are as high as 65%. The experience of countries such as Indonesia (Fig 2) and Thailand, show how HIV spread among drug users has been critical to the trajectory of the epidemics in Asia. The use of contaminated needles and syringes by drug users accounts for 30% of those outside of Sub-Saharan Africa. East Asia and the Pacific, which accounts for almost one third of the world's population, includes a number of countries where the use of contaminated needles and syringes by drug users continues to drive the HIV epidemic. These include China (42% of new infections in 2007), Indonesia (46%), Malaysia (65%), Myanmar (HIV prevalence is highest among drug users, at 43%) and Viet Nam (44%). Other countries have concentrated epidemics among drug users and this community continues to report high HIV prevalence, including Thailand. Still other countries have yet to report significant HIV infection among drug users. Some do not even have the data to report.
UNODC adheres to principles of equality and human rights which support the provision of HIV education, prevention, treatment and care to all, regardless of whether or not they do or have used illicit drugs; are (or have been) in prison; and regardless of their occupation or sexual orientation.
Agencies need accurate and reliable population estimates and qualitative information on the populations most vulnerable to HIV infection if they are to be successful in developing and delivering effective national HIV programmes. Unfortunately they face considerable challenges in this task because of poor or often unavailable data.
HIV incidence and prevalence data in this 'most at risk' group is problematic because the denominator itself is unreliable. Crucial qualitative data on the extent of drug use, drugs used, settings for drug use, modes of use, the relationship between drug use and unsafe sexual behaviour is similarly limited. A further complication arises because, while it is the use of contaminated injecting equipment which can result in HIV and other blood-borne infections, there is evidence that HIV risk is higher when people first begin injecting, suggesting that prevention messages are needed before risk behaviour commences.
Correctional settings include a range of facilities which necessarily limit individual freedom. These include gaols, remand centres, police lock-ups, juvenile detention facilities and compulsory drug treatment centres. Levels of HIV infection tend to be higher in such settings as do rates for other infectious diseases such as tuberculosis and hepatitis. For example, 28% of the estimated 88,000 prisoners in Viet Nam and 20% of the 100,000 prisoners in Indonesia are HIV positive. The Government of Viet Nam reports that HIV prevalence ranges between 40-50% among residents in rehabilitation centres and that there are between 18,000-22,600 people living with HIV in such centres.
Communicable diseases represent a threat to the health of both inmates and staff. The principle that prisons and prisoners remain part of the broader community means that the health threats of HIV within prisons, as well as outside, are both inextricably linked. This necessitates a coordinated response across community and prison settings which must include drug dependence treatment centres and services. In East Asia and the Pacific, it appears that the predominant approach to the provision of drug dependence treatment is through compulsory centres. There is little evidence available on such centres, but relapse rates are reportedly high, bringing into question their effectiveness.
Trafficking in Persons
Among victims of trafficking in persons, those trafficked for the purpose of sexual exploitation are, by the nature of their trafficking purpose, most vulnerable to HIV/AIDS. People who have been trafficked do not, generally, declare their status, and due to the clandestine nature of the crime many are not identified by law enforcement and immigration officials, or by NGOs and other civil society groups, during the trafficking experience.
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- While national HIV prevalence in the adult population has stabilized in many countries, prevalence remains high among people who inject drugs in several countries in the region. For example, HIV prevalence in this population exceeds 20% in Cambodia, Indonesia, Myanmar and Thailand.
- A review by RCEAP of the current coverage of needle and syringe programmes in nine countries in East and South East Asia (as of December 2012) indicated that approximately 315,390 (11 per cent) of the estimated number of people who inject drugs (n=2,917,176) were being reached with needle and syringe programme. The optimal level of coverage should be at least 60%, so there is still a big gap in effective service delivery.
- The coverage of opioid substitution therapy (OST) programmes recommended by WHO, UNODC and UNAIDS, also remains low in East and South East Asia. Approximately 274,148 opioid dependent persons were receiving opioid substation treatment by December 2012. The number is up from 178,700 one year earlier. However, in terms of coverage rate 274,148 translates to nine per cent of the estimated 2.917 million people who inject drugs in East and South East Asia, which is lower than the recommended optimal level of 40%. Nevertheless, two countries, China and Malaysia, both of which initiated piloting of Methadone Maintenance Treatment (MMT) in the mid-2000s, have achieved good levels of coverage due to strong national-level commitment. The number of people benefiting from OST is rapidly increasing in Vietnam where the first MMT clinics were opened in 2008.
- There remains a significant disconnect between national drug laws and policies (and their enforcement) and HIV strategies and policies. Criminalization of drug use, and policies aimed at 'drug free communities and societies', in context of the vision for a drug free ASEAN by 2015 often run counter to evidence-based harm reduction objectives.
- Several countries continue to rely on detention of people who use drugs in CCDUs for extended periods of time. The risk of transmission of HIV and other communicable diseases is high among people detained in such centres. At the same time there is an absence of, or limited availability of, HIV prevention, treatment and care services in such settings.
- Prevalence of Hepatitis C, including co-infection with HIV, is high among people who inject drugs and there is a lack of affordable treatment for Hepatitis C.
Implications for the future
Declining funding availability for HIV/AIDS
|The global economic and financial outlook on one hand, and multiple development priorities on the other hand will be impacting on the availability of financial resources to address HIV/AIDS, as well as to impact on the HIV programmes by UN agencies. Countries will be required to increase allocation of national resources for the HIV response.
Refocusing of HIV Advisers to "high HIV IDU burden" countries, in context of prioritisation of countries by UNAIDS for intensified action to meet the goals and targets in the 2011 Political Declaration, will be required to make strategic use of declining funding prospects for HIV within UNODC.
|Drug laws and police practices continue to impede implementation and scaling-up of HIV prevention, treatment and care services||National drug laws and policies continue to impose extremely harsh penalties for people who use, or who are dependent on, drugs. From the perspective of HIV prevention, treatment and care, there remain concerns that such laws pose an obstacle through limiting the availability and utilisation of life-saving services, such as needle-syringe and condom programmes, to people who use drugs and their injecting and sexual partners. Furthermore, frequent crack-downs on people who use drugs impede the uptake of those services which are available. Ongoing advocacy and sensitisation of law enforcement officers are required to improve the operational environment for the delivery of HIV services at community level. At regional level, inter-governmental dialogue on the impacts of drug laws and polices in the national HIV responses among drug control and health sector would be important..|
|Low coverage of needle-syringe programmes and opioid substitution therapy programmes||In terms of reducing the transmission of HIV among people who inject drugs, two interventions (in addition to antiretroviral treatment for people living with HIV) have proven to be particularly effective. There are needle-syringe programmes and opioid substitution therapy programmes (using either methadone or buprenorphine). However, the coverage of these two interventions remains at a lower level than that recommended by WHO, UNODC and UNAIDS, thus hindering the goal of achieving zero new HIV infections in this population.|
|Inadequate access to HIV services in prisons remains a major concern||The prevalence of HIV within many prison populations is of major concern. Yet access to HIV prevention, treatment and care services and effective drug dependence treatment in prisons is inadequate across most of the region. UNODC has a specific mandate to help address this problem, and needs to continue both advocating for, and supporting implementation of, improved access to HIV services in prison settings.|
|Continued use of compulsory centres for people who use drugs||Though the majority of people with drug dependence can benefit from treatment on an out-patient basis, a number of countries continue to rely on detention of people who use drugs in compulsory centres for months or years at a time. Yet, the available data indicates that relapse rates following release from the centres is as high as 95%. Where data is available, the centres have found to be cost- ineffective, thus raising the question about the strategic utilisation of scarce financial resources. UNODC advocates governments to establish and expand access to evidence based drug dependence treatment services for those who are dependent on drugs.|
Implications for follow-up in 2013 and beyond
The work of UNODC's HIV programme in the region is guided by the UNAIDS Strategy "Getting to Zero" 2012-2015 as well as the 'Strategy to Halt and Reverse the HIV Epidemic among People who Inject drugs in Asia and the Pacific 2010-2015". Both strategies call for review and amendment of punitive laws and policies that act as a barrier to universal access to HIV interventions among the population of people who use drugs. Therefore, support to countries that will be undertaking national consultations and reviews of laws and policies during 2013 and 2014 will be a priority area of work on UNODC's HIV programmes.
The strategies also call for zero new infections among people who use drugs as a broad vision. Furthermore, at the High Level Meeting on HIV/AIDS in June 2011 Heads of States and together with Government representatives committed to working towards reducing transmission of HIV among people who inject drugs by 50 per cent by 2015. UNODC will therefore prioritise support the efforts of Member States to achieve these targets by 2015.
In terms of compulsory centres, the UNODC Regional Centre will be organising, jointly with the DDR team, ESCAP and UNAIDS Regional Support Team, a Third Regional Consultation on Compulsory Centres for Drug Users in one of the three countries that came forward with an offer to host the third consultation at the inter-governmental dialogue in Malaysia in October 2012. The third consultation aims to take stock at progress made by countries in phasing out compulsory centres and expansion of evidence based voluntary treatment approaches for people who are dependent on drugs and in need of drug dependence treatment..