health sector response to hiv health sector response to hiv

The health sector has been playing a pivotal role in the national response to HIV of Member States of the South-East Asia Region of WHO. Member States have enormous opportunities, in the context of universal health coverage, to further scale up their responses to HIV with innovative service delivery models, including decentralization of HIV testing and treatment services, and integration of HIV services with maternal, newborn and child health services and tuberculosis control programmes. This report highlights the achievements, factors contributing to the successes and underlines the challenges to sustaining effective responses at the country level.

HealtH Sector reSponSe to HIV in the South-eaSt aSia Region

World Health OrganizationRegional Office for South-East AsiaWorld Health House, Indraprastha EstateMahatma Gandhi MargNew Delhi 110 002, India

www.searo.who.int

ISBN 978 92 9022 470 9

Cover_Health sector response to HIV, SEA 2013.indd 1 11/21/2014 4:38:54 PM

Health sector response to HIV in the South-East Asia Region, 2013

SEA - AIDS -194

Typeset_Health sector response to HIV, SEA 2013.indd 1 11/21/2014 4:36:09 PM

WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia. Health sector response to HIV in the South-East Asia Region, 2013. 1. HIV Infections - epidemiology – prevention and control 2. Acquired Immunodeficiency Syndrome - epidemiology 3. Sexually Transmitted Diseases - prevention and control 4. Antiretroviral Therapy, Highly Active ISBN 978-92-9022-470-9 (NLM classification: WD 308)

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c o n t e n t s

Acronyms iv

Executive summary vii

Introduction 1

Epidemiological status of HIV 3

Health sector response to the HIV epidemic 16

Prevention of HIV transmission in key populations 18

Prevention and control of sexually transmitted infections 28

HIV testing and counselling 35

Prevention of mother-to-child transmission of HIV 37

Antiretroviral therapy 45

Strategic information 55

Key challenges 60

Future priorities 61


iv

AIDS acquiredimmunedeficiencysyndrome

AMR antimicrobialresistance

ANC antenatalcare/clinic

ART antiretroviraltherapy

ARV antiretroviral

BSS behavioursurveillancesurvey

CHC communityhealthcentre

CS congenitalsyphilis

DBS driedbloodspot

DR (HIV)drugresistance

EID earlyinfantdiagnosis

EWI earlywarningindicator

FDC fixed-dosecombination

FSW femalesexworker

GARPR GlobalAIDSResponseProgressReporting

HIV humanimmunodeficiencyvirus

HTC HIVtestingandcounselling

IBBS integratedbiologicalandbehaviouralsurvey

IPT isoniazidpreventivetherapy

MCH maternalandchildhealth

MDG MillenniumDevelopmentGoal

MMT methadonemaintenancetherapy

A c r o n y m s


MNCH maternal,newbornandchildhealth

MSM menwhohavesexwithmen

NACO NationalAIDSControlOrganization(India)

NGO nongovernmentalorganization

NRHM NationalRuralHealthMission(India)

OST opioidsubstitutiontherapy

PCR polymerasechainreaction

PLHIV peoplelivingwithHIV

PMTCT preventionofmother-to-childtransmission(ofHIV)

POC point-of-care(testing)

PWID peoplewhoinjectdrugs

RTI reproductivetractinfection

STI sexuallytransmittedinfection

TB tuberculosis

TG transgenderperson

UNAIDS JointUnitedNationsProgrammeonHIV/AIDS

UNICEF UnitedNationsChildren’sFund

VDRL VenerealDiseaseResearchLaboratory(testforsyphilis)

WHO WorldHealthOrganization

v

Acronyms (continued)


vii

Executive summary

TheHIV epidemic remains a serious global public health concern. A large

numberofpreventablenewHIV infectionsoccureachyearandmillionsof

peopledieprematurelyofAIDS.In2013,anestimated35millionpeoplewere

livingwithHIVintheworldandanestimated1.5millionpeoplediedofAIDS.

Situation of the HIV epidemic in the World Health Organization (WHO) South-East Asia Region

• In2013,anestimated3.4millionpeoplewerelivingwithHIV/AIDS,of

whichwomenaccountedfor37%.

• TheHIVepidemicisreducinginmagnitudewiththeestimatednumber

ofnewinfectionsdecliningby34%overadecade(from350000in2001

to230000in2013).Anestimated190000peoplediedofAIDSin2013.

• TheHIVburdenamongMemberStatesofWHO’sSouth-EastAsia

Regionisasfollows:

— India,Indonesia,Myanmar,NepalandThailandaccountformore

than99%ofHIVinfections.

— NocaseofHIVhasbeenreportedfromtheDemocraticPeople’s

RepublicofKorea.

— Bangladesh,Bhutan,Maldives,SriLankaandTimor-Lestetogether

representlessthan1%ofallHIVinfectionsintheRegion.

• TheoverallHIVprevalenceamongtheadultpopulationwaslow(0.3%)

intheRegionin2013.Thailandwastheonlycountrythatdisplayeda

prevalenceofover1%.However,therearegeographicalvariationsin

prevalencebetweenandwithincountries.

• Theestimatednumberofannualnewinfectionsisshowingadownward

trendinIndia,Myanmar,NepalandThailand.InIndonesia,however,the

HIVepidemicisstillontherise.


viii

HEALTH SECTOR RESPONSE to HIV in the SOUTH-EAST ASIA REGION, 2013

• ThemajorityofHIVinfectionsaretransmittedsexually.Injectingdruguse

isthesecondmostcommonmodeofHIVtransmission.

• HIVisconcentratedprimarilyincertainkeypopulations,whichareata

higherriskforacquiringHIV.Thesepopulationsincludesexworkersand

theirclients,menwhohavesexwithmen, transgenderpopulationsand

peoplewhoinjectdrugs.

• TheoverallHIVprevalenceisdecliningamongfemalesexworkers.There

is,however,evidenceofcontinuinghightransmissionamongpeoplewho

injectdrugs,menwhohavesexwithmenandtransgenderpeople.

• The prevalence of sexually transmitted infections is high, particularly

amongkeypopulations.

• In2012, the estimated incidence ofHIV-positiveTB caseswas 170000

(9.2per100000population)intheSouth-EastAsiaRegion,althoughthe

incidencevariedwidelyamongcountries.

Health sector response to the HIV epidemic

• Amongfemalesexworkers,condomuseduringtheirlastsexualencounter

and consistent condom use is reaching a high level in some countries.

However,menwhohavesexwithmen,transgenderpersonsandpeople

whoinjectdrugshavelowratesofcondomuse.

• CoveragewithacomprehensivepackageofHIVinterventionsforpeople

who inject drugs, including needle–syringe programmes and opioid

substitutiontherapy,continuestobelow.Bangladeshistheonlycountry

intheRegionwhichhasreachedtheglobalstandardof200needlesper

yeardistributedtoeverypersonwhoinjectsdrugs.

TheoverallcoveragereachedbyHIVpreventionprogrammes isslightly

belowtheuniversalaccesstargetof80%forallkeypopulationgroups.India

came close to attaining an80% coverage of the preventionprogramme

targetedatfemalesexworkers,menwhohavesexwithmenandpeople

whoinjectdrugsin2013.NepalandMyanmararefollowingsuit.

• In 2013, over 10million people receivedHIV testingacross theRegion.


ix

Executive summary

Thenumberof facilities offering such serviceshasdoubled since2009.

However,accesstotestingandcounsellingforkeypopulationsremainslow.

• Only25%ofpregnantwomenhadaccesstoHIVtestingandcounselling

in 2013. Of the estimated number of HIV-infected pregnant women

givingbirth,only26%receivedantiretroviralstopreventmother-to-child

transmissionofHIV.

• Adual initiative foreliminationofmother-to-child transmissionofHIV

andsyphiliswaslaunchedin2011.Thegoalwastoeliminatecongenital

syphilisandnewpaediatricinfectionsby2015.In2012–2013,thereported

coverageoftreatmentforsyphilisamongpregnantwomenwhoweretested

wasmorethan80%inIndia,Myanmar,SriLankaandThailand.

• Approximately 1130000 people living with HIV were receiving

antiretroviraltreatmentin2013.Thiscovers33%(range27–29%)ofthe

estimatednumberofpeoplelivingwithHIVintheRegion.The12-month

retentionof thosereceiving treatmentranged from79%inSriLanka to

93%inBangladesh.

• Member States with dual epidemics of HIV/TB havemade substantial

progress in implementingcollaborativeactivities.However,detectionof

HIV/TB-coinfectedpatientsremainslow.

• Resistancetociprofloxacin(anantimicrobialtotreatgonorrhoea)isvery

high, ranging from 76% in Thailand to 87% in Bangladesh. The use of

ciprofloxacintotreatgonorrhoeaisnolongerrecommendedinthenational

guidelinesofmostcountries.

• Substantial progress has beenmade in expanding surveillance systems,

leading to a better understanding of national HIV epidemics. There is

scopetoimproveroutineprogrammemonitoringsystemstoimprovethe

qualityandoutcomeofHIVservices.

• Data on HIV drug resistance is limited and should be collected and

updated. Several countries areplanning to conduct surveys, and collect

and analyse early warning indicators of HIV drug resistance according

to the 2012 WHO HIV drug resistance surveillance strategy and

updatedprotocols.


1

Threedecadesago,HIVwasfirstdetectedintheSouth-EastAsiaRegion.Ever

since,MemberStates intheWorldHealthOrganization(WHO)South-East

AsiaRegionhavemadesignificantachievementstowardsthepreventionand

controlofHIV.Overall, in2013, therewere35million (33.2–37.2million)

peoplelivingwithHIV(PLHIV)globally,ofwhich3.4million(2.9–4million)

were in the Region, with an estimated adult prevalence of 0.3%.Over the

pastdecade,theestimatednumberofnewinfectionshasdecreasedbyalmost

34%.1Theepidemic,however,isheterogeneousintermsoflevelsandtrends,

andintheculturalandcontextual factorsdrivingit.Thesevaryamongand

withinMemberStates.

TheHIVepidemic in theSouth-EastAsiaRegion isprimarilyconcentrated

within certain high-risk population groups. These are female sex workers

(FSW),menwhohavesexwithmen(MSM),peoplewhoinjectdrugs(PWID)

andtransgenderpersons(TG).PreventionandcontrolservicesforHIVand

sexuallytransmittedinfections(STIs)amongthesegroups,andtheabilityto

ensureanenablingenvironmenttopromoteaccesstotheseservicesforthem,

arecrucialprogrammaticinterventionsforallMemberStatesoftheRegion.

ThehealthsectorhasplayedapivotalroleinthenationalresponsetotheHIV

epidemic,aidedbystrongpoliticalcommitment.Thishashelpedtoprevent

newHIVinfectionsamongthoseatrisk,providecareandtreatmenttothose

exposedandinfected,andmountcoordinatedintersectoralresponses.

This report summarizes the present state of the epidemic and describes

the achievements made by the Member States in HIV prevention, care

andtreatment.

Thefirst sectiondescribes the epidemiologyofHIV in theSouth-EastAsia

Region, highlighting the levels and trends of HIV in various geographical

areasandpopulationgroups.Thesecondsectionpresentstheachievements

Introduction


2


of the health sector’s response under the following subsections: HIV

prevention efforts amongkeypopulations; preventionof STIs;HIV testing

and counselling; prevention ofmother-to-child transmission (PMTCT) and

antiretroviraltreatment(ART)forPLHIV.

The reportalsohighlights factors thathavecontributed toachievementsat

thecountrylevelandunderlinestheforeseeablechallengesforsustainingan

effectiveresponseinthenearfuture.Innovativemodelsfordecentralization

ofHIVtestingandtreatmentservices,coupledwithamorecomprehensive

integrationofhealthservicesinthefieldsofreproductivehealth,tuberculosis

(TB)andHIV,wouldbeessentialtoachieveasubstantialimpactonthefight

againstHIV.

ToattainMillenniumDevelopmentGoal(MDG)-6,i.e.universalaccesstoHIV

treatmentandtheeliminationofchildhoodHIVinfections,MemberStateswill

havetoidentifyandaddresstheirspecificnational/regionalchallenges.The

sectiononstrategic informationprovides thestatusofdifferentmonitoring

and evaluation components, and highlights areas in need of operations

research.BestpracticesfromMemberStatesarelistedthereinaswell.

This report is based primarily on data reported byMember States for the

Global AIDSResponse Progress Reporting (GARPR), 2014, and the global

HIVestimatesbyUNAIDSandWHO.1,2Datadrawnfromthesesourcesare

not referenced throughout the report. In addition, information has been

drawn fromcountryHIV sentinel surveillance reports; presentationsmade

byrepresentativesfromMemberStatesatWHOregionalmeetings;theAIDS

DataHubforAsia–Pacificandpublishedpeer-reviewedliterature.

References1. UNAIDS,UNICEF,WHO.GlobalAIDS response progress reporting 2014: construction

of core indicators formonitoring the2011UnitedNationsPoliticalDeclarationonHIVandAIDS.Geneva:UNAIDS;2014(http://www.unaids.org/sites/default/files/en/media/unaids/contentassets/documents/document/2014/GARPR_2014_guidelines_en.pdf,accessed01November2014).

2. UNAIDS,WHO.GlobalHIVestimates.2014 UNAIDS/WHO/UNICEF/ECDC.GlobalAIDSresponseprogressreporting2014(https://aidsreportingtool.unaids.org/,accessed01November2014).


3

People living with HIV/AIDS: with an estimated 35 million (33.2–

37.2million) PLHIV globally, theHIV epidemic continues to pose serious

challenges.1At the endof 2013, an estimated3.4million (2.9–4.0million)

people (adults and children) were living with HIV in the South-East Asia

Region. The number of PLHIVwas rising in the 1990s, but has remained

stableataround3.4millionsince2001.Womenaged15+yearsaccountedfor

nearly37%ofthetotalnumber(Figure1).

Epidemiological status of HIV

0

500 000

1 000 000

1 500 000

2 000 000

2 500 000

3 000 000

3 500 000

4 000 000

4 500 000

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

PLHIV, all ages (SEA Region) PLHIV (Women 15+) SEA Region

Num

ber

of H

IV-in

fect

ed p

eopl

e

Figure 1: Estimated number of people and women living with HIV in countries of the South-East Asia Region

Data source: UNAIDS. AIDSInfo (http://www.unaids.org/en/dataanalysis/datatools/aidsinfo/, accessed 10 November 2014).

SEASouth-EastAsia


4


Themagnitude of the infection varied significantly, with India, Indonesia,

Myanmar, Nepal and Thailand accounting formore than 99% of the HIV

burdenintheRegion(Figure2).

NocaseofHIVhasbeenreportedfromtheDemocraticPeople’sRepublicof

Korea. Bangladesh, Bhutan,Maldives, Sri Lanka andTimor-Leste together

representlessthan1%ofallHIVinfections.

Estimated adult HIV prevalence:althoughtheHIVprevalenceintheRegionhascontinuedtoremainatalowlevelof0.3%(0.3–0.4%),itvaries

betweenMemberStates(Table1).

Except for Thailand, where theHIV prevalence is still above 1%, all other

MemberStatesrecordedaprevalenceoflessthan1%inadults(15–49years).

A declining trend was observed in India, Myanmar, Nepal and Thailand.

Comparedto2001,theestimatedadultHIVprevalenceforIndonesiashowed

anincrease(Figure3).

Figure 2: Five countries account for the major burden of the number of people living with HIV in the South-East Asia Region, 2013

-

500 000

1 000 000

1 500 000

2 000 000

2 500 000

India Indonesia Thailand Myanmar Nepal Bangladesh Sri Lanka Bhutan Maldives

Estim

ated

num

ber

of P

LHIV

PLHIVData source: UNAIDS. AIDSInfo (http://www.unaids.org/en/dataanalysis/datatools/aidsinfo/, accessed 10 November 2014).


5


Table 1: HIV burden in countries of the South-East Asia Region, 2013

Country Estimated number of people living with HIV (all

ages)

Estimated adult (15–49 years)

HIV prevalence (%)

Estimated number of new

HIV infections (all ages)

Estimated number of AIDS-related

deaths (all ages)

2013 2013 2001 2013 2001 2013

Bangladesh 9 500 <0.1 … 1 300 <100 <500

Bhutan <1 000 0.1 NA <100 <100 <100

DPR Korea NA NA NA NA NA NA

India 2 100 000 0.3 260 000 130 000 130 000 130 000

Indonesia 640 000 0.5 28 000 80 000 1 300 29 000

Maldives <100 <0.1 NA NA <100 <100

Myanmar 190 000 0.6 25 000 6 700 9 800 11 000

Nepal 39 000 0.2 7 800 1 300 1 100 3 300

Sri Lanka 2 900 <0.1 <200 <500 <100 <100

Thailand 440 000 1.1 24 000 8 200 61 000 18 000

Timor-Leste NA NA NA NA NA NA


Figure 3: Trends in adult HIV prevalence in five countries of the South-East Asia Region, 2001–2013

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Perc

enta

ge H

IV p

ositi

ve

Thailand Myanmar India Nepal Indonesia

Data source: UNAIDS. AIDSInfo (http://www.unaids.org/en/dataanalysis/datatools/aidsinfo/, accessed 30 October 2014).


6


Duringtheperiod2001to2013,theannualnumberofnewinfectionsfellby

50%to83%inIndia,Myanmar,NepalandThailand.However,theestimated

number of new infections in Indonesia showed a sharp increase of 186%

duringthesametimeperiod(Figure5).

Estimated new HIV infections:worldwide,2.1million(1.9–2.4million)people became newly infected with HIV in 2013, down from 3.4 million

(3.3–3.6million)in2001.ThenumberofnewHIVinfectionsamongadults

andadolescentshasfallenby38%from2001to2013.2In2013,anestimated

230000 (160000–370000) people were newly infected with HIV in the

South-EastAsiaRegion.TheestimatednumberofnewinfectionsinMember

Statesdroppedby34%,fromatotalof350000(310000–400000)in2001to

230000in2013.Figure4showsthatthenumberofnewinfectionshasbeen

steadilydecreasingsince2001,butthedeclinehassloweddownandplateaued

since2009intheRegion.

Figure 4: Trend in estimated number of new HIV infections among adults and children, South-East Asia Region, 2001–2012

-

50 000

100 000

150 000

200 000

250 000

300 000

350 000

400 000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Year

Num

ber

of n

ew H

IV in

fecti

ons



7


Figure 5: Proportionate change in estimated new infections in five countries with a major HIV burden, 2001–2013, South-East Asia Region

–100

–50

0

50

100

150

200

India

Indonesia

Thailand MyanmarNepal

Perc

enta

ge ch

ange

in n

ew in

fecti

ons

2001

–201

3

–50%

186%

–66% –73% –83%

Data source: UNAIDS, WHO. GARPR, 2014

TheoveralldecreaseinnewHIVinfectionsintheRegionreflectsareduction

inHIV transmissiondue to concerted effortsbyMemberStates toprevent

infectionamongkeypopulationscoupledwithscalingupofcareandtreatment

services for those infected.However, an increase in the estimated number

of new infections in Indonesia underscores the importance of intensifying

preventionandtreatmentefforts.

Estimated AIDS-related deaths:globally,thenumberofAIDS-relateddeathsisdeclining,with1.5(1.4–1.7)millionAIDSdeathsin2013,downfrom

2.4 (2.2–2.6)million in 2005.1 In 2013, an estimated 190 000 (160000–

220000)peoplediedduetoAIDS-relatedconditionsintheSouth-EastAsia

Region,ascomparedto210000(180000–290000)in2001.Thenumberof

AIDS-relateddeathspeakedin2005andthenstartedtodecline,mainlyasa

resultofinitiationandprogrammaticscaleupofARTintheRegion.However,


8


theextentofdeclineinAIDS-relateddeathsisnotassubstantialasexpected

(Figure6),mainlyduetosuboptimalcoverageofARTservicesinmostofthe

MemberStates.ThailandisanexceptionwithacurrentARTcoverageof82%;

theestimatedAIDS-relateddeathsdeclinedbyapproximately40000between

2001and2013(seeTable1).

Figure 6: Trend in AIDS-related deaths (male and female, all ages), South-East Asia Region, 2001–2013

-

50 000

100 000

150 000

200 000

250 000

300 000

350 000

400 000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Num

ber

of A

IDS-

rela

ted

deat

hs

Year

Data source: UNAIDS, WHO. Global HIV estimates, 2014

Mode of transmission: although the epidemic is heterogeneous, themajordriversoftheepidemicamongMemberStatesoftheRegionareunsafe

heterosexualandhomosexualsex,andinjectingdruguse.

HIV among key populations:althoughtheoveralladultHIVprevalenceintheRegionisrelativelylowat0.3%,itismuchhigheramongkeypopulation

groups,suchasFSWsandtheirclients,MSM,TGandPWID.


9


Prevalence of HIV among FSWs: according to recently reportedsurveillancesurveydata(2011,2012or2013),theprevalenceofHIVamong

FSWs inMemberStates variedbetween0.2%and9.4%;withMyanmar at

9.4%,Indonesiaat7%,followedbyIndia,Thailand,Nepal,BhutanandTimor-

Lesteat<5%,andBangladeshandSriLankaat<1%(Figure7).

Figure 7: HIV prevalence among female sex workers, South-East Asia Region

0.2 0.3

1.5 1.7 1.72.2

2.8

7.0

9.4

0.0

2.0

4.0

6.0

8.0

10.0

Sri Lanka 2011

Bangladesh 2012

Timor-Leste 2011

Bhutan2011

Nepal 2012

Thailand 2012

India 2013

Indonesia 2012

Myanmar 2011

Perc

enta

ge H

IV p

ositi

ve


Availabletrenddatafromconsistentsentinelsurveillancesitesshowthatthe

HIVprevalenceamongFSWsisdeclininginIndia,MyanmarandThailand,

buthasnotchangedsignificantlyinIndonesiaandNepal(Figure8).

VariationinthelevelsofHIVprevalenceamongFSWswithineachcountryis

common.InIndia,eightstatesreportedahigherHIVprevalenceamongFSWs

thanthenationalaverageof2.8%.3AlthoughHIVprevalenceisdecliningat

thenationallevelandinthesouthernstates,manypreviouslylow-prevalence

States (Assam,Bihar,HimachalPradesh, Jharkhand,MadhyaPradeshand

Puducherry) are depicting a rise.3 The other two states with a higherHIV

prevalencethanthenationalaverageareGoaandChhattisgarh.3InIndonesia,


10


HIVprevalenceamongFSWsisveryhighat>15%inJayawijaya,Batang,Kota

JayapuraandKotaDenpasar.4YangonandKyaingtonginMyanmarshowed

ahigherHIVprevalencethanthenationalaverageof9.4%amongFSWs.4 In

SriLanka,the2011sentinelsurveillancereportedanHIVprevalenceof0.2%

amongFSWsinGalleand0.9%inColombo.4

Prevalence of HIV among MSM:asperrecentdatafromsurveillancesurveys (2011, 2012 or 2013) reported to GARPR, the prevalence of HIV

amongMSMrangedbetween0.7%and10.4%inMemberStatesoftheRegion.

TheHIVprevalencewasmorethan5%inThailand,IndonesiaandMyanmar,

and lower than5%inothercountries (Figure9).However,HIVprevalence

amongMSMvariessignificantlywithincountries.InIndia,itwashigherthan

the national level of 5% in nine states.3 In Indonesia, the HIV prevalence

amongMSMwasparticularlyhighinJakarta(17%),Surabaya,Bandung,and

alsoamongthewariaapopulationinMalangandSemarang.4

India FSW

Indonesia FSW

Myanmar FSW

Nepal FSW

Thailand FSW

2005 2006 2007 2008 2009 2010 2011 2012

35

30

25

20

15

10

5

0

Perc

enta

ge H

IV p

ositi

ve (%

)

Year

Figure 8: Trends in HIV prevalence among FSWs in five high HIV-burden countries, South-East Asia Region, 2005–2012

Data source: HIV and AIDS Data Hub for Asia–Pacific

aWariaisatermfortransgenderedpeopleinIndonesia,derivedfromthewordswanita(woman)andpria(man).


11


RisingtrendsinHIVprevalencewerenotedamongMSMinBangkok,Thailand,

and in Indonesia.4 However, decreasing HIV prevalence was observed in

India3andMandalayinMyanmar4(Figure10).

Figure 9: HIV prevalence among MSM, seven countries, South-East Asia Region

0.7 0.91.3

3.84.4

7.1

8.5

10.4

0

2

4

6

8

10

12

Bangladesh 2013

Sri Lanka 2011

Timor-Leste2011

Nepal 2013

India 2013

Thailand 2012

Indonesia 2012

Myanmar 2013

HIV

pre

vale

nce

(%)

Data source: UNAIDS/WHO. GARPR, 2014

Figure 10: Trends in HIV prevalence among MSM in selected areas, South-East Asia Region, 2002–2011


0

5

10

15

20

25

30

35

40

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Perc

enta

ge H

IV p

ositi

ve (%

)

MSM, Myanmar (Mandalay)

MSM, Thailand (Bangkok)

MSM, Indonesia

MSM, India


12


InIndia,threeHIVsentinelsitesforTG(oneinMaharashtraandtwoinTamil

Nadu)reportedanHIVprevalencerangingfrom0.8%to18.8%in2012,when

thelastroundofthesurveillancewasconducted.3

Prevalence of HIV among PWID: as per recent data reported byGARPR (2011, 2012 or 2013), the prevalence ofHIV amongPWID ranged

between 1.1% and 36.4% in the Region (Figure 11). Based on surveillance

surveyresults,thereportedHIVprevalenceinMyanmarwasalarminglyhigh

at18%(in2013),Thailandat25%(in2012)andIndonesiaat36%(in2011),

while in India (2013), Nepal and Bangladesh (2011) it was less than 10%.

1.1

6.3 7.2

18.7

25.2

36.4

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Bangladesh, 2011 Nepal, 2011 India, 2013 Myanmar, 2013 Thailand, 2012 Indonesia, 2011

Perc

enta

ge H

IV p

ositi

ve (%

)

Figure 11: HIV prevalence among PWID, selected countries, South-East Asia Region, 2012

Data source: UNAIDS/WHO. GARPR, 2014

However,thenationalaveragemasksthewidevariationsinHIVprevalence

amongPWIDwithincountries.InIndonesia,Jakarta,SurabayaandMedan

reportedahigherHIVprevalencethanthenationalaverageof36%.InIndia,

thehighestprevalenceamongPWIDwasrecordedinPunjab(21%),followed

byDelhi(18%),Maharashtra(14%),Manipur(13%)andMizoram(12%).Nine

states in India recorded a prevalence ofmore than 5%, includingMadhya


13


Pradesh,OdishaandChandigarh.3Availabletrenddatafromconsistentsites

showthatHIVprevalenceamongPWIDisdeclining inKathmandu,Nepal.

ThereisevidenceofcontinuinghightransmissionamongPWIDinIndonesia,

Thailand,MyanmarandIndia(Figure12).4

InIndia,newpocketsofhighHIVprevalenceamongPWIDareemergingin

thenorth,while theepidemicamongPWID innortheastern India is stable

since 2008. InMyanmar,Mandalay (13%), Lashio (20%) andMyitkyeena

(32%)showhighlevelsofHIVprevalenceamongPWID.4Despiteasuccessful

HIVcontrolprogrammeinThailand,theepidemicamongPWIDstillposesa

challenge,withBangkokcontinuingtoremainatahighof30%HIVprevalence

amongPWIDsincethepastdecade.

Prevalence of HIV among antenatal care attendees:astheHIVepidemicinSouth-EastAsiaismaturing,it isspreadingwidelytoclientsof

FSWsandtheirspouses,andtofemalepartnersofPWID.Women(15+years)

accountfornearlyonethirdofthetotalnumberofPLHIVintheSouth-East

Figure 12: HIV prevalence among PWID in selected areas of the South-East Asia Region

0

10

20

30

40

50

60

70

80

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Perc

enta

ge H

IV p

ositi

ve (%

)

PWID, India

PWID, India (Punjab)

PWID, Indonesia

PWID, Myanmar

male PWID, Kathmandu Valley

PWID Thailand, (Bangkok)



14


AsiaRegion(seeFigure1).HIVsentinelsurveillanceamongwomenattending

antenatal clinics (ANC) could be a proxy for theHIV situation among the

general population. The available ANC testing data from India, Myanmar

andThailand indicate thatHIVprevalencehasbeendecliningamongANC

attendees in these countries from 2000 to 2013, though a rise has been

observedinMyanmarduring2011–2013(Figure13).

Figure 13: Trends in HIV prevalence among women aged 15–24 years attending antenatal clinics, selected countries, South-East Asia Region, 2000–2013

0

0.5

1

1.5

2

2.5

3

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Perc

enta

ge H

IV in

fect

ed

India Thailand Myanmar


InIndia,noneofthestatesshowedaprevalenceof1%ormoreamongANC

attendeesduring the2010–11 sentinel surveillance.Thehighestprevalence

was recorded in Manipur (0.78%), followed by Andhra Pradesh (0.76%),

Karnataka (0.69%) andNagaland (0.66%). The lowHIV-prevalence states

of Gujarat (0.46%), Jharkhand (0.45%), Odisha (0.43%) and Chhattisgarh

(0.43%) showed a rising trend and recorded a higher prevalence than the

nationalaverageof0.4%amongANCattendees.Moreover,therewasarising


15


trend among ANC attendees in the very low-prevalence states of Assam,

Haryana,PunjabandUttarakhand.3

New infections among children (0–14 years): with an overalldeclining trend in estimatednew infections among the general population,

andduetothegradualscaleupofpreventiveHIVservicesformothersand

children, the estimated number of new infections among children (0–14

years)showedadecline.Comparedwith2001,whenabout28000(25000–

39000)childrenwereestimatedasnewlyinfectedwithHIVintheRegion,a

dropof32%wasnotedin2012,withanestimateof19000(16000–28000)

newinfectionsamongthisagegroup.

References1. Global report. UNAIDS report on the global AIDS epidemic 2013. Geneva: UNAIDS;

2013(http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf, accessed 28 October2014).

2. The GAP report. Geneva: UNAIDS; 2014 (http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2014/UNAIDS_Gap_report_en.pdf,accessed02November2014)

3. HIVsentinelsurveillance2010–11.Atechnicalbrief.NewDelhi:NationalAIDSControlOrganization (NACO), Department of AIDS Control, Ministry of Health and FamilyWelfare,GovernmentofIndia;2012.

4. HIVandAIDSdatahub forAsia–Pacific.Evidence to action. [webpage]. (http://www.aidsdatahub.org/,28October2014).

5. National STD/AIDSControlProgramme.Report of the2011 survey.HIV sentinel sero-surveillance survey in Sri Lanka. Colombo, Sri Lanka: National STD/AIDS ControlProgramme; August 2012 (http://www.aidsdatahub.org/sites/default/files/documents/HSS_SriLanka.pdf,accessed28October2014).


16

WHO’sworkonHIVhasbeenguidedbyaseriesofbroad-basedstrategiesand

initiatives,includingtheGlobalHealthSectorStrategyonHIV/AIDS2003–

2007;1the“3by5”Initiative;2andtheWHO2006–2010GlobalStrategyfor

UniversalAccess.3InordertofurtherguidethehealthsectorresponsetoHIV,

theWHORegionalOfficeforSouthEastAsiadevelopedtheRegionalHealth

SectorStrategyonHIV/AIDS,2011–2015.4Thisstrategydescribesthefuture

directionandfocusofworkofthehealthsectorinrespondingtotheexisting

HIVepidemic,soastoachieveuniversalaccesstoHIVprevention,diagnosis,

treatmentandcare.Thestrategicdirectionsareasfollows:

• OptimizingtheoutcomeofHIVprevention,diagnosis,treatmentandcare

toensure

— preventionofsexualtransmissionofHIV,

— managementofSTIs,

— eliminationofcongenitalsyphilis,

— eliminationofnewHIVinfectionsinchildren,

— increasedaccesstoHIVtestingandcounselling,

— qualityHIVtreatmentforallthosewhoneedit,

— reductionincoinfectionsandco-morbiditiesamongPLHIV,

— strengthenedmechanismsforTB/HIVcollaboration,

— preventionandcareforkeypopulationsandother

vulnerablepopulations;

• Strengthening strategic information and research to ensure evidence-

based guidance for policy, decision-making, and planning for resource

allocation,servicedelivery,andmonitoringandevaluation(includingHIV

drugresistance[DR]monitoring);

• Strengthening health systems for the effective integration of health



17


servicestoensureavailability,access,affordabilityandquality,including

strengthening human resources, providing innovative approaches to

servicedelivery,optimallyutilizinglaboratorysupportandprovidingmore

effectivemanagementsupport;

• Creating a supportive and enabling environment to ensure equitable

accesstoHIVservices,reducingHIV-relatedstigmaanddiscrimination,

andremovingstructuralbarriers.

References1. Globalhealth-sectorstrategyonHIV/AIDS2003–2007.Geneva:WorldHealthOrganization;

2003(http://www.who.int/hiv/pub/advocacy/ghss/en/,accessed04November2014).

2. The3by5initiative:treatthreemillionpeoplewithHIV/AIDSby2005.Geneva:WorldHealthOrganization;2003(http://www.who.int/3by5/en/,accessed04November2014).

3. UniversalaccesstoHIV/AIDSprevention,treatmentandcare[webpage].(http://www.who.int/hiv/topics/universalaccess/en/,accessed04November2014).

4. RegionalhealthsectorstrategyonHIV,2011–2015.NewDelhi:WHORegionalOffice forSouth-EastAsia;2012(http://www.searo.who.int/entity/hiv/documents/SEA_AIDS_187/en/index.html,accessed28October2014).



18

The leveland trendof theHIVepidemicaswellas the factors thatdrive it

varyconsiderablyfromcountrytocountry.Theheterogeneityoftheepidemic

anditsdriversneedtobefactoredinwhilestrategizingtheresponsetothe

HIVepidemicatthenationallevel.Despitethis,HIVepidemicsintheSouth-

EastAsiaRegionshareanimportantfeature;theyarecentredmainlyaround

unprotectedpaidsex,sharingofcontaminatedneedlesandsyringesbyPWID,

and unprotected sex betweenmen. Clients who buy sex from sex workers

largelybelongtothe“general”populationandarethemostimportantfactorin

drivingtheepidemicbyinfectingtheirspouses.1Thereby,asignificantnumber

of otherwise “low-risk”women,who have sex onlywith their husbands or

boyfriends,areexposedtoHIV.ThelikelihoodofthesewomenpassingHIVto

anothermanisgenerallyverylow,asrelativelyfewwomeninSouth-EastAsia

havesexwithmorethanonepartner.HIVepidemicsinSouth-EastAsiaare

highlyunlikelytosustainthemselvesinthe“generalpopulation”independent

ofcommercialsex,PWIDandsexbetweenmen.Hence, inthepresentHIV

epidemic scenario, prevention of HIV among FSWs,MSM and PWID is a

crucialinterventioninordertocurtailtransmissionofthevirus.2

Prevention of HIV among sex workers: HIV prevention effortsamongFSWsconsistmainlyof condompromotion,preventionandcontrol

of STIs, HIV testing and counselling (HTC), and linkage to HIV care and

treatmentforthoseinfected.Figure14depictsthattheuseofacondomwith

theirmostrecentclientbysexworkersisreachinghighlevelsinmostMember

States;itisabove80%inMyanmar,Thailand,SriLankaandNepal.Inother

countriessuchasBhutan,Bangladesh,IndonesiaandTimor-Leste,however,

the reported condom use was lower, at 36–67%. Nationwide behaviour

surveillance surveys (BSS, 2001–2006) in India showed that consistent

condomuseamongFSWshadincreasedfrom50%to73%.3Consistentcondom

useamongFSWsinMandalay,Myanmar(BSS2008)wasreportedtobe97%,

Prevention of HIV transmission in key populations


19

Health sector response to the HIV epidemic: Prevention of HIV transmission in key populations

whileitwas35%amongdirectFSWsinIndonesia(integratedbiologicaland

behaviouralsurveillance[IBBS,2011].4

Figure 14: Percentage of FSWs reporting use of condom with their last client, selected countries of the South-East Asia Region, 2011–2013 (with available data in 2011, 2012 or 2013)

36 38

60

67

83

8994 96

0

20

40

60

80

100

Timor-Leste, 2011

Bhutan, 2011

Indonesia, 2011

Bangladesh, 2013

Nepal, 2011

Sri Lanka, 2011

Thailand, 2012

Myanmar, 2013

Cond

om u

se w

ith

last

clie

nt (

%)


IntheGARPR,coverageofpreventiveservicesisassessedbythepercentage

ofsexworkerssurveyedwhoanswered“yes”totwoquestions:knowledgeof

wheretoreceiveHIVtestingandwhethertheyhavebeengivencondomsin

thepreceding12months(Figure15).

63

7.5

0

20

40

60

80

100

Bangladesh, 2013

12

20

Indonesia, 2012

76

Myanmar, 2011

79

0

Nepal, 2012

74

54

Thailand, 2012

84.5

India, 2013

Perc

enta

ge o

f sex

wor

kers

Male Female

Figure 15: Percentage of male and female sex workers reached with HIV prevention programmes, selected countries, South-East Asia Region, 2011–2013



20


On the whole, the progress in HIV prevention efforts, as measured by

knowledgeofHIVtestsitesandbeinggivencondomsinthepast12months,

wasreportedasmoderatelyhighforFSWsinIndia(84.5%),Myanmar(76%)

and Thailand (54%), but low in Indonesia (20%) and Bangladesh (7.5%).

Formalesexworkers,however,thispercentagewashigherinNepal(79%),

Thailand(74%)andBangladesh(63%)butlowinIndonesia(12%).Important

elementsthatcontributedtothissuccessweremappingandsizeestimation;

community involvement through peer education and strong outreach

components; condomdistribution,both freeand throughsocialmarketing;

integratedSTIscreeningandtreatment;andmonitoringandsupervision.

Lokalisasi approach to condom promotion among FSWs works in Indonesia

The experiences of five brothel-based sex work settings (Denpasar, Jayapura, Malang, Surabaya and Tanjung

Pinang) on the implementation of a condom promotion programme were examined. The major focus of

these interventions was to empower sex workers so that they increase the use of condoms and access health

services and, through workplace programmes, promote a demand for condom use among high-risk men in

sex work. These interventions were supported by comprehensive clinical services as well as an improved

system to ensure uninterrupted condom supply.

The results showed that except in Surabaya, all the respondents from all five study sites graded the condom

support and use, as well as STI/HIV services and access as “strong/very good”. The empowerment, enabling

and coverage aspects were graded as “strong” by the majority of respondents. Condom use at last sex with a

client has increased in the past decade in four of the five study sites and, as a consequence, the incidence of

HIV/STI is declining.

Key lessons learned are as follows: (a) structural barriers to condom use still exist, such as (i) tax incentives

to conceal sex workers in some areas, (ii) owners who still support clients who refuse condoms. This implies

that advocacy is needed to overcome the remaining structural barriers that limit impact. (b) Control of sexual

transmission (STI/HIV) is feasible in direct sex work settings (lokalisasi) in Indonesia: four out of the five

sites had a high level of implementation. (c) Community engagement through pokja or “working groups” is

giving better results in all of these areas. (d) A combination of a good condom promotion programme, clinical

services with regular check-ups, sustained outreach and socialization, as well as involvement of sex workers

and other stakeholders are important for better results.

Source: Case study. WHO Regional Office for South-East Asia (unpublished document)


21


Prevention of HIV among MSM:HIVpreventioneffortsamongMSMadditionally focus on the provision of condoms and lubricants, expansion

of HTC and in creating an enabling environment through community

participation. In five Member States of the Region, condom use among

MSMwiththeirlastpartnerwasmorethan60%,butitwaslowerat49%in

Bangladesh(Figure16).

Figure 16: Percentage of MSM reporting use of condom with their last partner, selected countries of the South-East Asia Region, 2011–2013


49

60 6166

8285

0

20

40

60

80

100

Bangladesh 2013

Indonesia 2011

Sri Lanka 2011

Timor-Leste2011

Myanmar 2013

Thailand 2012

Cond

om u

se a

t la

st a

nal

sex

(%)

Consistentcondomusewasreportedlylowat24%amongMSMinIndonesia

(IBBS2011);468%amongMSMand50%amongTGinThailand.4Available

dataindicatethatthecoverageofpreventionprogrammesamongMSMvaries

acrossMemberStates.WhileIndia,MyanmarandNepalreportedover60%

coverage,BangladeshandIndonesiareportedlessthan25%(Figure17).The

mainbarrierstoaccessingservicesathealth-carefacilitiesaresocialstigma

and discrimination, coupled with inadequate legal support, which still pose a

crucialchallengeinreachingtheMSMpopulationgroupwithpreventiveservices.

Prevention of HIV among PWID:preventionoftransmissionofHIVthroughinjectingdruguseisespeciallyimportantduetotheextremelyhighrisk

ofHIVtransmissionthroughcontaminatedinjectingequipment.Thelimited


22


Figure 17: Percentage of MSM reached with HIV prevention programmes, selected countries of the South-East Asia Region 2011–2013 Data source: UNAIDS, WHO. GARPR, 2014

23 24

53

6468 69

0

20

40

60

80

100

Indonesia 2012

Bangladesh 2013

Thailand 2012

Nepal 2013

India 2013

Myanmar 2011

Perc

enta

ge o

f MSM

Figure 18: Percentage of PWID reporting use of condom the last time they had sex, selected countries of the South-East Asia Region, 2011–2013 Data source: UNAIDS, WHO. GARPR, 2014

45 47 4952

63

78

0

20

40

60

80

100

Bangladesh2011

Nepal2011

Thailand2012

Indonesia2011

India2013

Myanmar2011

Perc

enta

ge o

f PW

ID

informationavailableonthecoverageofpreventiveinterventionsshowsthat

ithasreached80%oftheestimatedpopulationofPWIDinIndia,whileitisat

22%inIndonesia.5Preventionofsexualtransmissionisalsoimportantamong

PWID.1CondomusewiththeirlastpartnerbyPWIDwasgenerallylow;about

50%inBangladesh,Indonesia,NepalandThailand,buthigherinIndia(63%)

andMyanmar (78%) (Figure18). In Indonesia, consistentcondomusewas

lowat30%amongPWID(IBBS2011).4


23


Accesstosterileinjectingequipmentandopioidsubstitutiontherapy(OST),

referred to as harm reduction, was highly effective in reducing the spread

ofHIVamongPWID.6Therewereatotalof642“needle–syringeexchange”

programme sites in 2012; Bangladesh (69), India (264), Indonesia (194),

Myanmar (50),Nepal (29)andThailand (36).5Therehasbeenan increase

inthenumberofneedle–syringeprogrammesitesalongwiththenumberof

sterileneedlesandsyringesdistributedinmostofthecountries.Thenumber

ofsyringesdistributedperPWIDperyearwas287,193and147inBangladesh,

IndiaandMyanmar,respectively,in2013,whichisaboveorclosetothe200

oftheglobalguideline.4Theindicatorshouldbeinterpretedwithcaveats,asit

needsaccurateprogrammedataonthenumberofcleansyringesdistributed

vis-à-vistheestimatednumberofandreportedusebyPWID.

However,thisnumberissignificantlylowerinNepal,IndonesiaandThailand,

highlightingthegapsinservicetoPWIDinthesecountries(Figure19).

Figure 19: Number of syringes and needles distributed per PWID per year by needle and syringe exchange programmes, South-East Asia Region, 2012–2013


237

163

116

3622

12

287

193

147

31 2612

0

50

100

150

200

250

300

350

Bangladesh India Myanmar Nepal Indonesia Thailand

Num

ber

of s

yrin

ges/

PWID

/Yea

r

2012

2013

global minimal standards


24


A total of 24 110 PWID were enrolled for OST across 361 sites in 2012;

Bangladesh (2), India (107), Indonesia (83), Maldives (1), Myanmar (18),

Nepal(3)andThailand(147).4Intermsofuseofsterileinjectingequipment

duringtheirlastinjection,availabledatashowthattheuseofcontaminated

injectingequipmentwaslowamongPWIDintheRegion(Figure20).Ascale

up of harm reduction services was enabled by funding community-based

organizations and nongovernmental organizations (NGOs) in India and

Bangladesh,andby theavailabilityof theseservicesatprimaryhealth-care

settingsinIndonesia.

Challenges: sustaining themomentumof these targeted interventions isa considerable challenge in the future forMemberStates.Countrieswould

need to sustain and intensify effective measures, especially strengthening

communityinvolvementandoutreachactivities,expandingHTC,andquality

STI services for key populations.Another important challenge, in terms of

sustenance,istogeneratelocalgeographical-levelevidence,forexample,on

Figure 20: Percentage of PWID (both sexes) reporting the use of sterile injecting equipment the last time they injected, South-East Asia Region, 2011–2013

34

7881

87

95

0

20

40

60

80

100

Bangladesh, 2012 Thailand, 2011 Myanmar, 2011 Indonesia, 2012 Nepal, 2012

Perc

enta

ge o

f PW

ID



25


thechangingpatternsandmodesofsexualwork, includingthepresenceof

male sexworkers, location andpresence of bars, use ofmobile phones for

solicitation,whichwouldneeddynamicassessmentforcontextualplanning

offutureinterventions.RegularmonitoringofinterventionsamongMSM,TG

andPWIDwouldensureoptimumcoverageofservices.However,identifying,

locating and reaching these high-risk and high-transmission groups with

serviceswillprovetobethemostimportantchallengeforHIVpreventionand

care. Stigma and discrimination against these communities in health-care

settingsaswellasinsocietyatlargearestillmajorbarrierstoaneffectivescale

upofresponseandaccesstopreventiveservices.6Lawsthatcriminalizesame-

Piloting opioid substitution therapy (OST) with methadone in Dhaka, Bangladesh

The pilot programme started in June 2010 with the opening of the methadone maintenance therapy

(MMT) clinic at the Central Drug Addiction Treatment Centre (CTC) of the Department of Narcotics

Control, with support initially from the United Nations Office on Drugs and Crime Regional Office for

South Asia and later also from Family Health International.

The pilot intervention is aimed at reducing high-risk behaviour leading to the spread of HIV,

psychological distress and drug dependency, with the goal of improving the quality of life of PWID. The

MMT clinic at CTC has been providing services, such as general medicine; counselling, motivational

enhancement and psychiatric services; laboratory investigations; community sensitization and

meetings with anonymous participants; free HIV testing services; and referral services if required to

the nearest hospital for TB screening and treatment; and a PLHIV self-help group for antiretroviral

(ARV) medication only for HIV-positive patients.

The study has been ongoing for about a year and a half, and 150 clients were enrolled in 2011 and

180 in 2012. A major achievement of the pilot programme has been the successful weaning from drug

dependence of 11 clients, all of whom are free from drugs for at least four months. In the case of all

these 11 PWID, earlier attempts to wean them away from drugs using conventional detoxification and

rehabilitation services had failed. Other notable features of the pilot have been the requirement of

relatively low doses of methadone for stabilization and a high retention rate (80%). The clients of the

MMT clinic at CTC were stabilized on an average dose of 49 mg in the maintenance phase.

Source: Case study, WHO Regional Office for South-East Asia (unpublished document)


26


sexrelationsandthosethatarepunitiveagainstPWIDcanbemajorobstacles

toeffectiveHIVprevention.7TheydriveMSMundergroundandprohibitharm

reductionforPWID,makingitmoredifficultforthenationalprogrammeto

reachthemorestablishsurveillancetoassesstheburdenandprovidethem

with the requiredhealth services.8A recent example is the SupremeCourt

ofIndia’sDecember2013judgment,whichsetasidetheDelhiHighCourt’s

progressive judgment that had decriminalized same-sex relations between

adultsinprivate,in2009.9

Supplies of condoms, lubricants, needles, syringes and other commodities

callformaintainingefficientprocurementandsupplychainlogistics.Limited

coveragewithharmreductionservicesisstillanimportantissuethatneedsto

beaddressed,inordertoensureoptimumpreventionamongPWID.Withnew

geographicallocationsreportinglocalizedepidemicsamongPWID,adequate

and timely response mechanisms would remain a challenge for national

programmes.TheuseofsuboptimaldosagesinOSTinterventionsisanother

problemidentifiedbyseveralMemberStates.10

References1. RedefiningAIDSinAsia:reportoftheCommissiononAIDSinAsia.NewDelhi:Oxford

UniversityPress;2008.

2. Garg R, YuD,Narain J. Epidemiology and transmission dynamics ofHIV in Asia. In:NarainJ,editor.ThreedecadesofHIV/AIDSinAsia.NewDelhi:SAGEPublicationsPvt.Ltd;2012.

3. Behaviour surveillance survey among general population. New Delhi: National AIDSControlOrganization India,Department of AIDSControl,Ministry ofHealth& FamilyWelfare,GovernmentofIndia;2006.

4. WHO,UNODC,UNAIDS.TechnicalguideforcountriestosettargetsforuniversalaccesstoHIVprevention,treatmentandcareforinjectingdrugusers:2012revision.Geneva:WorldHealthOrganization:2013 (http://www.who.int/hiv/pub/idu/targets_universal_access/en/,accessed29October2014).

5. UNAIDS/UNICEF/WHO.GlobalAIDSresponseprogressreporting2013:constructionofcoreindicatorsformonitoringthe2011UNPoliticalDeclarationonHIV/AIDS.Geneva:UNAIDS;2013(http://www.unaids.org/en/media/unaids/contentassets/documents/document/2013/GARPR_2013_guidelines_en.pdf,accessed02November2014).

6. BeasleyR.Briefreport.Reducingharm.Washington,DC:JanInstituteofMedicineoftheNationalAcadamies;2010.

7. HaldarP,KantS.ReadingdownofSection377ofIndianPenalCodeisawelcomemoveforHIVpreventionandcontrolamongmenhavingsexwithmeninIndia.IndianJCommunityMed.2011;36(1):57–8.


27


8. BeyrerC,BaralSD,vanGriensvenF,GoodreauSM,ChariyalertsakS,WirtzAL,etal.GlobalepidemiologyofHIVinfectioninmenwhohavesexwithmen.Lancet.2012;380(9839): 367–77.

9. SC says gay sex punishable, withdraws legal protection to LGBT community. IndianExpress[Internet]. (http://www.indianexpress.com/news/sc-says-gay-sex-punishable-withdraws-legal-protection-to-lgbt-community/1206701/,accessed29November2014).

10.SharmaM,OppenheimerE,SaidelT,LooV,GargR.AsituationupdateonHIVepidemicsamong peoplewho inject drugs and national responses in the South-East AsiaRegion.AIDS.2009;23(11):1405–13.


28

HIVisprimarilyanSTI.Bothulcerativeandnon-ulcerativeSTIshavebeen

showntoenhancethetransmissionofHIV.Thepublichealthproblemofnon-

HIV STIs also causes serious complications resulting in infertility, ectopic

pregnancy and pelvic inflammatory disease. This is of particular relevance

to theepidemic situation inMemberStatesof theSouth-EastAsiaRegion,

where STI prevalence is high among some key populations and in some

geographicalareas.

Prevalence of STIs among key populations:availableGARPRdatashowahighprevalenceofSTIsamongkeypopulations,particularlyamongFSWs

andMSMinIndonesia,Timor-LesteandMyanmar,andamongMSMinSriLanka

(Figure21).1

InIndonesia, theIBBS2011reportedveryhighpositivityrates forsyphilis,

gonorrhoea and chlamydia among the surveyed populations of FSWs and

Figure 21: Percentage of FSWs and MSM with active syphilis, selected countries, South-East Asia Region, 2011–2012

0.5 0.7 0.8 1.52.4

3.8

7.9

9.8

1.50.8

1.5

11.7

3.3

21.9

7.1

0

5

10

15

20

25

Thailand2011

Nepal 2012

India 2012

Bangladesh 2011

Sri Lanka 2011

Myanmar 2012

Indonesia 2012

Timor-Leste 2011

% of FSW positive for syphilis % of MSM positive for syphilis

Perc

enta

ge



Prevention and control of sexually transmitted infections


29

Health sector response to the HIV epidemic: Prevention and control of sexually transmitted infections

MSM.2 Syphilis seropositivity was 10% among direct FSWs, 3% among

indirectFSWs,9%amongMSMand25%amongthewariapopulationgroups.

AmongPWID,thesyphilisseropositivityratewas2%.Thepercentageofkey

populationspositiveforgonorrhoeawere:38%ofdirectFSWs,19%ofindirect

FSWs, 21% ofMSM and 29% ofwaria. The chlamydia positivity rate was

41%eachamongdirectaswellasindirectFSWs,21%amongMSMand28%

amongwaria.2TheIBBS2011alsofoundthatthemediannumberofclients

entertainedperweekbywariawasfour,andmorethansixinSurabayaand

Semarang.InMyanmar,HIVsentinelsurveillancein2011reportedsyphilis

seropositivityratesof4%eachamongmaleSTIpatientsaswellasFSWs,2.5%

amongMSMand1%amongPWID.2

Elimination of mother-to-child transmission of syphilis: syphilisisanSTIthatleadstoadversebirthoutcomessuchasstillbirth,neonataldeath,

pretermbirth,lowbirthweightandcongenitalsyphilis(CS).CSispreventableand

treatable.Screeningallpregnantwomenforsyphilis isacost-effectivestrategy,

eveninlow-prevalencesettings.3CoverageofsyphilistestingamongANCattendees

isconsistentlyhigh;morethan90%inBhutanandThailand,morethan80%in

MaldivesandSriLanka,around60%inIndia,butitisstillverylowinIndonesia

andMyanmar(Figure22).1

10096 95

83

67

9.7

0.1

9297

37

69

11.8

0.1

95.8

86

97

86

64

12

0.50

25

50

75

100

Thailand Sri Lanka Bhutan Maldives India Myanmar Indonesia

Perc

enta

ge o

f wom

en te

sted

for

syph

ilis

at A

NC

visi

t

2011 2012 2013

Figure 22: Percentage of women tested for syphilis at ANC visit, selected countries, South-East Asia Region, 2011–2013

Data source: UNAIDS, WHO. GARPR, 2012–2014


30


TheprevalenceofsyphilisamongANCattendeestestedwasstillhighinIndonesia

(1.04%)andMyanmar(0.6%)in2013.Therehasbeenasignificantreductionin

thesyphilisseropositivityrateamongANCattendees,from0.6%in2012to0.1%

in2013.In2013,Maldives,SriLankaandThailandreported0%syphilispositivity

(Figure23).1

For those countrieswithmoredatapoints available, the syphilis seropositivity

ratesamongANCattendeesshowedasteadydecliningtrend(Figure24).

Reporteddatashowthattreatmentwasprovidedtoalmost90%ofpregnant

womenwhotestedseropositiveforsyphilis(Figure25).

Figure 23: Percentage of ANC attendees who tested seropositive for syphilis, selected countries, South-East Asia Region, 2011–2013

0

0.2

0.4

0.6

0.8

1

1.2

Indonesia India Myanmar Thailand Maldives Sri Lanka

Perc

enta

ge sy

phili

s po

sitiv

e (%

)

2011

2012

2013

Data source: WHO, UNAIDS. GARPR, 2012–2014


31


Figure 24: Trends in syphilis seropositivity rates among ANC attendees in selected countries of the South-East Asia Region, 1991–2013

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Thailand India Myanmar Sri Lanka

Perc

enta

ge

5

4.5

4

3.5

3

2.5

2

1.5

1

0.5

0

Data source: WHO, UNAIDS. GARPR, 2014

0

20

40

60

80

10090

9486

Sri Lanka

10093

98

Thailand

78

8993

India

86

Myanmar

2011 2012 2013

Perc

enta

ge o

f AN

C at

tend

ees

Figure 25: Percentage of ANC attendees who tested positive for syphilis and received treatment, South-East Asia Region, 2011–2013



32


Managing syphilis infection among pregnant women in Sri Lanka

Antenatal screening with the Venereal Disease Research Laboratory test (VDRL) for pregnant mothers

has been offered since the early 1950s. The Ministry of Health has clearly identified this as a major

issue and facilities have been made available throughout the country. When a pregnant woman

gets registered for antenatal care in the public health services, VDRL testing is offered as a routine

screening test.

The majority of the tests are arranged through sexually transmitted disease (STD) clinic laboratory

services. Pregnant women who access services in the private sector get VDRL screening done through

private services. At the central level, the major institutions responsible for maternal and child health

(MCH) work closely with the National STD/AIDS Control Programme. The Family Health Bureau, which

is responsible for MCH services, emphasizes the importance of carrying out antenatal screening in

their regular training programmes and reviews. Links have been developed between the primary

health-care level and the district STD clinic through the provincial team, which consists of provincial

authorities, including the medical officers of the MCH and district STD clinic. The staff at the STD clinic

consists of both a clinical and public health team to work on prevention, which includes the antenatal

VDRL screening programme.

When pregnant women with positive non-treponemal (VDRL) tests are referred to the STD clinic, repeat

testing is done with specific treponemal tests to confirm the diagnosis. Pregnant women confirmed

to be having syphilis are given appropriate treatment, preferably with penicillin. After completion of

treatment, the pregnant woman is followed up regularly till delivery and partner treatment is also

completed during this period to prevent repeat infections. The obstetrician responsible for the delivery

is informed of the management of the mother, and need for testing and provision of prophylactic

penicillin injections for the baby. Irrespective of the mother’s treatment, all babies born to mothers

with positive treponemal tests are given prophylactic penicillin. If CS cannot be excluded, babies are

admitted to the paediatric ward for daily penicillin injections for 10 days.

Smooth functioning of the programme depends on the involvement of several stakeholders. While

MCH staff is responsible for collecting blood samples from pregnant mothers and delivering these

samples to the laboratories, the STD clinic provides testing facilities and further management of

mothers with syphilis. The link between the units is maintained through regular reviews and in-

service training. Continuing advocacy among key players, including the authorities, is also an essential

component of the programme.

Source: Case study, WHO Regional Office for South-East Asia (unpublished document)


33


Antimicrobial resistance (AMR) to gonorrhoeal infection: optimum treatment of Neissseria gonorrhoeae infection is necessary to

achieveamicrobiologicalcure,relieffromsignsandsymptomsofinfection,

andpreventseriouscomplications.Fromtheavailabledata,itisapparentthat

AMRtogonorrhoealinfectionisincreasing,causingtreatmentfailurewiththe

drugscurrentlyusedforitstreatmentintheRegion.Areviewoftheliterature

onthestatusofAMRintheSouth-EastAsiaRegionwasundertakenin2011:4

resistancetociprofloxacinwas83%inIndia(2008),76%inSriLanka(2008),

87% in Bangladesh (2006) and 76% in Thailand (2008). In India, 35% of

organismswerepenicillinase-producingN. gonorrhoeae strains(2008),inSri

Lanka53%(2008),inBangaldesh44%(2006)andinThailand81%(2008).

Challenges: effective prevention of STIs depends on a combination ofstrategies that include the prevention of infection, and diagnosis and care

for those infected. Almost all Member States in the Region have national

guidelines for the management of STIs based on either syndromic or

etiologicalmanagementorboth.Alargeproportionofpatientspreferprivate

practitionersforaddressingSTIs.Overtheyears,MemberStateshavescaled

up treatment and care activities for STIs focusing on key populations by

encouraging theparticipationofNGOsand involvementofprivatedoctors.

A sustained response, however, is challenged by inadequate participation

andcompliancebytheprivatesectorforreportingandadheringtostandard

treatmentguidelines,lackoflaboratorycapacityfordiagnosisatdecentralized

reportingcentres,andinadequateregularmonitoringandevaluation.

Meeting challenges to the STI programme in India

The National AIDS Control Organization (NACO) of India has taken strong initiatives to strengthen the

various challenges to the STI programme through a public health approach. Services for STIs have

been expanded across the country through the establishment of 1112 designated STI clinics in district

hospitals, to ensure minimum quality treatment and counselling. Fear and stigma of visiting such

centres are being addressed through various communication channels. Seven regional STI training,

reference and research centres have been strengthened; these are linked to 45 state reference centres

and in turn to STI clinics.


34


References 1. AIDSinfoOnlineDatabase[webpage].(http://www.aidsinfoonline.org/devinfo/libraries/

aspx/Home.aspx,accessed30October2014).

2. HIV andAIDS data hub forAsia–Pacific. Evidence to action [web page]. (http://www.aidsdatahub.org/,accessed28October2014).

3. Theglobal eliminationof congenital syphilis: rationale and strategy for action.Geneva:WorldHealthOrganization;2007(http://www.who.int/reproductivehealth/publications/rtis/9789241595858/en/,accessed29October2014).

4. BalaM.Antimicrobial resistance inNeisseriagonorrhoeae inSouth-EastAsia.RegionalHealth Forum. 2011; 15 (1):63–73. (http://www.searo.who.int/publications/journals/regional_health_forum/media/2011/V15n1/rhfv15n1p63.pdf,accessed29October2014).

Meeting challenges to the STI programme in India (continued)

They provide etiological diagnosis, validate syndromic diagnosis, monitor drug resistance to gonococci and implement quality control for syphilis testing. To reach beyond the district-level hospitals, programme planning and implementation have been converged under the National Rural Health Mission (NRHM), which enables joint planning and reviews of the national operational framework for delivery of services for sexually transmitted and reproductive tract infections (STI/RTI) at the level of subdistrict health facilities. It also provides colour-coded STI drugs at primary and community health centres, training of medical and paramedical staff, and auxiliary nurse midwives. Monthly reports on STI/RTI indicators are reported from these facilities in the existing management information system of NACO. As a result of this initiative, a total of 2.5 million episodes of STI/RTI were treated at subdistrict health facilities between April and December 2012.

In recognition of the fact that reaching out to the maximum number of people suffering from STI/RTI is not possible without the private sector, NACO partnered with professional associations and ministries such as railways and defence to support the delivery of STI services. For key populations, the preferred private provider approach was rolled out, resulting in about 2.3 million visits by key populations during 2012–2013.

Source: Annual report 2012–13. New Delhi: National AIDS Control Organization, Department of AIDS Control, Ministry of Health and Family Welfare, Government of India; 2012–13.


35

HIVtestingandcounsellingservicesaretheentrypointintothehealthsystem

forHIVpreventionandcareservices.MemberStatesaremakingefforts to

scaleupHTC,butgapsremain.In2013,around14.5millionpeoplereceived

HTC in theRegion, comparedwith20.7million in2012,anapproximately

30% fall.1,2 The reasons behind this fall need to be further explored, but

highlightthegapsandbottlenecksinprovidingHTCservicesintheRegion.

Thenumberoftestsper1000adultpopulationwasthehighestinIndiaand

Thailand(eachat20),followedbySriLanka,NepalandMyanmar(14,13and

11,respectively),Indonesia(1.9)andBangladesh(0.3).1,2

As South-East Asia has a concentrated HIV epidemic, policies and

guidelines recommend that HTC services should cover key populations in

particular.Approximatelyhalfofthekeypopulations(PWID,MSMandsex

workers)receivedHTC,asdeterminedandreportedbysurveillancesurveys

(Figure26).Therearesignificantvariationsamongthesekeypopulationsas

wellwithinandamongMemberStates.

Figure 26: Percentage of key populations receiving HIV testing and counselling in South-East Asia Region countries, 2011–2013

0

10

20

30

40

50

60

70

80

90

100

Bangladesh 2011+2013

Bhutan 2011

India 2013

Indonesia 2011

Myanmar 2011

Nepal 2011

Thailand 2012

Timor-Leste 2011

Perc

enta

ge o

f key

pop

ulati

ons

test

ed

PWID

SW

MSM

Data source: UNAIDS, WHO. GARPR, 2012–2014


HIV testing and counselling


36


References1. UNAIDS/UNICEF/WHO.GlobalAIDSresponseprogressreporting2013:constructionof

coreindicatorsformonitoringthe2011UNPoliticalDeclarationonHIV/AIDS.Geneva:UNAIDS;2013(http://www.unaids.org/en/media/unaids/contentassets/documents/document/2013/GARPR_2013_guidelines_en.pdf,accessed02November2014).

2. UNAIDS/UNICEF/WHO.GlobalAIDSresponseprogressreporting2014:constructionofcoreindicatorsformonitoringthe2011UNPoliticalDeclarationonHIV/AIDS.Geneva:UNAIDS;2014(http://www.unaids.org/en/media/unaids/contentassets/documents/document/2014/GARPR_2014_guidelines_en.pdf,accessed02November2014).


37

ItispossibletostopnewHIVinfectionsamongchildrenandkeeptheirmothers

aliveifpregnantwomenlivingwithHIVandtheirchildrenhavetimelyaccess

toqualitylife-savingARVdrugs—fortheirownhealthorasaprophylaxisto

stop HIV transmission during pregnancy, delivery and breastfeeding. The

JointUnitedNationsProgrammeonHIV/AIDS(UNAIDS)GlobalPlan20111

provided the foundation for countries tomove towards the elimination of

newHIV infections among children by 2015 and keep theirmothers alive.

TheGlobalPlan1coversalllow-andmiddle-incomecountriesbutfocuseson

22 countries that have the highest estimated numbers of pregnantwomen

livingwithHIV.These comprise almost 90%of all pregnantwomen living

withHIVglobally;withIndiabeingtheonlycountryfromtheSouth-EastAsia

Region.1WHO’sRegionalHealthSectorStrategyforSouth-EastAsia2callsfor

dualeliminationofmother-to-childtransmissionofHIVandsyphilis.Thisis

basedonthesimilaritiesbetweenvertical transmissionofHIVandsyphilis

prevention strategies. Reproductive health services are the most common

entrypointtothehealthsystemforthemotherandherchildren.Women’s

access to HIV prevention, testing and referral services depend upon basic

improvement inmaternal,newbornandchildhealth (MNCH)servicesand

theextentofintegrationofHTCservicesinMNCHcare.Strengtheningand

monitoring linkages of HIV services for pregnant womenwithHIVwould

furtherensurethatHIV-infectedwomenandtheirchildrenarelinkedtoHIV

treatmentandcareservices.

Coverage of HIV testing among pregnant women:accessandutilization of ANC services by pregnant women is the entry point for the

prevention and treatment of HIV as well as syphilis. Retention along the

continuumof care through the periods of delivery andpostpartum further

provide an opportunity to initiate prophylaxis for the prevention and


Prevention of mother-to-child transmission of HIV


38


treatmentofHIVandsyphilisamongexposed infants.Ensuringdeliveryof

care to pregnantwomen and their infants at each point of contact is thus

crucial. The overall proportion of pregnantwomen attendingANC at least

onceisover90%,rangingfrom35%to100%.In2013,however,onlyaround

10millionpregnantwomen(aroundonefourth)receivedHIVtestinginthe

Region,mostlythroughANCservicedeliverypoints(Figure27).Thisdenotes

amajorgapandvariationacrossMemberStatesincoverageofHTCamong

pregnantwomen.

Figure 27: Proportion of ANC attendees who received HIV testing, South-East Asia Region, 2013

0

10

20

30

40

50

60

70

80

90

100100% 100%

Thailand

70%

46%

Myanmar

97%

31%

India

100%

18%

Nepal

35%32%

Timor Leste

95%

9%

Sri Lanka

98%

2%

Indonesia

71%

0%

Bangladesh

Perc

enta

ge o

f pre

gnan

t wom

en a

tten

ding

AN

C se

rvic

es

Attended ANC at least once (out of Estimated number of pregnant women)

Received HIV test (out of those attending ANC at least once)


Between 2009 and 2012, coverage rates forHTC among pregnant women

increasedfrom18%to25%.3MemberStatesareassessingvariousstrategies

to address these gaps in coverage. For example,NACOof India is piloting

a community-based HIV screening initiative, where pregnant women who

aretestedduringlabouratthesefacilitieswillbetestedforHIVusingblood


39

Health sector response to the HIV epidemic: Prevention of mother-to-child transmission of HIV

from a finger prick and linked with treatment services. Couple-oriented

HTC initiatives have been taken up in India and Thailand to improve

maleparticipation.

Antiretrovirals for HIV-positive pregnant women: accordingtoWHO’s2013HIVtreatmentrecommendations,allpregnantwomenwithHIV

shouldreceiveARVdrugs;eitherARTforlife,ifeligible,orcombinedARVs

forprophylaxistoreduceHIVtransmission.Thoughsomeprogresshasbeen

made, the estimated ARV coverage among pregnant women infected with

HIVremainsrelativelylowat26%(19–31%)intheSouth-EastAsiaRegion,

ascomparedwiththeglobalcoverageof67%.4However,somecountriesin

theRegionhaveperformedwellinprovidingPMTCTservices.Forexample,

ThailandhasachievedPMTCTcoverageof95%,followedby72%inMyanmar

in2013.Ontheotherhand,thecoverageofPMTCTservicesis18%inIndia,

and9%inIndonesia(Figure28).

Figure 28: Proportion of HIV-positive women who received ARVs, South-East Asia Region, 2013

6155

4843

3066

1551

120 18

18%

95%

72%

9%

27%

13%

0

10

20

30

40

50

60

70

80

90

100

0

1000

2000

3000

4000

5000

6000

7000

India Thailand Myanmar Indonesia Nepal Bangladesh

Num

ber

of w

omen

rea

ched

by

PMTC

T se

rvic

es

Perc

enta

ge o

f wom

en r

each

ed b

y PM

TCT

serv

ices

Data source: WHO, UNAIDS. GARPR, 2014


40


Early infant diagnosis (EID) of HIV: the progression of HIV israpid in children. Infants infectedwithHIV during pregnancy, delivery or

early postpartum often die before the infection can be recognized. WHO

recommends that national programmes establish the capacity to provide

earlypolymerasechainreaction(PCR)-basedvirologicaltestingofinfantsfor

HIVatsixweeksofageorassoonaspossiblethereafter.Thiswillhelpearly

identificationofinfectedchildrenandlinkthemtoHIVtreatment,careand

support services.Out of thefivehighHIV-burden countries in theRegion,

IndiaandThailandhavewideravailabilityoffacilitiesforEID,buttheyare

stilllimitedinIndonesia,MyanmarandNepal.In2012–2013,theestimated

coverage of EID was still limited (<20%) at the Regional level. However,

the coverage of EID reached 78% in Thailand in 2013. The availability of

specialized laboratory infrastructure, logistics management, internal and

externalqualityassuranceofthelaboratory,andskilledhumanresourcesto

beabletoundertakecomplexPCRmethodsarecrucialfortheestablishment

andscaleupofEIDservices.Ensuringacountrywidescaleupisachallenge

fornationalprogrammes.Transportandmanagementofplasmaspecimens

fromremoteareastotheEIDlaboratoriesposesanotherimportantchallenge.

Theuseofdriedbloodspots(DBS)permitsbloodsamplestobecollectedin

remote locationsandallowscountrieswitha limitednumberofspecialized

laboratoriestoexpandaccesstovirologicaltesting.

Indiahasplansforaphasednationwideroll-outtoensuretheavailabilityand

accessibilityofHIVtestingbyDNAPCRtestsforchildrenbelow18months.

Thiswill be conductedat all the integrated counsellingand testing centres

usingDBSandatalltheARTcentresusingwholebloodsamples.5

Antiretroviral prophylaxis for infants: theriskofmother-to-childtransmission can be significantly reduced by the complementary strategies

of providing ARV drugs (as treatment or as prophylaxis) for the mother

duringpregnancy anddelivery,withARVprophylaxis for the infant,ARVs

to the mother during breastfeeding (if breastfeeding), and use of safe

delivery practices and safer infant feeding. From the available data from

select Member States in the South-East Asia Region, out of an estimated

43918 HIV-positive women giving birth, a total of 21505 (49%) infants


41


received ARV prophylaxis to reduce earlyMTCT (i.e. early postpartum, in

thefirstsixweeks)(Figure29).AmongthehighHIV-burdencountriesofthis

Region,thecoveragelevelvariedfrom12%inNepalto98%inThailand.

Figure 29: Proportion of infants born to HIV-positive mothers who received ARV prophylaxis within six weeks of birth, South-East Asia Region, 2012

39%

98%

87%

12%6%

100%34 382

4 923 3 591

933 85 4 0

20

40

60

80

100

120

-

5 000

10 000

15 000

20 000

25 000

30 000

35 000

40 000

India Thailand Myanmar Nepal Sri Lanka Timor-Leste

Perc

enta

ge in

fant

s re

ceiv

ing

ARV

Estim

ated

num

ber

of H

IV +

pre

gnan

t w

omen

Percentage of infants born to HIV+ mothers, receiving ARV prophylaxis in first 6 weeks

Estimated number of HIV-infected pregnant women giving birth


Challenges:nationwideprogrammesforPMTCTofHIVinfection,whichinclude HIV prevention, HTC, HIV treatment for women and infants,

postpartumfollowupandinfantfeeding,andfamilyplanning,havetheirown

barriers to successful scaleup.Optimumutilizationof services isadversely

affected by stigma,need for frequent visits, reluctance to initiateARVand

fearoflackofconfidentiality.HIVpreventionandtreatmentformothersand

children, rather than being perinatal interventions, need to be considered

asanopportunityforengagementofalongercontinuumofcare.Oneofthe

important challenges is theconspicuousgap incoverageofHIV testing for

pregnantwomen.AcrossMemberStates,whilemanywomencomeforANC,

exceptinThailand,notallofthemgettestedforHIV(seeFigure27).


42


ForpregnantwomendetectedtobeHIVpositiveduringthecourseoftheir

pregnancyordelivery,thesecondimportantpointofattritionisatthestage

ofreceivingARVs.ThereisalargegapincoverageofARVsforHIV-positive

pregnantwomeninthethreehighHIV-burdencountries in theSouth-East

AsiaRegion;India,IndonesiaandNepal(seeFigure28).Coverageofservices

forEIDislowinmostofthecountries.In2012,EIDwasreceivedbyonly39%

ofinfantsborntomotherswhotestedHIVpositiveinIndia,whileinThailand,

98%ofHIV-exposedinfantsreceivedEID(Figure29).

ThePMTCTprogramme inThailandhas extensively focusedon improving

thecapacityforHTCatalltiersofthehealth-caresystem,fromthesubdistrict

to the regional level, along with ensuring confidentiality of patient-related

informationandlaboratoryresults.AstudyinaruralsettinginIndiaassessed

a simultaneous triple point-of-care (POC) screening strategy for syphilis,

hepatitisBandHIV6amongpregnantwomen;itfoundthatthemethodwas

feasibleinaruralsettingandwasacceptedbyallstudyparticipants.

Significanteffortsare thus required to reduceattritionat eachstepofHIV

careservicedelivery.StrengtheningthelinkagebetweenMNCHcarefacilities

andfacilitiesprovidingEIDandARTwouldbefundamentaltopreventsuch

attrition. Addressing loss to follow up would require strong and effective

mechanismsforreferralandentryintotreatmentandcareforinfantsdiagnosed

withHIV,aswellasfortheirmotherswhorequiretreatmentafterpregnancy

andbreastfeeding.Greatercommunityengagementandotherhealthservice

deliveryandprogrammemonitoring forHIVwillalsobe required.Women

livingwithHIVmustalsohaveaccesstofamilyplanningservicestobeableto

avoidunwantedpregnancies.


43


Initiatives to scale up PMTCT at the subdistrict level in India

About 71% of the total estimated HIV-positive pregnant women in the South-East Asia Region reside in India. Hence, reaching regional targets for universal access will depend on increasing coverage in India. In 2012, 13 206 (35%) of the estimated HIV-positive pregnant women received ARV prophylaxis in India. Bridging the gap between the estimated number of pregnant women who need PMTCT services and the women actually detected by the PMTCT programme is a key challenge. Overall, out of the estimated 29 million pregnancies in India, more than 90% availed antenatal care at least once (in 2012), of which only 28% were counselled and tested for HIV. One of the important reasons for this large gap in HIV testing of pregnant women is inadequate service delivery at the subdistrict and block levels.

To address this gap, NACO under the National Strategic Plan for PMTCT, plans to expand HTC at the subdistrict level through “stand-alone” HTC centres at all community health centres (CHC), especially in high-focus districts. Service delivery points below CHCs are to be covered by the establishment of “facility-integrated” HTC centres. Under this model, staff from existing health facilities will be trained in counselling and testing, and service delivery will be ensured with logistical support from NACO. Ensuring service delivery at such a scale at the subdistrict level would involve consideration for human resource availability and laboratory facilities.

According to the Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection,7 India has opted for option B of the multiple drug regimen. This regimen has been successfully launched in the two high HIV-prevalence states of Andhra Pradesh and Karnataka since September 2012. A nationwide launch is planned in a phased manner. However, linking HIV-positive pregnant women to care and treatment is a challenge. A review of studies in India on the uptake of services in the PMTCT cascade found a mean ARV uptake (of mothers) of 46%, within a range of 9–84%.8

Recent programme data (January–June 2013) showed that 84%, 96% and 96% in Karnataka, Andhra Pradesh and Tamil Nadu, respectively, of women detected to be HIV positive in the PMTCT programme were linked to ART centres. Coverage of EID among infants born to HIV-positive mothers is challenged by the infrastructural set-up, as well as their linkage to care and follow up post delivery. A total of 5901 HIV-exposed infants received EID at two months after birth in 2012, out of the estimated 38 202 women requiring PMTCT. Early HIV virological


44


References 1. GlobalplantowardstheeliminationofnewHIVinfectionsamongchildrenby2015and

keepingtheirmothersalive2011–2015.Geneva:UNAIDS;2011(http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/20110609_jc2137_global-plan-elimination-hiv-children_en.pdf,accessed29October2014).

2. RegionalhealthsectorstrategyonHIV,2011–2015.NewDelhi:WorldHealthOrganizationRegional Office for South-East Asia; 2012 (http://www.searo.who.int/entity/hiv/documents/SEA_AIDS_187/en/index.html,accessed29October2014).

3. HIV/AIDSintheSouth-EastAsiaRegion:progressreport2012.NewDelhi:WorldHealthOrganizationRegionalOffice for South-EastAsia; 2012 (www.searo.who.int/entity/hiv/documents/hiv-aids_in_south-east_asia.pdf,accessed29October2014).

4. Global report: UNAIDS report on the global AIDS epidemic 2013. Geneva: UNAIDS;2013 (http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf, accessed 29 October2014).

5. NationalAIDSControlOrganization.Annualreport2012–13.NewDelhi:NationalAIDSControlOrganization,DepartmentofAIDSControl,MinistryofHealth&FamilyWelfare,GovernmentofIndia;2013.

6. PaiNP,KurjiJ,SingamA,BarickR,JafariY,KleinMB,etal.Simultaneoustriplepoint-of-caretestingforHIV,syphilisandhepatitisBvirustopreventmother-to-childtransmissioninIndia.IntJSTDAIDS.2012;23(5):319–24.

7. ConsolidatedguidelinesontheuseofantiretroviraldrugsfortreatingandpreventingHIVinfection: recommendations for apublichealthapproach.Geneva:WHO;2013 (http://www.who.int/hiv/pub/guidelines/arv2013/en/,accessed02November2014).

8. DarakS,PanditraoM,ParchureR,KulkarniV,KulkarniS,JanssenF.Systematicreviewofpublichealthresearchonpreventionofmother-to-childtransmissionofHIVinIndiawithfocusonprovisionandutilizationofcascadeofPMTCTservices.BMCPublicHealth.2012;12:320.

Initiatives to scale up PMTCT at the subdistrict level in India (continued)

testing of HIV-exposed infants aged two months or less is critical for appropriate follow-up care and treatment.

To enhance the coverage of early diagnosis of HIV-exposed infants, NACO plans to provide access to EID services at all the “stand-alone” HTC centres. Effective referral linkages between service delivery points, HTC centres, laboratories, ART centres and EID facilities are also planned.

Source: Annual report 2012–13. New Delhi: National AIDS Control Organization, Department of AIDS Control, Ministry of Health and Family Welfare, Government of India; 2012–13.


45

Considerable progress has been made in the South-East Asia Region in

improving access to ART for PLHIV. By the end of 2013, approximately

1100000peoplewerereceivingtreatment.Thisisanincreaseof160000over

2012,andtranslatestoamorethantwelvefoldincrease,from83000patients

who were on ART in 2004 (Figure 30). Scaling up the number of health

facilitiesprovidingARTisanimportantfactorthathashelpedinincreasing

accesstoART.BytheendofDecember2013,ARTwasbeingprovidedthrough

morethan2300healthfacilitiesinMemberStatesoftheRegion.Mostofthese

ARTcentreswerepartofthegovernmenthealthfacilities.Decentralizationof

ARTservicesatthedistrictorsubdistrictlevelswasanotherimportantfactor

thatfacilitatedaccesstoARTforeligiblePLHIV.Availabledisaggregateddata

fromMemberStatesintheRegionsuggestthataround46%ofthosereceiving

ART are women. Children (0–14 years) constitute around 5% of those

ontreatment.1

Coverage of ART:basedonthe2014UNAIDSguidelines,1ARTcoverageis calculated as a percentage of all PLHIV. Globally, the ART coverage is

estimatedat36%(range34–38%);2theoverallcoverageoftreatmentinthe

South-EastAsiaRegionis33%(range:27–39%)(Figure30).2

ThemajorityofpeoplereceivingARTresideinfivehighHIV-burdencountries

– India, Thailand, Myanmar, Indonesia and Nepal. ART coverage varies

widelyamongtheseMemberStates;57%inThailand,36%inIndia,35%in

Myanmar,23%inNepaland8%inIndonesia(Figure31).

Retention on ART: the results of the HIV Prevention Trials Network (HPTN)-052confirmedthatearlierinitiationofARTreducesHIVtransmission

by 96% among discordant couples in a stable relationship.3 The effect of

ARTat thepopulation leveldependson theuptakealong thecascade from

HIVtestingtotreatment,communicationacrossthecascadewithimproved


Antiretroviral therapy


46


Figure 30: Number of HIV-infected people receiving ART among adults and children in the South-East Asia Region, 2003–2013

-

200 000

400 000

600 000

800 000

1 000 000

1 200 000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Num

ber o

n A

RT

Number receiving antiretroviral treatment


Figure 31: Country-wise number of people on ART and estimated ART coverage (based on 2014 UNAIDS and WHO estimates and guidelines), South-East Asia Region, 2013

Data source: UNAIDS, WHO. GARPR 2014

747 175

246 049

67 643 54 144

8 866 1 083 387 60 38 5

36%

57%

35%

8%

23%

11%

18%20% 19%

0

10

20

30

40

50

60

-

100 000

200 000

300 000

400 000

500 000

600 000

700 000

800 000

India Thailand Myanmar Indonesia Nepal Bangladesh Sri Lanka Timor-Leste Bhutan Maldives

Perc

enta

ge A

RT c

over

age

Num

ber

on A

RT

Number on ART Percentage on ART


47

Health sector response to the HIV epidemic: Antiretroviral therapy

monitoringandevaluation,andpreventionandsurveillanceofHIV-DR.The

ARTcascadeconsistsofthefollowingsteps:

— Step1:diagnosingHIVinfection;

— Step2:linkingpeoplewhotakeanHIVtesttotreatmentand

preventionservices;

— Step3:enrollingandretainingpeopleinpre-ARTcare;

— Step4:initiatingART;and

— Step5:ensuringlong-termadherencetoultimatelyachieveandmaintain

viralloadsuppression.4

Impressive ART scale-up efforts in the Region have resulted in significant

improvements in retention among persons receiving therapy (Table 2).

Analyses of national programme data from six Member States indicated

that, of cohorts initiated on first-line ART, the overall 12-month retention

rates in2013weresatisfactoryandcomparablewiththatof2010,andwith

ratesfromotherresource-limitedsettings,rangingfrom79%inSriLankato

93%inBangladesh.Longer-termfollow-upinformationavailablefromsome

MemberStatesindicatedthatretentionratesat24monthsareallover70%.

It is noted that fewer countries are able to report longer-term retention at

60months.1

Country % on ART at 12 months (%)

% on ART at 24 months

% on ART at 60 months

2010 2013 2010 2013 2010 2013

Bangladesh 87 93 88 80 83 68

Indonesia 70 NA 62 NA NA NA

Myanmar 89 84 84 80 NA 76

Nepal NA 86 NA 78 NA NA

Sri Lanka 91 79 92 74 67 83

Thailand 81 83 80 78 NA 76

Table 2: Retention on ART at 12, 24 and 60 months among people on ART, selected countries, South-East Asia Region



48


Tracking information across the ART cascade is still patchy. The recently

publishedresultsofacohortstudy5fromAnantpurdistrictinAndhraPradesh,

India,whichfollowedmorethan7000HIV-positivepeople,reportedthat70%

enteredintocarewithinthreemonths;65%ofpatientswhowerenoteligible

forARTatthefirstassessmentwereretainedinpre-ARTcare;67%ofthose

eligibleinitiatedtreatmentwithinthreemonths;30%ofpatientswhoinitiated

ARTdiedorwerelosttofollowup,and82%achievedvirologicalsuppression

asseenbythelastviralloadresults.Mostoftheattritionoccurredinthepre-

ARTstagesofcare.Itwasestimatedthatonly31%ofpatientsdiagnosedwith

HIVandengagedincareachievedvirologicalsuppression.5

Antiretroviral drugs for children (0–14 years): In2013,atotalof54098childrenaged0–14yearsofagewerereportedlyonARTintheSouth-

EastAsiaRegion.Amongthese,41636(77%)were fromIndia, followedby

5142 fromThailand, 4925 fromMyanmar, 1695 from Indonesia, 638 from

Nepal and 60 from Bangladesh. ART coverage among children has been

calculatedasthepercentageonpaediatricARTdividedbythetotalestimated

numberofchildren(0–14years)livingwithHIV.ThepaediatricARTcoverage

intheRegionvaries;rangingfrom62%inThailand,to43%inMyanmar,34%

inNepal,30%inIndia,21%inBangladeshand7%inIndonesia(Figure32).1

Figure 32: Number on ART and coverage among children (0–14 years), selected countries, South-East Asia Region, 2013 Data source: UNAIDS, WHO. GARPR, 2014

21%

30%

7%

43%

34%

62%

0

10

20

30

40

50

60

70

0

5 000

10 000

15 000

20 000

25 000

30 000

35 000

40 000

45 000

Bangladesh India Indonesia Myanmar Nepal Thailand

Perc

enta

ge A

RT c

over

age

Num

ber o

n A

RT

Paediatric ART 2013 Percentage on ART


49


TB/HIV collaborative activities: TBinfectionacceleratesprogressionofHIVinfectiontoAIDSandleadstoearlymortality.Therefore,prevention

ofTB,andearlydetectionandtreatmentofTB/HIVcoinfectionareimportant

toensurereductioninmortality.ThegoalofcollaborativeTB/HIVactivitiesis

todecreasetheburdenofTBandHIVinpeopleatriskoforaffectedbyboth

diseases.AccordingtotheWHOGuidelines,2012,6theobjectivesofTB/HIV

collaborationare:(i)tostrengthenmechanismsforcollaborationbetweenthe

twoprogrammes;(ii)toreducetheburdenofTBinHIV-infectedpeopleand

theirfamiliesbydeliveryoftheThree I’s for HIV/TBthatincludesintensified

case-finding (ICF), isoniazidpreventive therapy (IPT)and infectioncontrol

(IC)atallclinicalencounters;and(iii)toreducetheburdenofHIVinpatients

with presumptive and confirmed TB and their families by providing HIV

Expansion of ART coverage in Myanmar

Since the start of the national ART programme in 2005, Myanmar has made impressive achievements in scaling up ART in the country. In 2013, 67 643 PLHIV, or 35% of the estimated number of PLHIV, were receiving ART, up from 3500 PLHIV on ART in 2005. In 2013, 4925 children (0–14 years) living with HIV were getting treatment.

This achievement is significant, given the limited funding for ARVs until the latter half of the past decade. ART services under the flagship of the National AIDS Programme were introduced with technical and financial support from the Management Sciences for Health Holland (2003), followed by funding support from the Fund for HIV/AIDS in Myanmar, Global Fund Round 3, the Three Diseases Fund from 2005, and accelerated since 2011 with funding from the Global Fund Round 9.

The country plans to attain universal ART coverage for all eligible patients by 2015 through rapid adaptation of the global guidance followed by strategic planning and programming as a key feature of scaling up ART in the country. Further actions are needed in terms of diagnostics and treatment simplification through the use of fixed-dose combination (FDC) drugs and POC tests, decentralization of services and improved quality of care to strengthen the testing–treatment linkage and retention in care.

Source: Case report, WHO Regional Office for South-East Asia (unpublished document)


50


prevention,diagnosisandtreatment.Figure33showstheestimatednumber

ofincidentTBcasesamongPLHIVwhoreceivedtreatmentforbothTBand

HIV in the South-East Asia Region in 2012. In India, NACO has planned

theimplementationofIPTatallARTcentresinthecountry,withroll-outin

2013–2014.7

Figure 33: Coverage of TB/HIV services, South-East Asia Region, 2012

94 000 27 939 18 000 12 900 630 150

27%

15%

24%28%

10%7%

0

20

40

60

80

100

1

10

100

1000

10 000

100 000

India Indonesia Myanmar Thailand Bangladesh Sri Lanka

Perc

enta

ge re

ceiv

ing

trea

tmen

t

Log

scal

e (Estimated

num

bers

)

Estimated number of incident TB cases in people living with HIV

Percentage of estimated HIV-positive incident TB cases that received treatment for both TB and HIV


Challenges: Justaboutathird(33%)ofPLHIVwerereceivingARTby2013in theSouth-EastAsiaRegion.This is lower than theglobalARTcoverage

of 36%.2 This gap in treatment coverage is an obstacle to the success of

thecurrentHIVprogramme.Thereare reasons for thisgap, fromboth the

health sector aswell as the client/patient perspective. Themost important

reason is the limited number of people getting tested for HIV, especially

among key population groups, such as sex workers,MSM, PWID and TG.

DifficultyincreatingeffectivelinkagesbetweenHIVtestingcentresandHIV


51


care at ART centres is still a fundamental issue that will need innovative

approachestosurmount.RetentionofpatientsthroughouttheHIVcareand

treatment continuum ensures an optimal outcome. However, low testing

coverageandattritionatdifferentlevelsofthecarecontinuumcontinuesto

hamper progress. Monitoring of the cascade at the local level will need

strengthening. Effective local solutions will need to be instituted through

linkedoperationalresearch.

IdentifyinginnovativemethodstodecentralizeARTservicesisimportantas

ART services continue to expand. The National HIV Programme of India,

which covers about 66% of the people in need of ART in the South-East

AsiaRegion, initiateddecentralizationofARTservicesthroughcentresthat

could dispense ART drugs once eligibility was ascertained and the patient

wasregisteredforART.Thisinitiativewasbasedontheevidencethatmany

HIV-positivepeoplewhowerestillasymptomaticfailedtoturnupregularly

at the designated ART centres, on account of difficulties in transportation

anddistancetobetravelled.7Thesesubdistrict-levelcentres,presently840in

number,8dispenseARTdrugsandscreenforanyadverseeffect,inwhichcase

thepatientsarereferredtothemainARTcentre.Tofurtherreducethegap,

pre-ARTmanagementhasbeeninitiatedinsomeselectcentres;patientsare

followedupatthesecentrescalled“LinkARTCentre-Plus”tilltheybecome

eligibleforARTorarereferredtoARTcentresforotherreasons.7

Decentralization of ART services provides an opportunity to strengthen

subdistrict-levelhealthsystemsthroughthedevelopmentofhumanresources

andinfrastructure.Oneof the importantconstraintsat thesubdistrict level

istheabsenceofanadequatelaboratoryset-up.POCtestingforHIVcanbe

mostusefulinresource-limitedoroutreachsettingswherethereisalackof

well-trainedlaboratorytechnicians,poorphysicalinfrastructure,extremesof

climateandlackofuninterruptedpowersupply,allofwhichimpacttheuse

oflaboratorytechnologies.8POCtestingforCD4assessmentisanothernovel

option.Studieshave shownPOC tests forCD4countwere able toperform

assessmentforARTeligibilitywithin20minutes9andwereinstrumentalin

reducingattritionbetweenHIV testingandassessment forARTeligibility.9

POCtechnologyformeasuringCD4countiscurrentlystilllimitedintheRegion.


52


Strategies that involve training primary health-care workers to effectively

providefollow-upARTserviceshavebeensuccessfullypilotedintheRegion.10

Experiences from Thailand have demonstrated the importance of a strong

health-care systemand stablehealthworkforce to successfullydecentralize

HIV treatment services.11 Linkagebetween theTBandHIVprogrammes is

crucialforensuringthatTB/HIV-coinfectedpatientsreceivetimelyART.The

linkagetoARTismoreofachallengewhenconsideringthesmallnumberof

ARTcentresincomparisontothehighdensityofTBtreatmentcentres.

Adoption of the new ARV policy in Member States of the South-East Asia Region: WHO has proposed new guidelines for

treatment12thatrecommendedinitiationofHIVtreatmentatCD4countsbelow

500cells/mm3.In2014,all10HIV-affectedcountriesintheRegionadopted

the new CD4 count cut-off.b To reduce HIV transmission to uninfected

partners, from2014, the infectedpartnersof serodiscordantcoupleswould

be provided ART irrespective of CD4 count in Bangladesh, Bhutan, India,

Indonesia, Nepal, Thailand, Sri Lanka and Timor-Leste. Indonesia has a

policyforprovidingARTtoallHIV-positivekeypopulations irrespectiveof

CD4count.ThailandhadrecentlyrolledoutnewguidanceonofferingARTto

allHIV-positivepeopleirrespectiveofCD4levels.

Some of the potential challenges associated with the new treatment

guidelines that expanded eligibility for initiating ART early are as follows:

(1)sustainability–fundingforuniversalaccesstotreatment.However,wider

treatment uptake would ultimately result in longer-term savings arising

fromareductionininfections.(2)HIV drug resistance–theoverallimpact

ofexpandingtreatmenteligibilityontheriskofdrugresistance isexpected

tobecruciallydependentontheviralsuppressionachieved,whichinturnis

affectedbypatternsofadherence.13Monitoringandsupportingadherenceto

treatmentisthereforecritical.(3)Logistics management–structuralfactors

thataffectadherencetoARTincludetreatmentdisruptionstoregimens,often

causedbydrugstock-outs14duetoinadequateforecasting,poortransportation

orinventorymanagementsystems,orlackoftrainedprofessionalstodeliver

treatment,careandmonitoring.

bCountryreportstoWHORegionalOfficeforSouth-EastAsia


53


References1. UNAIDS,UNICEF,WHO.GlobalAIDSresponseprogressreporting2014:constructionof

coreindicatorsformonitoringthe2011UnitedNationsPoliticalDeclarationonHIVandAIDS.Geneva:UNAIDS;2014(http://www.unaids.org/en/media/unaids/contentassets/documents/document/2014/GARPR_2014_guidelines_en.pdf,accessed29october2014).

2. Global update on the health sector response to HIV, 2014. Geneva: World HealthOrganization,2014 (http://www.who.int/hiv/pub/progressreports/update2014/en/,accessed02November2014).

3. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N,et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med.2011;365(6):493–505.

Targeting universal coverage with ART by 2015 in Nepal

The ART programme in Nepal started in 2004 with two centres. In 2005, 522 PLHIV were on ART, which increased to nearly 10 000 by 2013. This was an almost 20-fold increase in a decade. The National Investment Plan of Nepal (2013) has targeted provision of ART to 15 000 PLHIV by 2015. As of 2012, there are 44 sites providing ARVs, located in the districts with a large number of PLHIV.

Reasons for the success in up scaling ART in Nepal: these include political commitment, partners’ support, adaptation of WHO recommendations, use of FDCs since 2009; enhanced capacity of health staff in clinical management and counselling; increased supply of CD4 machines to clinics (currently, there are 19 ART sites equipped with CD4 machines); establishment of HTC sites targeting key populations – FSWs, MSM, PWID and migrants; uninterrupted supply of ARVs to sites and building the confidence of PLHIV; and implementation of TB/HIV collaborative activities. One innovative approach that contributed to increasing the uptake of ART was the involvement of key populations in various aspects of planning and implementing ART services at different levels, such as establishing social care units at ART sites with the engagement of PLHIV, who advocated positive prevention, traced those lost to follow up, and conducted adherence counselling for treatment.

Expansion of ART services not only contributed to HIV control activities, but also strengthened the national and district health systems in laboratory and logistical management by provision of equipment and additional cold room facilities.

Source: Case report. WHO Regional Office for South-East Asia (unpublished document)


54


4. WHO/UNICEF/UNAIDS. Global update on HIV treatment 2013: results, impact andopportunities. June 2013.Geneva:WorldHealthOrganization; 2013 (http://www.who.int/iris/bitstream/10665/85326/1/9789241505734_eng.pdf, accessed 02 November2014).

5. Alvarez-UriaG,PakamR,MiddeM,NaikPK.Entry,retention,andvirologicalsuppressionin an HIV cohort study in India: description of the cascade of care and implicationsfor reducing HIV-related mortality in low- and middle-income countries. InterdiscipPerspect Infect Dis. 2013;2013:384805 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3723357/,accessed02November2014).

6. WHOpolicyoncollaborativeTB/HIVactivities:guidelinesfornationalprogrammesandotherstakeholders.Geneva:WorldHealthOrganization;2012(http://whqlibdoc.who.int/publications/2012/9789241503006_eng.pdf,accessed02November2014).

7. AnnualReport2012–13.NewDelhi:NationalAIDSControlOrganization,DepartmentofAIDSControl,MinistryofHealth&FamilyWelfare,GovernmentofIndia;2013.

8. AroraDR,MaheshwariM,AroraB.Rapidpoint-of-caretestingfordetectionofHIVandclinicalmonitoring.ISRNAIDS.2013;2013:287269(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3767371/,accessed02November2014).

9. PattenGE,WilkinsonL,ConradieK,IsaakidisP,HarriesAD,EdgintonME,etal.ImpactonARTinitiationofpoint-of-careCD4testingatHIVdiagnosisamongHIV-positiveyouthinKhayelitsha,SouthAfrica.JIntAIDSSoc.2013;16(1):18518(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3702919/,accessed02November2014).

10.Chan P, Karthikeyan K, Stephen J, Ramesh N, Palicheralu B, Swaminathan S. WHOIntegratedManagementofAdultandAdolescentIllness(IMAI)packageforHIVcarehelpsstrengthenprimaryhealth systems in twohighHIVburdendistricts of southern India.[abstractWEPE0087].MexicoCity,Mexico;2008.

11. ChasombatS,McConnellMS,SiangphoeU,YuktanontP,JirawattanapisalT,FoxK,etal.NationalexpansionofantiretroviraltreatmentinThailand,2000–2007:programscale-upandpatientoutcomes.JAcquirImmuneDeficSyndr.2009;50(5):506–12.

12. Consolidated guidelines on the use of antiretroviral drugs for treating and preventingHIV infection. Recommendations for a public health approach. Geneva:World HealthOrganization;June2013.

13. CelumC,Hallett TB, Baeten JM.HIV-1 preventionwith ART and PrEP:mathematicalmodeling insights into resistance, effectiveness, and public health impact. J InfectDis.2013;208(2):189–91.

14. Pasquet A, Messou E, Gabillard D, Minga A, Depoulosky A, Deuffic-Burban S, et al.Impactofdrugstock-outsondeathandretentiontocareamongHIV-infectedpatientsoncombinationantiretroviraltherapyinAbidjan,Coted’Ivoire.PLoSONE.2010;5(10):e13414(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2955519/,accessed02November2014).


55

Data triangulation and contextual analysis for programmatic decision-making: given the widely differing characteristics of theepidemics between and within Member States, national responses must

beguidedby the latest factson thenatureof the respectiveHIVepidemic.

To ensure an effective health sector response despite resource constraints,

decision-makersfornationalHIVprogrammesshouldbeequippedwiththe

necessaryinformationtobeabletoprioritizeandmakeaninformeddecision.

Thisinformationset,termed“strategicinformation”,wouldbasicallyprovide

insightonthecurrentstateandtrendof theHIVepidemicbygeographical

areas and population groups affected; factors that drive the epidemic in a

givengeographicalarea,includingthepresenceandsizeofkeypopulations,

statusofSTIs,riskbehaviours;specialfactorsthatdrivetheepidemicbutare

contextualtothegeographicallocation;andstatusofprogrammeresponses,

including infrastructural and human resource information. Based on this

set of information, a gapanalysis ofprogramme response and information

wouldberequiredtohelpstrategizethedecisiontaken.Triangulationofdata,

i.e. collective interpretation of all the data elements,would further aid the

decision-makingprocess.

Programme monitoring: regular monitoring of programme data isimportantfortrackingthestatusofservicedeliveryofallcomponentsofthe

nationalHIV programme.Monitoring of the cascade of continuumof care

in PMTCT should be able to quantify, by geographical location, the losses

happeningatvariousnodes,namely:HIV-positivepregnantwomen—blood

drawn for CD4 count, received test results of CD4 count, did not initiate

treatmentorprophylaxis,delivery,infanttestedatsixweeks,infanttestedat

18months.TheunmetneedforARVdrugsforPMTCTshouldbemonitored

regularly,disaggregatedbygeographicalarea.Asseen fromareviewof the

55

Strategic information


56


2013dataintheSouth-EastAsiaRegion(Figures27–29),largegapsexistin

thecoverageofservicesforPMTCTbetweenattendingANCandgettingHIV

tested,diagnosisofHIVpositivityandARV formothers, earlydiagnosisof

infantsandARVprophylaxis for infants (<6weeks). Identificationof these

gapswouldrequireasearchforthecause,whichcouldbeglobalorlocalin

nature.Arecentreviewof individualcomponentsof thePMTCTcascade in

India2highlightedthelackofliterature,therebyindicatingtheneedtotakeup

high-qualityoperationalresearchwithaclearobjectiveofprovidinganswersto

thesequestions.ThecascadeinARTprogrammesshouldfocusupon:person

testedHIVpositive,enrolledinHIVcare(pre-ART);underwentCD4testing

and registered at anART centre.Retention cascade atART centres should

pursuecohortsregisteredatagivenpointoftimeforcontinuingonfirst-line

ART;failureoffirst-lineregimenandlosttofollowupanddeath.3Arecently

publishedWHO guidance document provides a simple yet comprehensive

frameworkforassessing,analysingandpresentingtheHIVcascadeofservices

atthenationalandsubnationallevels.4

NACO of India created a framework to classify and prioritize programmatic attention for HIV prevention and control in the 640-odd districts of the country using strategic information and data triangulation. In addition to the HIV prevalence levels among key populations and ANC attendees, this framework included a third data element on the size of key populations to capture the potential risks of an area, by considering its degree of vulnerability. Multiple data sources for the same information were triangulated, e.g. HIV-positivity rates among key populations from sentinel surveillance and HTC centre data on key populations; HIV-positivity rates among pregnant women; sentinel surveillance among ANC attendees and HTC centre data on pregnant women. As per this classification, as many as 103 districts moved higher in the risk category in the “low”-prevalence states, reflecting increasing vulnerability and emerging epidemics in these districts.

Source: Raj Y, Venkatesh S, Reddy DCS, Haldar P, Thomas M, Bakkali T, et al. Evidence for strategic planning: district re-categorisation through data triangulation as a strategic initiative guiding National AIDS Control Programme Phase-IV in India [Abstract]. In: XIX International AIDS Conference, 22–27 July 2012, Washington, DC, USA. (http://pag.aids2012.org/Abstracts.aspx?AID=17353, accessed 01 November 2014).1

Strengthening strategic information in India


57


Incountriesoptingforthenewguidelinesonexpandedeligibilityforinitiating

ARTamongadults,itwouldbecrucialtomonitorthefollowinginformation:

adversereactions,toxicityaswellascoinfectionsandco-morbidities,failure

onfirst-linetreatment,etc.,whichwouldbeimportantforclinicaldecision-

making; implications of starting early ART on the retention cascade; and

monitoring the number and percentage of different populations (such as

adults, adolescents, children,andpregnantandbreastfeedingwomen)who

have initiatedARTbasedon theneweligibility criteria.Pharmacovigilance

needstobebuiltintoARTprogrammes.IfaMemberStateplansintegration

ofARTserviceswithMCHorTBservices,oriftask-shiftingisbeingplanned

at theARTcentre, suchprogresswouldneed tobemonitored.Operational

monitoringrelatedtolaboratoryanddiagnosticservices,aswellasprocurement

andsupplychainmanagementsystemswouldrequirespecialattention.The

percentageofARTfacilitieswithARVdrugstock-outsinagivenperiodand

reasons thereofwould need to be identified and addressed promptly.New

formatsformonitoringwouldberequiredtoaccommodatethesechanges.c

HIV and STI surveillance: periodic HIV serological and behaviouralsurveillanceisbeingconductedineightMemberStatesoftheSouth-EastAsia

Region.Thiscontinuestogivecrucialinformationonthelevelsandtrendsof

theepidemicbyplaceandpopulationgroups,andalsofeedsintothemodelling

process for HIV estimation. Indonesia, Nepal, Thailand and Timor-Leste

haveconductedIBBS,whileIndia,MyanmarandSriLankaplantoconduct

the survey. Indonesia, Sri Lanka, Thailand and Timor-Leste are currently

conductingSTIsurveillance.dToensurecountry-levelplanningandeffective

localimplementationofSTIservices,reliableandconsistentepidemiological

informationisrequiredonthedistributionofSTIcases,ratesandtrendsof

newlyacquiredinfections,STIprevalenceinspecificpopulationgroupsand

the pattern of antimicrobial resistance.5 Information on STIs are also an

indicationof thesuccessofHIVpreventioneffortsamongkeypopulations,

whichisacriticalstrategyforMemberStatesoftheRegion.

c Detailedinformationcanbeavailedofatwww.who.int/hiv/pub/guidelines/arv2013/annexes.d Source:CountryreportstotheWHORegionalOfficeforSouth-EastAsia


58


HIV drug-resistance surveillance: substantial progress has beenmadeinexpandingsurveillancesystemsforHIV-DRintheRegion.Withthe

expansionoftreatmentinrecentyears,thereisapossibilitythattheprevalence

of transmitted HIV-DRmay have increased (i.e. pre-existing resistance in

thosewhohavenotreceivedARTandthosenewly infected),particularlyto

non-nucleoside reverse transcriptase inhibitors, among recently infected

populations in theareas surveyed. In theSouth-EastAsiaRegion,HIV-DR

thresholdsurveyswerecompletedinthreecountriesbetween2005and2007:

India(2),6Indonesia(1)7andThailand(3);8theseindicatedalowlevel(<5%)

oftransmittedDR,7andthatcurrentlyrecommendedfirst-lineARTregimens

areeffectiveformostpeopleinitiatingtreatment.AsARTcontinuestoberolled

out, theratesof transmittedDRmay increase.Robustsurveillancesystems

must be in place to detect potential future increases in a timely manner.

AccordingtotherecommendationsofrecentWHOguidelines,pre-treatment

andacquiredDRsurveillanceshouldbeprioritizedtoinformtheselectionof

ARTregimensforpeoplestartingtreatment,andthechoiceofsecond-and

third-linetreatmentregimensforpeoplefailingthefirst-lineARTregimen.9

Anotherkeyelementisthecollectionandfollowupofearlywarningindicators

(EWIs)forHIV-DR.Theseindicatorsassessfactorsthatareassociatedwith

determiningpreventableemergenceofHIV-DRatthe levelofARTcentres,

andcanbeactedonattheARTcentreandprogrammelevelforothersuch

typesofcentres.AnationalstrategyforHIV-DRwouldhelpprovidedirection

onthepreventionandassessmentofHIV-DRatthecountrylevel.

References1. Raj Y, Venkatesh S, Reddy DCS, Haldar P, Thomas M, Bakkali T, et al. Evidence for

strategic planning: district re-categorisation through data triangulation as a strategicinitiative guiding National AIDS Control Programme Phase-IV in India [Abstract]. In:XIXInternationalAIDSConference,22–27July2012,Washington,DC,USA(http://pag.aids2012.org/Abstracts.aspx?AID=17353,accessed01November2014).

2. DarakS,PanditraoM,ParchureR,KulkarniV,KulkarniS,JanssenF.Systematicreviewofpublichealthresearchonpreventionofmother-to-childtransmissionofHIVinIndiawithfocusonprovisionandutilizationofcascadeofPMTCTservices.BMCPublicHealth.2012;12:320.

3. Consolidated guidelines on the use of antiretroviral drugs for treating and preventingHIV infection: recommendations for a public health approach. Geneva: World HealthOrganization;2013(http://www.who.int/hiv/pub/guidelines/arv2013/download/en/,accessed01November2014).


59


4. Metrics formonitoring the cascade ofHIV testing, care and treatment services inAsiaand the Pacific. Manila: World Health Organization Regional Office for the Western Pacific; 2014 (http://www.wpro.who.int/hiv/documents/hiv_metrics.pdf, accessed 01November2014).

5. UNAIDS/WHO Working Group on Global HIV/AIDS and STI surveillance. Strategiesand laboratory methods for strengthening surveillance of sexually transmittedinfection 2012. Geneva: World Health Organization; 2012 (http://apps.who.int/iris/bitstream/10665/75729/1/9789241504478_eng.pdf?ua=1,accessed01November2014).

6. Thorat SR, Chaturbhuj DN, Hingankar NK, Chandrasekhar V, Koppada R, Datkar SR,etal.Surveillanceof transmittedHIVtype1drugresistanceamongHIVtype1-positivewomen attending an antenatal clinic in Kakinada, India. AIDS ResHumRetroviruses.2011;27(12):1291–7.

7. WHOHIVdrugresistancereport2012.Geneva:WorldHealthOrganization;2012(http://apps.who.int/iris/bitstream/10665/75183/1/9789241503938_eng.pdf, accessed01November2014).

8. SirivichayakulS,PhanuphakP,PankamT,O-CharoenR,SutherlandD,RuxrungthamK.HIVdrug resistance transmission threshold survey inBangkok,Thailand.AntivirTher.2008;13(Suppl2):109–13.

9. GlobalstrategyforthesurveillanceandmonitoringofHIVdrugresistance2012.Geneva:World Health Organization; 2012 (http://www.who.int/hiv/pub/drugresistance/drug_resistance_strategy/en/,accessed01November2014).


60

KeychallengesinachievinguniversalaccesstoHIVprevention,careand

treatmentservicesintheSouth-EastAsiaRegionincludethefollowing:

• continuingstigmaanddiscriminationagainstPLHIVandkeypopulations

inthesocietyandinthehealthsector;

• limited capacity of health systems, including lack of trained human

resources, inadequate supplies of equipment and/or drugs due to poor

logisticsandsupplychainmanagement,limitedlaboratorycapacity,weak

monitoringandevaluationsystems;

• needforcontinuedfocusandsustainedpoliticalcommitmenttoHIV;and

• limitedresourcesinthefaceofcompetinghealthpriorities.

Key challenges


61

Thefollowingneedtobedonetosustainablyscaleupthehealthsector

responsetoHIVintheSouth-EastAsiaRegion:

1) Designstructural interventions toreducestigmaanddiscrimination in

community and health-care settings, especially for key populations at

higherrisk,andaddress legalbarriersbyrepealingdiscriminativelaws

thathinderaccesstopreventioninterventions.

2) Increase the coverageof and access toHIVprevention, treatment

andcareservicesforwomenandchildrenthroughintegratedandlinked

responseswith sexual, reproductive andMCH services for eliminating

mother-to-childtransmissionofHIVandpreservingthehealthofwomen

andchildren.

3) EnablepeopletoknowtheirHIVstatusbydecentralizingHTCservices.

4) Improve access to and quality of HIV treatment through linkage and

decentralizationtothesubdistrictlevel.

5) Provide support for treatment adherence; ensure regular monitoring

throughEWIstodelaythedevelopmentofHIV-DR.

6) Continue toadvocate for reducing thepriceofARVdrugs through the

useof internationaltreatiesandinstrumentssuchasflexibilities inthe

Trade-RelatedAspectsofInternationalPropertyRights(TRIPs).

7) Support strengthening of health systems to increase the capacity for

implementingandscalingupHIVinterventions.

8) ContinuecommitmenttoandactivecollaborationwithTBprogrammes

toreducetheburdenofTB/HIV.

9) Strengthenstrategicinformationanditsuseforlocaldecision-making.

10) Invest in implementation science research for identifying the best-fit

responsetothelocalcontext.

Future priorities


The health sector has been playing a pivotal role in the national response to HIV of Member States of the South-East Asia Region of WHO. Member States have enormous opportunities, in the context of universal health coverage, to further scale up their responses to HIV with innovative service delivery models, including decentralization of HIV testing and treatment services, and integration of HIV services with maternal, newborn and child health services and tuberculosis control programmes. This report highlights the achievements, factors contributing to the successes and underlines the challenges to sustaining effective responses at the country level.

HealtH Sector reSponSe to HIV in the South-eaSt aSia Region

World Health OrganizationRegional Office for South-East AsiaWorld Health House, Indraprastha EstateMahatma Gandhi MargNew Delhi 110 002, India

www.searo.who.int

ISBN 978 92 9022 470 9

Cover_Health sector response to HIV, SEA 2013.indd 1 11/21/2014 4:38:54 PM

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