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HIV/AIDS in Asia
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Kiat Ruxrungtham, Tim Brown, Praphan Phanuphak
Excerpts from The Lancet July 3, 2004; 364: 69-82
Faculty of Medicine, Chulalongkorn University, the Thai Red Cross AIDS Research Centre and HIV-NAT, Bangkok 10330, Thailand (K Ruxrungtham MD, P Phanuphak MD), and East-West Center/Thai Red Cross Society Collaboration, Bangkok, Thailand (T Brown PhD)
INTRODUCTION. HIV (ie, HIV-1) epidemics in Asia show great diversity, both in severity and timing. But epidemics in Asia are far from over and several countries including China, Indonesia, and Vietnam have growing epidemics. Several factors affect the rate and magnitude of growth of HIV prevalence, but two of the most important are the size of the sex worker population and the frequency with which commercial sex occurs. In view of the present state of knowledge, even countries with low prevalence of infection might still have epidemics affecting a small percentage of the population. Once HIV infection has become established, growing needs for care and treatment are unavoidable and even the so-called prevention-successful countries of Thailand and Cambodia are seeing burgeoning care needs. The manifestations of HIV disease in the region are discussed with the aim of identifying key issues in medical management and care of HIV/AIDS. In particular, issues relevant to developing appropriate highly active antiretroviral treatment programmes in the region are discussed. Although access to antiretroviral therapy is increasing globally, making it work effectively while simultaneously expanding prevention programmes to stem the flow of new infections remains a real challenge in Asia. Genuine political interest and commitment are essential foundations for success, demanding advocacy at all levels to drive policy, mobilise sufficient resources, and take effective action.
Introduction
The extensive spread of HIV started late in Asia, compared with the rest of the world. The earliest cases of AIDS were reported from Asia in 1984 and 1985, but the potential for widespread epidemics was not appreciated until the more extensive spread of HIV in Cambodia, India, Burma, and Thailand in the early 1990s. Unfortunately, the lessons of devastation from AIDS in Africa and the Caribbean went unheeded in much of Asia, and success stories of disease prevention at the national level in the region remain few. This review will highlight the current extent and features of Asian epidemics, discuss growing care needs and the clinical presentations and treatment of HIV in Asia, and briefly discuss a few prevention and care successes in the region to encourage more aggressive action to contain national epidemics and provide appropriate care for the people of Asia.
The past, present, and future of HIV epidemics in Asia
As in many other areas, Asia shows extreme diversity in its HIV epidemics, both geographically and temporally. National adult HIV prevalence varies from near 0% in several countries to almost 3% in Cambodia. But a static map cannot show the time evolution of these epidemics--and therein lie major hints about the future of HIV in the region. Temporally, the countries of Asia can be divided into three categories: (1) those where HIV hit early and hard, and where adult HIV prevalence now exceeds 1%--eg, Cambodia, Burma, Thailand, and some states in India; (2) those currently in transition, with HIV epidemics growing noticeably in the past 5 years--eg, China, Indonesia, Nepal, and Vietnam; and (3) those having very low levels of infection such as: Bangladesh, Laos, the Philippines, and South Korea.
That HIV epidemics in Asia have been driven largely by sex work and injecting drug use is well established. In Asia, they typically follow a chain of transmission, as outlined by Weniger and colleagues. In most places HIV spreads first among injecting drug users, followed by HIV spread among sex workers. Clients of sex workers are the next link in the chain, and they then transmit the virus to their female sexual partners. Most women infected in Asia have been the monogamous wives or regular partners of higher risk men. HIV in children, through maternal infection, represents the final link in the chain.
Moreover, it is becoming clear that men who have sex with men are also contributing substantially to Asian epidemics, although they have been neglected for many years in the response to HIV. Early reported AIDS and HIV cases in many places in the mid to late 1980s were dominated by men who have sex with men, although the trend shifted in the 1990s to heterosexual transmission. In several Asian countries, men who have sex with men continue to play an important part in reported HIV infections--for example, 23% of reported infections in the Philippines up to the end of January, 2004, are attributed to such men (Philippine HIV/AIDS registry), 21% of cases in Korea during the late 1990s were in men who have sex with men, and newly reported infections among such men overtook heterosexual infections in Japan again in 1999 (Japanese surveillance data). These data are now being lent support by results of sero-epidemiological studies. Systematic sampling in Bangkok, Jakarta, and Phnom Penh have shown HIV infection rates of between 2·5% and 22% in men who have sex with men. Behavioural studies around Southeast Asia further verify high risk behaviour among many such men: in Vietnam, only 40% of men having anal sex used a condom at last sexual intercourse; in Beijing, 49% reported unprotected anal intercourse in the previous 6 months; and only 12% of waria (male-to-female transgender) in Indonesia reported consistent condom use in any sex act.
Figure 2 shows the evolution of HIV prevalence in several surveillance sites from countries around the region in female sex workers and injecting drug users. The early and fast growth of the sex work epidemic in Cambodia, parts of India, and Thailand is apparent, whereas those in China, Indonesia, and Vietnam have been substantially delayed and grown more slowly. The epidemic in Bangladesh and the Philippines remains low even now, but recent rises in numbers of injecting drug users in Bangladesh are worrying.
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National HIV epidemics in Asia are composed of many smaller geographically diverse epidemics such as those shown in figure 2, but the large size of many Asian countries, limitations in coverage, and changes over time in surveillance systems often make it difficult to clearly ascertain the overall national situation. For example, in both India and Burma, national surveillance systems include only two sites for sex workers, both in large urban centres, making it difficult to understand what is happening on a national basis. Even within countries substantial variability exists in timing and rate of epidemic growth in at-risk populations. In Yunnan, China, the epidemic among injecting drug users underwent rapid growth in the late 1980s, but in Guangdong this only took place in the late 1990s. In Vietnam, the quick rise of HIV in sex workers in Ho Chi Minh City and Hanoi began in 1997 and 1998 reaching 24% and 15%, respectively by 2002, whereas national rates have grown much more gradually but steadily to more than 5%. But in each case, even if it is happening more slowly than in countries such as Thailand and Cambodia, the chain of transmission is the same, and prevalence of infection in pregnant women in Vietnam tripled from 0·09% in 1998 to 0·28% in 2002.
Since the chain of transmission is generally the same, what are the reasons for this wide variation in the speed of evolution and severity of Asian epidemics? Several factors certainly contribute, including: (1) variations in behavioural factors--eg, the levels of risk behaviour, the frequency of sexual and needle-sharing behaviours, adoption of preventive measures, and variations in the linkage among different at-risk populations across the countries of Asia; (2) geographic and population differences in biological factors including the efficiency of different transmission modes, levels of other HIV-facilitating sexually transmitted infections, and circumcision; and (3) the timing of HIV introduction into populations with high behavioural risk.
The range of variation in these behavioural and biological factors between and within countries can be quite large. For example, the percentage of adult men visiting sex workers in the past year as seen in large-scale surveys varies from 5% in Hong Kong to 9% in China to 22% in Thailand (later reduced to 10% in response to the HIV epidemic). Consistent condom use between direct sex workers and clients, measured by behavioural surveillance, varies widely from lows of 2-3% in Bangladesh to almost 90% in Cambodia (Bangladesh and Cambodia Behavioral Surveillance). And as behavioural surveillance data around the region show, these values are changing over time. But they remain low in many countries in the region including China, Indonesia, and the Philippines. Assessing the HIV potential in every country of Asia needs careful consideration of the combined effect of these various behavioural and biological factors.
Chin and colleagues proposed that the most important of these factors determining the severity of Asian epidemics were the size of the adult male population visiting sex workers and the numbers of sex workers' clients per night. To test this hypothesis, Brown and Peerapatanapokin developed a model that incorporated all of the key factors outlined earlier. Based on a careful analysis of these factors, specific models, taking into account all these factors, were prepared for both Thailand and Cambodia. Starting from observed behavioural trends, these models accurately reproduced 10 years of HIV prevalence trends in the key populations in both countries. This model has been used here to assess the effect of client population size and frequency of commercial sex on the timing and severity of Asian epidemics under the behavioural and epidemiological conditions prevailing in the region.
Figure 3. growth of HIV epidemics in populations with different percentages of men visiting sex workers according to injecting drug use.
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Taking into account the introduction of HIV in 1985, with condom use at last commercial sexual intercourse remaining at the 30% level from 1990 onwards, the results of varying the size of the client population are shown in figure 3. Countries such as Thailand and Cambodia, where 20% of adult males were visiting sex workers in the early 1990s, would see the epidemic take off rapidly in the late 1980s or early 1990s and rise to 15% adult prevalence levels. Other countries such as China or Vietnam, where only 5-10% of men visit sex workers, would not see the epidemic happen until the mid or late 2000s and rise to 3-7% levels in the absence of interventions. Thus, it is not surprising that sex work epidemics in these countries only seem to be growing now. Epidemics in injecting drug users can accelerate the growth of this sex work component of the epidemic if these drug users are clients of sex workers, producing even earlier epidemics in sex workers and clients. Behavioural data from around the regions shows that a substantial proportion of injecting drug users are clients of sex workers.
Why then did Thailand and Cambodia not reach HIV prevalences of 15%? The reason is that they undertook extensive and intensive prevention campaigns with good coverage, which were focused specifically on reducing risk related to sex work in both clients and sex workers. In both countries, condom use between sex workers and clients increased to more than 90%, and the number of men visiting sex workers was halved (from 20% to 10%). As a consequence, adult HIV prevalence peaked at roughly 1·5% in Thailand in 1996 and at 3·3% in Cambodia in 1998. Prevalence is currently falling in both countries, rather than continuing a steady growth to 15% levels. Modelling data in both countries has shown that these prevalence declines are almost entirely linked to the behavioural changes described above.
This result then raises the issue of what is likely to happen in the countries in transition such as China, Indonesia, and Vietnam. In the absence of extensive prevention programmes to reduce HIV transmission in at-risk populations (clients and sex workers, injecting drug users, and men who have sex with men), they might be expected to see steadily climbing HIV prevalence, as in the lower curve of figure 3. In China and Indonesia, consistent condom use between sex workers and clients is essentially steady at 10% to 20% (national behavioural surveillance results), with no substantial increases over the past decade. And in all three countries, surveillance data show continuing epidemics of injecting drug users and growing sex work epidemics in several places.
And what of the countries that still have low prevalence of HIV? Some might continue to have little HIV spread. As figure 3 shows, if a country has only 5% of men visiting sex workers and no epidemic of injecting drug users, prevalence could remain quite low for a long period. But such assumptions about the future should be made with extreme caution. In many countries, knowledge of sex work and injecting risk is poor or is based on small, non-representative samples that are not generalisable. Behaviour might change with time, and an injecting drug population might develop in the future. And in some countries with pockets of high risk, such as Bangladesh, HIV might have only recently have gained a foothold. HIV surveillance in Bangladesh has now detected 4% prevalence in injecting drug users in one site that injecting drug users heavily visit sex workers (40% in the previous month in that site), and the data show many sex workers have four to seven clients per night. That this will remain a low prevalence country is not at all clear.
Unfortunately, the prevention successes of Cambodia and Thailand are not being well replicated in the other countries in Asia. Although there has been some progress, condom use in sex work remains low in many places, coverage of current prevention programmes for at-risk populations is very low (and few data are available for coverage), and low priority is accorded to HIV prevention because prevalence is currently low. Although what works in prevention in low prevalence settings is well known, measures are not being taken.
Failure to undertake early prevention programmes will have financial consequences for countries, especially as the world enters an era in which highly active antiretroviral treatment (HAART) is judged to be a right for people living with HIV. Currently, WHO estimates that 1·1 million Asians are in need of HAART, with only 6-7% having access. Table 1 shows the financial consequences for the five countries with the largest numbers of HIV infections in Asia. If one assumes that 20% of these populations need to be treated with the original brand name NNRTI (non-nucleoside reverse transcriptase inhibitor)-based HAART, the estimated antiretroviral (ARV) cost per year for Thailand and India will be US$241 million and US$1·43 billion, respectively. And yet, most Asian countries are judged to have intermediate income by the World Bank and are thus not eligible for at-cost prices for ARVs from many pharmaceutical companies. Recent progress has been made through production of generics in China, India, and Thailand--eg, the fixed dose combination of stavudine, lamivudine, and nevirapine, which has proven effective. However, good quality assurance programmes, such as that being developed by the Thai Red Cross AIDS Research Centre (TRC-ARC) HIV-NAT (Netherlands, Australia, Thailand) collaboration (pharmacokinetic laboratory), must accompany the development and manufacture of generics.
Table 1: Estimated annual budget to provide HAART in the five Asian countries with more than 100 000 people living with HIV/AIDS
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Est # Cases
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Estimated Budget in US$ million/yr
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generic NNRTI
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Original NNRTI
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PI HAART
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Indonesia
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120,000
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9 million
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43 million
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108 million
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Vietnam
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130,000
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9 million
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47 million
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117 million
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Cambodia
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170,000
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12 million
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61 million
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153 million
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Thailand
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670,000
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48 million
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241 million
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603 million
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India
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3,970,000
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286 million1
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429 million
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3573 million
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Responses to HIV and AIDS in Asia
Moving country responses from denial to action
Many Asian countries have chronically underfunded healthcare systems, overpopulation, high illiteracy rates, weak social safety nets, unwillingness of people to use condoms, governmental prohibition of harm reduction approaches to HIV prevention, and widespread discrimination against those living with and affected by HIV. According to authorities and experts from around the region, these factors contribute to poor or inadequate response to HIV epidemics in their countries.
The initial response in almost every country of Asia was denial, focusing on HIV/AIDS as an imported rather than indigenous disease. Many Asian countries found it extremely difficult to accept that sex work, injecting drug use, and same-sex behaviours existed in their countries, despite the fact that studies showed that from 5% to 20% of men were clients of sex workers. Sex education, condom promotion, and harm reduction for drug users all touched on political and religious sensitivities around the region. In the mid-1980s WHO through its Global Programme on AIDS (GPA) provided extensive financial and technical support for countries in the region to draft short and medium term plans to combat the epidemic. It was this initial global effort that encouraged the development of sentinel surveillance for HIV in southeast Asia.
The systematic and prospective surveillance of HIV in at-risk populations, as done in most Asian countries now, has been a key factor in raising political leaders' awareness and building commitment for HIV prevention and care. When HIV prevalence grows rapidly, as in Thailand and Cambodia, surveillance data alone made the case for urgent action. But when prevalence is still quite low and seems to be growing quite slowly, such data are less compelling and less likely to move decision makers to action. Unless such data are properly interpreted in a local country context with an Asian epidemiological perspective, and are used to advocate for adequate responses and to identify and direct appropriate programmes, it becomes a meaningless exercise in data collection. Unfortunately, despite the high rankings generally accorded Asian surveillance systems,134 significant gaps in coverage of key populations and quality problems remain, and few Asian countries have translated these data into effective prevention programmes, as can be seen by the continuing growth of epidemics throughout the region.
On the other hand, if surveillance data are comprehensive, regularly updated, properly interpreted, and relayed in an understandable form to policymakers, good and non-complacent leaders will take appropriate action, as they did in Cambodia and Thailand. Active use of surveillance data in conjunction with other sources of information, models, and policy analyses can then help to convince both government and civil society of the consequences of action and inaction, and assist in directing the response to achieve the greatest effect. In some other Asian countries response is now happening. Growing prevalence in Vietnam and closer examination of the national epidemic is forcing reconsideration of the unsuccessful social evils approaches of the past. Surveillance data in China have moved leaders to take a more active role, leading to the formation of a high-level national committee for HIV prevention. But in many countries responses remain stalled, and national commitment to addressing the epidemic is weak. Better advocacy based on improved local understanding of the specific epidemiological and behavioural country situation and an understanding of the most urgent local prevention needs is needed to break this complacency.
Lessons learned: effective prevention
Epidemiologically, almost all new HIV infections in Asia take place in those at increased risk (men who have sex with men, injecting drug users, clients, and sex workers), and their immediate longer-term sexual partners. This occurrence means that adequately resourced efforts focused on achieving good coverage in these populations can literally turn epidemics around.
When early epidemiological studies in Thailand and Cambodia showed the key role of sex work and sexually transmitted diseases in HIV transmission, national leaders in both countries quickly stepped up prevention efforts. The Prime Ministers of both countries made HIV/AIDS a national priority. In Thailand, the national HIV/AIDS budget grew from US$0·68 million in 1988, 90% of which came from bilateral donors, to $82 million in 1997, 96% of which came from the Royal Thai Government (the budget was reduced to $35 million in 1998 during the Asian crisis but has been maintained at this level throughout 2002). This budget supported programmes in every government Ministry, by non-governmental organisations (NGOs) and communities, and in the private sector. In Cambodia, international resources were mobilised to fill the needs. Major nationwide prevention programmes were mounted not only for sex workers and brothel owners, but reaching out to the large client population, encouraging condom use in sexual encounters and improving care for sexually transmitted diseases (STDs). The public was widely informed of the risk and educated about HIV and its prevention through extensive and intensive programmes in the media, schools, workplaces, and other venues. In response, condom use rose to more than 90% and the percentage of men visiting sex workers was halved in both countries. Figure 4 shows the benefits from this education in Cambodia--almost a million cumulative infections were averted and prevalence peaked at 3·3% then began to decline. Thailand had similar success, providing valuable lessons about the extreme effectiveness of properly focused and resourced prevention efforts in Asia.
The lessons learned in the successful responses in Cambodia, Thailand, and Uganda all point to the importance of leadership, commitment, and continued effort from all sectors of society, including people living with HIV and AIDS to a successful national response. These lessons have been learnt in other Asian countries. Recent attention by the Chinese leadership to the HIV epidemic, with the formation of a high-level national committee on HIV prevention is likely to galvanise similar responses there. Indonesia and Papua New Guinea have addressed HIV/AIDS as a developmental issue, calling for action and partnership with all civil sectors in the country. Such commitment and coordination will need to be expanded from national levels to provincial and sub-provincial levels. This expansion will be challenging for large countries like China, India, and Pakistan and needs careful planning in the many Asian countries that are now decentralising health services--eg, Indonesia and the Philippines.
But much more prevention coverage is needed in most of Asia, and urgently. Although most Asian countries have lower risk than Cambodia and Thailand, epidemics of 3-5% of adults are possible unless effective prevention efforts are in place. And rates of infection in the countries in transition are likely to accelerate in the near future. Yet, few countries have achieved substantial coverage of client and sex worker populations--in fact, many cannot even estimate the sizes of these populations.
STDs have re-emerged in China as a result of its open-door policy and economic and social reform. Urbanisation, increased spending power, and outside cultural influences are contributing to a rapid increase in STDs and expanding HIV spread. This increase in infection has led some to call for mandatory STD and HIV screening of sex workers, prostitution and pornography bans, and restrictions on the tourist industry. But in the long run, measures such as these will drive prostitution underground and make HIV/STD even more difficult to control. Instead, Asian countries need to learn from one another about what makes for successful HIV prevention.
Successful programmes are those that use NGOs to pilot prevention and care activities, but then collaborate with governmental entities to move them to scale. An example is the collaboration between the International Voluntary Services organisation and the Women's Union of Ho Chi Minh City to provide STD care, education, and services to sex workers or the TRANSSEX project educating transport workers and sex workers to become peer educators for HIV/AIDS and STD prevention. NGOs often have a catalytic role, leading in the development of new services and then fostering their adoption by the government. A good example is the anonymous clinic of the Thai Red Cross Society, which within a year of its opening, successfully lobbied the Thai government to lift the ministerial act requiring all laboratories to report the names and addresses of those with HIV to the Ministry of Public Health, and led to the government implementing voluntary counselling and testing services in every province. But many more such programmes are needed in Asia. HIV services for clients and sex workers remain restricted in most places.
Furthermore, no Asian country has good prevention programmes for men who have sex with men, and there has been strong resistance to adopting proven needle exchange and harm reduction approaches for injecting drug users as national policy. As such, older epidemics in injecting drug users and men who have sex with men continue unabated, potentially fuelling epidemics in sex workers, and new epidemics are arising constantly. As a consequence of this failure to address prevention effectively, HIV continues its march through Asia. Recent epidemic growth in China, India, Indonesia, Nepal, Vietnam and other countries give testimony to this statement.
Lessons learned: antiretroviral therapy in Thailand
Care is generally regarded as the expensive arm of the entire HIV/AIDS prevention and control programme. For countries such as Bangladesh with limited resources and few reported HIV infections, care was completely left out of the National AIDS/STD Program of Bangladesh until 2003. However, once the epidemic is established, the need for treatment and care is unavoidable, and antiretrovirals are now a mainstay of HIV care. Health care infrastructures vary widely across the region, but are weak in many places, limiting many people with HIV/AIDS to palliative care, often at home. Access to HIV testing is limited, and most of these people first learn their HIV status after developing serious symptoms that need medical care. Additionally, strong stigma and discrimination in much of the region keep many from accessing the care they need. The move towards wider antiretroviral access will help, but many barriers first need to be overcome.
One of the few developing countries in the region with much experience with antiretrovirals is Thailand. Thailand has built the medical infrastructure needed to manage and research antiretroviral care for those with HIV and AIDS, which serves as a positive example for other countries. Antiretrovirals have been provided free to poor HIV-positive Thais since 1992, although access was scaled back in 1995 because of growing budgetary demands related to the high costs of antiretrovirals.155 Since that time, Thailand has begun generic production of several antiretrovirals, drastically reducing the cost. A fixed dose combination of stavudine, lamivudine, and nevirapine costs only US$1 per day. With these price reductions and increased funding from both the government and the Global Fund for AIDS, Tuberculosis and Malaria, the Royal Thai Government plans to expand antiretroviral support from 13,000 to 50,000 patients in 2004, using this combination of drugs as the first-line HAART regimen.
Important lessons have been learned in Thailand about providing national level access to antiretroviral programmes for people living with HIV/AIDS. Several prerequisites and actions are needed in parallel to ensure efficient access to HAART: (1) committed leadership at the policy level; (2) significant reductions in ARV costs; (3) strengthening of the health care system and infrastructure; (4) expanded ability of care providers to manage HIV care through training to improve attitudes and build knowledge and skill in treatment of patients with HAART; (5) reduced cost for treatment monitoring, especially CD4+ counts and viral loads--eg, a generic monoclonal anti-CD4 reagent costing US$2 per test has been developed in Thailand; (6) comprehensive patient education on the principles of HAART, adherence, and its toxicity; (7) involvement of the community (non-profit organisations and people living with HIV/AIDS groups) in the process; (8) locally relevant clinical research--eg, HIV-NAT at the TRC-ARC has been doing many clinical trials, which not only contribute to region-specific HIV care, but provide HAART access for over 1500 patients; and (9) gaining supplemental international funding support--eg, from the Global Fund for AIDS, Tuberculosis and Malaria.
Nonetheless, several challenges remain for Thailand and other Asian countries in providing access for all, including weaknesses in management systems, limited resources, drug resistance, and the higher costs of second-line and subsequent therapies. Another challenge will be expanding access to voluntary counselling and testing to link those who test positive with early HIV care. Established in 1991, the anonymous clinic of the TRC-ARC has expanded services to include counselling and testing for CD4 counts and viral loads, and chemoprophylaxis for pneumonia P carinii, and cryptococcal meningitis for the immunocompromised.
Thailand has also been a leader in the prevention of mother-to-child transmission of HIV, successfully implementing nationwide coverage. After the ACTG076 protocol established that zidovudine could reduce mother-to-child transmission, the TRC-ARC and partners launched a public donation campaign in 1996 to provide a modified form of treatment set out in the ACTG076 protocol to poor HIV-positive pregnant women throughout Thailand. Vertical transmission fell to 5·8%, showing the effectiveness of the protocol in a non-clinical-trial setting. With supplemental support from Columbia University this programme is now being extended to provide lifelong antiretrovirals to mothers and other infected family members after delivery. Once the Bangkok short-course zidovudine study, which was controversial at the time, showed the effectiveness of short-course treatment,164 operational trials began immediately to implement this as national policy.158 In the first quarter of 2004, single-dose nevirapine was added for both mothers and newborn babies in hopes of further reducing transmission. However, recent findings of neviripine resistance in 24% of women receiving the drug near the time of delivery and 46% of their infants, raise concerns about the choice of antiretrovirals for prevention of mother-to-child transmission which could compromise later therapeutic options. Further study is needed to find suitable combinations of antiretrovirals for these women to avoid development of resistance.
Role of the global response in Asia
International collaboration has played an essential part in prevention, basic research, clinical trials, operational research, and capacity building in the region. American, French, Australian, and Japanese universities and government agencies have been major collaborating partners throughout Asia, especially in Cambodia, China, India, and Thailand. Examples of bilateral research collaboration include the joint US-Thai CDC collaboration study short-course zidovudine for prevention of mother-to-child transmission of HIV and joint US-Thai Armed Forces research on HIV vaccines.164,172 The HIV-Netherlands, Australia and Thailand Research Collaboration (HIV-NAT) is a good example of a three-continent collaboration in HIV clinical trials and patient care, enrolling more than 1600 patients in various antiretroviral trial protocols until the end of December, 2003.
The role of the Global Fund is expanding, and a growing number of Asian countries have received funds from the Global Fund for AIDS, Tuberculosis and Malaria. China, India, and Thailand have benefited the most from the these funds. However, several constraints restrict the Fund's effect: (1) grant proposal writing and fund release are still complex and need to be simplified; (2) care should be taken that such funds not replace national resources, but instead stimulate expanded national resource allocations in the upcoming years to ensure adequate prevention and care coverage is achieved; (3) local NGOs or institutions should be able to apply directly to GFATM without going through the country coordinating mechanism when conflicts of interest occur or government refuses to address key issues. Most country coordinating mechanisms still do not have effective, transparent, and accountable working mechanisms; (4) the GFATM should not exclude operational research, because it is essential to strengthen the infrastructure and generate the systematic knowledge needed for efficient and effective implementation of prevention and care.
Although a few countries in Asia have lost their chance to prevent the wider spread of HIV infection, others can still do so. Lessons from Thailand and Cambodia have shown that targeted interventions work, but only if implemented with high coverage and sufficient intensity. Few Asian countries have achieved these aims, and prevention will become even more essential as antiretroviral access potentially increases risk behaviour. Once HIV infection has become established, growing needs for care and treatment are unavoidable. Expanding access to antiretrovirals offers people with HIV/AIDS in Asia hope, but it must be complemented by country-specific research, which acknowledges the cost, accessibility of antiretrovirals, and medical management constraints faced in each location. And unless prevention programmes are strengthened simultaneously, the increasing flow of new infections will eventually make expanded access unsustainable in much of Asia. Now, more than ever before, treatment and prevention programmes clearly need to be integrated in ways that complement and boost each other's effectiveness and efficiency.
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