Book: HIV/AIDS in the South-East Asia Region

WHO, 2010, HIV/AIDS in the South-East Asia Region, http://apps.searo.who.int/PDS_DOCS/B4602.pdf

pp 72-74

Countries in the South-East Asia Region have made substantial progress in their response to the HIV epidemic in the past decade resulting in a slow decline in new HIV infections. Still, much remains to be done. An estimated 220 000 individuals were newly infected with HIV in 2009. HIV transmission rates remain unacceptably high among populations engaging in high-risk behaviours, namely sex workers, men who have sex with men and people who inject drugs. Two of three HIVinfected pregnant women do not receive prophylactic antiretrovirals resulting in a large number of children being born with HIV each year. The majority of the HIV-infected people are unaware of their HIV status and more than half do not receive treatment. Addressing these issues will require overcoming many challenges.

Key Challenges Stigma and Discrimination 
HIV prevention and control efforts are being undermined by HIV associated stigma in communities and discriminatory practices in health care settings. Unfavourable laws, policies, and cultural and social norms that increase the vulnerability of marginalized groups to HIV infection still exist. Sex work and drug use are illegal in most countries. The men who have sex with men population remains largely hidden due to criminal sanctions against this group in many countries. The transgender population is highly vulnerable to HIV; it is one of the most discriminated and stigmatized populations. Although there is government support in Member countries to engage with and provide services to these marginalized populations, the law enforcement agencies are often not adequately sensitized resulting in poor access to health services.

Weak Health Systems 
While effective interventions for the prevention and control of HIV have been successfully implemented in some areas in the Region, these could not achieve the level of coverage needed to make an impact because of weak health systems. There has been acknowledgement for the need to strengthen health systems, but in reality little progress has been made. The current weaknesses and gaps in the health system are largely due to underinvestment in health systems. District and subdistrict health facilities usually lack adequate equipments and commodities and referral mechanisms are usually nonexistent. Insufficient Health Workforce There continues to be a shortage of skilled staff in the majority of Member countries with many health facilities having vacant positions. National and subnational HIV control programmes face enormous challenges in recruiting skilled and competent staff due to inadequate incentives. Motivating and retaining good staff is equally challenging. Moreover, unfilled staff positions, constant transfers and frequent change of leadership due to the changing political environment, undermines the implementation capacity of national and subnational HIV control programmes. Not only are the number of health care workers insufficient, but they lack the necessary technical training to provide HIV/AIDS prevention, treatment and care services as well as the managerial skills to plan, prioritize and monitor HIV programmes.

High Prices of Antiretroviral Drugs 
Although the price of first-line antiretrovirals has dropped considerably over the years, these drugs continue to be unaffordable to the governments. There are also large variations in drug prices among countries in the Region. The revision of WHO global antiretroviral treatment guidelines in 2010, would lead to a substantial increase in the number of PLHIV needing treatment; and this will proportionately increase country expenditures for first-line drugs. Second-line treatment prices are very high, which presents a significant challenge for universal access because people currently on first-line treatment would progress on to second-line treatment. The prices of laboratory diagnostics and supplies also need to be reduced, to lower the financial burden of countries as more people start accessing HIV/AIDS treatment and care.

Data Gaps in Interventions for Most-at-Risk Populations 
While the Member countries of the Region in recent years generated lots of data, as a result of expanded information systems, vital information on most-at-risk populations (men who have sex with men, transgender persons, and clients of sex workers including migrants) is still inadequate. Surveillance sites for most-at-risk populations are not enough in number to capture the geographic diversity of the epidemics and data on HIV services is usually incomplete and untimely. Very little investment has been made on operational research to scale up interventions and a gap exists in synthesis and analyses of data leading to underutilization of available information for policy and programmatic reforms and improvements. In general, staff and resources dedicated to HIV information systems are limited; and available staff have limited training in surveillance, monitoring and evaluation as well as research. Lack of Sustainable Financing In most Member countries in the Region government funding of HIV programmes is too low to develop a scaled-up response to the HIV epidemic. Sustainable financing strategies are essential to enable countries to develop and implement long term responses to the epidemic. Heavy reliance on international funding is very common with many countries dependent on donor funds for implementing even essential services, such as blood safety. It is important to understand that donor funds are of limited duration and have unpredictable continuity. Also, though they have filled critical gaps and greatly boosted national responses in several countries with limited resources, these monies usually support “few pieces” of the national response. Expansion of interventions and service coverage cannot be scaled-up to the extent required to meet universal access and the Millennium Development Goals, unless there are substantial increases in domestic and international funding.


Future Directions

Given the setting of a concentrated epidemic and the above listed challenges, critical priorities for countries and development partners in the coming years are listed below. 1. Reducing HIV transmission among populations with the highest transmission of HIV, i.e. sex workers and their clients, men who have sex with men, the transgender population and people who inject drugs. 2. Removing barriers to access to health services for most-at-risk populations by repealing discriminatory laws and reducing stigma in communities and health settings. 3. Reducing perinatal HIV transmission by increasing access to prevention of mother-to-child transmission services for pregnant women. Integrating HIV services with related services such as maternal and reproductive health services to achieve high coverage of programmes for preventing mother-to-child transmission. 4. Ensuring timely access to treatment by effective linkages between testing, counselling and treatment centres. 5. Continuing advocacy for reduced prices of antiretroviral drugs. 6. Improving the quality of antiretroviral treatment while improving access. Ensuring adherence support and close monitoring to “slow” the development of HIV drug resistance. 7. Investing in building health systems and human resources to increase the implementation capacity for scaling-up HIV interventions. Integrating effective supervision and better management of HIV programmes into strong health systems. 8. Decentralizing HIV testing and counselling services to enable more people to know their status. 9. Filling in information gaps by building epidemiologic capacity (both institutional and human) within countries, to carry out relevant surveillance, monitoring and research activities. Undertaking research on priority topics to achieve targets for universal access to HIV prevention, care and treatment.