Human Development Network Health, Nutrition, and Population Series Addressing HIV/AIDS in East Asia and the Pacific Health, Nutrition, and Population Series This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank's Human Development Network. It provides a vehicle for publishing polished material on the Bank's work in the HNP sector, for consolidating previous informal publications, and for improving the standard for quality control, peer review, and dissemination of high-quality analytical work. The series focuses on publications that expand our knowledge of HNP policy and strategic issues that can improve outcomes for the poor and protect vulnerable populations against the impoverishing effects of illness. Best-practice examples of both global and regional relevance are presented through thematic reviews, analytical work, and case studies. The Editor in Chief of the series is Alexander S. Preker. Other members of the Editorial Committee are Mukesh Chawla, Mariam Claeson, Shantayanan Devarajan, Gilles Dussault, A. Edward Elmendorf, Armin H. Fidler, Charles C. Griffin, Jeffrey S. Hammer, Peter F. Heywood, Prabhat Jha, Gerard Martin La Forgia, Jack Langenbrunner, Ruth Levine, Maureen Lewis, Samuel S. Lieberman, Benjamin Loevinsohn, Elizabeth Lule, Akiko Maeda, Judith Snavely McGuire, Milla McLachlan, Thomas W. Merrick, Philip Musgrove, Ok Pannenborg, Oscar Picazo, Mead Over, Juan Rovira, George Schieber, and Adam Wagstaff. Addressing HIV/AIDS in East Asia and the Pacific Human Development Network Health, Nutrition, and Population Series Addressing HIV/AIDS in East Asia and the Pacific THE WORLD BANK Washington, D.C. © 2004 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone 202-473-1000 Internet www.worldbank.org E-mail feedback@worldbank.org All rights reserved. 1 2 3 4 07 06 05 04 The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. 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Addressing HIV/AIDS in East Asia and the Pacific. p. cm -- (Health, nutrition, and population series) Includes bibliographical references and index. ISBN 0-8213-5916-9 1. AIDS (Disease)--East Asia. 2. AIDS (Disease)--Pacific Area. 3. World Bank I. World Bank II. Series RA643.86.E18A325 2004 614.5'99392'0095--dc22 2004055291 Table of Contents Foreword vii Acknowledgments ix Acronyms and Abbreviations xi Key Public Health Definitions xiii Executive Summary 1 Characteristics of HIV/AIDS in the East Asia and Pacific Region 1 Lessons from the Region 3 Partners in the Response: Governments, Donors, and Beyond 5 Five Key Challenges 6 Strategic Response 7 World Bank Support: Analytic Work, Funding, and Regional Work 9 1 HIV/AIDS in the East Asia and Pacific Region 11 Characteristics of HIV/AIDS in the EAP Region 11 The Future of HIV/AIDS in the EAP Region 15 HIV/AIDS and Beyond: Implications for Other Diseases, the Health System, and the Society 16 2 Current National Responses to HIV/AIDS 19 The Thai Experience: Merging Political Commitment, Surveillance, and Civil Society 19 v vi · Contents The Cambodian Experience: Using the 100 Percent Condom Policy 23 The Philippines Experience: A Success Story in a Completely Different Context 23 The Indonesian Experience: The Importance of Political Commitment in Low-Level Epidemics 24 The Papua New Guinea Experience: A Different Epidemic 25 Other Countries Facing Similar Challenges 26 3 Key Challenges 29 Political Commitment and Multisectoral Support 29 Public Health Surveillance and Monitoring and Evaluation 30 Prevention 32 Care, Support, and Treatment 34 Strengthening Health Services Delivery 35 4 The World Bank Strategy for HIV/AIDS in the East Asia and Pacific Region 37 Lessons from the World Bank over the Last Decade 37 Strategic Directions 41 Analytic and Advisory Work 45 Lending and Funding for HIV/AIDS in the EAP Region 45 Regional Activities 46 Conclusion 47 Annex 1 Classification of the Epidemic 49 Annex 2 Country Overviews 51 Annex 3 Snapshot of Estimated Number and Risk Behaviors of Injecting Drug Users and Commercial Sex Workers in the EAP Region 65 Annex 4 Infectious Disease Epidemiology 71 Annex 5 Epidemiological Projections of HIV/AIDS in East Asia 75 Annex 6 Tuberculosis 79 Annex 7 Overview of Current Blood Safety Policy Status 81 Annex 8 Approved HIV-Related Projects Under the Global Fund for EAP Region 85 Notes 87 References 91 Bibliography 95 Web Sites 97 Index 99 Foreword Combating the spread of HIV/AIDS presents the international community with one of its most difficult global challenges. The tragedy now unfolding in Sub-Saharan Africa does not reflect the extent of the disease's devastat- ing effects on populations around the world, and there is now growing con- cern that the countries of the East Asia and Pacific Region may share a sim- ilar fate unless timely and appropriate measures can be taken. This strategy note is intended to help chart the nature of the epidemic in the East Asia and Pacific Region; to survey some of the successful practices being pioneered in its cities, provinces, and countries; and to offer sugges- tions as to how the distinct characteristics of the HIV/AIDS epidemic faced in each country can be addressed by effective and comprehensive responses. This regional strategy recognizes that the challenge posed by HIV/AIDS is further complicated by changing social patterns, weak health systems, high rates of tuberculosis, and large populations engaged in high- risk behaviors. Within this context, responses must take into account five key challenges: political commitment and multisectoral support; public health surveillance and monitoring and evaluation; prevention; care, sup- port, and treatment; and health services delivery. The sheer scale of the HIV/AIDS epidemic will require ongoing, dynamic cooperation among a broad coalition of stakeholders. It is hoped that this strategy--drawn from the World Bank's experience as well as that of the many partners with whom the Bank is working--will help inform future discussion and action. Jemal-ud-din Kassum Vice President East Asia and Pacific Region vii Acknowledgments This strategy note was prepared by Michael Borowitz, Elizabeth Wiley, Fadia Saadah, and Enis Baris. Significant inputs were sought and provided by EASHD staff. The strategy note was received, reviewed, and endorsed by Emmanuel Jimenez, EASHD Director. Enis Baris prepared the initial concept and commissioned most of the work on which the strategy was built. In addition, special thanks to Debrework Zewdie and Susan Stout for their help and support in preparing the manuscript and to Olusoji Adeyi, Martha Ainsworth, Gisele Biyoo, Donald Bundy, Dave Burrows, Sungwook Ryan Chung, Nick Crofts, Eric de Roodenbeke, Phoebe Folger, Peter Heywood, Janet Hohnen, Silvia Holschneider, Dale Huntington, Samuel Lieberman, Tony Lisle, Joan MacNeil, Elizabeth Mziray, Son Nam Nguyen, Elizabeth Pisani, Alex Preker, Alex Ross, Swarup Sarkar, Jagadish Upadhyay, Neff Walker, Shiyong Wang, Diana Weil, David Wilson, and Abdo Yazbek. Some of the background work was provided by a number of consultants, including Julian Gold, Alex Wilson, Don Smith, Elizabeth Dax, Vivian Lin, Alison Heywood, James Chin, and Sumera Haque. The authors also thank their colleagues in partner agencies, especially UNAIDS, WHO, USAID, JICA, AusAID, DFID, GFATM, and ADB. The text was edited by Meta de Coquereaumont, with Bruce Ross-Larson and Elizabeth McCrocklin, at Communications Development Incorporated. The authors of this strategy note are grateful to the World Bank for having published the strategy as an HNP Discussion Paper. The preparation of this regional strategy was cofinanced by the Global HIV/AIDS Program of the World Bank through the UNAIDS Unified Budget and Workplan (UBW) and by the East Asia and Pacific Region of the World Bank. ix Acronyms and Abbreviations ADB Asian Development Bank AIDS Acquired immune deficiency syndrome ASEAN Association of Southeast Asian Nations ART Antiretroviral treatment AusAID The Australian government's overseas aid program CAS Country assistance strategy CDC Centers for Disease Control and Prevention (United States) CSW Commercial sex worker DFID Department for International Development (United Kingdom) DOTS Directly observed treatment, short course EAP East Asia and Pacific EFA Education for All FSW Female sex worker GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria HIV Human immunodeficiency virus IDU Injecting drug user MOH Ministry of Health NGO Nongovernmental organization OECD Organisation for Economic Co-operation and Development STI Sexually transmitted infection TB Tuberculosis UN United Nations xi xii · Acronyms and Abbreviations UNAIDS Joint United Nations Programme on HIV/AIDS UNESCO United Nations Educational, Scientific, and Cultural Organization USAID United States Agency for International Development VCT Voluntary counseling and testing WHO World Health Organization Key Public Health Definitions Antiretrovirals: Drugs that inhibit the replication of HIV--generally three drugs in combination--and thus extend life expectancy. Behavioral surveillance: Tracking trends in behavior over time that carry a risk for HIV infection, such as sharing needles or having unprotected sex with multiple partners. Epidemic: The occurrence in a community or region of an illness or group of illnesses of similar nature, clearly in excess of normal expectancy or in excess of the endemic level. Incidence rate: The number of new cases of a disease over a defined period of time, generally a year, divided by the population at risk of acquir- ing the disease during the same period of time. Opportunistic infections: As HIV infection decreases human immunity, individuals are more susceptible to other infectious diseases, which are often the proximate cause of death. Pandemic: A disease epidemic across a wide area, usually crossing inter- national boundaries and affecting a large number of people. Prevalence rate: The total number of cases of disease at a certain time divided by the population at risk of having the disease. Reproductive rate: The average number of new infections caused by one infected individual in a native population. If the rate is greater than one, a xiii xiv · Key Public Health Definitions self-sustaining epidemic is possible; if it is less than one, the infection becomes extinct. Sentinel HIV surveillance: Measuring trends over time in the prevalence of HIV in defined populations with different levels of risk behavior. These populations include those with high-risk behavior such as commercial sex workers, injecting drug users, and men who have sex with men. They may also include populations more representative of the general population, such as pregnant women, prisoners, and others, depending on the culture. Addressing HIV/AIDS in East Asia and the Pacific Executive Summary With almost half the world's population, Asia will determine the future of the global human immunodeficiency virus/acquired immune deficiency syn- drome (HIV/AIDS) pandemic. If prevalence rates in China, Indonesia, and India increase to numbers similar to those seen in Thailand and Cambodia, the rate of HIV/AIDS would double globally. Such growth would be devas- tating for individuals--and for the region's health systems, economies, and social fabric. HIV/AIDS is therefore a multisectoral development challenge and, consequently, a corporate priority for the World Bank. This report outlines a strategic direction for the World Bank in its multi- sectoral response to HIV/AIDS in the East Asia and Pacific (EAP) Region. It describes the risk of a large-scale HIV/AIDS epidemic in the region. It also spells out what can be done to avert the growth of HIV/AIDS--and what government, civil society, and other partners are doing. And it identifies how the World Bank can assist at the country and regional levels. The World Bank will work with countries, civil society, the private sector, donors, and other key players to formulate country-specific strategies that try to respond to the needs of the population. Characteristics of HIV/AIDS in the East Asia and Pacific Region In trying to predict the course of the epidemic in East Asia, preconceived notions of the trajectory of HIV/AIDS in other parts of the world may not be applicable. East Asia is likely to experience concentrated epidemics among groups that practice high-risk behaviors, with spread to their part- 1 2 · Addressing HIV/AIDS in East Asia and the Pacific ners and their children. This could lead to large epidemics, because a rela- tively high percentage of the population engages in high-risk behaviors. The Joint United Nations Programme on HIV/AIDS (UNAIDS) pre- dicts a staggering 11 million new cases of HIV/AIDS in the region by 2010. However, this projection is based on limited data. Before accurate projec- tions can be developed, more needs to be known about the number of people who are affected by the disease and the number of people who prac- tice behaviors that put them at risk. In the EAP Region, the epidemic generally begins at a low level among commercial sex workers regularly having unprotected sex with clients, in- jecting drug users sharing needles and syringes, or men having unprotected sex with men. As HIV spreads among them, it becomes more heavily con- centrated in these populations. It could then spread among these (often overlapping) populations--and possibly to the general population.1 When HIV comes close to saturation in populations with high-risk behaviors and HIV rates grow to greater than 1 percent among the general population, the epidemic is considered to be generalized. The trajectory of growth de- pends on the size of the at-risk populations and their overlaps, but there is significant potential for growth. In this region, the data suggest that coun- tries are categorized2 as: · Generalized: Thailand, Cambodia, Myanmar. · Concentrated: Papua New Guinea, China, Indonesia, Vietnam, Malaysia. · Low level: Mongolia, Lao People's Democratic Republic, the Philippines, Timor Leste, Pacific Island Member States.3 The preceding list is based on the 2002 UNAIDS data. Other sources of information may lead to a slightly different classification. Because AIDS makes people more susceptible to opportunistic infec- tions, it would trigger concomitant growth in tuberculosis (TB) in the re- gion, which already accounts for almost a third of the global TB burden. Given these extremely high rates of TB, increases in HIV would lead to a dangerous dual epidemic. Globally, tuberculosis has already become the leading cause of death among people with HIV, accounting for about a third of the AIDS deaths worldwide (UNAIDS 2000). Increases in HIV/AIDS and tuberculosis would boost demand for health services and put added stress on already overburdened public health sys- tems, particularly in providing services to the poor. The effects would ex- Executive Summary · 3 tend beyond the health sector, as families would lose wage-earners and spend their limited resources on medical care. HIV/AIDS could also dis- rupt the social fabric by breaking up families, creating orphans, and forcing more households into poverty. In general, HIV/AIDS could lead to a sig- nificant reduction in human capital, by taking the lives of youths, and to slower economic growth. HIV/AIDS is thus a threat to development and to reaching the Millennium Development Goals. Lessons from the Region In a region as diverse as EAP, there are many lessons that can be learned. Some highlights of the fight against HIV/AIDS in various contexts in- clude experiences from Thailand, the Philippines, Indonesia, and Papua New Guinea. In the face of a major epidemic, Thailand led the way in prevention pro- grams, mobilizing civil society and building political commitment. By 1992, 31 percent of commercial sex workers were HIV-positive, and there were signs of HIV spreading to the heterosexual population. The national response was strong, swift, and comprehensive, thanks to strong political commitment from the king and prime minister. This multisectoral response was com- plemented by a sophisticated system of surveillance, including serological surveillance of the general population, sentinel surveillance of groups prac- ticing high-risk behaviors, and behavioral surveillance monitoring risky be- havior. This information was backed by strong leadership to support HIV prevention programs among commercial sex workers and their clients. The result: a profound decline in high-risk behavior, which reduced new cases of HIV and eventually decreased the level of HIV in the population. But HIV/AIDS transmission remains high among injecting drug users in Thailand, and prevention programs have been cut back, particularly since the Asian economic crisis in 1998. There is some concern that the behavior changes early in the epidemic could diminish as the perceived risks decline and prevention programs reach fewer people. The Philippines provides another success story for the region but in a completely different context. The epidemic in the Philippines has been stemmed by a set of contextual factors: differing commercial sexual prac- tices, low rates of injecting drug use, high rates of circumcision, and fewer ulcerative sexually transmitted infections. The country's measured response to the epidemic, including national law reform to reduce the likelihood of 4 · Addressing HIV/AIDS in East Asia and the Pacific discrimination, widely available voluntary counseling and testing services, and a fair sentinel surveillance system, has helped to keep the prevalence low and stable. Indonesia points to the need to maintain political commitment to pre- vention in the low-level stage of the epidemic. In 1996 the government rec- ognized the importance of an early intervention to prevent an epidemic and mobilized initiatives and funding. Several programs were designed to re- spond to the projected epidemic, including a World Bank-funded project that became effective in 1996. However, many of the efforts were not sus- tained or scaled up. For example, the World Bank project was closed in 1999 without implementing many of its planned activities. Several factors played into this, including the severe economic crisis and limited capacity. Respon- sibility for HIV/AIDS was split into several parts of the Ministry of Health, and there was limited coordination. Capacity among nongovernmental or- ganizations for preventive activities and support from some sectors of civil society, particularly religious groups, was also limited. Even so, HIV prevalence remained low, and the predicted epidemic did not materialize. But the trajectory of HIV/AIDS in Indonesia has since changed, with HIV prevalence rates of more than 60 percent among in- jecting drug users in some areas of the country. Recently, government com- mitment appears to be increasing, and a new HIV/AIDS strategy embraces HIV prevention for groups that practice high-risk behaviors. Limited capacity and cultural mores different from other countries in the region place Papua New Guinea at risk for an epidemic similar to those in Sub-Saharan Africa. Despite numerous alerts raised in the early 1990s to the emerging epidemic, few persons in positions of leadership acknowledged HIV/AIDS as an issue of concern. After recognition of the problem, how- ever, early efforts became difficult to sustain. The National AIDS Commit- tee functioned only sporadically from 1988 to 1994, and efforts in the early 1990s to establish a sentinel surveillance system faltered. More recent efforts have revitalized some programming; however, to date, limited capacity in the health system, poor implementation of HIV programs in general, and a lack of human resources have hampered efforts. In addition, the breakdown of traditional methods of social control in Papua New Guinea, combined with the cash economy, urbanization, and greater mobility, has resulted in signif- icant changes in sexual behavior. These factors place Papua New Guinea at risk for developing a large, heterosexual HIV/AIDS epidemic. Other countries will face similar challenges. It would be a difficult task to define the depth and breadth of lessons learned in all countries throughout Executive Summary · 5 the region. The examples given, however, show the broad range of experi- ences and highlight some important lessons. The concentrated epidemics of China, Vietnam, and Malaysia also exhibit a mixed fare of projects, re- sponses, and inputs. Unfortunately there is strong potential for HIV/AIDS growth in these countries, particularly China. China's emerging epidemic is considered to be the next big challenge on the horizon. HIV and AIDS cases are increasing, and there is spread from high-risk populations to the general population (China MOH/UNAIDS 2003). China has made dramatic progress in moving toward a system of vol- untary blood donations and creating the infrastructure necessary to ensure the safety of the blood supply. In addition, the Chinese central government recently reaffirmed its commitment to achieving the goals of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS). The government plans to improve laws and regulations, to launch public awareness campaigns, to protect the rights of people living with HIV/AIDS, to increase international cooperation on HIV/AIDS, and to provide antiretrovirals. Many other countries have created similar na- tional AIDS strategies, but actions are now needed. The way these and other strategies and lessons are adopted and adapted within the region will determine the future of the epidemic and the social and economic land- scape of Asian society. Partners in the Response: Governments, Donors, and Beyond Strong political commitment is a key element in confronting the epidemic; however, resources are also important. Although there has been a high level of commitment from many governments, funding has been low. The main source of funding for HIV/AIDS prevention and surveillance in the region has come from development agencies working alongside governments. The main development partners have been the World Bank; the Asian Devel- opment Bank; the U.N. agencies (especially UNAIDS); the large bilateral development agencies; the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and the World Health Organization. Nongovernmental organiza- tions are also offering key services and information. Although cumulative lending in the region for HIV/AIDS stands at more than $100 million, making the World Bank an important financier of HIV/AIDS projects in the region, the structure of those in the fight against HIV/AIDS has been changing rapidly, which will have an impact on World 6 · Addressing HIV/AIDS in East Asia and the Pacific Bank funding. The Global Fund channels a large amount of resources to countries that often lack full capacity to implement or support programs. However, it is largely a funding agency and is not designed to assist with the implementation of programs. As a result, new demands are being placed on governments and donors. Implementation and technical assistance will have to be provided by other agencies, for example, bilaterals, the World Bank, and other donors. This changing landscape makes it difficult to predict the exact role that the World Bank will play in the region, especially in relation to demand for World Bank lending/grants for HIV/AIDS. However, even in an era of increased grant funding through the Global Fund and other bilaterals, the World Bank may play an important role in resource mobilization for HIV/AIDS. Demand for analytic and advisory services and capacity-building efforts is also likely to increase. In addition, the Bank will continue its role as a co-convenor of multiple sectors, its long-term presence in countries, and its multisectoral programs. Five Key Challenges The EAP Region could avert a large HIV/AIDS epidemic if countries in- troduce effective HIV/AIDS programs that address five key challenges: · Political commitment and multisectoral support. Given the sensitivity of the disease, political commitment is key to effective HIV/AIDS programs. Preventing HIV among socially marginalized groups requires a multi- sectoral response, particularly an enabling legal environment with the support of law enforcement. · Public health surveillance, monitoring, and evaluation. Knowledge of the exact numbers of those with HIV and those practicing high-risk behav- iors is extremely limited. More information is essential to estimate the potential growth of the epidemic and to allocate resources and efforts accordingly. · Prevention. Prevention has been shown to be a cost-effective method of abating the epidemic. There is a wide scope for improving HIV preven- tion, particularly among groups that practice high-risk behaviors (com- mercial sex workers, injecting drug users, men who have sex with men, and migrant workers). Executive Summary · 7 · Care, support, and treatment. Demand is growing throughout the region for antiretroviral therapy. Treatment must also include care and support-- including psychosocial support, voluntary counseling and testing, and care for the dying. · Health services delivery. Prevention, care, support, and treatment have to be delivered by public health and social care systems, alongside the pri- vate sector, including nongovernmental organizations. There is a definite need to strengthen and build capacity to respond to the emerging needs of the epidemic. Strategic Response The World Bank strategy will respond to these challenges by developing country-specific strategies based on the needs of the country and the stage of the epidemic in the country. These HIV/AIDS country strategy notes will be the basis for World Bank engagement. They will be designed in con- cert with national strategic HIV/AIDS plans created by governments and the World Bank Country Assistance Strategies. The HIV/AIDS strategy notes will provide specific work plans that incorporate some mix of the fol- lowing tools: analytic and advisory work, lending, and regional activities. They will be designed to be flexible and innovative, focusing on the five key challenges. Political Commitment and Multisectoral Support An important part of making progress in any HIV/AIDS program is the use of communications to build the political understanding and commitment across a broad spectrum of sectors (for example, health, education, transport, and so forth) and to increase public awareness and support for HIV/AIDS prevention programs within countries. Analytic work and lending (granting) operations will help identify key stakeholders, their relative importance, and their institutional setting. These tools will also assist in identifying the key sectors and help the World Bank do a better job of integrating multisectoral approaches in country work. Public Health Surveillance, Monitoring, and Evaluation Public health surveillance. Good estimates of the number of injecting drug users and the number of commercial sex workers and the percentage of the 8 · Addressing HIV/AIDS in East Asia and the Pacific population visiting them do not exist in most countries. To estimate the growth of the epidemic, one needs to know the size of populations at risk and the overlaps among groups practicing high-risk behavior. This infor- mation is rarely known because it is governed by complex social taboos, with the behavior sometimes illegal and the population hidden. Thus it is neces- sary to use several methods to obtain this information, including routine information systems, surveys, and qualitative research. More funding is re- quired for regular behavioral surveillance and social science research on sexual and drug-using behaviors and for increasing the capacity to conduct this research in local universities and government agencies. Monitoring and evaluation. A key objective is to assist countries in monitor- ing and evaluating the effectiveness of HIV/AIDS programs. One element of this work will be policy dialogue with governments on spending on sur- veillance and prevention among groups that practice high-risk behavior through the development of National Health Accounts for HIV/AIDS. The World Bank will also work with governments to develop and implement monitoring and evaluation systems, including coverage of interventions for prevention and care, support, and treatment. In addition, the World Bank is assisting countries in developing approaches for monitoring and evalua- tion systems at the local level through the Global HIV/AIDS Monitoring and Evaluation Support Team.4 Prevention Although prevention programs exist among groups with high-risk behaviors, they are often small pilot projects. It is important to work with governments to understand the scale needed for prevention programs to have an epi- demiological impact. It is also important to understand sexual and drug- using networks and their overlap to gain more knowledge concerning the potential growth of the epidemic and to learn how to intervene effectively. There is a risk that, over time, prevention programs will receive less atten- tion. It is essential to maintain and strengthen these interventions as a key pillar of the fight against AIDS. Care, Support, and Treatment Analytic work is needed to understand how to operationalize issues related to antiretroviral therapy in the context of relatively weak systems of service delivery, including the private sector. Furthermore, antiretroviral therapy Executive Summary · 9 needs to be embedded into a large system of care and support, including so- cial services and care for the dying. Health Services Delivery The World Bank will work with governments to help in the formulation of better policies for both the public and the private sectors to improve access to care, support, and treatment. This will mean that the growing demand for treatment with antiretroviral therapy, now being met in the private sec- tor, will need to be addressed. In addition, strengthening the coordination between TB and HIV/AIDS programs to ensure maximum effectiveness and efficiency is important. Finally, overall strengthening of the health care system and of absorptive capacity within the broader government is key for delivery of HIV/AIDS interventions. World Bank Support: Analytic Work, Funding, and Regional Work Analytic work in the region will focus on gathering and sharing knowledge in relation to the five key challenges. This will include both country-specific and regional pieces. World Bank lending (granting) will need to be guided by the specific country assistance strategies and needs. The Bank will also work toward strengthening the collaboration with other sectors and main- streaming HIV/AIDS into other lending projects, such as those for infra- structure and education. A broad set of lending instruments and options for client countries to address the multisectoral nature of the disease and the diverse needs across the region is available. Another area in which there could be added value is the development of regional tools that can be uti- lized by several countries in coordination with other partners. These could include analytic work, knowledge-sharing initiatives, and other similar pro- grams. In disseminating lessons, the EAP Region will work closely with the World Bank Institute to strengthen and build institutional capacity for con- trolling HIV/AIDS throughout the region. Working together with governments, civil society, and other develop- ment partners, the World Bank can play a critical role in addressing the risks associated with concentrated HIV/AIDS epidemics in the EAP Region to prevent the region from becoming the future epicenter of HIV/AIDS. CHAPTER 1 HIV/AIDS in the East Asia and Pacific Region The East Asia and Pacific (EAP) Region of the World Bank is the world's most populous region. In such a large and diverse area, the HIV/AIDS epi- demic is as varied as the countries involved--from 12 fishermen with HIV inTuvalu,withpotentiallydevastatingconsequencesforthecountry'sfishing- based economy, to an estimated 1 million people infected in China by the end of 2002 with profound implications for the health system. As a region, EAP has an estimated 2.3 million adults and children living with HIV/AIDS, of the global burden of 42 million (Gold and Wilson 2002). Characteristics of HIV/AIDS in the EAP Region A sense of the magnitude of the HIV/AIDS epidemic can be drawn from a rough classification based on prevalence rates, which represent the total number of people with the disease as a share of the population at risk (Table 1 and Annex 1). It should be noted, however, that there are numerous discrepancies in HIV/AIDS data. To ensure a minimal level of standard- ization, numbers in Table 1 were first taken from 2002 UNAIDS data when possible. Other sources of information may lead to a slightly different clas- sification (for example, Papua New Guinea may be classified as a generalized epidemic based on recent national surveillance). · Generalized: Cambodia, Thailand, and Myanmar. HIV is close to sat- uration in populations whose members practice high-risk behaviors, and 11 GNI per 270 390 840 580 670 390 capita 2000 (US$) 2,020 3,250 0.5 0.0 0.0 in care Women clinics outside major urban areas (2000) 2000) (2000) (2000) (1996) (1996) (1992) (1999) antenatal 0.6­5.7 0.0­5.3 0.4­5.3 0.0­0.7 0.0­0.3 (percent) in a 2.7 0.0 0.0 -- 0.2 0.4 care areas clinics (2000) Women antenatal 2.0­3.5 (2000) 1.6­1.6 (2000) (2000) (1999) (1995) (2003) urban 8.5 2.5 4.2 7.0 major (1994) (2000) (2000) Male with 0.0­1.3 (2000) -- (1996) (1998) 2.0­3.2 patients sexually 12.1­13.0 transmitted infections ) (2002/2003) populations, 16.8 indicated -- (2000) (2000) 0.0­80 (2000) 19­48 (1996) (2003) selected drug users 37.1­63 39.6­50 -- Injecting 26.8­30.4 (2001/2002) otherwise prevalence, 16.0 HIV (2000) (2000) (2000) (unless sex 2.0­27 (2002) (1996) (2002) 26.3­31 4.2­6.0 Female 6.7­10.5 0.0­10.3 2.05­6.3 workers commercial 26.0­50.0 to (2000/2001) Up (2002/2003) 2001 EAP, with in Est. living with number adults number 42,000 17,000 HIV/AIDS of HIV/AIDS) 170,000 180,000­ 400,000 670,000 850,000 120,000 (41,000) (16,000) (est. living (160,000) (650,000) (850,000) (120,000) 130,000 (130,000) Epidemic 15­49) 79 (adult 13.4 (6.3) 4.9 48.3 (726) (118) 22.6 (2.4) (million) (25.8) 63.6 (36.6) 214.8 (11.8) (43.3) Population population, ages 1,284.9 HIV/AIDS of b Adult (ages rate 2.7 -- 1.8 0.1 0.1 0.4 0.7 0.3 15­49) Prevalence (percent) Overview 1 Guinea Cambodia Myanmar Thailand China Indonesia Malaysia Papua New Vietnam Country Generalized Concentrated Table in 290 390 1.54. 1,020 to World possible. 2003, 0.7 HIV/AIDS programming when 2002; from Burrows -- -- -- 2002); ); NASB UNAIDS HIV/AIDS ranging from Bank surveillance). 2003; (UNAIDS 0.0 en OH -- -- (1998) tak World sentinel first for prevalencefo 2002 d NASB/M were egularr 0.0 0.0 of Epidemic targete estimate -- (1989) (1994) be part an undated; numbers a will not gives HIV/AIDS Feng, that is it This future. Global 2.0 1.0 (http://www.worldbank.org/data/wdi2001/ 2002; cases the countries near where cases. reported standardization, on of the HIV 2001) in of Costigan No level primary Report high Indonesia, Bank and the in be number Reid 1.0 0.3 are to (as 2002); minimal (World (2000) -- (1994) a 2003; These estimated 2001 ensure expected population the to listed. or Khorloo are high report (UNAIDS/WHO Indicators general the 1,400 (1,300) <100 either Australia; (<100) 9,400 Therefore, Region (9,400) in doesit Updates are HIV. EAP but Development on the rates in data prevalence Melbourne, World of 5.4 (2.5) 2.5 77 in prevalence, Country­2002 (1.4) (39.6) countries prevalence by 2001); Institute, all report indicative not 2003. available. Not Sheets Burnet discrepancies because (WHO does not Fact The others <0.1 <0.1 <0.1 data. always concern not Region and numerous more is of UNAIDS Information are for care Pacific Pisani 2 level PDR the Epidemiological communication, cells: There countries Lao Mongolia Philippines Annex Myanmar, and 2003; Low are Antenatal In Blank Note: See or a. b. Source: Asia Personal Bank, 14 · Addressing HIV/AIDS in East Asia and the Pacific HIV rates are greater than 1 percent among the general population, as measured by antenatal clinic attendees. · Concentrated: China, Indonesia, Malaysia, Papua New Guinea, and Vietnam. HIV prevalence surpasses 5 percent in one or more subpopula- tions presumed to practice high-risk behavior, as measured by sentinel surveillance of groups such as commercial sex workers and injecting drug users, but prevalence among the general population is less than 1 percent. · Low level: Lao PDR, Mongolia, Pacific Island Member States, the Philip- pines, and Timor Leste. HIV prevalence is less than 5 percent in all known subpopulations presumed to practice high-risk behavior. Cambodia has the highest prevalence, with an estimated 2.7 percent of the adult population living with HIV/AIDS. Myanmar is presumed to have a generalized epidemic, with an estimated 180,000­400,000 adults living with HIV, or prevalence between 0.70 and 1.54 percent. Thailand is next, with an estimated prevalence rate among adults of 1.8 percent. Although this typology is useful, it paints with a very broad brush. As this classification system looks only at the national level, it can mask regional or local prevalence rates or patterns (FHI/USAID 2001a). In EAP, with huge countries like China, this is an important distinction. So this classification serves only as a broad categorization, best used with country and region- specific analysis. The prevalence rate does not tell the whole story.5 One also needs to know the number of new infections (incidence) to understand the epi- demic's direction. Other keys to the severity of the epidemic are the size of the population whose members practice risk behaviors and the nature of the behaviors. The main factor driving Asian epidemics is the high percentage of the population in groups engaging in risky behavior (commercial sex workers, injecting drug users) and the overlap among these groups. Many countries in the region have a large number of commercial sex workers, vis- ited by a significant percentage of the male population. There are increasing numbers of injecting drug users, and some resort to commercial sex to fund their addiction (see Annex 3). The number and behaviors of men having sex with men also plays a role. But without better knowledge of these groups, it is hard to fully understand the epidemic. (More information on the epi- demiology of HIV/AIDS is available in Annex 4.) Regional integration can also facilitate the spread of HIV/AIDS. Though linkages between HIV/AIDS and migration and mobility are complex, they HIV/AIDS in the East Asia and Pacific Region · 15 are evident in many parts of the world. The most obvious factor is labor mi- gration, with vast numbers of people traveling between and within coun- tries. Of the Filipinos reported to be living with HIV, 28 percent are workers who have returned home after working abroad (UNAIDS 2002). There are also regional networks trafficking in women and illicit drugs. These regional factors create the preconditions of high-risk behavior--behavior that can ignite an HIV/AIDS epidemic. Programs to mitigate the risks of mobility must address all stages of migration with a regional approach extending beyond country borders. The Future of HIV/AIDS in the EAP Region Although there are limited data, predictions about the epidemic in EAP range from rates similar to those in Sub-Saharan Africa to estimates of less than 1 percent prevalence in the general population (Annex 5). Three Predictions · High-range predictions: EAP as the epicenter of the epidemic. The predictions of large-scale growth of Asian epidemics are based on the experience of Sub-Saharan Africa, where concentrated epidemics began in groups practicing high-risk behavior, and then HIV spread to the general pop- ulation. Under this scenario, Asia is at great risk of becoming the epi- center of the HIV/AIDS epidemic in the next decade (Eberstadt 2002). · Low-range predictions: HIV/AIDS may not be a large problem in Asia. In contrast, low-range estimates predict Asian HIV/AIDS epidemics are constrained by low-risk sexual behavior in the general population (Chin 2003). Some analysts believe that the Asian HIV/AIDS epidemics will never become the generalized epidemics that are ravaging Sub-Saharan Africa. Multiple, overlapping partners and high rates of sexually trans- mitted diseases, which drive the Sub-Saharan African epidemics, do not exist in the region. Since risky behavior in the general population is low in Asia, HIV/AIDS will stay in concentrated pockets and will not spread widely through the general, heterosexual population. · Mid-range predictions: High-risk behavior drives a moderate epidemic. The U.S. Agency for International Development (USAID) commissioned a consortium led by Tim Brown and Wiwat Peerapatinapokin to develop a dynamic model of HIV/AIDS transmission to understand the trajectory 16 · Addressing HIV/AIDS in East Asia and the Pacific of HIV/AIDS in Thailand. The Asian Epidemic Model was used in Thailand and Cambodia where behavioral data were available and pre- dicted that growth of the epidemic would not be constrained by low-risk behavior in the general population. The growth is driven by the high rate of high-risk behavior in the population, with reports of over 25 percent of men having sex outside of long-term partnerships. Difficult to Tell Precise Extent of Epidemic: Call for Action Although the estimates for HIV/AIDS in the region vary widely, there is no doubt of the strong potential for the epidemic to grow in many countries, such as China, Indonesia, and Papua New Guinea. In the EAP Region, there are no large generalized epidemics with prevalence greater than 5 percent with growth sustained by heterosexual transmission in the general popu- lation.6 The main characteristic of Asian epidemics is they are concentrated epidemics in large populations of people practicing high-risk behaviors, with some spread to the general population. Even the generalized epidemics of Cambodia, Myanmar, and Thailand are primarily large, concentrated epidemics. However, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates suggest that epidemics can be sizable without HIV/ AIDS becoming a generalized epidemic in the entire population. It has been estimated that significant epidemics beyond 3­5 percent prevalence could occur in the adult population simply because of the size of the groups that practice high-risk behavior. (Cambodia Working Group on HIV/AIDS Projection 2002; Thai Working Group on HIV/AIDS Projections 2001). And because many of these groups overlap, the epidemic can become self- sustaining even without generalizing to low-risk populations. It is estimated that even without a generalized epidemic in the adult population, large epi- demics of grave public health concern could occur, leading to an additional 11 million infections in the EAP Region by 20107 (Figure 1). HIV/AIDS and Beyond: Implications for Other Diseases, the Health System, and the Society HIV/AIDS has significant effects beyond the number of people infected with HIV/AIDS. Many people who develop AIDS may also develop a num- ber of other opportunistic infections. HIV/AIDS lowers immunity and makes people more susceptible to infectious diseases such as tuberculosis, HIV/AIDS in the East Asia and Pacific Region · 17 Figure 1 UNAIDS HIV Projections for World Bank EAP Region already a significant challenge in many of the EAP countries. All countries in EAP have tuberculosis rates greater than 100 cases per 100,000, which is significantly high (Table 2 and Annex 6). Of the 22 countries identified by the WHO as bearing the highest burden of tuberculosis, seven are in EAP (Box 1). HIV/AIDS also makes tuberculosis and other infectious diseases more difficult to control by straining health systems. As HIV/AIDS epidemics mature, as in Thailand, and the number of peo- ple living with HIV/AIDS rises, so does the need for access to care, includ- ing antiretroviral therapy and scarce hospital resources. However, the effects extend beyond the health care system. A large-scale HIV/AIDS epidemic also threatens development by slowing the growth of human capital--and ultimately economic growth. Within this larger context of deteriorating human capital is an increasingly vulnerable population of chil- dren affected by HIV/AIDS. UNAIDS estimates that globally children or- phaned by AIDS now number 14.0 million (UNAIDS 2002). HIV/AIDS not only leaves children without families, it also strains education systems, weakening demand, eroding quality, widening the gender gap, and increas- ing sector costs (World Bank 2002). If the epidemic grows in EAP, the ris- ing numbers of AIDS orphans will have a lasting effect on the region. In addition, young women are especially vulnerable to HIV/AIDS. This and other gender dimensions of the epidemic must also be addressed. The good news, however, is that the HIV/AIDS epidemic can be con- trolled. The following chapters review countries' responses to HIV/AIDS, identify progress made, and define the key challenges that must be con- fronted to halt the growth of the epidemic in Asia. Table 2 Estimated Number of Individuals with Tuberculosis Estimated number of Adult Estimated cases of adults and prevalence tuberculosis (2003) children rate Population living with of HIV Rate (thousands, HIV/AIDS (percent, per Country 2001) (2001) 2001) Number 100,000 Generalized Cambodiaa 13,441 170,000 2.7 78,564 585 Myanmara 48,364 -- -- 78,473 162 Thailanda 63,584 670,000 1.8 85,870 135 Concentrated Chinaa 1,284,972 850,000 0.1 1,447,948 113 Indonesiaa 214,840 120,000 0.1 581,847 271 Malaysia 22,633 42,000 0.4 27,119 120 Papua New Guinea 4,920 17,000 0.7 11,602 236 Vietnama 79,175 130,000 0.3 141,353 179 Low level Timor-Leste -- -- -- -- -- Lao PDR 5,403 1,400 <0.1 8,512 158 Mongolia 2,559 <100 <0.1 4,969 194 Philippinesa 77,131 9,400 <0.1 228,931 297 Blank cells: Information not available. a Part of the WHO highest burden countries responsible for 80 percent of global tuberculosis. Source: Epidemiological Fact Sheets by Country­2002 Updates (UNAIDS/WHO 2002) (AIDS data); WHO Report 2003: Global Tuberculosis Control: Surveillance, Planning, Financing (WHO 2003) (tuberculosis data). Box 1 Tuberculosis in China: A Growing Threat As one of the 22 countries highlighted by the World Health Organization (WHO) as accounting for 80 percent of the global burden of tuberculosis, China has the second highest number of cases, though they have decreased significantly since China introduced DOTS (Directly Observed Therapy, Short-Course) as part of its national tuberculosis control program. The World Bank has been a key development partner in providing support for the pilot implementation of DOTS in 13 provinces (efforts in 10 other provinces were funded by the government). This was followed by a successor project in 2002, a blended operation with the Department for Inter- national Development (United Kingdom) (DFID) and in collaboration with the WHO. As a result, DOTS has expanded to cover more than two-thirds of the country, and there are plans to expand further, resulting in the likely achievement of the Millennium Development Goal target for tuberculosis. Control of tuberculosis in China is threatened by a large HIV epidemic, undoing many of the gains of the tuberculosis control program. With current high rates of latent tuberculosis, the risk for significant increases in tuberculosis would be en- hanced as socially marginalized populations, such as injecting drug users, commer- cial sex workers, and prisoners, develop AIDS and subsequently tuberculosis as an opportunistic infection. The interaction between HIV/AIDS and tuberculosis is critical in developing strategies for the control of both diseases in China and across the rest of the region. CHAPTER 2 Current National Responses to HIV/AIDS At the United Nations General Assembly Special Session on HIV/AIDS in 2001, all EAP countries committed themselves to confronting HIV/AIDS. This commitment was reconfirmed at several regional meetings, including the Seventh Summit of the Association of Southeast Asian Nations (ASEAN) in November 2001. Yet commitments are often difficult to put into prac- tice. To ensure accountability and promote sustainability, commitments must be translated into action. What lessons can be learned to date from ef- forts to address HIV/AIDS in the EAP Region? The Thai Experience: Merging Political Commitment, Surveillance, and Civil Society Thailand illustrates both what has been accomplished in the fight against the epidemic and what still needs to be done.8 The first country in the region with a generalized HIV/AIDS epidemic, Thailand has shown that a growing epidemic can be controlled through inexpensive, technically simple public health interventions. The initial response to the epidemic, identified in 1984, was muted. The government believed that the epidemic would remain concentrated in groups practicing high-risk behaviors, particularly injecting drug users and men who have sex with men. This view changed in 1989, when the first national epidemiological surveillance found that 44 percent of sex workers in the northern province of Chiang Mai were infected with HIV, leading 19 20 · Addressing HIV/AIDS in East Asia and the Pacific first to increasing rates of HIV infection among their male clients and then among the general population. The Thai Response Thailand's response was based on political commitment to tackle difficult social issues such as sexual behavior and commercial sex work. The gov- ernment, including the king and the prime minister, made HIV/AIDS pre- vention a priority and focused on decreasing high-risk behavior. Four main developments catalyzed political support for confronting HIV/AIDS. · AIDS policy was put under the Office of the Prime Minister, and the prime minister chaired the multisectoral National AIDS Prevention and Control Committee. This signaled high-level political commitment and opened up dialogue with nongovernmental organizations (NGOs) and other groups. · A public information campaign was launched with high-level political support from a nationally known political figure with experience in family planning campaigns and strong ties to NGOs. · HIV prevention among commercial sex workers was introduced. This innovative program provided regular testing of Commercial Sex Workers (CSWs), information and education for both CSWs and their clients, and condom provision. It depended on close cooperation between public health officials and law enforcement. · A variety of repressive policies were repealed, such as the mandatory re- porting of the names and addresses of people with HIV. The key to the Thai success was effective HIV prevention in CSWs and their clients. The Thai intervention was also grounded in a comprehensive surveillance system. Supported by more than a decade of technical coopera- tion with the U.S. Centers for Disease Control and Prevention, Thailand had good serological surveillance of the general population, sentinel surveil- lance of groups whose members practice high-risk behavior, and behavioral surveillance monitoring risky behavior. This surveillance identified some of the key sources of the spread of the disease and monitored the effectiveness of public health interventions. And this public health infrastructure enabled commercial sex workers to receive regular checkups for sexually transmit- Current National Responses to HIV/AIDS · 21 ted infections--infections that can increase the chance of contracting and transmitting HIV. These prevention programs are associated with a decreased demand for commercial sex, a significant increase in condom use in commercial sex, a decrease in sexually transmitted infections, and ultimately a decrease in new HIV infections. Condom use in brothels rose from about 14 percent to more than 90 percent between 1988 and 1992 (Figure 2). Between 1990 and 1993, the percent of men reporting any premarital and extramarital sex dropped from 28 percent to 15 percent, and the percent visiting sex workers dropped from 22 percent to 10 percent. HIV prevalence among 21-year-old army conscripts, which had risen to 4 percent in 1993, began a steady decline to 1.56 percent by 1999. The decline was even more profound in the North, where it dropped from 12 percent to less than 2 percent. Sexually transmit- ted infections among men also declined dramatically (Figure 2). The impact of these interventions on the epidemiology of HIV/AIDS is difficult to quantify. The Asian Epidemic Model predicts that without the interventions there would have been 6.7 million additional infections in Thailand by 2000 (Thai Working Group on HIV/AIDS Projections 2001). Figure 2 Rising Condom Use and Declining Sexually Transmitted Infections, 1988­94 Condom use among sex Male STD cases workers (thousands) 100% 250 80% 200 60% 150 40% 100 20% 50 Condom use 0 0 1988 1989 1990 1991 1992 1993 1994 Source: Rojanapithayakorn and Hanenberg (1996) as reported in World Bank (1999). 22 · Addressing HIV/AIDS in East Asia and the Pacific The model suggests that public health interventions were responsible for reducing the number of new cases of HIV from 143,000 in 1991 to 29,000 in 2000 (Thai Working Group on HIV/AIDS Projections 2001).9 The Thai Experience: Where to Go from Here? Although Thailand eventually slowed the growth of the epidemic, the high HIV prevalence rates in the past indicate that many people are now devel- oping and dying from AIDS. So Thailand must meet a growing demand for care, support, and treatment. Thailand has an estimated 20,000 patients on antiretroviral therapy, many through unstructured treatment in the private sector, and the number is expected to grow. To prevent the growth in re- sistance, medical treatment should be standardized, and people living with AIDS should also be treated for opportunistic infections. Treatment is more than medical interventions and should include care and support as well as palliative care for the dying. Finally, because there is a lot we do not know about the interactions between curative and preventive interventions, it is important to maintain vigilant surveillance to understand the potential for recurring growth. In addition, the HIV prevention agenda is unfinished. Despite the great success, Thailand continues to have high rates of HIV among injecting drug users, a major source of HIV infection that could drive future growth (Reid and Costigan 2002). Short-term substitution therapy has been introduced, but relapse rates are high, and longer-term maintenance therapy is being considered. There are few, if any, needle and syringe exchange programs. Under these circumstances it is likely that HIV will continue to grow among injecting drug users. To prevent this, the government will need to address issues that are extremely stigmatized. HIV prevention programs among men who have sex with men are also limited and would need similar levels of political support. There is also the chance that the 100 percent condom policy for com- mercial sex workers could break down. The condom policy is difficult to im- plement and enforce among "indirect" sex workers.10 There is also concern because of the significant decrease in HIV prevention funding, particularly after the Asian economic crisis. As the mature epidemics in Western Europe and North America have shown, high-risk behavior increases as the risk of HIV diminishes, particu- larly among the young who never experienced the HIV epidemic at its peak. Continued prevention programs in the general population are key to halt- ing the epidemic. Current National Responses to HIV/AIDS · 23 The Cambodian Experience: Using the 100 Percent Condom Policy Similar to the Thai model, Cambodia has also been successful in decreas- ing high-risk behavior and slowing the growth of the epidemic (Cambodia Working Group on HIV/AIDS Projection 2002).11 With Bank support, Cambodia successfully piloted its own version of a 100 percent condom use program in Sihanoukville (under conditions quite different from those in Thailand) and has adopted such a policy nationwide. Condom use among commercial sex workers in areas where the programs have been implemented has risen. Though there has been a recent decline in HIV prevalence, at- tributing this decline to the 100 percent condom use program is question- able because the pilot was not launched until 1998 and has still not been implemented nationally. Higher mortality may have played a role in the decline in HIV. Regardless, the program shows the importance of a local pilot and demonstrates the feasibility for wider replication that can improve political acceptability. The decline in HIV was accomplished with limited domestic funding and limited state capacity and supplemented by strong partnerships with international development agencies. Cambodia is a positive example of international development cooperation, linking UNAIDS, WHO, USAID, the Department for International Development (DFID), the Asian Develop- ment Bank, and the World Bank in fostering an effective national response to HIV/AIDS. The Philippines Experience: A Success Story in a Completely Different Context Another success in the region is the Philippines. In contrast to Thailand's experience, however, its success is found not only in the response to the epi- demic, but also in differing commercial sexual practices in the country, emphasizing yet again the diversity in the region. The success story of the Philippines lies in the country's measured response to the epidemic, with national law reform to reduce the likelihood of discrimination, widely avail- able voluntary counseling and testing services, and an adequate number of referral centers for the relatively few people living with HIV/AIDS. There is also a sentinel and behavioral surveillance system. However, the main factors constraining the epidemic in the Philippines appear to have less to do with prevention programs and more to do with contextual factors--for 24 · Addressing HIV/AIDS in East Asia and the Pacific example, commercial sex workers have few sexual partners, there are high rates of circumcision, and there are low levels of injecting drug use and ulcerative sexually transmitted infections. Although the epidemic is classified as low level, the Philippines must continue to invest in and improve public health surveillance. Currently, the sample sizes for surveillance are smaller than optimal for detecting changes in the general population. There are high levels of certain sexually transmit- ted infections in the population, and sexual behaviors appear to be changing (Philippines Department of Health 2002). The Indonesian Experience: The Importance of Political Commitment in Low-Level Epidemics In 1996 the government of Indonesia, recognizing the importance of early in- tervention in preventing an epidemic, developed and funded an HIV/AIDS and sexually transmitted infections program, which included some funding from several donors, including the World Bank. HIV was reported in men who have sex with men and transvestites, and there was high-risk behavior among commercial sex workers. The program focused on building surveil- lance capacity and expanding interventions to commercial sex workers and the general population. But the World Bank portion was closed in 1999 after the Asian economic crisis, disbursing only $4.52 million of $24.8 million allocated. There are many lessons from the HIV/AIDS project in Indonesia. The economic crisis played an important role, as the health sector was preoccu- pied with the immediate crisis. Pharmaceutical availability was severely af- fected and prices rose dramatically, and large increases in poverty threatened to overwhelm an already overburdened public health system (see Box 2 for a discussion of health sector capacity). Another contributing factor was limited government capacity. Respon- sibility for HIV/AIDS was spread throughout the Ministry of Health, with limited coordination across units. There was also inadequate capacity in the NGO sector. NGOs were generally too small and without the necessary experience to carry out complex interventions. Capacity for surveillance activities, particularly behavioral surveillance, was also limited, though the project did develop laboratory infrastructure for surveillance. As HIV pre- valence remained low and the predicted epidemic did not materialize, sustaining the political commitment to develop innovative multisectoral interventions for vulnerable groups became more difficult. Current National Responses to HIV/AIDS · 25 Box 2 Interactions Between HIV/AIDS and the Capacity of Health Systems: SARS as a Case Study In several countries in the region, HIV/AIDS is straining health systems. Health sys- tems in many of these countries already lack capacity and are overburdened--a major concern for countries with generalized epidemics, because demand for health services increases as people develop AIDS. It should also be a concern for countries with concentrated epidemics, because they need to look toward building infrastruc- ture and capacity to care for the sick and dying. A different, recent epidemic illustrates this point. The outbreak of severe acute respiratory syndrome (SARS) illustrated the critical importance of public health systems and surveillance, including accurate reporting on new cases and deaths. Health systems were overwhelmed by an influx of sick and dying people, quickly realizing that they lacked the capacity to deal with the disease. The short time be- tween contact with the disease and death heightened fears and created panic, high- lighting the need to create systems that can both allay fears and accurately report on the number of cases. The lag time between contact and the development of symptoms for AIDS is much longer, but the disease places similar strains on health systems, calling for actions to increase capacity. Over the years, the epidemiology of HIV/AIDS in Indonesia has changed. HIV/AIDS is now concentrated among injecting drug users and, in some places, more than 60 percent of injecting drug users are HIV-positive. HIV prevalence is also growing among commercial sex workers. HIV prevention among injecting drug users is very limited, and there is no 100 percent con- dom policy. More recently, government commitment appears to be increasing, with a new HIV/AIDS strategy embracing HIV prevention in groups whose members practice high-risk behavior. Indonesia has also introduced a good epidemiological surveillance system. Mounting an effective response will remain a challenge for Indonesia in the coming years. The Papua New Guinea Experience: A Different Epidemic Papua New Guinea (PNG) is at risk for developing a large, heterosexual HIV/AIDS epidemic that might even follow the trajectory of the disease in Sub-Saharan Africa. Together the breakdown of traditional methods of so- cial control in PNG, the cash economy, urbanization, and greater mobility have resulted in very significant changes in sexual behavior. These factors, 26 · Addressing HIV/AIDS in East Asia and the Pacific combined with a health system that lacks capacity to deal with even basic preventive care, place the country at significant risk. HIV was first reported in PNG in 1987. From the mid-1990s onwards the epidemic started to grow quickly. Despite numerous alerts raised in the early 1990s to the emerging epidemic, few persons in positions of leadership acknowledged HIV/AIDS as an issue of concern. With encouragement and funds from the Global Program on AIDS (GPA), the National AIDS Pro- gram was formed and enlisted membership from a wide variety of stake- holders into a National AIDS Committee. These and other efforts, however, were difficult to sustain. The National AIDS Committee functioned only sporadically from 1988 to 1994, and efforts in the early 1990s to establish a sentinel surveillance system faltered and by 1995 all that remained was lim- ited passive surveillance in some locations. In 1997 a new government re- sponse emerged, and a Medium-Term Plan (MTP) was constructed to cover 1998­2002. The multisectoral approach and objectives of the MTP, how- ever, were never operationalized, costed, prioritized, or implemented. All targeted interventions were disbanded and became imbedded in a planned, but unimplemented, national peer education program. A recent review of the implementation of the MTP reveals only limited success to date. Although the total resources available for the response to HIV/AIDS in Papua New Guinea are high (well in excess of $8 million; more than $1.60 per person per capita in 2003­04), commitment of the PNG govern- ment, the nature of the response, and the quality of the interventions are in question. There is a heavy bias toward interventions in urban areas, al- though more than half, and as much as three-quarters, of the infected peo- ple are in rural areas. Implementation is poor and hampered by a severe lack of human resources. Targeted prevention efforts (for people practicing high- risk behaviors), quality sentinel surveillance, and monitoring and evaluation of interventions are urgently needed to ameliorate the possible negative im- pacts of this epidemic. Other Countries Facing Similar Challenges It would be a difficult task to define the depth and breadth of lessons learned in all countries throughout the region. The examples given, however, show the broad range of experiences, highlighting some important lessons. Pre- vention, surveillance, and political commitment can have an impact. A strong response is needed in low-level epidemics. And care must be taken as soci- Current National Responses to HIV/AIDS · 27 ety and values evolve. The concentrated epidemics of China, Vietnam, and Malaysia also exhibit a mixed fare of projects, responses, and inputs. Un- fortunately, however, there is strong potential for HIV/AIDS growth in all of these countries. China's emerging epidemic is considered to be the next big challenge on the horizon. HIV and AIDS cases are increasing, and there is spread from high-risk populations to the general population (China MOH/UNAIDS 2003). One of the lessons from China is the importance of the blood sup- ply. China has made progress in moving toward a system of voluntary blood donations and creating the infrastructure necessary to ensure the safety of the blood supply. In addition, the Chinese central government recently re- affirmed its commitment to achieving the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) goals. It plans to improve laws and regulations, to launch public awareness campaigns, to protect the rights of people living with HIV/AIDS, to increase international cooperation on HIV/AIDS, and to provide antiretrovirals. Many other countries have created similar national AIDS strategies. For example, Vietnam recently completed its national strategy. But action is what is now needed. The way these and other strategies and lessons are adopted and adapted within the East Asia Region will determine the future of the epidemic and the social and economic landscape of Asian society. CHAPTER 3 Key Challenges To combat the epidemic, five key challenges must be addressed: · Political commitment and multisectoral support · Public health surveillance and monitoring and evaluation · Prevention · Care, support, and treatment · Health services delivery. Political Commitment and Multisectoral Support Given the sensitive nature of the disease, political commitment is key to ef- fective HIV/AIDS programs, as Thailand and Cambodia have shown. HIV prevention programs are difficult to implement because they often involve sexual and drug-using behaviors governed by complex social taboos. An im- portant aspect to facilitating dialogue and making progress around these issues is building political understanding by promoting public awareness of HIV/AIDS prevention programs. Gaining political commitment for prevention in low-level epidemics, as in Indonesia in the 1990s, can be extremely difficult. One lesson is the importance of having the ministry of health actively engaged and well organized. In Indonesia, where responsibility for HIV/AIDS was spread across the ministry of health, coordination was weak. In Thailand, where the HIV/AIDS program was run out of the high-profile office of the prime minister, the high level and visibility of political commitment helped to open dialogue with NGOs and other sectors. 29 30 · Addressing HIV/AIDS in East Asia and the Pacific Effective prevention also requires a social response beyond the health sector. A multisectoral response requires political commitment to imple- ment HIV prevention in groups with high-risk behaviors, such as com- mercial sex workers, injecting drug users, and men who have sex with men. It often requires changes in legislation to allow active prevention and out- reach programs to reach these hidden populations, activities rarely pro- vided by traditional public health services. And it also requires active collaboration with law enforcement agencies, as well as nongovernmental organizations. As the epidemic spreads and generalizes, care, support, and treatment become important elements of HIV/AIDS programming. When many people are living with AIDS, support services are required from a variety of sectors in addition to health, based on the needs of the country and the stage of the epidemic. It is also important to better understand the role of NGOs, civil society, cultural figures, champions, and key leaders. More analysis of their roles is needed to gain a better understanding of how to improve outcomes. In addition, there is a need to guard the human rights of individuals at risk of acquiring the virus and those living with the virus. Many people do not have appropriate access to services, prevention messages, care, support, or treatment. Individuals living with the virus face rejection from their family, friends, and society. To combat stigma, many governments have re- sponded by passing laws against discrimination and expanding access to treatment. Political commitment to face this issue will be a major key to suc- cessful initiatives. The World Bank has several comparative advantages in working in these arenas in the EAP Region. First, it works broadly across sectors and can bring together all parts of government for policy dialogue, including the ministries of finance, health, planning, and education. It can also play an important role in donor coordination. Although political commitment and multisectorality are key to an effective response, the important sectors and appropriate government involvement vary by the needs of the country, the stage of the epidemic, and the nature of the groups that practice high-risk behaviors. Public Health Surveillance and Monitoring and Evaluation Although much is known about HIV/AIDS in the East Asia and Pacific Region, more is unknown. To date, there are few good estimates of the size Key Challenges · 31 of populations practicing high-risk behaviors, such as commercial sex work- ers and injecting drug users--essential for estimating the potential growth of the epidemic. It is also necessary to know how these sex workers and drug-using populations overlap. Multiple approaches may be needed to un- derstand the potential for growth of HIV/AIDS in a society and the effec- tiveness of interventions. These include routine information collection systems, including surveys and qualitative research. More funding is needed for public health surveillance and social science research on sexual and drug-using behaviors, along with increased capacity for conducting research in local universities and government agencies. Also important is linking rou- tine information datasets from health, criminal justice, and social services. The importance of various components of public health surveillance varies with the stage of the epidemic. In low-level epidemics, it is very im- portant to understand the size of high-risk populations and the prevalence of high-risk behavior to determine the potential for growth. This requires national behavioral studies and good sociocultural studies with rapid situa- tional assessments that can be complemented by good sentinel and behav- ioral surveillance systems. Surveillance becomes even more important in concentrated epidemics, where there are relatively high rates of HIV/AIDS among populations with high-risk behaviors. In these situations, it is important to standardize the methodology for sentinel surveillance and to link it to behavioral surveillance. China, Indonesia, and Vietnam have sentinel surveillance systems. Though sociocultural studies on risk behavior are limited, there are some good exam- ples. Indonesia recently carried out a multimethod study on the size of at-risk populations, and this study could be replicated throughout the region.12 Sentinel surveillance in groups whose members practice high-risk behav- iors is also important in generalized epidemics, but surveillance must also be extended to the general population, through regular monitoring of HIV in antenatal clinics, sexually transmitted infection clinics, and the blood supply. It is also useful to have other proxies for the general population. When an epidemic is generalized, sexually transmitted infections and tuberculosis be- come even more important, and there should be good general surveillance of both in the general population. In late generalized epidemics, as increasing numbers of people develop AIDS, the need arises for a good reporting system, the ability to monitor the blood count of AIDS patients, and the capacity to monitor drug resistance. Surveillance helps to understand the nature of the problem and to identify solutions. This requires extending surveillance beyond diseases to moni- 32 · Addressing HIV/AIDS in East Asia and the Pacific toring and evaluating whether interventions have achieved their desired goals, such as reducing risk behavior and decreasing the incidence of HIV/AIDS, and applying the findings to prevention programs. Achieving a significant decrease in high-risk behavior requires large-scale social pro- grams that reach a substantial proportion of the targeted population. Only if these programs are widespread will they have an impact on the epidemi- ology of HIV/AIDS. Monitoring must ensure that care, support, and treat- ment improve life expectancy, reach the poor, and minimize drug resistance. It also requires improving routine health information systems to measure coverage of prevention and treatment programs, health outcomes, and financial costs. Prevention On the global level, fewer than one in five individuals at risk of HIV infec- tion has access to basic prevention services. In Asia, with combinations of drug use, unprotected sex, and rising rates of sexually transmitted infections, UNAIDS estimates that only 10 percent or fewer of injecting drug users and other vulnerable populations are benefiting from prevention interven- tions (Global HIV Prevention Working Group 2003). Still, there have been some major successes in this arena within the region. Thailand and Cam- bodia have demonstrated the cost-effectiveness of HIV prevention among commercial sex workers and their clients through the 100 percent condom policy. But this is not a panacea. UNAIDS notes that the HIV/AIDS epi- demic can be slowed if prevention programs such as these are scaled up and used in combination with other prevention efforts to target groups affected by HIV/AIDS and the diverse routes of transmission (Global HIV Preven- tion Working Group 2003). Another important public health approach, especially in the EAP Region, is to reduce risky behavior among injecting drug users and thus HIV trans- mission. This has been shown to be possible in many countries with concen- trated HIV/AIDS epidemics among injecting drug users, such as Australia, Canada, Germany, Netherlands, Switzerland, and United Kingdom. They applied an inclusive policy, called harm reduction, that recognizes drug use as an addiction and uses active social outreach to bring injecting drug users into contact with HIV/AIDS preventive services and drug treatment. Instead of harm reduction policies, some governments have pursued policies aimed at eliminating drug use, but from a public health standpoint, eradicating Key Challenges · 33 HIV/AIDS from the drug-using population is probably easier than elimi- nating drug use. There is broad scope for improving HIV prevention in injecting drug users. This is clearly an important issue on the HIV prevention agenda for the East Asia and Pacific Region. Drug treatment services are poorly de- veloped and substitution therapy is almost nonexistent.13 But there has been some change. Hong Kong, China, has an internationally recognized drug treatment system. In Indonesia a pilot project for harm reduction in Bali has been adopted by the Ministry of Health as national policy, though it has yet to be implemented. As noted above, one successful element of the Thai effort to prevent the spread of HIV was to improve the management of sexually transmitted in- fections in groups whose behaviors place them at risk. There is currently an epidemic of sexually transmitted infections in the region. This is important in and of itself, but also suggests there is strong potential for growth of HIV/AIDS in the region.14 The ability of sexually transmitted infections to fuel the HIV epidemic could be alarming, especially in countries like China and Indonesia. Treatment of sexually transmitted infections is a critical component of prevention. Another important group that needs to be addressed is youth. In 1999 half of the world's 15,000 new daily infections occurred among 15- to 24-year- olds (World Bank 2002). Because youth--and other subgroups--can engage in several risky behaviors, they may be an important entry point for preven- tion. A related concern is young women. Women, and young women in par- ticular, often have less bargaining power in sexual relationships, and are therefore more vulnerable to infection. This gender dimension should be ad- dressed in prevention efforts. Other groups, such as migrant laborers, pris- oners, and men having sex with men, also need to be targeted as part of prevention strategies and programs. In most of the preceding situations where prevention is necessary, in- cluding those involving youth, education is key. Information, education, and communication campaigns for the general public and high-risk groups are important components of an effective HIV/AIDS prevention strategy. There is also a need for a broader educational approach to prevention that includes the education sector. Another significant element of prevention is voluntary counseling and testing, which can be important for prevention for both HIV-positive and HIV-negative individuals. Knowledge of their status can assist individuals in making decisions about protecting themselves and their partners. Limited 34 · Addressing HIV/AIDS in East Asia and the Pacific access to voluntary counseling and testing, as well as stigma and discrimi- nation, however, can limit the effectiveness of this intervention. In order to provide these services, discrimination must be addressed. Similarly, the ser- vices should be provided in the context of comprehensive health and social systems and targeted to marginalized and hard-to-reach groups. Care, Support, and Treatment Care, support, and treatment activities aim to improve the quality of life of individuals and communities affected by HIV/AIDS, while boosting pre- vention efforts to prevent its further spread. A comprehensive plan of care and support includes diagnosis, treatment, referral and follow-up, nursing care, counseling, and support to meet psychological, spiritual, economic, social, and legal needs. Treatment with pharmaceutical drugs, including antiretroviral therapy, is also important (UNAIDS/WHO/International HIV/AIDS Alliance 2003). Demand for antiretroviral therapy is growing. To maximize the effec- tiveness of drug treatment, it should be complemented by care and support and implemented using standardized evidence-based clinical protocols. Im- plementing these protocols requires strengthening health systems, includ- ing improving clinical training, laboratory infrastructure, logistical systems to deliver medicines, and sustainable systems for funding clinical services that are delivering antiretrovirals. The uptake of antiretroviral therapy varies considerably across the re- gion. Thailand, with its more mature epidemic, has the greatest number of patients on combination therapy. It recently declared its intention to pro- vide universal access to antiretroviral therapy,15 and has its own generic drug manufacturing system.16 Cambodia, by contrast, had only about 100 pa- tients in official therapy programs (Calmette hospital) in 2002, while NGOs supported more than 750 patients in pilot studies in Phnom Penh and Siem Reap. In coming years, more patients are expected to receive treatment through the French program Ensemble pur une Solidarité Thérapeutique Hospitalière en Réseau and the expansion of NGO activities (Médecins Sans Frontières, Center of Hope, and Médecins du Monde). Most of them will still be in Phnom Penh and Siem Reap, but it is expected that expan- sion into Kompong Cham and Takeo Provinces might be possible. In most other countries, there are a limited number of patients on antiretroviral therapy (Gold and Smith 2003). Key Challenges · 35 Antiretroviral therapy is also very important in preventing mother-to- child transmission. Successful prevention programs for mother-to-child transmission require a mixture of prevention, care, support, and treatment, including voluntary counseling and testing, replacement feeding, and anti- retroviral therapy (FHI/USAID 2001b). Moreover, managing HIV infection requires a range of other services in- cluding clinical management of HIV/AIDS-related illnesses, prevention and control of opportunistic infections (for example, tuberculosis), palliative care, home care, and psychosocial support. Tuberculosis, as the most com- mon opportunistic infection of HIV/AIDS, is an important disease to target. Though fueled by the HIV/AIDS epidemic, tuberculosis does not confine itself to HIV-positive individuals. When targeting tuberculosis, coordina- tion of tuberculosis and HIV/AIDS services is important. Support is also necessary for families and dependents of people living with HIV/AIDS. As adults succumb to the disease, more children become orphans. Comprehensive systems of care need to be developed for these orphans, ensuring that they have people to take care of their emotional and financial needs, so that they can continue their educations and receive medical treatment. Programs and policies must be specific to each country's safety nets and varying cultural and social mores. Voluntary counseling and testing is another component of care and sup- port. Because HIV infection can be asymptomatic for many years, people with HIV who might benefit from early drug treatment are often unaware thattheyareinfected.Voluntarycounselingandtestinghelpsarrangeforearly clinical management of HIV infection before it progresses to AIDS (World Bank 2000). Such programs should first be targeted to groups whose be- haviors place them at highest risk, unless there is a generalized epidemic. Strengthening Health Services Delivery Most prevention, care, support, and treatment services can be provided by a combination of public health services and social care systems such as hospitals, clinics, and dispensaries, including the private sector and nongovernmental organizations. While some needs can be met outside the health system, much of the disease burden of HIV/AIDS is borne by health systems--hospital and clinical services, laboratory diagnostic support, delivery of pharmaceuticals, maternal-child health services, voluntary counseling and testing services, and palliative and home-based care. 36 · Addressing HIV/AIDS in East Asia and the Pacific Most people at risk of HIV infection or already infected live in resource- constrained settings. Many health facilities in these settings lack the re- sources to provide quality health care to the general population, much less meet the complex demands of HIV/AIDS-related morbidity and mortality. Additionally, given that there are going to be increased resources coming into countries through the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) and other donors, this will increase the strain on already burdened health and social service systems, as well as the broader gov- ernment. Capacity needs to be strengthened and built within health--and broader--systems if countries are going to scale-up prevention, care, sup- port, and treatment. Private sector involvement is critical for engaging with HIV/AIDS in the EAP Region. In general, the private sector plays a key role in the delivery of clinical care in the region (Gold and Smith 2003). Much of sexually trans- mitted infection care is also privately provided, causing significant problems of inappropriate and inadequate care. Scaling-up access to care, support, and treatment requires an innovative approach by and with the private sector. Additionally, as with prevention, public health services rarely reach socially marginalized groups. It is important to develop and strengthen NGOs and other sectors to reach marginal populations. At the heart of any health system are resources: where they come from, how and on what they are spent, and how effectively they are used. Account- ing for resources in this way is not well developed for health systems in gen- eral, but is especially poor for HIV/AIDS. It is, however, similar to the more standardized national health accounts used by the Organisation for Economic Co-operation and Development (OECD), the World Health Organization (WHO), and the World Bank. These accounts need to be developed to track overall domestic public spending in health on public goods such as surveil- lance and prevention among groups with high-risk behaviors. The national health accounts framework also emphasizes understanding private household spending, which is particularly important for HIV/AIDS, given the high levels of private treatment. CHAPTER 4 The World Bank Strategy for HIV/AIDS in the East Asia and Pacific Region Lessons from the World Bank over the Last Decade The World Bank is one of the leading financiers of HIV/AIDS prevention and control activities in the world. It has committed $1.77 billion (and dis- bursed nearly $800 million) on more than 70 current and future projects around the world. Between 1992 and 2002 the World Bank financed 11 health projects with HIV/AIDS-related components in seven EAP countries. Cumulative lending in the region for HIV/AIDS stands at over $100 mil- lion, making the World Bank the largest single financier of HIV/AIDS pro- jects in the region. Nonetheless, World Bank support for the region's health sector makes up only 5.7 percent of the $2.1 billion portfolio of World Bank lending in the EAP Region (Box 3). Of the 11 projects in the region on HIV/AIDS that the Bank has financed to date, only two have been exclusively for HIV/AIDS: Indonesia HIV/AIDS and STD Prevention and Management Project ($25 million), closed in 1999, and the Vietnam Blood Supply Management Project ($38.2 million). The other projects either included HIV/AIDS as part of an infectious disease pro- ject, a maternal health project, or a broader health systems project. The most significant financial support has been in China, with a small HIV/AIDS component in Health V (Infectious and Endemic Disease Control) and VII 37 38 · Addressing HIV/AIDS in East Asia and the Pacific Box 3 How Much Will It Cost to Prevent the Spread of HIV/AIDS in the EAP Region? The short answer? We don't know. UNAIDS and the London School of Hygiene and Tropical Medicine estimated that at least $9.2 billion annually is required to mount an appropriate response, including substantial funding for antiretroviral therapy. This estimate is for a basic program of prevention, care, support, and treatment in all de- veloping countries and does not include the cost of improving the health infrastruc- ture. For the EAP Region, they estimated 10 percent of the total, with the majority of funding allocated for prevention ($810 million) and $80 million for care and support (Schwarlander and others 1999). Such a general estimate is not very meaningful at the country level, since it should be based on effective strategies for each country sup- ported by detailed costing. However, even with limited knowledge of the resources needed, it is likely there will be resource gaps in some countries in the region. So how much is currently being spent? Although the data on domestic spending are sparse, it is clear that public funding for HIV/AIDS is not very significant, with a few exceptions like Thailand. Looking at overall public spending on health shows little room for spending on HIV/AIDS. In most countries, it is less than 1 percent of public spending, meaning that the region is far from the estimate of need. Of course, most of the money spent on HIV/AIDS may not come from public expenditures, but through private household spending. The spread of AIDS is likely to increase private expenditures significantly as households pay for antiretroviral therapy and care, and as they try to absorb the loss of income due to inability to work. With low levels of government spending on HIV/AIDS, international develop- ment assistance has become a large player in this arena. (Health Promotion) Projects, culminating in $25.6 million for HIV/AIDS prevention and control in Health IX. Although the projects differ based on country needs, they share some common elements, particularly the strengthening of national and provin- cial surveillance systems. All projects include health promotion to the gen- eral population and groups whose members practice high-risk behaviors, though earlier projects gave more emphasis to health services capacity. More recent projects tend to be more comprehensive, though issues of care and support for HIV/AIDS are addressed only in China Health IX. All pro- jects attempt to build multisectoral involvement, including NGOs, but ef- fectiveness appears to be mixed. Overall, the projects tended to be stronger on technical design than on implementation. The most effective components were related to hardware-- improving the laboratory network for HIV/AIDS and sexually transmit- ted infections in Indonesia or blood safety in China. (Additional information on blood safety in countries in the region is available in Annex 7). Limited The World Bank Strategy for HIV/AIDS in EAP · 39 national and provincial government capacity has impacted implementation effectiveness. Channeling funds and contracting with NGOs were concerns for some of these projects in earlier project designs. Inadequate monitoring and evaluation systems and capacity also affected programming. Analytic and advisory work within the region is becoming a more im- portant component of the World Bank response to HIV/AIDS. A seminal document on HIV/AIDS, Thailand Social Monitor: Thailand's Response to AIDS: Building on Success, Confronting the Future (World Bank 2000) fully explains the epidemic in Thailand and identifies areas of strategic priority. There are a number of new pieces of analytic work underway in several countries, including Indonesia, Thailand, and China, and demand appears to be increasing. Lessons Learned Lessons from the Bank's activities include the following: · MoreanalyticandadvisoryworkisneededtosupportHIV/AIDSprograms in the region and to provide the basis for financing/lending activities. · The Bank needs to pay closer attention to monitoring and evaluation across the health sector, especially in view of the increased emphasis on results. · Because insufficient capacity may cause even well designed projects to fail, the implementation capacity of national HIV/AIDS programs and NGOs needs to be enhanced. Innovation in project design to support NGOs and local governments, and to channel funds for multisectoral work, would help improve implementation. · The Bank has the capacity to work across sectors and incorporate HIV/AIDS components into a range of development projects (infra- structure, education projects). · The Bank is well placed to work across the health sector and to strengthen health services delivery. · With the increased emphasis on partnerships, different models to sup- port HIV/AIDS work can be developed. World Bank in Relation to Other Donors Because the groups involved in the fight against HIV/AIDS have been changing rapidly, it is important to review the sources of support to identify 40 · Addressing HIV/AIDS in East Asia and the Pacific gaps and decrease duplication. Though the World Bank is one of the re- gion's largest single financiers of HIV/AIDS programs, it will soon be dis- placed by the GFATM, which has committed over $400 million for the next 5 years. Set up in January 2002 to provide complementary financing to existing programs addressing HIV/AIDS, tuberculosis, and malaria, the GFATM seeks to attract, manage, and disburse additional resources to scale-up interventions and treatment through a new public-private part- nership. To date the GFATM has had three rounds of proposals with total commitments of over $2.0 billion (Annex 8). The role of the GFATM in providing resources for HIV/AIDS is likely to have implications for the World Bank. The GFATM serves primarily as a financing mechanism. The implication of this for countries is that imple- mentation and technical assistance have to be provided by someone else, for example, bilaterals, the Bank, and other donors. In addition, there are likely to be issues surrounding how the funds are used and whether countries have the capacity to implement large-scale programs of prevention and treat- ment and to monitor and evaluate the results. Another key player is the UNAIDS Secretariat, whose main purpose is to act as a catalyst and coordinator of action on HIV/AIDS, rather than as a di- rect funding or implementing agency. UNAIDS is playing a greater role in coordination and advocacy, including tracking international development as- sistance on HIV/AIDS, setting global standards for monitoring and evalua- tion, and tracking the HIV/AIDS epidemic. At the country level, UNAIDS is the convener of the U.N. family through the UNAIDS theme group that aims to help countries mount an effective multisectoral response to HIV/AIDS. The World Health Organization is playing an increasingly larger role in HIV/AIDS. They are the main source of technical guidance in areas such as diagnosis and treatment of sexually transmitted infections, care, treat- ment, and support of AIDS, prevention, and the interaction between HIV/AIDS and tuberculosis. Recently the WHO launched a new strategy aimed at increasing access to treatment (3 by 5 Initiative). Bilateral agencies [for example, USAID, the Australian government's overseas aid program (AusAID), DFID, and Japan International Coopera- tion Agency (JICA)] are in the forefront of interventions among populations whose members practice high-risk behaviors. AusAID is supporting harm reduction in China, Indonesia, Myanmar, and Vietnam, and DFID in China. These programs are generally limited in scope, but serve as models that could be replicated by governments. USAID plays a large role in de- veloping capacity for epidemiological surveillance, particularly behavioral The World Bank Strategy for HIV/AIDS in EAP · 41 surveillance. The U.S. Centers for Disease Control and Prevention (CDC) have partnered with the Thai CDC for more than a decade and have been instrumental in building capacity in epidemiological surveillance in the Un- tied States, China, and Vietnam. There are several regional initiatives working in HIV/AIDS as well, in- cluding the Asian Development Bank's program for the Mekong Delta. Other agencies are also working regionally: USAID is reopening a regional office in Thailand, and UNAIDS, the WHO, UNICEF, and the United Nations Office on Drugs and Crime (UNODC) are major regional players. The Association of Southeast Asian Nations (ASEAN) is working on a five- year plan to combat HIV/AIDS in mobile populations, including seafarers, truck drivers, and migrant workers. The World Bank also has a separate and specific role in the region. Specifically, as a co-convenor of multiple sectors, the World Bank has the opportunity to bring together a number of players to discuss--and take ac- tion on--HIV/AIDS, in collaboration with governments and other part- ners, including UNAIDS. In addition, the long-term presence of the World Bank in countries and its multisectoral lending program can help address long-term systemic issues. Even in an era of increased grant funding through the GFATM and other bilaterals, the World Bank may play an important role in resource mobilization for HIV/AIDS. Strategic Directions The World Bank strategy will respond to these challenges by developing country-specific strategies based on the needs of the country and the stage of the epidemic in the country. These HIV/AIDS country strategy notes will be the basis for World Bank engagement. They will also be designed in concert with national strategic HIV/AIDS plans created by governments and the World Bank Country Assistance Strategies. These HIV/AIDS strategy notes will provide specific work plans that incorporate some mix of the following tools: analytic and advisory work, lending, and regional ac- tivities. And they will be designed to be flexible and innovative, focusing on the following five key challenges. Political Commitment and Multisectoral Support The experience from Thailand, Cambodia, and other countries that have been successful in tackling HIV/AIDS shows the need for strong leadership 42 · Addressing HIV/AIDS in East Asia and the Pacific and a coordinated multisectoral response. More analytic work is needed to understand how the World Bank can increase political commitment across a broad spectrum of sectors and, with it, public awareness of HIV/AIDS. Analytic work will help identify key stakeholders, their institutional setting, and the barriers to political commitment. It will also help identify the key sectors and help the Bank better integrate multisectoral approaches into work at the country level. Communications are also necessary for building political understanding and commitment across a broad sectoral spectrum (health, education, trans- port) and for increasing public support for HIV/AIDS prevention programs. For example, the Eastern Europe and Central Asia Region is planning to use public opinion surveys to understand not only what people think, but why, and to identify their underlying motivations and biases about HIV/AIDS. Such understanding is critical to ensuring that communication aimed at achieving political commitment, raising awareness, and changing attitudes and behaviors is focused and resonates with critical audiences. A similar method could be used in East Asia, providing a resource for country and sec- toral teams working on HIV/AIDS issues and for client governments to gain a better understanding of stakeholder perceptions and the environment in which they operate. Public Health Surveillance and Monitoring and Evaluation Public health surveillance. All countries in the EAP Region need to improve their public health surveillance systems, a public good that tends to be un- derfunded. Improved HIV/AIDS surveillance includes HIV sentinel sur- veillance, behavioral surveillance, and sociocultural studies to determine the size and overlap of high-risk populations. The work can build on good mod- els for surveillance that already exist in the region. In addition, support and resources to implement these systems and build capacity are needed. Within surveillance, better HIV/AIDS projections are needed. To help governments design and prioritize programs, it is important to understand the future course of the epidemic under various hypotheses. Understand- ing the socioeconomic consequences of HIV/AIDS requires better data for epidemiological projections. Projections and operations research are also needed to assist governments in planning for the burden of HIV-related diseases, including tuberculosis. For example, the Cambodia tuberculosis program has worked with the National Center for HIV/AIDS, Dermatol- ogy, and STDs to project cases of HIV-related tuberculosis and to develop The World Bank Strategy for HIV/AIDS in EAP · 43 decentralized services to handle the increases in tuberculosis. This requires assessing the increased demand for health spending and then developing ac- tual models of service delivery. Socioeconomic impact models are also needed to understand the effect of HIV/AIDS on the health care system, household, and macroeconomy. Other models would also help in understanding the links between human development and poverty by analyzing the effects of HIV/AIDS on the household. Such models would combine epidemiological projection mod- els and household survey data on income and consumption. Monitoring and evaluation. In the EAP Region, monitoring and evaluation are likely to play a central role in the World Bank strategy, possibly involv- ing national health accounts for HIV/AIDS and monitoring of the coverage of interventions. To ensure sustainable domestic financing for HIV/AIDS for scaling-up interventions, governments first need to better understand the current level of spending. Analytic and advisory work could help govern- ments track public expenditures for HIV/AIDS using a national health ac- counts framework. This is currently being done in Indonesia and Cambodia and could be expanded across the region. The analysis should include pri- vate spending on HIV/AIDS prevention and treatment. This type of ac- counting is not well developed for HIV/AIDS, but is similar to that used in standard national health accounts. But tracking public spending on almost any social program in the EAP Region is difficult and related to public sec- tor management and reforms. Monitoring and evaluation require more than expenditure tracking--they also require systems to determine whether interventions are reaching the tar- get population at adequate coverage, especially for the poor. Many of these systems are weak and need to be improved. Where routine information sys- tems are unreliable, techniques such as household surveys and sentinel sites will be needed. The World Bank can work with governments to develop and implement monitoring and evaluation plans to track an effective response. Prevention The key to effective prevention programs is reaching high enough cover- age levels among high-risk populations to have an epidemiological impact. Though many countries have successful pilot projects, they have very lim- ited coverage. Many of these interventions are politically difficult, such as prevention among injecting drug users and commercial sex workers, but are 44 · Addressing HIV/AIDS in East Asia and the Pacific necessary and require strong political commitment. A first step would be to pull together all the epidemiological and financial information into a co- herent system. A second step would be to look at the resources needed for scaling-up related to human resources and financing. In some countries, the World Bank might also play a role in improving information on high-risk behavior and building capacity for behavioral re- search. Understanding sex workers and injecting drug users and their over- lap is important for estimating growth of the epidemic and for preparing effective interventions. But in most countries the information on sex work- ers and injecting drug users that is needed to design effective prevention programs is limited. In addition, political support and ensuring that there are adequate resources for prevention programs are key for addressing the HIV/AIDS epidemic. Again, depending on the country strategy and demand, the World Bank can play an important role. Care, Support, and Treatment Treatment of AIDS with antiretroviral therapy is occurring in almost all countries in the EAP Region and is likely to increase, particularly as donor support for treatment programs increases. Analytic work is needed to un- derstand how to increase treatment in the context of relatively weak systems of service delivery. Options might include using existing platforms of care, such as tuberculosis programs, to expand treatment with antiretroviral ther- apy. It is essential to engage with the private sector, because this is often where treatment is already occurring. Also treatment must be embedded within a larger system of care and support, including treatment of opportunistic in- fections, links between treatment and prevention, and care for the dying. Health Services Delivery Many health systems in the region are going through a transition. There is limited capacity in the public and private sectors and an important role for the nongovernmental sector, including the private sector, in service delivery. A better understanding of health system issues, opportunities, and constraints is essential for many HIV/AIDS interventions. While the exact type of work needed can be determined only at the individual country level, some examples could include funding public health interventions and surveillance under de- centralization; integrating the private sector and NGOs for HIV/AIDS pre- vention and treatment; integrating health and social services, particularly for groupswhosememberspracticehigh-riskbehaviors;improvingthelaboratory The World Bank Strategy for HIV/AIDS in EAP · 45 infrastructure for testing and treatment of HIV/AIDS; enhancing the safety of the blood supply; and building capacity in general, especially for care, support, and treatment. There will also need to be a focus on how to increase absorp- tive capacity within health systems as well as within the broader government. Additionally, the World Bank has been playing an important role in health systems development in several countries in the region. In the same way, the World Bank can assist governments in preparing health systems to deal with HIV/AIDS. Also, as many of these interventions require multi- sectoral activities and interventions, assisting with health systems issues in decentralized settings is another important area in which, together with the other partners, the World Bank may be able to provide support. Asstated,thesekeychallengeswillbeaddressedthroughspecificworkplans that incorporate some mix of the tools described in the following sections. Analytic and Advisory Work Analytic and advisory work assists the World Bank in carrying on policy dialogue with governments and civil society on an effective response to HIV/AIDS. The focus will vary based on the needs of the country and re- gion, the role of government and other partners, and the stage of the epi- demic. Analytic and advisory work will support all of the key challenges as part of an effective HIV/AIDS strategy in the region. As countries face various policy options, the World Bank has tradition- ally played an important role in this arena that can be expanded to include HIV/AIDS. Of course, the range of advisory and analytic work is wide and depends on country needs. Lending and Funding for HIV/AIDS in the EAP Region The International Development Association (IDA) can provide credits and/or grants for HIV/AIDS programs in IDA-eligible countries, while in middle- income International Bank for Reconstruction and Development (IBRD) countries, where grant funding is limited, there is an important role for partnerships with other development organizations. The exact demand for World Bank funding is hard to predict since it is a function of many variables, including the availability of domestic funding and grants. But there are clear 46 · Addressing HIV/AIDS in East Asia and the Pacific areas in which governments have a role and in which there is a general pattern of underinvestment--areas that may represent a priority for World Bank sup- port. For instance, many countries in the region could benefit from im- provements in public health surveillance and monitoring and evaluation. These could require a combination of investments in routine information sys- tems and research, hardware, software, and technical assistance. The World Bank stands ready to support both analytic and lending programs in countries in the region, depending on specific country needs and demands. Equally important is determining how the World Bank can be more effective in providing financial support for HIV/AIDS programs whether through lending or grants. Some of this may require a different way of doing business. Different options are needed for designing multisectoral projects, for channeling funds and building capacity of NGOs, for including the private sector, and for building monitoring and evaluation systems. With the introduction in recent years of more flexible designs and more options for addressing client needs and demands, there is room for more effective programs--programs that take into account the key lessons from the first cohort of projects. Regional Activities Where there is value added from cross-country experience or from country- specific interventions and analysis, a regional role for the World Bank might be appropriate, especially in support for public health surveillance and mon- itoring and evaluation. Regional Tools A number of areas were identified in which sharing experiences and tools could be helpful, such as experiences with implementation of national ac- counts for HIV/AIDS. Improvements in such areas could be facilitated by the development of new tools that are regional in scope but adapted to each country's needs. Examples include improved projection models for HIV/ AIDS, socioeconomic models of the impact of HIV/AIDS, optimization models of public spending, and other similar tools. Regional Dissemination of Best Practice The World Bank will work with partners, especially UNAIDS and the World Bank Institute, to disseminate best practice in HIV/AIDS preven- The World Bank Strategy for HIV/AIDS in EAP · 47 tion and control throughout the region. Thailand implemented an effective prevention program among commercial sex workers and a strong surveil- lance system. This is an example of an experience that can be shared more broadly in the region. A related and important point is that the World Bank, with its ability to work across sectors, can help build support and share knowledge through its convening role. The Bank will work in close partnerships on a regional level with other donors and agencies. With UNAIDS, the Bank will bring together key sectors of governments and many development partners to forge strategic country and regional responses to HIV/AIDS. · · · Conclusion Asia will determine the future of the global HIV/AIDS pandemic. Fortu- nately, many countries have already begun to fight. But there is much to be done. The World Bank, in close partnership with government, civil society, and other partners can also assist in this response--at both the country and the regional levels. Working with these partners, the World Bank can play a critical role in addressing the risks associated with HIV/AIDS epidemics in the East Asia and Pacific Region to prevent the region from becoming the future epicenter of HIV/AIDS. ANNEX 1 Classification of the Epidemic 49 50 · Annex 1 EAP HIV/AIDS Stage of Epidemic, per Country* High Level Generalized Level Cambodia Thailand Population Myanmar General the in Papua N. Guinea Rate Malaysia Philippines Vietnam Prevalence China Mongolia Lao PDR Indonesia Low Level Concentrated Level Average of HIV/AIDS Prevalence in HRG with Highest Prevalence Rates (Scored) Bubble size is proportional to population in country *Note: (1) In Y axis, countries were scored in decreasing order according to weighted averages of the highest HIV/AIDS prevalence rate among groups practicing high-risk behaviors (HRG); (2) Available data from 1994 to 2003. · Generalized: Greater than 1% among women attending antenatal clinics · Concentrated: Greater than 5% among STD patients and other risk groups · Low Level: Below 1% among STD patients and other risk groups ANNEX 2 Country Overviews The following country overviews provide a snapshot of HIV/AIDS data, programs, and policies in several of the countries in the EAP Region. It must be noted that there are many discrepancies in the available data. Thus in order to provide the greatest level of standardization, all data were first taken from one single source, if possible, and then supplemented with other data when available. The primary sources of data are: · Population numbers and prevalence data: UNAIDS Epidemiological Fact Sheets by Country (UNAIDS/WHO, 2002) · Number of people on antiretroviral therapy: background paper from Julian Gold (Gold and Smith 2003) · Tuberculosis data: WHO Report 2003: Global Tuberculosis Control: Sur- veillance, Planning, Financing (WHO 2003) · Blood safety: background paper from Julian Gold (Gold and Dax 2003) · GNI: World Development Indicators 2001 (World Bank 2001) (http:// www.worldbank.org/data/wdi2001/) · Snapshot of selected HIV/AIDS donors17: Lin and Heywood 2002; Asian Development Bank (ADB); AusAID; Development Gateway; DFID; GFATM; JICA; KFW; UNAIDS; UNDP; UNICEF; USAID; World Bank; M. Morimitsu, personal communication, Japan International Cor- poration Agency, Tokyo, 2003; Gold and Wilson 2002 51 52 · Annex 2 · Modes of transmission: UNAIDS Epidemiological Fact Sheets by Country (UNAIDS/WHO 2002) · Injecting drug user (IDU) data: Reid and Costigan 2002 Other information was provided by numerous sources, including: USAID (http://www.usaid.gov/); NASB/MOH 2003; NASB 2002; World Bank: World Development Indicators; Burrows, personal communication, The Burnet Institute,Melbourne,Australia,2003;Khorloo2003;ReidandCostigan2002; Feng, undated; WHO: HIV/AIDS in Asia and the Pacific Region (WHO 2001); GFATM applications. Country Overviews · 53 C A M B O D I A HIV Epidemic Status: Generalized Total population: 13,441,000 HIV Prevalence in Adult Population (15­49 years old). . . . . . . . . . 2.7% (160,000/6,314,000) HIV Prevalence in Female Sex Workers . . . . . . . . . . . . . . . . . 26.3­31% HIV Prevalence in Injecting Drug Users . . . . . . . . . . . . . . . . . . Unknown HIV Prevalence in Women in Antenatal Clinics . . . . . . . . . . . . 0.6­5.7% HIV Prevalence in Male STI Patients (urban). . . . . . . . . . . . . . . 8.5% Number of People on Antiretroviral Therapy . . . . . . . . . . . . . . 750 Estimated Incidence of TB (all cases/100,000 pop) . . . . . . . . 585 Estimated Adult Cases of TB that Are HIV+ (%). . . . . . . . . . . . . 20 Estimated Multidrug Resistance (new cases) . . . . . . . . . . . . . . 4.2 Per Capita Gross National Income (US$, 2000). . . . . . . . . . . 270 Modes of Transmission in Reported HIV/AIDS Cases (%) · Unknown . . . . . . 96.1 · Hetero . . . . . . . . 3.9 World Bank Projects with HIV Components · 1997: Disease Control and Health Development Project, 30.4 million total, 6.1 million HIV · 2002: Health Sector Support Project, 27.0 million total, 2.0 million HIV Snapshot of Selected Other Donors (U.S. millions) · USAID: Reduced transmission of STIs and HIV/AIDS in high-risk populations (1998­2002): 2.05 (2000) / 2.50 (2001) · JICA: Equipment Supply Program for AIDS Control and Blood Tests (2000): 0.16 · DFID: UNAIDS (2001­02): 0.10 · DFID: Enhancing the response to HIV/AIDS (2001­06): 14.05 · UNDP: Multisectoral assistance to the HIV/AIDS Program in Cambodia (1996­2000): 0.95 · ADB: Technical assistance to Cambodia for capacity building for HIV/AIDS prevention and control (2001­02): 0.07 · French Cooperation: Technical assistance to MOH and support for access to treatment (2000­05): 1.25 Global Fund (U.S. millions) · Partnerships for going to scale with proven interventions for HIV/AIDS, TB, and malaria: 30.8 Blood Safety · Policy: Since 1994. 2000--National blood policy. This policy confirms that the MOH has ultimate responsibility for the management of the National Blood Transfusion Service (NBTS). · Strategic Plan: In draft for 2003­07. Financed by MOH. Aims are to ensure sustainable self-sufficiency in safe blood and blood products. · Present Structure: Hospital based with a national center National Blood Transfusion Com- mittee (NBTC). · Statistics: 2 donations per 1,000 population; 70% replacement donors; 27% external blood donors; through mobile collection teams; 3% spontaneous regular donors. Quality as- sessment program for HIV testing from Pasteur Institute. Clinical guidelines available. 90% of blood transfusions are whole blood transfusions. The National Center for HIV/AIDS, Dermatology, and STD (NCHADS) is situated within the Health Ministry; it is the older of two AIDS bodies that has responsibility for a health response to AIDS. The National AIDS Authority (NAA) has evolved into a cross-cutting body promoting action against AIDS across governments. 54 · Annex 2 M Y A N M A R HIV Epidemic Status: Generalized Total population: 48,364,000 HIV Prevalence in Adult Population (15­49 years old) . . . . . . . Unknown HIV Prevalence in Female Sex Workers . . . . . . . . . . . . . . . . . 26­50% HIV Prevalence in Injecting Drug Users . . . . . . . . . . . . . . . . . . 37.1­63% HIV Prevalence in Women in Antenatal Clinics . . . . . . . . . . . . 0.0­5.3% HIV Prevalence in Male STI Patients (urban). . . . . . . . . . . . . . . 12.1­13.0% Number of People on Antiretroviral Therapy . . . . . . . . . . . . . . Unknown Estimated Incidence of TB (all cases/100,000 pop) . . . . . . . . 162 Estimated Adult Cases of TB that Are HIV+ (%). . . . . . . . . . . . . 11 Estimated Multidrug Resistance (new cases) . . . . . . . . . . . . . . 1.5 Per Capita Gross National Income (US$, 2000). . . . . . . . . . . 390 Modes of Transmission in Reported HIV/AIDS Cases (%) · Hetero . . . . . . . . 57.0 · IDU . . . . . . . . . . 22.1 · Unknown . . . . . . 13.5 · Blood. . . . . . . . . 4.4 · Perinatal . . . . . . . 1.8 · Homo/Bi . . . . . . 1.2 Snapshot of Selected Other Donors (U.S. millions) · AusAID: UNICEF: Mekong Subregional HIV/AIDS Program (1999­2002): 0.77 · AusAID: WVA: Eastern Shan State HIV/AIDS Project (1998­2002): 0.19 · AusAID: WVA: Southern Myanmar HIV/AIDS Project (1998­2002): 0.19 · DFID: Community action for HIV/AIDS care and support in the Mekong Subregion (2001­04): 0.34 · JICA: Equipment Supply Program for AIDS Control and Blood Tests (2000­02): 0.55 Global Fund (U.S. millions) · Strengthening of Prevention and Control Program on HIV/AIDS and Malaria: 54.3 Injecting Drug Use · Estimated Number of IDUs: 150,000­250,000 · Status of Interventions for IDUs: No substitution therapy; no needle exchange program Country Overviews · 55 T H A I L A N D HIV Epidemic Status: Generalized Total population: 63,584,000 HIV Prevalence in Adult Population (15­49 years old) . . . . . 1.8% (650,000/36,600,000) HIV Prevalence in Female Sex Workers . . . . . . . . . . . . . . . 6.7­10.5% HIV Prevalence in Injecting Drug Users. . . . . . . . . . . . . . . . 39.6­50% HIV Prevalence in Women in Antenatal Clinics . . . . . . . . . . 0.4­5.3% HIV Prevalence in Male STI Patients (urban) . . . . . . . . . . . . 2.5% Number of People on Antiretroviral Therapy . . . . . . . . . . . . 20,000 Estimated Incidence of TB (all cases/100,000 pop) . . . . . . 135 Estimated Adult Cases of TB that Are HIV+ (%) . . . . . . . . . . 12 Estimated Multidrug Resistance (new cases) . . . . . . . . . . . . 2.1 Per Capita Gross National Income (US$, 2000) . . . . . . . . 2,020 Modes of Transmission in Reported HIV/AIDS Cases (%) · Hetero . . . . . . . . 82.4 · Unknown . . . . . . 7.1 · IDU . . . . . . . . . . 4.8 · Perinatal . . . . . . . 4.6 · Homo/Bi . . . . . . 1.1 World Bank Projects with HIV Components · 1998: Social Investment Project, 300 million total, 2.6 million HIV Snapshot of Selected Other Donors (U.S. millions) · AusAID: Ambulatory Care Project (2000­01): 0.51 · JICA: Project for Model Development of Comprehensive HIV/AIDS Prevention and Care (1998­2003): 4.72 · JICA: Equipment Supply Program for AIDS Control and Blood Tests (2002): 0.03 · UNDP: HIV/AIDS prevention and care (1994­2000): 0.80 · UNDP: Prevention and control of AIDS in Thailand (1989­2000): 0.89 Global Fund (U.S. millions) · Strengthening national prevention and care programs on HIV/AIDS, tuberculosis, and malaria in Thailand: 109.5 · National prevention and control program of HIV/AIDS and malaria in Thailand: 81.3 · Preventing HIV/AIDS and increasing care and support for injection drug users in Thailand: 1.37 Injecting Drug Use · Estimated Number of IDUs: Currently unknown (in 1994, 100,000­250,000) · Status of Interventions for IDUs: First country to introduce widespread use of methadone as substitution therapy 56 · Annex 2 C H I N A HIV Epidemic Status: Concentrated Total population: 1,284,972,000 HIV Prevalence in Adult Population (15­49 years old). . . . . 0.1% (850,000/726,031,000) HIV Prevalence in Female Sex Workers . . . . . . . . . . . . . . 0­10.3% HIV Prevalence in Injecting Drug Users . . . . . . . . . . . . . . . 0­80% HIV Prevalence in Women in Antenatal Clinics . . . . . . . . . 0­0.5% HIV Prevalence in Male STI Patients (urban). . . . . . . . . . . . 0­1.3% Number of People on Antiretroviral Therapy . . . . . . . . . . . 3,000 Estimated Incidence of TB (all cases/100,000 pop) . . . . . 113 Estimated Adult Cases of TB that Are HIV+ (%) . . . . . . . . . . 0.4 Estimated Multidrug Resistance (new cases). . . . . . . . . . . . 5.3 Per Capita Gross National Income (US$, 2000) . . . . . . . . 840 Modes of Transmission in Reported HIV/AIDS Cases (%) · IDU . . . . . . . . . . 38.4 · Unknown . . . . . . 32.9 · Hetero . . . . . . . . 23.0 · Blood. . . . . . . . . 4.0 · Homo/Bi . . . . . . 1.4 · Perinatal . . . . . . . 0.4 World Bank Projects with HIV Components · 1996: Disease Prevention Project, 100 million total, 4.95 million HIV · 1999: Health Nine Project, 60 million total, 25.6 million HIV · 2002: Tuberculosis Control Project, 104 million total, 0.1 million HIV Snapshot of Selected Other Donors (U.S. millions) · AusAID: HIV/AIDS Prevention and Care Project (2002­07): 7.54 · DFID: HIV/AIDS Economic Impact Study (2001­02): 0.18 · DFID: HIV/AIDS Education Project (2001­06): 0.22 · DFID: Support for HIV/AIDS education for young people (2001­06): 21.87 · UNDP: Multisector approaches for HIV/AIDS control and prevention in China (1997­2000): 1.90 Global Fund (U.S. millions) · China Comprehensive AIDS Response: 97.9 Blood Safety · Policy: BTS are nonprofit organizations; 1984 nonremunerated, voluntary donor policy be- came law in 1998. · Strategic Plan: MOH issued temporary administrative measures in 1998. Standards for BTS are under development. · Present Structure: One BTS per province; one central BTS for each municipality. · Statistics: 53% volunteer donors. Injecting Drug Use · Estimated Number of IDUs: 3.5 million · Status of Interventions for IDUs: Methadone maintenance and needle/syringe social market- ing are now being piloted. In May 2001, the State Council issued a 5-year action plan (2001­05), with two priority action areas: (a) health education to develop a basic understanding of HIV prevention in the general population and (b) behavioral interventions among groups that practice high- risk behaviors. Country Overviews · 57 I N D O N E S I A HIV Epidemic Status: Concentrated Total population: 214,840,000 HIV Prevalence in Adult Population (15­49 years old) . . . . . . . 0.1% (120,000/118,000) HIV Prevalence in Female Sex Workers . . . . . . . . . . . . . . . . . 2.0­27% HIV Prevalence in Injecting Drug Users . . . . . . . . . . . . . . . . . . 19­48% HIV Prevalence in Women in Antenatal Clinics . . . . . . . . . . . . 0.0% HIV Prevalence in Male STI Patients (urban). . . . . . . . . . . . . . . Unknown Number of People on Antiretroviral Therapy . . . . . . . . . . . . . . Unknown Estimated Incidence of TB (all cases/100,000 pop) . . . . . . . . 271 Estimated Adult Cases of TB that Are HIV+ (%). . . . . . . . . . . . . 0.3 Estimated Multidrug Resistance (new cases) . . . . . . . . . . . . . . 0.7 Per Capita Gross National Income (US$, 2000). . . . . . . . . . . 580 Modes of Transmission in Reported HIV/AIDS Cases (%) · Hetero . . . . . . . . 55.5 · IDU . . . . . . . . . . 18.7 · Homo/Bi . . . . . . 14.2 · Unknown . . . . . . 9.6 · Perinatal . . . . . . . 1.4 · Blood. . . . . . . . . 0.6 World Bank Projects with HIV Components · 1996: HIV/AIDS and STD Prevention and Management Project, 24.8 million total, 24.8 million for HIV (project was closed in 1999, disbursing $4.52 million of the $24.8 million) · 1998: Safe Motherhood Project, 42.5 million total, 0.2 million HIV Snapshot of Selected Other Donors (U.S. millions) · AusAID: HIV/AIDS Prevention and Care Project­Phase 1 (1998­2002): 21.0 · AusAID: HIV/AIDS Prevention and Care Project­Phase 2 (2002­07): 30.0 · KFW: HIV/AIDS Prevention and Family Planning (2000­03): 9.42 · UNDP: Strengthening GOI/NGO Capacity and Partnership for HIV/AIDS Program implementation (1997­2000): 0.88 Global Fund (U.S. millions) · Strengthening directly observed treatment (short course) (DOTS) expansion in Indonesia (HIV/AIDS): 15.96 Blood Safety · Policy: Has a blood policy but not implemented. · Strategic Plan: Two systems--a government and a hospital-based system. · Present Structure: Province based over the last 3 years. · Statistics: Very little blood collected for the large population. Injecting Drug Use · Estimated Number of IDUs: 150,000 · Status of Interventions for IDUs: Pilot project on substitution therapy; pilot project on needle exchange and outreach 58 · Annex 2 M A L A Y S I A HIV Epidemic Status: Concentrated Total population: 22,633,000 HIV Prevalence in Adult Population (15­49 years old). . . . . . . 0.4% (41,000/11,800,000) HIV Prevalence in Female Sex Workers . . . . . . . . . . . . . . . . 2.05­6.3% HIV Prevalence in Injecting Drug Users . . . . . . . . . . . . . . . . . 16.8% HIV Prevalence in Women in Antenatal Clinics . . . . . . . . . . . 0.0­0.7% HIV Prevalence in Male STI Patients (urban). . . . . . . . . . . . . . 4.2% Number of People on Antiretroviral Therapy . . . . . . . . . . . . . <100 Per Capita Gross National Income (US$, 2000) . . . . . . . . . . 3,250 In 2003, there were 27,119 cases of TB in Malaysia, with a rate of 120/100,000. Modes of Transmission in Reported HIV/AIDS Cases (%) · IDU . . . . . . . . . . 54.7 · Hetero . . . . . . . . 21.2 · Unknown . . . . . . 21.1 · Homo/Bi . . . . . . 1.6 · Perinatal . . . . . . . 1.1 · Blood. . . . . . . . . 0.3 World Bank Projects with HIV Components · 1994: Health, 50.0 million total, 16.0 million HIV Snapshot of Selected Other Donors (U.S. millions) · JICA: Equipment Supply Program for AIDS Control and Blood Tests (2000): 0.22 Blood Safety · Policy: Detailed policy since ~1999. · Strategic Plan: Plan documented by MOH; BTS funded by MOH; move toward centralizing BTSs; central blood service seeking Good Manufacturing Practice (GMP) accreditation. · Present Structure: MOH advised by a Transfusion Committee; BTS often hospital-based central services seeking GMP accreditation. Country Overviews · 59 P A P U A N E W G U I N E A HIV Epidemic Status: Concentrated Total population: 4,920,000 HIV Prevalence in Adult Population (15­49 years old) . . . . . . . 0.7% (16,000/2,491,000) HIV Prevalence in Female Sex Workers . . . . . . . . . . . . . . . . . 16% HIV Prevalence in Injecting Drug Users . . . . . . . . . . . . . . . . . . Unknown HIV Prevalence in Women in Antenatal Clinics . . . . . . . . . . . . 0­0.2% HIV Prevalence in Male STI Patients (urban). . . . . . . . . . . . . . . 7.0% Number of People on Antiretroviral Therapy . . . . . . . . . . . . . . <100 Per Capita Gross National Income (US$, 2000). . . . . . . . . . . 670 The national incidence of TB has risen from 0.8 per 1,000 in 1974 to 10.7 per 1,000 in 1984 to 51 per 1,000 in 1999. In 2003, there were 11,602 cases, with a rate of 236/100,000. Modes of Transmission in Reported HIV/AIDS Cases (%) · Unknown . . . . . . 76.1 · Hetero . . . . . . . . 21.5 · Perinatal . . . . . . . 1.5 · Homo/Bi . . . . . . 0.6 · Blood. . . . . . . . . 0.3 World Bank Projects with HIV Components · 1993: Population and family planning, 6.9 million total, 0.66 million HIV Snapshot of Selected Other Donors (U.S. millions) · AusAID (2000­05): 30.78 Blood Safety · Policy: Papua New Guinea Red Cross does not have a policy document. · Strategic Plan: BTS operates under a Memorandum of Understanding (MOU) between the Department of Health (DOH) and Red Cross. Future plan: Government to rebuild BTS head- quarters (HQ) laboratory (AusAID funding) and retrain all staff (AusAID funding). BTS: Pheno- typing panel cell preparation. Plasmapheresis unit establishment. Red Cross: Withdrawal from BTS management after termination of MOU with DOH in 2003 and concentrate on developing donor recruitment only. · Present Structure: MOU outlines that DOH is responsible for finance, buildings, staff, and equipment and materials. Most of the guidelines are incorporated in the Standard Operat- ing Procedure (SOP) manual and DOH/Red Cross MOU. MOU terminates in 2003. Quality control exists. Internal controls at each blood bank. · Statistics: 50% blood donation voluntary, 49% family/replacement, <1% voluntary regular blood donors. Each hospital collects blood for its own use mainly as red cell concentrate and whole blood. Only BTS HQ produces fresh-frozen plasma, cryoprecipitate, and platelet concentrates. 2003: Legislation was designed that could improve the management of AIDS. The pro- posal includes human rights, proscribes national policy and practice on HIV testing and medical management, and provides voluntary counseling and testing. 60 · Annex 2 V I E T N A M HIV Epidemic Status: Concentrated Total population: 79,175,000 HIV Prevalence in Adult Population (15­49 years old) . . . . . 0.3% (130,000/43,300,000) HIV Prevalence in Female Sex Workers . . . . . . . . . . . . . . . 4.2­6.0% HIV Prevalence in Injecting Drug Users. . . . . . . . . . . . . . . . 26.8­30.4% HIV Prevalence in Women in Antenatal Clinics . . . . . . . . . . 0.0­0.4% HIV Prevalence in Male STI Patients (urban) . . . . . . . . . . . . 2.0­3.2% Number of People on Antiretroviral Therapy . . . . . . . . . . . . Approx. 50 in pilot study Estimated Incidence of TB (all cases/100,000 pop) . . . . . . 179 Estimated Adult Cases of TB that Are HIV+ (%). . . . . . . . . . . 1.4 Estimated Multidrug Resistance (new cases) . . . . . . . . . . . . 2.3 Per Capita Gross National Income (US$, 2000). . . . . . . . . 390 Modes of Transmission in Reported HIV/AIDS Cases (%) · Unknown . . . . . . 52.4 · IDU . . . . . . . . . . 38.2 · Hetero . . . . . . . . 8.6 · Perinatal . . . . . . . 0.8 World Bank Projects with HIV Components · 2002: Regional Blood Transfusion Centers Project, 38.2 million total, 38.2 million HIV Snapshot of Selected Other Donors (U.S. millions) · AusAID: HIV/AIDS Capacity Building Project (2002­04): 0.82 · AusAID: UNDP HIV/AIDS Youth Awareness Project (2002­05): 0.71 · AusAID: Care: NOVA2000: Confronting HIV/AIDS, project-NGO window (2000­03): 0.35 · AusAID: Participatory HIV/AIDS prevention (1998­2001): 0.57 · AusAID: UNDP/HIV/AIDS: Awareness raising for youth, cofinancing (2000­03): 1.14 · UNDP: HIV/AIDS capacity building (1999­2001): 0.75 · UNDP: HIV/AIDS, environment, and youth (1999­2001): 0.63 · UNDP: Strengthening the capacity for coordination, management, and planning of HIV/AIDS in Vietnam (1994­2000): 1.04 · DFID: HIV/AIDS control (2001­02): 24.59 Global Fund (U.S. millions) · Strengthening care, counseling, support to people living with HIV/AIDS (PLWHAs), and related community-based activities: 12.00 Blood Safety · The Regulation for Blood Transfusion issues in 1992 established standards and guidelines for blood safety. By 2000, the blood safety program had reached its objective of 100% blood units screened for HIV. Strategy for blood collection was recently shifted from collect- ing at district health facilities to provincial or regional facilities. Injecting Drug Use · Estimated Number of IDUs: 69,000 (1997) Country Overviews · 61 L A O P D R HIV Epidemic Status: Low Level Total population: 5,403,000 HIV Prevalence in Adult Population (15­49 years old) . . . . . . . <0.1% (1,300/2,500,000) HIV Prevalence in Female Sex Workers . . . . . . . . . . . . . . . . . 1.0% HIV Prevalence in Injecting Drug Users . . . . . . . . . . . . . . . . . . 2.0% HIV Prevalence in Women in Antenatal Clinics . . . . . . . . . . . . 0.0% HIV Prevalence in Male STI Patients (urban). . . . . . . . . . . . . . . Unknown Number of People on Antiretroviral Therapy . . . . . . . . . . . . . . Unknown Per Capita Gross National Income (US$, 2000). . . . . . . . . . . 290 The national incidence of TB has risen from 0.8 per 1,000 in 1974 to 10.7 per 1,000 in 1984 to 51 per 1,000 in 1999. In 2003, there were 8,512 cases in Lao PDR with a rate of 158/100,000. Modes of Transmission in Reported HIV/AIDS Cases (%) · Unknown . . . . . . 97.7 · Perinatal . . . . . . . 2.3 Snapshot of Selected Other Donors (U.S. millions) · AusAID: Mekong Subregional HIV/AIDS Care and Support Project (2000­02): 0.52 · USAID: HIV/AIDS (2002­06): 1.00 (2002)­1.00 (2003) · JICA: Equipment Supply Program for AIDS Control and Blood Tests (2000): 0.17 · UNDP: Lao PDR HIV/AIDS (1998­2000): 0.27 Global Fund (U.S. millions) · Prevention and control of HIV/AIDS/STI, TB, and malaria in the Lao PDR: 3.4 Blood Safety · Policy: In 1991 the MOH transferred BTS to the Lao Red Cross. Quality system is in place but not formal. · Strategic Plan: Reconsidering the organization system of the BTS and its tasks. · Present Structure: NBTC plus eight provinces exist. · Statistics: 80% blood is collected from mobile sessions, ~11,000 blood units are annually supplied, 63% is collected from voluntary donors. Lao PDR developed a National Strategic Plan (NSP) on HIV/AIDS/STD for 2002­05. Main issues declared as priorities included surveillance, STD prevention and treatment, and prevention of HIV among youth, mobile populations, and service women. 62 · Annex 2 M O N G O L I A HIV Epidemic Status: Low Level Total population: 2,559,000 HIV Prevalence in Adult Population (15­49 years old) . . . . . . . <0.1% (<100/1,400,000) HIV Prevalence in Female Sex Workers . . . . . . . . . . . . . . . . . Unknown HIV Prevalence in Injecting Drug Users . . . . . . . . . . . . . . . . . . No reported cases HIV Prevalence in Women in Antenatal Clinics . . . . . . . . . . . . Unknown HIV Prevalence in Male STI Patients (urban). . . . . . . . . . . . . . . 0.0% Number of People on Antiretroviral Therapy . . . . . . . . . . . . . . Unknown Per Capita Gross National Income (US$, 2000). . . . . . . . . . . 390 In 2003, there were 4,969 TB cases in Mongolia with a rate of 194/100,000. Modes of Transmission in Reported HIV/AIDS Cases (%) · Hetero . . . . . . . . 50 · Homo/Bi . . . . . . 50 Snapshot of Selected Other Donors (U.S. millions) · AusAID: STI/HIV education (UNDP), cofinancing (2000­02): 249.05 · UNDP: HIV/AIDS/STDs in Mongolia (1997­2000): 0.30 Global Fund (U.S. millions) · Strengthening national prevention and care programs on HIV/AIDS in Mongolia: 3.0 Blood Safety · Policy: 2000 National Blood Policy exists. · Strategic Plan: Central BTS; 25 centers in the country. · Present Structure: Areas of the country are very remote and not well planned for. · Statistics: Replacement donation. Need for training, quality management, and quality assur- ance on all levels. Number of transfusions difficult to document. Country Overviews · 63 P H I L I P P I N E S HIV Epidemic Status: Low Level Total population: 77,131,000 HIV Prevalence in Adult Population (15­49 years old) . . . . . . <0.1% (9,400/39,600,000) HIV Prevalence in Female Sex Workers. . . . . . . . . . . . . . . . 0.3% HIV Prevalence in Injecting Drug Users . . . . . . . . . . . . . . . . 1.0% HIV Prevalence in Women in Antenatal Clinics. . . . . . . . . . . Unknown HIV Prevalence in Male STI Patients (urban) . . . . . . . . . . . . . 0.0% Number of People on Antiretroviral Therapy. . . . . . . . . . . . . <200 Estimated Incidence of TB (all cases/100,000 pop). . . . . . . 297 Estimated Adult Cases of TB that Are HIV + (%) . . . . . . . . . . 0.4 Estimated Multidrug Resistance (new cases) . . . . . . . . . . . . . 3.2 Per Capita Gross National Income (US$, 2000) . . . . . . . . . 1,020 Modes of Transmission in Reported HIV/AIDS Cases (%) · Hetero . . . . . . . . 56.0 · Homo/Bi . . . . . . 35.0 · Unknown . . . . . . 4.0 · Perinatal . . . . . . . 2.0 · Blood. . . . . . . . . 2.0 · IDU . . . . . . . . . . 1.0 Snapshot of Selected Other Donors (U.S. millions) · USAID: The threat of HIV/AIDS and selected infectious diseases is reduced (1994­2004): 4.40 (2000) · USAID: The threat of HIV/AIDS and selected infectious diseases is reduced (1992­2004): 3.50 (2001) · JICA: Project for Prevention and Control of AIDS (1996­2001): 7.44 · JICA: Equipment Supply Program for AIDS Control and Blood Tests (1996­98, 2000): 1.11 · UNDP: Promoting multisectoral and community-based approaches to HIV prevention and care in the Philippines (2000): 0.26 · UNDP: Increasing awareness and understanding of the development implications of HIV/AIDS (2000): 0.15 Global Fund (U.S. millions) · Accelerating STI and HIV/AIDS prevention through intensified delivery of services to vulnera- ble groups and people living with HIV/AIDS in strategic areas in the Philippines: 5.5 Blood Safety · Policy: Policies and guidelines are well developed but not followed. 1994--National Blood Services Act. · Present Structure: National Center with regional directors. National Reference Laboratory is designated. Injecting Drug Use · Estimated Number of IDUs: 10,000 · Status of Interventions for IDUs: No substitution therapy; no needle exchange program The AIDS Prevention and Control Act was signed into law in February 1998. It created a legal and policy environment to prevent new infections and protect the human rights and civil liberties of people living with HIV/AIDS. ANNEX 3 Snapshot of Estimated Number and Risk Behaviors of Injecting Drug Users and Commercial Sex Workers in the EAP Region The information in both of these tables was compiled using data from numerous sources and is therefore not standardized. This is only to be used as an example of the variety and size of risk behaviors in the region. 65 in to the 90%, up to as IDUs some highest in high (2000/2001) prevalence the (2000); as (2001/2002) according among world HIV 48% states among the 80% region Unknown 37.1­63%, 39.6­50% 0­20.5% 19­ opium with opium metham- used mixed cooked Drug blackwater opium, methamphetamine, ketamine methamphetamine, phetamines diazepam heroin, juice, benzodiazapines Heroin, Heroin Heroin, Heroin, Heroin, use in of pass- inade- users and equipment drug the behaviors sharing widespread syringes, drug of blood and equipment, behaviors injecting other with of syringes to high-risk galleries," injecting, needles cleaning Risk and of of needles of heroin injecting no around of or evidence it "shooting needles sharing mixing ing quate Little Widespread Frequency Sharing Sharing IDUs 1994; of (in Estimated million 100,000­ 250,000) number Unknown 150,000­250,000 Unknown 3.5 150,000 Cambodia Myanmar Thailand China Indonesia Country Generalized Concentrated up Costi- to up estimates and (2003), cases Reid (1996), WHO higher 89.9% reported but be 2002); 76.3% to to 16.8% 26.8­30.4% 2% No 1%, (UNAIDS opium, amphet- Epidemic diaze- heroin pethidine, cocktails 2003. opium, some diazepam, blackwater phenobarbital drug HIV/AIDS others morphine, promethazine, pam, amines, dimedrol Global and Heroin Heroin, Blackwater Cannabis, Nubain, the on Pisani same drugs signs Report 2003; inade- with con- CSWs the of clear Bank use and 2002); equipment, using low IDUs syringes World equipment, the equipment equipment, of IDUs -- toward purposes, and 2002; injectors between injecting injecting customers injecting among needles (UNAIDS/WHO NASB of cleaning of tendency use of recreational linkages 2003; Updates quate professional unsterile multiple dom for of Sharing Sharing Growing Sharing NASB/MOH low Country­2002 but by undated; official Sheets considered estimates available. Feng, 200,000 69,000 Unknown, No 10,000 not Fact 2003; Information Khorloo level PDR Epidemiological Malaysia Vietnam Lao Mongolia Philippines cells: 2002; Low Blank Source: gan major major urban), urban), (2001/02) prevalence (2000) (outside (2000) (major (outside (2000) (2002) (major HIV 10.5% urban) 0­2.9% urban) 26.3­31% 26­50% 6.7% 0­10.3% 2.0­27% Aver- the 3.2 much Mean in rate visiting from aver- any 49), was 49), clients Sailors contact men clients HIV, of report clients clients fallen to of than (15­ (33.0); of night (18­ -- (7.8). adult has 25% 10% with level Risk rate CSW of 32,000 number week truckers CSWs groups group group % age number previous per (7.77) CSWs almost roughly infected age per and higher with other Age Age The About partner IDUs unsafe the use of proportion female one CSWs, of never large 49%) commercial unchanged intercourse, is in began and -- behaviors region very than workers sexual pattern the IDUs virtually Risk in involvement sex (more condoms practices of surveillance between prostitution, female use exchange highest sexual in of condoms encounters: since Unprotected Link Increasing Low CSWs est.) million of 3 (high -- -- 200,000 than 270,000 Estimated and number 12,290 More Between Cambodia Myanmar Thailand China Indonesia Country Generalized Concentrated in major partner urban), sex (outside (1996) (2002/03) -- NASB/MOH (major (2002) (2000) (1994) 2002); 2.05% urban) nonregular 6.3% 16% 4.2­6.0% 1.0% 0.3% or rcial (UNAIDS of week) is po- year clients of more of comme Epidemic of per paying truck truck or per quarter past a of 3 -- (3­5 contact times/ of a 24% the -- number either of number 60 in third and reported 32% and low (2.2­3.5 1999) HIV/AIDS CSW a sex, reported having per around month/SW drivers police for drivers lice partners clients week, Global Average Frequency About Average the reported on women Report 10% casual condoms City service in from 2002); of workers, movement of use use Minh sex 68% -- ranges of Chi -- -- IDU Ho population condom of of consistent in number However, (UNAIDS/WHO 40%) 2003. level 50%, lowest illegal. partnership to is (avg. cross-border is Updates Low Prevalence Increasing others and of : prostitution and Country­2002 Pisani by -- -- number women (35.7), (40.3), (16.7), -- -- (7.4) PDR, 2003; service 15­19 20­24 25­29 30 Lao Sheets in available. Bank 50,000 Average not Fact rare is World New a work 2002; Information Guinea level PDR sex year. Epidemiological cells: NASB Malaysia Papua Vietnam Lao Mongolia Philippines Low Formal past a. the Blank Source: 2003; ANNEX 4 Infectious Disease Epidemiology All socioeconomic models of the impact of HIV/AIDS depend on epidemio- logical predictions on the future course of the epidemic. Many economic models rely on simplistic assumptions that other parts of the world will fol- low the trajectory of Sub-Saharan Africa. This analogy reflects a profound misunderstanding of the epidemiology of HIV. To understand this one must develop a theoretical model of the growth of infectious diseases. Infectious diseases do not grow indefinitely--there must be some natural limit. In fact, when one views an epidemic over time, it has an initial phase of growth and then it tapers off and reaches a steady state before it eventu- ally disappears. The classic case of this type of infection is influenza or SARS. HIV/AIDS is similar, but the process is much slower because of the long in- terval between infection with HIV and the development of AIDS. In addi- tion, there is a long period of infectiousness, often years, which makes it very different from classical infectious diseases such as influenza. The figure on page 72 shows the course of an HIV/AIDS infection in a population.18 The key to understanding the dynamics of an infectious dis- ease is the reproductive rate (R0) common to all organisms. As can be seen, in the initial period of R0 > 1, the prevalence increases exponentially. However, as the number of people susceptible to the disease are "used up" by the epidemic, the reproductive rate begins to fall. If no new susceptible groups enter the population, then the infection will fade away. Given the long duration of HIV/AIDS, there is continuing growth in new susceptible populations, making extinction unlikely. 71 Course of an HIV/AIDS Infection A. Reproductive Rates for an HIV/AIDS Epidemic HIV prevalence/incidence 0.45 R1<1 0.4 R1>1 R1=1 0.35 HIV incidence Incidence HIV-associated mortality 0.3 HIV prevalence 0.25 0.2 0.15 0.1 0.05 0 0 5 10 15 20 Time (years) RO>1 B. Stages of an HIV/AIDS Epidemic Incidence of new HIV infections Size of the epidemic HIV HIV HIV HIV prevalence Incidence of HIV-associated deaths Epidemic Endemic Note: The relationship between the effective reproductive rate R, the incidence of HIV infections, and HIV prevalence is shown in (A). For simplicity, it is assumed that all incident cases of HIV die 8 years after in- fection. In this simple case, the incidence of AIDS deaths replicates HIV incidence. On entry to the popu- lation, the effective reproductive rate equals the basis reproductive rate and must be greater than 1 for an epidemic to occur. As the presence of infection increases, the effective reproductive rate decreases as contacts are made with those already infected. The epidemic continues to grow even when each new case generates fewer than one more case, because infections are still occurring. Incidence decreases be- fore prevalence; only when deaths remove those infected from population will prevalence decrease. The relationship between incident HIV infections and incident HIV-associated mortality is illustrated in (B). When incident infections match incident deaths, the epidemic will have reached an endemic steady state. Here the average effective reproductive rate must be 1 if the prevalence is to remain constant. Source: Garnett 1998. Infectious Disease Epidemiology · 73 What determines the value of R0? R0 = cD where = the likelihood of transmission when a contact is made between an infected and susceptible; c = the rate of contact in the population; and D = the duration of infectiousness. Understanding these three simple terms is the key to understanding the epidemic. represents the transmission probability. In the case of HIV/AIDS, this is the probability that HIV will be spread between two individuals based on their contact. For sexual contact this is the probability of transmission dur- ing the sex act, which is estimated to be quite low (0.001). Concurrent STIs increase 50- to 300-fold. The for transmission by sharing contaminated needles is significantly higher. The other key variable is c, the pattern of contacts. This simple concept is very complex because it depends on the overall sexual networks. There has been a large growth of sexual behavioral studies. Unfortunately, there has been limited growth in Asia and much more work is needed to more fully understand the sexual networks in Asia. One of the key differences compared with North America and Western Europe is the common use of commercial sex workers in Asian countries by men from a wide range of age groups and social classes. In Thailand, before HIV/AIDS, it was estimated that more than a quarter of the population visited sex workers. The final variable is D, the duration of effectiveness, which would be af- fected by treatment. This simple model can be increased in almost infinite complexity by adding subpopulations with different risk behavior and dif- ferent mixing patterns with other subpopulations. As the model increases in complexity, more parameter estimates are needed. These models play a key role in understanding epidemics. Economic models are only as good as the epidemiological-demographic projections. The models are dynamic and a country's position on the epidemic curve will determine the interventions needed and their relative cost-effectiveness. It is important to emphasize that the cost-effectiveness of interventions changes depending on the state of the epidemic. Therefore, these models are par- ticularly useful for modeling interventions and comparing relative cost- effectiveness. They can be a useful tool for program planning and for 74 · Annex 4 determining coverage targets needed to alter the course of the epidemic. They are also an important tool in predicting the trajectory of the HIV epi- demic. There is an urgent need to standardize these models and improve data collection for parameters. ANNEX 5 Epidemiological Projections of HIV/AIDS in East Asia Although there are limited data, many observers have made predictions con- cerning the course of the EAP epidemic. These range from rates similar to Sub-Saharan Africa to a prediction that most Asian epidemics will never reach 1 percent prevalence. The predictions of large-scale growth of Asian epidemics are based on the experience of Sub-Saharan Africa, where concentrated epidemics began in groups practicing high-risk behavior, and then HIV spread to the general population. Under this scenario, Asia is at great risk for becoming the epi- center of the HIV epidemic in the next decade. This was the approach adopted by the U.S. Central Intelligence Agency19 in its scenario planning and reinforced by Eberstadt's model,20 which pre- sumes the epidemic will become a sexually transmitted disease in the general population. According to Eberstadt, Eurasia (considered to be the continent of Asia, plus Russia) could soon house the largest number of AIDS victims, driven by the spread of HIV in China, India, and Russia. Even under the as- sumption of a mild epidemic, Eberstadt suggests that the total number of HIV cases in China, India, and Russia from 2000 through 2025 would equal 66 mil- lion. With high rates, China would alone account for 70 million new cases. Eberstadt predicts that even a mild epidemic would have dire economic effects leading to a decrease in economic growth by half. There is a countervailing view from some epidemiologists that Asian epi- demics are constrained by low-sexual-risk behavior in the general popula- tion (Chin 2003).21 Some analysts believe that the Asian HIV epidemics will 75 76 · Annex 5 Projections Based on the Eberstadt Model for China for 2025 Mild epidemic Intermediate Severe China (1.5%) epidemic (3.5%) epidemic (5%) Cumulative new 32 million 70 million 100 million HIV cases Cumulative 19 million 40 million 58 million AIDS deaths never become generalized sexual epidemics similar to Sub-Saharan Africa. According to them, there are not multiple, overlapping partners and high rates of sexually transmitted diseases that drive the African epidemics. They believe that because risk behavior in the general population is low in Asia, HIV will not become a sexually transmitted disease and spread rapidly through the general, heterosexual population. Under the scenario of low- risk behavior in the general population, they predict that concentrated epi- demics will remain concentrated and they will not spread to the general population. Such views suggest that the potential for growth in the concentrated epidemics in the region (China, Indonesia, Vietnam, and Malaysia) is low because of the lower rate of high-risk sexual behavior in the general pop- ulation and the low underlying prevalence of sexually transmitted diseases. Even repeating the pattern of growth similar to Thailand and Cambodia is unlikely for these countries because of the lower level of commercial sex work with fewer men visiting CSWs and less often. According to this the- ory, Asian epidemics are fundamentally different from the epidemics in Sub-Saharan Africa and none will become generalized epidemics in the heterosexual population. There is one country, Papua New Guinea, where the preconditions exist for the epidemic to follow a trajectory sim- ilar to Sub-Saharan Africa. USAID, intrigued by this hypothesis for HIV in Asia, commissioned a consortium led by Tim Brown and Wiwat Peerapatinapokin from the East- West Center to develop a transmission dynamic model of HIV/AIDS that would attempt to understand the dynamics of HIV/AIDS in Asia. The Asian Epidemic Model (AEM) has been used extensively in Thailand and Cambo- dia (Cambodia Working Group on HIV/AIDS Projection 2002; Thai Work- ing Group on HIV/AIDS Projections 2001). The model captures the interaction between groups, including CSWs, their clients, IDUs, and the Epidemiological Projections of HIV/AIDS in East Asia · 77 general population. The model requires extensive data, and Thailand is one of the few countries with adequate data to test empirically the model by comparing its projections to actual prevalence data. However, the model is actually fit to the existing data. AEM does not predict that the growth of the epidemic would be con- strained. Without interventions, the epidemic in Thailand would have con- tinued to grow toward 10 percent by 2010. What drives the growth is the high rate of high-risk behavior among the population, with over 25 percent of men reporting having sex outside of long-term partnerships. The AEM is a sophisticated model that requires a large amount of data, not available in most countries. UNAIDS has developed a simpler model, fairly conservative in approach, for predicting the future of the epidemic. The main consideration underlying this approach is a practical under- standing of the level and quality of data for HIV/AIDS at the country level. Also, the method should be able to be used by country programs using local capacity. The estimates are usually produced through a multimethod process using local experts with locally available data supplemented by targeted sur- vey data. The UNAIDS projections are based on determining the size of the at-risk populations, projecting growth until HIV saturates in the high- risk population, and factoring in the transmission from groups who practice high-risk behaviors to their partners. Interactions Between Groups that Practice High-Risk Behaviors and the General Population 5-20% 0.3-1% FSW Clients MSM IDUs Low- or no-risk males 0.1-5% 2-3% Low- or no-risk females Source: Brown 2002. ANNEX 6 Tuberculosis Estimated Cases of Tuberculosis: Rate per 100,000 (2003) Cambodia Philippines Indonesia Papua New Guinea Mongolia Vietnam Myanmar Lao PDR Thailand Malaysia China 0 100 200 300 400 500 600 Source: WHO Report 2003: Global Tuberculosis Control: Surveillance, Planning, Financing 79 ANNEX 7 Overview of Current Blood Safety Policy Status Country Policy Strategic plan Present structure Statistics Generalized Cambodia Since 1994. In draft for Hospital-based 2 donations 2000­National 2003­07. with a national per 1,000 blood policy. Financed by center (NBTC) population. This policy con- MOH. 70% replacement firms the MOH Aims are to en- donors. has ultimate sure sustain- 27% external responsibility able self- blood donors for the man- sufficiency in through mobile agement of safe blood and collection the NBTS. blood prod- teams. ucts. 3% spontaneous regular donors. Quality assess- ment program for HIV testing from Pasteur In- stitute. Clinical guidelines available. 90% of blood trans- fusions are whole blood transfusions. (continued) 81 82 · Annex 7 Country Policy Strategic plan Present structure Statistics Concentrated China BTS are nonprofit MOH issued One BTS per 53% volunteer organizations. temporary province. One donors. 1984 non- administrative central BTS for remunerated, measures each munici- voluntary in 1998. pality central donor policy Standards for BTS. became blood BTS under donor law in development. 1998. Indonesia Has a blood Two systems-- Structure is Very little blood policy but not a government province based collected for implemented. and a hospital- over the last the very large based 3 years. Has population. system have resulted Highly dis- grown up. in fewer organized, resources under- reaching the resourced, services and training is themselves. at a low level. There are ex- ceptions such as Bali and Surabaya. Malaysia Detailed policy Plan documented MOH advised by since 1999 by MOH. BTS a Transfusion funded by Committee. MOH. Move BTS often hos- toward central- pital-based izing BTS. central services Central blood seeking GMP service seeking accreditation. GMP accreditation. Papua Papua New BTS operates MOU outlines 50% blood New Guinea Red under a MOU that DOH is donation Guinea Cross does not between DOH responsible for voluntary, have a policy and Red Cross. finance, build- 49% family/ document. Future plan: ings, staff, and replacement Government: equipment and <1% voluntary rebuild BTS materials. Most regular blood HQ laboratory of the guide- donors. (AusAID fund- lines are incor- Each hospital ing), retrain all porated in the collects blood staff (AusAID SOP manual for its own use funding). and DOH/Red mainly as red BTS: pheno- Cross MOU. cell concen- typing panel MOU termi- trate and cell prepara- nates in 2003. whole blood. tion. Plasma- Quality control (continued) Overview of Current Blood Safety Policy Status · 83 Country Policy Strategic plan Present structure Statistics pheresis unit exists. Internal Only BTS HQ establishment. controls at produces Red Cross: with- each blood fresh-frozen drawal from bank. plasma, cryo- BTS manage- precipitate, ment after and platelet termination of concentrates MOU with (it is possible DOH in these are 2003­04 and flown to other concentrate on centers). developing donor recruit- ment only. Low level Lao PDR BTS started in Future plans will 1995 National Goal is 100% 1975 under be reconsider- Blood Policy voluntary un- MOH. In 1991 ing the organi- established. paid donors in the MOH trans- zation system National Blood the next few ferred BTS to of the BTS and Transfusion years. the Lao Red its tasks. Committee Mobile units are Cross. headed by the most Quality system is MOH and effective way in place but not president of to reach formal. Lao Red Cross donors. set up to super- 80% blood is vise NBP. collected Currently from mobile NBTC plus sessions. 8 provinces Since 1995 the exist. Lao Red number of vol- Cross governs untary donors NBC and has increased. partly governs 11,000 blood networks in units are annu- provinces. ally supplied, Provinces are 63% is col- hospital based. lected from vol- untary donors. Mongolia Low level of Central BTS. Areas of the Replacement donors--2000 25 centers in the country are donation. National Blood country. very remote Need for train- Policy exists. Financed by and not well ing, quality MOH--severe planned for. management, financial and quality constraints. assurance on all levels. Number of trans- fusions difficult to document. (continued) 84 · Annex 7 Country Policy Strategic plan Present structure Statistics Philippines Policies and National policy National Center 70% commercial guidelines are being imple- with regional donors well developed mented. Com- directors. (1994). but not mercial blood National Refer- 70% replace- followed. banks still ence Labora- ment donors 1994­National operate. tory is (2000). Blood Financed by designated. 20% commercial Services Act. DOH addi- donors tional funds as (2000). required. National capital (2001). Voluntary donors (53%), paid (2%). 110,000 dona- tions annually. Clinical use of blood is not under guidelines. Source: Gold and Dax 2003. ANNEX 8 Approved HIV- Related Projects Under the Global Fund for EAP Region Round/ 2-year 5-year Country Title Status Approved Approved Generalized Cambodia Partnership for going to scale 1 11,242,538 15,945,803 with proven interventions for Approved HIV/AIDS, TB, and malaria Partnership for going to scale 2 5,370,564 14,877,295 with proven interventions for Approved HIV/AIDS, TB, and malaria Myanmar Strengthening of Prevention 3 19,221,525 54,300,034 and Control Program on Approved HIV/AIDS and Malaria in Myanmar Thailand Strengthening national pre- 1 30,933,204 109,505,316 vention and care programs Approved on HIV/AIDS, TB, and malaria in Thailand National prevention and con- 2 20,253,183 81,348,535 trol program of HIV/AIDS Approved and malaria in Thailand Preventing HIV/AIDS and in- 3 911,542 1,371,348 creasing care and support Approved for injection drug users in Thailand Concentrated China China CARES (China Compre- 3 32,122,550 97,888,170 hensive AIDS RESponse)--a Approved community-based HIV treat- ment, care, and prevention program in Central China (continued) 85 86 · Annex 8 Round/ 2-year 5-year Country Title Status Approved Approved Indonesia Strengthening directly observed 1 6,924,971 15,960,103 treatment, short course Approved expansion in Indonesia Vietnam Strengthening care, counsel- 1 7,500,000 12,000,000 ing, support to people Approved living with HIV/AIDS (PLWHAs) and related com- munity-based activities Low level Lao PDR Prevention and control of 1 1,307,664 3,407,664 HIV/AIDS/sexually trans- Approved mitted infections, TB, and malaria in the Lao PDR Mongolia Strengthening national preven- 2 609,404 2,997,103 tion and care programs on Approved HIV/AIDS in Mongolia Multicountry Pacific Islands Regional Coor- 2 3,036,000 6,304,000 Western dinated Country Project on Approved Pacific HIV/AIDS, TB, and Malaria (PIRCCP) Philippines Accelerating STI and HIV/ 3 3,496,865 5,528,825 AIDS prevention through in- Approved tensified delivery of services to vulnerable groups and people living with HIV/ AIDS in strategic areas in the Philippines Total 142,930,010 421,434,196 Source: Global Fund to Fight AIDS, Tuberculosis, and Malaria, http://www.globalfundatm.org/ Notes 1. At the different stages, various risk behaviors will be the leading factors in driv- ing the epidemic. In a majority of EAP countries such as Vietnam, China, Indone- sia, and Myanmar, at the very beginning, "injecting" drug use was the driving force for the HIV epidemic, as it was responsible for the sharp increase of HIV in these countries. At least in the foreseeable future, the dual HIV epidemic among com- mercial sex workers and injecting drug users will be a key characteristic of HIV in the EAP Region. 2. This is the official classification of UNAIDS and the World Health Organiza- tion (WHO) (see UNAIDS/WHO 2000). It builds on the classification of the World Bank in Confronting AIDS (1999) with one significant difference: in the World Bank classification, the epidemic is not generalized until it reaches 5 percent prevalence in the general population. In this report, a generalized epidemic is de- fined as one that reaches greater than 1 percent in the general population. 3. The Pacific Island Member States include: Fiji, Kiribati, the Marshall Islands, the Federated States of Micronesia, Palau, Samoa, the Solomon Islands, Tonga, and Vanuatu. 4. Following extensive work to encourage agreement on core indicators for moni- toring and evaluating HIV/AIDS programs and policies, the UNAIDS family estab- lished the Global HIV/AIDS Monitoring and Evaluation Support Team (GAMET), based at the World Bank. Other key agencies such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), bilaterals like the United States Agency for In- ternational Development (USAID), and technical agencies such as the U.S. Centers for Disease Control and Prevention (CDC) are part of this partnership. GAMET actively works with countries and diverse donors to strengthen monitoring and evaluation 87 88 · Notes capacity at the country level, based on normative guidance from the UNAIDS Mon- itoring and Evaluation Reference Group. GAMET focuses, with other agencies, on helping countries to build and use monitoring and evaluation systems that will enable them to both report on progress internationally and, especially important, to identify and make tactical changes in HIV/AIDS programs and policies that improve their effectiveness. 5. Prevalence rates (determined by the number of people newly acquiring the dis- ease plus the number of people with the disease minus those dying) can come to a steady state at differing levels. If prevalence levels off, some might believe that this means the epidemic is under control. Although this could be true (few people get the disease, few people die from the disease), the exact opposite could also be happening (large numbers of people get the disease, large numbers of people die from the disease). 6. Using the World Bank definition in Confronting HIV/AIDS, all of the general- ized Asian epidemics would be reclassified as concentrated. 7. UNAIDS projections. 8. Much of the information in this section was drawn from the Thailand Social Monitor (World Bank 2000). 9. The Asian Epidemic Model predicts significant growth in the epidemic; however, other models suggest that the HIV/AIDS would decline regardless of the intervention because of saturation of high-risk populations (World Bank 1997, p. 142, Figure 3.3). Given existing data, it is difficult to determine what happened, but it is clear that there was a dramatic decline in risk behavior. This points to a need for better public health surveillance, particularly on the incidence of HIV among groups, better proxies for HIV in the general population, and more systematic information on risk behavior. 10. There are two main types of sex workers: brothel-based and "indirect." Indirect sex workers include those who work in massage parlors, restaurants, and beauty par- lors, and are believed to be "higher class" (as they do not self-identify as sex workers). In addition, there are less organized forms of sex work. 11. There is great difficulty in attributing the cause of the slowing of the epidemic in Cambodia. This may be due to saturation in the epidemic. Again, greater attention is needed to monitor changes in behavior and to understand the changing incidence and death rate of HIV/AIDS. 12. This is an example of international best practice identified by UNAIDS. The study was done with officials from many ministries, including health, social affairs, Notes · 89 statistics, tourism, and the police. It used routine information systems from multi- ple sources complemented by survey data. It reduced the wide variation in estimates of injecting drug users, which ranged from 50,000 to 1 million. This is the first step in developing better estimates; the next step would be to improve routine informa- tion systems and use capture/recapture techniques. See Directorate General of Communicable Disease Control and Environmental Health 2003, and Hickman and others 2003. 13. China also has harm reduction centers that use Chinese traditional methods, in combination with short-term methadone therapy, but often with high relapse rates. 14. Ulcerative sexually transmitted diseases increase the risk of HIV transmission significantly (Chin 2003). 15. This will be supported by a grant from the GFATM. See www.gfatm.org. 16. It produces GPO-vir (a combination tablet containing nevirapine, zidovudine, and lamivudine). 17. Not all donors are included. This only serves as a snapshot of the donors in a single country. 18. The course of an HIV epidemic. The relationship between the effective repro- ductive rate, the incidence of HIV infections, and HIV prevalence is shown. For sim- plicity it is assumed that all incident cases of HIV die 8 years after infection. In this simple case, the incidence of AIDS deaths replicates HIV incidence. On entry to the population, the effective reproductive rate equals the basic reproductive rate and must be greater than 1 for an epidemic to occur. As the presence of infection increases, the effective reproductive rate decreases as contacts are made with those already infected. The epidemic continues to grow even when each new case generates fewer than one more case, because infections are still occurring. Incidence decreases before preva- lence; only when deaths remove those infected from the population will prevalence de- crease. The relationship between incident HIV infections and incident HIV-associated mortality is illustrated below the graph. When incident infections match incident deaths, the epidemic will have reached an endemic steady state. Here the average ef- fective reproductive rate must be 1 if the prevalence is to remain constant. 19. NCI estimated that China currently has 1­2 million HIV cases compared with official estimates of 800,000. They expect prevalence to rise to between 1.3 and 2 percent leading to an estimate of 10­15 million HIV cases by 2010. 20. Nicholas Eberstadt, at the American Enterprise Institute, based his predictions on U.S. Bureau of the Census data analyzed using the spectrum software package 90 · Notes developed by the Futures Group International for USAID. His model assumes: (a) each epidemic began around 1985; (b) the median incubation period for HIV carriers between infection with HIV and the onset of AIDS is 9 years; (c) life ex- pectancy after the onset of AIDS averages 2 years; and (d) HIV epidemics in China, India, and Russia have "standard heterosexual" distribution between sexes and age groups witnessed in other low-income countries (especially Sub-Saharan Africa) (Eberstadt 2002). 21. James Chin is formerly from the WHO Global Program for AIDS and cur- rently a professor of epidemiology at the University of California, Berkeley. References Brown, T. 2002. 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Averting AIDS Crises in Eastern Europe and Central Asia: A Regional Support Strategy. Europe and Central Asia Region. Washington, D.C. Web Sites Asian Development Bank, http://www.adb.org/ AusAID, http://www.ausaid.gov.au/ Development Gateway, http://www.developmentgateway.org/ DFID, http://www.dfid.gov.uk/ Global Fund to Fight AIDS, Tuberculosis and Malaria, http://www.globalfundatm.org/ JICA, http://www.jica.go.jp/ KFW, http://www.kfw.de/DE/ UNAIDS, http://www.unaids.org/ UNDP, http://www.undp.org/ UNICEF, http://www.unicef.org/ USAID, http://www.usaid.gov/ World Bank, http://www.worldbank.org/ World Bank, World Development Indicators, http://www.worldbank.org/data/wdi2001/ World Health Organization, http://www.who.int/en/ 97 Index Page references followed by t, f, and n in prevention of mother-child refer to tables, figures, and notes transmission, 35 respectively. ASEAN. See Association of Southeast Asian Nations A Asian Development Bank (ADB) ADB. See Asian Development Bank anti-HIV/AIDS programs, 5, 23, AEM. See Asian Epidemic Model 41, 53 Analytic and advisory work Web site, 97 increasing need for, 6, 7, 39, 40, 42 Asian economic crisis, impact of, 3, 4, in World Bank anti-HIV/AIDS 22, 24 strategy, 9, 45 Asian Epidemic Model (AEM) World Bank role in, 6, 9, 39, 40, development of, 15­16, 76­77 45, 46­47 predictions for Cambodia, 16 Antiretrovirals predictions for Thailand, 16, 21, defined, xiii 77, 88n demand for, 7, 9, 34 Association of Southeast Asian Na- maximizing effectiveness of, 8­9, 34 tions (ASEAN) number of patients receiving anti-HIV/AIDS programs, 41 in Cambodia, 34, 53 Seventh Summit, 19 in China, 56 Australian anti-HIV/AIDS programs in Indonesia, 57 AusAID, 40, 54, 55, 56, 57, 59, 60, in Lao PDR, 61 61, 62 in Malaysia, 58 Web site, 97 in Mongolia, 62 domestic, 32­33 in Myanmar, 54 in Papua New Guinea, 59 B in Philippines, 63 Blood supply in Thailand, 22, 34, 55 HIV/AIDS transmission by in Vietnam, 60 in China, 56 99 100 · Index Blood supply (cont.) sex workers HIV/AIDS transmission by (cont.) HIV/AIDS prevalence, 12t, 53, 68t in Indonesia, 57 number and characteristics of, 68t in Malaysia, 58 treatment programs in, 34 in Myanmar, 54 tuberculosis in in Papua New Guinea, 59 incidence, 53, 79f in Philippines, 63 number of infected persons, 18t safety of percent of infected persons also in Cambodia, 53, 81t with HIV/AIDS, 53 in China, 5, 27, 38, 56, 82t treatment of, 42­43 in Indonesia, 57, 82t World Bank anti-HIV/AIDS pro- in Lao PDR, 61, 83t grams, 53 in Malaysia, 58, 82t Canada, anti-HIV/AIDS programs, in Mongolia, 62, 83t 32­33 monitoring, 31, 45 CDC. See U.S. Centers for Disease in Papua New Guinea, 59, 82t­83t Control and Prevention in Philippines, 63, 84t Children and youth in Vietnam, 60 impact of HIV/AIDS on, 3, 17, 35, Brown, Tim, 15­16, 76 43 Bureaucracy for HIV/AIDS policy incidence of HIV/AIDS, 33 importance of, 5, 6, 7, 26, 29­30, orphaned, care of, 35 41­42 China Indonesia, 4, 24, 29­30 antiretroviral patients, 56 Papua New Guinea, 4, 26 blood supply safety in, 5, 27, 38, Thailand, 20­21, 29 56, 82t drug treatment programs, 33 drug use, intravenous, 56, 66t C Global Fund funding, 56, 85t Cambodia GNI per capita, 12t, 56 antiretroviral patients, 34, 53 incidence of HIV/AIDS, predicted blood supply safety in, 53, 81t trends in, 1, 5, 16, 27, 33, 75, 76 drug use, intravenous, 66t mode of HIV transmission, 56 Global Fund funding, 53, 85t multidrug resistance in, 56 GNI per capita, 12t, 53 number of HIV/AIDS-infected mode of HIV transmission, 53 persons, 11, 12t, 18t multidrug resistance in, 53 population, 12t, 18t, 56 national health accounts in, 43 prevalence of HIV/AIDS, 12t, 14, NGOs in, 34 18t, 50f, 56, 66t number of HIV/AIDS-infected prevalence of SDIs, 76 persons, 12t, 18t response to HIV/AIDS, 5, 27, 40, population, 12t, 18t, 53 56 prevalence of HIV/AIDS, 11­14, funding of, 37­38, 56, 85t 12t, 18t, 23, 50f, 53, 66t sex workers predicted trends in, 16 HIV/AIDS prevalence, 12t, 56, 68t response to HIV/AIDS, 23, 32 number and characteristics of, 68t funding of, 53, 85t surveillance in, 30­31, 41 Index · 101 tuberculosis in in Philippines, 63 incidence, 56, 79f in Thailand, 55 number of infected persons, 18t Drug users, intravenous percent of infected persons also access to prevention programs, 32 with HIV/AIDS, 56 HIV/AIDS prevention programs treatment measures, 18 for, 4, 22, 25, 30, 32­33, 43­44 World Bank anti-HIV/AIDS HIV/AIDS transmission by efforts in, 56 in China, 56 CIA. See U.S. Central Intelligence in Indonesia, 57 Agency in Malaysia, 58 Commercial sex workers (CSWs). See in Myanmar, 54 Sex workers in Philippines, 63 Condom use in Thailand, 55 programs to encourage, 20, 23, 32 in Vietnam, 60 rate of number and characteristics of, 14, 44 Cambodia, 23 in Cambodia, 66t Thailand, 21, 21f in China, 56, 66t Control of HIV/AIDS epidemic, in Indonesia, 57, 66t complicating factors, vii in Lao PDR, 67t CSWs (commercial sex workers). See in Malaysia, 67t Sex workers in Mongolia, 67t in Myanmar, 54, 66t D in Philippines, 63, 67t Data on HIV/AIDS, limitations of, 2, in Thailand, 55, 66t 6, 8, 11, 31, 44, 51 in Vietnam, 60, 67t Death, leading cause of, in as origin of HIV/AIDS, 2, 14, 87n HIV/AIDS, 2 prevalence of HIV/AIDS, 14 Department for International Devel- in Cambodia, 12t, 14, 53, 66t opment (DFID) in China, 12t, 56, 66t anti-HIV/AIDS programs, 18, 23, in Indonesia, 4, 12t, 25, 57, 66t 40, 53, 54, 56, 60 in Lao PDR, 13t, 61, 67t Web site, 97 in Malaysia, 12t, 58, 67t Development Gateway, Web site, 97 in Mongolia, 13t, 62, 67t DFID. See Department for Interna- in Myanmar, 12t, 54, 66t tional Development in Papua New Guinea, 12t, 59 Directly Observed Therapy, Short- in Philippines, 13t, 24, 63, 67t Course (DOTS), 18 in Thailand, 3, 12t, 22, 55, 66t Discrimination against HIV/AIDS- in Vietnam, 12t, 60, 67t infected persons, legal reforms to reduce, 3­4, 23, 30, 34 E DOTS. See Directly Observed Ther- Eberstadt, Nicholas, 75, 76t, 89n­90n apy, Short-Course Economic development, impact of Drug treatment programs, 33 HIV/AIDS on, 3, 17, 43, 75 in China, 56 Ensemble pur une Solidarité in Indonesia, 57 Thérapeutique Hospitalière en in Myanmar, 54 Réseau, 34 102 · Index Epidemic. See also Models of Gross national income (GNI) per HIV/AIDS spread; Spread of capita, 12t­13t HIV/AIDS Cambodia, 12t, 53 defined, xiii China, 12t, 56 generalized, defined, 2 Indonesia, 12t, 57 of HIV/AIDS Lao PDR, 13t, 61 magnitude, by nation, 2, 11­14, Malaysia, 12t, 58 12t­13t, 50f Mongolia, 13t, 62 risk level, by nation, xvif Myanmar, 12t, 54 of tuberculosis, potential for, 2 Papua New Guinea, 12t, 59 Epidemiology of HIV/AIDS. See also Philippines, 13t, 63 Models of HIV/AIDS spread; Thailand, 12t, 55 Spread of HIV/AIDS Vietnam, 12t, 60 in Indonesia, 4, 25 in Thailand, 21­22 H Harm reduction policies, 32­33, 40 F Health care systems. See also Treat- French Cooperation, anti-HIV/AIDS ment of HIV/AIDS programs, 53 impact of Asian economic crisis on, 3, 4, 22, 24 G impact of HIV/AIDS on, 2­3, 17, Germany, anti-HIV/AIDS programs, 25, 35­36, 43 32­33 in Indonesia, 24 GFATM. See Global Fund to Fight in Thailand, 22 AIDS, Tuberculosis, and Malaria impact of SARS on, 25 Global Fund to Fight AIDS, Tuber- improvement of, 7, 35­36, 44­45 culosis, and Malaria (GFATM) funding for, 37­38 projects funded by, 5, 6, 36, 40, in World Bank anti-HIV/AIDS 85t­86t strategy, 9, 44­45 in Cambodia, 53, 85t Homosexuals in China, 56, 85t HIV/AIDS prevention programs in Indonesia, 57, 86t for, 22, 30, 33 in Lao PDR, 61, 86t number of, as key to future of epi- in Mongolia, 62, 86t demic, 14 in Myanmar, 54, 85t as origin of HIV/AIDS, 2 in Philippines, 63, 86t prevalence of HIV/AIDS in, 24 in Thailand, 55, 85t transmission of HIV/AIDS by in Vietnam, 60, 86t in China, 56 Web site, 97 in Indonesia, 57 Global HIV/AIDS Monitoring and in Malaysia, 58 Evaluation Support Team, 8 in Mongolia, 62 Global program on AIDS, anti- in Myanmar, 54 HIV/AIDS programs, 26 in Papua New Guinea, 59 GNI. See Gross national income in Philippines, 63 (GNI) per capita in Thailand, 55 Index · 103 Hong Kong, drug treatment pro- prevalence of SDIs, 76 gram, 33 response to HIV/AIDS, 4, 24­25, Human rights. See Discrimination 29­30, 38, 40 against HIV/AIDS-infected funding of, 37, 57, 86t persons sex workers HIV/AIDS prevalence, 12, 25, I 57, 68t IBRD. See International Bank for Re- number and characteristics of, construction and Development 68t IDA. See International Development surveillance in, 24, 31 Association tuberculosis in Incidence of HIV/AIDS incidence, 57, 79f in children and youth, 33 number of infected persons, 18t as key to future of epidemic, 14 percent of infected persons also predicted trends in, 1­3, 15­16, with HIV/AIDS, 57 75­77. See also Models of World Bank anti-HIV/AIDS ef- HIV/AIDS spread forts in, 57 and anti-HIV/AIDS program Influenza, epidemiology, 71 design, 8, 42­43 International Bank for Reconstruc- China, 1, 5, 16, 27, 33, 75, 76 tion and Development (IBRD), Indonesia, 1, 16, 33, 76 45 Malaysia, 76 International Development Associa- Papua New Guinea, 16, 76 tion (IDA), 45 Russia, 75 Thailand, 16, 21, 33, 77, 88n J Vietnam, 76 Japan International Cooperation Incidence rate, defined, xiii Agency (JICA) India, prevalence of HIV/AIDS in, 1, anti-HIV/AIDS programs, 40, 53, 75 54, 55, 58, 61, 63 Indonesia web site, 97 antiretroviral patients, 57 Joint United Nationals Program on blood supply safety in, 57, 82t HIV/AIDS (UNAIDS) drug treatment programs, 33 on access to anti-HIV/AIDS pro- drug use, intravenous, 57, 66t grams, 32 Global Fund funding, 57, 86t on AIDS orphans, 17 GNI per capita, 12t, 57 anti-HIV/AIDS programs, 5, 23, incidence of HIV/AIDS, predicted 40, 41, 53 trends in, 1, 16, 33, 76 best practice dissemination, 46­47 mode of HIV transmission, 57 on cost of preventing spread of multidrug resistance in, 57 HIV/AIDS, 38 national health accounts in, 43 HIV/AIDS data, 2, 11, 51 number of HIV/AIDS-infected models of HIV/AIDS epidemiol- persons, 12t, 18t ogy, 77 population, 12t, 18t, 57 predicted spread of HIV/AIDS, prevalence of HIV/AIDS, 4, 12t, 1­2, 16, 17f 14, 18t, 24, 25, 50f, 57, 66t Web site, 97 104 · Index K prevalence of SDIs, 76 KFW Bankengruppe sex workers anti-HIV/AIDS programs, 57 HIV/AIDS prevalence, 12t, 58, 69t Web site, 97 number and characteristics of, 69t tuberculosis in L incidence, 58, 79f Lao PDR number of infected persons, 18t antiretroviral patients, 61 World Bank anti-HIV/AIDS blood supply safety in, 61, 83t efforts in, 58 drug use, intravenous, 67t Men Global Fund funding, 61, 86t percent of sex worker use, 14, 21, GNI per capita, 13t, 61 73, 76, 77 mode of HIV transmission, 61 practicing homosexuals number of HIV/AIDS-infected HIV/AIDS prevention programs persons, 13t, 18t for, 22, 30, 33 population, 13t, 18t, 61 number of, as key to future of prevalence of HIV/AIDS, 13t, 14, epidemic, 14 18t, 50f, 61, 67t as origin of HIV/AIDS, 2 response to HIV/AIDS, 61 prevalence of HIV/AIDS, 24 funding of, 61, 86t transmission of HIV/AIDS by sex workers in China, 56 HIV/AIDS prevalence, 13t, 61, 69t in Indonesia, 57 number and characteristics of, 69t in Malaysia, 58 tuberculosis in in Mongolia, 62 incidence, 61, 79f in Myanmar, 54 number of infected persons, 18t in Papua New Guinea, 59 Leaders and public figures, anti- in Philippines, 63 HIV/AIDS programs and, 30 in Thailand, 55 London School of Hygiene and rate of sex outside of long-term Tropical Medicine, on cost of relationships, 16, 21, 77 prevention, 38 with STDs, HIV prevalence, by nation, 12t­13t M Migration, and spread of HIV/AIDS, Malaysia 14­15, 33, 41 antiretroviral patients, 58 Models of HIV/AIDS spread, 71­73, blood supply safety in, 58, 82t 72f, 89n drug use, intravenous, 67t Asian Epidemic Model GNI per capita, 12t, 58 development of, 15­16, 76­77 incidence of HIV/AIDS, predicted predictions for Cambodia, 16 trends in, 76 predictions for Thailand, 16, 21, mode of HIV transmission, 58 77, 88n number of HIV/AIDS-infected Eberstadt model, 75, 76t, 89n­90n persons, 12t, 18t UNAIDS model, 77 population, 12t, 18t, 58 Mongolia prevalence of HIV/AIDS, 12t, 14, antiretroviral patients, 62 18t, 50f, 58, 67t blood supply safety in, 62, 83t Index · 105 drug use, intravenous, 67t tuberculosis in Global Fund funding, 62, 86t incidence, 54, 79f GNI per capita, 13t, 62 number of infected persons, 18t mode of HIV transmission, 62 percent of infected persons also number of HIV/AIDS-infected with HIV/AIDS, 54 persons, 13t, 18t population, 13t, 18t, 62 N prevalence of HIV/AIDS, 13t, 14, National Center for HIV/AIDS, 18t, 50f, 62, 67t Dermatology, and STD response to HIV/AIDS, funding of, (NCHADS), 42­43, 53 62, 86t National health accounts, 8, 43 sex workers NCHADS. See National Center for HIV/AIDS prevalence, 13t, 62, HIV/AIDS, Dermatology, and 69t STD number and characteristics of, Netherlands, anti-HIV/AIDS pro- 62, 69t grams, 32­33 tuberculosis in NGOs. See Nongovernmental incidence, 62, 79f organizations number of infected persons, 18t Nongovernmental organizations Monitoring (NGOs) of anti-HIV/AIDS programs, 32, anti-HIV/AIDS programs, 5, 30 38­39 efficacy of, 39 of spread of HIV/AIDS. See also in Indonesia, 4, 24 Surveillance in Thailand, 20 approaches to, 6, 31 implementation support for, 39 for recurrence, 22 treatment programs in World Bank anti-HIV/AIDS in Cambodia, 34 strategy, 8, 43 in World Bank anti-HIV/AIDS Myanmar strategy, 44 antiretroviral patients, 54 Number of HIV/AIDS-infected drug use, intravenous, 54, 66t persons Global Fund funding, 54, 85t Cambodia, 12t, 18t GNI per capita, 12t, 54 China, 11, 12t, 18t mode of HIV transmission, 54 in EAP Region, 11 multidrug resistance in, 54 Indonesia, 12t, 18t number of HIV/AIDS-infected Lao PDR, 13t, 18t persons, 12t, 14, 18t Malaysia, 12t, 18t population, 12t, 18t, 54 Mongolia, 13t, 18t prevalence of HIV/AIDS, 11­14, Myanmar, 12t, 14, 18t 12t, 18t, 50f, 54, 66t Papua New Guinea, 12t, 18t response to HIV/AIDS, 40 Philippines, 13t, 18t funding of, 54, 85t percent returning from abroad, 15 sex workers Thailand, 12t, 18t HIV/AIDS prevalence, 12t, 54, Tuvalu, 11 68t Vietnam, 12t, 18t number and characteristics of, 68t worldwide, 11 106 · Index O Philippines OECD. See Organisation for Eco- antiretroviral patients, 63 nomic Co-operation and blood supply safety in, 63, 84t Development drug use, intravenous, 63, 67t Opportunistic infections Global Fund funding, 63, 86t defined, xiii GNI per capita, 13t, 63 increased risk in HIV/AIDS, 2, mode of HIV transmission, 63 16­17 multidrug resistance in, 63 Chinese health measures and, 18 number of HIV/AIDS-infected treatment of, 22, 35 persons, 13t, 18t Organisation for Economic Co- percent returned from abroad, 15 operation and Development population, 13t, 18t, 63 (OECD), 36 prevalence of HIV/AIDS, 13t, 14, 18t, 24, 50f, 63, 67t P response to HIV/AIDS, 3­4, Pacific Island Member States 23­24, 63 funding of, 63, 86t members, 87n sex workers prevalence of HIV/AIDS, 14 HIV/AIDS prevalence, 13t, 24, Pandemic, defined, xiii 63, 69t Papua New Guinea number and characteristics of, 69t antiretroviral patients, 59 surveillance in, 23, 24 blood supply safety in, 59 tuberculosis in GNI per capita, 12t, 59 incidence, 63, 79f incidence of HIV/AIDS, predicted number of infected persons, 18t trends in, 16, 76 percent of infected persons also mode of HIV transmission, 59 with HIV/AIDS, 63 number of HIV/AIDS-infected Population, 12t, 18t persons, 12t, 18t Cambodia, 12t, 18t, 53 population, 12t, 18t, 59 China, 12t, 18t, 56 prevalence of HIV/AIDS, 11, 12t, of EAP Region, 11 14, 18t, 50f, 59 Indonesia, 12t, 18t, 57 response to HIV/AIDS, 4, 25­26, 59 Lao PDR, 13t, 18t, 61 risk factors for epidemic in, 4, 25­26 Malaysia, 12t, 18t, 58 sex workers Mongolia, 13t, 18t, 62 HIV/AIDS prevalence, 12t, 59, 69t Myanmar, 12t, 18t, 54 number and characteristics of, 69t Papua New Guinea, 12t, 18t, 59 spread of HIV/AIDS in, 26 Philippines, 13t, 18t, 63 surveillance in, 4, 26 Thailand, 12t, 18t, 55 tuberculosis in Timor Leste, 18t incidence, 59, 79f Vietnam, 12t, 18t, 60 number of infected persons, 18t Prevalence of HIV/AIDS, 11­14, World Bank anti-HIV/AIDS 12t­13t, 15f efforts in, 59 Cambodia, 11­14, 12t, 18t, 23, 50f, Papua New Guinea, blood supply 53, 63t safety in, 82t­83t predicted trends in, 16 Peerapatinapokin, Wiwat, 15­16, 76 China, 12t, 14, 18t, 50f, 56, 66t Index · 107 India, 1, 75 in Indonesia, 4, 24, 29 Indonesia, 4, 12t, 14, 18t, 24, 25, in Papua New Guinea, 4, 26 50f, 57, 66t in Thailand, 20­21, 29 Lao PDR, 13t, 14, 18t, 50f, 61, 67t Thailand, 3, 19­21, 29, 32, 33, 39, 41 Malaysia, 12t, 14, 18t, 50f, 58, 67t success of, 3, 21­22, 21f Mongolia, 13t, 14, 18t, 50f, 62, 67t Vietnam, 27, 37, 40 Myanmar, 11­14, 12t, 18t, 50f, 54, in World Bank anti-HIV/AIDS 66t strategy, 8, 43­44 Pacific Island Member States, 14 Prisoners, prevention strategies for, 33 Papua New Guinea, 11, 12t, 14, Public information campaigns 18t, 50f, 59 importance of, 7, 29, 33, 42 Philippines, 13t, 14, 18t, 24, 50f, in Thailand, 20 63, 67t Public opinion, importance of Thailand, 3, 11­14, 12t, 18t, gauging, 42 19­20, 21, 50f, 55, 66t Timor Leste, 14 R Vietnam, 12t, 14, 18t, 50f, 60, 67t Reporting requirements for Prevalence rate, defined, xiii, 88n HIV/AIDS case, in Thailand, 20 Prevention of HIV/AIDS. See also Reproductive rate, 71­73, 72f Prevention programs defined, xiii cost of, 38 Resistance, multidrug projecting, 73 in Cambodia, 53 current spending on, 38 in China, 56 Prevention programs in Indonesia, 57 access to, 32 in Myanmar, 54 approaches to, 6, 32­34 in Philippines, 63 Cambodia, 23, 32 in Thailand, 55 China, 5, 27, 40, 56 in Vietnam, 60 funding of, 37­38, 56, 85t Response to HIV/AIDS. See also Pre- funding of, 3, 4, 5­6, 22, 23, 24, 26, vention programs; Treatment of 30, 37­38, 39­41, 85t­86t HIV/AIDS groups requiring special attention, 33 public commitments to, 5, 19, 27 harm reduction programs, 32­33, 40 Risk behaviors. See also Drug users, implementation vs. design of, 38­39 intravenous; Sex workers importance of maintaining, 8, 22, 24 and access to anti-HIV/AIDS pro- Indonesia, 4, 24­25, 29­30, 37, 40 grams, 32 Lao PDR, 61 efforts to decrease, 20­21, 30, 38, 40 lessons learned in, 4­5, 26­27, 39 in general population, 15 monitoring of, 8, 31­32, 38­39, 43 risk of HIV infection and, 22 multisector involvement in, 7, 36, size of population practicing, 2, 14, 38, 41­42 16, 75­76, 77 Myanmar, 40 importance of ascertaining, 6, Papua New Guinea, 4, 25­26, 59 7­8, 31, 42 Philippines, 3­4, 23­24, 63 as key to future trends, 14 political support for spread to general population from, importance of, 5, 6, 7, 26, 29­30, 1­2, 3, 5, 15­16, 19­20, 27, 41­42 71, 77f 108 · Index Russia, incidence of HIV/AIDS, pre- males with, HIV prevalence dicted trends in, 75 in Cambodia, 12t, 53 in China, 12t, 56 S in Indonesia, 12t, 57 SARS. See Severe acute respiratory in Lao PDR, 13t, 61 syndrome in Malaysia, 12t, 58 Severe acute respiratory syndrome in Mongolia, 13t, 62 (SARS) in Myanmar, 12t, 54 epidemiology, 71 in Papua New Guinea, 12t, 59 impact on health care systems, 25 in Philippines, 13t, 63 Sex workers in Thailand, 12t, 55 HIV/AIDS prevention programs in Vietnam, 12t, 60 for, 3, 20­21, 22, 23, 24, 25, prevalence 30, 32, 43­44 in China, 76 number and characteristics of, 14, 44 in Indonesia, 76 in Cambodia, 68t in Malaysia, 76 in China, 68t in Vietnam, 76 in Indonesia, 68t as proxy for HIV/AIDS, 31 in Lao PDR, 69t Social fabric, impact of HIV/AIDS in Malaysia, 69t on, 3, 17 in Mongolia, 69t Spread of HIV/AIDS. See also Models in Myanmar, 68t of HIV/AIDS spread in Papua New Guinea, 69t factors affecting, 14­15, 33, 41, in Philippines, 69t 71­73, 72f in Thailand, 68t from high-risk population to gen- in Vietnam, 69t eral population, 1­2, 3, 5, as origin of HIV/AIDS, 2, 14, 87n percent of males using, 14, 21, 73, 15­16, 19­20, 27 76, 77 monitoring of. See also Surveillance prevalence of HIV/AIDS, 14 approaches to, 6, 8, 30­31 in Cambodia, 12t, 53, 68t for recurrence, 22 in China, 12t, 56, 68t in Papua New Guinea, 26 in Indonesia, 12t, 25, 57, 68t predictions for, 1­3, 15­16, 75­77 in Lao PDR, 13t, 61, 69t and anti-HIV/AIDS program in Malaysia, 12t, 58, 69t design, 8, 42­43 in Mongolia, 13t, 62, 69t by UNAIDS, 16 in Myanmar, 12t, 54, 68t prevention of. See Prevention in Papua New Guinea, 12t, 59, 69t STDs. See Sexually transmitted in Philippines, 13t, 24, 63, 69t diseases in Thailand, 3, 12t, 19­20, 55, 68t Surveillance in Vietnam, 12t, 60, 69t behavioral, 3, 20, 23, 24, 31, 42 Sexually transmitted diseases (STDs) defined, xiii checking sex workers for, 20­21 in China, 31, 41 control of, 33 development of, 4, 24, 26, 38, 41, 46 incidence funding of, 31, 38 in Philippines, 3, 24 of general population, 31 Thailand, 21, 21f, 33 of high risk behaviors, 31 Index · 109 importance of maintaining, 22, 24, 26 treatment programs in, 34 in Indonesia, 24, 31 tuberculosis in as key to effective programs, 6, incidence, 55, 79f 31­32 number of infected persons, 18t in Papua New Guinea, 4, 26 percent of infected persons also in Philippines, 23, 24 with HIV/AIDS, 55 sentinel HIV, 3, 4, 20, 23, 31, 42 World Bank anti-HIV/AIDS ef- defined, xiv forts in, 55 serological, 3, 20 Thailand Social Monitor: Thailand's Re- in Thailand, 3, 20, 22 sponse to AIDS: Building on Suc- in United States, 41 cess, Confronting the Future in Vietnam, 31, 41 (World Bank), 39 in World Bank strategy, 7­8, 42­43 Timor Leste Switzerland, anti-HIV/AIDS pro- number of HIV/AIDS-infected grams, 32­33 persons, 18t population, 18t T prevalence of HIV/AIDS, 14, 18t Thailand tuberculosis, number of infected antiretroviral patients, 22, 34, 55 persons, 18t drug use, intravenous, 55, 66t Transmission of HIV/AIDS Global Fund funding, 55, 85t likelihood of, 72­73 GNI per capita, 12t, 55 mode of health care systems, impact of in Cambodia, 53 HIV/AIDS on, 17, 22 in China, 56 high-risk behavior in, 77 in Indonesia, 57 incidence of HIV/AIDS, predicted in Lao PDR, 61 trends in, 16, 21, 33, 77, 88n in Malaysia, 58 incidence of STDs, 21, 21f, 33 in Mongolia, 62 mode of HIV transmission, 55 in Myanmar, 54 multidrug resistance in, 55 in Papua New Guinea, 59 number of HIV/AIDS-infected in Philippines, 63 persons, 12t, 18t in Thailand, 55 population, 12t, 18t, 55 in Vietnam, 60 prevalence of HIV/AIDS, 3, 11­14, Treatment of HIV/AIDS. See also 12t, 18t, 19­20, 21, 50f, 55, 66t Antiretrovirals; Health care sys- response to HIV/AIDS, 3, 19­21, tems; Opportunistic infections 30, 32, 33, 39, 41 access to, 36, 40 efficacy of, 3, 21­22, 21f adequacy of, 36 funding of, 55, 85t counseling and referral, 4, 7, 23, sex workers 34, 35 HIV/AIDS prevalence, 3, 12t, funding of, 36 19­20, 55, 68t goals of, 34 number and characteristics of, 68t importance of, 30 spending on HIV/AIDS preven- NGOs and, 34, 44 tion, 38 planning for, 8­9, 42­43 surveillance in, 3, 20, 22 private spending on, 38, 44 110 · Index Treatment of HIV/AIDS (cont.) in Papua New Guinea programs and methods, 7, 22, incidence, 59, 79f 34­35, 44 number of infected persons, 18t reporting systems for, 32 in Philippines in World Bank anti-HIV/AIDS incidence, 63, 79f strategy, 8­9, 44 number of infected persons, 18t Treatment of tuberculosis percent of infected persons also methods, 18, 35 with HIV/AIDS, 63 planning for, 42­43 as proxy for HIV/AIDS, 31 Tuberculosis in Thailand in Cambodia incidence, 55, 79f incidence, 53, 79f number of infected persons, 18t number of infected persons, 18t percent of infected persons also percent of infected persons also with HIV/AIDS, 55 with HIV/AIDS, 53 in Timor Leste treatment of, 42­43 number of infected persons, 18t in China treatment of, 18, 35 incidence, 56, 79f planning for, 42­43 number of infected persons, 18t in Vietnam percent of infected persons also incidence, 60, 79f with HIV/AIDS, 56 number of infected persons, 18t preventive measures, 18 percent of infected persons also in EAP Region, 16­17 with HIV/AIDS, 60 increasedriskinHIV/AIDS,2,16­17 Tuvalu, number of HIV/AIDS- in Indonesia infected persons, 11 incidence, 57, 79f number of infected persons, 18t U percent of infected persons also UNAIDS. See Joint United Nationals with HIV/AIDS, 57 Program on HIV/AIDS in Lao PDR UNGASS. See United Nations Gen- incidence, 61, 79f eral Assembly Special Session on number of infected persons, 18t HIV/AIDS as leading cause of death in UNICEF. See United Nations Chil- HIV/AIDS, 2 drens Fund in Malaysia United Kingdom, anti-HIV/AIDS incidence, 58, 79f programs, 32­33 number of infected persons, 18t United Nations, anti-HIV/AIDS in Mongolia programs and, 5 incidence, 62, 79f United Nations Childrens Fund number of infected persons, 18t (UNICEF) in Myanmar anti-HIV/AIDS programs, 41 incidence, 54, 79f Web site, 97 number of infected persons, 18t United Nations Development Pro- percent of infected persons also gramme (UNDP) with HIV/AIDS, 54 anti-HIV/AIDS programs, 53, 55, number of infected persons, by 56, 57, 60, 61, 62, 63 nation, 18t Web site, 97 Index · 111 United Nations General Assembly surveillance in, 31, 41 Special Session on HIV/AIDS tuberculosis in (UNGASS) [2001], 5, 19, 27 incidence, 60, 79f United Nations Office on Drugs and number of infected persons, 18t Crime (UNODC), 41 percent of infected persons also United States, surveillance in, 41 with HIV/AIDS, 60 UNODC. See United Nations Office World Bank anti-HIV/AIDS on Drugs and Crime efforts in, 60 U.S. Agency for International Devel- opment (USAID) W anti-HIV/AIDS programs, 23, Women 40­41, 41, 61, 63 in antenatal care clinics, HIV Asian Epidemic Model prevalence development of, 15­16, 76­77 in Cambodia, 12t, 53 predictions for Cambodia, 16 in China, 12t, 56 predictions for Thailand, 16, 21, in Indonesia, 12t, 57 77, 88n in Lao PDR, 13t, 61 Web site, 97 in Malaysia, 12t, 58 U.S. Centers for Disease Control and in Mongolia, 13t, 62 Prevention (CDC), 20, 21 in Myanmar, 12t, 54 U.S. Central Intelligence Agency in Papua New Guinea, 12t, 59 (CIA), 75 in Philippines, 13t, 63 USAID. See U.S. Agency for Interna- in Thailand, 12t, 55 tional Development in Vietnam, 12t, 60 V mother-child transmission, preven- tion of, 35 Vietnam antiretroviral patients, 60 vulnerability to HIV/AIDS, 17, 33 blood supply safety in, 60 World Bank drug use, intravenous, 60, 67t anti-HIV/AIDS efforts Global Fund funding, 60, 86t in Cambodia, 53 GNI per capita, 12t, 60 in China, 56 incidence of HIV/AIDS, predicted efficacy of, 38­39 trends in, 76 funding of, 4, 5, 23, 24, 37­38, mode of HIV transmission, 60 40, 45­46 multidrug resistance in, 60 in Indonesia, 57 number of HIV/AIDS-infected lessons learned from, 39 persons, 12t, 18t in Malaysia, 58 population, 12t, 18t, 60 monitoring of, 8, 38­39 prevalence of HIV/AIDS, 12t, 14, in Papua New Guinea, 59 18t, 50f, 60, 67t role in, 5­6, 9, 30, 39, 40, 41, 45, prevalence of SDIs, 76 46­47 response to HIV/AIDS, 27, 37, 40 in Thailand, 55 funding of, 37, 60, 86t in Vietnam, 60 sex workers anti-HIV/AIDS strategy, 7­9, 41­47 HIV/AIDS prevalence, 12t, 60, 69t analytic and advisory work in, 9, 45 number and characteristics of, 69t funding in, 45­46 112 · Index World Bank (cont.) World Bank Institute, 46­47 anti-HIV/AIDS strategy, (cont.) World Health Organization (WHO) policies, 41­45 and anti-HIV/AIDS programs, 5, regional tools, 9, 46­47 23, 40, 41 anti-tuberculosis efforts, 18 and health spending accountability, and health spending accountability, 36 36 3 by 5 initiative, 40 lending in EAP Region, 5, 9, 37, 46 on tuberculosis, 17, 18 Web site, 97 Web site, 97 Selected Titles from the World Bank's Health, Nutrition, and Population Series Assessing the Economic Returns to Investing in Youth in Developing Countries. 2003 (J.C. Knowles and J.R. Behrman) HIV/AIDS in Latin American Countries: The Challenges Ahead. 2003 (A.G Abreu, I. Noguer and K. Cowgill, editors) HIV/AIDS Treatment and Prevention in India: Modeling the Cost and Consequences. 2004 (M. Over, P. Heywood, J. Gold, I. Gupta, S. Hira, and E. Marseille) Improving Women's Health: Issues and Interventions. 2000 (A. Tinker, K. Finn and J. Epp) Interactive Learning Exchanges: Exploring Strategies to Reach and Work with Adolescents. 2004 (L.K. Elder) Investing in the Best Buys: A Review of the Health, Nutrition, and Population Portfolio, FY1993­99. 2000 (M. Claeson, T. Mawji, C. Walker) Optimizing the Allocation of Resources among HIV Prevention Interventions in Honduras. 2002 (G. Beehary, N. Schwab, D. Akhavan, R. Hernandez and C. Paredes) Public Health and World Bank Operations. 2002 (M. Claeson, A.E. Elmendorf, D.S. Miller and P. Musgrove) Addressing HIV/AIDS in the East Asia and Pacific Region. 2004 (EASHD, The World Bank) The World Bank Strategy for Health, Nutrition, and Population in the East Asia and Pacific Region. 2000 (F. Saadah and J. Knowles) Who Would Gain Most from Efforts to Reach the Millennium Development Goals for Health? Inquiry into the Possibility of Progress that Fails to Reach the Poor. 2002 (D.R. Gwatkin) World Bank Pharmaceuticals Discussion Paper. 2000 (R. Govindaraj, M.R. Reich and J.C. Cohen) Combating the spread of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) presents the international development community with one of its most difficult global challenges. With almost half the world's population, East Asia and the Pacific may well become the next battleground in the war against HIV/AIDS. Using knowledge drawn from experience, Addressing HIV/AIDS in East Asia and the Pacific outlines a strategic direction the World Bank can use to respond to this enormous challenge. This concise volume shows how the World Bank, working together with governments, civil society, and other development partners, can play a critical role in focusing efforts on the risk factors associated with concentrated HIV/AIDS epidemics. This book charts the nature of the epidemic in the region, surveys some of the successful practices currently being pioneered, and offers suggestions as to how the distinct characteristics of the HIV/AIDS epidemic faced in each country can be addressed by effective and comprehensive responses at both the country and regional levels. Addressing HIV/AIDS in East Asia and the Pacific will be of interest to policymakers, specialists, and all individuals and institutions that share the World Bank's goal of preventing the East Asia and Pacific region from becoming the future epicenter of HIV/AIDS. ISBN 0-8213-5916-9