The Issue
UNAIDS estimates that although overall adult HIV prevalence in South Asia is still relatively low at less than 1% [0.1%-0.5%], the HIV epidemic affects a large number of people. An estimated 4 million were living with HIV in this sub region in 2007. India significantly revised its HIV estimation which resulted in a dramatic change in the size of the epidemic in the region and globally. However, low national HIV prevalences mask serious epidemics concentrated (i.e., higher than 0.5%) in some geographical areas and amongst high risk populations such as injecting drug users, sex workers, and men who have sex with men. Among these groups, infection rates are high and rising and in many areas there is strong evidence that the epidemic is more rapidly diffusing into the general population. Widespread poverty, huge economic disparities, low literacy, deep-rooted and pervasive discrimination against women and their low levels of empowerment, and large mobile and migrating populations, aided by a wall of denial, are all now combining potently to spread the epidemic into the general population. What makes HIV/AIDS in South Asia an enormous challenge to overcome is that there is no single epidemic in the region, but a diversity of epidemics. The two interlinked generalisations that can be made are that across Asia the epidemics have all followed a similar pattern, and that the virus has spread mostly through identifiable risk behaviours that the majority of the population do not engage in. The epidemic starts among a few behaviorally linked at-risk groups such as intravenous drug users (IDUs), men who-have-sex-with-men, and female sex workers and their clients and then spreads to their lower-risk partners and through them to infants through mother-to-child tranmission. Such delayed epidemics now include much of Nepal and Pakistan where HIV levels have grown more gradually and do not yet exceed 0.5 percent. Afghanistan, Bhutan, the Maldives and Sri Lanka have yet to see extensive HIV spread and still have national prevalence rates below 0.1 percent, but there is evidence that risk behaviours are increasing. South Asian countries are still at relatively early stages of the epidemic curve, so there is still an opportunity to reverse the spread of HIV/AIDS if carefully targetted and scaled-up prevention work is done now. A recent estimate suggests that, if nothing changes, 12 million new infections could occur accross the Asia-Pacific region between 2005-2010. But it doesn't have to be that way. If the region undertakes a determined response of comprehensive prevention, care and treatment, new infections can be held to 6 million. South Asia's young people are now moving to the centre of AIDS epidemic. A growing number of young people aged 15-24 are HIV-positive. Adolescent girls suffer a great disadvantage because in South Asia's environment of pervasive gender bias such as early (often forced) marriage to much older men. Young girls are susceptible to many forms of abuse and exploitation and therefore are more vulnerable to infection, even though evidence suggests that boys engage in high-risk behaviours more than girls. Infection from mother to infant can take place during pregnancy, at birth or during breastfeeding. There is a 35 percent risk that an HIV-positive mother will pass the infection on to her infant, in several Indian states HIV prevalence among pregnant women has already crossed the 1 per cent threshold. Antiretroviral drugs, caesarean deliveries, and alternative feeding options for infants can reduce the risks, but for many these options are restricted by poverty, poor sanitation or limited access to quality health services. Families and communities are already coping with relatively large numbers of orphans due to factors like high maternal mortality rates. The inevitable increase in the number of maternal, paternal and double orphans due to AIDS-related deaths will greatly stress already weak and overburdened family and community safety nets unless systems to strengthen capacities over the long term are developed now.
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