The struggle against AIDS in Asia is far from over
MELBOURNE: HOW often do Asian women have sex, and with whom? This sort of question is too indelicate to be asked in public, but it will be hotly debated in the corridors at the sixth international congress on AIDS in Asia and the Pacific, due to open in Melbourne on October 5th. The reason is this: the Asian regional office of the World Health Organisation (WHO) is declaring HIV more or less under control in Asia. It says there is just not enough drug-taking and risky sex to sustain a major epidemic.
Everyone agrees that HIV is high and rising among those who inject drugs, but some find this relatively unimportant, maintaining that the epidemic is “self-contained” in this group. In the words of Malaysia’s prime minister, Mahathir Mohamad, “HIV and drug use are problems that will solve one another.”
Men who have sex with men are another obvious source of infection, but they do not even register on the radar screen for most Asian governments. So that leaves prostitutes and their clients as the only door through which HIV might enter the general population. And the wives of those clients hold the key to that door. If the wives are not having sex with anyone else, they may get infected themselves, but then the virus will hit a dead end. That, thinks the WHO, is the picture in Asia.
The good news is that survey data indicate that Asian women are indeed less likely to have extramarital sex than women in other continents. On almost every other count, however, the WHO’s comfortable calculations fly in the face of the evidence, according to epidemiologists from many Asian countries.
In the first place, all the data suggest that people who inject drugs are having sex with people who don’t, giving the lie to the idea that they form a closed group. Besides having wives and casual partners, drug injectors in Asia often visit prostitutes. For example, a quarter of the injectors surveyed in the Vietnamese capital of Hanoi also patronise prostitutes, and few of them use condoms. To make matters worse, prostitutes are injecting drugs. With prostitutes taking drugs and drug-takers having lots of sex, a “self-contained” epidemic among drug-takers is something of a dream.
Next, the ignored population of male homosexuals. Though few admit it, almost every country in Asia has a market in which men buy sex from other men. Transvestites sell sex to men who think of themselves as “straight”. Male prostitutes sell sex to clients who prefer sex with men but may be married to conform to social norms. In a recent survey in Cambodia, 40% of men who had had anal sex with other men in the previous month had also had sex with women in that time. Again, not exactly a self-contained epidemic.
This, together with the fact that between 7% and 25% of men in Asian countries report buying sex from women, means that the region has the potential for a very large epidemic. For proof, look no farther than northern Thailand, where 10% of adults were infected before the government’s HIV-prevention campaign drastically increased condom use and cut new infections. It is unlikely that these high levels of infection in the general population would be repeated across the continent, partly because prostitutes in other countries have far fewer clients than they do in Thailand. But an infection rate that might reach 2% seems plausible in many countries. That would imply 36m HIV infections in Asia, a fivefold increase on current estimated rates.
The optimists point out that risky behaviour has been recorded in Asia for years, and few countries have seen a major epidemic. Unfortunately, though, they are behind the times. At the last regional Asian AIDS conference two years ago, only Thailand, Cambodia and India had any epidemics to speak of. At this week’s meeting China, Indonesia, Nepal and Vietnam—home to over 1.5 billion people—will all report huge rises in infection in groups with high-risk behaviour.
The prevalence of HIV infection now ranges from 40% to 70% of those who inject drugs in all of those countries, even though in some of them, such as Indonesia, it was said to be zero at the time of the last AIDS conference. HIV is increasing among prostitutes in that country too, rising from virtually nothing to 8-25% in several places since the last regional pow-wow. Vietnam and China are showing the same abrupt rise in rates of infection in prostitutes. Bangladesh and the Philippines are recording much the same patterns of risky behaviour as the worst-affected countries. Unless the successful prevention models of Thailand and Cambodia are quickly replicated throughout the continent, Asia could yet face a ghastly AIDS epidemic.