the-south-asian.com January 2004
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AIDS epidemic in South Asia
The AIDS epidemic claimed an estimated 3 million lives in 2003, and an estimated 5 million people acquired the human immunodeficiency virus (HIV) in 2003 - bringing to 40 million the estimated number of people globally living with the virus. These are the latest estimates published in the recently released UNAIDS/World Health Organization annual report "AIDS epidemic update 2003".
As the world enters the third decade of the AIDS epidemic, the evidence of its impact is undeniable. Wherever the epidemic has spread unchecked, it is robbing countries of the resources and capacities on which human security and development depend. In some regions, HIV/AIDS, in combination with other crises, is driving ever-larger parts of nations towards destitution. The scale of the AIDS crisis now outstrips even the worst-case scenarios of a decade ago. Dozens of countries are already in the grip of serious HIV/AIDS epidemics, and many more are on the brink. Around the world, an estimated 5 million people became infected in 2003, 700 000 of them children. Over the next decade, without effective treatment and care, they will join the ranks of the more-than-20 million people who have died of AIDS since the first clinical evidence of HIV/AIDS was reported in 1981. It is equally clear that the vast majority of people (including those living in countries with high national HIV prevalence) have not yet acquired the virus. Enabling them to protect themselves against HIV, and providing adequate and affordable treatment and care to people living with the virus, represent two of the biggest challenges facing humankind today.
Afghanistan has a population of 22 million. After 23 years of war and civil strife, Afghanistan ranks at the bottom of the UNDP HDI, with literacy levels at 32% (16% among women). Although, since 1992, there have been no reported data on HIV/AIDS or other STIs (due to an absence of surveillance), there are several indicators of HIV risk factors faced by Afghan people (such as unsafe blood supply, and lack of access to education and health services), which should be taken as warning signs of a potential HIV epidemic. Evidence from other countries has shown that HIV/AIDS thrives in conflict areas, post-conflict situations and areas with high numbers of internally displaced populations and refugees. Iran and Pakistan already host some 4 million Afghan refugees and there are unconfirmed reports of refugee women turning to sex work in order to provide for themselves and their offspring. The low socioeconomic status of women renders them particularly vulnerable. The fertility rate is high at 6.9 children per woman. Maternal mortality, at 820 (estimated range 300 - 1700) per 100,000, is among the highest in the world and under-five mortality the fourth-highest in the world. Another risk indicator is related to drug production, trade and consumption. Neighboring Uzbekistan, Tajikistan, Pakistan and China have reported outbreaks of HIV among injecting drug users. While Afghanistan produces the largest quantity of opium globally, little is know about how many Afghans inject drugs.
Bangladesh with a population of 129M people has an HDI rank of 132 out of 192 (UNDP, 2001). Poverty remains a major challenge. Infant Mortality rates (per 1000 live births) are 113/116 for male/female children. Bangladesh is a country with low HIV prevalence but high vulnerability. Second Generation Surveillance for HIV conducted among vulnerable population groups (mainly male clients of sex workers) has been <1% with the highest levels in IDUs (1.7%). Prevalence rates in sex workers & hepatitis C in IDUs are very high. Risk behaviours are comparable to rates in other countries in the region that are experiencing a concentrated epidemic. WHO/UNAIDS estimates that the number of HIV+ cases is approx. 13,000. Bangladesh has documented the lowest condom use, very high numbers of clients of sex workers, low knowledge of HIV/AIDS, extensive needle/syringe sharing by drug users in the region. In spite of this, national commitment to HIV/AIDS prevention & care is high. Bangladesh has the key ingredients for a successful response, a nationwide network of NGOs implementing effective interventions; effective examples of government organization/NGO collaboration; a sector-wide approach to health with mechanisms for donor collaboration; an enabling multisectoral policy; & strong commitment from the government as well as civil society. The available funding must be augmented substantially to adequately address vulnerability in the general population.
India, with 1.027 billion people, 28% of whom live in urban areas, has a HIV/AIDS infection rate estimated at 0.7% of the adult population. In 2001, it is estimated that 3.97 million adults were infected with HIV. India is one of the few countries that initiated HIV-prevention activities in the very early stages of the epidemic and the country has maintained its commitment to prevention efforts. The government is a Federal Republic with 35 states and union territories. The Indian Prime Minister announced in August 2001 that the government would attach topmost priority to HIV as a national issue. However, due to the vast size of the country, there are many challenges involved in expanding the high-level commitment to all 35 states and to the grass-roots level, involving ministries other than health, and scaling up interventions to meet the projected needs for prevention and care. Indian demographics reveal a life expectancy of 63 years, a fertility rate of 3.1% & a literacy rate of 65% (75.85% for males, 54.16% for females). Thirty-five per cent of the population live below the poverty line and the country ranks 115th out of 162 countries on the HD Index.
Nepal is one of the least economically developed countries in the world, ranking 142 out of 173 in the Human Development Index (2002). The total population is estimated to be 23.2 million (2001), with approximately 85% of the population living in rural areas, and over 40% of the population living under the national poverty line. Nepal is a Hindu Kingdom, with distinct sociocultural boundaries and low status given to women, resulting in a lower female life expectancy (57.8) compared to that of males (58.3). The country has an adult literacy rate of 58% for males, compared to only 23% among the female population, and the maternal mortality rate is one of the highest in the world (540/100,000). Nepal has recently recognized HIV/AIDS as a burning development issue. The AIDS epidemic is concentrated among sex workers, injecting drug users and labour migrants, with infection rates rapidly increasing in recent years. Stigmatization, political turmoil, poverty, gender inequality and competing developing priorities fuel the HIV/AIDS epidemic and may make AIDS the leading cause of death among 15-49-year-olds over the next 10 years. Key challenges: rapid scaling-up of behavioural change interventions among vulnerable groups and young people, establishment of an adequate care and support system, rapid expansion of multisectoral response both at national and decentralized level, capacity-building, second generation surveillance, M&E.
Unlike many other countries, Pakistan has a narrow window of opportunity to prevent a generalized HIV/AIDS epidemic. While the HIV/AIDS burden is still low, this Islamic Republic must move rapidly to protect the future of its approximately 152 million citizens. However, Pakistanís many competing needs (including provision of basic social services and debt servicing and drug control expenditures) have made resource mobilization for HIV/AIDS difficult. This difficulty has been compounded by an almost total donor freeze on grant aid after the 1998 nuclear tests and the coup dítat in 2000. Despite these challenges, political commitment to HIV/AIDS has greatly increased in recent years. The government has undertaken a comprehensive and participatory strategic planning process which has resulted in a prioritized and multisectoral National Strategic Framework. The operationalization and costing of this Framework has been completed and principally approved by the GOP.
Sri Lanka, with its 19.5 million population is a low prevalence but highly vulnerable country. Approximately 23% of the population lives in urban areas. With a literacy rate of 94% for males and 88% for females, health messages readily penetrate to the public. However, financial resources are scarce with a GDP of $756 and 40% of the population living below the poverty line. The external debt has been significantly increasing during the recent years, in part due to the 18 year civil war in the north and eastern provinces of the island. Life expectancy at birth is 69 years for males and 75 years for females. Infant mortality rate is 17 per 1000 births. Sri Lanka has a democratic parliamentary system. The National AIDS Prevention Activities have been primarily funded by the UNDP, WHO, UNICEF, UNFPA and the World Bank. The newly elected governmentís main challenges are the cessation of the northeast war and the strengthening of the economy. Even among high-risk groups such as sex workers, HIV (+) rate is less than 1%. Currently only a few cents per capita is spent on HIV/AIDS and this is mainly for awareness creation. In the new strategic plan, a paradigm shift has been made toward behaviour change, priority for vulnerable populations and young people with nation wide coverage. The government has shown keen interest in mobilising resources for the national programme and is actively considering a loan from the World Bank.
Text courtesy UNAIDS
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