Global Policy Forum

By David Brown

Many Asian countries are on the verge of a potentially explosive epidemic of AIDS, and in a few, notably Indonesia, China and Vietnam, the number of infections is already starting to rise steeply, a new report says.

Data gathered from dozens of sites throughout the continent have dashed the theory that much of Asia might mysteriously escape the epidemic, despite having all the variables that have permitted human immunodeficiency virus to spread to crippling levels elsewhere.

"No country is immune," said Karen Stanecki, chairman of Monitoring the AIDS Pandemic Network, an international consortium of epidemiologists, demographers and statisticians that released the report yesterday at a meeting in Australia.

Stanecki, who works for the U.S. Census Bureau, hastened to add that the network "doesn't want to be alarmist."

"We see a window of opportunity," she said. "The spread of HIV is not inevitable. It is imperative that countries not waste time but act now."

The urgency of the findings was echoed by Bernhard Schwartlander, a World Health Organization epidemiologist, who added that threatened Asian countries might do well to study the experience of two of their neighbors.

"In Thailand . . . [a prevention] program has prevented millions of HIV infections. Cambodia is another example," he said. "We encourage other countries to also become active in similar ways now in order to avoid something that could be a massive, massive epidemic in the future."

The report doesn't attempt to estimate each Asian nation's HIV prevalence, which the World Health Organization calculates biannually for every country in the world. Instead, it gathered data on specific risk groups in specific places to sketch a more detailed picture of the evolving epidemic in the region.

In most of Asia, HIV infection is still confined largely to populations known to be at high risk -- intravenous drug users, homosexual men and prostitutes of both sexes. All three groups have substantial interaction with each other and with some members of the wider, low-risk population.

However, despite those ingredients for the spread of HIV, Asia has lagged far behind the rest of the world in AIDS cases. The exceptions are three countries where the virus was introduced relatively early: Thailand (where 2.2 percent of adults were infected at the end of 1999); Cambodia (4 percent); and Burma (2 percent). Elsewhere, the prevalence is below 1 percent.

Indonesia is the classic example of country that seemed curiously immune to the AIDS epidemic. Since 1988, public health agencies in the huge nation have routinely tested a sample of prostitutes and found virtually no cases of HIV infection.

This puzzled many epidemiologists, given that prostitution was common in Indonesia; that between 30 percent and 50 percent of prostitutes had a venereal disease when tested; and that even in recent years, only about 12 percent reported using condoms regularly.

"Some even thought that perhaps there were factors in Indonesian society which would continue to protect the country against HIV indefinitely," the authors wrote. "Unfortunately, this proved not to be the case."

Since 1999, however, HIV prevalence in prostitutes has risen from 1 percent to 2 percent to up to 8 percent in several cities at both ends of the archipelago. At several sites in Jakarta, it was as high as 18 percent.

At the same time, the intravenous use of drugs has risen substantially in Indonesia and with it the prevalence of HIV infection among addicts. In a sample of drug users in Jakarta, 40 percent were infected. Among imprisoned addicts in Bali, the prevalence was 53 percent.

Vietnam has seen a similar rise in prostitution and intravenous drug use -- and with both, HIV infection. HIV prevalence among addicts in the port city of Haiphong has risen from near zero in 1997 to about 65 percent last year. In Ho Chi Minh City, formerly Saigon, prevalence in the same group rose from about 30 percent to about 50 percent during that period. In 1994, less than 1 percent of prostitutes carried the AIDS virus; now about 3.5 percent do.

There is also substantial mixing of the risk groups. In a recent survey in Hanoi, 20 percent of street-based (as opposed to brothel-based) prostitutes reported having recently injected drugs. That behavior is likely to further raise HIV prevalence among them and increase their customers' exposure to the disease.

China remains the biggest question mark. In three cities where prostitutes were tested, HIV prevalence in one, Guangxi, has risen from zero to 11 percent over the past five years. In the others it rose, but less steeply. Condoms are used less than 15 percent of the time, according to the surveys. Over the same period, the number of cases of treated venereal disease doubled, from 430,000 in 1997 to 860,000 last year.

Schwartlander speculated that the number of people living with HIV infection or AIDS in China may reach 1 million by the end of this year, up from 500,000 at the end of 1999. Bangladesh and the Philippines resemble Indonesia in their active sex trades and low condom use. The Philippines also has a large overseas migrant population, which increases the risk of disease introduction.

Both countries have a chance to abort a runaway epidemic by instituting prevention measures, the authors wrote. The Philippines enacted a law in 1998 aimed at promoting AIDS education, counseling and testing.

India was discussed only briefly in the report. It had about 3.7 million infected people in 1999, or about 0.7 percent of adults. The epidemic there varies greatly by region, and is concentrated in the south.

To read the report

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