AIDS in South Asia

South Asia's HIV epidemic is highly heterogeneous. As a result, informed, prioritized, and effective responses necessitate an understanding of the epidemic diversity between and within countries. Further spread of HIV in South Asia is preventable. The future size of South Asia's epidemic will depend on an effective two-pronged approach: firstly, on the scope and effectiveness of HIV prevention programs for sex workers and their clients, injecting drug users and their sexual partners, and men having sex with men and their other sexual partners; and secondly, on the effectiveness of efforts to address the underlying socio-economic determinants of the epidemic, and to reduce stigma and discrimination towards people engaging in high risk behaviors, often marginalized in society, as well as people living with HIV and AIDS.This review was undertaken to provide a basis for rigorous, evidence-informed HIV policy and programming in South Asia.

Figures, Tables, and Boxes

ix

Foreword

xi

Acknowledgments

xiii

Abbreviations

xv

Executive Summary

xvii

1. Background and Rationale

1

(6)

Rationale

2

(5)

2. Analytic Framework

7

(8)

Epidemic Potential

7

(4)

Epidemic Phase

11

(1)

Biological Factors

11

(2)

Behavioral and Structural Factors

13

(2)

3. HIV and Related Surveillance in the South Asia Region

15

(6)

India

15

(2)

Nepal

17

(1)

Pakistan

17

(1)

Bangladesh

18

(1)

Sri Lanka

18

(1)

Afghanistan, Bhutan, and the Maldives

19

(2)

4. Sexual and Injecting Drug Use Behaviors

21

(10)

Female Sex Workers

21

(2)

Clients of Female Sex Workers

23

(2)

Men Having Sex with Men

25

(1)

General Population

26

(1)

Injecting Drug Users

27

(2)

Female Sex Workers, Clients, and MSM Who Also Inject Drugs

29

(1)

IDUs Who Also Have Risky Sex

30

(1)

5. HIV Prevalence and Spread

31

(10)

Female Sex Workers

31

(1)

Men Having Sex with Men

32

(1)

Injecting Drug Users

33

(2)

Other High-Risk Male Groups

35

(1)

General Population

36

(5)

6. Country-Specific Analyses

41

(38)

India

41

(19)

Nepal

60

(4)

Pakistan

64

(4)

Bangladesh

68

(3)

Sri Lanka

71

(3)

Afghanistan

74

(3)

Bhutan

77

(1)

The Maldives

77

(2)

7. Scaling Up HIV Prevention Programs

79

(4)

Distribution of High-Risk Networks

79

(1)

Elements of Scaling Up of Program Coverage

80

(1)

Tactics for Scaling Up Coverage

80

(2)

General Considerations

82

(1)

8. Summary of Recommendations

83

(6)

Recommendation 1: Build Capacity

83

(1)

Recommendation 2: Expand Prevention Programs

84

(1)

Recommendation 3: Devote Resources to Condom Use and Needle Exchange

84

(1)

Recommendation 4: Increase and Expand Baseline and Continued Surveillance

85

(1)

Recommendation 5: Conduct Additional Studies

85

(1)

Recommendation 6: Expand Mapping of High-Risk Populations

85

(1)

Recommendation 7: Improve Understanding of Rural Epidemics

86

(1)

Recommendation 8: Reduce Stigma

86

(1)

Recommendation 9: Improve Coordination by Expanding Cooperation

87

(2)

Appendix A: The World Bank Response to AIDS in South Asia

89

(2)

Appendix B: Definition of Targeted and General Population Interventions

91

(4)

Appendix C: Country Analysis Summaries

95

(6)

References

101

(8)

Index

109

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