Summary
The paper reviews the HIV/AIDS epidemic
situation in the ESCAP region and discusses the existing
country programmes dealing with this emerging epidemic.
Based on experiences from several countries, especially
Thailand where the epidemic has already reached its peak,
the paper raises several issues with regard to the prevention,
treatment and care. These are some of the challenges requiring
urgent action to control the epidemic and to seek more cost-effective
management in the implementation of the
programmes.
In order to improve the effectiveness of
the HIV/AIDS prevention programmes, it is essential that
the public be given full and accurate information and knowledge
of transmission and prevention, especially those groups
that are most at risk. The paper suggests that STDs and
HIV treatment services should be integrated into existing
primary health services and that new preventive technology
be developed to reduce the rate of transmission. Due to
substantial movements of population across border, it is
essential that greater attention be focused and concerted
efforts be made in implementing HIV/ AIDS preventive measures
to effectively attain the hard-to-reach groups and highly
mobile populations. It is especially important that these
measures reach illegal migrant workers, including female
sex workers who are trafficked across borders, who usually
have little access to information, counseling and services.
In connection to this, multinational collaborative programme
against women and girl child trafficking should be strengthened
as another effort towards HIV/AIDS prevention.
The main concerns on the effectiveness
of provision of treatment usually centers around issues
of coverage of treatment, accessibility to cheaper antiretroviral
(ARV) drugs and availability of treatment of people living
with HIV/AIDS (PLWHAs). The followings are some considerations
deserving special attention. In many countries, access to
medical treatment for AIDS-related illness is still hard
to reach for the majority of PLWHAs. More importantly, the
availability of affordable ARV drugs to reduce viral loads
remains a major obstacle. The challenges for the Governments
are to find ways to ensure access to cost-effective prevention
and treatment and to provide non-discriminating health care
to cover as many PLWHAs as possible, including infected
migrant workers (both legal and illegal). The Governments
should find ways to strengthen alternative treatment (herbal
treatment, supplement diet, meditation for mental tranquility
and other self-care practices) since it has become a necessity
for PLWHAs in many societies to become increasingly self-reliant
due to their lesser access to modern treatment (ARV and
other medical services). In order to reduce mother-to-child
transmissions, the provision of AZT (for both mother and
child) should be seriously considered by countries where
the HIV infections are more prevalent among pregnant women.
The voluntary counselling and testing services should be
promoted and made widely available. In this regard, NGOs
can play a key role in ensuring nondiscrimination and respect
for human rights. For countries where the clinical trial
of HIV candidate vaccine is planned, ethical issues on safety
of volunteers and potential social harms must be carefully
considered as top priority.
The community, including PLWHAs self-help
network, should find ways to reach out and extend the assistance
directly or indirectly to the PLWHAs who are living in hiding
to have greater access to proper health-care service in
a more equal basis. In addition, family and community should
be strengthened through various approaches in order to be
able to care for the PLWHAs who will become a heavy burden,
especially among poor families. The community should learn
how to develop a “strong community” and become
more independent from outside assistance. The PLWHAs network
and NGOs
should also be encouraged to involve fully in all activities,
from planning to the implementing stages. This principle
is known as GIPA or Greater Involvement of People Living
with HIV/AIDS. Under the new development of health-care
approach, religious institutions and religious leaders in
many societies become strong partners in providing care
and spiritual supports for PLWHAs and the family in the
most difficult time.
Therefore, it is essential that these institutions
are strengthened and developed to their full capabilities
with an acceptable health-care standard to alleviate the
burden of the Governments in providing care and support
for those who are in need. The issue of orphans and young
children affected by HIV/AIDS deserve much attention since
they are in a vulnerable position both in the family and
in the community.
In this regard, it is important to identify
strategies to which the States, NGOs and the community could
extend their help to care for this group of children. Programmes
to reduce social stigma and discrimination are also important.
In order to provide a more effective family or community-based
care programmes, it is recommended that systematic compilation
of information and data regarding this issue should be undertaken.
Lastly, it is urged to do more research
on the “often neglected issue” of psychological
care and support, especially among those who are at the
terminal stage. The in-depth understanding of this issue
would enable the PLWHAs and their families to cope with
the life-threatening disease and access a better quality
of life.
Introduction
The ESCAP region is home to approximately
62 per cent of the world’s population. Since the mid-1980s,
the unprecedented increase in the number of cases infected
with the human immunodeficiency virus (HIV), which causes
the acquired immunodeficiency syndrome (AIDS), in this densely
populated region has become a global threat.
The Asian HIV/AIDS pandemic is highly dynamic.
The risky behaviour and vulnerability, which promote, fuel
and facilitate the rapid transmission of HIV, are present
in virtually all countries of the region. Thus, the potential
for its further spread is significant (Larson and Narain,
2001). Based on evidence from various sources, behaviours
that produce the highest risk of infection in this region
are unprotected sex (both heterosexual and homosexual) and
needle sharing among intravenous drug users (UNAIDS and
World Health Organization, 2001).
In the early 1980s when the HIV/AIDS pandemic
was becoming significant in the Western Hemisphere and Africa,
only a few cases of HIV infection were reported in Asia.
Relatively little attention was paid to HIV/AIDS by the
population at large. However, the HIV/AIDS pandemic in Asia
took a new turn in the 1990s. WHO estimated that HIV is
spreading faster in parts of Asia than in other regions
of the world. Some have predicted that the magnitude of
the HIV/AIDS pandemic in this region in the twenty-first
century could be much worse.
Based on UNAIDS and WHO estimates, at the
end of 2001, 40 million adults and children around the world
were living with HIV/AIDS. Out of this total number, 6.1
million infected persons were living in South and South-East
Asia, while another 1 million were living in East Asia and
the Pacific. This made the Asian and Pacific region the
worst affected by the epidemic after sub-Saharan Africa
where more than 28 million people have been infected (UNAIDS
and World Health Organization, 2001). The spread
of HIV in Asia is expected to accelerate if Governments
fail to act with a sense of urgency, and if preventive action
is taken too little or too late. In this regard, the Monitoring
the AIDS Pandemic Study has warned that the recent increase
in HIV prevalence in specific locations in Asia should be
regarded as a serious warning of more widespread epidemics.
The Study noted that the low current HIV prevalence rates
in parts of Asia do not necessarily signify that these rates
will remain low forever (POPLINE, 2001).
Evidence from behavioural studies suggested
that the potential exists for substantial expansion of HIV
epidemics in many Asian societies. Within the region, parts
of South-East Asia have shown a pattern of dramatic increase
(Brown, 2002a). The following four countries are considered
in the advanced stage of the HIV/AIDS epidemic. India is
the most adversely affected country; nearly 4 million HIV
infections have been reported. Thailand, the first country
in Asia to report HIV infections and to have experienced
an explosive epidemic, has seen a decline in the number
of new infections owing to the implementation of a rigorous
national AIDS prevention programme; however, about 2 per
cent of pregnant women have been found to be HIV-positive.
High HIV prevalence levels have been also detected in Cambodia
where more than 3 per cent of pregnant women have been found
to be infected; a successful intervention programme has
somewhat reduced this rate. In Myanmar, where the HIV/AIDS
situation is not quite certain, an increase in HIV prevalence
has been evident among injecting drug users (IDUs), that
is, from 17 per cent of certain groups in 1989 to 65 per
cent in 1996. Approximately 20 per cent of commercial sex
workers and 2 per cent of pregnant women are reported to
be HIV-positive (Larson and Narain, 2001).
The second group of countries in Asia is
still in a transitional stage, with recent evidence of rapidly
growing HIV prevalence in specific populations and regions.
These include China, Indonesia, the Islamic Republic of
Iran, Japan, Nepal and Viet Nam. In China, where almost
all cases of HIV/AIDS were previously transmitted through
IDUs and unsafe blood transfusions, the epidemic is currently
spreading through heterosexual contact. In China’s
Guangxi Province, 9.9 per cent of sex workers were found
to be HIVpositive in the second quarter of 2000; by the
fourth quarter of that year, the proportion rose to 10.7
per cent. Early UNAIDS and WHO estimates revealed that about
600,000 Chinese were living with HIV/AIDS in 2000. By the
end of the following year, the numbers were estimated to
exceed 1 million. In Indonesia, infection rates were rising
rapidly following a decade of consistently low rates. The
infection rates increased rapidly among blood donors, injecting
drug users and sex workers. Indonesia has recorded an increase
in HIV among sex workers from 6 per cent during the late
1990s to 26 per cent in 2000 in three major centres. In
Ho Chi Minh City, Viet Nam, HIV infection rates among certain
sex workers increased from virtually nil in 1996 to more
than 20 per cent in 2000 (POPLINE, 2001; Brown, 2002a).
The last group of countries and areas,
where extensive HIV epidemics have yet to be seen, include
Bangladesh; Hong Kong, China; the Lao People’s Democratic
Republic; the Philippines; and the Republic of Korea (POPLINE,
2000; UNAIDS and WHO, 2001; Brown, 2002a; Bangkok Post,
3 July 2002). In the Pacific subregion, only a little information
on HIV/AIDS is available. Although some HIV/AIDS cases have
been reported to the authorities, the number was thought
to be substantially underreported and to provide an incomplete
picture of the HIV situation in that subregion. Nevertheless,
there is the potential for a rapid transmission of HIV in
the Pacific since many States are becoming tourist attractions
(Lewis and Bailey, 1992/93).
Overall, the HIV/AIDS situation is serious.
As stated during the Fourteenth International AIDS Conference
held at Barcelona, Spain during the period 7-12 July 2002,
“Asia holds the key to the future of the global epidemic.
It is the home to two thirds of humanity and the potential
for the spread of HIV in the region is high”. This
serious situation calls for much stronger commitment and
full participation of the parties concerned at all levels,
which include the Government, the community and the family
as well as the people living with HIV/AIDS (PLWHAs). The
“deep denial” reaction, which still exists among
many Governments in the region must be replaced by realism
and acceptance of the fact that the rapid spread of HIV/AIDS
is a real threat to human society.
Patterns of HIV/AIDS
transmission
It has been quite evident that patterns
of HIV transmission detected in many Asian countries follow
Thailand’s epidemic; HIV transmission was first detected
among homosexuals in 1984. Subsequently, the virus emerged
among IDUs and later spread rapidly among commercial sex
workers. In the mid-1990s, HIV transmission was recorded
among the male population who were clients of commercial
sex workers, before spreading to their regular partners.
At a later stage, the transmission was especially high among
pregnant women who transmitted the virus to their foetus
or infant children (Weniger and others, 1991). In other
countries, including Cambodia, Japan, Malaysia and Myanmar,
there have been reports of HIV/AIDS spreading among men
having sex with men. Many countries and areas have experienced
the rapid spread of HIV through IDUs: Indonesia, Myanmar,
Nepal and Thailand as well as India’s Manipur State
and China’s Yunnan Province. As mentioned previously,
Cambodia and Thailand had earlier experienced very high
HIV prevalence rates among commercial sex workers, but this
situation later subsided owing to the strong national preventive
programme. However, HIV prevalence has been on the rise
in many countries, including urban areas of China, India,
Indonesia and Viet Nam. Currently, mother-to-child transmission
(MTCT) has become a health threat among pregnant women in
many Asian countries. This new emerging trend requires urgent
action for prevention (Brown, 2002a).
HIV/AIDS prevention
programmes
In responding to the HIV/AIDS pandemic during
the previous two decades, each country in Asia has developed
various intervention measures thought to be appropriate
for the country’s social and cultural conditions,
and available resources. Control measures implemented in
most countries were aimed at reducing risky behaviour (drug
injection, unsafe sexual contact, blood transfusion) practised
among various target groups, and promoting safe behaviour
(clean needle and syringe exchange, condom use as well as
heath education).
Within the region, Thailand has been praised
for its rigorous and comprehensive preventive programmes.
Among the many important factors contributing to the effective
control and preventive programmes in Thailand has been the
Government’s strong and continuous commitment to dealing
with HIV/AIDS-related problems. Since the early 1990s, the
Prime Minister has assumed chairmanship of the national
AIDS Committee in setting up HIV/AIDS-related policies.
In the formulation of national policies during the previous
two decades, three different phases of national responses
to the HIV/AIDS epidemic (with regard to prevention, treatment
and care) have gradually developed and have been actively
implemented. Phase I used a health approach to monitor the
epidemic’s trend, especially among the so-called “risk
groups”. The health-oriented activities covered case
reporting, control of sexually transmitted screening of
blood for transfusion, treatment of opportunistic infections,
awareness-creation campaigns and
health education. Phase II, which used social programmes
to deal with the social consequences of the epidemic, involved
the public at large in activities such as the establishment
of AIDS committees from the national to the grass-roots
levels, promoting multisectoral collaboration, organizing
a sentinel survey to monitor trends, and intensive campaigning
on various preventive measures. Phase III involved efforts
to engage civil society and foster community participation
as well as build capacity for caring for vulnerable groups
affected by HIV/AIDS and their families (Siraprapasiri,
2002a).
Thailand has implemented various preventive
programmes on a national scale: continuous, large-scale
IEC campaigns on prevention; intensive health education;
and promotion of the 100 per cent condom use in sex establishments.
Various programmes on prevention and control have also been
implemented among IDUs. However, the Government continues
to be reluctant to implement needle and syringe exchange
programmes, a situation which also exists in India, Malaysia
and Myanmar. On the other hand, in order to reduce the transmission
of HIV from mothers to children, the use of the antiretroviral
drug azidothymidine or zidovudine (AZT) has been adopted
by State hospitals throughout the country. In addition,
other preventive measures have been also carried out, that
is, total blood screening, counselling services at reproductive
health clinics, anonymous clinics and comprehensive care
services for PLWHAs. These preventive measures proved to
be quite effective in HIV/AIDS prevention and control in
Thailand, as the number of annual new infections was reduced
from 143,000 in 1991 to approximately 25,000 in 2001 (Bangkok
Post, 3 July 2002; Thaineau, 2002). Many of these preventive
measures served as examples for many other countries to
replicate and implement. The 100 per cent condom programme
is especially widely known within the region; Cambodia has
also adopted this strategy for prevention.
The success of programme implementation
very much depends upon the amount of budget allocated for
this purpose. In the case of Thailand, WHO initially allocated
$500,000 to the Thai Government in 1998; later, more funding
support was provided by many other international donor agencies.
However, the major part of the budget spent on HIV/AIDS
prevention measures has been allocated by the Thai Government.
For instance, a World Bank study (cited in Poolcharoen and
others, 1999) revealed that during the period 1993-1995,
Thailand annually spent about $4.67 per capita for HIV/AIDS
prevention and control activities; 72 per cent of that amount
was from the Government, 16 per cent from NGOs and 12 per
cent from international donors. The Government’s share
allocated for these activities has increased over time from
58 per cent in 1998 to 96 per cent in 1997, while donations
from outside resources have been declining because of Thailand’s
relatively advanced economic status (Poolchareon and others,
1999). By contrast, in large parts of Asia and the Pacific
prevention programmes are poorly funded largely because
many high-risk practices are frowned upon, if not criminalized
(UNAIDS and WHO, 2001). Ineffective prevention and control
could be one of the reasons for the rapid spread of HIV/AIDS
epidemics in various countries of the region.
The negative impacts of HIV/AIDS spread
on human well-being have also been strongly felt at the
global level. Several attempts have been made to seek solutions.
During the period 25-27 June 2001, the United Nations General
Assembly Special Session on HIV/AIDS (popularly referred
to as UNGASS) adopted the Declaration of Commitment on HIV/AIDS
as a joint effort at the global level to fight against the
HIV/ AIDS pandemic. That Declaration, which states that
prevention must be the mainstay of the global response,
established a number of time-bound national targets (2003-2010)
and various preventive measures, such as efforts to address
risk factors, making available a wider range of information,
education and communication (IEC) prevention programmes,
and offering the public easy access to preventive services.
Special focus is given to the young population (aged 15-24),
migrants and mobile populations in the most seriously affected
countries. The Declaration also calls for a reduction in
HIV infection among
infants (20 per cent by 2005 and 50 per cent by 2010). Further,
the majority of pregnant women should have greater access
to information, counselling and other preventive services
so as to reduce the mother-to-child transmission rates (United
Nations and UNAIDS, 2001).
Issues for consideration
regarding prevention
Based on the review of the epidemic situation
and experiences of many countries in the region, a number
of lessons can be drawn with regard to HIV/AIDS prevention
and programme implementation. In addition, there are several
issues that need to be taken into consideration for improving
the effectiveness of the programmes.
First, for countries where an HIV epidemic
has just started, it is essential that full and accurate
information and knowledge on routes of transmission and
prevention be made known to the public, while avoiding the
use of stigmatizing messages. In addition, prevention efforts
should move quickly to provide effective coverage of the
groups most at risk (Brown, 2002b). Many groups, especially
the poor and those who live in the marginal areas, are still
at high risk of being infected owing to their limited access
to
information and services, and their continued risky behaviour.
Second, to improve the prevention and treatment
of STDs and HIV/AIDS, three major lines of action should
be pursued: integrating STD and HIV services into existing
primary and community-based health services; developing
new preventive technologies (female condoms, microbicides);
and promoting gender equality in sexual and family relationships
(United Nations, 2001a).
Third, for the most effective prevention
programme, the country needs to closely monitor epidemic
trends in order to be able to quickly adapt preventive programmes
to changing transmission patterns. This issue of concern
can be well illustrated by the Thai situation. Although
Thailand has been successful in reducing new infection cases
in recent years through an effective prevention programme,
there have been some concerns that the epidemic could break
out of its current pattern and spread further unless prevention
efforts are adapted to new changes. It has been suggested
that Thais remain at high risk of infection as a result
of illicit drug injection among methamphetamine addicts
and unprotected casual sex among adolescents (Bangkok Post,
3 July 2002). It is proposed that, in order to respond to
the rapidly changing situation, all current preventive strategies
should be carefully and continuously reviewed regarding
their effectiveness. New strategies may have to be developed
to deal with the changing problems. Additional and concerted
efforts in preventing the epidemic will have to be made,
while applying best practices among various target groups.
Successful preventive strategies should also be scaled up
(Siraprapasiri, 2002a).
Fourth, movement across borders in Asia
has accelerated where many countries share borders. Also,
many countries’ new economic policies encourage international
trade, which usually induces more travel. Tourism is being
highly promoted with less restrictive immigration requirements,
inviting large numbers of visitors into countries of the
region. More people move easily through the new roads and
bridges built to link intercountry transportation networks.
Among people who are on the move, there are thousands of
illegal and unskilled labour migrants. In addition, cross-border
movers, both short and long term, are unavoidably exposed
to commercial sex services. This link opens the gate wide
for the rapid transmission of HIV within and across the
region. Such movers could create transmission bridges from
borders to larger towns further inland, and accelerate the
progress of epidemics. Therefore, it is essential that greater
attention and concerted efforts be made in implementing
HIV/AIDS preventive measures to effectively reach the hard-to-reach
groups, such as highly mobile populations and migrant workers,
especially illegal migrants who usually have little access
to information, counselling and services.
Fifth, in recent decades, the volume of
human trafficking of girls and women in the sex trade across
countries within the Asian region and to other continents
has been substantial and has become more evident. Vulnerable
women movers could well be potential sources of HIV transmission.
In order to fight HIV/AIDS across countries, it is therefore
necessary for countries in the region to develop much closer
collaborative programmes against trafficking in females.
Sixth, in connection with trafficking, some
health education and AIDS prevention programmes have proved
to be ineffective, especially among sex workers and male
clients. It is even more difficult for sex workers who work
illegally in foreign countries. Such women are at high risk
of contracting HIV, since they have no ability to speak
or understand the local language in order to negotiate condom
use with foreign clients. In addition, these women have
little access to health education and AIDS preventive
programmes because of their illegal migration and employment
status. Therefore, it is essential that various innovative
prevention measures – such as using a non-verbal approach,
for instance – be developed for these women to learn
about prevention and be able to convince their clients to
take measures necessary to protect themselves from being
infected.
Seventh, for the effective implementation
of preventive programmes, the strong commitment of the Government
and sufficient funding invested in the programmes are crucial
factors. Good examples can be seen from Cambodia and Thailand
where prompt, rigorous and large-scale prevention programmes
are holding the epidemics at bay (UNAIDS and WHO, 2001).
Treatment of HIV/AIDS
infected persons
With regard to treatment, the UNGASS 2001
Declaration (item 55) recommended that national strategies
should strengthen the health-care system while addressing
factors affecting the provision of HIV-related drugs (antiretrovirals
or ARVs), affordable pricing, and technical and health care
capability. All countries are urged to provide the highest
standard of treatment for HIV/AIDS (i.e., treatment of opportunistic
infection, improve adherence and effective use of quality-controlled
ARV therapy). National pharmaceutical policies and practices
should be strengthened in order to promote innovation and
development of domestic industries consistent with international
laws (United Nations and UNAIDS, 2001).
The epidemics in many countries of Asia
are now entering a new phase. Several hundred thousand people
infected during the explosive start of epidemics are becoming
ill and are undergoing treatment. The treatment of infections
becomes a great burden for the country concerned, because
HIV/AIDS requires long-term and effective medical care,
periodical hospital-based care and trained manpower to provide
comprehensive healthcare services. For countries where resources
are scarce, easy access to treatment and care remain very
questionable and prohibitive for many PLWHAs.
For Thailand, reported cases of AIDS have
increased over the years since the start of the HIV/AIDS
epidemic in the mid-1980s. It has been estimated that in
2000 there were 60,000 HIV-infected persons who sought treatment
from the health system, the total cost of which was approximately
37,000 million baht (approximately $925 million). The estimated
direct cost for medical care per person per year was $1,500.
This cost does not include other indirect costs and the
cost of antiretroviral drugs, which are not accessible to
the large majority of infected persons. Not many PLWHAs
can afford to pay for medication out of their own pockets.
At the regional level, it has been estimated that the cost
of HIV/AIDS treatment for countries in Asia could be as
high as 4 per cent of the gross domestic product (GDP).
Thus, this substantial financial burden requires wellplanned
management of funding allocations in order to provide the
most effective outcomes (Kunanusont, 2000).
Opportunistic infections such as tuberculosis,
pneumocystis carinii pneumonia, or cryptococcal meningitis
are the most common illnesses among HIV-infected patients
in need of immediate treatment. The medical treatment which
is usually provided by hospitals or private clinics covers
opportunistic infection treatment and prophylaxis as well
as antiretroviral therapy. However, such treatment is not
always available or sufficient in many countries. Judging
from a 1997 UNAIDS survey of 22 university
teaching hospitals (19 in Africa and 3 in Asia), these institutions
had suitable diagnostic facilities and the correct drugs
to treat only three conditions: pneumonia, pulmonary tuberculosis
and oral thrush. For other HIV-related illnesses, the diagnostic
capacity and drug supplies were so inadequate that a patient
would have less than a 50 per cent chance of being correctly
diagnosed and treated (UNAIDS, 2001). In Thailand, access
to HIV/AIDS medical care has been made available since the
early 1990s, and has gradually shifted to many new therapies
over time. For instance, mono-therapy (AZT alone) was provided
to PLWHAs during the period 1992-1995. Then, dual therapy
(AZT+ddI [didanosine] and AZT+ddC [zalcitabine]) was provided
during the period 1995-1996. The HIV Clinical Research Network
(dual and triple antiretrovirals (ARVs)) was later implemented
during the period 1997-2000. Since 2000, triple ARVs and
the means for preventing and treating opportunistic infections
have become more accessible. Thailand also set up strategies
to expand access to ARVs in 2002 including drug price negotiation,
generic drug production, in-house technique development
for drug and laboratory tests, capacity-building for health-care
personnel, infrastructure improvement and quality assurance,
resource mobilization and health-care insurance integration
(iraprapasiri, 2002b). Currently, Thailand has a policy
to provide all pregnant women HIV testing free of cost.
If the test is positive, the woman is provided a short,
antiretroviral regimen of zidovudine before and after delivery.
For the newborn child, AZT syrup and a one-year supply of
infant formula are provided to the mother to substitute
her breast milk in order to reduce mother-to-child transmission.
These therapies, however, are not yet available in most
other Asian countries (Brown, 2002b).
The treatment of HIV-infected persons and
AIDS patients is becoming more complicated where there is
a high prevalence of tuberculosis, an opportunistic infection
closely associated with HIV/AIDS. A recent report from WHO
ranked Thailand as sixteenth among countries with the highest
number of tuberculosis cases; India, China and Indonesia
were ranked as the top three countries plagued with this
communicable disease. The situation in Thailand has become
more critical during the previous 10 years when those testing
positive to tuberculosis increased by 40 per cent. According
to the Thai Ministry of Public Health, about 70,000 Thais
or 113 per 100,000 population have been diagnosed with tuberculosis;
the disease is especially prevalent in the northern and
northeastern parts of the country. It has been speculated
that the problem stems from an increase in the number of
AIDS patients and alien workers (mostly working in fishing
industries and farming) from neighbouring countries, especially
from Cambodia, the Lao People’s Democratic Republic
and Myanmar, where tuberculosis is endemic. Bangkok and
a few lower central provinces near the Gulf of Thailand
are the areas most affected because large numbers of alien
immigrants and AIDS patients are located there (Bangkok
Post, 20 August 2002). It has been reported that the sharp
rise in tuberculosis associated with HIV and the high prevalence
of pneumocystic carinii pneumonia and other preventable
opportunistic infections are clear evidence that many –
if not most PLWHAs – are not receiving primary prophylaxis1,
even though these drugs are effective and low in cost (World
Bank, 2000).
The very high costs of the ARV therapy
programmes in combination with longterm medical treatment
(maintenance therapy) have become a major burden on the
health systems of most countries, and directly prevent the
large majority of PLWHAs from gaining access to treatment.
Currently, there are enormous variations in access to antiretrovirals
in middle-income countries; in most of Asia, PLWHAs have
only limited access to treatment (UNAIDS, 2001). As of July
2002, WHO estimated that in developing countries there were
6 million PLWHAs who urgently required affordable ARV treatment;
by contrast, only 230,000 PLWHAs in the same group of countries
had access to ARVs. This situation is due mainly to the
lack of commitment of the parties concerned to provide life-saving
drugs even after affordable ARVs become available (INTAIDS,
2002).
According to the first World Bank report
in November 2000 on Thailand’s response to HIV/AIDS,
Thailand faces the enormous challenges of a severe HIV/AIDS
epidemic, despite international recognition for performing
well in handling HIV/AIDS problems. The report further stated:
“With Thailand’s level of income and its strong
health infrastructure, it can again show access to treatment
of opportunistic infections for
people living with HIV/AIDS, both rich and poor”.
At the same time, the Government should improve access to,
and facilitate reduced prices for, combination antiretroviral
treatment for patients who can afford it and implement adequate
safeguards to minimize inappropriate use of antiretroviral
drugs (Bangkok Post, 17 September 2000).
In many countries, large-scale campaigns,
protests and negotiations for obtaining cheaper drug prices
have been intensively carried out through many different
channels in order to help PLWHAs to gain greater access
to ARV drugs. For example, in October 2002, some HIV-positive
Cambodians demanded access to free antiretroviral medication.
An estimated 500 of approximately 169,000 HIV-positive Cambodians
are currently able to access free ARVs made available by
Medicins Sans Frontieres and other NGOs. If others are to
obtain them, they must buy the drugs at market prices, raging
from $150 to $400 per month, which is prohibitive for the
overwhelming majority of patients. PLWHAs in Cambodia live
on average only five to seven years owing to the lack of
adequate health and medical care; in comparison in neighbouring
Thailand, HIV-positive persons may live 10 to 20 years (Bangkok
Post, 2 October 2002).
The situation of PLWHAs in China is similar
to that of Cambodia. The current monthly cost of treatment
($233-350) is far too high for the vast majority of PLWHAs.
At the time of writing this paper, the Chinese Northeast
Pharmaceutical Group, which has produced AZT for export
since early 2000, is expected to get approval from the Chinese
Government to make AZT available to patients in specific
AIDS hospitals. Domestically produced AZT could be made
available for about a tenth of the price of imported versions
(Bangkok Post, 17 August 2000).
In early 2002, the Government Pharmaceutical
Organization (GPO) of Thailand introduced “GPO-VIR”,
a locally produced anti-AIDS drug proven effective in cutting
viral loads while causing few side-effects. The drug is
a combination of three antiviral drugs: stavudine, lamivudine
and nevirapine. The drug cocktail costs less than $30 a
month, making it one of the cheapest antiretrovirals in
the world. This low-cost drug is expected to relieve the
economic burden of AIDS patients and give them greater access
to
antiretroviral treatments (Bangkok Post, 22 March 2002).
In addition to its attempts to produce cheaper
ARVs, Thailand has been actively participating in several
vaccine development programmes since 1993. Ten clinical
trials of HIV candidate vaccines have already been undertaken,
and the final results are expected in 2003 (Thaineau, 2002).
It is important to recognize that HIV/AIDS
cases are often underreported. Those who do not have access
to modern medication and hospital treatment because of economic
hardship or their status as alien illegal migrants usually
seek alternative treatments and other forms of health care,
including herbal medicines, special diets and supplements,
and meditation. While PLWHAs may gain some health benefits
from alternative treatments, many have been taken advantage
of by quacks or self-claimed healers who charge excessively
high prices for their treatments. In this regard, the aforementioned
World Bank report also suggested that the authorities concerned
provide critical information about the costs and benefits
of alternative treatment for patients. |
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