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Scientific Sessions 2015: Global and sri lankan hiv situation among msm

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Br Dr Neelamani Punchihewa

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Scientific Sessions 2015: Global and sri lankan hiv situation among msm

  1. 1. Global and Sri Lanka HIV situation among MSM 15 th October 2015 SCOV Annual scientific sessions
  2. 2. Introduction • HIV epidemic is declining , HIV prevelence , PLHIV & new infections are declining and AIDS free world is become a reality • Despite decades of research and community, medical, and public healt efforts, high HIV prevalence and incidence burdens havebeen reported in MSM throughout the world. This risk has been presentsince the syndrome now known as AIDS was fi rst described in previously healthy homosexual men in Los Angeles (CA, USA) in 1981. Past 3 decades HIV has severely affected gay & other MSM In many • high-income settings—including Australia, France, the UK, and the USA—overall HIV epidemic trends are in • decline except in MSM, where they have been expandin in the era of highly active antiretroviral therapy (HAART • MSM excluded from surveillance in settings where same sex behaviour is stigmatised or criminalised • Stigma , criminalisation bar access to asses burden, difficult to reach pockets • size of the population /denominator • Now LGBT made success international gay community developing through internet & other media, net working, demanding recognition, rights , challenge social exclusion , discrimination • data is sparse or limited ,96 out of 196 (most countries ) have not reported MSM rates last 5 years, • Re-emergent MSM epidemics in high income countries UK, USA ,France , epidemic among MSM increase in (HARRT) ART era increasing 8% /year since 2011 • Asia , Africa Latin america the highest rates of HIV among any KAP is is MSM • 3% -5% middle east & North africa to caribbean
  3. 3. Who is a MSM • Definition –introduced in 1992 to capture a range of male to male sexual behaviour avoid charactersing men engaging in these sexual behaviours by gender identity or sexual orientation that happens in any male setting • TG -Biological men choosing to have female identity -TG or transgendered women if gender assignment surgery done carry risk if receptive anal sex but due to nature of female identity is not considered as MSM
  4. 4. Background • From 2000 to 2014 new HIV infections fell by 35% globally ,sharpest declines occurred in the Caribbean (50% decline) and sub-Saharan Africa (41% . Asia and the Pacific fell by 31%. • In 2 Regions Eastern Europe and central Asia and the Middle East and North Africa, new infections however have increased since 2000. • New infections appear to be stable among gay and other MSM ,with small peaks in Caribbean , Eastern Europe and central Asia. • overall HIV epidemic trends are in decline except in MSM. HIV prevalence has not declined as seen among sex workers & IDU globally. • Past 3 decades HIV has severely affected gay & other MSM In many high-income settings—including Australia, France, the UK, and the USA—Re-emergent MSM epidemics, epidemic among MSM increase 8% /year in (HARRT) ART era increasing since 2011 • Prevalence is not a good indicator of disease burden in the ART Era , incidence surveys are lacking
  5. 5. • MSM excluded from surveillance in settings where same sex behaviour is stigmatised or criminalised . Data is sparse or limited ,96 out of 196 (most countries ) have not reported MSM rates last 5 years • MSM are 19 times more likely to have HIV than the general population, review of 15 countries found that around 20% transgender people are living with HIV. Transgender women are almost 50 times at risk of HIV than adults in the general population • In China, it is estimated that more than one third of the people acquiring HIV infection are men who have sex with men. • Projections for Asia indicate that unprotected sex between men could account for half or more of all new infections by 2020 • Fewer than one in 10 MSM worldwide have access to most basic package of services , services are not sensitive to their need or they are not led by community members • HIV testing and know the status is low 42% and condom use at last sex is very low among gay , MSM. • a median of 69% of men who have sex with men were reportedly reached with HIV prevention programmes . • Countries lack legal protection for MSM , 25 countries had protecting laws while 75 reported negative
  6. 6. Total: 36.9 million [34.3 million – 41.4 million] Middle East & North Africa 240 000 [150 000 – 320 000] Sub-Saharan Africa 25.8 million [24.0 million – 28.7 million] Eastern Europe & Central Asia 1.5 million [1.3 million – 1.8 million] Asia and the Pacific 5.0 million [4.5 million – 5.6 million] North America and Western and Central Europe 2.4 million [1.5 million – 3.5 million] Latin America 1.7 million [1.4 million – 2.0 million] Caribbean 280 000 [210 000 – 340 000] Adults and children estimated to be living with HIV  2014
  7. 7. Estimated number of adults and children newly infected with HIV  2014 Middle East & North Africa 22 000 [13 000 – 33 000] Sub-Saharan Africa 1.4 million [1.2 million – 1.5 million] Eastern Europe & Central Asia 140 000 [110 000 – 160 000] Latin America 87 000 [70 000 – 100 000] Caribbean 13 000 [9600 – 17 000] Total: 2.0 million [1.9 million – 2.2 million] Asia and the Pacific 340 000 [240 000 – 480 000] North America and Western and Central Europe 85 000 [48 000 – 130 000]
  8. 8. New infections among key populations 70000110000 330000 140000 1865000 New infections among key populations sex workers people who injects drugs Men who have sex with men clients of sex workers other adults
  9. 9. Why risk is high & what drives HIV in MSM- • High probability of per act- and per partner transmission through receptive anal sex • Spread speedily in large networks • Clustering of HIV is high in networks • High rate of dual & multivariant HIV in MSM than heterosexual
  10. 10. Global prevalence of MSM
  11. 11. Pooled HIV prevalence among men who have sex with men in low- and middle income countries, by region, 2000–2010 0 5 10 15 20 25 30 HIV Prevalence among MSM percentage
  12. 12. HIV prevalence by Region& country 0 5 10 15 Armenia Belarus Georgia Kazakhstan Kyrgyzstan Republic of Moldova Ukraine Uzbekistan Azerbaijan Tajikistan 2011 2012 2013 2014 0 10 20 30 40 50 60 Democratic Republic of the Congo Lesotho Madagascar Malawi Mali Mauritania Senegal United Republic of Tanzania Benin Botswana Central African Republic Congo Nigeria Seychelles Togo Uganda Cameroon Côte d'Ivoire Ghana Guinea Mauritius Kenya Swaziland 2012 2013 2014 Latin America Sub Saharan Africa percentage
  13. 13. 0 5 10 15 20 25 30 35 40 Belarus Georgia Kyrgyzstan Republic of Moldova Uzbekistan Barbados Cuba Jamaica Bahamas Dominica Haiti Saint Vincent and the Grenadines Argentina Colombia Guyana Honduras Nicaragua Panama Paraguay Peru Belize Brazil El Salvador Mexico Uruguay Chile Costa Rica Ecuador europe&CAcaribbeanlatinAmrica 2011 2012 2013 2014 Regional variation in HIV prevalence among MSM in Latin America, Caribbean Europe & central America
  14. 14. Disparity by urban cities • HIV epidemics among men who have sex with men are expanding rapidly in urban areas across the region • In Thailand overall, an average 7% of men who have sex with men are estimated to be living with HIV, but in Bangkok, the figure is closer to 25%. • Similarly, in Nigeria, the HIV infection level among men who have sex with men is 17%; in the Federal Capital Territory it is more than twice as high (38%) • A study in 24 Mexican cities among men who have sex with men found that about 17% of them were HIV-positive. • Since 2007 there has been an upwards trend of HIV infections from 1% to nearly 7%in Quezon city in Philippine
  15. 15. MSM behaviours by Region Average condom use HIV test uptake Sub Saharan Africa 54% Caribbean 40 -80% 16-99% Asia Pacific 1-90% 2-87% Middle East & North America <50% (except 75% in Lebanon) 60% Latin America 7-100% Majority <50% < 50% Western & central Europe 20-77% majority less than 50% Eastern Europe &central Asia 50%-80% 24-74% *Wide Variation between countries in the Regions Can we reach new global 90 90 90 Targets? Is C urrent behavior modification (IEC/ BCC strategies make sense? Bio medical interventions?
  16. 16. MSM are disproportionately affected In Asia Have a higher risk of HIV infection Asian Epidemic Model projects by 2020, around 46% of new infections in Asia will be among MSM. Estimated Population of MSM in Soth East Asia & pacific is
  17. 17. Fig 14a :Adult new infections by mode of transmission in Non-Papua Indonesia - 20,000 40,000 60,000 80,000 100,000 120,000 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 Husband->wife Wife->husband Casual sex Needle sharing Sex work Male-male sex Waria sex Source ;National AIDs control programme Indonesia, based on ASIA epidemic model and spetcrum
  18. 18. population size estimates Asia Pacific
  19. 19. MSM size estimates, countries where data is available Estimated MSM (a) Year of estimate Year of reporting HIV prevalence (b) 1 Afghanistan (Kabul) 1,729 2012 2014 0.5 (2012) 2 Australia 190,000 2011 2014 10.9 (2012) 3 Bangladesh 110,581 2010 2014 0.7 (Dhaka, 2013) 4 Cambodia 21,000 2008 2014 2.1 (2010) 5 China 3,830,000 2011 2014 7.3 (2013) 6 Hong Kong SAR 120,000 2011 … 4.08 (2011) 7 India 427,000 [High risk MSM, interventions] 3,500,000 [MSM at-risk] 2012 2014 4.4 (2010-11) 8 Indonesia 1,095,970 2012 2014 8.5 (2011) 9 Lao PDR 17,000 [High risk MSM] 49,330 [All MSM and TG] 2011 2010 2014 3.1 (Vientiane, 2011) 10 Malaysia 173,000 2009 2014 12.6 (2012) 11 Maldives 4,100 2009* 0 (2008) 12 Mongolia 11,500 -15,000 (homo and bisexual) 2006 10.7 (Ulaanbaatar,2012) 13 Myanmar 230,000 2010 2014 10.4 (2013) 14 Nepal 196,270 2012 2014 3.8 (2012) 15 Philippines 540,000 (390,733-689,529) 2011 2011* 3.3 (2013) 16 Singapore 90,000 2011 3.1(2013) 17 Sri Lanka 7,551 2013 2014 0.9 (2011) 18 Thailand 550,571 2010 2014 7.1 (2012) 19 Timor Leste 11,197 2010 1.3 (2011) 20 Viet Nam 382,506 2013 2014 3.7 (2013) Prepared by www.aidsdatahub.org ; Note: a) Please see next slide for references; b) National HIV Sentinel Surveillance surveys and Integrated Biological and Behavioral surveys reported in GARPR 2013 and 2014 * Year of source reference
  20. 20. 0.1 1 1 1 1 1 1.5 1.6 1.6 2.2 2.3 3.1 3.1 4.3 4.8 0 5 % Regional median 1.6%; Range 0.14% - 4.8% Size estimates of MSM as proportion of adult male population (15-49) years Source: Prepared by www.aidsdatahub.org based on size estimates of MSM ( please see the information provided in the previous 2 slides) and the data on adult male population (15- 49) years is based on 2012 population based on UN Population Division. (2013). World Population Prospects: The 2012 Revision - Extended Dataset.
  21. 21. HIV prevalence and epidemiology Asia Pacific
  22. 22. 7.1 7.3 8.5 10.4 12.6 0 5 10 15 20 Thailand (2012) China (2013) Indonesia (2011) Myanmar (2013) Malaysia (2012) % Countries with >5% HIV prevalence among MSM in national estimates from surveys, 2011-2013
  23. 23. 6.0 6.5 7.7 7.9 8 10.1 10.3 10.4 10.7 12.4 12.5 13.6 13.7 14.8 15 17.2 17.8 19.5 24.4 0 5 10 15 20 25 30% Source: Prepared by www.aidsdatahub.org based on National AIDS Committee Thailand. (2012). Thailand Global AIDS Response Progress Report, 2012; HIV Sentinel Surveillance Reports; Integrated Biological and Behavioral Surveillance Reports; Lan, W., et al. (2012). HIV Prevalence and Influencing Factors Analysis of Sentinel Surveillance among Men who have Sex with Men in China, 2003-2011 and Chengdu Center for Disease Control and Prevention. (2014). Intensifying HIV response among MSMs with city-approach in Chengdu city, China.
  24. 24. Countries and select cities with rising HIV prevalence trend among MSM, Asia pacific 2000-2013 7.3 17.8 8.5 17.2 3.3 7.7 0 5 10 15 20 % China China (Chengdu) Indonesia Indonesia (Jakarta) Philippines Philippines (Cebu) Source: www.aidsdatahub.org
  25. 25. Cities with stabilizing/ declining HIV prevalence trend among MSM, 2000-2013 10.5 6.0 3.8 0 10 20 30 40 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 % Bangladesh (Dhaka) India (Manipur) Myanmar (Mandalay) Nepal (Kathmandu Valley) Source: Prepared by www.aidsdatahub.org
  26. 26. HIV prevalence among MSM by region, latest available year, 2008-2013 0 0.7 0.5 0.9 3.8 4.4 0.5 4.4 7.3 10.7 1.3 2.1 3 3.1 3.1 3.3 3.7 4.2 7.1 8.5 10.4 12.6 0 5 10 15 20 Maldives(2008) Bangladesh(2013)* Afghanistan(2012) SriLanka(2011) Nepal(2012) India(2010-11) Fiji(2011) PNG(2009)** China(2013) Mongolia(2012)*** Timor-Leste(2011) Cambodia(2010) Rep.ofKorea(2011) Singapore(2013) LaoPDR(2011)**** Philippines(2013) VietNam(2013) Japan(2010) Thailand(2012) Indonesia(2011) Myanmar(2013) Malaysia(2012) South Asia Pacific East Asia South-East Asia % *Dhaka, ** Port Moresby, *** Ulaanbaatar, ****Vientiane
  27. 27. 54 22 21 11 2 1 4 12 41 66 70 0 20 40 60 80 100 % newly reported HIV cases cumulative HIV cases * both homosexual and bisexual Proportion of newly reported and cumulative HIV cases attributable to homosexual transmission, 2011-2014 Source: Prepared by www.aidsdatahub.org
  28. 28. Adult new infections by mode of transmission in Non-Papua Indonesia - 20,000 40,000 60,000 80,000 100,000 120,000 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 Husband->wife Wife->husband Casual sex Needle sharing Sex work Male-male sex Waria sex Source ;National AIDs control programme Indonesia, based on ASIA epidemic model and spetcrum
  29. 29. HIV and AIDS Data Hub for Asia-Pacific Correlation between reported homosexual mode of transmission and HIV prevalence among MSM Source: Prepared by www.aidsdatahub.org based on data from Ministry of Health HIV statistics and AIDS Registry; HIV Sentinel Surveillance Reports; Country Global AIDS Response Progress Reports 2012 to 2014 3 6 9 12 15 19 21 7.3 0 2 4 6 8 0 5 10 15 20 25 2007 2008 2009 2010 2011 2012 2013 %HIVprevalence %homosexual transmission China % homosexual transmission HIV prevalence (National) 2 5 7 11 8.5 0 2 4 6 8 10 0 2 4 6 8 10 12 2007 2008 2009 2010 2011 2012 2013 %HIVprevalence %homosexual transmission Indonesia % homosexual transmission HIV prevalence (National) 70.4 72 78 80 79 3.3 0 1 2 3 4 0 20 40 60 80 100 2007 2008 2009 2010 2011 2012 2013 %HIVprevalence %homosexual transmission Philippines % homosexual transmission HIV prevalence (National) 34 41 36 46 51 51 54 3.1 0 1 2 3 4 0 10 20 30 40 50 60 2007 2008 2009 2010 2011 2012 2013 %HIVprevalence %homosexual transmission Singapore % homosexual transmission HIV prevalence (National)
  30. 30. Syphilis prevalence among MSM, 2011-2013 0.7 0.8 1.7 2 4.1 6 7.1 7.5 8.4 10.2 18.4 19.9 2 24.4 0 5 10 15 20 25 30 Viet Nam (2013) Nepal (2012) * Bangladesh (2013) * Philippines (2013) Mongolia (2012) * Myanmar (2013) Timor-Leste (2011) China (2012) Guangxi, China… Afghanistan (2012) * Singapore (2013) # Indonesia (2013) # Sri Lanka (2011) ** Thailand (2013) # % Source: Prepared by www.aidsdatahub.org based on 1) HIV Sentinel Surveillance Reports; 2) Integrated Biological and Behavioral Surveillance Reports; 3) Global AIDS Response Progress Reporting 2013 and 2014 ; 4) Wang et al.(2014). HIV and syphilis prevalence trends among men who have sex with men in Guangxi, China: Yearly cross-sectional surveys, 2008–2012. BMC Infectious Diseases 2014, 14:367
  31. 31. Risk behaviours
  32. 32. Mean number of male sexual partners among MSM in last month, countries where data is available, 2006- 2012 1.3 2.7 3 2.5 3.2 6 0 1 2 3 4 5 6 7 8 9 10 Bangladesh (2006-07) * Cambodia (2010) PNG (2010) * Nepal (2012) * Philippines (2011) Viet Nam (2009) * Meannumber male commercial partner male sex partner
  33. 33. 58 49 48 43 38 13 4 34 8 23 60 10 27 64 63 44 0 10 20 30 40 50 60 70 80 90 100 % last 12 months last 6 months last 3 months last month last sex Undefined period Source: Prepared by www.aidsdatahub.org based on 1) Integrated Biological and Behavioural Surveys and Behavioural Surveillance Surveys; 2) Lan, W., Lu, W., L.Norris, J., Dong-min, L., Wei, G., Zheng-wei, D., & Ning, W. (2012). HIV Prevalence and Influencing Factors Analysis of Sentinel Surveillance among Men who have Sex with Men in China, 2003-2011. Chinese Medical Journal, 125(11), 1857-1861.; 3) Bavinton, B., Singh, N., Naiker, D. S., Deo, M. N., Talala, M., Brown, M.,Navokavokadrau, S. (2011). Secret Lives, Other Voices: A Community-based Study Exploring Male-to-Male Sex, Gender Identity and HIV Transmission Risk in Fiji.;4) Philippines Department of Health, National Epidemiology Center (2013). 2011 Integrated HIV Behavioral and Serologic Surveillance (IHBSS)
  34. 34. Proportion of MSM who reported buying sex from male and female, 2006-2013 8 8 19 20 27 29 58 62 3 6 14 16 4 49 50 25 0 10 20 30 40 50 60 70 80 90 100 % bought sex from male bought sex from female Source: Prepared by www.aidsdatahub.org based on Integrated Biological and Behavioural Surveys and Behavioural Surveillance Surveys
  35. 35. 23 27 34 36 36 44 49 56 0 20 40 60 80 100 Sri Lanka (2006-07) Nepal (2012)* Philippines (2011) Cambodia (2013) Mongolia (2012) * Fiji (2010) ** Viet Nam (2009) * Bangladesh (2006-07) * % Risk of transferring infection to General population Proportion of MSM who had sex with female partners in the last year, 2006- 2013
  36. 36. Proportion of MSM who reported condom use at last anal sex with male partner, 2006-2013 91 87 86 82 79 77 70 66 66 63 61 60 51 49 41 21 17 1 65 0 20 40 60 80 100 Condomuseatlastsex(%) Still many have not reached the target
  37. 37. Condom use at last anal sex and consistent use among MSM, 2009-2013 90 85 64 74 70 60 5868 68 66 41 43 48 25 6 57 0 20 40 60 80 100 National,2013* National,2013* National,2010 Bangkok,2010 ChiangMai,2010 National,2012 National,2012 National,2011 National,2011 Ulaanbaatar,2011 Ulaanbaatar,2011 National,2011 Jakarta,2011* Bandung,2011* Manipur,2009 **Mumbai,2009 Cambodia Thailand Viet Nam China Mongolia Indonesia India % Condom use at last sex Consistent condom use
  38. 38. Figure 24: Percentage of men who have sex with men using condoms during last anal sex, South-East Asia Region 2011 0 20 40 60 80 100 Condom use at last anal sex all <25 years >25 years 82 84 78 75 75 76 85 85 85 66 61 61 61 60 64 58 29 37 23 %ofMSMusingcondom Myanmar Nepal Thailand Timor Leste Sri Lanka Indonesia Bangladesh Target Condom use in MSM is below the target in most countries Source: Monitoring and reporting on the global response to HIV and AIDS 2008- 2011; Reports of behavioural surveys, national AIDS programmes. Sample size was adequate as per national protocols.
  39. 39. 0 20 40 60 80 100 % Total <25 yr 25+ yr Percentage of MSM with comprehensive HIV knowledge, by age group, countries where data is available, 2005-2009 Source: Prepared by www.aidsdatahub.org based on UNGASS Country Progress Reports 2006,2008 & 2010
  40. 40. 77 70 69 68 67 64 64 53 46 42 24 23 23 64 0 20 40 60 80 100 Preventioncoverage(%) Definition of reach : Know where to go to receive an HIV test and had been given condoms in the last 12 months * Programme data ** Data for Kathmandu Proportion of MSM reached with HIV prevention programmes in the last 12 months, 2009-2013
  41. 41. Proportion of MSM who received an HIV test in the last 12 months and know their results, 2006-2013 87 79 68 65 56 48 46 42 39 36 33 29 26 17 16 15 14 10 9 0 10 20 30 40 50 60 70 80 90 100 Testingcoverage(%) Data is not strictly comparable across countries since methods and sampling varied.
  42. 42. HIV and AIDS Data Hub for Asia-Pacific Criminalisation of same-sex sexual activities between consenting adult males in South-East Asia and the Pacific countries 42Sources: Prepared by www.aidsdatahub.org based on UNAIDS, Data Hub, UNDP, UNFPA, and UNODC. (2014). Punitive Laws Hindering the HIV Response in Asia and the Pacific in October 2014 *Federated States of Micronesia South-East Asia Pacific Brunei YES Fiji NO Cambodia NO Kiribati YES Indonesia NO Marshall Islands NO Lao PDR NO FSM* NO Malaysia YES Nauru YES Myanmar YES Palau NO Philippines NO Papua New Guinea YES Singapore YES Samoa YES Thailand NO Solomon Islands YES Timor-Leste NO Tonga YES Viet Nam NO Tuvalu YES Vanuatu NO
  43. 43. HIV and AIDS Data Hub for Asia-Pacific Criminalisation of same-sex sexual activities between consenting adult males in South Asia and East Asia countries 43 South Asia East Asia Afghanistan YES China NO Bangladesh YES Japan NO Bhutan YES Mongolia NO India YES DRP Korea NO Maldives YES Rep of Korea NO Nepal NO Pakistan YES Sri Lanka YES Sources: Prepared by www.aidsdatahub.org based on UNAIDS, Data Hub, UNDP, UNFPA, and UNODC. (2014). Punitive Laws Hindering the HIV Response in Asia and the Pacific in October 2014
  44. 44. HIV and AIDS Data Hub for Asia-Pacific Adult new infections by mode of transmission in Non-Papua Indonesia - 20,000 40,000 60,000 80,000 100,000 120,000 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 Husband->wife Wife->husband Casual sex Needle sharing Sex work Male-male sex Waria sex Source ;National AIDs control programme Indonesia, based on ASIA epidemic model and spetcrum
  45. 45. HIV and AIDS Data Hub for Asia-Pacific Young Key Populations 45
  46. 46. HIV and AIDS Data Hub for Asia-Pacific 46 “The analysis carried out by the Commission shows that over 95% of all new HIV infections among young people occur among most-at-risk adolescents.” Report of the Commission on AIDS in Asia. Redefining AIDS in Asia: Crafting an Effective Response (2008), p. 146.
  47. 47. HIV and AIDS Data Hub for Asia-Pacific The ethical considerations needed to include minors in studies that ask questions that relate to their sexual behavior, use of drugs and other risk behaviors What is different about surveying young key populations(YKPs)?
  48. 48. HIV and AIDS Data Hub for Asia-Pacific Data need for young key populations To understand how HIV affects young key populations… • Surveys have to include enough of young key populations to yield meaningful results • Reports of surveys have to include the age disaggregated data and results • Age of inclusion differs , comparison difficult Age of inclusion
  49. 49. HIV and AIDS Data Hub for Asia-Pacific Age of inclusion of YKPs in surveys of key populations, based on available data from survey reports 49Source: Prepared by www.aidsdatahub.org based on National HIV Sentinel Surveillance, HIV Prevalence Surveys and Behavioral Surveys; Global AIDS Response Progress Reports 2012 to 2014; UNGASS Progress Reports (2010). HIV prevalence surveys – 9-14yrs : Maldives (FSW 13, MSM 10); Pakistan (MSW 13); PNG (FSW 14, MSW 9) – 15+yrs : Cambodia (FSW 15, MSM 18); Lao (MSM, TG 15); Maldives (PWID 17); Myanmar (FSW, MSM, PWID 15); Nepal (FSW, MSM, PWID 16); Pakistan (FSW, Hijra 15); Viet Nam (FSW, MSM, PWID 16) – 18+yrs : Afghanistan (FSW,MSM, PWID 18); India (FSW, MSM, TG, PWID 18); Pakistan (PWID 18); Malaysia (MSM,PWID 18) Behavioral surveys – 9-14yrs : Maldives (FSW 13, MSM 10); Pakistan (MSW 13); PNG (FSW 14, MSW 9 ) – 15+yrs : Bangladesh (FSW, MSW, MSM, TG, PWID 15); Lao (FSW, MSM, TG 15); Maldives (PWID 17); Myanmar (FSW, PWID 15); Nepal (FSW, MSM, PWID 16); Pakistan (FSW, Hijra 15); Sri Lanka (FSW, MSM 16, PWID 17); Timor Leste (FSW, MSM 16) – 18+yrs : Afghanistan (FSW, MSM,PWID 18); Cambodia (FEW, MSM 18);India (FSW, MSM, TG, PWID 18); Pakistan (PWID 18); Malaysia (MSM,PWID 18)
  50. 50. HIV and AIDS Data Hub for Asia-Pacific Young MSM are getting infected with HIV! 50 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org HIV prevalence among MSM by age group, countries where the data is available from 2009- 2013 0.0 0.0 0.8 1.1 1.9 1.9 2.0 2.5 3.0 3.5 5.3 5.6 6.1 6.2 8.8 10.0 1.1 0.9 0.6 4.1 5.3 6.4 6.7 4.8 30.4 4.9 16.3 7.3 9.8 16.0 12.4 11.1 0 5 10 15 20 25 30 35 %HIVprevalence <25 yr 25+ yr Countries with HIV prevalence < 5% among MSM < 25 years Countries with HIV prevalence > 5% among MSM < 25 years
  51. 51. HIV and AIDS Data Hub for Asia-Pacific Young PWID are getting infected with HIV! 51 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org HIV prevalence among PWID by age group, countries where the data is available from 2010- 2013 1.1 13.0 5.1 6.5 19.4 7.7 43.9 20.7 25.3 25 48.1 0.7 1.1 2.7 3.7 4.8 5.3 11.6 11.7 25 33.9 41.2 0 10 20 30 40 50 60 %HIVprevalence 25+ yr <25 yr Countries with HIV prevalence < 5% among PWID < 25 years Countries with HIV prevalence > 5% among PWID < 25 years
  52. 52. HIV and AIDS Data Hub for Asia-Pacific Condom use among young MSM is generally lower than their older counterparts 52 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org Condom use at last anal sex among MSM by age group, countries where the data is available, 2007-2013 17 24 38 44 45 60 61 64 66 69 70 72 76 84 86 91 65 18 24 45 69 52 66 61 58 69 62 69 79 76 78 88 92 68 0 20 40 60 80 100 Condomuse(%) < 25 yr 25+ yr
  53. 53. HIV and AIDS Data Hub for Asia-Pacific Proportion of MSM with comprehensive HIV knowledge, by age group, countries where data is available, 2007-2013 53Source: Prepared by www.aidsdatahub.org based on 1.UNAIDS Report on The Global AIDS Epidemic, 2010; 2. UNGASS Country Progress Reports ; 3. Integrated Biological and Behavioural Survey Reports 0 20 40 60 80 100% Total <25 yr 25+ yr * Manipur
  54. 54. HIV and AIDS Data Hub for Asia-Pacific Laws and regulations that allow adolescents to seek services without parental/spousal consent, countries where data is available 54 Source: Prepared by www.aidsdatahub.org based on Department of Maternal, Newborn, Child, and Adolescent Health (WHO) at http://www.who.int/maternal_child_adolescent/documents/countries/indicators/dashboards/en/ (accessed Feb 4, 2015) Country (reporting period) Contraceptive services except sterilization HIV testing and counselling services Cambodia (Dec-2013) India (Feb-2014) Indonesia (Jan-2014) Kiribati (Jun-2014) Lao PDR (Dec -2013) Malaysia (Dec -2013) Myanmar (Feb- 2014) Nepal (Jan-2014) Pakistan (Feb-2014) Papua New Guinea (Jan-2014) Philippines (Mar-2014) Solomon Islands (Dec-2013) Sri Lanka (Jan-2014) Timor Leste (Jan-2014) Vanuatu (Dec -2013) Viet Nam (Jan-2014) Yes No No information
  55. 55. HIV and AIDS Data Hub for Asia-Pacific Compared to their older counterparts, 55 • less young key populations are being reached by prevention programmes • less young key populations have access to HIV testing services and approximately 3 in 4 young key populations do not know their HIV status
  56. 56. HIV and AIDS Data Hub for Asia-Pacific 21 30 25 21 52 47 61 73 78 64 68 78 80 61 12 18 20 29 39 43 49 55 62 63 71 76 80 49 0 20 40 60 80 100% Proportion of MSM reached with HIV prevention programmes in the last 12 months, 2008-2013 25+ yr < 25 yr Proportion of MSM reached by prevention programmes, by age group, 2008-2013 56 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org
  57. 57. HIV and AIDS Data Hub for Asia-Pacific 3 in 4 young MSM surveyed in the region do not know their HIV status…. 57 Source: Prepared by www.aidsdatahub.org based on www.aidsinfoonline.org 7 7 7 12 15 17 22 24 33 36 38 39 45 56 63 24 20 22 13 8 20 37 13 41 36 48 33 45 51 69 51 36 0 20 40 60 80 100 % Proportion of MSM who received an HIV test in the last 12 months and know their results, 2008-2013 < 25 25+ Malaysia and Indonesia data is not included in regional median calculation since the denominators of reported proportion for HIV testing coverage do not reflect total surveyed MSM and these denominators represent only those who answered HIV testing related questions
  58. 58. Scenario in Sri Lanka
  59. 59.  People living with HIV/AIDS Adults >15 Years - 3200 (2200-5600) Children <15 Years - 100  AIDS deaths in 2014 - 100  Adult HIV Prevalence rate - <0.1%
  60. 60. 2133 •Cumulative Number of HIV Positives as of 2015 2nd quarter 568 •Cumulative Number of AIDS Cases Reported 348 •Cumulative Number of AIDS deaths reported
  61. 61. Cumulative HIV Cases by District as of end 2014 (N= 1985) Data not available for 88 cases. Courtesy :Epidemiologist
  62. 62. 69% 24% 5% 2%0% Probable Mode of transmission among cumulative reported HIV Hetero Sexual Same sex/Bisexual MTCT DU/IVDU N = 783
  63. 63. PLHIV (newly diagnosed) reported male to male transmission shows an increasing trend annually…. 1 2.4 6 6 8 3 12 7 16 20 27 28 0 33 72 0 10 20 30 40 50 60 70 80 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 all age groups 15-24 percentage 76.3 18.2 0.7 0.3 4.4 Hetero Homo/Bi IDU Blood Perinatal
  64. 64. MSM population in Sri Lanka National estimate for MSM in 2013 7551 Range (6547- 8554)
  65. 65. Distribution by locations and type of MSM. home /shanty 16% lodge hotel, 4% night club /massage parlour, 0% street /public places , 78% others , 6% Cruising sites Source :2013 size estimation survey 35% 36% 29% MSW Nachchi other MSM typology
  66. 66. Geographical distribution of MSM locations- 0 1000 2000 3000 4000 5000 6000 7000 number of MSM hot spots
  67. 67. Progressive coverage of MSM by provinces …….3 provinces can prioritise to cover 80% of MSM to have an impact 0 10 20 30 40 50 60 70 80 90 100 western southern central N central northern north western Eastern Sabaragamuwa Uva 65% 73% 81% 86% 90% 93% 97% 99% 100% Cumulative coverage
  68. 68. Risk behaviours for HIV
  69. 69. Sexual Risk behaviours among MSM • Mean number of partners ranged , 10.7-12.5 in the last 6 months • 27.5% MSM have sold sex while 19.6% have bought sex in colombo • 58.9% ever had sex with women, 73% during last 12 months, condom use was less than 46% , risk for transmitting HIV to general population • Almost all had ever anal sex 96%
  70. 70. Are MSM safe ? Risk reduction Behaviours among MSM 63.7 13.6 57.9 15.4 19.3 30.46 0 20 40 60 80 100 condom use HIV testing reached with prevention comprehensive knowledge 2014 2006 percentage
  71. 71. limitations • Data gap Even after 30 years 90 countries have no reports past 5 years .the available available HIV prevalence and incidence data are incomplete. Lack of population based prevalence estimates and same sex behaviour . only one incidence estimate in Africa, 2 in Asia. few prospective cohort studies . Social response bias in reporting anal receptive sex affects estimates of risks Heavily Urban sampling Lack of data from middle East & North Africa Limited data among young MSM – shows high incidence, TI cannot wait till 18 years Interventions If transmission is heavily biologically determined , the current programmes Heavily dependent in IEC & behaviour modification approaches make sense.? Combined approaches –bio medical interventions –ART for treatment & prevention, Prep medical circumcision , with BCC & structural interventions –reduce stigma, discriminatory laws. More research on biology & epidemiology Simulationmodels –converting homosex-heterosex reduces transmission by80-96%, role change from receptive to insertive sex to Highrates ofSTI have the same risk ofHIV transmission to no condoms

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