South-East Asia Regional Conference on Epidemiology

226 | <strong>South</strong>-<strong>East</strong> <strong>Asia</strong> <strong>Regional</strong> <strong>Conference</strong> on Epidemiology
terms of accessing treatment than prevention. In terms of prevention, by analogy, with making
ART more effective by combining active drugs in combination ART, there is a movement towards
combination prevention. Learning from the combination of treatment with prevention in TB and
malaria programmes, it is clear now that the packages of prevention interventions, which are known
to work, need to be effectively implemented to reduce the number of new infections.
The entry point to both prevention and care and treatment is voluntary testing and counselling of
the individual about his or her HIV status. Of course, knowing whether infected or uninfected is a very
important piece of information to the individual to base their prevention interventions on or to access
current treatment. For preventable interventions at community level, products like condoms or clean
needles and syringes for intravenous drug users (IDUs) are needed and behavioural changes need to
be promoted and supported. Some of the structural constraints which limit individuals, particularly
in marginalized groups, from accessing preventive services because of stigma and discrimination or
punitive legal laws need to be overcome. (The recent decision of the Delhi High Court striking down
Article 377 against sex between men is a forward step.) Finally, medical interventions are needed, e.g.
antiretroviral drugs to prevent mother-to-child transmission (MTCT) or offering opioid substitution
therapy for intravenous drug users. Combination prevention has actually been responsible for quite an
impressive decline in the incidence of AIDS but more can and must be done.
The incidence rates of HIV, particularly in sub-Saharan Africa, peaked in the 1990s. Although,
often, there has been criticism of not having effective measures of prevention, it is clear that there
has been a significant decline in several regions of the world. Importantly for <strong>Asia</strong>, there is an early
peak and decline in both India and China. It is clear that secular trends are there (Fig. 1). While HIV
incidence rates have gone down quite significantly in many parts of the world, they are appearing to
stabilize. Rapid decline, which was probably due to somewhat more easy interventions on targeted
groups, particularly in Africa, has not been sustained, and there appears to be a flattening out. That is
one of the reasons why it is more of AIDS being endemic rather than HIV being epidemic.
Fig. 1:Trends in HIV incidence rates by region, 1980 onwards
Source: Bongaarts J et al. Development and Population Review. 2008;34:199-224