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December 2007: People light candles in recognition of World Aids Day in Multan -- Reuters

Reviewed by Nadia Jajja 

Cambodia’s first case of HIV was detected in 1991. The same year, in Thailand, the government allocated additional budgets for the purchase and supply of condoms to local sex workers; in Pakistan, the government allowed HIV awareness ads to appear in public for the first time.

Three countries with three different trajectories: the Cambodian government’s serious interest and “high level political commitment” saw the disease go down from two per cent prevalence in 1997 to 0.7 per cent in 2001 with 90 per cent adults and children in need of antiretroviral (ART) drugs having access to them. In Thailand, in a few years time, the government ensured 100 per cent condom use among sex workers. On the other hand, in Pakistan, where the first case of HIV was detected in the 1980s, the government’s laid-back approach means that the coverage available to those in need of HIV therapy is still unsatisfactory. In fact, compared to regional partners, Pakistan has lagged behind in awareness campaigns, blood screening and needle use while 100 per cent condom use among sex workers remains a distant dream.

As direct and mundane as the title may sound, Three Decades of HIV & Aids in Asia is one of the most comprehensive and intelligent treatises on the disease in the region. It is filled with facts, including the above. Spread across 22 chapters, the book is a compilation of reports that trace the history of and current practices in managing the disease in countries across Asia and highlights the pitfalls and successes of various preventive strategies.

Credit is due to Dr Jai P. Narain, formerly with the WHO Regional Office for South-East Asia (SEARO), New Delhi, India, who took on the mammoth task of editing the book and maintaining quality. His experiences with public health over the last few decades — including participating in the Global Smallpox Eradication Programme during 1975 — and his affiliation with reputable institutes such as the All India Institute of Medical Sciences and Centers for Disease Control and Prevention in the US, reflects in his work.

The first few chapters comprise the preamble and state facts about the disease in the region. In absolute numbers, Asia has a large number of HIV-positive individuals but overall prevalence in less than one per cent. Asia is also home to the second-largest population of HIV-positive individuals. In 2009, 4.9 million people were affected by the disease. Meanwhile, “household surveys to asses disease prevalence have been carried out in India and Cambodia only.”

Three Decades of HIV & Aids tells us that currently “Thailand is the only country in this region in which the prevalence is above one per cent.” Other countries, including India, China, Cambodia, Vietnam, Nepal, Thailand, Malaysia and Pakistan, have prevalence between 0.9 per cent and 0.1 per cent. We also learn that women play a significant role in transmission: “In 1990, they accounted for 21 per cent of the infection transmission, in 2009 that went up to 35 per cent. However, as compared to the global average of 51 per cent that is relatively smaller.”

It is quite obvious that all these countries, with the exception of Pakistan, have a thriving tourist industry and precautions have been taken to make the disease a less taboo subject. In Pakistan, drug-injecting needles are the primary mode of HIV transmission, yet the public discourse is not as open as it needs to be.

After the epidemiological distribution in the region, the book discusses clinical associations and perhaps the most interesting fact is that unlike in the West, the most common opportunistic infection associated with HIV in South Asia is tuberculosis.

In a chapter on the clinical treatment of the disease the authors note: “Despite the rapid scale-up of ART in the past few years, it is available to only 32 per cent of those who need it, as per the latest WHO criteria. There is an obvious gap on implementation, i.e. low coverage of services, [and] low percentage of funds allocated from national budgets for spending on health.”

The rest of the book contains case studies from each country, the most enlightening of which are from Thailand, Cambodia and Malaysia, where local mosques offer heroin addicts methadone therapy to kick the addiction.

Pakistan’s efforts in containing the disease pale in comparison to those of its regional partners and even Islamic states, where governments have been involved at every level. As the Pakistani contributors comment, social awareness of the disease falls short of expectations.

Three Decades of HIV & Aids also highlights the major influence foreign donors have: chapter upon chapter talks about the funds funneled into Asia and the impact when they are pulled. Various governments, such as Thailand’s, stepped in to bridge the gap when that happened.

The book is a must-read for local epidemiologists and infectious diseases specialists in the region as it provides up-to-date information till 2011. However, for readers without backgrounds in public health policy, it can be tedious and the quality of language leaves a lot to be desired in many chapters. The onslaught of abbreviations is also bothersome and some would be unfamiliar even for those with a medical background: FSW (female sex workers), MSW (male sex workers), MARPs (most-at-risk populations), BSS (behaviour surveillance survey), SSS (STI sentinel surveillance) and so on.

But if one has to recommend a chapter that ought to be read by all, it would be “HIV Epidemic Among People Who Inject Drugs in Asia” for a comparison of good practices in the region. The syringe and needle exchange programme is promising and Pakistan needs to join in.

Three Decades of HIV & AIDS in Asia


Edited by Jai P. Narain

Sage Publications, New Delhi

ISBN: 978-81-321-0907-5 (HB)

468pp. $59.95