Behavior of johns key to AIDS fight

By Emma Ross
July 12, 2004

Bangkok - The behavior of men who visit prostitutes will determine how bad the emerging HIV epidemics in Asia will get, according to an analysis by leading scientists.

The potential course of the virus in the planet's most populous continent came under scrutiny this week during the largest international AIDS conference ever, where more than 17,000 public health specialists, community leaders and scientists gathered to take stock of the global HIV disaster and step up the effort to fight it.

While southern Africa remains the worst-afflicted region, the front line of the pandemic is gradually shifting to Asia, where even low prevalence means that already more than 7 million people are living with the virus.

The region stands at a crossroad, experts say, where countries can either confront the disease head on and prevent it escaping the confines of prostitutes and their clients, drug addicts and homosexual and bisexual men, or let it creep into the general population.

"Asia will never be a sub-Saharan Africa," said Tim Brown, an expert on AIDS in Asia. "They are never going to see 20 to 30 percent of the population infected, like in Africa. Maybe 1 or 2 percent. The percentages don't sound bad, but the actual numbers are serious. We are talking big countries here."

"Every 1 percent I add in India or China adds 5 million people to the global HIV infection rate in India and 7 million in China. So, 1 percent in China or India is the grand total equivalent of what has happened in South Africa already. That's why we've got to worry, because the populations are so huge compared to the African populations," said Brown.

The virus is moving through Asia quite differently than it did in sub-Saharan Africa, the United States or Western Europe, said Brown, a researcher at the Hawaii-based East West Center.

The epidemics in Asia were seeded chiefly by injecting drug users, nearly all of them men, Brown said.

HIV prevalence keeps growing among drug addicts until a saturation point, which can reach 80 percent. When enough infected drug addicts visit prostitutes, an outbreak among sex workers takes off. The infection then moves from prostitutes to their clients, passing easily because the women are often also infected with other sexually transmitted diseases.

Some years later, the clients bring the disease to their wives, who then pass it on to their babies. Studies have indicated that about 20 percent of men who pay for sex infect their wives within two years. Over the course of their marriage, almost all of them go on to infect their wives, Brown said.

"That pattern has held in virtually every country in Asia. However, we do see huge diversity in the speed at which that pattern plays out," he said.

Homosexual and bisexual men also play a role in seeding the epidemics, but are not the main drivers in Asia, Brown said.

"Men who visit prostitutes are going to be the crux of the Asian epidemic. It is the men who drive this," he said.

The U.S. and Western European epidemics are almost entirely confined to injecting drug users, men who have sex with men and their immediate female partners.

In Africa, there's not much evidence that drug use contributed heavily. Prostitution played a role in the early days, but was not the dominant force. Experts agree that casual sex, coupled with poor control of other sexually transmitted diseases, was an important underpinning of problems in sub-Saharan Africa.

Both men and women there tend to have multiple partners. Studies have indicated that in the region, 20 percent of the men and about 10 percent of the women had multiple lovers.

The other engine driving the sub-Saharan Africa epidemic is sex across the generations, where young women are getting infected by older men.

Unlike in Africa, where 60 percent of those infected are women, females are unlikely to dominate the Asian epidemics, Brown said. He predicts that the prevalence will remain twice as high among men than women there.

"Women in Asia largely have sex within marriage and, for the most part, premarital sex is mostly confined to their future husband," he said. "On the other hand, the men are generally given a great deal of latitude in Asia. Sex remains a part of Asian business culture and that creates an imbalance and creates the demand for sex workers."

The fate of the Asian epidemics depends chiefly on what happens around the buying and selling of sex, Brown said.

Key factors influencing the results in Asia will be how busy the prostitutes are, how good control of other sexually transmitted diseases are, how widespread condom use is in commercial sex and ensuring that if the virus gets to the wives, it is not passed on to the babies, experts say.

However, Dr. Helene Gayle, incoming president of the International AIDS Society, said there are indications that Asia's next generation of women may not adhere to the sexual mores of their mothers and that casual sex is growing, increasing concern over the region's HIV epidemics.

So far, only Thailand and Cambodia have prevention on a scale that would make a difference. Aggressive programs focusing on commercial sex have brought new infections down, but drug addicts are largely being ignored.

Clean needles are considered important because delaying the spread from those men to the prostitutes buys time to get widespread condom use in place.

The worry is that some of the epidemics in Asia will progress so slowly that leaders will not view them as urgent enough.

"We have to get started now because unless we get the condom use up to 50 percent of 60 percent levels in the next few years we are going to lose control of these epidemics.

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