Intimate Partner Transmission of HIV Cambodia, Indonesia, Lao PDR and Thailand

1. Intimate Partner Transmission of HIV Cambodia, Indonesia, Lao PDR and Thailand KarabiBaruah PhD

2. …a focus on the transmission of HIV to women from their long-term male partners including men who: inject drugs have sex with other men buy sex migrate Intimate Partner Transmission of HIV

3. Who is at risk? Asian Population: 3.3 billion 10 million Women sell sex 75 million Men in Asia visit sex workers (2-20% of adult men) 10 million Men who inject drugs 50 million Women married to men who visit sex workers 10 million Men who have sex with men 1 million infants and children Men Women

4. Projected new infections in Asia

5. Cambodia

6. Indonesia Population: 150 million 233,000 Women sell sex 3.3 million Men in Asia visit sex workers (4% of adult men) 231,000 Men who inject drugs 1.6million Women married to men who visit sex workers 809,000 Men who have sex with men Infants and children Men Women

7. Lao PDR HIV tests by occupation (1990 – June 2008)

8. Thailand Husband-to-wife and MSM transmission produce most new infections in 2010

9. What makes women vulnerable to HIV infection? Source: NiranjanSaggurti, Population Council, 2009

10. HIV response coverage in Asia Men who have sex with men Female sex workers Injecting drug users Percentage of population covered Percentage of population NOT covered Prevention of mother to child transmission Antiretroviral therapy for those in need

11. Success in targeted interventions

12. Success in targeted interventions

13. Success BUT…change in modes of transmission Thailand: HIV infections 1985-2002

14. 100% condom use? The need for redesigning condom messaging? In Cambodia • Sex workers in Cambodia report 80% condom use • But 53% reported an STI symptom • 100% condom-use campaign reaches: • 50% of brothel workers • 8% of indirect workers In Thailand • Sex workers report 94% condom use with clients • Clients report 49-76% with sex workers • Sex workers report 40% condom use with husbands or co-habiting partner • In all four countries • Condom use has become stigmatised and inappropriate in intimate partner relationships

15. Preliminaryfindings IPT shared issues • Gender equality in law (mostly) but not in practice • Women lack sexual agency and decision making • Gender expectations: • Men – sexually experienced, multiple partners • Women – sexually inexperienced, monogamous, no sex before marriage • Low male involvement in SRH • Focus on MARPs but epidemics are changing • Male clients of sex workers not considered higher risk • Gender-based violence • Condoms synonymous with sex work only • Vulnerable and hard to reach migrants • Discussing sex is taboo

16. Preliminaryfindings • Transactional sex seeking behaviour of men • Low condom use among male clients of sex workers • MSM who are married • sero-discordance among people on treatment and their partners • Sexual behaviour of people living with HIV • barriers to disclosure in married couples • the behaviour of male clients of sex workers • Low access to SRH services for people living with HIV • High HIV prevalence among young women • Gender-based violence Cambodia: women and IPT

17. Preliminaryfindings Lao PDR: women and IPT • Sex work drives Lao’s epidemic • Migration – 50% of Laotians migrants are women (and illegal) • Low HIV prevalence = low perception of risk • Sex work accepted, takes place though entertainment venues • Constitution promotes gender equality • But Family Law reflects unequal gender expectations • Women lack decision making power in sex • Highly dispersed rural population • Low uptake of ANC • Abstinence during pregnancy legitimizes extra marital sex (men’s preference)

18. Preliminaryfindings Indonesia: women and IPT • Gender inequality drives epidemic • Women (including sex workers) cannot negotiate condom use • Sex work illegal and stigmatized • Female IDU extremely vulnerable to abuse • Masculinity - Men perceive themselves immune to STIs and HIV • Gender biased legislation • Some progressive harm reduction for IDU but low coverage • Homosexuality illegal – MSM often marry women • Social caste system (Bali) – local leaders not included in HIV awareness • Reliance on external donor funding and priorities

19. Preliminaryfindings Thailand: women and IPT • 100% condom campaign not focussed on the rights of sex workers • Health policy and practice shaped by paradigms of maternity • Polarisation of ‘good’ and ‘bad’ women • Preference for oral contraception and sterilisation • Positive women identified in 2nd or 3rd pregnancies • ‘Stay Negative’ program but limited coverage • Gender equality in legislation slow to filter into practice • Decentralisation of health system • Abstinence during pregnancy (women’s preference) • Lack of youth-friendly services

20. How can we reach women to 'halt and reverse the Trend'? • Scale up prevention for male MARPs and include emphasis on protecting regular female partners • Include men who buy sex in prevention responses • Target male IDUs, MSM • Develop inclusive responses for female partners • Promote VCT for couples

21. How can we reach women to 'halt and reverse the Trend'? • Structural interventions to address the needs of vulnerable women and their male sexual partners • Rights-based approach to health delivery • Target women before their first pregnancy • Increase men’s involvement in ANC and SRH • Address gender inequality • De-stigmatise condoms (female condom for couples?)

22. How can we reach women to 'halt and reverse the Trend'? Prevention for mobile and migrant populations to include components to protect intimate partners • Regional cooperation • Identify migrants without criminalising them • Increase services in different languages • Increase legal protection • Target internal migrants

23. How can we reach women to 'halt and reverse the Trend'? Prioritise operations research to understand dynamics of HIV transmission in intimate partner relationships • Gender power dynamics • More gender and age disaggregated data • Discordant couples • Female IDUs • Female partners of MARPs • Sex workers and their intimate partners

24. In summary: target HIV prevention • Women in sero-discordant relationships • Women reporting partners who inject drugs • Women reporting anal sex or partners of men who have sex with men • Female victims and survivors of violence • Female partners of mobile and migrant workers • Female sex workers and their intimate partners • Women diagnosed with TB • Women living with HIV • Male MARPs: positive prevention with their intimate partners • Men living with HIV: positive prevention with their intimate partners

25. Acknowledgements Based on research commissioned by UNIFEM. The reports of the research findings: • Roberts, J. Preventing Spousal Transmission of HIV in Cambodia: A Rapid Assessment and Recommendations for Action, UNIFEM East and Southeast Asia Regional Office, February 2009 • Kaybryn, J. Responding to Feminization of AIDS: A Rapid Assessment on Intimate Partner Transmission of HIV in Indonesia, Laos PDR and Thailand, UNIFEM East and Southeast Asia Regional Office, July 2009 In-country research teams: • Indonesia: Ikatan Korban Napza (IKON) Bali (Balinese Association of People Affected by Drugs) • Laos PDR: Laos Women’s Union • Thailand: Center for Health and Policy Studies, Mahidol University

26. Karabi Baruah PhDProgramme Manager, Gender & HIV and AIDS UNIFEM East and Southeast Asia Email: karabi.baruah@unifem.org Website: http://unifem-eseasia.org/