Asia Pacific

One-third of people living with HIV in Asia and the Pacific are women. But their issues are often hidden.

Gender-based violence. Restricted economic opportunities. Child marriage. Underage pregnancy. Denial of property rights.

A UNAIDS-supported initiative by the International Community of Women Living with HIV Asia and Pacific (ICWAP) supports positive women’s organising. The Feminist School is a learning and consciousness raising programme that began in South Africa, and has been utilised in Asia-Pacific since 2016. The methodology, anchored in feminist principles, is specifically designed to enable women living with HIV to understand their personal experiences, locate them politically and develop strategies for community-driven advocacy. 

“Marching in the month of March is not enough to realize women’s rights,” insists ICWAP Regional Director, Sita Shahi. “We need to speak up on the issue of gender inequality in the HIV response and the need for increased investments in women and girls. Women and girls living with HIV are going through serious human rights violations that, in turn, undermine their right to health.”

The Feminist School brings together women living with HIV, women from key populations, and young women from across the region.  In the past two years, with support from UNAIDS, ICWAP has made adaptations to include modules on sexual and reproductive health and rights, movement building, leadership skills and the elimination of mother-to-child transmission (EMTCT).

“Feminist leadership training reveals the challenges faced by women living with HIV in the region. I have gained a lot of knowledge from the cross-country discussions and learned lessons about how women from different countries are breaking down human rights-related barriers, including stigma and discrimination,” said Salina from Malaysia.

Last year, a new module on the Global Fund processes was added.

“We recognized the importance of ensuring that interventions led by women living with HIV are included in Global Fund funding requests,” explained UNAIDS Asia Pacific Regional Adviser for Community-Led Responses, Michela Polesana.

UNAIDS supported a Global Fund Grant Cycle Seven (GC7) project focused on supporting the engagement of networks of women living with HIV in Cambodia, India, Thailand and Viet Nam in the current process. It found that organizations in these countries were at different stages of readiness and involvement. For example, India’s Positive Women Network (PWN+) was already participating in the process and benefitted from ICWAP’s technical support to strengthen their advocacy and organization.

Another UNAIDS-supported strategy ICWAP employed to bolster GC7 engagement was the facilitation of peer-to-peer growth by and for women living with HIV through the roll-out of an online Feminist School training. Through this initiative, country networks were supported in engaging in the Global Fund process and learned about its gender equality strategy, including the gender equality markers (GEM). They also received training to support them in their work to hold governments accountable.

The organization partnered with Ikatan Perempuan Positif Indonesia (IPPI), the Thai Positive Women’s Network, Viet Nam’s Women’s Network, the Association of Positive Women Advocates Inc (APWAI) from the Philippines, Women affected by HIV and AIDS (WABHA) from Papua New Guinea and an informal network of women living with HIV in Cambodia.

The groups identified priority issues for advocacy and recommendations for next steps and devised country-specific advocacy plans.

The advocates agreed on a set of three shared priorities. First, a seat for women living with HIV on each Country Coordinating Mechanism. Second, for positive women networks to reclaim antenatal care activities in prevention of mother-to-child transmission programmes. And finally, for capacity building for young positive women leaders.

Feminist school is helping women living with HIV to organize to secure their human rights. To protect women’s health it is vital to protect women’s rights. And to protect women’s rights it is vital to support women’s leadership.

“This is all about bridging the gap between outgoing leaders and an incoming, new generation,” Ms. Shahi said.

Ibu Mawar (not her real name) learned she was living with HIV after receiving a test during an antenatal care visit.

 “I was surprised, of course, when they told me. But I didn’t really doubt or deny the result,” she remembered from the Sorong City Health Office in West Papua. She immediately started treatment to prevent transmission to her son. “Even though I’m positive,” she said, “our child is not.”

In principle, since 2009 every pregnant woman receiving antenatal care in Indonesia should receive an HIV test. And every woman found to be living with HIV should receive medicines to prevent transmission to their babies just as Ms Mawar did.

But this isn’t yet the reality.

In 2022 more than one-third (37%) of all pregnant women in Indonesia did not get screened for HIV and just 18% of mothers living with HIV had access to antiretroviral therapy. There were an estimated 2800 new HIV infections among children that year.

But now stakeholders in Indonesia are mobilising. Not only will they scale-up prevention of mother-to-child HIV transmission services, but they will work toward eliminating vertical HIV transmission while assuring the health and wellbeing of women and children living with HIV. At the centre of this approach is the engagement of women, who comprise roughly one-third of the adult population living with HIV.

In June 2023 Indonesia established the National Alliance to End AIDS in Children. This partnership between government, civil society and international organizations seeks to provide access to health services and support for women and children living with HIV. It has committed to three main priorities. The first is advocacy for the needs of adolescent girls and children living with HIV. Second is promotion and dissemination of information on Prevention of Mother-to-Child Transmission (PMTCT), Early Infant Diagnosis, treatment literacy and comprehensive sexual education. And third is the empowerment of communities regarding issues pertaining to children living with HIV.

The Alliance’s first major initiative was an Elimination of Mother-to-child Transmission symposium—the first ever in Indonesia. Partners have embraced the World Health Organization (WHO) triple target of eliminating mother-to-child transmission of HIV, syphilis and hepatitis B by 2030. A series of sessions were delivered in-person and online. A total of 115 participants from the government, communities, academia, healthcare and media joined the EMTCT Symposium in Jakarta.

Dr. Laila Mahmudah, Head of the Neo Maternal Division at the Ministry of Health, underlined the importance of accelerating EMTCT efforts across the range of issues. She noted that currently 66% of pregnant women received hepatitis B early detection services while just 25% of pregnant women are tested for syphilis.

Multisectoral stakeholders and participants discussed strategies with participants from Malaysia and Thailand, which have both received EMTCT validation for HIV. Dr Anita Suleiman, Director of Disease Control of the Ministry of Health of Malaysia, pointed to the importance of effective leadership and health system governance for country-wide implementation.

“One of the lessons from countries that achieved EMTCT is that it is possible to end AIDS and vertical transmissions, especially in low-prevalence regions like Indonesia, through robust governance and good-quality performance. Indonesia can also achieve EMTCT by 2030, and I hope this symposium leverages the coordination efforts towards the elimination of HIV, syphilis and hepatitis B,” said Dr Shafflq Essajee, Senior Advisor, HIV, UNICEF New York.

However, it was emphasised that political commitment must be bolstered by community-led strategies to reach and retain mothers living with HIV. Community mobilization and community health workers are critical approaches. Ikatan Perempuan Positif Indonesia (IPPI), the national network of women living with HIV, also endorsed the Thai approach of providing free formula for mothers living with HIV in low-resource districts.

Ayu Oktariani, IPPI National Coordinator and a member of the National Alliance to End AIDS in Children reiterated her organization’s commitment to implementing the community-led strategies in support of EMTCT in the coming years.

“This Symposium means more than words I can explain,” said Ayu Raka from the Akar Cinta Kasih Foundation, a community organisation in Bali. “When I return to Bali, I will advocate for EMTCT with local multisectoral stakeholders and communities in my region. I am confident we can make a healthier society and improve health for all mothers and babies.”

UNAIDS Country Director for Indonesia, Krittayawan Boonto, promised the continuous backing of UNAIDS.

“We will continue to support not only mothers, but also fathers, in protecting babies from new HIV infections. I wish for Indonesia to become the fifth country in Asia Pacific to achieve EMTCT. But we can only do it with the leadership of communities,” she ended.

Divyanshi is an enthusiastic 18-year-old Indian girl with an inspiring personal story of courage and resilience. She was diagnosed with HIV at a very young age. She has never given up on her dreams.

“I became aware of my status around 2013-14 but it wasn’t until I moved to a care home that I understood the challenges of living with this virus,” said Divyanshi. “As a person living with HIV, I face stigma and discrimination when a friend or someone else gets to know about my positive status. But I take it as an opportunity to educate people about HIV and break their myths. I want to show the world that I can live a normal, healthy, and happy life as a person living with HIV.”

Divyanshi joined the Positive YUVA Network (PYN)—an innovative community-based organisation striving to uplift young people living with HIV—where she found support and guidance from her peers.

As a network of young people living with HIV, Positive YUVA Network is a community-based organization committed to support young people living with HIV and LGBTQI+ people in India. The organization focuses its efforts on supporting the mental health of the young people living with HIV through its “Buddy System”. This initiative acknowledges the psychological challenges experienced by young people living with HIV and supports them with professional counsellors who provide tailored assistance. 

The organization provides skills development opportunities, recognizing that empowering young people living with HIV with practical skills enhances their socio-economic prospects. Through mentorship programs, the Positive YUVA Network aims to instil confidence and self-reliance among the youth, helping young people to redefine their narrative.

At the Positive YUVA Network, Divyanshi discovered her passion for photography and with the help of her mentor, is now interning at a startup, capturing moments of joy and hope. Divyanshi is an inspiration to many in how she shows that no obstacle can deter her from chasing her aspirations.

The Positive YUVA Network also works to reduce stigma and discrimination associated with HIV by raising awareness in schools. For instance, the organization used the most recent World AIDS Day as an opportunity to initiate open discussions and correct myths about HIV and AIDS among school going children with a goal to create a supportive and inclusive environment that fosters understanding and empathy for all people. By fostering empathy and a respect for the rights of everyone, the initiative helps to advance the health of everyone.

Global HIV statistics reveal that 1 out of every 4 new HIV infections globally in 2022 were among young people (15–24 years). Recognizing this demographic vulnerability, a focus on youth-specific interventions is imperative for an effective HIV response.

This community-driven initiative, and many others like this one, is playing a critical role in removing barriers for young people to meaningfully engage in the HIV-response in India. It is a powerful example of how community-led organisations are transforming the AIDS response at grassroots level. 

“In India's HIV response, youth-led organizations infuse hope and resilience. These groups, driven by the energy and innovation of young minds, are building a more inclusive and informed society. Rights, recognition and respect are essential for public health efforts to succeed. The impact of organisations like the Positive YUVA Network is not limited to young people living with HIV and LGBTQ+ youth, it benefits everyone,” said David Bridger, UNAIDS Country Director in India. “We all need to recognize the indomitable spirit of these organizations—pillars of strength in our collective journey. Together, let us do all we can to support the vital role of youth-led initiatives as they lead us along the path that ends AIDS,” he added.

Imagine this: you’re a person living with HIV, and your household is facing financial hardship. You decide to run a small grocery business at home, keeping your status hidden. Despite accessing free HIV treatment, you cannot afford other essential health services. And when you need to buy medicine, you don't have enough for your children’s school supplies or nutritious meals.

Low incomes.

Unaffordable healthcare.

Employment insecurity due to HIV-related stigma and discrimination.

These realities create financial hurdles for the poor among people living with HIV and the key populations—gay men and other men who have sex with men, transgender women, sex workers and people who inject drugs.

In Cambodia, stakeholders are working to ensure that the social protection safety net specifically covers people living with, and at risk of contracting, HIV.

“People living with HIV do not only need medication, but also food. If we provide only the drugs they will not survive,” said  Tia Phalla, Deputy Director of Cambodia’s National AIDS Authority (NAA). He explained that nutrition support and other non-health related care are an integral part of the national policy for responding to HIV.

Cambodia is among the countries that are on-track to reach the 2025 Global AIDS Strategy testing and treatment targets. As of the end of 2022, an estimated 86% of people living with HIV in Cambodia were aware of their status. Impressively, more than 98% of diagnosed people were receiving treatment and 98% of those on treatment achieved a suppressed viral load last year.

The country hopes to further improve these results while enhancing the quality of life of people living with HIV.

“A key part of the strategy we have advocated for is to include HIV sensitivity in social protection schemes and programmes,” explained Patricia Ongpin, UNAIDS Country Director for Cambodia, Lao PDR and Malaysia. Individuals and families affected by HIV can now benefit from a range of programmes including cash transfer, food assistance, social health protection and scholarships.

Once a person living with HIV registers their household for an Equity Card, they are entitled to monthly stipends. The card also gives holders access to additional medical care. This frees individuals and families from having to choose between healthcare and expenses for other essentials such as education and food.

In 2019 Cambodia officially included people living with HIV in its IDPoor mechanism. This is a system to identify and register households living in poverty. This was followed by the HIV and Social Protection Assessment, conducted in 2020 by UNAIDS and the NAA.

“The assessment made it clear that promoting HIV-sensitive social protection could help reduce the risk of HIV, increase demand for HIV prevention services, and promote HIV testing and safe sexual behaviors, as well as adherence to treatment,” said Ms Ongpin.

To ensure a more inclusive approach for IDPoor registration there must be engagement from key stakeholders including government, local authorities, development partners, and civil society organizations.

With support from UNAIDS and UNDP, Cambodia’s Ministry of Planning launched a web-based system and mobile application for IDPoor registration in December 2022. This approach makes it easier for individuals living with HIV to register at their treatment centers. As of August this year, more than 13,600 people living with HIV have been enrolled.

By leveraging this technology-driven approach, people living with HIV feel confident revealing their HIV status and are empowered to access much-needed healthcare benefits with dignity and autonomy. The solution can also be used to register people from key population communities at risk of contracting HIV.

Community leadership is a key strategy for expanding the initiative’s reach.  The Joint Forum of Networks of People Living with HIV and key populations (DFoNPAM) coordinates with the Department of Planning at district level in order to help with IDPoor registration. 

One initiative specifically targeted female entertainment workers. A national registration campaign was co-organized by the Ministry of Planning, the Phnom Penh City Hall, and the NAA, with technical assistance from UNAIDS. Around five dozen workers registered during the two-day campaign, receiving Equity Cards for their households.

According to the UNAIDS Country Director, this inclusive approach is key to creating a better future for people living with HIV and key populations.

“To mobilize their participation and register them for Equity Cards, we need to understand the barriers. And to understand the barriers, we need to listen to their experiences, in their own words. By taking this step, people living with HIV and key populations can help shape the conversation and ensure that their voices are heard,” Ms Ongpin ended.

The collaboration between UNAIDS and China was the focus of a consultation that took place on the sidelines of the 53 meeting of the UNAIDS Programme Coordinating Board.

The consultation brought together members of UNAIDS senior leadership, representatives from WHO and the Global Fund, and Chinese health authorities, to develop a bilateral strategic action framework and a memorandum of understanding (MoU) to expand and quicken the pace of the HIV response in China and globally. 

“We are at a critical time in the HIV response, and we have a great opportunity that the Chinese delegation is here for our Programme Coordinating Board meeting”, said Rosemary Museminali, UNAIDS Director of the Office of Multilateral Systems, in her introductions.

Building on China’s long-standing international cooperation on health, participants acknowledged the potential to engage China more prominently in global efforts to end AIDS, especially under the South-South Cooperation framework and in line with China’s development schemes including Belt and Road Initiative and Global Development Initiative which aim at promoting global development and helping other developing countries to achieve the Sustainable Development Goals.

UNAIDS pointed out that China has a pivotal role to play in promoting local production of medicines and health commodities. At the same time, there is a need to build and expand relationships with other government departments to leverage all available resources to implement international best practices, promote access to quality services and support civil society’s engagement in HIV response.

Ren Minghui, Director of Global Health Institute of Peking University Health Science Center, is helping UNAIDS develop the framework and MoU. He outlined some initial key points in positioning HIV in the overall health strategy and broader development agenda. He also highlighted China’s specific context, including its increased contributions to global health and the HIV response, China-led initiatives and South-South collaboration, as well as a special call from President Xi to build a community with a shared and healthy future for mankind.

“There are important elements for China and for the global AIDS response, but for these we need to address equality and have a multisectoral mechanism,” said Ren Minghui.

Participants shared ideas on how to facilitate the development process of the two documents, which will take place over the next six months.

Prior to the consultation meeting, UNAIDS Executive Director Winnie Byanyima met with the Chinese delegation for the PCB meeting. She congratulated China’s progress in HIV prevention and treatment and urged more efforts to be made to address challenges such as providing quality treatment for people living with HIV, increasing testing, improving HIV prevention and eliminating stigma and discrimination.

“I hope China can play a bigger role to end AIDS at home and globally”, Winnie Byanyima told the delegation. 

As part of its ongoing support for ending AIDS in Southeast Asia and the Pacific, the Australian Government is investing up to AU$12 million in a new partnership supported by UNAIDS and Health Equity Matters. The funding will help local communities and governments in the region improve HIV prevention, testing and treatment while reducing stigma and discrimination.

"UNAIDS values Australia's long-standing partnership globally and in the Asia-Pacific region, and particularly its commitment to community leadership,” said Eamonn Murphy, UNAIDS Regional Director, Asia Pacific and Eastern Europe and Central Asia. "By both increasing service access and lowering HIV-related stigma and discrimination, we can accelerate progress toward ending AIDS as a public health threat."

In her announcement of this partnership, marking World AIDS Day, Australian Minister for Foreign Affairs, Senator the Hon Penny Wong said, "Globally we have made remarkable progress in the fight against HIV, but there is still more to be done. It is critical that Australia supports communities in our region to end the HIV epidemic, including through sharing our own knowledge and experience."

Australia’s own national testing, treatment and viral suppression results are on track to reach the 95-95-95 targets by 2025. As of the end of 2021, 91% of people living with HIV were diagnosed, 92% of those diagnosed were on treatment and 98% of those on treatment were virally suppressed. “Among the factors contributing to Australia’s prevention, testing and treatment success is its historical bipartisan commitment to partnering with civil society in the HIV response,” Mr Murphy said. “It is this approach that we need to expand throughout the region.”

HIV infections in the region are not yet falling fast enough to meet vital targets, and there are rising epidemics in a number of countries including Papua New Guinea, Fiji and the Philippines. Stigma and discrimination are contributing to the rise in new HIV infections, obstructing access to HIV prevention, testing and treatment services for men who have sex with men. Community- and key population-led service delivery is a critical tool for reaching people, especially young people, not yet accessing services.

"The most effective way to treat and prevent HIV is to empower the people who most feel its impact,” stressed Health Equity Matters CEO, Adjunct Professor Darryl O'Donnell.

The initiative, currently still under development, reflects a new model of partnership with community organizations which UNAIDS highlighted in this year’s World AIDS Day report as critical to ending AIDS.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

In 2022, the Indian Supreme Court ruled that sex workers were covered by Article 21 of the Constitution which assures every person the right to life. It recognized that sex workers are entitled to equal protection under the law.

The court instructed both central and state governments that sex workers should not be arrested, penalised, harassed or victimised during brothel raids. (Running a brothel is illegal in India. Individual sex work is not.) Nor should the possession of condoms and other safer sex commodities be treated as evidence of an offence. And the police should be sensitised to the community’s rights.

Moreover, the court also stressed the vital need to uphold the basic protection of human decency for the children of sex workers who, “bearing the brunt of social stigma… are removed to the fringes of the society, deprived of their right to live with dignity”. This ruling will help ensure that the children of sex workers can access essential services, including healthcare and education.

To commemorate this landmark judgment, the All-India Network of Sex Workers (AINSW) conducted a three-day National Consultation titled ‘Sisterhood and Solidarity with Sex Workers: One Year Since the Historic Supreme Court Ruling of 2022’. AINSW has been working on the issues of sex worker rights since 2011 across several states.

“Laws make a difference,” said David Bridger, UNAIDS Country Director to India in his keynote address. “The Supreme Court ruling was historic because with this, India joins a handful of countries like Canada and New Zealand that have explicitly instituted legal protection for sex workers. Recognizing the equal worth and dignity of every person is not only ethical, but also critical for ending AIDS.” 

While giving an overview of the Supreme Court ruling, Senior Advocate, Anand Grover, noted that sex workers have taken steps which have contributed to the decline of HIV in India by negotiating condom use with their clients.  A 2021 study found that 98% of sex workers used condoms. The work to educate and empower this community to have safer sex is paying off. HIV prevalence among female sex workers is now just under 2%. Protecting the safety and human rights of key populations expands their access to HIV services, accelerating progress in the response to HIV.

Mr Grover called for a full understanding of the law and how it impacts the lives of sex workers. He also stressed the importance of community participation in law and policy development, noting that the Court itself called for sex workers to be involved in decision-making processes linked to issues which affect them.

Shyamala Natraj, Executive Director of the South India AIDS Action Programme (SIAAP), briefed the audience about what went into making the 2022 ruling possible. She said the judgment was the result of strategic and consistent advocacy which centred on the lived experiences of sex workers.

In 2020, for example, the National Human Rights Commission issued an advisory recognising sex workers as entitled to the same social protection as other informal workers for the first time. Sex workers had been among the hardest hit during the COVID-19 pandemic. Not only did they experience an abrupt loss of income, but some were excluded from state social safety net responses. The fallout was extreme, including hunger, homelessness, debt, depression, and even suicide.

The SIAAP shared an example from Usha Ram (not her real name) from the town of Theni: “I did not have money to pay rent. The house owner forced me to vacate and humiliated me in front of my neighbours for doing sex work. I was on the streets with my children and did not even get the advance back.”  

Ms Natraj encouraged the community to assert their human rights and secure access to the services that would ordinarily be provided to them under the law, including the issue of Aadhar (identification) cards, rations, poverty alleviation support and proof of residence documentation.

But despite the Supreme Court’s ruling that “sex work is a profession” with the same human rights as others, and that sex workers should not be harassed by the police, inequalities, stigma, and discrimination persist. Many sex workers are still reporting police harassment; some say they are still charged for soliciting clients.

To safeguard the human rights of sex workers, experts reiterated the need to implement the Supreme Court judgment at the grassroots level. UNAIDS and its cosponsors are committed to working with communities, policy makers and law enforcement to increase awareness and to ensure the universal upholding of sex workers’ human rights. 

Thailand’s HIV response can provide important learning for other Southeast Asian countries, with the experience of having already reached 90-90-97 in the treatment cascade in 2022, on the way to the achieving the “triple 95s”. The country was first in the region to eliminate mother-to-child HIV transmission. AIDS-related deaths have declined by 65% since 2010. With support from Australia’s Department of Foreign Affairs and Trade (DFAT), UNAIDS helped organise for Thailand to share lessons it has learned in its HIV response with Indonesia through a south-to-south learning exchange mission of Indonesian delegates to Thailand.

On day one, the Indonesian Ministry of Health and Thai Ministry of Public Health delegates discussed the HIV epidemic, trends, and challenges in each country. They shared insights on HIV prevention, treatment and stigma reduction in the HIV response. The following day, the mission team visited community organisations— including the Service Worker in Group Foundation (SWING), a non-governmental organization working for sex worker rights, and the Rainbow Sky Association of Thailand (RSAT), an organization that offers sexual healthcare for men who have sex with men, migrants, people who use drugs, sex workers and transgender people.

Multidisciplinary care is provided in Thailand to people living with HIV and to key populations through community service providers, incorporating certified community counsellors, medical technicians and caseworkers at the community facilities, and through doctors, nurses, pharmacists and laboratory scientists through the telehealth system.

Indonesia’s delegates on the visit highlighted that they had found helpful areas to improve community engagement in their national HIV programme, with a focus on effectively addressing the barriers and limitations in the HIV response that are interlaced with stigma and discrimination across Indonesia.

“We learned how Thailand prioritised zero discrimination, one of which is developing an e-learning curriculum for healthcare workers to minimise stigma and discrimination in healthcare facilities,” said Dr Endang Lukitosari, who heads the National AIDS Programme of Indonesia’s Ministry of Health.

Thailand’s delegates shared experiences from their community complaint support and crisis response system. Health workers, communities and clients can use QR codes at various locations to report rights violations, promoting accountability and coordination between health facilities and community organisations.

The Ministry of Public Health of Thailand noted that community workers are actively involved in the HIV response throughout a robust system of accreditation for both individual community health workers and community organisations. There are health insurance options for all users, including three that can be accessed by migrants. These initiatives help create an enabling environment, led by the government, to connect communities with marginalised groups and tackle issues such as loss to follow-up.

Indonesia’s delegates noted the significance of community mobilisation in the HIV response and envisaged that by putting community in the centre they would reach the most marginalised and underserved groups across different islands and highlands in Indonesia.

“Thailand's comprehensive service delivery inspired me, especially through the Ministry of Public Health's accreditation and certification system for communities. This cooperative mechanism across the government and community stakeholders is the one we haven’t sufficiently addressed in Indonesia. Perhaps by applying this approach, we can minimise the gaps in the treatment cascade by ensuring we leave no one behind”, said Irfani from GWL-INA, Indonesia’s network of men who have sex with men and transgender people.

Over the five days, Indonesian delegates explored public HIV service centres and treatment facilities in Bangkok, Thailand and learned about how efforts of communities and government in HIV prevention and control could be streamlined and coordinated by enhancing the continuum of care and minimising loss to follow up. Notably, Thailand emphasised integrated, One-Stop, services as pivotal for a successful HIV response. Indonesia’s delegates sought a pathway for sustainability in the HIV programme through lessons from the continuity of HIV treatment services in Bangkok, which connects clients with community clinics and public health facilities through referral system and telehealth.

Delegates agreed that this learning mission highlighted key features in efforts to reduce stigma and discrimination, mobilise communities in HIV response, and improve access to quality healthcare by tackling barriers. In addition, the mission underscored efforts to support the delivery of client-centred services for key populations. The debriefing concluded with a commitment to continue the technical partnership on HIV between the two countries.

"I believe Indonesia can do it," said Krittayawan Boonto, UNAIDS Country Director of Indonesia. "Indonesia is in a similar situation to the one Thailand faced a few years ago. Thailand's strategies contributed to getting closer to their goals. I see potential in Indonesia to accelerate progress towards triple 95s. I hope these learnings from Thailand mission can advance the HIV response in Indonesia. UNAIDS Indonesia will keep supporting efforts to end AIDS by 2030."

“Drugs were a way to escape from reality. But because of it, I have faced a lot of discrimination,” said Yukusna Kurumbang. “After a while I had no one around me. No friends I could contact. I have my family but they do not trust me. I am trying to improve.” 

There aren’t many resources at Ms. Kurumbang’s disposal. She’s fashioned her own path to recovery including volunteering with YKP Lead Nepal—a youth-led organisation. 

“I’m investing in myself and others to escape drugs,” she explained. “I’m trying to control my mind.” 

The organisation’s President, Rojal Maharajan, recalls the feeling of isolation he too faced while using: “It’s very humiliating—the gossiping and negative comments. My family also got sick and tired of me. Eventually I had no one to tell about my problems and my mental health status.” 

He started his advocacy eight years ago after a successful rehabilitation stint.  

“I wanted to do this work to make sure young people who use drugs are treated as human beings. They deserve to have a good life and better opportunities,” he said. 

These deeply personal perspectives help YKP Lead Nepal respond to the addiction challenge facing Nepal’s youth. And it’s a complex challenge.  

There was a 2021 review of the human rights situation of people who use drugs in Nepal by the International Drug Policy Consortium, Recovering Nepal, YKP LEAD Nepal and Youth Rise International. It notes that the Narcotic Drugs Act criminalises not only drug possession, but addiction itself. According to a 2019 survey of people who use drugs, almost half had been arrested for drug use or a related offence. Among people who injected drugs the arrest rate shot up to 63%.  

Treatment for drug dependence is privatised and inaccessible to most, including residents of border towns where services are most scarce. Among those who have had access to drug treatment, one in ten reports having experienced ill-treatment, violence and even torture.

The Government of Nepal has made progress around the provision of harm reduction services including needle and syringe programmes and opiate agonist therapy (OAT). However there are allegations that police frequently harass and detain people visiting these facilities.  

“Punitive drug policies across the region have created a culture of violence and impunity by law enforcement,” said Ikka Noviyanti, Regional Coordinator of Youth LEAD, the Asia and the Pacific young key population network. “This makes it more difficult for people to reach the range of prevention and treatment services they need to stay safe. The situation is even more dire for youths.” 

A 2019 Ministry of Home Affairs survey determined that over three-quarters of people who use drugs in Nepal are under age 30. Another study found that one-third of young people who use drugs started before age 15, with almost half commencing drug use between 15 and 19. The advocates say that in lieu of heroin which is expensive, there’s a growing trend of young people mixing and injecting tranquilizers like Diagepam, Nitrazepam and Dormin. 

Injecting drug use increases the risk of abscesses as well as illnesses including HIV, Hepatitis B and C. HIV prevalence for injecting drug users is 3% for males and 2% for females. By comparison, Nepal’s adult general population HIV prevalence is 0.1%.  YKP Lead Nepal is advocating for disaggregated data so they can better grasp the scale of the HIV burden carried by young people.  

The organisation shares safety information with clients along with clean needles and syringes. During the Covid-19 lockdowns, for example, they home delivered both food and harm reduction packages. Their outreach includes homeless young people.  

But the advocates say that even when clients are aware of the risks, there are barriers to staying safe.  

“Most of them don’t want to go to the service sites,” Mr Maharajan explained. “Many of the young women have told us they are harassed at the OAT clinics. Others have a concern that the people running the needle exchange programmes are from rehabs. They don’t want to be forced to go (to rehab) because they are fearful of torture.”  

UNAIDS Country Director for Nepal, Masauso Nzima, says that the Government of Nepal has made a move in the right direction with its investment in harm reduction services. However, more needs to be done to ensure a people-centred approach to drug policies “if we are to make a sustained difference in the lives of young people”. 

“A critical step is the adoption of laws that treat drug dependence as a health condition rather than a crime. Action is also needed to outlaw torture and ill treatment, holding violators accountable and providing increased oversight for rehabilitation centres. Finally, we are advocating for expanded access to drug treatment and harm reduction programmes, without discrimination,” Mr Nzima said. “That means young people, women and people living in all parts of the country should have equitable access.” 

YKP Lead Nepal goes a step further, calling for designated days for young women to access harm reduction services and for young people to be among the service providers.  

With support from UNAIDS Asia Pacific, Youth LEAD is now piloting a “Regional Healthcare Worker Training Manual: Friendly HIV and SRHR services for young key populations in Asia Pacific”. The approach is meant to address the multiple barriers to young key populations accessing services including concerns about privacy and confidentiality, stigma and discrimination among healthcare providers, inconvenient opening hours and service packages that do not speak to their specific needs. 

“Young people account for one of four new HIV infections in Asia and the Pacific,” Ms. Noviyanti said. “We are failing young people. But with targeted investments for youth-led responses and action we can turn the tide.”

At his previous factory job, Tom Wang (not his real name) says coworkers gossiped about his sexuality and made fun of him. When he visited a public health facility for an HIV test, the nurse peppered him with questions like “Why do you need it? Have you been sleeping with many partners?”

Thailand is a country famed for its tolerance. It is among the world’s top locations for gender affirming care. Same-sex sexual activity hasn’t been criminalised since 1956. And the policy tide is turning on other key population issues. A 2021 Drug Law allows for harm reduction as opposed to automatic imprisonment, while a bill is in the pipeline to affirm the rights of sex workers. Yet stigma and discrimination persist. In homes, communities, schools, workplaces and—critically—healthcare settings, discriminatory attitudes can take their toll.

“Microaggressions—intentional or unconscious verbal or behavioural slights toward stigmatised groups—can drive people away from HIV prevention and treatment,” noted UNAIDS Regional Human Rights and Law Adviser, Quinten Lataire. “There are evidence-based approaches for measuring and lowering both overt and subtle stigma and discrimination in healthcare settings.”

It was this need for stigma-free services that led to the establishment of the Rainbow Sky Association of Thailand (RSAT). RSAT offers sexual healthcare for men who have sex with men, migrants, people who use drugs, sex workers and transgender people. It also advocates for the full rights and equity of lesbian, gay, bisexual and transgender (LGBT) communities. Tom Wang is amongst the clients who have benefited from their support.

This work is critical if HIV programmes are to reach and retain key population communities. In Thailand, as in the rest of Asia, these groups carry the heaviest HIV burden. Nationally HIV prevalence is 1% for sex workers, 8% for people who use drugs, 11% for transgender women and 12% for men who have sex with men.

A one stop shop for sexual health services

RSAT’s approach demonstrates how programmes can improve outcomes by implementing strategies to affirm and empower clients. They are jointly supported by PEPFAR, USAID, EpiC, the National Health Security Office (NHSO) and Thailand’s Institute of HIV Research and Innovation (IHRI).

There are no depressing charts or drab walls at their five key population clinics. At the Bangkok site the rainbow motif appears on the floors and walls. There are swarms of cut-out butterflies. Signs are either upbeat and multi-coloured or a soothing blue.

Most of the staff are themselves members of key population groups. All staff receive anti-stigma and discrimination training which even addresses the fine point of body language. Nothing about staff’s interactions should make a client feel judged or uncomfortable. The entire team is retrained annually. There is an internal complaint mechanism that allows clients to confidentially flag issues, as well quality assurance staff to ensure Standard Operating Procedures are followed. Every team member signs a confidentiality agreement.

RSAT’s service package includes on-site testing for HIV and other sexually transmitted infections, Hepatitis C, Tuberculosis and Covid-19. For transgender clients they offer hormone level monitoring. Mental health screenings which evaluate for depression, anxiety and stress have been integrated into the HIV service package. Where required, clients are referred for additional mental healthcare.

“Many of our clients engage in chem sex (recreational drug-use during intercourse). Some clients inject meth so we need to provide more than condoms. They also need clean syringes and needles which are part of our harm reduction package,” said Deputy Director, Kao Kierati Panpet.

Pre- and post-test counselling are critical. All counsellors are certified and accredited by the Ministry of Public Health according to Counsellor Supervisor, Sasiprapha Khamthi. Even before receiving HIV test results, clients know that treatment is available. Following a positive test, the counsellors reassure clients that with treatment they can live a normal life, explained Niphon Raina, Care and Counselling Supervisor.

“We also ask what their concerns are and give basic information about how HIV is and is not transmitted, using a picture book so they are clear on the facts,” Care and Counseling Officer, Bussarin Poonvisitkun added.

RSAT keeps a stock of antiretroviral therapy drugs onsite and can initiate new clients’ treatment on the day of diagnosis by giving them one month’s supply. Although HIV care is provided at the Ratchaphiphat Hospital, RSAT is able to dispense right away in accordance with instructions from a hospital doctor, delivered via telemedicine. Clients living with HIV receive help from the care and support team to navigate their next steps, including attending hospital visits.

RSAT also provides pre-exposure prophylaxis or PrEP services with hospital supervision. Mr. Tom Wang explains how this has protected his health: “I decided to get on PrEP because I am changing partners. To me PrEP is another means of protection in case you are intoxicated or the condom breaks. It’s a way to ensure I stay HIV-free.”

A redress mechanism for rights violations

The organisation advocates for structural changes to eliminate stigma and discrimination. For example, they are currently making recommendations for the Gender Recognition Draft Bill.

“But the reality is that policy and legal changes take a lot of time,” said RSAT Director, Tanachai Chaisalee.

While this longer-term work proceeds, a redress mechanism helps clients address current concerns. RSAT is tapped into the Crisis Response System (CRS) initiated by the Ministry of Public Health in collaboration with the Office of the Attorney General, Ministry of Justice. People with complaints about prejudice or rights violations in any sphere can scan a QR code and report their experience. Reports may also be sent via Facebook, email or LINE, Thailand’s answer to WhatsApp. A multi-disciplinary team conducts investigations and works with the client and other stakeholders to help.

The lion’s share of reports made via RSAT come from transwomen (78%) while gay men have lodged 17% of reports. The most common challenges relate to requirements for gender confirming attire, social exclusion (particularly during job application processes) and HIV status.

RSAT’s Human Rights Manger, Watcharawit Waraphattharanon, shares that they have been able to resolve some cases very quickly. For instance, if a person living with HIV is being forced to take an HIV test as a requirement for work, the Attorney General’s office does an emergency intervention.

“We can close these cases within one week,” he said.

“The work of key population-led, community-based organisations like RSAT is critical to reach those who most need HIV services,” UNAIDS Country Director, Patchara Benjarattanaporn stressed. “The Government’s progress in funding Community-led Health Services and building partnerships between these organisations and the public health system puts us on the path to end AIDS.”

A group of journalists visited the Ozone Foundation as part of the UNAIDS, UNDP, APN Plus and USAID/PEPFAR Southeast Asia Regional Workshop on HIV-related Stigma and Discrimination in Bangkok, Thailand on June 8, 2023. Learn more about this novel training