Linking Early Detection and Treatment of HIV Disease to Overall HIV Prevention among Migrants in South Asia


Early Diagnosis and treatment as prevention:


Knowing one’s HIV status is key to the use of ART for HIV prevention. HIV infection that is detected in-time can be managed successfully, permitting the majority of PLHIV to lead productive lives that may extend for decades.1 There are also increasing levels of evidences that suggest that early detection of HIV, and the use of ART, has significant HIV prevention benefits. A trial conducted by HIV Prevention Trial Network (HPTN-52) demonstrated that there is a correlation between HIV viral load (blood levels) and HIV transmission. The results confirmed that the use of highly active ART decreased HIV transmission among serodiscordant couples by 96%. Additionally, the study showed that starting ART earlier was associated with more than a 40% reduction in the rate of disease progression. All of this information strongly suggests that ART may make HIV infected people less contagious.2 Meta-analyses of data from treatment cohorts have also found that the efficacy of ART, as reflected by rates of viral load suppression and CD4 cell count recovery, is similar among patients treated in both high- income and as well as resource-limited settings 3&4.


Patients entering ART programmes in resource- limited settings have typically had their HIV diagnosis made following presentation to the health services with advanced symptomatic disease typically are diagnosed with advanced symptoms of HIV. A number of studies suggest that such patients have a high mortality risk in the period leading up to ART, as well as during the early stages of ART. A study compared outcomes from 18 ART programmes in lower income settings (predominantly in Africa) and found that early mortality following initiation of ART was higher among patients in resource-limited settings compared to that of patients treated in high-income settings.5 Another meta-analysis suggests that low baseline CD4 cell count was a strong risk factor for early mortality.6 Late diagnosis is also a precursor for ongoing HIV transmission and there is overwhelming evidence that people who are aware of their HIV status substantially curtail their high-risk behaviors.7


Despite a 20% drop in new HIV infections and a three-fold increase in access to antiretroviral therapy (ART) since 2001, the overall coverage of ART in East, South and South-East Asia is one of the lowest in the world. At 31% in 2010, it stands lower than that of the global ART coverage. At the end of 2009, over 60% of PLHIV that are eligible for ART had no access to it.8


Data for selected countries in Asia as presented in Table 1 shows that average ART coverage has increased from 41.49% in 2009 to 48.18% in 2011. This change is significant in the context of the new WHO Antiretroviral Treatment Guideline (2010), which recommends initiation of ART among patients at CD4 count of 350 or lower. However, ART coverage in some countries is still below 10%. This is also compounded by poor case detection rate, as well as late HIV diagnosis. In a recent study, the self-reported baseline average CD4 count was lower than 300 cells/mm3 in five out of seven countries surveyed.11


Table 1 ART coverage, case detection rate and baseline CD4 levels in the seven Asian countries

People Living with HIVART Coverage (9)Case Detection Rate (10)Self Reported
Baseline CD4
Levels (11)
Adult HIV prevalence < 0.1%
(681 / 1,513)
(2,533 / 7,500)
Adult HIV prevalence 0.2%
(24,410 / 61,025)
(76,879 / 386,300)
Adult HIV prevalence 0.2%
(1,988 / 3,801)
(4,942 / 10,350)
Adult HIV prevalence 0.3%
(6,483 / 27,356)
(19,118 / 50,200)
Adult HIV prevalence< 0.1%
(2,491 / 28,554)
(5,256 / 98,000)
Adult HIV prevalence < 0.1%
(1,992 / 2,346)
(8,364 / 19,335)
Adult HIV prevalence 0.5%
(60,924 / 112,727)
(249,660 / 263,317)

Mobility and HIV


Mobility is often associated with a number of infectious diseases spreading across the globe. Rapid economic growth and its associated employment opportunities remain the major driving forces behind migration in South Asia. A study comparing risk factors and HIV prevalence between migrants and non-migrants has established migration as an independent risk factor for HIV infection.12 A diverse range of structural factors also makes migrants more vulnerable to HIV. Such vulnerabilities are fuelled by stigma and cultural impediments to sexual discussion; high rates of sexually transmitted infections (STIs); limited condom use; a large, structured sex-work industry; low social status of women; trafficking of women into commercial sex; porous borders; poverty, inequality, and illiteracy; and high levels of mobility, including widespread rural-urban, interstate, and cross border migration.13


Many migrants are unaware of AIDS and continue to remain so even after testing HIV positive. A general absence of support services and treatment for sexually transmitted infections, including HIV, throughout the migration cycle is evident in all countries of South Asia. Due to limited information, available status of migrants accessing early diagnosis and ART is imprecise. An evaluation of migrant HIV program in Thailand suggested that 8% of migrants were tested for HIV and only a limited number of migrants are accessing ART.14


Ways forward:


Aside from improving delivery of ART and providing it free of charge, services must also include earlier diagnosis of HIV infection, strengthening of longitudinal HIV care and timely initiation of antiretroviral treatment. Providing accessible and user-friendly HIV testing and CD4 cell count services is also vital to promote early HIV diagnosis and assessment of ART eligibility. Strategies to reduce HIV incidence must therefore focus not only on delivery of care within ART programmes, but more fundamentally, they must promote early HIV diagnosis and improved pre- ART HIV care.


Anecdotal evidence and experience from the region suggests that it is possible to provide sustained preventive and curative HIV services to migrants. There is also increasing level of realization that a healthy society is not possible without healthy migrants. Countries like Thailand are increasing the number of migrants who are accessing healthcare though a temporary registration system. Furthermore, migrants’ access to ARVs, as well as other health and social support programs, is proven possible in countries like India and Thailand.


In conclusion, increasing the number of people on ART saves lives, saves money, and decreases the number of new HIV infections. HIV program targeting migrants should balance HIV prevention programs with curative HIV secondly prevention benefits based on the principle of ART access for all.




1 Porter K, Babiker A, Darbyshire J et al. Determinants of survival following HIV-1 seroconversion after the introduction of HAART. Lancet

2003 362; 1267-1274

2 Cohen MS, McCauley M, Gamble TR. Curr Opin HIV AIDS. 2012, 7: 99-105 PMCID: 3486734

3 Braitstein P, Brinkhof MW, Dabis F, Schechter M, Boulle A, AMiotti P, et al. Mortality of HIV-1-infected patients in the first year of

antiretroviral therapy: comparison between low-in- come and high-income countries. Lancet 2006; 367:817–824.

4 Ivers LC, Kendrick D, Doucette K. Efficacy of antiretroviral therapy programs in resource-poor settings: a meta-analysis of the published

literature. Clin Infect Dis 2005; 41:217–224.

5 Braitstein P, Brinkhof MW, Dabis F, Schechter M, Boulle A, AMiotti P, et al. Mortality of HIV-1-infected patients in the first year of

antiretroviral therapy: comparison between low-in- come and high-income countries. Lancet 2006; 367:817–824.

6 Stephen D. Lawna,b, Anthony D. Harriesb,c,d, Xavier Anglarete,f, et al. Early mortality among adults accessing antiretroviral treatment

programmes in sub-Saharan Africa. AIDS 2008, 22:1897–1908

7 Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected

with HIV in the United States: Implications for HIV prevention programs. J Acquir Immune Defic Syndr 2005; 39: 446–453

8 UNAIDS. HIV in Asia and the Pacific. Getting to zero. Geneva: Joint United Nations Programme on HIV/AIDS, 2011

9Number of people currently receiving ART/ estimated number of people currently requiring ART. Data taken from Country AIDS Report


10Taken from Country AIDS report 2012. Indicative value only. Numerators and denominators for Indonesia, Vietnam and Pakistan were

from different years.

11 Using early data from self-reported baseline CD4 count from Community Access to Treatment, Care, and Support study. APN+

12 Lurie M N. Williams B G. Zuma, K M et al. The Impact of Migration on HIV-1 Transmission in South Africa: A Study of Migrant and Nonmigrant

Men and Their Partners. Journal of Sexually Transmitted Diseases:Volume 30 – Issue 2 – pp 149-156

13 Markus Haacker and Mariam Claeson, (eds.), HIV and AIDS in South Asia – an Economic Development Risk, World Bank, 2009.

14 Prevention of HIV/AIDS Among Migrant Workers in Thailand (PHAMIT) website available online at

accessed June 25, 2013

(C) Koirala S. Aquino E.