2. Issues relevant to the South East Asia Pacific Region

The situation of Mother To Child Transmission is not as preoccupying in South-East Asia as it is currently in Africa. Yet, prevalence rates among pregnant women are currently on the rise in countries such as China, Vietnam and more importantly Cambodia and Myanmar. Thailand offers a contrasted situation with prevalence decreasing in the Northern most affected region but increasing in other areas. (see profile in table below)

HIV epidemic profile East Asia And Pacific
end of 1997	Vietnam	Lao PDR*	Papua New Guinea*	Cambodia*	China*	Thailand*	Myanmar**
Population	76.5 million	5.2 million	4.5 million	10.5 million	1.2 billion	59.2 million	46.7 million
Estimated number of people living with HIV***	80, 000 adult rate 0.20%	1, 200 adult rate 0.01%	4, 000 adult rate 0.19%	180, 000 adult rate 3.70%	300-500, 000 adult rate 0.1%	770, 000 adult rate 0.1%	440, 000 adult rate 1.80%
Rate of HIV	*0.22	0.04	0.19	2.40%	0.06	2.23	1.79
Estimated number of people living with HIV in year 2000**	180-300, 000	No data	no data	over 40, 000	2000:1 million	850000 adult rate 2.3%	no data
Pregnant women nationally	0.10%	No data	0.2% (1995)	2.90%	0.2% (Yunnan, 1991)	1.87% (from Sentinel Surveillance, June 1998)	2.65% (from Sentinel Surveillance March-April, 1999)
Pregnant women high prevalence areas	0.5%-0.7%	no data	no data	19.50%	no data	5.50%	13.07% (from Sentinel Surveillance March-April, 1999)
IV drug users	64.90%	no data	no data	no data	0.4 - 73.2%	43.38% (from Sentinel Surveillance, June 1998)	50.92% (from Sentinel Surveillance March-April, 1999)
Cswers	4.20%	1.2% (1993)	no data	39.30%	< 1.0% (1991 and 1993)	7.82 - 21.69% (from Sentinel Surveillance, June 1998)	26% (from Sentinel Surveillance March-April, 1999)
STD patients	2.70%	no data	0.37% (1992)	no data	no data	9.3% (from Sentinel Surveillance, June 1998)	8.37 - 8.82% (from Sentinel Surveillance March-April, 1999)
Blood donors	1.90%	no data	no data	no data	no data	0.45% (from Sentinel Surveillance, June 1998)	0.9% (from Sentinel Surveillance March-April, 1999)
Incidence national	14.8 per 100, 000					(AIDS) 33.67 per 100, 000 (from Surveillance report, March 99, Epidemiological division, MOPH)
Incidence high prevalence areas	54.1 - 163.3 per thousand	no data	no data	no data	no data

(* From UNAIDS/WHO Epidemiological Fact Sheet June 1998)
(** From The Mekong partnership, UNICEF EAPRO, August, 1999)
(*** UNAIDS-APICT, October, 1999)

Currently, most of these countries at the exception of Thailand have not yet initiated activities to prevent MTCT of HIV. The reluctance of East Asia and the Pacific countries to initiate activities of PMTCT is grounded in three major difficulties:

1. Doubtful Affordability: although the cost of ARV has been reduced with the use of abbreviated regimens, it is felt that the cost combination of counseling, HIV test, ARV, and replacement feeding is very high for countries other than Thailand and Malaysia. These countries already struggle with financing highly cost-effective interventions of basic essential drugs, EPI, and micronutrient supplementation.

2. Risks of Replacement Feeding: in countries like Myanmar and Cambodia, high levels of specific infant mortality linked to acute respiratory infections (ARI), malaria, diarrhea, lack of drugs in MCH centers to treat childhood illnesses, risks of stigma linked to non breast-feeding, and spill-over of breast-milk substitutes make health managers wary about the introduction of replacement feeding as a “public health” recommendation.

3. Low Allocative Efficiency: most countries in the region deal with an emerging epidemic. In China and Vietnam, HIV rates in women of reproductive age and subsequent MTCT are still considered a lower priority problem as compared to spread of HIV in other risk groups (commercial sex workers or IV drug users) or under-five mortality due to ARI, diarrhea, and malaria. Hence, in a context of scarce resources, implementing PMTCT is therefore seen as highly cost-effective only if it contributes to reinforce the efforts of primary prevention of HIV and of revitalization of MCH services.

Recent developments presented above suggest that the countries can address these issues successfully.

Affordability/Feasibility

· Use of the cheaper Nevirapine alternative (US$3.5 per course) represents a further cost reduction of the antiretrovirals as compared to the short regimen of AZT. As a major consequence, feasibility and affordability constraints shift away from the high cost of antiretrovirals and what remains are high costs and risks of replacement feeding.

· Combining the low cost Nevirapine regimen with exclusive breastfeeding (with or without antiretrovirals to the child during the breastfeeding period) further shifts the constraint to cost and feasibility of VCCT, which remains the major bottleneck in most countries.

· Due to the low cost of Nevirapine, areas with a high prevalence of HIV may envision offering treatment to all women or to specific risk groups, thus saving on the cost of VCCT and short-circuiting one of the key difficulties of implementation especially in countries with severe resource constraints, a weak MCH system, or a high level of discrimination in cases of HIV+ tests.

· Even if VCCT is skipped, the continuous procurement of Nevirapine in short-term and large-scale programs is still ensured.

Replacement feeding

Health decision-makers need to know more about:

· The likely benefits for the association of (i) Nevirapine intra and post-partum, (ii) exclusive breast-feeding and (iii) early weaning following the exclusive breastfeeding period in children born to HIV+ mothers who choose to breast-feed. In terms of feasibility and affordability, this regimen may be extremely important to the context of Myanmar and Cambodia.

· The likely additional benefits of adding a postnatal ARV treatment component either of Nevirapine or AZT to the above regimen for breast-fed children until they reach the early weaning age

Allocative Efficiency and priority setting

· Existing information shows the cost of the Nevirapine regimen to be similar in cost to the HIV rapid test and to be probably lower than the unit cost of HIV VCCT if cheaper tests are used. As a result from an economical point of view, it’s more cost-effective (effectiveness measured as the reduction of MTCT) regardless of the level of HIV prevalence to offer Nevirapine to all women than to implement VCCT and provide treatment to HIV+ mothers only.

· Yet countries have to take into account not only the cost effectiveness of one single intervention but the overall cost-effectiveness of “packages” to respond to both the HIV epidemic and the major causes of child and maternal mortality.

· Although there are significant costs in implementing VCCT, its benefits are not only limited to reducing MTCT. Strategies in South East Asian Countries raise awareness for men and women of reproductive age, protect partners in discordant couples, and allow for early identification of families affected by HIV.

· Conversely, if resources saved from VCCT are actually used to strengthen an essential health care package, allocative efficiency is likely to increase.

· As a consequence, the decision of whether or not to implement VCCT cannot solely be used on the basis of cost effectiveness of PMTCT but to also take into account the public health benefits of VCCT on primary prevention. The potential public health benefits due to simplifying the intervention (avoiding the operational constraints, cost of organizing VCCT in many countries, and the risk of discrimination) need to be weighed against the potentially large adverse effects of providing Nevirapine to numerous HIV negative women in countries with low prevalence and the loss of other benefits of VCCT such as primary prevention and awareness raising.

Advantages of a program that implements VCCT and
ARV versus a program offering only ARV

	VCCT	No VCCT
Advantages	* Side effects especially for many women when low incidence * Other benefits of VCCT * Low level of adverse effects in HIV-women in low incidence areas only	* Economical (cost-effective) * Diminish Operational constraints in countries with low readiness * Lower Stigma/Discrimination * Large scale public health effect in countries with high prevalence
Disadvantages	Use of resources that may be used more efficiently for other priority interventions	* Adverse effects of distributing Nevirapine without VCCT may outweigh public health impact on MTCT if HIV incidence is low * No benefits of primary prevention