HIV/AIDS in the GMS: the underlying issues
At the end of 2005, an estimated 20 per cent of the almost 40 million people living with HIV worldwide were from Asia and the Pacific, of which nearly one million were from the lower Mekong subregion - Cambodia, Lao People's Democratic Republic (Lao PDR), Thailand, and Viet Nam. In the People's Republic of China (PRC), about 850,000 people out of 1.3 billion had HIV/AIDS.
Several factors have converged in the Greater Mekong Subregion (GMS) to provide a fertile breeding ground for the HIV/AIDS pandemic in the region. Rapid (but uneven) development and the nexus of drug use, human trafficking and sex work can be considered defining factors for the spread of HIV/AIDS in the GMS.
The Mekong region has formed a coherent cultural, ecological and economic zone for centuries. Nonetheless, the GMS is characterized by widespread political, economical and social diversity. Uneven economic growth and human development, often combined with political instability and displacement, have lead to surges in domestic and cross-border migration in the GMS. The opening of national borders to tourism and trade in the last decade, including through the efforts of the ADB, has further increased the movement of goods and populations for - both legal and illegal - trade and employment purposes.
The degree and nature of mobility both within and between countries in the region has major implications for both the epidemiology and prevention of HIV/AIDS. The ongoing development of the transport sector and the required infrastructure has the same potential to contribute to the increase of HIV transmission as it has to contribute to trade and development. Infrastructure development, urbanization, rising disposable incomes, and growing mobility all contribute to structural and socio-economic vulnerabilities. In turn, such vulnerabilities lead to behavior that places people at an increased risk of acquiring HIV/AIDS.
Increased drug use, especially among injecting drug users, has exacerbated the spread of HIV/AIDS in the GMS, as the sharing of contaminated needles and syringes becomes more prevalent. The "Golden Triangle," encompassing parts of Myanmar, Lao PDR, and Thailand, still represents a leading supplier of opiates, particularly heroin. This supply of drugs finds an easy market throughout the region as drug trafficking routes dissect the GMS and provide easy access to a variety of illicit drugs. The recreational and occupational use of amphetamine-type stimulants (ATS) in the GMS is on the rise, especially among young people. Illicit drugs are still readily available throughout the GMS despite strong government action in some countries.
The link between the use of illicit drugs and high-risk sexual behaviour is commonly acknowledged, as risk perception among drug users is often compromised. This is compounded by the fact that illicit drug use is closely associated with sex work in the region. For example, in Yunnan Province (PRC), about 21% of female injecting drug users also engage in commercial sex work, thereby further increasing their vulnerability and risk to HIV/AIDS.
Closely related to the widespread sex industry in the GMS is the problem of human trafficking, which involves the transport of people (women, children, and men) - generally by coercion or deception - for the purpose of exploitative labor in a new location. The past decade has witnessed an enormous increase in the trafficking of girls and women from Myanmar and Yunnan Province (PRC), into Thailand to work in the sex industry. In some cases, human trafficking networks rival drug trafficking networks and in many cases these networks co-exist to their mutual benefit. Moreover, with the opening of borders and improved transportation routes, Lao PDR is on the brink of also becoming a major supplier and transit place for girls to Thailand. Boys are not - as yet - a major factor in this trade.
Ethnic minorities in the GMS: populations at risk
Accelerated development has been key to the economic success of the region. However, it is clear that such development does have unintended - but nonetheless significant - consequences. The social impact on ethnic minority groups living in border areas of the GMS has been particularly dire due to the unique set of factors that places them at special risk, including of HIV infection. In many areas, rates of HIV infection among ethnic minority groups are increasing faster than among the general population.
Of the estimated 255 million people living in the GMS, an estimated 75 million belong to about 200 ethnic minority groups. These groups are culturally diverse and linguistically complex. Typically concentrated in remote mountainous areas, they traditionally depend on subsistence agriculture. In many areas, ethnic minority groups face a rise in non-traditional drug use, human trafficking and involvement in the sex trade of ethnic minority girls and women. This threatens not only their collective cultural survival but - more - importantly their direct personal survival. Lack of access to education, health and other basic human rights (in some cases associated with lack of citizenship), poverty, and cultural and social breakdown within some communities has compromised the capacity of these communities and their individuals to negotiate the challenges of accelerated development.
Ethnic minority women are disproportionably represented in the trafficking of women and girls. A number of structural issues add to the vulnerability of these women. Ethnic minority women are more vulnerable to exploitation and at higher risk of HIV transmission. They are physically more susceptible and have less power to make decisions due to existing gender disparities. The greatest collective impact is on the upland minority groups of the Thailand-Myanmar-Lao PDR-China periphery. Networks reach into remote mountain villages to buy, abduct, or lure young women and girls into the pipeline that feeds the lowest levels of the Thai sex industry. Poverty, conflict, forced labor, and repression also bring whole families across the Myanmar border, and make entry into the sex industry a rational (if dangerous) choice for young women eager to contribute to the well-being of their households.
In Thailand, UNESCO has identified "lack of citizenship" as the major risk factor for highland girls and women to be trafficked or, otherwise, exploited. Without legal status, ethnic minority people are considered "illegal aliens" and subject to arrest, deportation, extortion and other forms of abuse. These women and girls are denied basic human rights and do not have access to the services and information they need to develop much-needed life skills.
In Lao PDR, displacement of highland populations through resettlement programs, opium eradication, road building and tourism has pushed minority girls and women into formal and informal sex work, and increasingly exposed young people to non-traditional drug use and greater risks for being trafficked or otherwise exploited. Experiences from upland Thailand demonstrate that it is highly probable that traditional opium users among ethnic minority groups, deprived of access to their drug of choice due to opium eradication programs, will turn to heroin - initially, smoking; then, injecting. Despite a low overall HIV incidence in the country, this has the potential of driving HIV infection rates in the country up whereby ethnic minority peoples stand to be disproportionately impacted by the impending epidemic.
In the People's Republic of China, the HIV/AIDS epidemic first started to assume alarming proportions in Yunnan Province - the upper Mekong subregion - and that province continues to be a high concentration of new infections. Here too, minorities are among the most vulnerable segments of the population. In particular, those minority groups living in border regions that are particularly exposed to the easy availability of intravenous (I.V.) drugs. In addition, Yunnan Province is the major hub for girls and women trafficked into and out of China, and the majority of these are non-Han national minorities. Moreover, as the Chinese epidemic makes the transition from primarily an I.V. drug epidemic to one based on sexual transmission, the impact of poverty - driving women into sex work at home and abroad - and ignorance of protective measures will further imperil these populations. Many individuals will also face language or cultural barriers in their new destinations that limit access to information and other needed support services.
Ongoing development in Cambodia poses grave needs, and serious challenges for ethnic minority populations. Concentrated in Mondolkiri, Ratanakiri and Preah Vihear Provinces, the ethnic minority populations only make up a little more than 1% of the total population of Cambodia. However, they are disproportionately at risk for HIV/AIDS, trafficking and unsafe migration because of their isolation and lack of materials in their own languages. These groups are currently under severe threat from the consequences of a number of development projects being carried out in their areas, for example, major road projects linking Cambodia with Lao PDR and Vietnam, and airport expansion for future tourism development. Land tenure issues figure prominently in Ratanakiri and Mondolkiri provinces. Wealthy developers from Phnom Penh and other large towns are snatching traditional lands from ethnic minorities despite laws to the contrary. Without their land and traditional livelihoods, many young ethnic minority people are moving into nearby towns seeking job opportunities. Young women, especially, are taking jobs in the commercial sex industry.
Barriers to prevention among ethnic minorities
The Mekong Region is also a region characterized by wide-ranging ethnic diversity, cultural pluralism and linguistic complexity. One of the main barriers to preventive education among ethnic minorities is the vast number of distinct languages from different language families. Many of these are unwritten languages with no indigenous scripts. While there is considerable multilingualism even (or especially) among the non-literate people of the region, minority women are even less likely to have command of either the national language or other minority languages than men. This has led to a notable lack of culturally appropriate HIV preventive and other risk-reduction and awareness information for ethnic minorities.
Furthermore, while their physical isolation has in the past offered some protection, it has also limited their access to preventive education programs and campaigns. Recent developments in cross-border infrastructure links have begun to reverse the situation. Improved access now allows limited information and support to enter these once isolated areas. Nonetheless, innovative measures are still required to effectively deliver potentially life-saving messages and information to the ethnic minority peoples of the GMS on a larger scale. So far, ethnic minorities have not yet featured centrally in many countries' responses.
