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HIV/AIDS in the GMS: a cross-border issue

The Greater Mekong Subregion comprises Cambodia, the Lao People's Democratic Republic, Myanmar, Thailand, Viet Nam, and Yunnan Province of China - all of whom share the Mekong River, the world's twelfth longest river at 4,200 kilometres.

The history of the GMS represents centuries of a coherent cultural, ecological and economic zone. Beyond their common borders, these areas are connected in many ways. Trade and migration networks are not recent developments, although new and accelerated forms of cross border movements have recently emerged. The opening of borders to tourism and trade in the region has increased the flow of populations across borders for trade (legal and illegal) and employment.

The GMS is also a region characterized by wide-ranging ethnic diversity, cultural pluralism and linguistic complexity. They differ in terms of individual history, political and governmental structures, economic base, and level of production and development. As these countries have opened up their borders to tourism and trade, the increased cross-border movements have hastened the spread of drug abuse, human trafficking, and HIV/AIDS.

HIV/AIDS, drug use and human trafficking

The GMS is the epicenter of Asia's HIV/AIDS pandemic. At the end of 2002, of the estimated 42 million people living with HIV/AIDS (PLWHA) worldwide, more than 7 million were from Asia and the Pacific. Of the Asia and the Pacific numbers, more than 1.6 million were from the 5 GMS countries Cambodia, Lao PDR, Myanmar, Thailand, Viet Nam and including Yunnan, Province of China.

Several factors have converged in the GMS to provide this fertile breeding ground for the spread of HIV/AIDS. First, injecting drug use is a serious problem throughout the region. The "Golden Triangle," encompassing parts of Burma, China, Lao PDR, and Thailand, represents a leading supplier of opiates, particularly heroin. Drug trafficking routes dissect the GMS and provide easy access to illicit drugs.

Another contributing factor is the degree and nature of mobility both within and between countries in the region. Refugees escaping political instability and displacement and economic migrants in search of improved opportunities are but 2 of the many examples of mobile populations.

HIV/AIDS is not confined to national borders. Much of southern Viet Nam, for example, is bordered on the west by Cambodia, where HIV prevalence is high, but dropping among the general population. The borders between Viet Nam, Lao PDR, and the People's Republic of China are porous, as are those between China and Myanmar. As goods, services, and people move in large numbers among neighbouring countries, in some cases border points record a higher incidence of HIV. In other cases, people migrate across borders from nearby poor districts, acquire HIV infections, and, when they return, serve as bridges of HIV transmission in their home border districts, causing prevalence levels to rise.

These border and urban areas are also sites for the booming sex industry in Southeast Asia. Related to this industry 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 mobility of people to and from areas providing access to sex work and illicit drugs increases the potential risk for HIV infection.

Political and economic dynamics

Though linked geographically, the countries of the GMS are quite diverse - politically, economically, and socially. Five of the six GMS economies are still undergoing a transition to a market-based economy and opening their sectors to foreign participation. With the exception of Thailand, which has had a free market economy for decades, the GMS economies were previously centrally planned and characterized by state-owned means of production. Low levels of productivity, inadequate amounts of goods, and severe economic problems compelled the governments in five of the GMS countries to reduce the state's productive role in the economy and allow the business sector to take a greater role in developing the countries both economically and socially. The structural reform process is not complete, but the private sector now functions openly and in most cases has surpassed the state-owned portion of the economy. These undercurrents of divergence and confluence shape the nature of the HIV/AIDS pandemic, which, in turn, increasingly influences the region's socioeconomic conditions.

Political instability and displacement have uprooted thousands of families and individuals - for example, refugees and migrants from Myanmar in Thailand. People are also drawn to border and urban areas in search of improved economic opportunities. Mobility, increased tourism, the presence of peacekeeping forces, the opening up of formerly centrally-planned economies, human trafficking, a lack of educational and economic opportunities for women and girls, and other factors have all facilitated the growth of sex industries.

Social and cultural politics

Ethnic minority populations in the Greater Mekong Subregion are numerous and diverse in and across the focus countries. Across the region, minority groups are concentrated in the highland areas, and are mainly involved in uplands and subsistence agriculture. Among the nearly 240 million people living in the GMS (2003), an estimated 21 million were of ethnic minority heritage. In addition, many are socially marginalized, leading to poorer health, lower educational attainment, fragile means of livelihood, and, therefore, a compromised ability to attain a decent standard of living or to contribute to the economic development of the region.

The interlocking relationships among poverty, health, education, and ethnic status contribute to the problem of human trafficking as families, under pressure to repay debts, may sell their children to traffickers, while other individuals are lured away by the promise of high paying jobs. Aside from working in exploitative conditions, people who are trafficked are often at an extreme disadvantage due to separation from families and support systems, cultural and language barriers, and lack of control over the decisions affecting their lives and health. Those who are forced into the sex industry are particularly at risk for STIs, HIV infection, and physical and sexual abuse.

Tourism trade and transport

The GMS countries adopted an important development strategy change since the late 1990s with the endorsement of the "economic corridor" approach. The expectation is that these corridors will stimulate nodes of economic activity, such as tourism, special production and trade zones, from the existing opportunities and endowments along the routes. Presently four economic corridors are featured in the GMS.

The framework for transport is aimed at a subregional transport sector that would facilitate trade. The plans included road, railway, water, and air transportation projects, but road projects were given the highest priority. Goods, services, labour and tourists are already moving in large numbers among neighbouring GMS countries. The development of the transport sector has the potential to contribute to the increase of HIV transmission as it has to contribute to trade and development.

More transport means more people travel, and HIV can spread further and faster. Transport can connect areas of high and low prevalence. Building of transport and other infrastructure often involves mobility of truck drivers, migrant construction workers, engineers, businessmen and communities. This brings people into situations which increase their vulnerability to HIV transmission. In other cases, people move across borders from nearby poor districts, acquire HIV infections, and, when they return, serve as bridges of HIV transmission in their home border districts, causing prevalence levels to rise.

Risks and vulnerabilities

Several factors contribute to the HIV vulnerability of populations across the GMS borders. Infrastructure development (especially transport networks), urbanization, rising disposable incomes (especially for men), and growing mobility are often associated with more extensive sexual activity and growth in the sex industry. Many people who migrate do so because of economic hardship or political instability. Already disadvantaged, they may turn to occupations (e.g. sex work) that increase risk for HIV infection. Separation from families, coupled with disposable income, may increase the likelihood that persons from these groups will engage in high-risk behaviours, such as unprotected sex or injecting drug use.

Minority peoples are at special risk because of lack of access to education, poverty, lack of culturally appropriate information in their own languages, cultural and social breakdown within some communities, non-traditional drug use, and involvement in the sex trade. Many individuals will also face language or cultural barriers in their new destinations that limit access to information and other needed support services.

Barriers to prevention

HIV is mostly spread through sexual intercourse without condoms, and through sharing of injecting equipment when people are using drugs: medical or social drugs or through contaminated blood.  So a key approach to reduce HIV transmission is to ensure people change these behaviours.

These behaviour changes require ongoing commitment of the individual as well as a supportive environment.  Education to promote changes must be clear about their reasons for doing so by providing information about HIV/AIDS, how it is spread and what can be done to prevent transmission.

Additionally, while interventions such as Thailand's "100% Condom Use Program " may have decreased the spread of HIV and STIs via sex work in brothels, the use of condoms by sex workers and male clients with their regular partners (e.g., spouses, sweethearts) tends to be low. In addition, in some countries, there is also an increasing shift from direct to indirect sex work, which is harder to address through condom use programs that target brothels and sex establishments. Education to promote behaviour change must, therefore, be targeted beyond the establishments.

One of the main barriers to preventive education in the GMS is the vast number of distinct languages from different language families. Many of these are unwritten languages with no indigenous scripts. While some have transcriptions developed by Western missionaries, these are frequently based on the Roman alphabet and not widely used. While there is considerable multilingualism even (or especially) among the non- literate people of the region, minority women are notably less likely to command either the national language or other minority languages.

A case in point is Yunnan Province in southwestern China. With a population of 40 million (2003), there are 13 million people belonging to 26 different ethnic groups. In Northern Thailand, there are six major upland minorities. In many villages, there has been a dramatic rise in injecting drug use, entry of girls and women into the sex trade, and consequent HIV/AIDS infection. If effective preventive action is not taken, researchers believe that the Akha could well be the first ethnic group in the world to be wiped out by AIDS.