According to a new World Bank report South Asia's HIV and AIDS epidemic will continue to grow rapidly unless the eight countries in the region, especially India, can saturate high-risk groups such as sex workers and their clients, injecting drug users, and men having sex with men with better HIV prevention measures.
The report launched at the 16th International AIDS Conference in Toronto, Canada says more than 5.5 million people are infected with HIV in South Asia and India has over 60% of Asia's estimated HIV infections.
The report says the epidemic is being increasingly driven by the region's flourishing sex industry and injecting drug use.
Widespread stigma and discrimination about HIV, along with poverty, inequality, and illiteracy, exacerbate the situation.
The low social status of women, trafficking of women into commercial sex, cultural restrictions on discussing sex, high rates of sexually transmitted infections, and limited condom use are also factors, along with porous borders, widespread migration and high levels of mobility.
Activists warn that AIDS is spiraling out of control in Asia among men who have sex with other men and the epidemic is likely to spread because many of these men also marry or have sex with women.
The issue of homosexual sex is taboo in many Asian cultures, and such men are difficult to identify and reach through public health campaigns.
Organizations which work with men who have sex with men say that unless male to male sex is addressed along with HIV risks and vulnerability, a major impact on the general population will be seen because the men concerned are also married.
In India as in many other Asian countries it is a cultural expectation that men will marry and many have no choice in the matter and men who have sex with men are often married.
In China for instance, 80 percent of men who admit to having sex with other men say they are married or plan to get married and many have dangerously false beliefs about sexual health and have never used a condom in the belief that anal sex is safer than vaginal sex.
In Africa and Latin America too the rates of HIV infections among men who have sex with men are also really spiraling out of control.
In such countries public health experts use the term "men who have sex with men," or MSM, because many of these men are not strictly homosexual or even bisexual.
For instance, it says, 65 percent of MSM in Nepal have regular sex with females, and 45 percent of male sex workers have sex with women as well as with men, and 22 percent of MSM in Vietnam's Ho Chi Minh city have sex with women as well as men.
Julian Schweitzer, Director for Human Development in the World Bank's South Asia regional team says reaching and involving people at risk of HIV is the greatest challenge in South Asia because they're frequently marginalized within their own communities because of what they do.
The report says halting the spread of the epidemic will depend on a two-pronged approach: first, establishing effective prevention programs for groups at increased risk of HIV infection such as sex workers and their clients, injection drug users, and men who have sex with men; and, second, resolving the social and economic drivers of the epidemic such as poverty, stigma, and sex trafficking of women.
The report also says cross-border programmatic cooperation is also required as working on HIV prevention with injecting drug users in Afghanistan and Pakistan would benefit from coordination with similar initiatives in Iran and Central Asia.
The report focused mainly on five countries in the region for which there is adequate data, Bangladesh, India, Nepal, Pakistan and Sri Lanka and concludes that such countries must tailor their HIV prevention programs to suit their own local conditions rather than rely on generic global or regional approaches which have failed to make a difference in individual countries.