Chapter 9
HIV and AIDS Worldwide

SCOPE OF THE PROBLEM

Few factors have changed global demographics as inalterably as the pandemic (worldwide epidemic) of HIV/AIDS. As an illustration of this statement, United Nations (UN) officials projected that sub-Saharan African countries would be 4% less populated in 2005 than they would have been without the losses attributable to AIDS. Whether this prediction bears out awaits the publication of the United Nations-World Health Organization 2005 AIDS update. According to information released in 1996 by the International Programs Center of the U.S. Census Bureau, by 2025 the sub-Saharan population would have reached almost 1.3 billion without AIDS. A moderate spread of AIDS, however, could reduce that number by more than one hundred million.

The HIV/AIDS pandemic is actually many separate epidemics, each with its own distinctive origin and shaped by specific geography and populations. Each epidemic involves different risk behaviors and practices, such as unprotected sex with multiple partners or sharing intravenous drug equipment. According to the UNAIDS 2004 AIDS update, in a half-dozen sub-Saharan African countries the majority of the high-risk urban population—prostitutes and their customers and sexually transmitted disease (STD) patients—are HIV-positive. International authorities project that unless the rate of HIV/AIDS infection slows in thirteen sub-Saharan countries, Brazil, and Haiti, childhood mortality rates could triple by 2010.

In 1997 approximately 30.6 million people were infected with HIV, and the pandemic was growing by sixteen thousand new infections per day. By the end of 2004 the Joint UN Program on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) estimated in "AIDS Epidemic Update: December 2004; Maps" (Joint United Nations Program on HIV/AIDS, http://www.unaids.org/wad2004/EPI_1204_pdf_en/Chapter11_maps_en.pdf, December 2004) that approximately thirty-nine million people worldwide were living with HIV. This count included 17.6 million women and 2.2 million children younger than fifteen years. The report estimated that more than 13,500 new infections occurred each day, translating to almost five million new infections per year—4.3 million adults and 640,000 children in 2004. More than 95% of these HIV cases occurred in the developing world, particularly in sub-Saharan Africa and Southern and Southeast Asia. This number will increase as infection rates continue to rise in the face of poverty and inadequate health resources and health care infrastructure.

UN medical experts note that, before 1997, data coming from just a few countries in any particular area were used as models for other countries with comparable or fairly similar regional factors. As a result, for some countries the spread of HIV/AIDS was woefully underestimated. Beginning in 1997 separate models constructed for each country replaced regional models, resulting in more accurate statistics and projections.

UNAIDS estimated in AIDS Epidemic Update: December 2004; Maps (Joint United Nations Program on HIV/AIDS, http://www.unaids.org/wad2004/EPI_1204_pdf_en/Chapter11_maps_en.pdf, December 2004) that, in 2004, 3.1 million people worldwide died from AIDS, a marked increase from the 2.3 million deaths that occurred in 1997. Of these deaths, 2.6 million were adults and more than five hundred thousand were children younger than fifteen.

The 2004 UNAIDS report once again confirmed that the developing world bears the brunt of the AIDS misery. Approximately 64% of the world's HIV-infected population (25.4 million cases) lives in sub-Saharan Africa, while 18% (7.1 million cases) resides in South and Southeast Asia. Taken together, these two regions represent 82% of the world's HIV/AIDS population.

AIDS is also making inroads elsewhere. Until recently, AIDS in China had been largely confined to the traditional high-risk populations such as intravenous drug users (IDUs). But by 2002 the spread of the epidemic to heterosexual populations was clear. In Guangxi Province, for example, HIV infection rates among sex workers increased from 0% in 1996 to 11% in 2000. Another example is the Russian Federation and Eastern Europe, where HIV is increasing faster than anywhere else. In Ukraine nearly 25% of new infections occur through heterosexual encounters.

In order to understand the enormity and consequences of the AIDS pandemic worldwide, the focus should not be on the number of reported AIDS cases, but instead on the number of people infected with HIV (the virus that causes AIDS), most of whom have not yet developed full-blown AIDS. The HIV incubation period (the interval between the initial HIV infection and the development of AIDS) is estimated to be about seven to eleven years. With an estimated 4.9 million people newly infected in 2004 alone, the number of future AIDS cases will continue to increase dramatically.

Global Trends and Projections

Although public health programs have made impressive progress in eliminating and controlling many infectious diseases, HIV/AIDS is not one of them, according to the WHO. This is due to the constantly changing character and the complex role of factors that determine the progression from HIV infection to full-blown AIDS. In addition, medical treatments that can slow the progression of HIV are generally too expensive, and as a result inaccessible, for most people living in developing countries.

The World Bank projects that by 2020 AIDS will account for a large portion of deaths from infectious diseases in the developing world. In Latin America and the Caribbean, 74% of adults who die from an infectious disease will likely die from HIV/AIDS, while in the Middle East and North Africa only 18% of adults who die from an infectious disease will likely die from HIV/AIDS.

In 1990 HIV/AIDS accounted for 9% of adult deaths due to infectious diseases worldwide; but by 2020 HIV/AIDS is projected to account for 37% of adult deaths due to infectious diseases. The following observations describe the nature of the HIV/AIDS pandemic in 1998, which, without effective interventions, should develop in a similar manner through at least 2010:

• Most new HIV infections occurred in fifteen- to twenty-four-year-olds.
• Three-fourths or more (75 to 85%) of HIV-positive adults worldwide were infected through unprotected sex. Heterosexual intercourse accounted for more than 70%, and male to male sexual activity (MTM) accounted for 5 to 10%.
• Transfusions of HIV-infected blood caused 3 to 5% of all global adult infections.
• Sharing of HIV-infected injection equipment by drug users accounted for 5 to 10% worldwide.
• More than 90% of HIV-positive children throughout the world were infected by their mothers perinatally (before or during birth) or through breastfeeding. Approximately 30% of mother-to-child transmission took place through breast-feeding.

In the absence of expanded prevention and treatment efforts, the future outlook could be grim. UNAIDS projects that sixty-eight million people will die of AIDS by 2020, a toll that is more than five times the thirteen million deaths of the prior two decades in the developing world. Of the six million people in the developing world who are in need of HIV therapy (such as antiretroviral drugs), only 230,000 people were receiving such treatment at the end of 2001. "Access to adequate care and treatment is a right, not a privilege," Peter Piot, the executive director of UNAIDS, remarked in a press release announcing the publication of the 2004 UNAIDS AIDS update. Piot also remarked that although progress has been made, more action is needed to make sure that the people who need treatment get it. Costs must fall, and continued health care funding will be necessary.

Effect of AIDS on Death Rates

Life expectancy at birth is an important measure for comparing death rates within and between countries over time. In some countries hardest hit by AIDS, the number of years one may expect to live has returned to the levels of the 1960s. Other countries now have levels equivalent to those of the early 1990s, and child survival rates are slipping as well. Even in countries with a somewhat lower prevalence of HIV infection, AIDS accounts for 80% of deaths of people between twenty-five and thirty-four years of age, according to the UNAIDS report.

In the sub-Saharan African nation of Zimbabwe, one of the countries hardest hit by the AIDS pandemic, life expectancy is only forty-two years—twenty-two years less than it would be if not for the impact of AIDS. In Harare, the capital of Zimbabwe, deaths among children five years and younger rose from eight per one thousand population in 1988 to twenty per one thousand in 1996. In East Africa, where 10% of the rural population has HIV, adult mortality has more than doubled. In southern Africa life expectancy between 2005 and 2010 is expected to drop to forty-five years (from fifty-nine years in the early 1990s), largely as a result of AIDS. In the South American country of Brazil, one may expect a life span of sixty-two years, five years shorter than a decade ago. In the Asian country of Thailand, where strong prevention programs are in place, the life span is sixty-nine years, just two years shorter than a decade ago.

Because HIV/AIDS epidemics differ considerably from country to country, most current mortality estimates, especially in developing countries, do not accurately reflect the impact of AIDS-related mortality. The HIV/AIDS epidemic is changing the course of demographic events in developing countries where the impact has been particularly severe.

PATTERNS OF INFECTION

Globally, HIV/AIDS is primarily an STD, transmitted through unprotected sexual intercourse between men and women or MTM. Like some other STDs, HIV infection can also be spread through blood, blood products, donated organs, or semen, and perinatally from a woman to her unborn child. More than 75% of worldwide cumulative (over the entire time that statistics have been kept) HIV infections in adults are estimated to have been transmitted through heterosexual intercourse, although the relative proportion of infections resulting from heterosexual contact as opposed to MTM varies greatly in different parts of the world.

HIV-1 and HIV-2

Two types of HIV have been recognized and identified: HIV-1, the predominant worldwide virus, and HIV-2. HIV-1 and HIV-2 show an extraordinary difference in global distribution. In North and South America HIV-1 has reached epidemic proportions among certain risk groups, primarily through unprotected MTM contact and intravenous drug use. Some African and Asian countries have also experienced extensive heterosexual transmission of HIV-1. HIV-2 has spread among heterosexual populations in West Africa.

DIFFERENCES IN EPIDEMIOLOGY, INCIDENCE, AND TRANSMISSION

The epidemiological characteristics (factors such as distribution and incidence that determine the presence, extent, or absence of a disease) of HIV-2 are different from those of HIV-1. Perhaps reflecting these differences, the international spread of HIV-2 is quite limited. In the early course of infection, people with HIV-2 are less infectious than those with HIV-1. This is due to the low levels of the virus isolated from the blood of immunodeficient people with HIV-2. As time passes and an individual's immunodeficiency progresses, HIV-2 probably becomes more infectious, but this more infectious period is relatively shorter than for HIV-1 and tends to occur in older individuals.

Several studies provide reasonable evidence that HIV-2 is not frequently transmitted from mother to child. While the mechanics of perinatal transmission are not completely understood, advanced immunodeficiency of the mother is certainly a risk factor. Low levels of the virus are not sufficient to transmit to the baby and, as mentioned earlier, higher levels of virus infection in women past childbearing years may explain why perinatal transmission is less frequent. This is the most likely explanation for the observation that HIV-2 infection is so rare in children.

Compared to HIV-1, relatively little is known about how HIV-2 is spread. This may reflect the rarity of HIV-2 in the Western world, particularly the United States.

Interactions and HIV Transmission

One of the major concerns of public health officials worldwide is the possible interaction between HIV and other infections. The same risky behaviors that expose individuals to potential HIV infection also expose them to other STDs such as gonorrhea, syphilis, and chancroid (a genital ulcer). Considerable data suggests that STDs, particularly herpes simplex, chancroid, and syphilis (which all cause ulcerative lesions), promote the transmission of HIV.

TUBERCULOSIS

HIV infection is recognized as the strongest known risk factor for the development of active tuberculosis (TB), since people with latent TB infection are more apt to develop the disease once their immune system has been compromised by HIV. Latent TB infection is believed to be present in about 30 to 50% of adults in most developing countries. People with latent TB have positive tuberculosis skin tests but are not sick with tuberculosis—they have been infected with Mycobacterium tuberculosis at some point in their lives but have not developed active TB.

Up to 8% of people infected with both latent TB and HIV are expected to develop active TB each year. The WHO estimates that at least four million adults worldwide, primarily in sub-Saharan Africa, Latin America, and Asia, have been infected with both HIV and M. tuberculosis. Not only are people infected with HIV who test tuberculin-positive more likely to develop TB, they are also likely to develop TB more rapidly than people without HIV infection. An even more disastrous consequence is that half of all people infected with both will develop contagious TB, which they could then spread to any susceptible individual, even those not infected with HIV. Currently, TB kills about two million people annually in developing countries, a figure that has grown dramatically since the HIV/AIDS epidemic has swept through many countries. The number of cases will continue to grow.

Geographic Differences

In North America and Western Europe during the 1980s and early 1990s, HIV was transmitted predominantly through unprotected sexual intercourse among MTMs and through intravenous drug use (IDU) with contaminated needles. During the late 1990s heterosexual intercourse and IDU became the prevailing modes of HIV transmission in North America and Europe.

In sub-Saharan Africa the overwhelming mode of transmission has been heterosexual intercourse. In that part of the world, transmission through MTM contact or through IDU is slight. Because many women have been infected, rates of perinatal transmission are increasing. In 2004, 90% of HIV-positive babies born worldwide were in sub-Saharan Africa.

The rates of MTM transmission in Latin America are similar to those of Europe and the United States, but IDU is less frequent, while heterosexual transmission is considerably higher. In South and Southeast Asia, the rapid increase of HIV can be traced to shared contaminated injection equipment and heterosexual intercourse.

In other areas, such as East Asia and the Pacific region, the predominant modes of transmission are not as clearly defined because of the relatively recent (late 1980s) spread of HIV in these areas. While the infection rate has peaked in other parts of the world, it is escalating in Asia, mainly from heterosexual intercourse through prostitution. According to UNAIDS, in 2003 South and Southeast Asia had between 700,000 and 1.3 million adults and children living with HIV, representing an average of 1.0 million. By the end of 2004 the estimated numbers were 4.4 to 10.6 million, representing an average of 7.1 million and a sevenfold increase over the previous year.

AFRICA

Rural Africa Catching Up

Studies conducted in remote areas of the African country of Zaire in both 1976 and 1985 revealed HIV in only about 1% of the hundreds of people tested. At the time HIV was a rarity and existed at a stable level. In urban areas, however, the virus spread through increased sexual activity and the relaxation of traditional tribal values. As more poor rural workers left their villages to search for jobs, the epidemic spread. Able-bodied workers often could not (and still cannot) bring their families with them when they leave their homes to seek work, and many took new sexual partners in the cities where they worked. These workers returned to their villages, bringing HIV and other STDs with them.

Unparalleled Infection Rates

In early 1997 the South African government estimated that 2.4 million South Africans were living with HIV. UNAIDS estimated that by the end of 2004 25.4 million adults and children in sub-Saharan Africa were infected. The national prevalence rates (the number of cases of the disease present in a specified population at a given time) of HIV infection among adults varied widely. Some West African countries report less than 2%. Others, in the southern portion of the continent, experience much higher rates. For example, in Botswana—which has the highest HIV infection rate in the world—almost 39% of adults were living with HIV at the end of 2001, an increase from 36% only two years before. In Zimbabwe—where 25% of adults were HIV-positive in 1997—one-third of the adult population was infected with HIV at the end of 2001.

SEVERAL MODES OF TRANSMISSION

Because heterosexual transmission is the predominant mode of transmission in Africa, men and women appear to be almost equally infected (twelve to thirteen females per every ten males). Commercial sex workers, or prostitutes, and their customers play a significant role in the spread of HIV in many countries. In many African cities the risk of contracting HIV infection approaches 50%. In some cities infection is rampant, especially among sex workers in the lower classes.

In the late 1990s four out of five HIV-positive women in the world lived in Africa, as did 87% of children who lived with HIV. There are several reasons for this. The female childbearing population is larger in Africa than any other place, and African women generally have more children than women in other parts of the world. This means that one woman can pass the virus on to more children. Furthermore, nearly all children in Africa are breastfed, and breastfeeding is responsible for more than one-third of mother-to-child transmissions of HIV. Although there are new drugs and drug combinations available to sharply reduce mother-to-child transmission, they are expensive and women in developing countries generally cannot afford them.

In response to routine screening of donated blood and the more careful use of blood for procedures such as transfusions, the role of transmission through HIV-infected blood has diminished considerably over the past several years, accounting for less than 10% of the total reported HIV infections. Ancient practices of ritual scarification and the use of improperly sterilized skin-piercing instruments (such as needles and syringes) account for a very small proportion of all HIV infections in sub-Saharan Africa.

PAYING THE PRICE FOR YEARS OF EVASION

Although their country had experienced the ravages of AIDS for about a decade, Kenya's Parliament and cabinet did not debate the issue publicly until 1993. Physicians diagnosed the first AIDS cases in 1984, but the government did not issue national statistics until 1986, when it announced one AIDS-related death. Although the nation's president and vice president regularly warned the public in speeches to avoid infection, and national officials instructed district administrators, including local tribal chiefs, to encourage their people to practice safe sex and limit their partners, there had been no official statement.

The government's belated commitment to dealing with HIV/AIDS came too late for many Kenyans. By 2000, 2.1 million citizens had been infected with HIV, representing nearly 15% of all sexually active adults. About six hundred deaths per day in Kenya are attributable to AIDS, and by 2005 this number is projected to climb to 820 deaths per day (as of mid-2005 the projection was unconfirmed). Moreover, the National AIDS/STD Control Program (NASCP) estimates that more than 730,000 Kenyan children under the age of fifteen have lost their mothers to AIDS. NASCP projects that this number will reach one million by 2005 (unconfirmed as of mid-2005).

The Kenyan government's reticence and seeming inability to deal with the epidemic came as a surprise to many observers. Kenya has endured an economic decline that many blame on corruption and the collapse of global commodity prices. Nonetheless, Kenya is still one of Africa's wealthiest countries and has remained relatively stable since gaining its independence from Britain in 1963. Many observers thought that if any African country could cope with or even head off an HIV/AIDS epidemic, it would be Kenya.

But Kenyan officials chose to downplay the threat, lest it frighten away much-needed tourist dollars. By contrast, Kenya's neighbor Uganda began an aggressive campaign against the spread of HIV/AIDS in the mid-1980s, when it had the highest number of recorded HIV cases in Africa. With virtually every family touched by HIV/AIDS, much of the cultural, religious, and psychological stigma has disappeared in Uganda, where HIV infection rates now appear to be declining. In Kenya, on the other hand, many HIV-infected people still mistakenly believed, many years after the epidemic first hit, that the absence of symptoms meant they were not infected.

Faced with an epidemic that by 2010 will orphan more than 30% of Kenyan children under age fifteen, Kenyan authorities have now developed a long-term strategy to deal with HIV. In 1997 Parliament adopted Sessional Paper No. 4. The law called for a vigorous campaign aimed at changing society's attitudes toward casual sex and proposed that anyone who intentionally infects another with HIV be found guilty of manslaughter.

Much of the HIV/AIDS epidemic in Kenya and other nations of East Africa can be attributed to the preponderance of wars and political upheaval. In addition, many prostitutes reside along long-haul truck routes linking Tanzanian and Kenyan ports to landlocked interior nations: Ethiopia, Uganda, Rwanda, Burundi, and the eastern part of Zaire. Male and female adolescents between the ages of fifteen and nineteen have begun to frequent truck stops along the Trans-Africa Highway in Kenya. Teenagers in families that cannot adequately provide them with food and clothing trade sex for money and gifts.

International experts report that HIV in these areas is also prevalent among people with higher-paying jobs, such as businessmen in Nairobi and Mombasa and truck drivers who frequent the roads between the eastern coast and the interior. It is not uncommon or socially unacceptable for a man of means to have a family as well as a couple of girlfriends. As in other parts of Africa, the big cities draw men from rural areas in search of work. Separated from their families for several months, many of these men turn to prostitutes and eventually contract HIV and carry it home to their villages. A considerable number of women in the cities who are abandoned or need additional income turn to prostitution to eke out a living.

"Wife inheritance" was once a socially useful tradition; now it is a large contributor to the ever-increasing spread of HIV/AIDS. In western Kenya, when a woman is widowed, her former husband's family takes care of her and her children. For generations, a brother-in-law or male cousin took her in with his family. Initially, tradition frowned on his having sexual relations with the inherited wife. Unfortunately, the inheritors began to ignore that restriction and had sex with the widow. If the widow's former husband had died of AIDS, she was likely to be infected and could pass the infection on to her inheritor, who would pass it on to his wife, causing the disease to multiply exponentially.

UGANDA'S DECLINING HIV RATES

Scientists think that more than twenty years ago truck drivers first spread HIV in Uganda's Rakai District, which lies along a Lake Victoria trade route to the capital city of Kampala. Because commercial sex is widely available along the trade route, HIV quickly spread throughout Uganda and all of Africa. At one time, Uganda had the world's highest HIV infection rates. By the early 2000s it became one of only two developing nations (Thailand is the other) where there was nationwide evidence of declining HIV rates due to strong prevention programs. According to the UN, Uganda reduced the prevalence of HIV infection by more than one-third, from almost 13% in 1994 to 8% in 1998.

Uganda was the first African country to respond strongly to its HIV/AIDS epidemic. The government began by gathering religious and traditional leaders, along with representatives of other sectors of society, in an effort to reach agreement that the problem had to be confronted. Prevention efforts targeted specific populations or communities. For example, prevention programs that focused on delaying sex and behaving in a safe manner were presented in schools. Community groups were formed to counsel and support those living with the virus. Condom use was heavily promoted.

Infection rates, particularly for the young, have begun to fall in both rural and urban surveillance sites. In 1989, according to the UN, 69% of fifteen- to nineteen-year-old males and 74% of fifteen- to nineteen-year-old females reported that they had had sexual intercourse. By 1995 those percentages had dropped to 44% among the young men and 54% among the young women. Young Ugandans seem to be postponing sexual initiation, seeking fewer sexual partners, and using condoms more.

EUROPE

Western Europe

While HIV in Europe is spread primarily through MTM contact, intravenous drug use is gaining as a mode of transmission. In the mid-1980s about 63% of AIDS cases among adult Europeans was due to MTM contact; by the early 1990s that proportion had dropped to 42%. Meanwhile, the proportion of European AIDS cases attributable to IDU jumped more than sevenfold, from 5% in the mid-1980s to 36% in the early 1990s, where it has remained through 2005.

According to the Centers for Disease Control and Prevention (CDC), the reported number of AIDS cases stabilized in 1994 and 1995. In 1996 the number of AIDS cases reported throughout the European Union (EU) dropped about 10%. In 1997 CDC statistics indicated that the AIDS epidemic had declined sharply in Western Europe (39%); UNAIDS reported thirty thousand new cases in Western Europe that same year. Since the late 1990s the decline appears to have leveled off; just over thirty thousand new cases were reported in 2002, and 570,000 people were estimated to be living with HIV/AIDS at the end of that year. The majority of HIV transmissions in Spain and Italy was through IDU, while in France, Germany, and the United Kingdom, it was through MTM contact. Mother-to-child transmission rates were low due to the availability of antiretroviral drugs for pregnant women and safe alternatives to breast-feeding for HIV-infected mothers. UNAIDS estimated that fewer than five hundred children under the age of fifteen were infected with HIV in 2002.

SPAIN

Spain has the highest number of HIV/AIDS cases per capita in the European Union. The first case of HIV was reported in Spain in 1981; by the end of 2001, 110,000 to 150,000 people were living with HIV. In 2001 alone 2,500 to 3,000 new cases were reported. Spain accounts for one-fourth of all HIV cases in Western Europe. (Italy and Portugal also have high rates.)

Drug use in Spain began to increase during the 1970s and 1980s after the long Franco dictatorship ended. Isabel Noguer of the Health Ministry describes this period as a time of heavy heroin use, with addicts sharing infected needles. In 1997 drug users still made up the highest risk group, while unprotected heterosexual relations was the next most common form of transmission. According to Spain's Health Ministry in 2000, 56% of HIV infections among men and 48% among women were attributable to intravenous drug use, while heterosexual transmission was responsible for 22% of all cases (male and female).

Spain developed education and prevention programs, and the number of new cases began to level off in 1996. The Health Ministry gives more than $1 million in aid to two hundred nongovernmental groups annually. Condom sales in the mid-1990s were double the number in the 1980s. These efforts appear to have been effective. The number of AIDS cases dropped 13% from 1999 to 2000, and from 1995 to 2000 there was an overall decrease of 64% in reported AIDS cases and an 85% reduction in cases of mother-to-infant transmission of HIV.

Eastern Europe

The HIV epidemic did not reach Eastern Europe until the mid-1990s. According to the UN, only 31,000 out of 450 million people were infected in 1995 throughout all of Eastern Europe. By 1997 about 190,000 adults were infected with HIV, and by the end of 2002 an estimated one million people throughout Eastern Europe were infected. By the end of 2004 the figure was estimated at 1.4 million people. Intravenous drug use has been the primary source for the spread of the virus.

Ukraine and the Russian Federation have been the hardest-hit countries in Eastern Europe, showing the steepest increase in HIV infection from 1996 to 1999. According to estimates by UNAIDS and the WHO, the former Soviet Union, as well as the rest of central and Eastern Europe, saw a one-third increase in the total number of HIV infections during 1999. In the entire east European region during 1998 and 1999, 90% of AIDS cases reported during that period were from Ukraine. As of 2004 HIV continued to spread at a rapid pace in the Russian Federation.

In 1994 only forty-four people in Ukraine tested positive for HIV. In 1996 more than twelve thousand tested positive, and in 1997 fifteen thousand more new infections were identified. In 2000 an estimated 250,000 people were living with HIV/AIDS in Ukraine. The story is much the same in the Russian Federation. In 1994, 165 people tested positive for HIV; most of those cases were attributed to MTM contact, while only two of the cases were reported among IDUs. In 1997 nearly forty-four hundred people tested positive, three times as many as in 1996. In 1998 four out of five newly diagnosed cases were reported IDUs. During 2000 nearly sixty thousand new cases of HIV infection were reported, far more than the twenty-nine thousand cases registered in the twelve years between 1987 and 1999. The proportions of the epidemic may be significantly underestimated since, by its own admission, the Russian system manages to register only a small proportion of all cases.

ASIA

Asia—home to two-thirds of the world's population—could eventually overtake Africa as the continent most affected by HIV. The HIV/AIDS epidemic arrived in Asia much later than in the rest of the world. Until the mid-1990s HIV/AIDS was uncommon, but because the average incubation period is approximately ten years, more people are now beginning to die from the disease. UNAIDS estimates that the number of Asian adults and children infected with HIV exceeded eight million at the end of 2004, with an estimated 1.2 million Asians contracting the infection that year alone.

Most countries in Southeast Asia have been hard hit, with the exception of Indonesia, Laos, the Philippines, and Sri Lanka. In these countries fewer than one out of one thousand adults was infected in 1999. Most of the Southeast Asian countries have not developed sophisticated systems for monitoring the spread of HIV, so estimates are often made using less information than in other regions of the world. In populous countries small differences in reported rates can mean a large difference in the actual numbers of infected people.

Thailand

The spread of HIV in Thailand had been almost unprecedented. Thailand's commercial sex industry is notorious, and travel packages based on the availability of sex workers in Thailand are common in Asia (as they are in other countries, including the United States). In the capital city of Bangkok, brothels are found in virtually every neighborhood. A 1990 survey found that 20% of all Thai men reported they had paid for sex in the previous year. After a military coup in 1991, the transitional government instituted a comprehensive AIDS education program, which included a media campaign and condom distribution to brothels and massage parlors. Brothels that refused to use condoms were closed down. While the anti-HIV program came too late for those infected in the mid- to late 1980s, Thailand recorded a drop in new HIV infections until the late 1990s.

Unfortunately, HIV appears to be spreading among other high-risk groups, such as IDUs and MTM, who have not received as much attention in prevention campaigns. According to UNAIDS, in 2001 an estimated 2% of adult males and 1% of adult females in Thailand were living with HIV/AIDS. The majority of those 675,000 adults are believed to be sex workers, their clients, and IDUs. Even if effective prevention measures continue, the epidemic will claim fifty thousand Thais every year until 2006. The HIV infection rate is expected to persist in excess of 1.5% among adult males. In addition, more than 90% of AIDS deaths will occur in people ages twenty to forty-four, the mainstay of the workforce.

Other Southeast Asian Countries

In other parts of Southeast Asia, current statistics on the epidemic show different patterns. As mentioned earlier, Indonesia, Laos, the Philippines, and Sri Lanka still record low rates of HIV infection. The reasons for the low rates are not clear. Moreover, there are no guarantees that prevalence will remain low. Some early indicators suggest changing patterns of incidence and prevalence.

Cambodia is the hardest-hit country in the region, with an estimated prevalence of 2.8% infected in 2000. According to a 2001 survey published by the Cambodian National Center for HIV/AIDS, Dermatology and STD (NCHADS), one out of thirty pregnant women, one out of sixteen soldiers and police officers, and one out of every two sex workers tested positive for HIV. Condom use has become much more common, with sales rising from zero to one million units per month in fewer than three years. But commercial sex is still very popular. In a recent survey three-fourths of respondents in the military and the police force and two-fifths of male students reported visiting a prostitute in the previous year.

In Myanmar (formerly Burma) HIV infection among sex workers rose from 4% in 1992 to more than 20% in 1996, and nearly two-thirds of IDUs are infected. Tests of pregnant women in six urban areas showed that approximately 2% were infected with the virus. UNAIDS estimates the prevalence at about five hundred thousand HIV/AIDS cases in 2000 and projects the addition of as many as fifty-five thousand adult cases per year by 2005 (a projection that remains unconfirmed in mid-2005, pending publication of the UNAIDS 2005 annual global AIDS survey).

India

At the International AIDS Conference held in Vancouver, British Columbia, in July 1996 a UN official reported that India had emerged as the country with the most people infected with HIV. This news came as a surprise to many of the conferees because HIV was not detected in India until 1986. In fact, by the end of 1993 only five thousand AIDS cases had been reported to the WHO from all of Asia. In 2000, according to the UNAIDS program, about five million of India's 950 million people were HIV-positive. Little is known, however, about how the infection flourished so quickly.

Although surveillance is irregular, recent testing indicates that the virus continues to spread. In Pondicherry, in the southeastern area of India, about 4% of pregnant women have tested positive. The states of Maharashtra, Tamil Nadu, Karnataka, Andhra Pradesh, and Manipur reported prevalence rates higher than 1%. AIDS deaths were estimated at 350,000 in 2000 and about a half a million are anticipated in 2005.

In March 1996 industrialists in India launched a nationwide campaign to educate their workers about HIV and help prevent its spread. Most of India's HIV-infected population resides in the cities, especially Mumbai (formerly Bombay), the country's financial capital, and along trade routes lined with brothels that serve truck drivers. Mirroring the situation in some regions of Africa, the infection rate among Indian prostitutes is upward of 50%. With India's population of one billion people, half of whom are illiterate, the task of instituting effective HIV education and prevention programs is a daunting one for the government.

China

The first HIV case in China was identified in 1985, but the disease did not begin to spread until the early 1990s, when changes in the structure of the economy produced an increase in drug use and prostitution. At the end of 1996 the government of China estimated that as many as 250,000 people were living with HIV/AIDS, approximately 10% of them teenagers. By the beginning of 1998 that estimate had doubled. By 1999 half a million Chinese were estimated to be HIV positive, and by the end of 2000 the estimate had risen to six hundred thousand. As noted earlier, by the end of 2002 indications were that HIV was spreading throughout China, affecting mainly heterosexuals. Despite these estimates, the confirmed cases were much lower. By March 1998 only 9,970 HIV infections were confirmed, up from 8,277 in September 1997.

The HIV/AIDS epidemic appears to be growing largely among two groups in China. One is among IDUs in the southwestern portion of the country; the other, newer epidemic is among heterosexuals along the eastern seaboard. Prostitution along the eastern coast of China is growing as the gap between rich and poor widens. The number of reported cases of STDs has escalated sharply in recent years, a sure warning sign of the high-risk behavior that leads to HIV/AIDS. Paid blood donations are on the rise as well, and this is also fueling the rapid spread of the virus through donated blood that is contaminated.

In 1997 the UN gave China a $1.8 million grant to help fight the disease over a four-year period. The funds were used to train ministry workers and to increase prevention education among high-risk populations. Although HIV education programs are common in urban areas, they have not reached the rural areas, where, when questioned, one-third of medical workers could not explain how HIV was transmitted.

Estimates of Chinese AIDS deaths in 2004 ranged from sixty thousand to one hundred thousand. Most of these likely occurred in the provinces where HIV prevalence is already high: Yunnan, Xinjiang, Guangxi, and Sichuan.

Overall, through 2004 about 8.6 million people were believed to be living with HIV in Asia and the Pacific—about 22% of the world's total cases, according to the UN. The huge populations of India and China dominate any assessment of HIV. Because the countries have so many inhabitants, small percentage changes in the estimates of national infection rates result in large changes in the estimates of the total number of people infected. For example, a rise of just 0.1% prevalence among adults in India would add more than a half million people to the national total of adults living with HIV.

LATIN AMERICA

According to UNAIDS, through 2004 an estimated 1.7 million adults and children in Latin America were living with HIV. An estimated 240,000 adults and children became infected that year.

Initially, the majority of HIV/AIDS cases in Latin America could be traced to MTM transmission. However, as of 2004, the greatest increases were among IDUs, although there were also increases attributable to heterosexual transmission. Levels of transmission among MTM in urban areas of Brazil, Mexico, Argentina, and Honduras range from 20 to 35%. There are also indications of high HIV infection rates among commercial sex workers in some areas. As a rule, infection rates among IDUs have reached or exceeded 30%. In Brazil HIV infection rates among IDUs have been reported to be as high as 40% in Rio de Janeiro, 54% in Sao Paulo, and 57% in Santos.

The picture in Latin America is mixed. In some countries prevalence is rising rapidly, but in other parts of Latin America infection rates are falling or remaining stable. Nearly every country in Latin America now reports HIV infections. More than half report concentrated epidemics. These include the most heavily populated countries in the region: Brazil and Mexico.

The spread of HIV in Latin America mirrors the pattern of that in industrialized countries. MTM and IDUs who share needles continue to make up the highest risk groups. Studies done in Mexico indicate that about 14% of MTMs may be living with HIV. Between 3 and 11% of IDUs in Mexico are infected. In Argentina and Brazil the proportion may be closer to half.

Rates are rising for women, which is indicative of an increase in the heterosexual transmission of the virus. In 1986 one out of seventeen AIDS cases in Brazil were in women. By 1997 the number was one out of four—one-fourth of the 550,000 adults living with HIV in Brazil were women. In Latin America and the Caribbean during 2000 about 210,000 adults and children became HIV infected, and an estimated 1.8 million were believed to be living with HIV/AIDS. About one-fifth of those infected were women. By the end of 2002 UNAIDS estimated that 1.9 million people were living with HIV/AIDS in Latin America and the Caribbean. By the end of 2004 that figure had increased to an estimated 2.1 million.

Several Latin American countries are beginning to establish programs to help care for those living with HIV/AIDS, including programs that provide life-prolonging antiretroviral drugs. For example, in Brazil more than eighty-five thousand people with HIV received government-subsidized antiretroviral therapy during 2000. Although overall access to care is better in Latin America than in most other areas of the developing world, it is not consistent throughout the region.

THE CARIBBEAN

In 1982 the first suspected AIDS cases in the Caribbean appeared in Jamaica. Since then, the epidemic has changed from a mostly homosexual phenomenon to a heterosexual one, with 65% of reported cases resulting from heterosexual transmission, according to UNAIDS. About 35% of all HIV-infected adults in the Caribbean are women, and the prevalence rate among pregnant women has been rising each year. Unlike in other parts of the world, in the Caribbean the connection between HIV and intravenous drug use is low. But the rapidly growing popularity of crack cocaine and the traditionally common practice of men (and, more recently, women) having multiple sexual partners are fueling the spread of HIV.

Through 2004, an estimated 440,000 adults and children in the Caribbean were living with HIV, and fifty-three thousand had contracted the infection during that year, according to UNAIDS.

Caribbean countries are confronting an epidemic that has left the region with the world's second-highest incidence rate after sub-Saharan Africa. According to UNAIDS, in 2000 Haiti was the Caribbean nation hardest hit; about 8% of adults in urban areas and 4% in rural areas were infected, as were 13% of pregnant women who were anonymously tested. According to UNICEF (http://www.unicef.org/infobycountry/index.html), 2001 prevalence rates among adults were 3.2% in Trinidad and Tobago and 1.7% in the Dominican Republic. UNAIDS estimates that at the end of 2004, 440,000 people were living with HIV/AIDS in the Caribbean.

A number of factors contribute to these high prevalence rates:

• For many years, some Caribbean governments did not want to admit the problem for fear of losing their tourist trade.
• The area has seen years of political and social unrest.
• There are high poverty rates and low levels of education.
• Many Caribbean communities are vulnerable because of their socioeconomic disadvantages and lack of information.
• Migration among countries and from rural to urban areas contributes to the continued spread of HIV and makes it harder to prevent.
• There is little tolerance for MTM in the Caribbean, which means that many governments were unwilling to fight the disease until recently, when officials realized that most HIV/AIDS patients in the Caribbean were heterosexuals.

THE MIDDLE EAST AND NORTH AFRICA

Less is known about HIV infection rates in North Africa and the Middle East than in other regions of the world. According to UNAIDS, through 2004 an estimated 540,000 adults and children were infected with HIV, with ninety-two thousand acquiring the infection during that year.

Middle Eastern countries with large numbers of immigrant workers carry out mass screenings for the virus, but no estimate places the number of infections at more than one adult in one hundred. The infection rate is estimated to be a low 0.13%. Approximately 220,000 adults and children are thought to be living with HIV in these countries. In Djibouti and Sudan, an estimated 2.9 and 2.3%, respectively, of those between the ages of fifteen and forty-nine were infected with HIV at the end of 2003, according to statistics from UNICEF. These were markedly higher than the other reporting Middle Eastern countries.

Because social and political attitudes in the Middle East and North Africa are generally conservative, it has proven difficult for governments to deal with risky behavior directly. Nonetheless, there are some community and nongovernmental organizations that help sex workers and IDUs whose behaviors put them at risk for HIV infection.

The WHO reports that in Middle Eastern countries HIV/AIDS is viewed as a social stigma associated with MTM, a practice strongly disapproved of by the cultures and religions of the region. A large number of North African and Middle Eastern countries cannot be classified because of lack of data. Although limited data is available, there are indications that extensive spread of HIV has begun in some parts of the region, with 18% of adult deaths from infectious disease resulting from HIV/AIDS. The epidemic in the Middle East was just beginning in 1998, but there is some evidence that HIV infections are increasing among IDUs in Bahrain and Egypt. Although drug use is also frowned upon in these conservative cultures, trade in addictive drugs such as heroin appears to be substantial in some parts of the region.

CONTROVERSIES

While great strides have been made in treating HIV infection and AIDS, and in raising public awareness about the nature of the disease and preventing its spread, several controversies dampen the enthusiasm about the fight against AIDS being effective worldwide.

Prohibitive Cost of Treatment in Developing Countries

A study conducted by the Rand Corporation and published in the New England Journal of Medicine in 2001 estimated that in 1998 treatment of HIV in the United States cost about $1,410 per month, or nearly $17,000 for the year. The additional treatment costs for AIDS can inflate the annual tally to more than $70,000. Even in a wealthy country like the United States, this is beyond the reach of most Americans. In the developing world, where the annual income can be only several hundred dollars, this treatment cost can prove absolutely prohibitive in the absence of government subsidies for HIV treatment.

Government subsidies can provide relief. A study published in the July 15, 2005, issue of Clinical Infectious Diseases reported that countries like Botswana that have government-funded AIDS treatment programs to provide free or low-cost treatment achieve greater treatment success than countries that do not provide such subsidized assistance. In the case of Botswana, six months after the initiation of the subsidized program, almost 30% more patients had undetectable viral levels when they received the drugs at no cost than did those who had to pay.

However, as the study's authors pointed out, this success could only be maintained in the long term if the drugs are either provided free of charge to the countries through an international aid program or can be obtained at a substantially lower cost than was the case as of 2005.

Cost of Treatment

The high price of HIV/AIDS drugs is a contentious issue. While manufacturers did freeze their prices briefly in 2002, they subsequently began to raise them again. In February 2003, for example, Roche announced that the price of Fuzeon, then the most expensive AIDS treatment on the market, would more than double in Europe.

As with other drugs, some advocate for the availability of generic versions of HIV/AIDS treatment drugs. Generic drugs invariably carry a lower purchase price than their patent-protected counterparts. But without the benefit of the market exclusivity that patent protection carries for the company that develops a drug, the motivation to continue the search for new drugs might vanish. A pharmaceutical manufacturer must cover the cost not only of research and development for the approximately three out of ten drugs that succeed, but also for many of the drugs—seven out of ten—that fail to make it to the marketplace. Because of this cost, once a new drug receives Food and Drug Administration (FDA) approval its manufacturer typically has the exclusive right to market the drug, usually for anywhere from three to twenty years. This allows the manufacturer to recoup its investment and realize a profit. During this time the drug is priced much higher than if other manufacturers were allowed to compete by producing generic versions of the same drug. The lower cost of the generic versions reflects the fact that the generic manufacturer does not have to pay for the successes and failures that occurred in the drug development pathway or pursue the complicated, time-consuming process of seeking FDA approval. The producer of generic drugs has the formula and must simply manufacture the drugs properly. Because of the lower cost of the generic drug after the original patent or exclusivity period has expired, competition among pharmaceutical manufacturers generally lowers the price. HIV/AIDS drugs are granted seven years of exclusivity under legislation aimed at encouraging research and promoting development of new treatments.

The concern over patent protection for HIV/AIDS drugs is understandably contentious. In contrast to generic versions of, for example, cold medications, HIV/AIDS drugs can literally be lifesavers. Pharmaceutical manufacturers argue that patent protection is vital to alleviate the financial burden associated with drug development. However, to those directly affected by HIV/AIDS, and those governments or health care systems that provide care, especially in developing countries, the enormous costs can be infuriating, especially with the knowledge that generic drugs carrying a lower price tag are possible.

In November 2002 the World Trade Organization (WTO) adopted a resolution affirming that the governments of WTO member countries have the right to take whatever actions they deem necessary to protect public health, including overriding pharmaceutical patents. In May 2003 the government of Zimbabwe declared a national emergency for six months over the HIV/AIDS pandemic, enabling it to purchase and make available generic versions of HIV/AIDS drugs that are still under patent protection. Prior to this, the passage of the Kenya Industrial Property Bill 2001 allowed the importation and production of more affordable medicines for HIV/AIDS in that country.

Tying Foreign Policy Aid to Abstinence

Another controversial issue surrounding HIV/AIDS treatment is the U.S. foreign policy initiative in place in 2005—dubbed the President's Emergency Plan for AIDS Relief (PEPFAR)—that ties funding for developing countries to programs that stress abstinence as the only prevention option.

Abstaining from sexual intercourse does prevent the sexual transmission of HIV, although most experts, who agree that it is not realistic to expect sexual abstinence from many segments of the population, stress that condom use is essential in stopping the spread of the disease. Reflecting President George W. Bush's 2004 State of the Union Address, which urged a new emphasis on abstinence-only education and doubled the funding for abstinence-only programs, abstinence is a critical part of PEPFAR. Launched in 2003, PEPFAR is a five-year, $15 billion program intended to fight the spread of HIV/AIDS in twelve African countries and the Caribbean. South Africa received almost $90 million in PEPFAR funds in fiscal year 2004 and is expected to receive another $149 million between October 2005 and September 2006. A third of PEPFAR's money goes to programs promoting sexual abstinence, and prevention efforts that focus on the promotion of monogamy (having just one sex partner) are favored.

Many AIDS activists decry PEPFAR, saying it slights the Global Fund to Fight AIDS, Tuberculosis and Malaria, set up in 2002. The United States has committed only $200 million a year to the Fund, far short of the expected contribution. Many critics also believe that PEPFAR attempts to export the Bush administration's conservative ideology globally.

In mid-2005 the United States Agency for International Development (USAID) cut funding to Population Services International (PSI)—a Washington, D.C.-based nonprofit group that promotes healthy behavior and products to low-income people in seventy developing countries—because Republican senator Tom Coburn of Oklahoma voiced his objections to a PSI program in Central America that used easy-to-understand games to encourage illiterate prostitutes to use condoms to prevent the spread of HIV/AIDS. According to Helene Cooper, writing in the New York Times ("What? Condoms Can Prevent AIDS? No Way!," August 26, 2005, http://www.nytimes.com/2005/08/26/opinion/26fri4.html?n=Top%2fOpinion%2fEditorials%20and%20Op%2dEd%2fEditorials), Coburn wrote to President Bush that the PSI program was a "misuse of funds to organize and sponsor parties and dance contests to exploit victims of the sex trade." PSI regional executive director Michael Holscher countered that the games were "a simple activity for largely illiterate people" to encourage and teach proper condom use among a high-risk population. PSI says of its Central American anti-AIDS programs, run by its regional affiliate, Pan-American Social Marketing Organization (PASMO): "As many as 57% of CSWs [commercial sex workers, or prostitutes] in some Central American countries benefited from PASMO activities, resulting in both a reduced number of occasional clients and reported high and consistent condom use with clients" ("Reaching Vulnerable Girls and Women through a Balanced and Targeted Approach," PSI Profile, August 2005, http://www.psi.org/resources/pubs/womenHIV.pdf). Several other members of the U.S. Congress raised their own objections to the funding cuts, urging USAID to restore the money to PSI's programs.

According to the Web site of the organization Human Rights Watch (http://hrw.org/campaigns/aids/2005/uganda/):

"Abstinence-only" programs (like PEPFAR) teach that abstaining from sex until marriage is the only effective way to prevent contracting HIV through sex. They deny young people critical information about condoms and other safer sex strategies, and promote marriage as a safeguard against HIV infection. These programs do not work, they violate kids' right to complete information about HIV/AIDS and leave young people at risk of contracting HIV in marriage, particularly women and girls.