BOX: Brazil

The first Brazilian AIDS cases were diagnosed in the early 80’s primarily in MSM and blood product recipients. Changes in the epidemiological profile have been observed over time. In the last three years, the incidence rate of new AIDS cases has stabilized around 14.0 per 100,000 inhabitants, the incidence among MSM and IDU has been decreasing and heterosexual transmission seems to be on the increase.

The role of local or regional NGOs, supported by the government, has been crucial for innovative approaches as well as reaching target high-risk and vulnerable populations. During the 1994-1999 period, 900 NGO projects were granted, involving an amount of US$ 25.2 million dollars.

Health promotion and intervention activities, considered the most important priorities, have been implemented all over the country. National campaigns have focused on information on modes of HIV/STD transmission and prevention, the preventive role of consistent condom use, as well as the importance of the human and civil rights of people living with HIV/AIDS. Educational school programs, including health promotion and sexual education, have been set up and teacher training has been done through long distance teaching by TV broadcasting networks.

A national survey conducted in 1998/1999 showed significant sexual behavior changes. Results suggested that condoms were used by 48 percent of all young males in their first sexual encounter. This proportion rises to 71 percent among individuals with higher educational level. Current use of condoms is 12 times higher than in 1986, when they were used by scarcely 4 percent.

Data from the same survey also show that 24 percent of the population regularly use condoms and this proportion reaches 44 percent among young people aged 6-25. In sexual relations with non-steady partners among males between 16-65 years old, 63 percent report consistent use of condoms. Additional evidence shows an increase in commercial sales of condoms from 70 million in 1993 to 320 million in the year 1999.

A national public laboratory network was set up to guarantee the availability as well as quality control of laboratory tests including: HIV infection diagnoses, opportunistic infections diagnoses, viral load quantification and CD4/CD8 count, HIV characterization and most recently, an HIV resistance monitoring and an HIV genotyping network. Free access to lab tests is guaranteed in the public health system, following the National ARV Consensus.

The most important policy decision on HIV/AIDS was taken in December 1996, when the President signed a decree assuring free access to anti-retrovirals and drugs for opportunistic diseases to all people living with HIV/AIDS, allocating at the same time the required financial resources.

By February 2000, 85,000 people living with HIV/AIDS were receiving ARV treatment provided by the Ministry of Health (MOH) 5 percent of them were children. Annual expenditures for ARV rose from US$ 34.3 million in 1996 to US$ 335.0 million in 1999 and to an estimated US$ 400 million in the year 2000. The number of new patients has also increased over time, from about 24,000 in January 1997 to more than

 75,000 in December 1999. However, during the same period, US$ 472 million was

 saved due to the reduction in hospitalization and the cost of drugs for treating opportunistic infections. This amount does not take into account the reduction of retirements supported by public funds, or the wages otherwise lost to the economy. It does not take into account a non-measurable return: the welfare of patients and relatives, better quality of life, and longer survival.

As a result of this policy, the AIDS mortality rate has decreased over time. At the national level, a reduction of 38 percent in the fatality rate is observed from 1995 to 1997. In Sao Paulo, where one-third of Brazilian AIDS patients are found, a reduction in mortality of 50 percent was observed from 1995 to 1999.

The decision of the Brazilian Government also covers technological support to national production of ARV. Five state laboratories are now responsible for providing almost 30 percent of MOH acquisition and this proportion will increase to 70 percent by the end of the year 2000.  The state companies mostly produce generic copies of drugs. Due to the introduction of local state production, a very significant price decrease occurred over time. From 1996 to 2000, there was an average cost decrease of about 60 percent compared to a 9 percent reduction for drugs produced exclusively by multinational companies.

In conclusion, the Brazilian case shows the positive impact of strong societal concern and commitment in responding to the HIV/AIDS epidemic, followed by a very clear government political decision. Even in developing countries, it is possible to change the face of the epidemic and to create new hope for the future.

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“Minority” countries: the small islands, nations and territories of the Caribbean and the Central American Isthmus

Rightly so, most HIV/AIDS prevention efforts and international resources are being channeled  to developing countries with a high HIV/AIDS prevalence.  However, some of the smaller nations and territories with a worsening or potentially significant HIV/AIDS epidemic have not received sufficient attention by the international community.  The Caribbean has one of the most severe HIV/AIDS epidemics outside sub-Saharan Africa.  PAHO/WHO/UNAIDS estimate that there are about 360,000 people living with HIV infection in the Caribbean and that 1 in 50 persons between the ages of 15 and 49 are already infected with HIV.  As of the end of 1999, more than 26,000 AIDS cases had been reported in 19 English and Dutch-speaking small countries and territories in the Caribbean representing a population of approximately 6.6 million.  Yet, the size of individual country populations – ranging from 8,000 in Anguilla to 2.5 million in Jamaica (with a median of approximately 80,000 for Dominica and Grenada) – has limited both the availability of local full-time, qualified personnel and the much needed international resource mobilization efforts commensurate with the national and regional magnitude of the HIV/AIDS epidemic.

A similar situation  prevails in some of the Central American nations with increasing HIV prevalence such as Honduras, Belize, Guatemala and El Salvador, where demand for HIV prevention and care services clearly exceeds current capacity for response.  Characteristically, the Caribbean and Central American countries host highly mobile populations which travel from country to country (e.g. migrant workers, CSW, truck drivers, sailors) and have significant trade, tourism and migration movements to and from other regions of the world, especially North America and Western Europe.  In a fast-moving and shrinking world, “size really doesn’t matter”, and the impact of an unchecked HIV/AIDS epidemic in the Caribbean and Central America may be felt around the world (see also box x).

The Former Soviet Union

In the countries of the former Soviet Union, the HIV epidemics continue to be mainly concentrated in IDU. In the Newly Independent States, the IDU-associated epidemic only started in 1995/6, but now affects a large number of cities, and virtually all administrative regions in Ukraine, Russia, Belarus, and Moldova. In 1999, more than 5,000 drug injectors were identified as HIV infected in Moscow alone. Due to this outbreak in the Moscow region, more HIV infections have been registered in 1999 in Russia alone compared to all previous years put together (Figure CCC). HIV prevalence varies between less than 2 percent of IDU registered officially in Russia to about 30 percent in sentinel surveys in Ukraine and Russia and more than 60 percent in Svetlogorsk in Belarus and drug injecting sex workers in Kaliningrad. HIV prevalence among other population groups seems to have remained low so far.

While about 130,000 Russians are believed to be already living with the virus, the Russian Ministry of Health estimates the number of IDUs in Russia at about 3 million, 2 percent of the total population, providing for a large pool of highly vulnerable but not yet infected persons. Although not confirmed in scientific studies, similarly high estimates have also been made for Ukraine and other Newly Independent States. With the economic situation of women deteriorating, the number of women engaging in sex work, potentially at high risk of infection, is believed to have increased considerably.

At the same time, large epidemics of syphilis and other STIs have been reported from these countries. Between 200,000 and 400,000 new cases of syphilis have been reported annually in the past few years from Russia alone. And that my only be the tip of the iceberg, as under-reporting is believed to be high. Although major spread of HIV via heterosexual transmission in the population at large has not yet been confirmed, the massive increase in STIs in the populations of Eastern European countries does prove the potential for more wide spread epidemics of HIV. Early and effective interventions are needed now to prevent what could develop into one of the major epidemics around the globe.

As described in more detail later in this report, the epidemics in industrialized countries follow a pattern with massive decreases in HIV morbidity and mortality since 1995 due to the introduction of Highly Active Anti-Retroviral Therapy (HAART). However, infection rates have been stable over the last decade and risk behavior seems to be increasing in some sub-populations.
 

The Demographic Impact of AIDS

Since the beginning of the epidemic, more than 18 million people have died of HIV/AIDS. However, with more than 30 million people currently living with the virus, and more than 5 million new HIV infections every year, this is only the beginning of the epidemic’s impact. Globally, HIV/AIDS is now well established in the list of the top ten leading causes of death. It is only surpassed by disease groups such as ischiaemic heart disease, cerebrovascular disease, and lower respiratory infections – all typical causes of death among old people. In sub-Saharan Africa, where the epidemics are worst, AIDS kills by far more people than any other cause of death. More than 1 out of 5 deaths in the sub-continent are caused by HIV. And, unlike many other causes of death, AIDS deaths will continue to rise in the coming years. And it is highest in young women and men in their most productive years

As a result of high levels of HIV infection, estimated crude death rates including AIDS mortality are greater by 50 to 500 percent in eastern and southern Africa over what they would have been without AIDS. For example, in Kenya, with an adult HIV prevalence of 14 percent at the end of 1999, crude death rates in the year 2000 are estimated to be twice as high (14.1 deaths per thousand population), than they would have been without AIDS (6.5 deaths per thousand population). In South Africa, with an estimated 20 percent adult HIV prevalence level, crude death rates are also twice as high (14.7 per thousand population), than they would have been without AIDS (7.4 per thousand population). In Asia and Latin America the estimated crude death rates are also higher than they would have been without AIDS in many countries, although by a smaller amount.

AIDS deaths cause reduction in population growth

At the beginning of the 21^st century the population growth rate in Zimbabwe has been reduced to nearly zero due to AIDS mortality, according to new population projections done by the U.S. Census Bureau. Other countries with sharply reduced growth rates include several other southern African countries: Botswana, Malawi, Namibia, South Africa, Swaziland, and Zambia. In Asia, AIDS mortality results in slightly reduced growth rates in Myanmar, Cambodia and Thailand.

By the year 2003, Botswana, South Africa and Zimbabwe will be experiencing negative population growth, down to –0.1 to –0.3 percent from the 1.1 to 2.3 percent it would have been without AIDS. This is the first time ever that negative population growth has been projected for developing countries. Lack of growth is due to high levels of HIV prevalence in these countries coupled with relatively low fertility. In other countries, populations will still grow despite high levels of mortality, due to very high levels of fertility.

International development goals will not be achieved due to HIV/AIDS

Life expectancy and child mortality rates have been traditionally used as markers for development. While major achievements have been observed for both parameters in most countries over the past decades, AIDS has caused a reversal of these positive trends in many countries.

Children born today in Botswana, Malawi, Mozambique, Rwanda, Zambia, and Zimbabwe have life expectancies below 40 years of age. They would have been 50 years or greater without AIDS. In Botswana, life expectancy at birth is now estimated to be 39 years instead of 71 without AIDS.  In Zimbabwe, life expectancy is 38 instead of 70.

In Latin America and the Caribbean, the impact on life expectancy is not as great as in sub-Saharan Africa because of lower HIV prevalence levels. However, they are still lower than they would have been without AIDS. In The Bahamas, life expectancy at birth is now 71 years instead of 80. And in Haiti, life expectancy is now 49 instead of 57. In Asia, Thailand, Cambodia, and Myanmar have lost three years of life expectancy.

The impact on child mortality is highest among those countries that had significantly reduced child mortality due to other causes and where HIV prevalence is high. Many HIV-infected children survive their first birthdays, only to die before the age of 5.  In Zimbabwe, 70 percent of all deaths among children less than 5 are due to AIDS.  In South Africa, that percentage is 45. In The Bahamas, 60 percent of deaths among children less than 5 are due to AIDS. In Myanmar, Cambodia and Thailand, 1 percent of deaths among children are due to AIDS.

Due to these substantial increases in child mortality, only 5 out of 51 countries in sub-Saharan Africa will reach the International Conference on Population and Development goals for decreased child mortality.

AIDS mortality will produce population structures never seen before

Particularly in those countries with projected negative population growth, Botswana, South Africa and Zimbabwe, population “pyramids” will acquire a new shape “the population chimney”. The implications of such new population structures are truly shocking. Large numbers of children will have lost their parents before graduating from school. Many of these will have to work to earn their living and that of their siblings. Increased child labor will be unavoidable. There will also be profound impacts on the labor force structure, which is already felt in many sectors in many countries. As projected by UNAIDS and UNICEF (see Progress of Nations, UNICEF, July 2000), the “teacher” to “pupil” ratio will be substantially reduced due to death of teachers from HIV/AIDS.

Data on HIV infection rates and mortality do not tell the whole story

Many individuals have difficulty grasping the results of these high prevalence levels.  The resulting AIDS mortality is difficult to comprehend.  Given the current HIV prevalence rates, many more millions of individuals will die due to AIDS over the next decade than have over the past 2 decades. Many of the southern African countries are only beginning to see the impacts of these high levels of HIV prevalence.

Current prevalence data, horrifying as they are, do not convey the full picture facing individuals in high HIV prevalence populations.  Because prevalence is a measure of current infection levels amongst living individuals, it does not capture infections amongst those who have already died or who have not yet become infected but will be in the future.  We can look at current incidence and mortality patterns and estimate the lifetime risks of contracting HIV and dying from AIDS faced by young people embarking on the sexually active phase of their lives.  This analysis shows that in a country such as South Africa, or Zambia, where prevalence in the year 2000 has reached about 20 percent, a 15-year old teenager would face a lifetime risk of HIV infection and of death from AIDS on the order of 60 percent if experiencing current age-specific incidence rates throughout his or her life.

There have been success stories: Thailand, Senegal, and Uganda. In Thailand and Uganda, concerted efforts at all levels of civil society have turned around increasing HIV prevalence rates. In Senegal, programs put into place early in the epidemic have kept HIV prevalence rates low.  These successes can be repeated.  However, the current burden of disease, death and orphanhood, will be a significant and increasing problem in many countries of sub-Saharan Africa for the near future.

BOX: New Glimmers of Hope in South Africa and Cambodia?

Cambodia has the highest general population HIV prevalence in Asia. Prevalence in adult males and females aged 15-49 is estimated at 3.2 percent, with many women now being infected by their husbands, who form a bridge population with sex workers and other casual partners. National surveillance has monitored HIV since 1995 and behavior change since 1997.

Given the urgency of this situation, the nation has mounted a multisectoral, multilevel response. National AIDS Authority meetings, other national forums, and brochures on impacts have informed national and provincial authorities about the situation. The multisectoral National AIDS Authority, with 7 ministries represented, has enabled curriculum development for HIV/AIDS education in schools, condom promotion in the ministry of defence, and capacity building in the other ministries. Fourteen of 24 provinces have decentralised budgets for cross-sectoral HIV prevention and care projects, which are being mainstreamed into other activities. NGOs have been active in community level work with students, sex workers, police, military, and factory workers. Their Royal Highnesses the King and the Queen, held audiences for people living with AIDS on World AIDS Day in 1999 and His Royal Highness, Prince Norodom Ranariddh, chairs the National Assembly for AIDS Patients.

These combined efforts have produced a number of favourable outcomes. Twelve million condoms were sold last year, 80 to 90 percent of which were used for HIV and STD prevention. Consistent condom use in brothels increased from 42 percent to 78 percent between 1997 and 1999, accompanied by declines in a range of STIs among sex workers, who now receive correct treatment for these infections. HIV prevalence among sex workers under age 20 declined in 1999. These data offer glimmers of hope that another national response is having a substantial impact on HIV transmission.

Antenatal HIV surveillance data have been collected in South Africa since 1990, and indicate that HIV prevalence in pregnant women rose steadily until it reached 23 percent in 1998. However, there was no significant change in prevalence between 1998 and 1999. This slow down in prevalence change was due to very different trends in younger and older women. Teenage prevalence declined from 21 percent to 18 percent, prevalence in women in their twenties remained unchanged at 27 percent, whereas trends in those aged 30 and over rose from 17 percent to 20 percent. The decline in teenage prevalence occurred in most provinces, with the exception of West Cape (a low prevalence province) and North West and Free State.  Age at first birth rose between 1998 and 1999, suggesting that the decline in HIV prevalence was very likely due to an increase in age at first sex among teenagers. Although this is an encouraging trend it might not lead to a sustained decline in HIV prevalence, unless it is followed by behavior change at older ages.

How reliable are antenatal clinic sentinel surveillance data?

Data on HIV prevalence are among the most complete disease-specific data available in the world.  And countries in sub-Saharan Africa have some of the most complete sentinel surveillance programs.  In the absence of widely available information from general population samples, the most widely used method of estimating general population HIV prevalence utilizes data on sentinel surveillance in antenatal clinics. 

Despite this practice, HIV seroprevalence based on antenatal clinic data may likely be a biased estimate of prevalence in the population.  Not all pregnant women attend antenatal clinics, and attendance will vary with age, locality, education level, parity, ethnicity and religion--factors also likely associated with HIV status. Data from pregnant women only provide information about those sexually active and tend to over-estimate the prevalence of HIV in the community, particularly in the youngest age groups. On the other hand, these data only pertain to fertile women, and HIV is associated with reduced fertility. These biases might lead one to question the use of data on pregnant women as a proxy for the general population.  However, several studies have shown that HIV prevalence among antenatal clinic attendees still gives a reasonable overall estimate of HIV prevalence in the general adult population, although they tended to underestimate HIV prevalence among women and overestimate HIV prevalence among men.  As a result of these concerns, there is a continuing interest in research comparing HIV infection in pregnant women and in the general population.

A new study, using identical methods in each site, has compared HIV prevalence measured in random samples of adults in the community with that measured in sentinel surveillance in antenatal clinics in Yaoundé (Cameroon), Kisumu (Kenya), and Ndola (Zambia). In Yaoundé and Ndola, the HIV prevalence in pregnant women was lower than that in women in the population, overall, and for age groups over 20. In those under 20 in Yaoundé, HIV prevalence was higher in pregnant women than in the population. In Ndola the overestimate in young women was only seen up to age 18; thereafter HIV prevalence in pregnant women was lower than that in women in the population. In contrast, in Kisumu the HIV prevalence in pregnant women was similar to that in women in the population at all ages. The age-standardized HIV prevalence in pregnant women was similar to that in the combined male and female population aged 15-40 in Yaoundé and Ndola, but overestimated in Kisumu (see figure). These results, together with other studies, suggest that, in a generalized epidemic where the predominant mode of transmission is heterosexual, HIV prevalence data among pregnant women are a reasonable estimate of overall (male and female) HIV prevalence in the population, and are unlikely to overestimate HIV prevalence in women except in the youngest age group.

Epidemics in Russia and the other Newly Independent States, China and Vietnam: opportunities for focused prevention among injecting drug users and sex workers

In the countries of the former Soviet Union, as well as in China and Vietnam, the HIV epidemics continue to be heavily concentrated in IDU. Russia and many of the Newly Independent States have seen rapid growth of HIV among injectors in the last 3 or 4 years. In both China and Vietnam, over 60 percent of detected HIV infections have been among IDU. Yet, prevalence among other population groups has remained comparatively low so far. At the same time, large epidemics of other STIs have been reported from these countries. Between 200,000 and 400,000 new cases of syphilis are reported annually from Russia alone. China has seen a steady growth of STIs over the last several years. HIV prevalence among sex workers in southern Vietnam continues to grow, while studies of street sex workers have found many now injecting drugs. These data raise the possibility of major sexual epidemics that may bootstrap off of or run concurrently with the injecting drug epidemics.

Epidemics of this type are particularly sensitive to early and focused prevention efforts. Because the epidemic is concentrated in a limited number of smaller populations, efforts that work with the communities of IDU and with sex workers and their clients to reduce both their injecting and sexual risk can be particularly effective in slowing the spread of HIV to the general population.

However, as has been the case in many countries of the world, the major barriers to effective prevention remain in the policy arena. HIV prevention among marginalized groups such as IDUs and sex workers can only succeed in an environment that is conducive to the adoption of safe injection and safe sex behavior. Yet, IDU and sex workers face ongoing criminal sanctions in many of these places. This makes it difficult to work with the communities of drug users and sex workers and often keeps them from accessing prevention programs for fear of identification or arrest. Furthermore, public policies often prevent the distribution of clean needles or the possession of clean injecting equipment or condoms. For example, in other countries the police will often arrest those carrying injecting equipment. In other places, police will use possession of a condom as presumptive evidence of illegal sex work. Such policies discourage safer behavior among both injectors and sex workers. These public policies make it difficult or impossible for many injectors and sex workers to protect themselves.

The present epidemiological situation calls for an urgent coordinated response, before the window of opportunity to prevent a further spread from drug users and sex workers into the general population closes. Together with drug supply and demand reduction to reduce the number of IDUs exposed to HIV, harm reduction approaches, which international experience has shown to be effective to prevent HIV transmission, need to be adopted and operationalized. Similarly programs for sex workers and clients need to be expanded and strengthened to ensure that they have the coverage needed to contain sexual transmission. Approaches focused on greatly increasing condom use in commercial sex have been effective in radically slowing HIV transmission in Thailand and now appear to be showing results in Cambodia.

These efforts need to be scaled up as a matter of urgency. MAP therefore calls upon all government sector in the countries concerned, including health, justice and internal affairs, as well as NGOs to join in a collaborative effort to establish effective HIV prevention programs that reach the majority of injecting drug users and sex workers in their countries.

BOX: HIV/AIDS in Nigeria – the fourth largest number of infections in the world

Surveillance is a crucial component of HIV/AIDS prevention and control in Nigeria. So, far four sentinel surveys have been successfully conducted among different sentinel groups in Nigeria: antenatal clinic women (ANC), STI patients, pulmonary tuberculosis (PTB) patients, long distant transport workers, and female sex workers. The last sentinel survey was carried out among ANC in 1999.

HIV prevalence in Nigeria has increased from 1.8 percent in 1992 to 5.4 percent in 1999 among ANC women. However, some hot spots have been found to have prevalence of up to 21 percent.  The age group mostly affected is 20-24 years (8.1 percent). Rates were substantially higher in some high risk groups such as female sex workers (34.2 percent). HIV prevalence among blood donors has reached an alarming

11.0 percent, probably due to the lack of a national blood transfusion service in the country.  It is hoped that the National Blood Transfusion policy, having just been launched, will have an impact on the safety of the blood supply.

Based on results of sentinel surveillance, the estimated number of adults and children living with HIV/AIDS in Nigeria is 2.7 million at the end 1999, the fourth largest number of infections in a country in the world.

Due to the level of the current epidemic and its dynamics, it has been recommended that HIV sero-prevalence surveys among ANC be conducted on an annual basis.  HIV/AIDS sero-prevalence surveillance and behavioral surveillance among high risk populations is planned in 12 sentinel sites. The results of these surveys will provide a better picture of the dynamics and determinants of HIV spread in the country.

There is at the moment strong commitment by the Government to implement a multisectoral strategy with participation of all development partners to see how the epidemic can be controlled in the country. This has culminated in the inauguration of the Presidential committee on AIDS and the National Action Committee on AIDS to coordinate the implementation of this strategy.

HIV/AIDS in Industrialized Countries: Have We Done Enough?

The HIV epidemics in most industrialized countries are concentrated in specific high-risk populations, primarily MSM and IDU.  The epidemics in these populations are evolving at different speeds in each country, and in some, HIV is beginning to affect new population groups. Although there are differences in the specific aspects of these changes between countries, the major trends are common to many industrialized countries and are described in this section. 

Reduced morbidity and mortality due to improved treatments

The overwhelming good news comes from improved regimens for treatment. The more effective Highly Active Anti-Retroviral Therapies (HAART) available in industrialized countries since 1995/1996 have prevented or delayed progression to AIDS and death in those treated.  The r