The Status and Trends of
the HIV/AIDS Epidemics
in the World
5-7 July 2000
MAP receives financial support from:
United Nations Programme on HIV/AIDS
The United States Agency for International
Monitoring the AIDS Pandemic (MAP) Network
MAP is a collegial network of internationally recognized
technical experts seeking to assess the status and trends of
the global HIV/AIDS pandemic.
MAP was created in 1996, through the collaboration of the AIDS
Control and Prevention (AIDSCAP) Project of Family Health
International, the Francois-Xavier Bagnoud Center for Health
and Human Rights of the Harvard School of Public Health, and
the Joint United Nations Programme on HIV/AIDS (UNAIDS).
MAP's more than
100 members in 40 countries are epidemiologists, modelers,
economists, and social, behavioral, public health and
international development specialists, recruited through a
nomination process and currently guided by an Interim Global
MAP workshops and membership meetings are held in conjunction
with regional and international HIV/AIDS conferences.
This enables MAP to function on a small budget and to
distribute results from its analyses promptly to conference
Specific workshops are convened as needed, with expertise
drawn from MAP members and other invited experts.
Regional experts are encouraged and supported by MAP in
the collection, analysis, synthesis and dissemination of
regional information, which is then incorporated into MAP's
global reports. AIDS service organizations and regional
networks of people living with HIV/AIDS are invited to
participate in MAP workshops.
MAP works toward building consensus in an atmosphere of
collegiality, cultural sensitivity, and mutual respect for
conflicting points of view.
It functions on the basis of volunteerism and personal
and institutional contributions, with limited financial
support from international organizations, including UNAIDS,
and thus provides an independent perspective on issues raised
by the HIV/AIDS pandemic.
The reports represent the views of the individual participants
and not the organizations from which they are affiliated.
MAP reports are
available through the following websites:
Family Health International
François-Xavier Bagnoud Center
for Health and Human Rights
US Census Bureau
Karen Stanecki DeLay
Steering Committee Members:
Karen Stanecki Delay
International Programs Center
U.S. Census Bureau
The Durban Monitoring the AIDS Pandemic (MAP) Network
Symposium, The Status
and Trends of the HIV/AIDS in the World was held on 5-7
July 2000. This
was an official satellite symposium of the XIIIth
International AIDS Conference, 9-14 July 2000.
The three-day MAP Network symposium held in Durban was the
seventh symposium formally organized by this global network
formed in December 1996.
It was part of a continuing series of regional and global
symposia that have been organized to understand the trajectory
of the HIV/AIDS epidemics.
Starting with The
Status and Trends of the HIV/AIDS Epidemics in Africa
Symposium that was held in Kampala, Uganda in December
1995, a team of internationally recognized technical
specialists in epidemiology, modeling, economics, demography,
public health, and international development was formed to
monitor the dynamics of the HIV/AIDS pandemic and various
regional epidemics. By collecting, analyzing, and disseminating information on
HIV/AIDS, this team of experts, which has grown rapidly over
the course of four years into a global network, seeks to
assist governments, organizations and the world at large to
respond more actively and effectively to the challenges posed
by the HIV/AIDS pandemic.
The MAP symposium in Durban brought together 38 global and
regional experts, including MAP members and some specially
invited participants, to achieve the following objectives:
To present and share new information on the status and trends
of the HIV/AIDS epidemics in the world;
To review the epidemiological and behavioral patterns among
the HIV/AIDS epidemics affecting the different populations;
To identify specific data needs for monitoring and estimating
the HIV/AIDS epidemics; and
To produce and disseminate a consensus report on the current
status of the HIV/AIDS epidemics in the world.
This report, co-authored by the Durban MAP Symposium
participants and produced in less than 24 hours, reflects a
consensus of the analysis, projections and recommendations
brought forward during the symposium. Its aim is to provide information that can be used by
international bodies, to briefly review the most important
aspects of the history of the HIV/AIDS epidemics to date, to
recognize the current status of and trends within these
epidemics, and to take immediate action to affect the course
of these epidemics in the future.
Statement of the Global Network of People Living
with HIV/AIDS (GNP+):
Impact of data on the HIV/AIDS epidemic on the
lives of people living with HIV/AIDS
The importance of
data concerning the trends and determinants of the HIV/AIDS
pandemic cannot be denied.
For people living with the virus it impacts us in many
ways. Data can help improve the level and scope of care and
treatment services which we receive and it can contribute to
mitigating at least some of the impact of the stigma and
discrimination which we face on a daily basis.
Governments, donor organizations, communities, NGOs
and the private sector all need
HIV/AIDS monitoring data. Data can be used to mobilize
political will in order to increase the scale of both
prevention and care interventions, to identify priorities for
the allocation of scarce resources, to select and target
activities, and to monitor the progress in the response to the
epidemic. True, accurate and reliable data regarding the
pandemic are essential to ensure that the scale of the crisis
is both understood and to improve our collective response.
People living with HIV/AIDS, organized under GNP+,
are concerned when different information about the epidemic is
collected and presented by different groups of people and
institutions. Information about the global and national trends
which is not consistent cannot be used for planning and
setting priorities for prevention and care investment. This
directly affects the lives of people living with HIV in the
respective countries as time is lost in debating the validity
of the sources of information and preference is often given to
the source that paints the picture less gloomy. We are
concerned that those who wish to deny the true scope and
nature of the crisis can also misuse data.
In addition, endless debate can yield ongoing inaction
or misallocation of funds.
We therefore call upon the International
Organizations, National Institutes/Ministries of Health and
the National AIDS Control Programs to emphasize the need for
reasonably accurate statistics on the epidemic for planning
and making the right decisions. Factors that bring about the
inaccuracies should therefore be isolated and corrective
measures put in place. At the same time, academic discussion
about the validity of the data should give room to concrete
action for preventing further spread of HIV and ensuring
access to care for those infected.
People living with HIV/AIDS can be a valuable
resource to assist epidemiologists and program managers in
their difficult work to provide a true picture of the
our participation in cohort studies to assistance in
identifying potential sample populations for participating in
behavioral surveillance investigations, we offer our
experience and abilities to assist in ensuring that data
collected are not only valid but are further transformed from
mere numbers to action and hope for our future.
Board Member for Africa
The AIDS Pandemic at the
start of the 21st Century
Global and regional overview
At the turn of the millennium, UNAIDS and WHO estimated that
34.3 million adults and children were living with HIV/AIDS.
More than 18 million have already died of the disease. The
vast majority – about 95 percent – of all people living with
HIV/AIDS (PLWHA) live in developing countries. The proportion
will continue to rise in these countries, where poverty, poor
health systems, gender inequality, limited resources for
prevention and care, as well as denial and stigma fuel the
spread of the virus.
As seen above the situation is worst in sub-Saharan Africa.
With 24.5 million infections, almost one in ten adults 15-49
years of age is already living with the virus throughout the
sub-continent. The spread is not equal within sub-Saharan
Africa. While the first major epidemics were described in
countries of central and eastern Africa, the epidemic is now
far worse in the southern part of the continent. In South
Africa, infection rates increased from less than 1 percent in
the adult population at the beginning of the 90s to about 20
percent within less than one decade. Twenty percent and more
of the adult population are also living with the virus in
Botswana, Lesotho, Namibia, Swaziland, Zambia, and Zimbabwe.
The latest data show that more than one-third of all men and
women 15-49 years of age are now living with the virus. Such
rates were never thought to be possible and are hard to grasp.
Women are harder hit in Africa than men. About 55 percent of
all adults living in the sub-continent with HIV/AIDS are
women. The difference between men and women is most pronounced
in those less than 25 years of age. A population-based survey
in Kisumu, Kenya, showed HIV rates in 15 and 16 year old girls
of 8 and 18 percent while no infections were documented in
boys of the same age. In 19 year old girls the rates were up
to 33 percent, while that in boys was almost 9 percent. The
reasons for these extremely high rates in girls are not fully
understood. Biological vulnerability of young girls and the
fact that girls frequently have sex partners of much higher
age – with high levels of infection – likely play a role.
Vulnerability to HIV Infection in Young Women in sub-Saharan
Several studies in sub-Saharan Africa
have noted that HIV prevalence is high in young women within
the first few years of sexual activity but rises more slowly
in young men. Recent data from four urban populations and one
rural population confirm dramatic male-female differences in
HIV prevalence in young adults (see Figure). To a degree,
these differences could be an artifact due to inadvertent
failure to include young men with higher rates of HIV
seropositivity in the surveys but the consistency of the
finding and the magnitude of the difference makes this
unlikely as a full explanation.
HIV Prevalence in Young Men and Women in sub-Saharan Africa
Women may have higher HIV prevalence
than men because they are more exposed to infected partners
and/or because they are at higher risk of acquiring HIV
infection from an infected partner. The risk of exposure to an
HIV infected partner at a young age depends on the age at
sexual debut, the number of partners, and the likelihood that
those partners are infected. Reported age at first sex is
similar for men and women, and even at young ages men
generally report higher numbers of partners than do women.
Since HIV prevalence increases with age, the tendency for
young women to have older partners both within and outside
marriage may increase their exposure to HIV-infected partners.
Age differences between partners similar to those recorded in
Mutasa have been found in a number of studies. In Mutasa, the
older a woman's most recent partner, the more likely she was
to be infected with HIV.
Although age difference between
partners provides a partial explanation for the
early rise in prevalence in young women, it does not appear to
be the full answer. It has been estimated that, in Kisumu and
Ndola, the risk of having an HIV infected partner is similar
for young unmarried men as for unmarried women. This suggests
that young women may be particularly susceptible to HIV. There
is some evidence that HIV transmission from men to women is
more efficient than from women to men. Several studies of
discordant couples in Africa and elsewhere have found higher
Age Difference between Respondent and Partner
seroconversion rates in initially seronegative female partners of
male index cases, than in the initially seronegative male
partners of female index cases, though other studies have
found similar seroconversion rates for men and women in HIV
discordant partnerships. Susceptibility to HIV infection in
very young women may be particularly high due to immaturity of
the genital tract and laceration of the hymen at first sexual
intercourse. Young women were also found to have high
prevalence of other sexually transmitted infections, including
HSV-2, in these studies. These infections, which are
frequently acquired from older partners, increase
susceptibility to HIV infection.
In Asia, rates of infection are generally much lower. They
reach two percent or more of the adult population in three
countries, Thailand, Cambodia and Myanmar. In many of the very
populous nations of the region, prevalence does not exceed 1
in a thousand. However, nationwide average prevalence
estimates do not tell the full picture. China and India are
home to more than one-third of the world’s total population.
Each of these countries has more inhabitants than all African
nations together. As in Africa, the spread of HIV is different
from one province to another in China, or from one state to
another state in India. In fact, while HIV seems to be
extremely rare in some states in India, especially in the
northern parts of the country, rates have reached 2 percent
and more in the state of Tamil Nadu. One can easily imagine
what it would mean in terms of total numbers if HIV would
spread at similar levels to others states, given the sheer
size of the country’s population.
China’s transition since 1978 from a planned economy to an
open market has led to an unprecedented period of economic
However, these changes have also been accompanied by
changes in social norms and individual behavior.
Up until this point in time, the number of reported
AIDS cases is quite small, but all 31 provinces have reported
AIDS. With a population of over 1.2 billion even a limited
epidemic could affect millions of people. Indeed, the China Government/UNAIDS/WHO estimate that 500
thousand Chinese were HIV positive at the end of 1999.
Given the right conditions, China’s HIV/AIDS epidemic
could begin to spread even more rapidly.
One worrisome indication of
the presence of just those conditions is the increasing number
of reported cases of sexually transmitted infection (STI).
Reported cases of STI have increased from 5.8 thousand
in 1985 to over 836 thousand in 1999.
Considering the fact that reported cases are thought to
be seriously underreported, these data suggest the increasing
potential for rapid spread of HIV.
According to official estimates,
there are a minimum of 3 million drug users in China. Limited
studies show that needle-sharing is common, with more than 45
percent of injectors sharing needles. HIV infection is
reported among injecting drug users (IDU) from 25 provinces.
In 1995, data from eight IDU sentinel sites found HIV
infection ranging from 0 to 0.2 percent. By 1999, based on
data from 19 sites, prevalence
ranged up to over 77 percent.
There are also indications of increasing risk for heterosexual
transmission in China.
With official estimates of more than 3 million sex workers in
China, condom use and HIV prevalence among sex worker
populations are important indications of heterosexual risk of
infection. Data from sentinel surveillance sites show that
fewer than 10 percent of sex workers reported always using
condoms with clients, and more than half reported never using
condoms. Sentinel surveillance of this population in 1999
shows prevalence ranging up to over 6 percent.
China faces many challenges in the coming years in preventing
rapid growth of HIV infection. Public resources for prevention
are limited and some government leaders are not convinced of
the potential for rapid epidemic growth. Information campaigns
have been few and the level of knowledge of prevention
measures is low. The illegal nature of injecting drug use and
sex work make populations with these behaviors very difficult
to reach. Finally, China’s increasingly mobile population will
pose challenges to effective implementation of public health
In Latin America, the picture is
diverse as well. Rates are generally highest in Central
America and the Caribbean where heterosexual spread of HIV
seems the predominant mode of transmission. In Haiti rates
today exceed 5 percent, the only country with such rates
outside the African continent. In countries of South America,
the epidemics are generally concentrated in sub-populations at
highest risk, such as men having sex with men (MSM) and IDU.
Trends seen in these countries are similar to the patterns in
the United States. While overall incidence of HIV infection is
rather stable over the past several years, the proportion of
infections through heterosexual contacts and consequently in
women is increasing. Countries such as Brazil, Argentina, and
Mexico have also made strong efforts in the provision of
adequate care for those infected. In Brazil, like in other
countries of the continent, access to ARV (anti-retroviral)
treatment through the public service is guaranteed by a
presidential law. As a consequence, these countries have seen
reduced morbidity and mortality from AIDS in recent years.
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
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
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
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
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.
“Minority” countries: the small islands, nations
and territories of the Caribbean and the Central American
Rightly so, most HIV/AIDS prevention efforts and international
resources are being channeled
to developing countries with a high HIV/AIDS
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
AIDS deaths cause reduction in population growth
At the beginning of the 21st 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
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
Data on HIV infection rates and mortality do not tell the
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
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
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
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.