Discussion

The Next Wave of HIV/AIDS:  Nigeria, Ethiopia, Russia, India, and China

The Scope of the Next Wave

The HIV/AIDS pandemic continues to spread around the world at an alarming rate, and the number of people with the disease will grow significantly by the end of the decade, as it becomes more geographically diffuse. By 2010, we estimate that five countries of strategic importance to the United States—Nigeria, Ethiopia, Russia, India, and China—collectively will have the largest number of HIV/AIDS cases on earth (see figure 1).  These five countries, which comprise over 40 percent of the world’s population, are in the early-to-mid-stages of the epidemic.

·        All five countries are major regional or global players, and efforts to manage the growing AIDS problem have the potential to impinge upon their political and economic outlook.

·        The disease also is a special cause for concern in these five states because their governments have yet to demonstrate the kind of sustained commitment that has been key to managing the spread of HIV/AIDS in such countries as Uganda, Thailand, and Brazil.

We project the total number of people with HIV/AIDS in these "next-wave" countries is likely to soar from 14 to 23 million currently to 50 to 75 million by 2010, eclipsing the projected 30 to 35 million cases in central and southern Africa, the current geographic epicenter of the epidemic (see figure 2).

Through 2010, HIV/AIDS will increase more slowly or even decline in southern and central

*Estimates of percent are based on population data from the US Bureau of the Census.

Africa—now in the sixth decade of the disease.

·        HIV adult prevalence  in central and southern Africa currently is the highest in the world.  For example, as of July 2002, UNAIDS estimated that 39 percent of adults in Botswana (300,000 people) and 20 percent of adults in South Africa (4.7 million people) were HIV positive. 

Although current adult prevalence rates in the next-wave countries range from less than one percent in China to as high as 18 percent in Ethiopia, the number of people infected already is substantial, ranging from 1 to 2 million in China and Russia to upwards of 5 million in Nigeria and India (see table 1).

The spread of HIV/AIDS in the next-wave countries will be difficult to check by 2010.  Treatment of existing infections and prevention of new infections is minimal.  Even if effective programs could be implemented in the coming years, such practical concerns as cost, scale, and experience in health service delivery probably will result in the omission of services to a large number of infected individuals, and the burden of disease will continue to rise.

·        We project that China probably will have 10 to 15 million HIV/AIDS cases by 2010.  India is likely to have 20 to 25 million—higher than projected for any other country.  We estimate Nigeria probably will have 10 to15 million cases, Russia 5 to 8 million, and Ethiopia 7 to 10 million.

Country Profiles

Nigeria.  The HIV/AIDS epidemic in Nigeria is significantly ahead of that in India, China, and Russia—already advancing well beyond high-risk groups and into the general population.  The official adult prevalence rate is almost 6 percent, but unofficial estimates range as high as 10 percent—which represents 4 to 6 million people infected.

Heterosexual transmission of the HIV virus is the primary mode of spread in Nigeria, and infections appear to be as numerous in rural areas as in the cities.  The reported rate of infection apparently varies significantly by region, with the lowest reported rate found generally in the predominantly Muslim northern parts of the country (see

figure 3).  Infections are most numerous among men ages 20 through 24, but some experts caution that infection rates are rising quickly in young women.

Given the already advanced state of the disease and the government’s limited capacity to respond, we expect HIV/AIDS to infect as many as 10 to 15 million people by 2010.  This number would constitute roughly 18 to 26 percent of adults—close to the current rates in some of the hardest hit countries in southern Africa. 

Ethiopia.  Ethiopia’s adult prevalence rate—estimated at between 10 and 18 percent—is the highest among the five countries, indicating that—like Nigeria—the disease has moved significantly into the general population.  Government figures cite 2.7 million Ethiopians currently as HIV positive, although experts believe the actual number may be between 3 and 5 million.  Adult prevalence is much higher in cities (13 to 20 percent) than in rural areas (5 percent) (see figure 4).  The generally poor health of Ethiopians as a result of drought, malnutrition, limited healthcare, and other infectious diseases has caused HIV to progress rapidly to AIDS.  Heterosexual transmission is the primary mode of spread, and people with multiple partners—especially those with sexually transmitted diseases (STDs) and prostitutes—have significantly higher infection rates, ranging from 30 to 40 percent in STD-positive individuals to 50 to 70 percent in prostitutes.

Unlike conditions in other next-wave countries, war has significantly contributed to the spread of the disease in Ethiopia.  Many soldiers contracted HIV/AIDS during the civil war in the 1980s by having contact with multiple sex partners.  When the war ended in 1991, thousands of infected soldiers and prostitutes returned home, spreading HIV/AIDS in their villages and towns.

·        Another surge of infections may be underway.  Ethiopia has demobilized 150,000 soldiers over the last two years as the conflict with Eritrea has wound down.  More troops will be sent home as the border dispute is settled.

·        As soldiers demobilize, prostitutes—who have even higher rates of infection—disperse around the country as well.

Looking ahead, we expect 7 to 10 million Ethiopians probably will be infected by 2010 because of the high current rate of adult prevalence, widespread poverty, low educational levels, and the government’s limited capacity to respond more actively.

Russia.  Official statistics list about 200,000 people in Russia as HIV positive, but the government’s sampling efforts are poor, especially outside major cities.  Academic and medical experts believe the actual number probably is between 1 and 2 million, which would indicate an adult prevalence rate of around 1 to 2 percent.

·        Infection rates vary significantly across the country, with the biggest concentrations in cities (see figure 5).  Males comprise 77 percent of all the infected, and 60 percent of infected men are between the ages of 17 and 25. 

Intravenous drug use drives the spread of the disease in Russia more than in any of the other next-wave countries.  An estimated 80 to 90 percent of all infections in Russia stem from intravenous drug use, which is rampant and rising. 

·        In most countries, the concentration of HIV among drug users and generally low adult prevalence rates would suggest the disease still has not broken out into the general population.  Experts warn, however, that drug use is so widespread in Russia that many users are integrated into society with jobs and families, suggesting the disease is moving into the mainstream.

Prostitutes and prison inmates—many of whom are intravenous drug users—are contributing to the spread of the disease.  An estimated 20 to 25 percent of intravenous drug users in prison, where there is easy access to drugs, are HIV positive. 

·        Russia’s frequent use of prison amnesty programs that release infected inmates will worsen the HIV/AIDS epidemic among the general population unless accompanied by prevention and treatment programs.

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