·        The growing number of prisoners infected with both HIV and tuberculosis is compounding the burden; HIV infection increases the likelihood that a person with TB will develop the active, contagious form of TB.

·        Moreover, laws allowing the incarceration of suspects for up to two years prior to be-ing charged create a revolving door of inmates who often are intravenous drug users infected with TB and/or HIV.

HIV/AIDS also is a growing problem in the Russian military services.  Currently up to one-third of prospective conscripts are deemed unfit for service owing to the effects of prior drug use (chronic hepatitis or HIV infection).  Amongst enlisted men, ground troops have the largest number of infections, while strategic military forces and airborne troops have the lowest.

Driven by widespread drug use, inadequate healthcare infrastructure, and the government’s limited capability to respond, the number of HIV positive people probably will rise to 5 to 8 million by 2010.  This condition would reflect an adult prevalence rate of around 6 to 11 percent, exacerbating Russia’s population decline.

India.  According to official Indian Government statistics, 4 million people in India are HIV positive.  India also has high rates of TB, however, which may be indicative of undiagnosed HIV/AIDS.  Some experts believe that 5 to 8 million Indians may be infected.  We

expect India to have the largest number of people with HIV/AIDS in the world within the next few years.  But even with the large number of infected people, India’s adult prevalence rate is only around one percent.

·        Adult prevalence rates vary across the country, however, in some areas (Mumbai and Pune) the rate is as high as 4 percent, according to unofficial estimates
(see figure 6).

Heterosexual transmission is the driver of infections, except in two regions (Nagaland and Manipur) where intravenous drug use is a serious problem.  Thirty to 60 percent of prostitutes and up to 15 percent of all truck drivers are infected with HIV/AIDS.

·        Sexually transmitted diseases and reproductive tract infections are rampant in India, increasing the risk that HIV/AIDS infections will be transmitted.

The current trajectory of the disease, limited public awareness, and the lack of resources for a major anti-AIDS program will continue to drive the spread of the disease.  Approximately 20 to 25 million Indians are likely to be infected by 2010—even if the disease does not break out significantly into the mainstream population. 

China.  China has significantly raised its official estimate of the number of HIV-positive people over the last two years from 600,000 to one million.  The UN now estimates that 1.5 million are infected, while other experts believe the number probably is closer to 2 million or even higher.  Owing to China’s massive population, even these higher figures, however, represent an adult prevalence rate of only 0.15 to 0.25 percent. 

HIV:  The Science of the Disease

HIV-1 is a fatal infection acquired by contact with the blood or body fluids of an infected person.  A transfusion with infected blood almost always results in spread of the virus, and children born to infected mothers have an up to 40 percent chance of contracting the virus—prior to birth, during birth, or through breastfeeding.  The transmission rate of the disease through sexual contact ranges from 1 to 3 percent.  Reusing infected needles results in infections less than one percent of the time.

Sexually transmitted diseases or reproductive tract infections greatly increase the risk of contracting HIV, and uncircumcised men transmit HIV and other STDs to their partners more frequently than circumcised men.

As the disease progresses, a type of infection-fighting white blood cell—the CD4 positive-t cell—decreases, leading to an irreversible loss of immune function.  This period is marked by many illnesses, or unusual “opportunistic” infections that healthy immune systems protect against. 

HIV-positive persons are susceptible to opportunistic and infectious diseases, especially TB.  Once they have contracted TB, the disease progresses to the highly infectious, active stage much more quickly and frequently than in HIV-negative persons and is often what kills them.

Antimicrobial medications are used to treat opportunistic infections of bacterial, viral, and fungal origin.  Frequent or prolonged use of antimicrobials promotes genetic mutations that result in drug resistance.  This often makes opportunistic infections more serious and difficult to treat, and may drive the spread of resistant organisms in both HIV-positive and HIV-negative people. 

Antiretroviral and other antimicrobial medications can prolong life, but eventually the immune system becomes so damaged that HIV progresses to Acquired Immune Deficiency Syndrome (AIDS), and death usually follows in a few years.  No cure for HIV/AIDS is available, and no vaccine has proven a sure way to prevent it; avoidance of high-risk behavior is the only proven way to prevent the disease.

A generally milder form of the virus (HIV-2) also exists and has limited geographic reach—primarily in West Africa, including Nigeria—and is less transmissible and less lethal than
HIV-1.  Patients with HIV-2 have lower viral loads and slower immune decay but acquire the same opportunistic infections as those infected with HIV-1. 

Several factors are driving the epidemic in China—the large migrant population, intravenous drug use, and poor hygiene in plasma sales—increasing the odds that the disease will continue to spread. 

Migration.  An estimated 100 million ruralmigrants are on the move in China, relocating to cities to find work.  Sexual contact between migrant men and prostitutes has spread the disease, which advances over an even wider geographic area if the migrants return to their villages to visit their families.

Drug abuse.  HIV/AIDS also is rising among intravenous drug users, especially in southern regions adjacent to Southeast Asia’s “GoldenTriangle” of heroin production and distribution routes.  Infection rates also soar as high as 85 percent among intravenous drug users in the Xinjiang Autonomous Region in western China  (see figure 7).

Plasma sales.  The practice of plasma selling in rural areas also has been a major contributor to the spread of HIV/AIDS (see textbox).  Mixing infected blood plasma causes one of the highest known transmission rates for HIV/AIDS, and the practice has infected large numbers of rural, heterosexual villagers who would otherwise be considered at low risk for the disease.

Despite growing concern over the disease among senior leaders, China’s sheer size, resource constraints, widespread ignorance of AIDS, cultural taboos about discussing sex, and coordination problems between levels of government will make it difficult to check the spread of the disease. 

·        Even if adult prevalence rates rose only to two percent by the end of the decade, China would have about 15 million infected people by 2010—surpassed only by India.

Prospects for Control

We assess that all five next-wave countries will have difficulty controlling their HIV epidemics in the short to medium-term.  The disease has built up significant momentum—especially in Nigeria and Ethiopia—and the governments have been slow to respond.  None of the five next-wave countries in this report is on a trajectory to replicate the success of such countries as Uganda, Thailand, and Brazil in stemming the spread of the disease.  Several leaders of the next-wave countries are focusing more attention on the AIDS threat, but all face a host of competing demands.  In addition, these countries have weak healthcare infrastructures and severe budget constraints, which will create difficulty in financing education and treatment programs for their large populations. 

China:  HIV Infections from Blood Selling

Most of China’s blood supply is purchased from poor villagers by brokers who collect only plasma for the manufacture of therapeutic and diagnostic products.  These brokers often try to save money and time by mixing the blood of several donors before spinning out the plasma in a centrifuge.  Reinjecting the mixed blood back into the donors to prevent anemia has spread HIV like wildfire, with infection rates as high as 60 percent in some villages.  The government has
ordered a stop to the practice, but press reports suggest that it continues in some areas.  The practice of blood selling began as a way to raise money for rural health projects after the central government cut subsidies to the provinces.

·        Chinese media report that people selling blood in Qinghai, Henan, and Shaanxi claim that they earn between $12 and $15 for each bag of donated blood—a large sum of money in these poor provinces.  Some farmers report donating blood 50 times in two months.

The high cost and complexity of treatment programs probably will continue to feed the debate over the relative cost/benefit of treatment versus prevention in addressing HIV/AIDS. 

·        Pressure for antiretroviral drugs has jumped in recent years because such drugs afford one of the most tangible ways for governments to respond to the AIDS problem. 

·        Nonetheless, successful efforts to combat HIV in Uganda, Thailand, and other countries suggest that high-profile education programs to change behaviors remain key to long-term success, although this approach requires more time and persistence by senior leaders.

The Leadership Challenge

The commitment of senior political leadership to persist in the struggle against HIV/AIDS has been a key variable in the few successful programs around the world.  The leaders of Nigeria, Ethiopia, Russia, India, and China will be challenged to maintain sustained high-level interest, however, given the scope and severity of other domestic and foreign policy issues.  Some leaders are beginning to pay more attention to AIDS, but they have not given it the sustained priority thus far that has been needed in other countries to blunt the spread of the disease.

Overcoming Social Stigmas 

Many citizens and government officials in next-wave countries are reluctant to acknowledge the spread of the disease owing to strong social and cultural norms.  HIV/AIDS still is associated with behaviors widely considered taboo, including prostitution, drug use, and homosexuality.  HIV-positive people often do not seek testing and treatment because they fear being ostracized by their families, neighbors and friends and losing their jobs or access to public services. 

·        In China, few people publicly acknowledge HIV-positive status because they might be barred from school, fired from their jobs, or even expelled from their community, according to press reports.  Largely as a result of China’s “one-child” policy to reduce population growth, Chinese men are under such pressure to carry on family lines that some HIV-infected gay men marry and have families and risk spreading the disease to their wives and children.

·        A 2001 law in one Chinese province prohibits HIV-infected persons from marrying.

·        In India, recent studies found that HIV-infected people were refused admission to some hospitals and denied treatment.  Furthermore, HIV test results often are not kept confidential, which discourages people from getting tested.  Some experts say that women in India’s male-dominated society are reluctant to insist on condom use, and the widows of men who die from AIDS sometimes are denied healthcare or contact with their children.

HIV/AIDS:  Success Stories to Model

Uganda, Thailand, and Brazil have managed the spread of HIV largely through active, high-level leadership to increase awareness, destigmatize the disease, and treat victims—all of which help change the behaviors that transmit the disease.  These countries are widely considered to have the most successful anti-HIV programs and are potential models for other countries ravaged by the disease.

·        Bold leadership by Uganda’s President Museveni largely is responsible for driving down the country’s infection rate from 30 percent in 1992 to 11 percent in 2000.  The HIV/AIDS problem remains significant, but Museveni has had success in his relentless campaign to change behavior by urging people not to have sex with multiple partners, publicly acknowledging the threat posed by AIDS, destigmatizing the disease, and decentralizing HIV education programs down to the village level.

·        Thailand launched a massive HIV/AIDS public awareness and condom distribution campaign in the early 1990s—with the support of several key senior officials—which significantly reduced the spread of the disease.  More recently, the government announced it would make antiretroviral drugs available for less than one dollar a day.  AIDS still is the leading cause of death in Thailand, but the government probably has averted millions of HIV infections (see figure 8). 

·        In Brazil, the government has invested heavily in education and treatment programs, including providing free antiretroviral drugs to HIV/AIDS patients distributed through the public health system.  HIV adult infection prevalence also is declining among intravenous drug users, suggesting that programs teaching safer injection habits also are successful.   

Active leadership will be especially critical given the widespread public ignorance of AIDS in next-wave countries.  The challenge is especially great in these countries because of fragile communications links, numerous government jurisdictions, and different ethnic and language groups.  The five countries also lack strong domestic advocacy groups that can raise awareness and increase pressure for responsive programs.

·        A survey two years ago found that 20 percent of Chinese respondents had never heard of HIV/AIDS, and over 60 percent did not know how the disease spreads or how to prevent infection.

·        A World Bank study in India indicates that public awareness of the disease and condom use remain low despite government education programs.

·        In Nigeria, a healthcare worker was
fired after she tested positive for HIV, although a court ultimately agreed to hear her appeal.

·        Russia appears to be a major exception.  A survey last year by an independent pollster found that 90 percent of those polled see combating HIV/AIDS as an important issue.

Nigeria’s leadership has been the most active of the five countries in trying to raise AIDS awareness, for example, by hosting a regional AIDS conference in 2000 and publicly warning about the risk of “extinction” on the continent.  Nonetheless, the Obasanjo administration is beset by such other pressing problems as an approaching election and rising ethnic and religious tensions.  Moreover, Nigeria’s government institutions have deteriorated so badly over the last decade that Obasanjo has few functioning public sector assets left to mobilize even if he chose to engage fully on the issue.

·        Nigeria has taken some steps, however, to build domestic monitoring and diagnostic capabilities—especially in Lagos—and a major study on the economic effects of HIV/AIDS is underway.

·        The Nigerian military, concerned about the loss of key personnel from AIDS, now mandates training about the disease for soldiers.

The Ethiopian Government does not appear focused on AIDS, despite occasional statements on the issue.  The government has focused in recent years on the conflict with Eritrea.  Healthcare workers privately have criticized efforts in recent years as half hearted, and UN officials have publicly warned Ethiopian leaders to take more measures to stem the epidemic.

The Russian Government has not mounted a sustained effort up to now to publicize the growing threat of HIV/AIDS.  Russia faces so many other serious problems that HIV/AIDS is unlikely to receive high-level attention for an extended period until the economic and security costs of neglect become more
tangible.

Sections: 1 2 3 4