·        In 2001, Moscow promised $133 million to fight AIDS over five years, but it has only appropriated $80 million ($16 mil-lion per year).  Treating 3 million HIV- infected adults would cost $30 billion a year, according Vadim Pokrovsky, the chief of the Russian Federal AIDS Center.

·        In 2001, Moscow refused a World Bank loan to fight TB and HIV/AIDS, apparently because Russia did not wish to increase the amount of its debt.  However, Moscow recently re-opened negotiations for the loan.

The Indian Government has taken numerous steps to highlight the risk that AIDS poses to the country, but tensions with Pakistan and growing religious strife clearly are considered more pressing issues.  Furthermore, India faces competing priorities to address such other health challenges as TB.  Nonetheless, the Indian Government did react to the emergence of HIV/AIDS in 1986 by creating the National AIDS Control Organization (NACO).

·        NACO faced many difficulties throughout most of its early years, although new leadership in 1999 has improved and expanded the HIV/AIDS program.

The Chinese Government has become significantly more open over the last year in acknowledging the rising HIV/AIDS problem after ignoring it for years.  The central government has organized some public relations events to increase awareness of the disease, and Beijing has sought bilateral assistance from the United States and others to improve its anti-AIDS campaign. 

·        A Chinese government official has publicly expressed concern that there could be 10 million people with AIDS by the end of the decade.

·        The turnaround suggests that senior leaders are concerned about the potential economic, social, and political ramifications of the spreading disease.

Nonetheless, domestic funding to combat the disease remains low, and Chinese leaders will have difficulty keeping HIV/AIDS high on the agenda as they struggle to deal with such challenges as maintaining economic growth, defusing rural discontent, managing the Communist Party leadership transition, opening Chinese markets more widely to trade, and modernizing the military.  Moreover,
decisionmaking has become so decentralized in China on healthcare and education that senior leaders in Beijing cannot always count on provincial and local leaders to follow through.

·        Local government commitment to HIV/AIDS is likely to be uneven, given the low funding for such programs from the central government, lack of awareness of the disease, stigmatization of those infected, and corruption.

·        Some government leaders probably will be especially reluctant to highlight HIV/AIDS because they may be linked to the blood selling programs that have become a major means of transmission.

·        In July 2002, Chinese police detained for several months the country’s most prominent AIDS activist for circulating a “secret” government memo acknowledging that poor management of the blood supply had contributed to the AIDS problem.

Weak Healthcare Infrastructure

Although significant differences in capabilities exist among next-wave countries, all five have overburdened and under funded healthcare systems and limited abilities to provide integrated, nationwide programs to test people, track infections, and deliver treatment and education programs.  Even within each of the five next-wave countries there are disparities in the ability of cities and regions to deal with the epidemic that are likely to grow in the coming years.

·        Nigeria’s public healthcare system, which has been deteriorating for years, is hard pressed to provide even the most basic public services.  Many facilities lack electricity, water, and soap; even better-equipped hospitals are beset by strikes by medical staff.

·        Ethiopia has never had a viable national healthcare system because of overwhelming poverty and years of war.  The government is soliciting international assistance to build its capabilities, but progress on this front is likely to take years. 

·        Russia’s dwindling health services are unable to provide treatment for many victims of heart disease and the skyrocketing number of TB cases.  Since the breakup of the Soviet Union, Russia’s health infrastructure has deteriorated so much that most experts believe that the population is less healthy now than at any time in the past 50 years.

·        India has established nationwide HIV/AIDS centers and a monitoring system, but access to basic medical care is not universal and the free public health- care system often is highly inefficient.  Nonetheless, the government’s AIDS organization was able to reach an estimated 70 percent of households in a recent survey of AIDS-related behavior.

·        In China, a growing number of citizens cannot afford quality healthcare because of privatization of the public health service.  Rural areas, which have the highest HIV infection rates and where 70 percent of the population lives, suffer from major shortages of resources.  Funds are being directed toward modernizing urban facilities.

Treatment

Brazil’s successful emphasis on treatment and the expanded use of antiretroviral drugs has raised hopes for improving the length and quality of life for HIV/AIDS patients.  Nonetheless, we believe treatment will be a

Antiretroviral Drug Resistance

Natural viral mutation and improper use of drugs to control HIV (halting use, intermittent use, or habitually missed doses) have caused some strains of HIV to evolve resistance to antiretroviral medications.  These resistant strains continue to reproduce and destroy immunity in the presence of medications meant to control the virus, and already they have spread around the world.  These drug-resistant variants are spread less efficiently than other forms.

·        HIV strains have an amazing ability to recombine to form mosaic viruses.  This pace of genetic change forces changes in treatment regimens and has placed unprecedented pressure on the pharmaceutical industry to develop new drugs for continued viral control.

·        Most HIV drug resistance can be traced to improper use of medications.  Weak healthcare infrastructures in some next-wave countries will lead to poor distribution and incorrect use of antiretrovirals, which are likely to promote drug resistant strains of HIV and reduce the effectiveness of medicines.

·        Treatment failure rates can be as high as 60 percent in some countries.

To help control resistance, therapies now often employ a combination of several drugs from different classes.  In addition, some researchers are now trying to curb the growth of antiretroviral resistance by having medical workers personally watch and record patients taking medication—known as direct observed therapy—a technique that has slowed the development of resistance to anti-TB medications.

·        Important new drugs inhibiting viral entry into healthy cells also are in development, but prohibitive costs are likely to limit their distribution in the developing world.

difficult primary strategy for the next-wave countries because of the high cost of providing antiretroviral drugs for such large populations and drug resistance.

·        The cost of antiretroviral drugs has plunged in recent years—from around $10,000 per year per patient down to as low as $500 to $600—because of pressure from many countries on pharmaceutical companies and the increasing use of generic drug alternatives.

·        Pharmaceutical industries in an increasing number of countries—including Russia, India, and China—are likely
to develop and produce such drugs in
the interest of reducing the cost of
medication.

·        A Chinese government official publicly warned in September 2002 that Beijing would authorize domestic firms to manufacture generic drugs in defiance of patent laws unless prices come down, although the Ministry of Health later said it would not violate WTO obligations.

Even as prices decline, the total cost of providing drugs for millions of patients is likely to be prohibitively high for populous, low-income countries.  Moreover, the cost of the drugs is only a small portion of the overall cost of treatment programs.  Costly laboratory tests and equipment are needed to determine which combination of drugs is appropriate for each infected person.

·        The effectiveness of the drug combinations must be monitored and adjusted on an ongoing basis as well. 

The effectiveness of antiretroviral drugs also is being undermined by a growing drug resistance problem, owing both to the natural mutation of the virus and improper drug use.

·        Weak HIV and TB treatment programs in Russian prisons will foster the emergence of drug-resistant strains, which eventually are likely to appear outside Russia because of growing international travel.

·        Scientists at the July 2002 international AIDS conference in Barcelona presented numerous research papers on the challenge of drug resistance and the consequences of not taking medicines as
prescribed.

Implications

The rise of HIV/AIDS will have significant economic, social, political, and military implications in Nigeria, Ethiopia, Russia, India, and China, although the percentage of the adult population in each country that is infected is likely to remain below the hardest hit countries in southern and central Africa.  The impact of the disease by the end of the decade will vary among the five countries, given differences in disease trajectories government responses, available resources, and demographic profiles.

Nigeria and Ethiopia:  Hardest Hit

The social and economic impact of AIDS in Nigeria and Ethiopia probably will be similar to the hardest hit countries in Africa.  The disease is likely to negatively impact almost all sectors of society by 2010.  AIDS will take a heavy economic toll by robbing the countries of many key government and business elites and by discouraging foreign investment, although the oil sector is unlikely to be hurt significantly.

·        The professional classes in Nigeria and Ethiopia—like other African countries—are more vulnerable in comparison to other next-wave countries because adult prevalence rates already are much higher and relatively fewer elites are concentrated in a smaller number of key
positions.

·        The drag of AIDS on economic growth will further reduce the ability of the government to handle the rising social and healthcare costs.

The further deterioration of already weak government institutions by the escalating HIV/AIDS crisis could leave Nigeria and Ethiopia seriously weakened states and is likely to reduce their ability to continue to play a regional leadership role.

·        HIV/AIDS probably will complicate staffing in the military officer corps of the two countries as it has in other African states.  Ethiopia is more likely to suffer military manpower shortages through the lower ranks, however, because it has a much larger army and smaller population than Nigeria, which plans to reduce the size of its force.

·        Rising social tensions over AIDS and related economic problems could exacerbate regional and ethnic tensions within Nigeria and Ethiopia while leaving both governments less able to manage the problem.

AIDS Vaccines Coming, But Not a Panacea

Many research and clinical trials are underway to develop a vaccine against HIV.  Clinical trials of two commercial vaccines—intended to confer immunity by introducing a harmless portion of HIV protein into the body—have progressed to Phase III human testing in the United States, Canada, Netherlands, and Thailand.  Results are expected within the year.  Nonetheless, even if a viable vaccine to protect against certain viral subtypes of HIV that are prominent in the test countries becomes available in the coming years, it probably will not to be effective against the most common subtypes of HIV in Nigeria, Ethiopia, Russia, India, and China. 

Moreover, first-generation HIV-vaccines probably would provide lower immunity or shorter-lived protection than future product iterations that incorporate what is learned from wider use.  Studies suggest that if the vaccine is at least 30 percent effective, delivering it to persons engaging in high-risk behaviors may be beneficial, although there is a danger that it could encourage risky sexual conduct in individuals who believe they are protected by the vaccine.  Unless the vaccine was widely affordable, however, it would remain beyond the reach of the developing world—which is likely to fuel intense political pressure on Western countries and drug companies to slash prices or subsidize the cost.

Both vaccine effectiveness and good distribution are necessary for HIV transmissibility to decrease enough for the epidemic to die out eventually.  For example, some estimates indicate that to stem the epidemic, the world would need 50 percent coverage with a 75 percent effective vaccine.  Until a highly effective vaccine is in wide distribution, anti-AIDS programs aimed at encouraging behavioral change will remain essential in controlling HIV/AIDS.

·        If the governments prove unable to respond, public confidence in political leadership could be weakened further, especially if efforts to respond are seen to be undermined by corruption.

Researchers estimated there were 2.6 million AIDS orphans in Nigeria alone in 2000—higher even than in South Africa—and the problem will get much worse.  AIDS orphans often are taken in by relatives during the early stages of the disease, but the phenomenon in other African countries suggests that Nigeria and Ethiopia are likely to reach a point before the end of the decade when the number of caregivers is insufficient to cope with the burden.

Russia:  HIV/AIDS Worsening Demographic Situation

The rising AIDS problem in Russia is likely to exacerbate the significant social, economic, health, and military problems already facing the country.  These challenges, added together, will complicate Moscow’s efforts to rebuild Russia.

·        HIV/AIDS will accelerate Russia’s population decline.  A contracting work force and exploding healthcare costs will be serious counterweights to energy-driven economic growth.

·        A recent World Bank study projects that HIV/AIDS could cut annual economic growth in Russia by half a percentage point by 2010 and a full percentage point by 2020.

As the disease spreads, the high cost of treatment and education programs could drive out other claims on health systems, leading to a steeper decline in general health than caused by HIV/AIDS alone.  Even if more resources are committed to combat HIV/AIDS—either by Russia or outsiders—considerable time and money would be required to expand and reform the healthcare infrastructure, suggesting that the disease will continue to spread at a rapid pace.

·        These economic problems are likely to fuel social and political tensions over spending priorities.  Devoting more money to combating HIV/AIDS probably would just leave that much less for such other pressing health problems such as heart disease and TB.

India and China:  A Big Problem but Probably not Devastating

India and China are likely to generate the largest number of people infected with AIDS of any countries in the world by 2010, but the impact will be lessened because these individuals will remain diffused among very large populations.  Even if the number of infected people rises to the upper side of our projections, the percentage of the adult population that is infected still would be significantly lower than in the other next-wave countries at the end of the decade. 

·        Fifteen million HIV-positive people in China would represent roughly 2 percent of the adult population.

·        Twenty-five million infected Indians would reflect a 4 percent adult prevalence rate.

Judging the broader impact on economic growth and productivity is more difficult, however, because it depends largely on which demographic groups get hit the hardest.  Several researchers in 1999 estimated that AIDS cost India roughly 1 percent of GDP per year because of lost productivity and treatment of secondary infections.  The study did not include numerous factors—such as the cost of drugs and retraining workers—however, and there is no consensus on a formula to calculate the economic costs.[4]

·        At a minimum, AIDS will drive up healthcare costs in both countries, forcing difficult trade-offs on spending. 

·        The more the disease remains among rural and lower skilled people, the more likely that the abundant labor supply of both China and India can fill the gap. 

·        The more the disease spreads among young, educated, urban professionals, however, the higher the economic costs will be, given the premium on skilled
labor.

·        Chinese leaders are likely to fear that the perception in global markets of a rising AIDS problem could discourage the huge flow of foreign investment into the country that has been vital to growth.

We believe the HIV/AIDS epidemic, by itself, will not pose a fundamental threat through 2010 to the rise of China and India as major regional players.  Given the relatively low current prevalence rates and the relatively long period from infection to death, the two countries can manage the impact of the disease through the end of the decade.  Nonetheless, the mounting AIDS problem will further add to the complex problems and trade-offs facing leaders in both countries in the coming years.

·        Beyond 2010, HIV/AIDS will become an even more significant problem for China and India if government programs prove ineffective and prevalence rates jump significantly.

There is no sign that HIV/AIDS will become a lightning rod for widespread public discontent in either China or India.  Nonetheless, the protests of rural Chinese who became infected through plasma sales suggest that anger with the government’s slow response will add to growing frustration in rural areas over rising unemployment, widespread corruption, and poor services.

·        Press reports indicate that several small-scale AIDS-related protests have erupted in Chinese villages over the last year.  Journalists report that many villagers
are angry over the issue but are afraid to speak out because of government
intimidation.

·        For several days in November, police detained HIV-positive protesters and a group of reporters who came to interview them.

·        Protests by Chinese in urban areas almost certainly would spark deeper concern among Chinese authorities.

·        HIV/AIDS may become more of a political issue in India as infection rates climb.  The debate is likely to focus on who pays for and receives the antiretroviral drugs that Indian firms now are producing.

Both Beijing and New Delhi probably will try to push the rising cost of dealing with HIV/AIDS down to state and local governments, as they have on other issues.  Local authorities, however, are unlikely to have the staff, expertise, or funding to assume the growing burden.

·        Most Indian state governments already have curbed spending on healthcare and education to cope with severe fiscal strains—and some are even struggling just to pay the wages of government workers.

·        Likewise, Chinese localities already are overburdened with responsibilities for public health that Beijing has passed along in decentralizing many government duties.

HIV/AIDS is unlikely to undermine general military capabilities in China and India because of the large pool of potential recruits for the respective armies.  China began testing conscripts for HIV in 2001.

·        China and India increasingly will monitor AIDS in the military to ensure that the disease does not complicate staffing among smaller, more highly trained units operating sophisticated weapon systems.

As HIV/AIDS moves more into the general population in China, past experience in other countries suggests it will exacerbate an already existing gender imbalance because of the practice of female infanticide.

·        In India and China, because of cultural norms, boys are more likely to be taken care of by their relatives than girls.

International Implications

The surge in the disease outside southern Africa will fuel calls for more support from donor countries to address the problem and intensify the debate over how to allocate such international resources as the Global Fund for AIDS, TB, and Malaria.

·        UN Secretary General Annan set a goal of raising international spending on AIDS to $7-10 billion a year when he proposed the Global Fund last year.  Based on rising projections for the next-wave countries, pressure will grow to significantly raise that amount.

·        A debate is likely over how much the Global Fund should focus on heading off AIDS in large, next-wave countries where it is in the earlier stages, and how much to devote to the hardest hit countries in southern Africa.  Similarly, differences are likely to arise between those wanting to allocate money to programs on the basis of proven success or greatest need. 

·        Should resources be shifted away from central and southern Africa, Africans there probably will accuse the West of ignoring them and paying more attention to large countries that are more economically and strategically important.

The rising focus on HIV/AIDS worldwide has the potential to draw international attention and funding away from other infectious diseases such as TB, malaria, hepatitis, as well as other critical non-infectious health problems.

International tensions over medical treatment for HIV/AIDS almost certainly will grow, even though access to antiretrovirals will
increase.

·        The manufacture of generic antiretroviral drugs by several next-wave countries will increase pressure on international pharmaceutical companies to further lower the price and increase availability of their drugs.  European countries have stated their support for countries buying AIDS drugs from companies in India and Brazil that challenge patents.

·        The increasing use of antiretrovirals in next-wave countries, however, almost certainly will increase misuse due to their weak healthcare systems, undermining their effectiveness and fueling resistant HIV strains throughout the world.  If the effectiveness of antiretrovirals declines, recipient countries are likely to charge donors with supplying faulty drugs.

·        Developed countries will face overwhelming pressure to provide any new vaccines that are discovered to countries around the world.  These countries will complain bitterly if the early vaccines are not designed for the HIV subtypes common in their regions or blame the donors for their limited effectiveness.  

Despite these likely frictions, however, the rising AIDS crisis probably will make the next-wave countries more open to seeking technical assistance from the United States and other donor countries to help track, prevent, and treat the disease.

Sections: 1 2 3 4

These estimates reflect the expected number of HIV and AIDS cases at that time—not a cumulative total of all cases over the entire period.

 Although the lethal human immunodeficiency virus (HIV-1) was not characterized until the early 1980s, blood samples from Sub-Saharan Africa in the 1950s and 1960s have been tested retrospectively and found to be HIV-positive.

 Prevalence refers to the total number of people infected as a percentage of the adult (ages 15 to 49) population.

Anand K Pandav, CS and Nath LM:  The Impact of HIV/AIDS on the National Economy of India.  Health Policy 47 (1999) pps 195-205.  The costs of antiretroviral therapy, retraining the work force, strengthening the healthcare system, R&D, communications and prevention of mother-to-child transmission were not included in this model.