The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and
China Part 1
The Next Wave of HIV/AIDS:
Nigeria, Ethiopia, Russia, India,
Prepared under the auspices of
David F. Gordon, formerly
National Intelligence Officer for
Economics and Global Issues.
Intelligence Community Assessment (ICA) highlights the rising
HIV/AIDS problem through 2010 in five countries of strategic
importance to the United States that have large populations at
risk for HIV infection: Nigeria, Ethiopia, Russia,
India, and China. The paper does not attempt to make
aggregate projections about global trends. The five
countries were selected
because they are:
the world’s most populous countries, together representing
over 40 percent of the world population.
the early-to-mid-stages of an HIV/AIDS epidemic.
by governments that have not yet given the issue the sustained
high priority that has been key to stemming the tide of the
disease in other countries.
paper builds on the December 1999 unclassified National
Intelligence Estimate, The Global Infectious Disease
Threat and Its Implications for the United States,
which focused on the spread of AIDS in the context of
other growing infectious diseases. Excerpts from the
1999 Estimate presage the expansion of the HIV/AIDS epidemic
beyond the geographic focal point of southern Africa:
infection and death rates for HIV/AIDS have slowed
considerably in developed countries…the pandemic continues
to spread in much of the developing world. Sub-Saharan
Africa currently has the biggest regional burden, but the
disease is spreading quickly in India, Russia, China, and much
of the rest of Asia.
to UNAIDS, Asia alone is likely to outstrip Sub-Saharan Africa
in the absolute number of HIV carriers by 2010.
National Intelligence Council (NIC) convened a conference of
US Government officials and outside experts to share their
current assessments and expectations for the future of the
disease in these five countries. Given the range of
estimates of the current numbers of infected people and the
lack of consensus on which infectious disease models calculate
future rates most accurately, the future projections in this
paper represent consensus estimates by experts. The NIC,
in addition to coordinating the draft within the Intelligence
Community, had the paper reviewed by several leading experts
from outside the Intelligence Community as part of its effort
to seek out expertise from inside and outside the government.
The experts included Dr. Anthony Fauci, Director of the
National Institute of Allergy and Infectious Diseases at the
National Institutes of Health; Dr. Robert C. Gallo, Director
of the Institute of Human Virology and Professor of Medicine
at the University of Maryland Biotechnology Institute; Dr.
Phillip Nieburg, Associate Director for Public Health Practice
in the Global AIDS Program for the Centers for Disease
Control; and Dr. Nicholas Eberstadt of the American
Scope of the Next Wave
and Ethiopia: Hardest Hit
HIV/AIDS Worsening Demographic Situation
and China: A Big Problem But Probably Not
Next Wave of HIV/AIDS:
Ethiopia, Russia, India, and China
number of people with HIV/AIDS will grow significantly by the
end of the decade. The increase will be driven by the
spread of the disease in five populous countries—Nigeria,
Ethiopia, Russia, India, and China—where the number of
infected people will grow from around 14 to 23 million
currently to an estimated 50 to 75 million by 2010.
This estimate eclipses the projected 30 to 35 million cases by
the end of the decade in central and southern Africa, the
current focal point of the pandemic.
project China will have 10 to 15 million HIV/AIDS cases, and
India is likely to have 20 to 25 million by 2010—the highest
estimate for any country. By 2010, we project Nigeria
will have 10 to 15 million cases, Ethiopia 7 to 10 million,
and Russia 5 to 8 million.
is spreading at different rates in the five countries, with
the epidemic the most advanced in Nigeria and Ethiopia.
In all countries, however, risky sexual behaviors are driving
infection rates upward at a precipitous rate.
prevalence rates—the total number of people infected as a
percentage of the adult population—are substantially lower
in Russia, India, and China, where the disease remains
concentrated in high-risk groups, such as intravenous drug
users in Russia and people selling blood plasma in China,
where some villages have reported 60 percent infection rates.
the disease is spreading to wider circles through heterosexual
transmission in India, the movement of infected migrant
workers in China, and frequent prison amnesty releases of
large numbers of infected prison inmates and rising
prostitution in Russia.
will be difficult for any of the five countries to check their
epidemics by 2010 without dramatic shifts in priorities.
The disease has built up significant momentum, health services
are inadequate, and the cost of education and treatment
programs will be overwhelming. Government leaders will
have trouble maintaining a priority on HIV/AIDS—which has
been key to stemming the disease in Uganda, Thailand, and
Brazil—because of other pressing issues and the lack of AIDS
governments of Nigeria, India, and China are beginning to
focus more attention on the HIV/AIDS threat.
if the five next-wave countries devote more resources to
HIV/AIDS programs, implementation is likely to miss
significant portions of the population, given weak or limited
government institutions and uneven coordination between local
and national levels.
and Ethiopia have very limited public services to mobilize.
Russia is beset by other major public health problems.
China has decentralized most responsibility for health and
education issues to local governments that often are corrupt.
has taken some steps to improve its healthcare infrastructure
to combat HIV/AIDS, but the government has few resources to
treat existing infections and must cope with other major
health problems such as tuberculosis (TB), which has become
linked to the spread of HIV/AIDS.
rise of HIV/AIDS in the next-wave countries is likely to have
significant economic, social, political, and military
implications. The impact will vary substantially among
the five countries, however, because of differences among them
in the development of the disease, likely government
responses, available resources, and demographic profiles.
and Ethiopia will be the hardest hit, with the social and
economic impact similar to that in the hardest hit countries
in southern and central Africa—decimating key government and
business elites, undermining growth, and discouraging foreign
investment. Both countries are key to regional
stability, and the rise in HIV/AIDS will strain their
Russia, the rise in HIV/AIDS will exacerbate the population
decline and severe health problems already plaguing the
country, creating even greater difficulty for Russia to
rebound economically. These trends may spark tensions
over spending priorities and sharpen military manpower
will drive up social and healthcare costs in India and China,
but the broader economic and political impact is likely to be
readily absorbed by the huge populations of these countries.
We do not believe the disease will pose a fundamental threat
through 2010 to their status as major regional players, but it
will add to the complex problems faced by their leaders.
The more HIV/AIDS spreads among young, educated, urban
populations, the greater the economic cost of the disease will
be for these countries, given the impact on, and the need for,
growing AIDS problem in the next-wave countries probably will
spark calls for more financial and technical support from
donor countries. It may lead to growing tensions over
how to disburse international funds, such as the Global Fund
for AIDS, TB and Malaria.
cost of antiretroviral drugs—which can prolong the lives of
infected people—has plunged in recent years but still may be
prohibitively high for populous, low-income countries.
More importantly, the drug costs are only a portion of
HIV/AIDS treatment costs. Drug-resistant strains are
likely to spread because of the inconsistent use of
antiretroviral therapies and the manufacture overseas of
unregulated, substandard drugs.
an effective vaccine is developed in the coming years, Western
governments and pharmaceutical companies will come under
intense pressure to make it widely available.
next-wave countries are likely to seek greater US technical
assistance in tracking and combating the disease.
Statistics: Official and Unofficial Estimates
statistics on HIV/AIDS are difficult or impossible to get for
many countries. UNAIDS maintains the most comprehensive
databases of information in the world on AIDS, but the UN
organization relies on official government statistics from
each country—which experts believe sometimes understate the
number of infected people. Our estimates of infection
rates and their likely trajectories go beyond the official
statistics by incorporating the assessments of academics and
NGOs with field experience. As a result, all of the
numbers in this assessment should be viewed as rough
estimates, and our projections employ ranges to convey the
general magnitude of the disease within a relatively high
margin of error.
often do not spend enough money to get quality infection
surveillance because they have other budget priorities, do not
want to acknowledge the extent of the epidemic, and the drug
users and prostitutes at high risk of infection are not key
hidden pockets of infection include TB patients—some of whom
have contracted TB because they are HIV positive—and
patients with venereal diseases and reproductive tract
is difficult to get data on HIV prevalence rates in foreign
military ranks, which harbor significant numbers of infected
if testing is available, many people do not get tested because
of denial, stigma, discrimination, or resignation.
drug users, prostitutes, and homosexuals usually are reluctant
to identify themselves for fear of punishment.
avoid testing when healthcare and treatment for the disease is
surveillance of women attending prenatal clinics is considered
the most reliable indicator of adult HIV prevalence in the
general population. But even these statistics can be
affected by poor clinic attendance when fee for services or
mandatory HIV testing is instituted.