Important note: Information in this article was accurate in June 2000. The state of the art may have changed since the publication date.
At the close of this past decade, an estimated 33.6 million men, women, and children worldwide were infected with the human immunodeficiency virus (HIV). This virus, unknown until 17 years ago, now dominates national and international affairs. The HIV/AIDS epidemic is now acknowledged to be a contributing factor to changing national economies, to population displacement, and most recently, to national and international security.
The following list highlights key findings from the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) as of December 1999.
32.4 million adults and 1.2 million children will be living with HIV by the end of 1999. While this is a modest increase in comparison with the global HIV totals published at the end of 1998, the WHO states that the true increase is larger due to improved surveillance. Infections in a few populous countries of Latin America and Asia were overestimated in 1998, hence the difference.
It is estimated that in 1999, approximately 5.6 million people became infected with HIV worldwide.
The highest death rate from HIV/AIDS to date, 2.6 million in 1999, is a higher global total than in any year since the beginning of the epidemic -- in spite of new antiretroviral therapies shown to extend survival, which are widely available in wealthier countries.
With the HIV positive population expanding rapidly, the annual number of AIDS deaths can be expected to increase for many years before peaking. If prevention programs managed to eliminate new infections, deaths among those already infected would continue mounting for some years.
HIV has had an unprecedented impact on an important population demographic: young, sexually active adults. Approximately one-half of all people who acquire HIV become infected before they turn 25 and typically die of one of the life-threatening opportunistic infections (OIs) associated with AIDS before they reach 35 years of age.
As a result of this age-associated epidemic, children are highly impacted. The WHO estimates that as of 1999, there was a cumulative total of 11.2 million AIDS orphans, defined as those having lost their mothers before reaching the age of 15. Many of these maternal orphans have also lost their fathers to AIDS.
In 1999, an estimated 570,000 children aged 14 or younger became infected with HIV. Over 90% were babies born to HIV positive women; these babies acquired the virus either at birth or through their mother's breast milk. Approximately 90% of these pediatric infections occurred in Sub-Saharan Africa.
The overwhelming majority of people with HIV -- some 95% of the global total -- live in the developing world. That proportion is set to grow even further as infection rates continue to rise in countries where poverty, poor public health systems, and limited resources for prevention and care fuel the spread of the virus.
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Twenty years into the HIV/AIDS epidemic, much is known about preventing HIV infection. Yet the epidemic continues and is in fact unrelenting in some places. Worldwide, surveillance and prevention responses vary as a result of many factors.
This article cannot provide a full description of all aspects of the epidemic in every country or the vast and diverse range of cultural, social, environmental, biological, and even political dynamics of this devastating epidemic. Instead, this article will provide a snapshot of some of that diversity and range by describing the epidemiology (i.e., frequency, distribution, and behavior) of HIV in a few representative regions and countries.
The HIV/AIDS epidemic is fraught with paradox and true drama: life-saving treatments bring hope as well as risk; countries that share borders have vastly different epidemics. HIV has changed the world and is still changing it.
The numbers of new AIDS cases and AIDS deaths are both falling significantly in countries that provide antiretroviral therapy for a majority of those diagnosed with HIV. However, there is no sign that new HIV infections are following the same downward course. On the contrary, extremely worrying recent evidence suggests that the advent of life-prolonging therapies may have led to complacency among some groups of people about the dangers of HIV, and that that complacency may be leading to rises in risky behavior.
For the past several years in San Francisco, for example, there have been decreases in the number of men who have sex with men (MSM) reporting consistent condom use, increases in the number of men reporting unprotected anal sex with multiple partners, and increases in rectal gonorrhea. Many of the men sampled in these studies reported that they did not know their partners' HIV status. Of particular concern is that the absolute number of HIV positive people is probably growing because of improved survival.
Theoretically, antiretroviral therapy could reduce a person's infectiousness, or the likelihood that an infected person might pass on the virus to a sexual partner. Evidence of this effect is not conclusive, but some new research has demonstrated reduced transmission in a study of serodiscordant heterosexual couples (i.e., those in which only one partner is HIV positive). On the other hand, even if a person's overall infectiousness is reduced by anti-HIV drugs, there is good evidence that viable virus (i.e., virus capable of reproducing) can be recovered from seminal fluid in men taking highly active antiretroviral therapy, or HAART.
Yet until further studies of HIV treatment and infectivity are done, it must be assumed that a higher level of HIV in the pool of potential sexual partners means a higher risk of transmission whenever unprotected sex occurs with a partner of unknown HIV status. More than ever, prevention leaders, community-based organizations, and public health officials must continue to pursue effective HIV prevention efforts in communities where HIV incidence (number of new infections) has declined and prevalence (infection levels) is stable or increasing.
Two countries in Latin America, Brazil and Argentina, provide antiretroviral treatment for all people in those countries infected with HIV.
Brazilian officials estimate that they spent approximately US$300 million in 1999 providing drugs for 75,000 people. Health officials there say that savings in episodes of hospitalization and medical care for HIV-infected persons justify the costs of purchasing and providing drugs that improve survival. Considerable savings also accrue from avoiding the indirect costs of illness.
The Brazilians maintain that without antiretroviral therapy, many more people with HIV would develop OIs associated with the immune impairment that accompanies disease progression. Brazilian health officials estimated that over a one-year period between 1997 and 1998, they averted approximately US$136 million in hospital admission and treatment costs alone for people with HIV. Argentina also provides antiretroviral therapy for those who are HIV positive. The result has been a decrease of over 40% in the rate of new AIDS cases reported each year, from a peak of 71.6 per million people in 1996 to 41.3 per million people just two years later.
HIV surveillance in Brazil includes data from antenatal (prenatal care) clinics, sex workers, and injection drug users (IDU). In 1988-1989, approximately 4% of women in antenatal clinics in the port city of Santos tested HIV positive. (Santos has been an epicenter of the HIV epidemic in Brazil, with infection rates spreading continuously, and geographically, outward.) In 1990, 1% of women in antenatal clinics tested positive in São Paulo. In other cities, including Pôrto Alegre and Rio de Janeiro, 3% of such women tested HIV positive in 1996.
HIV prevalence among sex workers is estimated to be highest in Santos, where 14% tested positive when they were last measured in 1991. In the mid-1990s, HIV prevalence among sex workers was 6% in the state of Minas Gerais and 11% in Rio de Janeiro.
The highest HIV prevalence in Brazil has been found in IDU. Fifty percent of IDU tested in two sites in Santos were HIV positive in 1989. Since 1990, one-third of all IDU in major urban areas tested positive. A recent study found HIV in 12% of jail inmates.
Data on HIV infection among MSM are limited; however, some estimate that up to 10% of MSM in major urban areas are infected. In 1995, 18% of males tested HIV positive at sexually transmitted disease (STD) clinics in Rio de Janeiro.
In Central America and the Caribbean island states, access to antiretroviral therapy is extremely limited. In Guatemala, an estimated 185 people have access to antiretroviral drugs, out of an estimated number of over 50,000 living with HIV and AIDS. In 1999, HIV infection was detected in 2% to 4% of pregnant women tested at antenatal clinics in urban areas. Overall, health expenditures are only US$64 per person per year in Guatemala. In Guyana, HIV was detected in 3.2% of blood donors -- a population generally thought to be at low risk. In contrast, surveillance among urban sex workers in Guyana in 1997 showed that 46% were infected.
The Caribbean basin has one of the most severe HIV/AIDS epidemics outside of Sub-Saharan Africa. This is particularly evident in Haiti. Approximately 6% of pregnant women in Haiti tested positive for the virus in 1996. Infection rates approaching 8% were found in some Haitian antenatal clinics in 1993. Currently, UNAIDS/WHO estimates that 40% of female sex workers in the capital, Port-au-Prince, are HIV positive. In the Dominican Republic, which makes up the rest of Hispaniola Island, prevalence rates for women in 1995 ranged from 1.2% to 4% in both major and nonmajor urban areas, suggesting a generalized heterosexual epidemic. In Santo Domingo, the capital and principal city, HIV infection rates among sex workers increased from 1% in 1986 to 11% in 1993. In 1994 and 1995, 5% to 6% of sex workers tested were HIV positive.
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One of the most dramatic increases in HIV detection in 1999 was recorded in the newly independent states of the former Soviet Union, where the proportion of the population living with HIV doubled between the end of 1997 and the end of 1999. Nearly one-half of all cases of HIV infection reported in that region since the start of the epidemic were reported in the first nine months of 1999 alone. UNAIDS/WHO estimates that the number of infected people rose by a third over the course of 1999, reaching a total of 360,000 in the region comprising the former USSR as well as the remainder of Central and Eastern Europe. The bulk of new HIV infections were caused by unsafe injection drug use, and they occurred primarily in two countries, the Russian Federation and the Ukraine.
HIV has recently been introduced into networks of injection drug users in Russian cities where previously the virus was almost unknown. This is true of smaller provincial cities as well as of large metropolitan areas.
Since injecting drugs is illegal in these areas, it is very difficult to estimate the size of the drug-injecting population, let alone the extent to which they are linked in sexual networks with noninjectors. By the end of 1996 in Poland, 4,374 HIV infections had been reported (67% of them being in IDU, 7% in homosexual men, and 21% in other or unknown groups). Most of the infections have been seen in Warsaw, the Gdansk region, and Katowice in the south. Prevalence among IDU in Warsaw is estimated to be anywhere between 15% and 50%. Surveillance is not systematic, thus the uncertainty in the range.
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In contrast, HIV prevention has been very successful in Western Europe. In the Netherlands, for instance, the HIV incidence has dramatically declined among MSM. Acohort study of 770 initially seronegative homosexual men showed a decrease in incidence from 7.2 per 100 person-years in 1985 to 1 per 100 person-years in 1995. (The number of persons multiplied by the number of years equals person-years; e.g., one person followed for ten years equals ten person-years and ten persons followed for one year also equals ten person-years.) Research among IDU has also shown decreases in HIV incidence: from 8.9 per 100 person-years in 1986 to 2 to 3.6 per 100 person-years between 1991 and 1995. Prevalence of HIV among women at antenatal clinics has remained low (0.2%-0.4%), and no significant changes have been observed at STD clinics or among female sex workers (around 2%).
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With a population of nearly 3.5 billion, representing almost 60% of the world's people, the Asia/Pacific region has the potential to greatly impact the direction of the global HIV/AIDS pandemic.
This region -- stretching from and including Pakistan in the west, to Japan and other island nations in the Pacific, and from China in the north to the countries forming Oceania in the south -- has diverse, localized, and varying HIV epidemics. HIV infections were first introduced by MSM into several countries and major cities of the region, including Australia, New Zealand, Singapore, and Hong Kong; this occurred in the early 1980s rather than the late 1970s, as in the U.S. and Western Europe.
While the epidemic among MSM in these areas of south Asia and Oceania peaked in the mid- to late 1980s, the same apparently has not yet occurred in this population in other Asian countries. Epidemiologic data are very difficult to obtain, since many MSM in these regions do not identify themselves as being MSM, and thus remain "hidden." Across this area as a whole, UNAIDS/WHO estimates that over 7 million adults and children were living with HIV at the end of 1999, over five times as many as have already died of AIDS in the region.
HIV spread quickly through IDU populations in many Asian/Pacific countries. In Bangkok, Thailand, in late 1987, 1% of IDU were HIV positive. By the end of 1988, that rate had increased to 30%. Since 1988, HIV prevalence among IDU who have been tested has remained between 20% and 45% both in and outside of Bangkok.
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Similarly, HIV prevalence among IDU in other Asian countries, such as Myanmar, Malaysia, (northeastern) India, and Vietnam is estimated to range from 30% to 90%. The response to drug injection-related HIV epidemics has traditionally been inadequate. Most countries depend on prevention efforts that emphasize criminalization and abstinence. Health and HIV prevention officials in Australia, by contrast, have been successful in preventing a major epidemic of HIV among IDU. HIV prevalence there remains below 5%, which is largely attributable to widespread harm reduction efforts such as needle exchange and peer and community efforts.
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Since HIV came later to Asia in general, the region has had the opportunity to learn from the experience of other countries. It seems that some lessons are indeed translating into successful prevention efforts, although prevention failures can also be found. In Thailand, condom use programs have been very successful. Significant reductions in HIV infection have been noted among women at antenatal clinics and among female sex workers, and it is believed that the epidemic is stabilizing in the heterosexual population. For instance, in women under 25 experiencing their first pregnancy, HIV prevalence fell by 40% over a three-year period (1994-1997). HIV prevalence and risk behaviors have all declined among 21-year-old male military personnel, a population believed to be fairly representative of the younger male population in Thailand.
Thailand's neighbor, Cambodia, however, has seen HIV spread rapidly since the early 1990s. In 1992, HIV prevalence among sex workers was 10%, and reached 40% by 1996. Currently, it is estimated that up to 50% of sex workers are infected. Surveillance activities in Cambodia show that up to 10% to 15% of military personnel and policemen are infected, and in Phnom Penh, the capital, 3% of women at antenatal clinics are positive. The evolution of the epidemic in this country illustrates the potential for HIV to spread fast and widely when patterns of commercial sex involve high mobility, a high sexual partner exchange rate, and low condom use. Recently, Cambodia has been trying to learn from Thailand's success by officially endorsing a 100% Condom Use program countrywide.
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The huge populations of India and China inevitably dominate any assessment of HIV in Asia. Because these countries have so many inhabitants, small percentage changes in estimates of national infection rates result in large changes in the estimates of the total number of people infected.
India is home to more people than the African continent as a whole, and many Indian states have larger populations than most countries in the world. A rise of just 0.1% prevalence among adults in India could add over half a million people to the national total of adults living with HIV. The National AIDS Control Organization (NACO) in India has undertaken major efforts to improve the HIV surveillance system. Sentinel sites are now located all over the country in both rural and urban areas. Targeted surveillance groups include childbearing women, IDU, sex workers, and people treated for STDs. Most recent calculations have estimated that 3.5 million people in India were infected with HIV as of mid-1998, with overall prevalence among adults ranging from 1% to 5%, and the epidemic appears to be increasing rapidly.
In China, HIV infections have been detected among female sex workers, people being treated at STD clinics, and IDU. Current estimates developed by the Chinese government and others range between 300,000 to 500,000 as of the end of 1998. The forecast is unclear in this country with a population of over one billion in which most new infections are concentrated in injection drug users.
The HIV/AIDS pandemic in Africa continues to thrive relentlessly despite efforts being made throughout Africa to minimize its spread and reduce its impact on individuals, families, communities, and nations. At the start of the 21st century, some 23.3 million Africans, mostly from south of the Sahara, are estimated by UNAIDS/WHO to have HIV infection or AIDS. This figure represents almost 70% of the world's total cases in a region that is home to only 10% of the world's population. This enormous number of infections has at least doubled since the end of 1994, when UNAIDS/WHO had estimated that 11 million adults were living with HIV and AIDS in Africa.
The AIDS cases reported to the WHO by African countries represent only a fraction of the cases that have actually occurred. Multiple reasons contribute to the problem of underreporting HIV/AIDS statistics in Africa, including economic realities (such as lack of infrastructure) and entrenched social stigma attached to HIV/AIDS. Nevertheless, the over 23 million estimated infections are taking an enormous toll on the health of entire nations and on their social and economic well-being. The number of people who have died from AIDS thus far in Africa represents less than one-third of the deaths expected to occur among people who are currently infected with HIV. The major impact of the pandemic on the African population is yet to come.
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Sub-Saharan Africa is the area of the world most seriously affected by HIV and AIDS. Infection levels there are highest, access to care is lowest, and social and economic safety nets that might help families cope with the impact of the epidemic are badly frayed, in part because of the epidemic itself. However, Africa is not uniformly affected by HIV/AIDS -- it is a mosaic of epidemics progressing with varied intensity and velocity. For example, in antenatal clinics of several cities in southern Africa, up to 45% of women tested during pregnancy carry HIV, a rate ten or more times greater than in pregnant women seen at urban antenatal clinics in most countries in central or western Africa. Heterosexual contacts and perinatal (mother-to-infant) transmission of HIV account for the vast majority of HIV infections in Sub-Saharan Africa, and ongoing prevention programs must expand their reach to curb the spread of HIV through these routes. The information required to monitor these trends and the impact of prevention programs remain incomplete. For example, while data exist on the proportion of 15- to 19-year-old women who visit antenatal clinics in Sub-Saharan Africa who are infected with HIV, little is known about the levels of infection in girls younger than 15.
Although major success has been achieved elsewhere in preventing mother-to-child transmission, Africa remains burdened by the highest rates of pediatric (child-related) infection in the world. UNAIDS/WHO estimates that nearly 90% of the one-half million children born with HIV or infected through breastfeeding in 1999 were living in Sub-Saharan Africa.
Fifteen new, unlinked surveillance studies conducted in various African countries from the general population and from pregnant women at antenatal clinics suggest that in many African countries, antenatal estimates tend to underestimate the real levels of HIV infection in women. The reason is that infected women become progressively less fertile: the longer their HIV infection progresses, the less likely they are to get pregnant. And because many HIV-infected women are no longer becoming pregnant, they are not visiting antenatal clinics where blood samples for anonymous HIV testing are taken. At the same time, these studies suggest that infection levels in men are lower than the levels of HIV recorded among pregnant women. On average, however, these recent studies conducted in both rural and urban areas in nine different African countries indicate that between 12 and 13 African women are infected for every 10 African men.
Why more women than men are infected is likely due to a complex array of biological, behavioral, and social factors. For instance, HIV passes more easily from men to women through sex than from women to men. Age, however, remains the biggest factor. The rates of newly acquired HIV infections are highest in the 15-29 age group among both females and males, but the peak of new infections occurs five to ten years earlier in young women than in young men. Most of the infections in 15- to 19-year-olds are in females. In Masaka, Uganda, for example, HIV prevalence in 13- to 19-year-old females is over 20 times higher than in males of the same age. Apart from possible biological factors, there are at least two reasons for the disproportionate risk of young women acquiring HIV infection early: (1) an earlier age of sexual debut for girls (in Masaka, the median age at first sexual intercourse is 15 for females and 17 for males), and (2) the patterns of sexual mixing -- young women tend to have sex with older men in the context of marriage or in exchange for money or advantages, whereas young men tend to have sex with young women. For many women, the major risk factor for HIV is the behavior of their spouses or regular sexual partners. Women who believe themselves to be in monogamous relationships cannot protect themselves against HIV infection if their spouses are not similarly monogamous. This highlights the need for enhancing prevention programs targeted at adult men and for developing effective and safe female-controlled HIV prevention methods such as microbicides.
Explosive increases in new infections, as measured in rapidly rising levels of infection over a short period of time, appear to be a predictable pattern of HIV spread for many areas in Sub-Saharan Africa. The epidemiological situation in Zimbabwe, for instance, has had a pattern of spread that is now being seen in other countries, such as Botswana, Lesotho, South Africa, and Swaziland. HIV surveillance in Zimbabwe, conducted since 1989, has shown that prevalence of HIV among women at antenatal clinics has increased from 10% in 1989 to 31% in 1995 in major urban areas (Harare and Bulawayo), and from 15% in 1990 to 47% in 1996 outside major urban areas. In Harare, 26% of women under age 20 who visited antenatal clinics tested HIV positive. One study measured HIV prevalence among sex workers between 1994 and 1995 -- 86% tested HIV positive. In the same period (1994-95), 71% of males treated at STD clinics in Harare tested HIV positive. In STD clinics outside of Harare, HIV prevalence among males has increased from 7% in 1987 to 70% in 1994.
There is hope, however, that this trend can be reversed. Evidence that the number of new infections may have decreased comes from studies of the epidemic in Uganda, a country with one of the oldest HIV/AIDS epidemics in Africa. A study of recent trends in HIV infection in women at several Ugandan antenatal clinics reveals significant declines in HIV prevalence. In antenatal clinics in Kampala, HIV prevalence increased from 11% in 1985 to 31% in 1990. Beginning in 1993, HIV prevalence at antenatal clinics began to decline, reaching 14.7% in 1997. Analyses of HIV infection levels by age over time found consistent and significant declines in levels of infection among younger age groups as well. In 1992, 38% of HIV infections detected were among women under age 20, and in 1996, 7% of HIV infections were in the same age group. Similar age trends have been seen outside of the major urban area of Kampala. Since infection levels in this young age group reflect more recent patterns in new infections, these data suggest a substantial reduction in the incidence of HIV infection in young people over time. Surveillance among males treated at STD clinics also indicates a declining epidemic. In 1989, 42% of such males tested in Kampala were HIV positive, compared with 46% in 1992 and 34% in 1995.
Government-sponsored prevention campaigns may be responsible for these declines. This type of stabilization in HIV prevalence can also occur as a natural result of a dynamic balance between new infections and deaths occurring in people already infected. An
underlying high incidence of HIV infection in younger age groups may therefore be masked by high numbers of deaths removing people who have died of AIDS. Yet to conclude from stabilizing or even declining prevalence rates either that the epidemic will wane by itself in the absence of prevention, or that prevention efforts are no longer necessary, would have tragic consequences for future generations, especially given the overall pandemic in Africa.
One of the major indicators of the impact of the HIV/AIDS pandemic on Africa is the dramatic decline in life expectancy. According to the 1999 Human Development Index, a ranking published by the United Nations Development Programme (UNDP) to reflect health, wealth, and education, many African nations now show significant downward trends in these rankings. According to the WHO, almost all of the major downward changes could be ascribed to declining life expectancy -- the direct result of AIDS. Increasingly, data from surveillance systems and studies throughout Sub-Saharan Africa demonstrate that the HIV/AIDS epidemics are taking an increasing toll on young people, especially young women. The HIV/AIDS epidemics in Africa have become the epidemics of the young.
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The enormous rise in deaths among young, economically active adults will have a major impact on economic growth in Africa. What does this mean, though, in an area of the world where many nations already have poor economic management, high inflation, rampant corruption, and deteriorating infrastructure, as well as widespread military conflicts and population displacement? Where resources for education and health, not to mention antiretroviral therapies, are severely limited? The HIV/AIDS pandemic in Africa will continue to impact negatively the already precarious situation faced by many of these developing countries.
Questions such as those raised in the preceding section apply to regions of the world beyond Africa. Additionally, many issues beyond the scope of this article -- including orphans, the sex trade, mobile populations, and care of the ill and dying -- are profoundly entwined with the HIV epidemic worldwide and merit mention.
The number of orphans resulting from AIDS mortality is large and expected to increase rapidly in the near future. The current estimate of over 11 million orphans, most of whom are in Africa, may well be an underestimate, and it will certainly increase in the future. Regarding the sex trade, it has long been known that sex workers are particularly at risk of HIV infection. However, trafficking and sexual indenturing of young women in many parts of Asia, Eastern Europe, and elsewhere is increasingly gaining international notice. Mobile populations, which include all those who cross borders and move within a country, such as workers (farm workers, truck drivers, fishermen), traders, and refugees, are believed to have significantly contributed to the sexual spread of HIV throughout Sub-Saharan Africa. Finally, in Africa and other developing regions of the world, one of the most profound challenges of the spreading HIV/AIDS pandemic is how to care for the millions of people infected with and affected by the virus.
All of these issues and many more must be faced in the decade ahead. In order to find solutions, political, business, social, and scientific communities worldwide will have to develop an integrated and cooperative approach.
Kimberly Page-Shafer, PhD, MPH, is Assistant Adjunct Professor of Medicine at the Center for AIDS Prevention Studies of the University of California, San Francisco.
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