Important note: Information in this article was accurate in January 2001. The state of the art may have changed since the publication date.
Two decades ago clinicians in New York City, San Francisco, and Los Angeles recognized a new immunodeficiency syndrome among men who have sex with men (MSM). Initially, the illness was called GRIDS for Gay-Related Immunodeficiency Syndrome. However, it soon became apparent that this disease was not confined to one segment of the population, but had silently disseminated through other high-risk populations, including injection drug users (IDUs), hemophiliacs, blood transfusion recipients, and high-risk heterosexuals. By the end of 1981, several hundred cases had been identified, the disease was renamed AIDS, and the search was on for its cause. Three years later the human immunodeficiency virus (HIV) had been discovered, and diagnostic tests soon became available to identify those infected and to screen the blood supply. With great optimism, the Secretary of Health confidently announced at the time that this infection could soon be controlled, since we knew what caused it, we had the diagnostic tests to detect it, and we knew how it was transmitted. We only needed to convert this knowledge into action to prevent further spread of the disease. Little did we know that we were facing one of the worst pandemics of the twentieth century.
Fast forward 20 years to 2001, to assess the current epidemic. Nearly 60 million people have been infected with HIV, of whom an estimated 22 million have died, and 35 million people are living with HIV/AIDS (see table, p. 15). In 2000, an estimated 5.3 million people became newly infected with HIV, the majority of whom were under 25 years of age and living in developing countries. Last year 3 million people died as a result of AIDS, and in the 1990s over 13 million children were orphaned due to the premature death of their parents. The statistics are grim, but the impact on humanity is even worse. Those who are hardest hit by the epidemic are between the ages of 15 and 49, a time when people are in their most productive years of life. In the most affected countries, AIDS is single-handedly reversing the development gains of the last several decades. In southern Africa, life expectancy, which had risen steadily from the 1950s until the early 1990s, is being completely reversed as a result of AIDS. Life expectancy in sub-Saharan Africa is expected to drop from 59 years of age to 45 within the next five years. In some countries such as Zimbabwe and Botswana 15-year-old boys now face the prospect that one half to 70% of them could expect to die from AIDS (see figure, p. 5). The situation is just as bad for women: the likelihood of a 15-year-old girl dying before the end of her reproductive years quadrupled from 11% in the early 1980s to over 50% in 1999. This impact of AIDS has reverberated through every sector of the society, from health to agriculture, education, and the private sector, and is draining economies of the vital resources and the contributions of a whole generation.
Lifetime Risk of AIDS Death for 15-year-old Boys, Assuming Unchanged or Halved Risk of Becoming Infected with HIV, Selected Countries
The recent International AIDS Conference held in Durban, South Africa focused the world's attention on the region's staggering problem with HIV. Currently, 25 million people are living with HIV/AIDS in Africa, and last year alone four million people became infected, with an equal number of fatalities. There are now 16 countries in which more than 10% of the adult population aged 15 to 49 is infected with HIV. In seven countries in the southern cone of the continent at least one adult in five is living with HIV. In Botswana, a shocking 36% of adults are now infected with HIV, while in South Africa, 20% are infected. With a total of 4.2 million infected people, South Africa has the largest number of people living with HIV/AIDS in the world. For all of sub-Saharan Africa, HIV/AIDS is the leading cause of disability-adjusted life-years lost; it is responsible for twice as many years lost as any other cause. HIV is now deadlier in sub-Saharan Africa than war itself: In 1998, 200,000 Africans died in war, but more than 2 million died of AIDS. Because of its widely destabilizing effect, superimposed on an already fragile and complex geopolitical system, AIDS became the key issue for human security in sub-Saharan Africa. On January 10, 2000, at the beginning of this millennium, AIDS in Africa was chosen as the theme for the United Nations Security Council, the first time that body had dealt with a developmental issue pertaining to an infectious disease.
The following statement of James D. Wolfensen, President of the World Bank, in his address to the Security Council, is particularly poignant and bears repeating: Mr. President, I come here today because AIDS in Africa is not only claiming lives, it is changing the very nature of development. As one farmer in South Africa put it: 'Today, we are spending more time turning the bodies of the sick than we are turning the soil.' Over the last four decades in Africa, we have seen life expectancy increase by 24 years . . . we have seen the growth of a new generation of African leaders, greater voice for the people and more democratic regimes. But today Africa is in a crisis of a type never seen before. Nothing will put Africa back more quickly, reverse the gains, and throw countries into turmoil than the current AIDS epidemic. In too many countries the gains of life expectancy won are being wiped out. In too many countries more teachers are dying each week than can be trained. Judges, government officials, military personnel, women, and girls and the young are being ravaged with enormous economic reversals of development gains.
Nothing we have seen is a greater challenge to the peace and stability of African societies than the epidemic of AIDS. In AIDS we face a war more debilitating than war itself, because in so many countries it is seldom spoken of, because it does not catch the headlines, because the voices of its victims do not reach the corridors of power. We face a major development crisis, and more than that, a security crisis. For without economic and social hope, we shall not have peace and AIDS surely undermines both. However, there are some glimmers of hope. Uganda was the first government in Africa to recognize the danger of HIV to national development. The government took active steps to fight its spread through action by the government and other groups, including religious leaders and community development organizations. This broad-based approach to the epidemic contributed to a reduction in HIV infection among young pregnant women living in towns and cities. Data from a large community-based study now show similar reduced infection rates in rural Uganda. Condom use is increasing among young people, but unfortunately these changes are limited and are taking place against a backdrop of very high prevalence that limits the overall effectiveness.
The introduction of nevirapine in Uganda and other African countries to prevent mother-to-infant transmission has the potential to dramatically slow the spread of HIV among newborn infants. Unfortunately, enormous obstacles still exist in terms of an inadequate clinical infrastructure, limited counseling and testing of all pregnant women, and little or no drug delivery programs.
Perhaps the greatest success story in limiting the spread of HIV belongs to Thailand. After several years of rising HIV prevalence rates among commercial sex workers and young men, the government of Thailand implemented an HIV educational program promoting 100% condom use that effectively slowed the spread of HIV and led to a dramatic decline in sexually transmitted diseases among young adults. This program still remains a shining light to other countries in Asia, where HIV continues to spread. Asia now represents the region with the second greatest numbers of HIV-infected individuals. China and India, which together account for 36% of the world's population, are witnessing rapid growth in HIV infections, with estimates of 5 to 6 million people living with HIV/AIDS. Other countries such as Indonesia, Cambodia, Myanmar, and Vietnam have also witnessed alarming increases in HIV infection.
In Eastern Europe the HIV epidemic continues to be concentrated heavily in IDUs. In Ukraine, the number of diagnosed HIV infections jumped from virtually zero before 1995 to 20,000 from 1996 onwards, with 80% of cases among IDUs. In the Russian Federation a new outbreak of HIV among IDUs in the Moscow region in 1999 resulted in the reporting of more than three times as many new cases in that year than in all previous years combined. Approximately 130,000 Russians are infected with HIV, but recent estimates project that this number will increase rapidly over the next few years. For eastern Europe and central Asia, the number of people living with HIV has almost doubled in one year from 400,000 to 700,000.
In Latin America the HIV epidemic is highly diverse. Originally an epidemic of MSMs, HIV is now spread predominantly through heterosexual contact, although high rates still occur among MSMs and IDUs. Likewise HIV is ravaging the populations of several Caribbean island states. Indeed, some have worse epidemics than any other country in the world outside of sub-Saharan Africa. In Haiti, over 5% of adults are living with HIV, and in the Bahamas the adult prevalence rate is over 4%. In the Dominican Republic and Trinidad and Tobago the rate exceeds 1%. As in Africa, the heterosexual epidemic in Latin America and the Caribbean is driven by the deadly combination of early sexual activity, lack of condom use, and frequent partner exchange by young people.
Back to the U.S., where this disease was first recognized, and where the number of AIDS cases has risen to over 750,000 cases with 430,000 deaths. Although the incidence of new infections peaked in the 1980s, approximately 40,000 new cases still occur each year in this country. The number of persons living with HIV in the U.S. was recently estimated to be 920,000.
While the majority of cumulative HIV infections has occurred among MSM and IDUs, persons in other risk categories account for a greater proportion of AIDS cases than in years past. For instance, heterosexual transmission of HIV has become the dominant cause of new infections among women who make up 25% of new AIDS cases and an even greater percent of new HIV infections. Racial and ethnic minorities represent an increased proportion of AIDS cases. Among people aged 20 to 25, the highest estimates of AIDS incidence occurred among black men (124 cases per 100,000) and black women (60 cases per 100,000) followed by Hispanic men (56 cases per 100,000). Several factors are thought to contribute to the disproportionate impact of HIV in communities of color. The relative importance of these factors is not entirely understood. Race itself is not a risk factor for HIV. Race may be considered a marker for socioeconomic factors, but racial disparities remain, even after considering socioeconomic status. Other factors probably include high rates of STDs that facilitate transmission of HIV and higher rates of sexual risk behaviors, such as lower rates of condom use and higher rates of partner change.
More than any other single development, the advances in HIV/AIDS therapeutics have caused a decrease in both AIDS incidence and death in the U.S. and Europe. With the introduction of protease inhibitors, antiretroviral treatment has resulted in an extraordinary increase in quality of life and life expectancy among HIV-infected individuals. From 1996 to 1999, the number of deaths from AIDS has decreased by more than 40%. Interestingly, much of the benefit of the new therapy in reductions in AIDS mortality may have been fully realized. While AIDS mortality was decreasing by an average of 40% each year, within the last year mortality declined by only 20%. In addition, since the advent of more aggressive treatment regimens, side effect profiles have expanded. Complacency regarding risk of transmission has also increased with subsequent increases in high-risk activity among MSM. As a consequence anorectal gonorrhea among MSM has more than doubled in five cities, and in Seattle, syphilis has increased dramatically in MSM, particularly in HIV-positive MSM. These increases in STDs have lead to an increase in HIV incidence in MSM reminding us of the early phases of the epidemic in this country. Aggressive educational campaigns on safer sex practices are once again urgently needed to prevent a repeat of our past experiences.
As we begin this new millennium and enter into the beginning of the third decade of AIDS, it is evident that the small epidemic recognized among a handful of homosexual men in 1981 is quite different from the global pandemic of today. For developed countries, current antiretroviral regimens are allowing HIV-infected individuals to live longer, healthier lives. However, the use of these regimens may be associated with complacency and a relapse to unsafe sexual practices resulting in sustenance of the HIV epidemic. For developing countries the problem is far more complex. The infrastructure to support the use of antiretroviral drugs is not in place, the cost of the drugs is too high, and the vast majority of HIV-infected people do not even know they are infected. Education and condom distribution campaigns have had limited success, and consequently they will remain the primary avenues of prevention.
To meet the enormous challenges of controlling HIV we must support the development and worldwide distribution of inexpensive antiretroviral drugs, and promote the accelerated development and distribution of a safe and efficacious vaccine. There is no doubt that the clinical science of HIV research has made and will continue to make a dramatic difference in this epidemic. But the initial optimism that followed the discovery of HIV, the development of diagnostic assays, the prophylaxis of opportunistic infections, the identification of effective antiretroviral drugs, and the prevention of perinatal transmission, has been tempered by the stark reality and magnitude of global HIV pandemic. Much work needs to be done, and let us hope we can learn from our past.
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