Important note: Information in this article was accurate in September 2002. The state of the art may have changed since the publication date.
On the eve of the XIV International AIDS Conference in Barcelona, UNAIDS released its “Report on the Global HIV/AIDS Epidemic, 2002.” This is the most comprehensive and detailed report on the epidemic that has ever been released by either the World Health Organization or UNAIDS. The 226-page report, made available to every participant at the International AIDS Conference, is available on the web at http://www.unaids.org. This article will summarize some of the highlights from the UNAIDS report, which, according to Dr. Peter Piot, Executive Director of UNAIDS, “Provides positive proof that HIV, if left to run its natural course, will cause devastation on an unprecedented scale.”
The report illustrates the stark reality of the status of the global HIV pandemic with the following estimates:
According to Piot, “The scale of the AIDS crisis now outstrips even the worst case scenarios of a decade ago.” Without effective treatment and care, over the next decade millions more will join the ranks of the more than 20 million people who have died of AIDS since the first reported cases in 1981.
Sub-Saharan Africa
Africa remains by far the worst affected region in the world: 3.5 million new infections occurred in Africa in 2001, bringing to 28.5 million the total number of people living with HIV/AIDS in the region (Figure 1). In contrast to the developed world, where up to 30% of all infected people receive antiretroviral therapy, fewer than 30,000 people (0.1%) of the 28.5 million infected Africans were estimated to have received antiretroviral therapy (Figure 2). Of the 14 million children orphaned by AIDS worldwide, 11 million live in sub-Saharan Africa. The highest HIV prevalence rate worldwide for pregnant women stands at 44.9% in Botswana. In neighboring countries, HIV prevalence rates continue to rise among pregnant women: In Zimbabwe the rate rose from 29% in 1997 to 35% in 2000; in Namibia, it rose from 26% in 1998 to 30% in 2000. As startling as these prevalence levels are, they do not reflect the actual risk of acquiring HIV. For example, prevalence rates are higher among specific age groups. In Botswana, among 25 to 29-year-old women attending antenatal clinics in urban areas, 55.6% of pregnant women (one out of two) were living with HIV/AIDS. In Swaziland, the corresponding prevalence was 33.9%, and in Zimbabwe, it was 40.1%. For South Africa, HIV prevalence rates may be now leveling off at 25%. One in nine South Africans (5 million people) is living with HIV/AIDS, an alarming statistic from a country that has been slow to respond to the epidemic. Increasing HIV prevalence is also being reported from West Africa. Nigeria, the most populous country in sub-Saharan Africa, has reported an increase in prevalence from 1.9% in 1993 to 5.8% in 2001 in the general population. Already more than 3 million Nigerians are estimated to be living with HIV/AIDS.
The report balances these harsh statistics with some good news from Uganda. Over the past eight years, seroprevalence has fallen from 29.5% to 11.2% among pregnant women in Kampala. Countrywide prevalence stands at 5%. However, despite efforts to expand treatment and care, the vast majority of Ugandans with HIV infection do not have access to antiretroviral therapy, and the Ugandan orphan crisis continues to strain the society’s resources. Nevertheless, the experience in Uganda underscores the fact that a rampant HIV/AIDS epidemic can be brought under control with intensive prevention programs. Similar reports from Cote d’Ivoire and Senegal help provide further evidence of successful prevention programs that need to be replicated in many other countries.
Asia and the Pacific
Despite the well-documented and successful HIV prevention programs in Thailand, the HIV/AIDS epidemic continues to spread rapidly in Asia and the Pacific. This region serves as a reminder that no country is immune to the HIV epidemic. Low national prevalence rates conceal serious localized epidemics in several areas, including China, Indonesia, and India, where large numbers of people are infected and affected, proof that the national HIV prevalence figures in highly populous countries do not tell the full story of the epidemic. Currently, it is estimated that 6.6 million people in Asia are living with HIV/AIDS and that one million adults and children became newly infected last year (Figure 1). Less than 30,000 (0.4%) people are on antiretroviral therapy (Figure 2). In China, while the initial HIV outbreak occurred among injecting drug users, with rates as high as 70% in Xinjiang and Yunnan Province, there are now signs of heterosexually transmitted HIV epidemics in at least three provinces. To compound the tragedy of the epidemic in China, recent reports in Henan Province in central China demonstrate that tens of thousands and possibly more rural villagers became infected by selling their blood to collecting centers that did not follow basic blood donation safety procedures. It has been estimated that 150,000 people have been infected through these practices. To further compound the epidemic in China, sexually transmitted infections have quadrupled in the last four years. Other neighboring countries are also witnessing the rapid expansion of HIV. India now estimates 4 million people living with HIV/AIDS, more than any other country after South Africa. Indonesia, the world’s fourth most populous country, demonstrated how suddenly the HIV/AIDS epidemic could emerge. After more than a decade of negligible HIV prevalence rates, the country is now seeing infection rates increase rapidly among injecting drug users and sex workers, with rates as high as 40% in drug treatment centers in Jakarta. In contrast, Thailand and to some degree Cambodia have imple-mented strong prevention programs that have slowed the course of the epidemic within these countries.
Eastern Europe and Central Asia
Eastern Europe is experiencing the fastest growing epidemic in the world (Figure 1). Within three to four years, the number of HIV infected people rapidly rose from less than 100,000 to over 1 million, a ten-fold increase. Unfortunately, fewer than 1,000 people (0.1%) are estimated to be receiving antiretroviral therapy (Figure 2). The Russian Federation remains at the forefront of the epidemic in this region. However, neighboring countries such as the Ukraine, Belarus, Moldova, Latvia, Estonia, and Kazakhstan, are following trends set by the Russian Federation for rapidly rising HIV rates (Figure 3). Currently, the Ukraine remains the most affected country in the region, with an estimated adult HIV prevalence rate of 1%. Three-quarters of the HIV infections in Ukraine are related to injecting drug use, but the proportion of sexually transmitted HIV infection is increasing. In China, the rates of other STDs, particularly syphilis, are increasing dramatically. The public health efforts to stem the tide of these epidemics are limited and in some cases nonexistent. In contrast to these countries, prevalence remains low in Poland, the Czech Republic, Hungary, and Slovenia, where well-designed national HIV/AIDS programs are in operation. If effective interventions are not implemented in the more severely affected countries, it is likely that the situation will become dramatically worse over the next five years.
Latin America and the Caribbean
An estimated 1.9 million adults and children are living with HIV in this region (Figure 1), and an estimated 170,000 (8-9%) people were receiving antiretroviral treatment (Figure 2). Brazil has led the way with a nationalized antiretroviral therapy campaign that provides drugs for all eligible HIV-infected individuals. Prevention programs among injecting drug users have also featured strongly in the country’s response, with a substantial decline in prevalence among IDUs in several large metropolitan areas. By reducing HIV/AIDS related morbidity through treatment, Brazil’s treatment and care program is estimated to have avoided 234,000 hospitalizations in 1996 to 2000, thereby demonstrating a cost-effective approach to care.
Unfortunately, such aggressive camp-aigns in treatment and care are still not in place in many poorer countries. In the Caribbean, adult HIV prevalence rates are the second highest in the world after sub-Saharan Africa. HIV/AIDS is the leading cause of death in some of these countries. Worst affected are Haiti, with a national prevalence rate over 6%, and the Bahamas with a prevalence of 4%.
High Income Countries
Western Europe, North America, and Australia have benefited from broad access to treatment for the nearly 1.5 million people living in these regions (Figure 1). For example, approximately 500,000 (33%) people are receiving antiretrovirals (Figure 2). As noted in the report, a major concern is the high rate of sexually transmitted infections among men who have sex with men (MSM), signaling a rise in unsafe sex and highlighting the need for renewed prevention efforts, especially among young people. In addition, heterosexual transmission of HIV now accounts for a bigger share of new infections with young, disadvantaged people appearing to be at particular risk. The rise in new HIV infections among MSM is particularly striking (Figure 4). Rising incidence of other STDs among MSM in Amsterdam, Sydney, London, San Francisco, Seattle, and Los Angeles confirms that widespread risk-taking is eclipsing the safer sex ethic promoted so effectively in the 1980s and 1990s.
Global Impact of AIDS
Other areas addressed in the report include the demographic, social, and economic impact of the HIV/AIDS epidemic. HIV/AIDS is now the leading cause of death in sub-Saharan Africa and the fourth largest global killer. Average life expectancy in sub-Saharan Africa is now 47 years, when it would have been 62 years without AIDS. Life expectancy at birth in Botswana has dropped to a level not seen in that country since the 1950s. Even in Haiti, life expectancy is nearly 6 years less than it would have been in the absence of AIDS. In Asia, Cambodia has also experienced a reduction in life expectancy of 4 years. Current HIV prevalence levels merely hint at the much greater lifetime probability of becoming infected with HIV. In Lesotho, it is estimated that a person who is 15 has a 74% chance of becoming infected with HIV by his or her fiftieth birthday.
According to a separate report from the U.S. Census Bureau, AIDS is expected to cause a decline in life expectancy in 51 countries over the next 20 years. Seven nations in sub-Saharan Africa now have life expectancies less than 40 years, and this number will increase to 11 countries over the next seven years. The declining life expectancies will soon reach levels that have not existed since the 19th century. In Zimbabwe and South Africa, the infant mortality rate is higher than it was in 1990. Five African nations will experience more deaths than births by 2010 with a resultant decrease in population size. The Bureau predicted that life expectancy will drop to just 27 years in Botswana and Mozambique in the next eight years, while Swaziland will have an estimated life expectancy of 33, and Zimbabwe, Zambia, and Namibia will have an expected lifespan of 34 years. In contrast, the Bureau estimated that without AIDS, the life expectancy in Africa would have been approximately 70 years by 2010.
Aside from the demographic impact, HIV is also having a dramatic impact on the health sector, the education sector, enterprises and workplaces, and on both micro- and macroeconomics. The report has much more detailed statistics that cannot be summarized here, but the reader is encouraged to review the report on the web.
Care, Treatment, and Support
This section of the UNAIDS report addresses the issues surrounding access to antiretroviral drugs, improvement of infra-structure in developing countries, and provision of medicines for opportunistic infections and tuberculosis. The report provides a balanced approach to both therapy and prevention by discussing the need for a continuum of care and support coupled with strong prevention programs. Unfortunately, financial resources are not available to meet this need. As of mid-2002, aggregate spending for HIV/AIDS was projected to approach $3 billion in low and middle-income countries, much of it underwritten by international assistance. By 2005, an estimated $9.2 billion will be required, three times greater than the current spending projections for this year. If expenditures on AIDS were to remain at current levels, the funding shortfall will be at least $7 billion. The Global Fund for AIDS, Tuberculosis, and Malaria was established to help address this shortfall in current funding. Unfortunately, total pledges to the fund stood at just under $2 billion in 2002, and only 60% of these funds are dedicated to support HIV/AIDS prevention and treatment programs. Consequently, other programs will be necessary to help address this shortfall in funding if the world is to support more comprehensive care and prevention programs. As stated in the report, “The evidence presented here could not be starker: Where care is most needed, it is least accessible.” The agenda for building the capacity to extend care to those who need it is presented, but the resources to support this agenda remain severely limited and in short supply. The report tries to balance the good with the bad, but it is clear that without a significant increase in financial resources, the epidemic will continue unabated and will continue to “cause devastation on an unprecedented scale.”
Just prior to the release of the UNAIDS report, the WHO and the International AIDS Society formally launched new international guidelines for public health response to treatment of AIDS in resource-poor settings. Lisa Spacek, M.D, has previously reported these guidelines in the Hopkins HIV Report [see HHR 2002;14(4):1 ]. The WHO believes that using appropriate resources, at least 3 million people needing care could be treated with antiretroviral therapy by 2005–a more than ten-fold increase in the developing world.
A Call to Action
In the opening ceremonies UNAIDS Director Dr. Peter Piot “openly challenged” political leaders to follow through on previous commitments by allocating the estimated $10 billion needed annually to fight HIV/AIDS on an international scale. Piot also advocated for treatment in developing nations saying, “Treatment is technically feasible in every part of the world. It is political will that is required.”
This plea for increased support was repeatedly echoed in the closing ceremony by two former presidents: Bill Clinton and Nelson Mandela, co-chairs of the International AIDS Trust. Both individuals called AIDS a threat to the world’s economic well-being and said it was the job of the rich nations to live up to their promise to contribute to the global fund. Mandela called HIV/AIDS a “war against humanity”that requires the mobilization of entire populations and stated that antiretroviral drugs need to be made available for all those who need them, wherever they may be in the world, regardless of whether they can afford them, and that it is the job of the rich nations to live up to this ideal.
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