When AIDS first emerged, no-one could have predicted how the epidemic would spread across the world and how many millions of lives it would change. There was no real idea what caused it and consequently no real idea how to protect against it.
Now we know from bitter experience that AIDS is caused by the virus HIV, and that it can devastate families, communities and whole continents. We have seen the epidemic knock decades off countries’ national development, widen the gulf between rich and poor nations and push already-stigmatized groups closer to the margins of society. We are living in an ‘international’ society, and HIV has become the first truly ‘international’ epidemic, easily crossing oceans and borders.
However, experience has also shown us that the right approaches, applied quickly enough with courage and resolve, can and do result in lower national HIV infection rates and less suffering for those affected by the epidemic. We have learned that if a country acts early enough, a national HIV crisis can be averted.
It has been noted that a country with a very high HIV prevalence rate will often see this rate eventually stabilise, and even decline. In some cases this indicates, among other things, that people are beginning to change risky behaviour patterns, because they have seen and known people who have been killed by AIDS. Fear is the worst and last way of changing people’s behaviour and by the time this happens it is usually too late to save a huge number of that country’s population.
Already, more than twenty-five million people around the world have died of AIDS-related diseases. In 2007, around 2.1 million men, women and children lost their lives. 33 million people around the world are now living with HIV, and most of these are likely to die over the next decade or so. The most recent UNAIDS/WHO estimates show that, in 2007 alone, 2.5 million people were newly infected with HIV.
It is disappointing that the global numbers of people infected with HIV continue to rise, despite the fact that effective prevention strategies already exist.
It is in Africa, in some of the poorest countries in the world, that the impact of the virus has been most severe. At the end of 2007, there were 9 countries in Africa where more than one tenth of the adult population aged 15-49 was infected with HIV. In three countries, all in the southern cone of the continent, at least one adult in five is living with the virus. In Botswana, a shocking 23.9% of adults are now infected with HIV, while in South Africa, 18.1% are infected. With a total of around 5.7 million infected, South Africa has more people living with HIV than any other country.
Rates of HIV infection are still extremely high in sub-Saharan Africa, and an estimated 1.7 million people in this region became newly infected in 2007. This means that there are now an estimated 22 million people living with HIV/AIDS. In this part of the world, particularly, women are disproportionately at risk. As the rate of HIV infection in the general population rises, the same patterns of sexual risk result in more new infections simply because the chances of encountering an infected partner become higher.
Whilst West Africa is relatively less affected by HIV infection, the prevalence rates in some large countries are creeping up. Côte d’Ivoire is already among the fourteen worst affected countries in the world, and in Nigeria over 3% of adults have HIV. In West Africa the epidemic displays a diversity not seen to such an extent in other parts of the continent. National prevalence rates can remain low, while infection rates in certain populations can be very high indeed.
Infection rates in East Africa, once the highest on the continent, hover above those in the West but have been exceeded by the rates now seen in the southern cone. In 2007, the HIV prevalence rate among adults in Kenya, Tanzania and Uganda exceeded 5%.
It is widely thought that North Africa managed to sidestep the global AIDS epidemic – perhaps due to its strict rules governing sexual behaviour. However, the latest UNAIDS estimates indicate that 35,000 people in North Africa and the Middle East acquired an HIV infection in 2007, bringing the total number of people living with HIV/AIDS in the Middle East and North Africa to an estimated 380,000. AIDS killed a further 27,000 people in 2007.
Increasing prevalence rates are not inevitable. In Uganda the estimated prevalence rate fell to around 5% from a peak of about 15% in the early 1990s. This trend is thought in part to have resulted from strong prevention campaigns, and there are encouraging signs of the same effect happening in parts of Zambia, Kenya and Zimbabwe. Yet the suffering generated by HIV infections acquired years ago continues to grow, and a drop in HIV prevalence is generally associated with a massive number of AIDS deaths. Just under a third of Africans in need of antiretroviral treatment were receiving it at the end of 2006.
The diversity of the AIDS epidemic is even greater in Asia than in Africa. The epidemic of AIDS in Asia appears to be of more recent origin, and many Asian countries lack accurate systems for monitoring the spread of HIV. Half of the world’s population lives in Asia, so even small differences in the infection rates can mean huge increases in the absolute number of people infected.
In 2007, there were 2.4 million people living with HIV in India. Other large epidemics are present in China (700,000), Thailand (610,000) and Myanmar (240,000). The total number of people living with HIV in Asia is thought to be around 5 million.
National adult prevalence is still under 1% in the majority of this region’s countries. However some of the countries in this region are very large and national averages may obscure serious epidemics in some smaller provinces and states. Although national adult HIV prevalence in India, for example, is below 1%, some states have an estimated prevalence well above this level.
In most Asian countries the epidemic is centred among particular high-risk groups, particularly men who have sex with men, injecting drug users, sex workers and their partners. However the epidemic has already begun to spread beyond these groups into the general population. Some Asian countries, such as Thailand, have responded rapidly to the epidemic with extensive campaigns to educate the public and prevent the spread of HIV – and have succeeded in cutting prevalence. Other very populous regions, such as China, have only recently admitted that the spread of HIV threatens their populations, and as a result their prevention work is lagging behind the spread of the virus. Unless rapid and effective action is taken in this part of the world, then the size of the epidemic to come will dwarf the many deaths that have already occurred.
The epidemic in Asia has ample room for growth. The sex trade and the use of illicit drugs are extensive, and so are migration and mobility within and across borders. The fluidity in international markets and especially the lack of economic stability in Asia has erupted into non-stop movement within countries and among countries, mirrored in the growing prevalence of HIV. India, China, Thailand and Cambodia, to name only a few, have highly mobile populations within their borders, with people moving from state to state and from rural to urban areas. In China, permanent and temporary migrants may total as many as 120 million people.
Eastern Europe & Central Asia
The AIDS epidemic in Eastern Europe & Central Asia is rapidly increasing. In 2007, some 1.5 million people were living with HIV, compared to 630,000 in 2001. AIDS claimed an estimated 58,000 lives during 2007, which is approximately seven times as many as in 2001.
In any country where rates of injecting drug use and needle sharing are high, a fresh outbreak of HIV is liable to occur at an
y time. This is especially true of the countries in Eastern Europe where the HIV epidemics are still young and have so far spared some cities and sub-populations. Heroin smuggled into the West crosses through a number of Eastern European countries, and its path is marked by a high concentration of injecting drug users, and a high HIV prevalence.
The Russian Federation, Ukraine, and the Baltic states (Estonia, Latvia, and Lithuania) are the worst affected, although HIV continues to spread in Belarus, Moldova and Kazakhstan, and more recent epidemics are emerging in Kyrgyzstan and Uzbekistan. An estimated 940,000 HIV-infected people were living in the Russian Federation at the end of 2007. However, as reporting of HIV cases in many areas of Russia is at best patchy, it is difficult to determine a precise figure. The epidemic in Eastern Europe is primarily driven by injecting drug use, and the criminalisation of this practice makes it difficult to gain an accurate picture of the proportion of drug users who are living with HIV.
HIV is ravaging the populations of several Caribbean island states. Indeed some have worse epidemics than any other country in the world outside sub-Saharan Africa. In the most affected countries of the Caribbean, the spread of HIV infection is driven by unprotected sex between men and women, although infections associated with injecting drug use are common in some places, such as Puerto Rico.
The Bahamas is the worst affected nation in the region, with a prevalence of 3%. Haiti, where the spread of HIV may well have been fuelled by decades of poor governance and conflict, is has also been hard hit by the AIDS epidemic. An estimated 2.2% of Haitian adults were living with HIV at the end of 2007, though rates vary considerably between regions. HIV transmission in Haiti is overwhelmingly heterosexual, and both infection and death are concentrated in young adults. Many tens of thousands of Haitian children have lost one or both of their parents to AIDS. Among pregnant women in urban areas, HIV prevalence appears to have fallen by half between the mid-1990s and 2003-2004. Probably much of this decline is due to an increase in the AIDS death rate, though behaviour change might also have played a part. There is still an urgent need for intensified prevention efforts in Haiti.
On the Caribbean coast of South America, Suriname and Guyana had adult HIV prevalence rates of 2.4% and 2.5% respectively at the end of 2007. There are only limited data on HIV in Guyana, but it appears the country has a rapidly growing epidemic, which is becoming established within the general population.
The heterosexual epidemics of HIV infection in the Caribbean are driven by the deadly combination of early sexual activity and frequent partner exchange by young people. A study published in 2005 found that in Trinidad and Tobago, HIV infection levels are six times higher among 15-19 year old females than among males of the same age. In another survey in Barbados, one quarter of 15-29 year old women said they had been sexually active by the age of 15, and almost one in three men aged 15-29 years reported multiple sexual partnerships in the previous year.
AIDS is now high on the agendas of many governments in this region, as they are beginning to notice the significant impact of the epidemic on their medical systems and labour force. Cuba’s comprehensive testing and prevention programmes have helped to keep its HIV infection rate below 0.2%, and the country provides free AIDS treatment to all those in need. In Barbados and Bermuda, wider access to antiretroviral treatment has cut AIDS deaths in half. Other countries are now seeking to emulate such successes.
Around 1.7 million people were living with HIV in Latin America at the end of 2007. During that year, around 63,000 people died of AIDS and an estimated 140,000 were newly infected. The HIV epidemics in Latin America are highly diverse, and are fuelled by varying combinations of unsafe sex (both between men, and between men and women) and injecting drug use. In nearly all countries, the highest rates of HIV infection are found among men who have sex with men, and the second highest rates are found among female sex workers.
The Central American nation of Belize has well-established epidemic, with adult HIV prevalence rate above 2%. The virus is mainly spread through unprotected sex, particularly commercial sex and sex between men.
Commercial sex and sex between men are the major drivers of smaller epidemics elsewhere in Central America, where national HIV prevalence rates vary between 0.2% and 1%. Men who become infected via these routes are likely to pass the virus on to their wives and girlfriends.
Brazil had an adult HIV prevalence rate of 0.6% at the end of 2007, but, because of its large overall population, this country accounts for nearly half of all people living with HIV in Latin America. In Brazil, heterosexual transmission, sex between men and injecting drug use account for roughly equal numbers of infections.
HIV in Argentina was initially seen as a disease of male injecting drug users and men who have sex with men. But now the virus is spread mostly through heterosexual intercourse, and is affecting a rising number of women. The other Andean countries are currently among those least affected by HIV infection, although risky behaviour has been recorded in many groups.
One of the defining features of the Latin American epidemic is that several populous countries, including Argentina, Brazil and Mexico, are attempting to provide antiretroviral therapy to all those who need it. The governments of these countries have invested and encouraged local pharmaceutical manufacturers to produce generic copies of expensive patented medicines. This allows them to distribute drugs to a much greater proportion of their population that they would otherwise be able to help.
Treatment coverage still varies widely, but these efforts are having a definite impact. While they are improving both the length and the quality of people’s lives, they are also increasing the proportion of people living with HIV, and thus HIV prevalence figures. Some concern has been voiced over the risk that HIV prevention activities may suffer if much effort and money is devoted to providing treatment.
In high-income nations, HIV infections have historically been concentrated principally among injecting drug users and gay men. These groups are still at high risk, but heterosexual intercourse accounts for a growing proportion of cases. In the United States, about one third of people diagnosed with HIV in 2005 were female, and more than three quarters of these women were probably infected as a result of heterosexual sex. In several countries in Western Europe, including the United Kingdom, heterosexual contact is the most frequent cause of newly diagnosed infections.
Very early in the epidemic, once information and services for prevention had been made available to most of the population, the level of unprotected sex fell in many countries and the demand rose for reproductive health services, HIV counselling and testing and other preventive services. However prevention activities are now lagging behind as the epidemics move beyond their traditional at-risk groups.
Prevention work in high-income countries has declined, and sexual-health education in schools is still not universally guaranteed, in spite of the fact that the risks of HIV are well-known to governments. Political factors have been allowed to control the HIV prevention work that is done, and politicians are commonly keen to avoid talking about any sexual issues. Furthermore, it is very hard to show that a number of people are not HIV positive who otherwise would be – and politicians like the electorate to see results.
Among gay men, the virus had spread wid
ely before it was even identified and had established a firm grip on the population by the early 1980s. With massive early prevention campaigns targeted at gay communities, risk behaviour was substantially reduced and the rate of new infections dropped significantly during the mid- and late 1980s. Recent information suggests, however, that risky behaviour may be increasing again in some communities. People think that the danger is over because of lack of media coverage of the issues around HIV and AIDS – and many new infections continue to occur.
Some communities and countries have initiated aggressive HIV prevention efforts, particularly among high-risk groups such as injecting drug users. But in many places the political cost of implementing needle-exchange and other prevention programmes has been considered too high for such programmes to be started or maintained. As a result, there are continuing high prevalence rates among injecting drug-users in many high-income countries, particularly Italy, Spain and Portugal.
Many high-income countries suffer from the belief that HIV is something that affects other people, not their own populations. On a national level, this belief prevents policy-makers and budget-setters from seeing the epidemic on their own door-steps, looking instead to the situation in areas such as Africa. Some high-income countries fund medication provision for low-income countries whilst failing to provide medicines for their own citizens who have AIDS. Even in the US, there are people who are unable to afford to buy the drugs they need.
Where do we go from here?
Money is finally being spent on both treating the disease and on preventing new infections from occurring. This spending needs to increase both in its magnitude and its effectiveness. Many people fail to realise that actually spending money, in the very large sums the fight against HIV requires, is a difficult task, and one of which many organisations have little experience.
The Global Fund, an organisation created to channel money to where around the world it is most needed, is an already-existing way of effectively spending money. Many governments, however, wish to exert control over how their donations are spent and on what projects, so they prefer to channel their funding through other channels.
In January 2003, President Bush announced a bold new initiative known as PEPFAR, through which the USA will spend $15 billion over five years on HIV/AIDS prevention, treatment and care programmes in other countries. In 2008, Bush reauthorised PEPFAR, pledging a further US$39 billion to tackle the AIDS epidemic.
Prevention and education
Education has already been proved to be effective and necessary, both for people who are not infected with HIV, to enable them to protect themselves from HIV, and for people who are HIV+, to help them to live with the virus. There is a huge wealth of educational resources available around the world, and yet in many places people still lack the knowledge they need to protect themselves.
AIDS is a preventable disease, but to avoid HIV infection people need more than just factual information. People need empowerment to negotiate safe and responsible sexual relationships; gender inequalities must be confronted; and those who choose to have sex need access to condoms. Needle exchanges should be encouraged, as they have proven highly effective at preventing HIV transmission among injecting drug users.
Antiretroviral AIDS medication is now being distributed to low-income, high prevalence countries, but it is taking a long time to actually reach the people who need it. Access to treatment must greatly improve if millions of deaths are to be avoided. When treatment finally reaches the areas where it is needed, trained nurses must be available to carry out HIV tests, administer the medicines, and teach people how to use them.
HIV has now finally been recognised as a global threat, and people are beginning to take action to prevent it killing many more millions than those who have already died. This action needs not only to continue, but to be speeded up considerably. The HIV epidemic is growing, and efforts to fight it need to grow at an even greater rate if they are to be successful.
An ever-growing AIDS epidemic is not inevitable. However, unless action against the epidemic is scaled up drastically, the damage already done will seem minor compared with what lies ahead. This may sound dramatic, but it is hard to play down the effects of a disease that stands to kill more than half of the young adults in the countries where it has its firmest hold. Entire families, communities and countries will begin to collapse if this situation is allowed to occur.