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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 international borders.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, in 2004, 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’
Just as clearly, experience shows 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.
Globally, we have learned that if a country acts early enough, a national HIV crisis can be averted.
It has also been noted that a country with a very high HIV prevalence rate will often see this rate eventually stabilise, and even decline. 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 that this happens it is usually too late to save a huge number of that country’s population.
Already, more than twenty million people around the world have died of AIDS-related diseases. In 2004, 3.1 million men, women and children have died. Around twice the amount who have died until now - almost 40 million - 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 2004 alone, 4.9 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. Altogether, there are now 16 countries in Africa in which more than one-tenth of the adult population aged 15-49 is infected with HIV.
In seven countries, all in the southern cone of the continent, at least one adult in five is living with the virus. In Botswana, a shocking 37.5% of adults are now infected with HIV, while in South Africa, 20.1% are infected, up from 12.9% just three years ago. With a total of 5 million infected people, South Africa has the largest number of people living with HIV/AIDS in the world.
Rates of HIV infection are still increasing in many countries in Sub-Saharan Africa, and an estimated 3.1 million people in this region were infected in 2004, the most recent year for which data is available. This means that there are now an estimated 25.4 million people here 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. Sub-Saharan Africa has, relative to its population, by far the most severe HIV epidemic anywhere in the world, and has become the focal point of a number of initiatives to prevent the onward transmission of HIV and to provide antiretroviral medication to infected people, but these initiatives have yet to have a significant impact on death rates.
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 15 worst affected countries in the world; in Nigeria over 5% of adults have HIV but the prevalence rate in other West African countries remains below 3%. In Western Africa the epidemic displays a diversity not seen to such an extent in other parts of Africa. 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 of the continent but have been exceeded by the rates now being seen in the southern cone. The prevalence rate among adults in Ethiopia and Kenya has reached double-digit figures and continues to rise.
These rises are not inevitable. Uganda has brought its estimated prevalence rate down to around 5% from a peak of close to 14% in the early 1990s with strong prevention campaigns, and there are encouraging signs that Zambia's epidemic may be following the course charted by Uganda. Yet, even in these countries, the suffering generated by HIV infections acquired years ago continues to grow, and a falling prevalence rate usually indicates that a high number of deaths have already occurred.
Asia and the Pacific
The diversity of the AIDS epidemic is even greater in Asia than in Africa. The epidemic here 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 absolute numbers of people infected, can make huge differences in the infection rates.
Around 1.2 million people in Asia and the Pacific acquired HIV in 2004, bringing the number of people living with HIV to an estimated 8.2 million. A further 540,000 people are estimated to have died of AIDS in 2004.
National adult prevalence is still under 1% in the majority of this region's countries. That figure, though, can be misleading. Several countries in the region are so large and populous that the attention is only drawn to major urban areas, which may obscure serious epidemics in some smaller provinces and states. Although national adult HIV prevalence in India, for example, is below 1%, five states have an estimated prevalence of over 1% among adults.
In most Asian countries the epidemic is centred among particular high-risk groups – men who have sex with men, injecting drug users, sex workers and their partners. The epidemic has already spread beyond these groups, however, 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 appeared to show some success. 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 s 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.
However, 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 shows no signs of declining. Some 210,000 people were infected with HIV in 2004, bringing the total number of people living with the virus to around 1.4 million, and AIDS claimed 60,000 lives in the past year. Eastern Europe is home to the fastest growing arm of the global HIV epidemic.
In any country with unsafe drug-injecting practises, a fresh outbreak of HIV is liable to occur at any 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. In the Russian Federation, a new outbreak of HIV among injecting drug users (IDUs) in the Moscow region in 1999, resulted in the reporting of more than three times as many new cases in that year as in all the previous years combined. The route of heroin smuggled into the West crosses through a number of Eastern European countries, and it’s path is marked by a high concentration of IDUs, and a high HIV prevalence.
Worst affected are the Russian Federation, Ukraine, and the Baltic states (Estonia, Latvia, and Lithuania), but HIV continues to spread in Belarus, Moldova and Kazakhstan, while more recent epidemics are now evident in Kyrgyzstan and Uzbekistan. It is now estimated that around 860,000 people aged 15-49 are living with HIV in the Russian Federation, although reporting of HIV cases is at best patchy in many areas. The epidemic in Eastern Europe is driven by injecting drug use, and the criminalisation of this practise makes it difficult to gain an accurate picture of the proportion of drug users who are 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.
Haiti, where the spread of HIV may well have been fuelled by decades of poor governance and conflict, is the worst affected nation in the region. In some areas, 13% of anonymously tested pregnant women were found to be HIV-positive in 1996. Overall, around 8% of adults in urban areas and 4% in rural areas are infected. HIV transmission in Haiti is overwhelmingly heterosexual, and both infection and death are concentrated in young adults. It is estimated that nearly 200,000 Haitian children had lost one or both of their parents to AIDS by the end of 2001. Haiti has been traumatised by decades of almost continual mass-unemployment, brutal governments, and conflict. With this as a background, the spread of HIV has largely been undisturbed. The danger is that Haiti will eventually solve it’s social issues, only to find that HIV has already devastated the 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. In Saint Vincent and the Grenadines, where the prevalence of sexually transmitted diseases is high for the region, a quarter of men and women in a recent national survey said they had started having sex before the age of 14, and half of both men and women were sexually active at the age of 16. In a large survey of men and women in their teens and early twenties in Trinidad and Tobago , fewer than a fifth of the sexually active respondents said they always used condoms, and two-thirds did not use condoms at all.
A mixing of ages, which has contributed to pushing the HIV rate in young African women to such a high levels, is common in this population too. Whilst most young men had sex with women of their own age or younger, over 28% of young girls said they has sex with older men. As a result, HIV rates are five times higher in girls than boys aged 15-19 in Trinidad and Tobago, and at one surveillance centre for pregnant women in Jamaica, girls in their late teens had almost twice the prevalence rate of older women.
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. It remains to be seen if action can and will be taken rapidly enough to avert a crisis.
The HIV epidemic in Latin America is highly diverse. Most transmission in Central American countries and countries on the Caribbean coast occurs through sex between men and women. Brazil, too, is experiencing a major heterosexual epidemic, but there are also very high rates of infection among men who have sex with men and injecting drug users. In Mexico, Argentina, and Colombia, HIV infection is also confined largely to these sub-populations. The Andean countries are currently among those least affected by HIV infection, although risky behaviour has been recorded in many groups.
Around 1.7 million people are living with HIV in Latin America. In 2004, around 95,000 people died of AIDS and an estimated 240,000 people were newly infected.
The countries with the highest prevalence rates in the region tend to be found on the Caribbean side of the continent. Over 7% of pregnant women in urban Guyana tested positive for HIV in 1996. Strikingly, the rates in pregnant women were similar to those in patients attending clinics for sexually transmitted diseases (STDs) – one would have expected them to be lower.
In Honduras, Guatemala and Belize there is also a fast-growing epidemic, with HIV prevalence rates among adults in the general population between 1 and 2%. In 1994, less than 1% of pregnant women using antenatal services in Belize District tested positive for HIV, while one year later the prevalence rate had risen to 2.5%, the rate in one health centre, in Port Loyola, hitting 4.8%. Much of the problem is concentrated in teenagers, suggesting that the worst is still to come.
Heterosexual transmission of HIV is rarer in other countries of Central America . In Costa Rica, for example, HIV is transmitted mainly during unprotected sex between men. In this country, as in many other parts of Latin America, there is little systematic surveillance for HIV among groups with high risk behaviour, but studies among men who have sex with men in Costa Rica showed infection rates of 10-16% as long ago as 1993.
In Mexico, too, HIV has affected mainly men who have sex with men, more than 14% of whom are currently infected. HIV rates among pregnant women, however, are extremely low. Data from a programme to reduce the transmission of HIV from mothers to infants suggest that less than one in every 1,000 women of childbearing age is infected. Even among female sex workers in Mexico, the prevalence rate is well under 1%.
A low prevalence of HIV infection among heterosexuals is the norm in the Andean region, at least in the countries for which data are available. For example, Argentina has typically high rates of HIV infection among injecting drug users and men who have sex with men, but a relatively low prevalence of 0.4% among pregnant women.
One of the defining features of the Latin American epidemic is that several populous countries, including Argentina, Brazil, Cuba and Mexico, are attempting to provide antiretroviral therapy for all people infected with HIV. 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.
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. Nevertheless, some concern has been voiced over the risk that HIV prevention activities may suffer if too 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, and this is largely still where the main thrust of the epidemic lies. However, in several Western European countries a significant proportion of new HIV diagnosis (59% more, overall, between 1997 and 2001) is occurring through heterosexual intercourse. 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.
Among gay men, the virus had spread widely before it was even identified and had established a firm grip on the population by the early 1980's. 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 1980's. 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 new infections continue to occur
While the infection rates have been low in high-income countries, some countries have been reporting increases in their HIV rates. For example, Sweden currently has one of the lowest rates of HIV infection in the world. According to the Swedish Institute for Infectious Disease Control the rate of new HIV cases in Sweden rose by 48% during the first half of 2001.
Prevention work in high-income countries has declined, and sexual-health education in schools is still commonly not by any means 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 anysexual issues. Furthermore, it’s very hard to show that a number of people are not HIV+ who otherwise would be – and politicians like the electorate to see results.
Some communities and countries, however, have initiated aggressive HIV prevention efforts, particularly among high-risk groups such as injecting drug users, containing the HIV prevalence rate at below 5%. In many places, however, 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. For example, in Spain, a recent study in Barcelona found a prevalence rate of 51% among injecting drug users.
Many high-income countries suffer from the belief that HIV is something that effects 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 . Many 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 it’s magnitude and it’s 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 which many organisations have little experience of. 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 diverse organisations, which may often have no experience of spending such sums. The Global Fund, as a direct result of this, is in danger of being unable to meet it’s funding agreements. Governments need to meet their promises to the Global Fund, and to increase them.
In the early days of the epidemic, HIV prevention work was done at a high-profile, national level in many high-income countries. This work has all-but foundered, and needs to be re-invigorated. Education has already been proved to be effective and necessary, both for people who are not infected with HIV, to empower 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.
Anti-retroviral 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. The provision and distribution of medication needs to be greatly speeded up if millions of deaths are to be avoided. When the medication 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 considerable. The HIV epidemic is growing, and efforts to fight it need to grow at a greater rate then the epidemic if they are to be successful.
An ever-growing AIDS epidemic is not inevitable; yet, 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.