Aids Alert International-HIV is a time bomb in Asia and a brush fire in Russia

Developing world accounts for 95% of epidemic

Despite antiretroviral medications and wide spread knowledge of prevention strategies, the world saw a record 2.6 million deaths from HIV/AIDS and 5.6 million new infections in 1999, statistics that prove the epidemic is far from over.

But the epidemic disproportionately affects people living in developing nations. These countries have 95% of the total number of people infected with HIV. And these nations also have the fewest resources to devote to treating and preventing the disease. This is why life expectancy in southern Africa, which had risen to age 59 in the early 1990s, now is expected to drop to 45 within the next 10 years.

And this is why illness and death have replaced old-age retirement as the leading reason why employees leave service in some commercial industries of Africa.

"I think we are now at the turning point in the nearly 20-year history of the HIV epidemic in Africa because the whole continent is facing a real crisis," says Peter Piot, MD, PhD, executive director of UNAIDS in Geneva, Switzerland.

"Everywhere I go, I hear the African leaders speaking out about AIDS, and they see this now as the major factor affecting their continent's development," Piot says. "And this is a positive change."

The HIV epidemic has taken different paths in various parts of the world. While heterosexual transmission is the primary mode of spreading the virus in Africa, injecting-drug use and homosexual transmission are of greater concern in Europe and the United States.

Piot, who spoke recently about the state of the global HIV epidemic worldwide, offers this snapshot of the disease in different parts of the world:

• Africa: Southern African nations are struggling with providing basic treatment to people with AIDS and opportunistic infections while at the same time trying to increase efforts at counseling and HIV testing, Piot says.

"The overwhelming majority of people with HIV/AIDS don't know they're infected," he adds.

UNAIDS is focusing on helping these nations build up their health care infrastructure, and the organization is working with drug companies to bring down the price of antiretrovirals purchased by these developing countries. The latter effort has been somewhat successful, Piot says, adding that the price of AZT has declined by 75%.

Orphan problem has skyrocketed in Africa

But there's another major challenge in Africa, and that involves the problem of orphans who are left behind by parents dying of AIDS. There are an estimated 11.2 million children orphaned by AIDS, and 95% of them are in sub-Saharan Africa.

UNICEF Executive Director Carol Bellamy says the percentage of all children who are orphans has jumped to 11% in many African countries. Before AIDS, about 2% of all children in developing countries were orphans.

"Worse, the skyrocketing number of AIDS orphans is putting a severe strain on traditional support systems in Africa, in addition to the loss of life caused by AIDS," Bellamy says. "The grandparents who in many cases are taking care of their orphaned grandchildren have limited resources."

Because half of the people with HIV are infected before age 25, and most of these people die within 10 years of infection, they typically die of AIDS while their children are young, Piot explains.

• Asia: Asia still is in the early years of its epidemic. In eastern and southern Asia, the epidemic started in the late 1980s, and it still has a low pre valence rate among adults ages 15 to 49. (See regional HIV/AIDS chart, p. 4.)

Regional HIV/AIDS Statistics and Features, December 1999
Region Epidemic started Adults & children living with HIV/AIDS Adults & children newly infected with HIV Adult prevalence rate (*) Percent of HIV-positive adults who are women Main mode(s) of transmission (**) for adults living with HIV/AIDS
Sub-Saharan Africa late '70s-early '80s 23.3 million 3.8 million 8.0% 55% Hetero
North Africa & Middle East late '80s 220,000 19,000 0.13% 20% IDU, Hetero
South & Southeast Asia late '80s 6 million 1.3 million 0.69% 30% Hetero
East Asia & Pacific late '80s 530,000 120,000 0.068% 15% IDU, Hetero, MSM
Latin America late '70s-early '80s 1.3 million 150,000 0.57% 20% MSM, IDU, Hetero
Caribbean late '70s-early '80s 360,000 57,000 1.96% 35% Hetero, MSM
Eastern Europe & Central Asia early '90s 360,000 95,000 0.14% 20% IDU, MSM
Western Europe late '70s-early '80s 520,000 30,000 0.25% 20% MSM, IDU
North America late '70s-early '80s 920,000 44,000 0.56% 20% MSM, IDU, Hetero
Australia & New Zealand late '70s-early '80s 12,000 500 0.1% 10% MSM, IDU
TOTAL 33.6 million 5.6 million 1.1% 46%
* The proportion of adults (15 to 49 years of age) living with HIV/AIDS in 1999, using 1998 population numbers.
** MSM (sexual transmission among men who have sex with men), IDU (transmission through injecting drug use), Hetero (heterosexual transmission).
Source: Joint United Nations Programme on HIV/AIDS. AIDS epidemic update: December 1999. Geneva: 1999, pp. 1-24.

But because a nation like India has such a huge population, even a small rise of 0.1% in prevalence among adults could mean 500,000 more HIV cases. An estimated 4 million Indians are infected with HIV.

The UNAIDS and World Health Organization "AIDS Epidemic Update: December 1999" reports that one major problem with the epidemic in India is that it is highly stigmatized, with many hospitals turning HIV-infected patients away.

Also, uninfected widows of men who have died of AIDS often are blamed for their late spouse's infection and are thrown out of their homes by in-laws.

China's HIV infection rate remains low at about 500,000. Most of these people are injection-drug users, Piot says.

"On the one hand, the government has declared AIDS as a national priority," Piot says. However, strategies like needle exchanges that have worked elsewhere are out of the question because drug use is illegal and even carries death penalties.

Plus, injection-drug users in China typically are young migrants who move from one area to another. So Chinese officials have begun to put HIV prevention messages on trains, and they've opened testing and counseling centers in major railway stations, Piot says.

The potential exists for the epidemic to spread to the non-drug using population because the country has four million prostitutes, most of whom do not use condoms.

Asia's success story so far is Thailand, where the government has made prevention efforts a top priority. One study of the northern Thai prov ince of Chiang Rai found that the proportion of people infected with HIV fell from a peak of 6.4% in 1994 to 4.6% in 1997.1

• Caribbean and Latin America: The Caribbean region has among the world's worst HIV epidem ics. In Haiti, for example, HIV surveillance of pregnant women in 1996 found that 6% tested positive. And in Guatemala in 1999, 2% to 4% of pregnant women tested positive for HIV.

But there is a wide variance among infection rates in the region, Piot says.

"There is an enormous difference among countries, with Haiti leading and the Dominican Republic having increasing rates," he says.

On the other hand, Mexico's HIV epidemic is relatively stable, affecting an estimated 140,000 people, and it's primarily spread through men who have sex with men.

Mexico is trying to build strong local coalitions to combat the epidemic, Piot says.

"The problem is, promotion in an aggressive way has been problematic and criticized by parts of the Catholic Church," he adds. "But last year, the president stood up in favor of condom promotion."

Likewise, a few Latin American countries, like Brazil and Argentina, are providing antiretroviral therapy to HIV-infected citizens.

"That's a very deliberate political choice that has come under fire during the recent crisis in Brazil, for example," Piot says. "Brazil spent $300 million this year on providing drugs to about 75,000 people."

By contrast, in Guatemala, only about 185 people out of 50,000 HIV-infected individuals have access to antiretroviral drugs.

• Eastern Europe: Russia is a troubling example of a very recent addition to the worldwide epidemic. The proportion of the former Soviet Union's population that is living with HIV doubled between mid-1997 and the end of 1999.

UNAIDS and WHO estimate that 360,000 people are infected in central and Eastern Europe, a 33% increase during 1999. Most of these cases are caused by injection-drug use, Piot says.

"Once HIV is introduced in a circle of drug users, you have a real explosion," he adds. "It's a real problem among prisoners, and the key question is, how will the countries deal with injecting drug use?"

Public health officials have established outreach programs in St. Petersburg and some Ukrainian cities in attempts to reach drug users. But the efforts lack conviction, Piot says. "The sad reality is that preventing AIDS is not a priority in those countries, not a political priority or a priority for public spending."


1. Joint United Nations Programme on HIV/AIDS. AIDS epidemic update: December 1999. Geneva: 1999, pp. 1-24.