International AIDS Conference

HIV/AIDS epidemic wreaks havoc on youths worldwide

800,000 infants infected last year

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Most people across the world who became infected with HIV last year were younger than age 25, showing that the epidemic’s toll is worst for the age group that typically is relied upon for a nation’s most promise and productivity. Equally alarming: In many developing nations, HIV infection is higher among young women of childbearing years than among men. In 2001 in sub-Saharan Africa, the overall proportion of women infected with HIV had risen to 50%, up from 41% in 1997, and in some countries, the rates of HIV infection among girls is five or six times that of boys. For example, in Botswana, young women (15-24) are estimated to have a 45% HIV prevalence rate, which is twice the HIV rate of Botswana young men.1 This has led to a situation in which 800,000 infants were infected with HIV last year, and greater numbers of children are becoming orphans or heads of households because their parents have either died or are sick from AIDS.

"The future of AIDS is youth," says John Chittick, EdD, executive director of TeenAIDS-PeerCorps Inc. of Boston. Chittick leads global walks to raise awareness about HIV/AIDS and to train teens to fight the spread of the epidemic. "Since my Harvard research in the late 1980s and early 1990s, I have been talking about this new wave of HIV among adolescents," Chittick says. "We now have solid evidence that my predictions have come true."

In some regions, as many as one in 10 young women are infected with HIV, and the situation has compounded the problem of AIDS orphans, now estimated at more than 13 million.1 "What we see is that the number of orphans is increasing dramatically," says Anne Peterson, MD, MPH, assistant administrator in the Bureau for Global Health for the U.S. Agency for International Development in Washington, DC. Peterson spoke about AIDS and orphans at the 14th International AIDS Conference in July in Barcelona, Spain. "In Africa, 30 million children are orphans, one-third of them are due to AIDS," she adds. "By 2010, 40 million children will be orphans, but half will be due to AIDS."

AIDS orphans typically are impoverished and are at greater risk of becoming infected with HIV, compounding the problem.1 Unfortunately, the epidemic’s ripple effect on children takes a long time to turn around even when HIV prevention programs succeed. "Even if we could stop the spread of AIDS starting today, the number of orphans would continue to increase for the next decade," Peterson says.

AIDS has become a family disease that affects the most vulnerable groups in society, says Peter Piot, MD, PhD, executive director of UNAIDS of Geneva, Switzerland.

Loss of childhood

Children often are the primary caregivers of sick parents, and they have taken up the roles of adults in many communities, working adult jobs at the expense of their education and development, Piot explains.

"There’s just a whole generation that has disappeared because of AIDS," he says. "And as a result, one could safely say that the very fabric of society is disappearing with family structures crumbling."

Typically, when HIV destroys a family, the chain reaction that occurs begins with the girls dropping out of school and a decline in the family’s social and economic status. Then the children of AIDS parents, whether the parents are living or dead, grow up without the guidance they need to develop healthy principles of life. As such, they are prone to prostitution or becoming child warriors, Peterson says.

"They become very vulnerable to all of the externalities and harm that can come to unprotected children," she says.

Unfortunately, statistics show that this is a widespread phenomenon in sub-Saharan Africa, and it has the potential to explode in Asia, the Caribbean, and other parts of the world as well.

According to a recent report by the Menlo Park, CA-based Henry J. Kaiser Family Foundation, 58% of the 5 million people who were infected with HIV last year were under age 25, and 40% of new infections occurred among those in the 15-24 age group.1 (See figure 3. All figures are from the Henry J. Kaiser Family Foundation, Menlo Park, CA.)

 In the United States, half of the estimated 40,000 new HIV infections each year are believed to be among youth under age 25, and the epidemic particularly hits hard in communities of color.2 HIV/AIDS prevalence among the 15-24 year-old age group accounted for 8.6 million HIV infections in sub-Saharan Africa, 240,000 infections in industrialized countries, and 1.1 million infections in South and Southeast Africa. In all, 11.8 million youths were among those infected in 2001, according to statistics by UNAIDS. (See figure 5.)

As the epidemic continues and life expectancy falls in many sub-Saharan nations, the populations grow younger, meaning there are fewer mature adults available to teach the next generation. (See figure 4.)

Deaths among those in the prime productive and reproductive years of ages 20-34 have climbed dramatically in 50 countries that have been hard hit by the epidemic, according to a Kaiser Family Foundation analysis of U.S. Census Bureau data. An estimated 26.7 million people in this age group are expected to have died from AIDS by 2010, and about 59% of these deaths will be among young women. (See figure 6.)

For all of these reasons, the United Nations is making HIV prevention among youths a priority and has set a prevention goal of reducing HIV infection in the 15-24 age group by 25% by 2005, Piot says. "I hope when we issue our next report for the international conference held in Bangkok, Thailand [in 2004], that we’ll see a number of countries where that decline is happening," he says. "We’re starting to see a slowing down of the increase in HIV infection rates, and for the first time, we’re seeing some kind of leveling off, but that will have to be monitored country-by-country," Piot explains. One of the more sinister findings among current AIDS epidemic data is that there has not been the expected leveling off of HIV prevalence in Africa as had been predicted in the early 1990s, he says.

"When we started with UNAIDS, the predictions were that by the year 2000, the number of infected individuals in Africa would reach a certain level, and we’ve gone far beyond that," says Neff Walker, a senior epidemiologist with UNAIDS. "In 1995, epidemiologists predicted numbers of one-third to one-half of what we’re seeing now in southern and central Africa."

What epidemiologists failed to grasp was how insidious AIDS can be with an infection lifetime of nine to 10 years. They assumed that once a population of at-risk people became infected, there would be a saturation point, explains Walker, who spoke about the epidemic’s epidemiological challenges at a telephone conference held prior to the Barcelona conference.

However, one of the possible reasons that the saturation point hasn’t been reached is because children, who are at very low risk before puberty, enter an at-risk population of sexually active youths during the time period in which the generation of HIV-infected adults ahead of them remain alive and capable of transmitting the virus to the younger members.

"What we missed is that people move in and out of risk groups," Walker says. "The HIV prevalence rate is so high it basically puts everyone in the population at risk." UNAIDS and other international organizations have sounded the alarm and are pushing for more prevention and treatment money to combat the epidemic among youths as well as the general population, but their efforts have fallen far short of the estimated $4.8 billion needed.

"We need a massive scale-up of what we know works to avert millions of infections over the next decade," says Helene Gayle, MD, MPH, formerly with the Centers for Disease Control and Preven-tion (CDC) of Atlanta, and now a representative of the Bill and Melinda Gates Foundation of Seattle. Gayle spoke the UNAIDS’ telephone prevention conference prior to the Barcelona conference.

The most effective and cheap prevention efforts are those that are levied on a population that is new to HIV infection, but this is where the world’s leadership has failed when it comes to the AIDS epidemic, Piot says. "We lost such precious time, and that waste of time is translated into millions and millions of deaths," he says.

Still time for some

While it’s too late for sub-Saharan Africa, the United States, and other nations that were the first to experience the epidemic to limit the disease’s toll, it is still possible for Eastern European nations, China, and India to stop the epidemic before it takes firm hold, Piot says. "You need absolutely watertight, safer sexual behavior to bring down the rate of new infections," he says. "That’s the message we have for China, India, and East Europe: If they invest now seriously against AIDS, that investment will save them billions of dollars later on."

Such a mission is a formidable challenge. New research presented at Barcelona indicates that nearly 17% of Chinese people have never heard of AIDS, and more than half do not know the cause of the disease.3 Another study shows that injection drug use continues to spread HIV throughout south China, and the region is on the verge of a generalized AIDS epidemic if prevention measures aren’t quickly and effectively put in place.4

In Moscow, sexually transmitted diseases (STDs) are rampant among the city’s homeless with more than 30% having at least one STD. While HIV infection among this population still is low (at 1% prevalence) by sub-Saharan African standards, it is already more than five times the rate of the general population, indicating that it is on the verge of exploding. Homeless women have a 3% HIV prevalence rate, which means their risk is considerably greater.5

The HIV epidemic doubled in Russia in 2001, and most of the people infected are 15-29. In a study that looked at unsafe sex and drug use among Moscow students, investigators found that Moscow high school students are at high risk for HIV infection and are in need of prevention campaigns aimed at this population.6

Meantime, UNAIDS and other international AIDS organizations are continuing to find better treatment and prevention methods for sub-Saharan African nations.

"The key challenge is access to effective prevention," Gayle says. "Only one in five people at risk have access to prevention, so there’s a huge gap in access."

Even in success stories, such as Uganda’s mother-to-child transmission prevention efforts, there is limited access to the drugs needed to prevent newborns from becoming infected, notes David Serwadda, MBChB, MPH, of Makerere University in Kampala, Uganda. Serwadda also spoke at the UNAIDS prevention conference. "Uganda is the country that initiated studies on nevirapine and reported widely the results, and we find that up to now we have less than 5% of pregnant women accessing these drugs," he says. "The challenge has been to actually try to find a method of distributing or having pregnant women access this drug."

References

1. Summers T, Kates J, Murphy G. The Tip of the Iceberg, the Global Impact of HIV/AIDS on Youth. Menlo Park, CA: Henry J. Kaiser Family Foundation; July 2002.

2. Grosz J, Harvey DC. A new generation at risk: Youth HIV. Presented at the 14th International AIDS Conference. Barcelona, Spain; July 7-12, 2002. Abstract TuPeB4657.

3. Holtzman D, Hsia J, Rubinson RB, et al. HIV/AIDS-related knowledge among residents in seven countries in China: Implications for action. Presented at the 14th International AIDS Conference. Barcelona, Spain; July 7-12, 2002. Abstract WePeC6174.

4. Chen J, Liu W, Zhu QY, et al. HIV epidemic trends in Guangxi, and south China, 1996-2001: Ongoing HIV transmission in a heroin trafficking zone. Presented at the 14th International AIDS Conference. Barcelona, Spain; July 7-12, 2002. Abstract MoPeC3385.

5. High rates of sexually transmitted diseases (STDs) and related risk behaviors in homeless population in Moscow – potential impact for HIV transmission. Presented at the 14th International AIDS Conference. Barcelona, Spain; July 7-12, 2002. Abstract ThPeC7598.

6. Trubnikov MN, Savchenko TN, Kotov LN, et al. Unsafe sex and drug use as risk factors of HIV infection among Moscow students. Presented at the 14th International AIDS Conference. Barcelona, Spain; July 7-12, 2002. Abstract MoPeC3479.