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The United Nations Report on the State of the Global Epidemic

August 2001

Article: The United Nations Report on the State of the Global Epidemic

From June 25 to 27, heads of state and government and ambassadors from around the world met to discuss the problem of global AIDS in an unusual special session of the United Nations General Assembly, the body in which virtually all nations of the world are represented. The leaders expressed themselves to be "deeply concerned that the global HIV/AIDS epidemic, through its devastating scale and impact, constitutes one of the most formidable challenges to human development and security which undermines social and economic progress throughout the world and affects all levels of society -- national, community, family and individual." While pledging themselves to action, the obstacles to tackling AIDS at the global level are formidable, as revealed in this excerpt from the most recent (December 2000) Epidemic Update published by the Joint UN Program on HIV/AIDS (UNAIDS).

The human immunodeficiency virus (HIV) which causes AIDS has brought about a global epidemic far more extensive than what was predicted even a decade ago. UNAIDS and the World Health Organization (WHO) now estimate that the number of people living with HIV or AIDS at the end of the year 2000 stands at 36.1 million. This is more than 50 percent higher than what WHO's Global Program on AIDS projected in 1991 on the basis of the data then available.

The challenges thrown up by HIV vary enormously from place to place, depending on how far and fast the virus is spreading and on whether those infected have started to fall ill or die in large numbers: In all parts of the world except sub-Saharan Africa, there are more men infected with HIV and dying of AIDS than women. Men's behavior -- often influenced by harmful cultural beliefs about masculinity -- makes them the prime casualties of the epidemic. Altogether, an estimated 2.5 million men aged 15 to 49 became infected during 2000, bringing the number of adult males living with HIV or AIDS at year's end to 18.2 million. Male behavior also contributes to HIV infections in women, who often have less power to determine where, when and how sex takes place. "Men Make a Difference" -- the theme of the 2000 World AIDS Campaign -- acknowledges these factors and recognizes men's enormous potential to make a difference when it comes to curbing HIV transmission, caring for infected family members, and looking after orphans and other survivors of the epidemic.

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During the year 2000, more new HIV infections will have been registered in the Russian Federation than in all previous years of the epidemic combined. Taking into account the continuing expansion of the epidemic in Ukraine as well, a conservative estimate puts the number of adults and children living with HIV or AIDS in Eastern Europe and Central Asia at 700,000 by end-2000, compared with 420,000 just a year before. Unsafe drug-injecting practices are still the main driving factor.

For the first time, there are signs that HIV incidence -- the annual number of new infections -- may have stabilized in sub-Saharan Africa. New infections in 2000 totaled an estimated 3.8 million, as opposed to a total of 4.0 million in 1999. However, if HIV infections start to explode in countries that have had relatively low rates up to now, such as Nigeria, regional incidence could start rising again. Africa's slight fall in new infections is probably a result of two factors. On the one hand, the epidemic in many countries has gone on for so long that it has already affected many people in the sexually active population, leaving a smaller pool of people still able to acquire the infection. At the same time, successful prevention programs in a handful of African countries, notably Uganda, have reduced national infection rates and contributed to the regional downturn.

Even as they face a daunting prevention challenge, African countries are buckling under the impact of large-scale disease and death. In South Africa, the epidemic is projected to reduce the economic growth rate by 0.3-0.4 percent annually, resulting by the year 2010 in a gross domestic product (GDP) 17 percent lower than it would have been without AIDS and wiping US$22 billion off the country's economy. Even in diamond-rich Botswana, the country with the highest per capita GDP in Africa, in the next 10 years AIDS will slice 20 percent off the government budget, erode development gains, and bring about a 13 percent reduction in the income of the poorest households. Scaling up the response to Africa's epidemic is imperative and affordable. Setting ambitious but achievable targets for coverage, countries would need at least US$1.5 billion a year for prevention measures to reduce the HIV risk to their population, including infants, young people, workers, and recipients of blood transfusions. For people with HIV and their families, the bill for palliative care for pain and discomfort, the treatment and prevention of opportunistic infections, and care for orphans would come to at least US$1.5 billion annually. Adding antiretroviral therapy would cost several billion dollars more a year.


Eastern Europe and Central Asia

The estimated number of adults and children living with HIV or AIDS in Eastern Europe and the countries of the former Soviet Union was 420,000 at the end of 1999. Just one year later, a conservative estimate puts the figure at 700,000. Most of the quarter-million adults who became infected this year are men, the majority of them injecting drug users. During the year, new epidemics among drug injectors emerged in Uzbekistan and in Estonia, a country which reported far more HIV cases in 2000 than in any previous year. HIV shows no sign of curbing its exponential growth in the Russian Federation. Judging from the number of cases reported during the first nine months of the year, registered new infections during the year 2000 may well reach 50,000. This is far more than the total of 29,000 infections registered in the country between 1987 and 1999. However, even this massive rise understates the real growth in the epidemic: by Russian estimates, the national registration system captures just a fraction of the infections. Unsafe drug-injecting practices are still the major spur to HIV transmission in this huge nation. In many countries of Eastern Europe and Central Asia, the fight against the epidemic is being waged against a complicated backdrop. Socioeconomic instability in the region is fueling drug use and commercial sex, and thus increasing the spread of HIV. On a more positive note, however, political and legal reforms are creating more effective avenues to HIV prevention. For instance, instead of relying on ineffective mass screening of the population to track and control HIV, most countries are using a range of channels to inform and educate their citizens about the virus. In Belarus, an inter-ministerial committee brings 12 different ministries into an AIDS response that ranges from harm-reduction measures for injecting drug users to awareness-raising campaigns conducted by the national railways. The involvement of practically all ministries and state committees helped achieve a reduction in the overall number of infections reported annually between 1996 and 1999. Prevention efforts have been particularly successful among teenagers. In Kazakhstan, a small non-governmental organization (NGO) in the capital, Astana, sends its 8-man prevention team (who also perform in a rock theatre) into the streets to deliver safer-sex information and condoms to the sex workers operating there. The team also escorts the sex workers to an outpatient clinic where their sexually transmitted infections can be treated confidentially and free of charge -- a departure from the region's traditional approach of arrest and compulsory screening. Increasingly, too, the region is turning to proper HIV surveillance in "sentinel" populations, for example, in sex workers, pregnant women, injecting drug users, or people with a sexually transmitted infection. The Czech Republic and Slovenia can already boast of excellent HIV sentinel surveillance systems -- among the best in Europe. While the annual number of new cases registered in Ukraine seems to have declined since 1997, the virus appears to be making inroads into the general population, to judge from the evidence of HIV infection recently found in pregnant women. Ukraine has implemented a high-quality sentinel surveillance system, which can be expected to yield a clearer picture of infection trends in the future. A watershed law adopted in 1998 endorsed the principle of voluntary HIV testing and broad AIDS education in Ukraine. In perhaps the toughest test of the country's new approach to the epidemic, a recent survey has confirmed that Ukrainian prisons are no longer conducting compulsory screening of inmates or isolating those found HIV-positive. This turnaround was achieved through an innovative project that could be a model for AIDS and prison reform in the region. However, like many of its neighbors, Ukraine faces such stringent budgetary restrictions that it struggles to feed its prisoners, let alone supply them with condoms, disinfectant, syringes and needles.


Asia

An estimated 700,000 adults, 450,000 of them men, have become infected in South and Southeast Asia in the course of the year 2000. These estimates are in line with known risk behavior in this region, in which men not only form the majority of injecting drug users but help drive the earliest wave of sexual HIV transmission, much of it through commercial sex and some through sex between men. Overall, as of end-2000, the region is estimated to have 5.8 million adults and children living with HIV or AIDS. Bangladesh has taken the impressive step of monitoring HIV and behavioral risk at a very early stage of its epidemic. Following a first round of surveillance two years ago, HIV and syphilis testing and behavioral surveys were conducted in a second round between August 1999 and May 2000. The work was carried out in collaboration with NGO and governmental partners, including clinics for sex workers, needle exchange programs and drug detoxification centers. The studies turned up evidence of a range of risk factors, including unsafe drug-injecting practices and inadequate condom use, but extremely low rates of HIV infection so far. The region of East Asia and the Pacific is still keeping HIV at bay in most of its huge population. Some 130,000 adults and children became infected in the course of the year. This brings the number of people living with HIV or AIDS at end-2000 to 640,000, representing just 0.07 percent of the region's adult population, as compared with the prevalence rate of 0.56 percent in South and Southeast Asia. However, the epidemic in East 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. With a hundred million people or more on the move, China in particular is experiencing population movement that dwarfs any other in recorded history. In addition, having practically eradicated sexually transmitted infections by the 1960s, China is now seeing a steep rise in these rates that could translate into higher HIV spread down the road. With the Asian epidemic simmering at low levels, there continues to be a risk of complacency about the danger of HIV. A major challenge will be to maintain high rates of condom use in places where these have already been achieved. High levels of condom use not only protect the individuals immediately involved but avert what could become a long chain of transmission. If condom use declines, countries like Thailand could again see an upsurge in HIV infections.


Estimated Number of Adult and Child Deaths from HIV/AIDS During 2000

Estimated Number of Adult and Child Deaths from HIV/AIDS During 2000


North Africa and the Middle East

Because of insufficient data, few new country estimates of HIV infection were produced for this region between 1994 and 1999. Recent evidence, however, suggests that new infections are on the rise. For example, localized studies in southern Algeria show rates of around 1 percent in pregnant women attending antenatal clinics, and surveillance sites in both northern and southern Sudan indicate that HIV is spreading among the general population. With an estimated 80,000 new infections in the region during 2000, the number of adults and children living with HIV or AIDS had reached 400,000 by end-2000.


Latin America and the Caribbean

The epidemic in Latin America is a complex mosaic of transmission patterns in which HIV continues to spread through male-to-male sex, sex between men and women, and injecting drug use. In Latin America an estimated 150,000 adults and children became infected during 2000. In many countries, thanks to antiretroviral therapy, HIV-positive people are living longer, healthier lives. By year's end some 1.4 million adults and children in the region were estimated to be living with HIV or AIDS, as compared with 1.3 million at the end of 1999. When HIV spreads mainly within a small population group, such as men who have sex with men, this puts a temporary cap on the number of people exposed (although bisexuality and drug use can provide bridges to the general population). In places where HIV is transmitted through sex between men and women, however, a far larger proportion of the whole population is immediately at risk. This is the transmission pattern in the Caribbean, where HIV rates are the highest in the world outside Africa. Though ministries of health in the Caribbean have long been aware of the galloping epidemic and its implications for the region, a series of high-level meetings during the year 2000 have ushered in a new stage of public awareness and visibility of AIDS. At a meeting of the Caribbean Group on Cooperation in Economic Development organized by the World Bank in June, prime ministers and finance ministers looking at the time frame 2000-2020 focused on AIDS as a key development challenge. In July, the heads of government of the Caribbean Community (CARICOM) publicly recognized that the epidemic threatens to reverse the region's development achievements of the last three decades. This was followed by a high-level meeting on HIV/AIDS hosted by the Prime Minister of Barbados in September 2000. Attended by prime ministers and ministers from the region as well as by bilateral donors and officials from the World Bank and the United Nations system, the Barbados meeting achieved a breakthrough in political commitment to fighting the epidemic as well as new pledges of funding, notably from the Netherlands. To help scale up action, the World Bank announced a program of new loans for HIV/AIDS interventions in the Caribbean amounting to US$85-100 million. The Prime Minister of Barbados, who is about to take on the presidency of CARICOM, has put AIDS on the agenda of its February 2001 meeting. At that time, it is expected that CARICOM will officially launch a Caribbean partnership on HIV/AIDS.


High-Income Countries

The news from the richer countries of the world is that prevention efforts are stalled. Though HIV incidence is not tracked through national sentinel surveillance, available information indicates that the number of newly infected people is no lower this year than last. Altogether, in the course of the year 2000, 30,000 adults and children are estimated to have acquired HIV in Western Europe and 45,000 in North America. Overall HIV prevalence has risen slightly in both regions, mainly because antiretroviral therapy is keeping HIV-positive people alive longer. Thousands of infections are still occurring through unsafe sex between men. In this era in which few young gay men have seen friends die of AIDS, and some mistakenly view antiretrovirals as a cure, there is growing complacency about the HIV risk, judging from reports of increased sexual risk behavior, mainly in young men. An ongoing problem for prevention is the persistent stigma of homosexuality, which can make growing up difficult for boys who sense that they are "different"; many of them wind up exposed to needless risk and vulnerability. If prevention is falling short, however, the repercussions are being felt above all by injecting drug users and their families, who are thought to account for the bulk of new infections in many high-income countries. Most of these infections could have been averted. Prevention programs consisting of AIDS education, condom promotion, needle exchange and drug treatment (which can include maintenance on methadone, which is not injected) have proven their effectiveness not only in the highly industrialized countries but in transitional economies such as Belarus, where a harm reduction program managed to avert over 2000 cases of infection by its second year of operation at a cost of around US$29 per infection prevented. In the USA, too, a recent study shows that averting HIV cases through harm reduction makes economic sense. What is needed is the political will to apply genuinely effective measures and to reach out to marginalized individuals and their partners.


Estimated Number of Adults and Children Living with HIV/AIDS As of the End of 2000

Estimated Number of Adults and Children Living with HIV/AIDS As of the End of 2000


Sub-Saharan Africa

In Africa south of the Sahara desert, an estimated 3.8 million adults and children became infected with HIV during the year 2000, bringing the total number of people living there with HIV/AIDS at year's end to 25.3 million. Over the same period, millions of Africans infected in earlier years began experiencing ill-health, and 2.4 million people at a more advanced stage of infection died of HIV-related illness. The region thus continues to face a triple challenge of colossal proportions: bringing health care, support and solidarity to a growing population of people with HIV-related illness; reducing the annual toll of new infections by enabling individuals to protect themselves and others; coping with the cumulative impact of over 17 million AIDS deaths on orphans and other survivors, on communities, and on national development.

Though sub-Saharan Africa once again heads the list as the region with the largest annual number of new infections, there may be a new trend on the horizon: regional HIV incidence appears to be stabilizing. Because the long-standing African epidemics have already reached large numbers of people whose behavior exposes them to HIV, and because effective prevention measures in some countries have enabled people to reduce their risk of exposure, the annual number of new infections has stabilized or even fallen in many countries. These decreases have now begun to balance out the still-rising infection rates in other parts of Africa, particularly the southern part of the continent. Overall, therefore, new infections in 2000 totaled 3.8 million, slightly less than the 1999 regional total of 4.0 million. However, this trend will not hold if countries such as Nigeria begin experiencing a rapid expansion. For the moment, overall HIV prevalence -- the regional total of people living with HIV or AIDS -- continues to rise because there are still more newly-infected individuals joining it each year than there are people leaving it through death. However, as people infected years ago succumb to HIV-related illnesses (average survival in the absence of antiretroviral therapy is estimated at around 8-10 years), mortality from AIDS is increasing. AIDS deaths in 2000 totaled 2.4 million, as compared with 2.2 million in 1999. In the coming years, unless there is far broader access to life-prolonging therapy, and providing that new infections do not start rising again, the number of surviving HIV-positive Africans can be expected to stabilize and finally shrink, as AIDS increasingly claims the lives of those infected long ago.


How Is Africa Coping with HIV?

As can be seen from the early sections of this Epidemic Update, HIV has penetrated every country across the globe. But one continent is far more touched by AIDS than any other. Africa is home to 70% of the adults and 80% of the children living with HIV in the world, and has buried three-quarters of the more than 20 million people worldwide who have died of AIDS since the epidemic began. Over and above the personal suffering that accompanies HIV infection wherever it strikes, the virus in sub-Saharan Africa threatens to devastate whole communities, rolling back decades of progress towards a healthier and more prosperous future. In the next few sections, we look at how AIDS affects the lives and livelihoods of the men, women and children of the hardest-hit countries, especially those in southern Africa.

The information presented reveals two things. The first is that the devastation wrought by HIV is very real, whether the impact is measured in terms of children's future prospects or companies' bottom line. The second thread running through this report is that the epidemic is stimulating a new resilience. Governments, businesses, families and communities are adapting -- with more or less effort and pain -- to the new landscape being sculpted by the epidemic. This illustrates the encouraging ability of people across Africa to rise to new challenges just when the situation seems hopeless.


Estimated Number of Adults and Children Infected with HIV During 2000

Estimated Number of Adults and Children Infected with HIV During 2000


Households: Coping According to Their Ability

In countries that are worst affected by the epidemic, rising sickness and death often take place against a background of deteriorating public services, poor employment prospects and endemic poverty that are not directly related to the HIV epidemic, but that may be exacerbated by it. These factors not only reduce the capacity of communities to step in and help those most affected by AIDS but complicate the task of measuring the impact of AIDS at the household level. Many of the studies that look at AIDS-affected households do not simultaneously collect information from unaffected households, so they have difficulty distinguishing between the impact of sickness and death in a young adult and the impact of other shocks, such as drought, inflation, or a rise in school or health service fees.

And since most household studies are conducted at a given point in time, they miss the households that have failed to cope, those that have been dissolved by AIDS, sending young people to the streets and old people to destitution and death. What information there is available shows that households bear the brunt of misery caused by the epidemic. Nevertheless, new analyses of information collected at an earlier stage of the epidemic in the United Republic of Tanzania suggest that households and communities may be more resilient than once thought. A large study of rural households surveyed over a period of several years, at a time when HIV prevalence among young adults in the Kagera region was in the range of 10 to 25% and when AIDS had increased young adult mortality by two thirds, casts doubt on some earlier assumptions about the consequences of a recent premature death.

Very few households experiencing such a death were composed entirely of old and young people. Fewer than one household in 10 had no surviving member aged between 15 and 50. Old people were no more likely to suffer ill-health than those living in households unaffected by AIDS or other mortality, nor were they any more likely to be driven to do farming or take other jobs. Similarly, orphans were not significantly more likely to show signs of malnutrition than non-orphans, regardless of who was caring for them after their parents' death. Another analysis in the same Tanzanian population looked in greater detail at what households do to cope financially with the loss of a young adult. The study found that there was a dramatic difference in coping ability depending on the wealth of the household. In poor households, spending on food fell by nearly a third and food consumption by about 15% in the 6 months following the death of a young adult, while in non-poor households both food spending and food consumption rose, possibly because of funeral feasting. The difference may be explained by wealthier households' better access to financial help. In the six months following a young adult death, non-poor households received an average of around 20,000 shillings per household member (around US$25 at current exchange rates) from family, friends, or other private sources.

Poor families, on the other hand, tend to receive virtually no help from friends and family, and are forced to borrow money or to rely on public assistance, which often does not arrive until several months after the death. This reinforces the importance of targeting AIDS alleviation measures at the households in greatest need. A study of AIDS-affected households in Zambia drew similar conclusions about the need to target resources, arguing that different impact mitigation strategies would be needed for different segments of the population. This study found that children in AIDS-affected households in urban areas were likely to drop out of school because their carers did not have the cash to pay school fees -- a problem that might be alleviated by subsidies for the education of orphans.

In rural areas, on the other hand, where children were taken out of school to work the fields in the place of a sick or dying adult, one solution might be a pool of communal labor made available to AIDS-affected households. Another challenge in rural areas is passing on knowledge to the younger generation.

Studies have found that orphaned children are rarely able to cope with the agricultural tasks left to them. In Namibia, children left with small livestock -- chicken and goats -- saw many of their animals die, simply because they did not have the experience to care for them properly. In a Kenyan study, four out of five orphans who were farming in one rural area said they did not know where to go for information about food production. Unfortunately, the resources that might help these children get back on their feet are themselves being eroded by HIV. The Namibian study estimated that agricultural extension staff, whose job is to support farmers with information and skills training, spent at least a tenth of their time attending funerals. Similarly, in Gweru district, Zimbabwe, attendance at funerals brought about a 10% loss in salary for agricultural extension workers. In Malawi, employee deaths at the Ministry of Agriculture and Irrigation doubled from 5 per 1,000 in 1996 to 10 per 1,000 in 1998, an increase largely attributable to AIDS.


Regional HIV/AIDS Statistics and Features, End of 2000
RegionEpidemic StartedAdults & Children Living with HIV/AIDSAdults & Children Newly Infected with HIVAdult Prevalence Rate*% of HIV+ Who Are WomenMain Mode(s) of Transmission for Those Living with HIV/AIDS**
Sub-Saharan Africalate '70s -early '80s25.3 million3.8 million8.8%55%Hetero
North Africa & Middle Eastlate '80s400,00080,0000.2%40%Hetero, IDU
South & Southeast Asialate '80s5.8 million780,0000.56%35%Hetero, IDU
East Asia & Pacificlate '80s640,000130,0000.07%13%IDU, Hetero, MSM
Latin Americalate '70s - early '80s1.4 million150,0000.5%25%MSM, IDU, Hetero
Caribbeanlate '70s - early '80s390,00060,0002.3%35%Hetero, MSM
Eastern Europe & Central Asiaearly '90s700,000250,0000.35%25%IDU
Western Europelate '70s - early '80s540,00030,0000.24%25%MSM, IDU
North Americalate '70s - early '80s920,00045,0000.6%20%MSM, IDU, Hetero
Australia & New Zealandlate '70s - early '80s15,0005000.13%10%MSM
TOTAL 36.1 million5.3 million1.1%47% 
*The proportion of adults (15 to 49 years of age) living with HIV/AIDS in the year 2000, using 2000 population numbers.

**Hetero (heterosexual transmission), IDU (transmission through injecting drug use), MSM (sexual transmission among men who have sex with men).

Source: UNAIDS


AIDS and Education: Complex Links

Just as the better-educated segments of the population in the industrialized countries were the first to adopt health-conscious lifestyles featuring exercise, non-smoking and a healthy diet, a similar pattern seems to be emerging in sub-Saharan Africa with respect to HIV. An analysis of studies focusing on 15 to 19-year-olds found that teenagers with more education are now far more likely to use condoms than their peers with lower education, as well as less likely, particularly in countries with severe epidemics, to engage in casual sex.

This was not the case early in the African epidemic. At that stage, education tended to go hand in hand with more disposable income and higher mobility, both of which increased casual sex and the risk of contracting HIV. But as information about HIV has become more widely available, education has switched from being a liability to being a shield. Because more-educated people are better equipped to act on prevention information, and because they have more options in life in general, they are now exposing themselves less to the risk of HIV.

In the period 1991 to 1994, young women with secondary education were more likely to be infected than their illiterate counterparts. By 1995-97, however, the infection rate of educated women had dropped by almost half, whereas it had fallen much less for women without formal schooling.

If this is the good news, the bad news is that AIDS now threatens the coverage and quality of education.The epidemic has not spared this sector any more than it has spared health, agriculture or mining. On the demand side, HIV is reducing the numbers of children in school. HIV-positive women have fewer babies, in part because they may die before the end of their childbearing years, and up to a third of their children are themselves infected and may not survive to school age.

Many children who have lost their parents to AIDS, or are living in households which have taken in AIDS orphans, may be forced to drop out of school to start earning money, or simply because school fees have become unaffordable. On the supply side, teacher shortages are looming in many African countries. In Zambia, teachers are increasingly dying of AIDS and many more show up to teach class only sporadically because they are sick. Swaziland estimates that it will have to train more than twice as many teachers as usual over the next 17 years just to keep services at their 1997 levels. Without this extra teacher training, class sizes would balloon to over 50 pupils for every teacher. Together with sickness and death benefits for teachers, Swaziland's extra hiring and training costs are expected to drain the treasury of some US$233 million by 2016 -- more than the 1998-1999 total government budget for all goods and services.


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