Global Overview

• Eastern Europe and Central Asia
  
• Asia
  
• North Africa and the Middle East
  
• Latin America and the Caribbean
  
• High-income Countries
  
• Sub-Saharan Africa

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 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% higher than what WHO's Global Programme 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 behaviour -- often influenced by harmful cultural beliefs about masculinity -- makes them the prime casualties of the epidemic. Altogether, an estimated 2.5 million men aged 15-49 became infected during 2000, bringing the number of adult males living with HIV or AIDS at year's end to 18.2 million. Male behaviour 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 this year's 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 ago. 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 totalled 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 programmes 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% annually, resulting by the year 2010 in a gross domestic product (GDP) 17% 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% off the government budget, erode development gains, and bring about a 13% 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 in 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 fuelling 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 interministerial 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 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 neighbours, 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 South-East Asia in the course of the year 2000. These estimates are in line with known risk behaviour 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 behavioural risk at a very early stage of its epidemic. Following a first round of surveillance two years ago, HIV and syphilis testing and behavioural 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 programmes and drug detoxification centres. 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% of the region's adult population, as compared with the prevalence rate of 0.56% in South and South-East 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 which 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.

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% 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 break-through 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 programme 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 behaviour, 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 programmes 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 programme 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.

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; and

• 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 behaviour 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 totalled 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 totalled 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.

In sub-Saharan Africa, national HIV prevalence rates, as published in the UNAIDS Report on the Global HIV/AIDS Epidemic -- June 2000, continue to vary widely between countries. They range from under 2% of the adult population in some West African countries to around 20% or more in the southern part of the continent, with countries in central and East Africa having rates midway between these. One must bear in mind, however, that prevalence rates do not convey people's lifetime risk of becoming infected and dying of AIDS. In the eight African countries where at least 15% of today's adults are infected, conservative analyses show that AIDS will claim the lives of around a third of today's 15-year-olds.

*Adults, as defined here, are those between 15 and 49 years old.