II. Epidemic Overview
February 16, 2001
In December 2000, the Joint United Nations Programme on HIV/AIDS (UNAIDS) secretariat and the World Health Organization (WHO) reported that by the end of 2000, 36.1 million men, women and children around the world were living with HIV or AIDS and 21.8 million had died from the disease. The same year saw an estimated 5.3 million new infections globally and 3 million deaths, the highest annual total of AIDS deaths ever. The spread of HIV has brought about a global epidemic far more extensive than was predicted even a decade ago, with the number of people living with HIV or AIDS worldwide 50 per cent higher than the figure projected in 1991. Modes of transmission continue to be unprotected sex, unscreened blood and blood products, contaminated needles, mother-to-child transmission and breastfeeding.
AIDS is now found everywhere in the world but has hit hardest in sub-Saharan Africa. Africa is home to 70 per cent of adults and 80 per cent of children living with HIV, and to three quarters of the nearly 22 million people worldwide who have died of AIDS since the epidemic began. During 2000, an estimated 3.8 million people became infected with HIV in sub-Saharan Africa and 2.4 million people died. AIDS is now the primary cause of death in Africa. Today, an estimated 25.3 million Africans are living with HIV or AIDS, and in 16 countries more than one tenth of all adults (people aged 15 to 49) are infected. A tragic aspect of the epidemic is the growing population of orphaned children: of the world's 13.2 million children orphaned by AIDS, 12.1 million are in Africa.
Within sub-Saharan Africa, Southern Africa has more people living with HIV than any other region. One in four women aged 20 to 29 is infected. In West Africa, infection rates are up, and they continue to be high in East Africa. The countries of North Africa and the Middle East have so far been the least affected by the epidemic. With the exception of the Sudan and Djibouti, prevalence rates are 1 per 1000 adults or lower. However, recent data suggests that these countries are not immune to the epidemic. There are reports of increasing prevalence among pregnant women in some areas, as well as among some high-risk populations.
In 2000, for the first time the number of new infections in the region was not higher than in the previous year. Two factors may be responsible. First, the epidemic has existed for so long that it has already affected many sexually active persons, shrinking the pool of available people to whom the infection could still spread. Second, successful prevention programs in a handful of countries -- notably Uganda, parts of Zambia and the United Republic of Tanzania -- have reduced national infection rates, particularly among young people. In Senegal, the prevalence rate appears to be stable, at the low level of 1.7 per cent of the general population, while South Africa and Kenya's rates may have stabilized but at much higher rates, of 19.9 and 13 per cent, respectively.
Africa faces a triple challenge of daunting proportions: it must reduce new infections by enabling individuals to protect themselves and others; it must bring health care, support and solidarity to an increasingly infected population; and it must cope with the cumulative impact of millions of AIDS deaths on survivors, communities and national development.
Asia and the Pacific
Asia has so far escaped the high infection rates registered in Africa. Only three countries -- Cambodia, Myanmar and Thailand -- have prevalence rates exceeding 1 per cent among 15- to 49-year olds. But infections are rising. In South and South-East Asia during the past year, 780,000 adults, almost two thirds of them men, became infected. East Asia and the Pacific registered 130,000 new infections. In Thailand, the strong response that was built around a programme promoting 100 per cent condom use in commercial sex has cut prevalence in young men by over 50 per cent.
The HIV/AIDS epidemic is relatively recent in Asia and its dynamics vary greatly across the continent, both among and within countries. These differences hide broadly recognizable patterns, however, including a considerable spread of HIV among the heterosexual population, a large concentration in drug-injecting groups, and a high incidence of HIV among sex workers and among men who have sex with men. While infection rates are low in the general population in countries like China and India -- which between them account for more than one third of the world's total population -- even a low rate of infection means that huge numbers of people are affected. China is experiencing population movement that dwarfs any other in recorded history. Having practically eradicated sexually transmitted infections by the 1960s, China is now witnessing a steep rise in these rates, which could translate into higher HIV spread. In India, HIV surveillance has found prevalence rates of above 2 per cent among pregnant women in some areas, and in studies among injecting drug users in Manipur State, rates have varied between 40 and 75 per cent.
Eastern Europe and Central Asia
The countries of the former USSR present some of the most dramatic trends in the worldwide AIDS epidemic. Previously characterized by very low prevalence rates, the region now faces an extremely steep increase in the number of new infections, up from 420,000 at end-1999 to at least 700,000 one year later. In 2000 alone, more new infections were registered in the Russian Federation than in all previous years combined. Of the region's 250,000 new infections, most occurred among men, the majority of them injecting drug users. However, recent data in the Ukraine has found increasing prevalence among pregnant women.
A complicated backdrop of economic crisis, rapid social change, increased poverty and unemployment, growing prostitution and changes in sexual norms have all contributed to fuelling the rapid spread of HIV throughout the region.
The Central Asian Republics have until recently been little affected by the HIV/AIDS epidemic, but recent data from some countries suggest that the spread of HIV has begun to spread among injecting drug users.
Latin America and the Caribbean
The epidemic in Latin America is a complex mosaic of transmission patterns, in which HIV continues to spread through sex between men, sex between men and women, and injecting drug use. An estimated 150,000 adults and children became infected during 2000, bringing the total number of infected to 1.4 million. Brazil, the most populated country in the region, has the largest number of people living with HIV -- 540,000. At the same time, the number of AIDS cases, especially the number of AIDS-related deaths, has significantly decreased as a result of widespread access to life-prolonging treatments. From 1995 to 1998, mortality from AIDS in Brazil fell by 30 per cent.
The Caribbean has the highest rate of HIV infection in the world after sub-Saharan Africa, and AIDS is already the single greatest cause of death among young men and women in this region. In Haiti, the Caribbean's worst-affected country, about 8 per cent of adults in urban areas and 4 per cent in rural areas are infected. Across the Caribbean, the epidemic is spreading particularly fast through heterosexual transmission. It is driven by early sexual activity combined with frequent partner changes and age mixing -- younger women having sex with older men.
In Central American countries -- ravaged by years of armed conflict, environmental destruction and uneven social development -- the epidemic is concentrated among disadvantaged and mobile populations, with increasing prevalence rates among women.
A major challenge that cuts across the region remains the need for awareness programs aimed at men who have sex with men and injecting drug users.
High-income countries witnessed a major decline in AIDS-related deaths in the 1990s from AIDS because effective treatment, mainly antiretroviral therapy, is keeping people alive longer. However, that good news is tempered by a stall in prevention efforts and by new infections, which show no sign of slowing. In 2000, despite years of awareness about AIDS, 30,000 people in Western Europe were infected and 45,000 in North America.
Thousands of new infections occurred through unsafe sex between men. In recent years, fewer young men have lost friends to AIDS and many mistakenly consider antiretrovirals a cure, reflecting a growing complacency among this high-risk population. At the same time, stigma around homosexuality persists, hampering prevention efforts and reinforcing discriminatory attitudes.
Heterosexual sex is now the main mode of HIV transmission in some European countries. In the United States, HIV/AIDS is also affecting minority populations disproportionately, with disadvantaged young African-Americans in rural areas one of the groups at high risk of HIV infection.
The bulk of new infections continues to occur in men who have sex with men and injecting drug users, however. While prevention programs consisting of AIDS education, condom promotion, needle exchange and drug treatment have proven effective, strong political determination is now needed in order to apply energetic prevention measures and reach out to marginalized people and their partners.
This article was provided by UNAIDS. It is a part of the publication Review of the Problem of HIV in All Its Aspects. Visit UNAIDS' website to find out more about their activities, publications and services.