The UNAIDS Report on the Global HIV/AIDS Epidemic, released in July 2002, tracks the spread of the disease, points out why HIV constitutes a severe development crisis, and chronicles the hits and misses in the battle to control the epidemic. A summary.
In 2001, around the world, an estimated 5 million people became infected with HIV /AIDS, 800,000 of them were children. Over the next decade, without effective treatment and care, they will join the ranks of the more than 20 million people who have died of AIDS since the first clinical evidence of HIV/AIDS was reported in 1981.
More than 60 million people have been infected with the virus, since the epidemic began. In the 45 most-affected countries, it is projected that, between 2000 and 2020, 68 million people will die earlier than they would have in the absence of AIDS.
Despite well-documented and successful HIV- prevention programmes in a few countries, the HIV/AIDS epidemic continues to spread. HIV/AIDS is now by far the leading cause of death in sub-Saharan Africa, and the fourth- biggest global killer.
Dozens of countries are already in the grip of serious HIV/AIDS epidemics, and many more are on the brink. Twenty years into the HIV/AIDS epidemic, the majority of countries in the world still register national HIV prevalence rates of less than one per cent, for the global epidemic is still in its early stages. But two decades ago, there was no country in the world that had nationwide adult HIV prevalence rates above one per cent; today there are nearly 50 and in 12 of them, national adult HIV prevalence is estimated to be more than 10 per cent. In fact no country today is immune to the HIV epidemic.
One of the most devastating epidemics in human history, HIV/AIDS also threatens development in major regions of the world.
Enabling people to protect themselves against HIV and providing adequate and affordable treatment and care to people living with the virus are two of the biggest challenges facing humankind today.
The HIV/AIDS crisis today
Sub-Saharan Africa, remains by far the worst-affected region in the world.
Approximately 3.5 million new infections occurred in 2001 alone, bringing the total number of people living with HIV/AIDS in sub-Saharan Africa to 28.5 million. The estimated number of children orphaned by AIDS in the region is 11 million.
The HIV/AIDS epidemic continues to spread in Asia and the Pacific.
Low national prevalence rates conceal serious, localised epidemics in several areas, including China and India, where large numbers of people are infected and affected -proof that national HIV prevalence figures do not tell the full story of the epidemic. In fact, the region as a whole is home to more people living with HIV/AIDS than any other (besides sub-Saharan Africa) - an estimated 6.6 million people at the end of 2001, including the 1 million adults and children who were newly infected with HIV in that year. Of these, less than 30,000 people are on antiretroviral treatment in this region. Also, Asia is estimated to have the largest number of injecting-drug-related HIV cases.
India, too, is experiencing serious, localised epidemics. At the end of 2001, India 's national adult HIV prevalence rate was under one per cent, yet this meant that an estimated 3.97 million Indians were living with HIV/AIDS - more than in any other country besides South Africa.
The epidemic is spreading among the general population and beyond groups with high-risk behaviour. Indeed, median HIV prevalence among women attending antenatal clinics was higher than two per cent in Andhra Pradesh and exceeded one per cent in four other states - Karnataka, Maharashtra, Manipur and Tamil Nadu. India 's epidemic is also strikingly diverse, both among and within states. The factors facilitating the rapid spread of HIV/AIDS epidemics are present throughout the region.
HIV infection levels in Bangladesh are still low, even among population groups that are at high risk of infection. But the risk factors are so widespread that, once the virus is introduced, it will probably spread very rapidly. Only 0.2 per cent of brothel-based sex workers in central Bangladesh, for example, said they used condoms consistently during paid sex, while condom use is also very low among men who have sex with men. Ninety three per cent of men who sell sex to other men in central Bangladesh said they seldom or never used condoms; among men buying sex, 95 per cent gave the same answer. Meanwhile, needle-sharing is a common practice among injecting drug users, with a 2001 survey showing that over 60 per cent of users in northern Bangladesh and 93 per cent in central Bangladesh shared equipment.
In China, home to a fifth of the world 's people, HIV is moving into new groups of the population and raising the spectre of a much more widespread epidemic. Surveillance data on China 's huge population is sketchy, but it is estimated that around 850,000 Chinese were living with HIV/AIDS in 2001, with reported HIV infections having risen more than 67 per cent in the first six months of 2001.
There are also signs of heterosexually transmitted HIV epidemics in at least three provinces, where many tens of thousands of rural villagers in Henan Province of central China have become infected since the early -1990s by selling their blood to collecting centres that did not follow basic blood-donation safety procedures. There are concerns that similar tragedies might have unfolded in other provinces, including Anhui and Shanxi. Overall, it has been estimated that 150,000 (and possibly many more) people may have been infected through these practices.
Reported sexually transmitted infections increased significantly from
430,000 cases in 1997 to 860,000 cases in 2000.This suggests that unprotected sex with non-monogamous partners is on the rise in China.
HIV/AIDS continues to threaten high-income countries too, such as the US, UK, Sweden where approximately 75,000 people became infected with HIV in 2001. A total of 1.5 million people are now living with the virus in these countries.
An estimated 200 million women around the world become pregnant each year, of whom about 2.5 million are HIV-positive. One of the biggest challenges is enabling the nearly 99 per cent of pregnant women who have not acquired the virus to remain HIV-negative.
In 2001 alone, an estimated 800,000 children were newly infected with HIV - almost all through mother-to-child transmission.
Despite significant achievements in the past two years, the vast majority of the 38 million people living with the virus in low- and middle-income countries at the end of 2001 remained severely deprived of even basic medications for treating HIV-related illnesses and for relieving pain.
Despite recent reductions in the price of antiretroviral drugs, the lowest prices currently on offer still greatly exceed the annual per capita health expenditures of most low-and middle-income countries. Health systems in such countries are ill-equipped to deliver effective treatment of HIV/AIDS and its associated illnesses. Finally, in places where these services are available, fear and stigma associated with HIV/AIDS and the abuse of human rights of people living with the virus contribute to the ongoing reluctance among many people to come forward for testing and treatment.
AIDS and its impact on development gains: The challenge to low- and middle-income countries
AIDS marks a severe development crisis and efforts to contain the spread of infection are vital.
Since the 1960s, most countries have made impressive strides in human development. However, such achievements are being undermined as countries lose young, productive people to the epidemic, economies stumble, households fall into deeper poverty, and the costs of the epidemic mount.
AIDS erodes human development achievements, deepens poverty, and further hinders access to education, health and viable livelihoods, in the following ways:
In many countries, AIDS is erasing decades of progress made in extending life expectancy. Average life expectancy in sub-Saharan Africa is now 47 years, when it would have been 62 years without AIDS.
The toll of HIV/AIDS on households can be very severe. In many cases, the presence of AIDS means that the household will dissolve, as parents die and children are sent to relatives for care and upbringing. A study in Zambia revealed that 65 per cent of households in which the mother had died had dissolved.
But much happens to a family before this dissolution occurs. HIV/AIDS strips the family of assets and income-earners, because of mounting medical expenses, further impoverishing those already poor. Once households are stripped of their productive assets, the chances of them recovering and rebuilding their livelihoods grow ever slimmer.
A decline in school enrolment is one of the most visible effects of the epidemic. The contributing factors include - the removal of children from school to care for parents and family members; an inability to afford school fees and other expenses; AIDS-related infertility and a decline in birth rate, leading to fewer children; and the fact that more children are themselves infected and do not survive through the years of schooling.
Besides affecting the quality of education, demands on the health and welfare services might divert resources from education to other sectors.
Enterprises and workplace
HIV/AIDS dramatically affects labour, setting back economic activity and social progress. The vast majority of people living with HIV/AIDS worldwide are between the ages of 15 and 49 -in the prime of their working lives. AIDS weakens economic activity by squeezing productivity, adding costs, diverting productive resources, and depleting skills.
One of the more unfortunate responses to a prime-age adult death in poorer
households is that of removing the children (especially girls) from school as school uniforms and fees become unaffordable and the girls' labour and income-generating potential are required in the household.
The burden of coping with an HIV-infected family member especially rests
on women as the demands for their income-earning labour, household work, child-care and care of the sick multiply. As men fall ill, women often step into their roles outside the homes. In parts of Zimbabwe, women are moving into the traditionally male-dominated carpentry industry, for instance.
Food security and hunger
HIV/AIDS poses a potentially major threat to food security and nutrition, mainly by diminishing the availability of food (due to falling production and loss of family labour, land, livestock and other assets) and reducing access to food as households have less money.
In all affected countries, the HIV/AIDS epidemic is putting additional pressure on the health sector. In countries where per capita health expenditure is low, extending prevention and care for sexually transmitted infections, counselling and testing, prevention of mother-to-child transmission services, and HIV treatment and care strains health budgets and systems. As the epidemic matures, the demand for care of those living with HIV/AIDS rises, as does the toll among health workers.
The response to AIDS: Hits and misses
The impact of AIDS on societies and economies, can however, be dealt with. The need is to integrate care and support with prevention efforts.
Whether through community action or programmes, institutions can be retooled and capacity can be built to defend societies' from the worst ravages of AIDS.
The success stories of Cambodia, Senegal, Thailand, Uganda and urban Zambia, as well as a number of high-income countries, show that comprehensive prevention approaches are effective.
By translating national, local examples of success into a global movement, the epidemic can be contained. The report cites a number of examples from the sub-continent and other countries.
* Sahodaran (in Chennai, India) and the Bandhu Social Welfare Society (in Dhaka, Bangladesh) are community-based agencies providing both outreach and on-site services to men who have sex with men. 'Safe spaces' in their central offices offer stigmatised and marginalised men an opportunity to socialise and to access a range of services. The Bandhu Social Welfare Society has an innovative clinic service for sexually transmitted infection diagnosis and treatment and Sahodaran has contributed strongly to national advocacy.
* For many years, Manipur in India was emblematic of a region in the grip of a rising injecting-drug-related HIV epidemic. By the late-1990s, there were already an estimated 40,000 injecting drug users in Manipur, many of whom were HIV-positive. To many observers, it seemed a 'lost cause'. But, after studies revealed that most of the users shared injecting equipment because they feared arrest if caught with needles and syringes, the Society for HIV/AIDS and Lifelines Operations (SHALOM) took the bold step of setting up a needle-and-syringe-exchange programme in Churachandpur township. Police were persuaded not to harass SHALOM workers or users found with injecting equipment. HIV incidence among users dropped from almost 77 per cent in 1997 to just under 59 per cent in 2001 - still high, but a marked decrease. Persuaded by the effectiveness of the programme, the Manipur minister of state for health integrated the approach into the official state AIDS policy.
*The Sonagachi Sex Worker Project in Kolkata is another success. About one-third of the 5,000 sex workers operating here come from Bangladesh and Nepal. Most work out of brothels. Extensive surveys were done of sex workers, clients, boyfriends and sex workers' children's needs. Sex workers themselves took part in the project's design and operation. Gradually, the scale and impact of the project grew, as women's groups, legal rights organisations and some government agencies backed the sex workers' bids to reform the social system in which they worked. The project has been replicated in 30 red light districts reaching more than 31,000 sex workers in the state of West Bengal, and covering almost the entire state. The Sonagachi principle has also spread to Bangladesh, where both brothel-and street-based workers have been mobilised. Increasingly, in all these sites, sex workers' communities have been involved in community development, non-formal education, community banking schemes, vocational training, and children's schooling.
*When national programmes work in partnership with non-governmental and community-based organisations, a great deal can be accomplished. An example of such collaboration is the Continuum of Care Project in Manipur. Its cooperative approach links non governmental and community-based organisations (including World Vision, Sneha Bhavan, Manipur Network of Positive People) to government health services, and permits many people (particularly those who are hard to reach) to access services they might otherwise be unaware of or shun.
*Brazil is a prominent example where comprehensive care of infected people had been combined with a renewed commitment to prevention. The numbers of new HIV infections have been kept much lower than forecast less than a decade ago. Also the country's 1996 decision to establish a legal right to free medication has brought treatment and care to more than 100,000 HIV-positive people. As a result, the number of annual AIDS deaths in Brazil in 2000 was a third of that in 1996.
However even in the poorest countries, in urban areas, in particular, there is already a huge shortfall in HIV treatment.
An estimated 6-9 billion condoms are distributed annually (including those sold commercially) - considerably fewer than the estimated 8-24 billion condoms that are needed if all populations are to be able to protect themselves from HIV and other sexually transmitted infections. In sub-Saharan Africa alone, the condom gap has been estimated at 2 billion a year.
The United Nations Population Fund estimates that the number of condoms needed to prevent HIV/AIDS and other sexually transmitted infections will more than double in the next 15 years.
HIV/AIDS epidemics in many countries are concentrated in specific populations that are often marginalised and vulnerable to a broad range of health and psychosocial difficulties apart from, or in addition to, HIV/AIDS.
Complex and interlinked factors influence their vulnerability. Firstly, their socioeconomic circumstances (such as poverty, lack of education, displacement, separation from families, etc.) may hinder their ability to protect themselves, and may reduce their access to HIV prevention and care information, services and commodities.
Resources needed to tackle the AIDS scourge
An estimated US $400-500 million is currently spent on HIV vaccine research annually, with most of this going into basic research.
But AIDS-related spending needs to rise to US$7-10 billion to meet the main prevention and care needs of low-and middle-income countries. A detailed calculation of the estimated total financial need in low-and middle-income countries for HIV/AIDS, done by an international team convened by the UNAIDS Secretariat, has shown that, in 2005,US $9.2 billion will be required. In creating optimal conditions for national governments to increase their AIDS efforts, more funds need to be liberated through debt relief or debt cancellation. But there is also no escaping the need for the world's high-income countries to step up their support for the world's poorer countries. Up to 80 per cent of total resources needed in sub-Saharan Africa and South and South-East Asia will have to come from international sources.
This projected, staggered rise in spending assumes that many countries cannot immediately mount the entire range of activities needed. Indeed, most countries would take several years to build up the human and infrastructural capacity to programme their expanded responses. These projections are based on conservative estimates of possible costs for each of the 18 prevention, treatment and care services used in the calculations of overall resource needs, and do not include costs for building up infrastructure.
If expenditures on AIDS were to remain at current levels, the funding shortfall would grow to at least US $7 billion by 2005, unless significant amounts of additional funding become available.