When AIDS first started, no one could have predicted how the epidemic would spread across the world and how many millions of lives it would change. There was no real idea what caused it and consequently no real idea how to protect against it.
Now we know from bitter experience that HIV is the cause of AIDS and that it can devastate families, communities and whole countries. We have seen the epidemic knock decades off countries' national development, widen the gulf between rich and poor nations and push already stigmatised groups closer to the margins of society. We are living in an 'international' society, and HIV has become the first truly 'international' epidemic, easily crossing oceans and borders.
However, experience has also shown us that the right approaches, applied quickly enough with courage and resolve, can and do result in lower national HIV infection rates and less suffering for those affected by the epidemic. We have learned that if a country acts early enough, a national HIV crisis can be averted.
It has been noted that a country with a very high HIV prevalence will often see this eventually stabilise, and even decline. In some cases this indicates, among other things, that people are beginning to change risky behaviour patterns, because they have seen and known people who have been killed by AIDS. It can also indicate that a large number of people are dying of AIDS.
back to topAfrica
It is in Africa, in some of the poorest countries in the world, that the impact of HIV has been most severe. At the end of 2009, there were 9 countries in Africa where more than one tenth of the adult population aged 15-49 was infected with HIV.3 In three countries, all in the southern cone of the continent, at least one adult in five is living with the virus. In Botswana, 24.8% of adults are now infected with HIV, while in South Africa, 17.8% are infected. With a total of around 5.6 million infected, South Africa has more people living with HIV than any other country.4
Rates of HIV infection are still extremely high in sub-Saharan Africa, and an estimated 1.9 million people in this region became newly infected in 2010.5 This means that there are now an estimated 22.9 million people living with HIV in sub-Saharan Africa. In this part of the world women are disproportionately at risk, accounting for 59% of all people living with HIV in the region.6 As the number of people living with HIV in the general population rises, the same patterns of sexual risk result in more new infections simply because the chances of encountering an infected partner become higher.
Although West Africa is less affected by HIV infection, the number of people living with HIV is reaching extremely high numbers in some of the larger countries. An estimated 3.3 million adults and children are living with HIV in Nigeria, accounting for nearly 10% of the global number of people living with HIV.7 Another country particularly affected by HIV in West Africa is Cote d’Ivoire, where 450,000 people are living with HIV.8
Whilst the number of people living with HIV remains high in sub-Saharan Africa, rapid scale up ofantiretroviral treatment has been associated with a significant decline the number of new HIV infections across a number of countries in this region.9 In 2010, 22 countries in sub-Saharan Africa reported a decline in HIV incidence. However, despite an increasing number of countries in the region achieving universal access to treatment, under half of those in need of antiretroviral treatment in this part of the world were receiving it at the end of 2009.10
Prevention campaigns and the number of AIDS related deaths also have a notable impact on a country’s HIV prevalence. In Uganda the estimated prevalence fell to around 7% in 2001 from a peak of about 15% in the early 1990s, by 2009 prevalence was 6.5%.11 The decrease in HIV prevalence in the 1990s is thought in part to have resulted from strong prevention campaigns although it could also have been associated with a vast number of people dying from AIDS.12
It is widely thought that North Africa managed to sidestep the global AIDS epidemic - perhaps due to its strict rules governing sexual behaviour. However, the latest UNAIDS estimates indicate that 59,000 people in North Africa and the Middle East acquired an HIV infection in 2010, bringing the total number of people living with HIV/AIDS in the Middle East and North Africa to an estimated 470,000.13 A further 35,000 people died from AIDS in this region in 2010.
back to topAsia
The diversity of the AIDS epidemic in Asia is even greater in Asia than in Africa. Half of the world's population lives in Asia, so even small differences in the infection rates can mean huge increases in the absolute number of people infected.
The total number of people living with HIV in Asia is thought to be nearly 4.8 million.14 Around half (2.4 million) of these were in India followed by China (740,000), Thailand (530,000) and Myanmar (240,000).15
National adult prevalence is under 1% in all Asian countries except Thailand. However some of the countries in this region are very large and national averages may obscure serious epidemics in some smaller provinces and states. For example, five provinces account for more than half of people living with HIV in China.16
In most Asian countries the epidemic is centred among particular high-risk groups, particularly men who have sex with men, injecting drug users, sex workers and their partners. However the epidemic has already begun to spread beyond these groups into the wider population. Some Asian countries, such as Thailand, responded rapidly to the epidemic with extensive campaigns to educate the public and prevent the spread of HIV – and have succeeded in cutting prevalence. Other very populous regions, such as China, have only recently admitted that the spread of HIV threatens their populations, and as a result their prevention work is lagging behind the spread of the virus.
The epidemic in 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. The fluidity in international markets has erupted into non-stop movement within countries and among countries, facilitating the spread of HIV. India, China, Thailand and Cambodia, to name only a few, have highly mobile populations within their borders, with people moving from state to state and from rural to urban areas.
back to topEastern Europe & Central Asia
The AIDS epidemic in Eastern Europe & Central Asia is rapidly increasing, with a rise of around 250 percent in the total number of people living with HIV since 2001. In 2010, some 1.5 million people were living with HIV, compared to 410,000 in 2001.17 AIDS claimed an estimated 90,000 lives during 2010, over ten times 2001's figure.18
In any country where rates of injecting drug use and needle sharing are high, a fresh outbreak of HIV is liable to occur at any time. This is especially true of the countries in Eastern Europe where the HIV epidemics are still young and have so far spared some cities and sub-populations. Heroin smuggled into the West crosses through a number of Eastern European countries, and its path is marked by a high concentration of injecting drug users, and a high HIV prevalence.
The Russian Federation, Ukraine, and the Baltic states (Estonia, Latvia, and Lithuania) are the worst affected, although HIV continues to spread in Belarus, Moldova and Kazakhstan, and more recent epidemics are emerging in Kyrgyzstan and Uzbekistan. An estimated 980,000 HIV-infected people were living in the Russian Federation at the end of 2009. However, as reporting of HIV cases in many areas of Russia is at best patchy, it is difficult to determine a precise figure.19 The epidemic in Eastern Europe is primarily driven by injecting drug use, and the criminalisation of this practice makes it difficult to gain an accurate picture of the proportion of drug users who are living with HIV. However, reports from St Petersburg, Russia, indicate that HIV prevalence has seen a significant rise; particularly among injecting drug users, among whom HIV prevalence is estimated at almost 60 percent.20
back to topCaribbean
Outside sub-Saharan Africa, the Caribbean has the highest HIV prevalence. In the most affected countries of the Caribbean, the spread of HIV infection is driven by unprotected sex between men and women, although infections associated with injecting drug use are common in some places, such as Puerto Rico.
The Bahamas is the worst affected nation in the region, with a prevalence of 3%.21 Haiti, where the spread of HIV may well have been fuelled by decades of poor governance and conflict, has also been hard hit by the AIDS epidemic. An estimated 1.9% of Haitian adults were living with HIV at the end of 2009, though rates vary considerably between regions. HIV transmission in Haiti is overwhelmingly heterosexual, and both infection and death are concentrated in young adults. Many tens of thousands of Haitian children have lost one or both of their parents to AIDS. Among pregnant women in urban areas, HIV prevalence appears to have fallen by half between the mid-1990s and 2003-2004. Probably much of this decline is due to an increase in the AIDS death rate, though behaviour change might also have played a part. Whilst HIV incidence has reduced by around 12 percent since 2001, there is still an urgent need for intensified prevention efforts in Haiti.22
AIDS is now high on the agendas of many governments in this region, as they are beginning to notice the significant impact of the epidemic on their medical systems and labour force. Cuba's comprehensive testing and prevention programmes have helped to keep its HIV infection rate below 0.1%, and the country provides free HIV treatment to all those in need. In 2002, the Pan Caribbean Partnership Against HIV/AIDS (PANCAP) signed a deal with six pharmaceutical companies which lowered prices for ARVs and led to wider access to treatment. In 2009, 48% of those in need of treatment in the Caribbean were receiving it.23
back to topLatin America
Around 1.5 million people were living with HIV in Latin America at the end of 2010. During that year, around 67,000 people died of AIDS and an estimated 100,000 were newly infected.24 The HIV epidemics in Latin America are highly diverse, and are fuelled by varying combinations of unsafe sex (both between men, and between men and women) and injecting drug use. In nearly all countries, the highest rates of HIV infection are found among men who have sex with men, and the second highest rates are found among female sex workers.
The Central American nation of Belize has a well-established epidemic, with the adult HIV prevalence above 2%. The virus is mainly spread through unprotected sex, particularly commercial sex and sex between men.
Commercial sex and sex between men are the major drivers of smaller epidemics elsewhere in Central America, where national HIV prevalence varies between 0.2% and 1%. Men who become infected via these routes are likely to pass the virus on to their wives and girlfriends.
Brazil had an adult HIV prevalence between 0.3 and 0.6% at the end of 2009, but, because of its large overall population, this country accounts for nearly half of all people living with HIV in Latin America. In Brazil, heterosexual transmission, injecting drug use and sex between men account for roughly equal numbers of infections.25
HIV in Argentina was initially seen as a disease of male injecting drug users and men who have sex with men. Now the virus is spread mostly through heterosexual intercourse, and is affecting a rising number of women. The other Andean countries are currently among those least affected by HIV, although risky behaviour has been recorded in many groups.
One of the defining features of the Latin American epidemic is that several populous countries, including Argentina, Brazil and Mexico, are attempting to provide antiretroviral therapy to all those who need it. The governments of these countries have encouraged local pharmaceutical manufacturers to produce cheapergeneric copies of patented medicines. This allows them to distribute drugs to a much greater proportion of their population that they would otherwise be able to help.
Treatment coverage still varies widely, but these efforts are having a definite impact. While they are improving both the length and the quality of people's lives, they are also increasing the proportion of people living with HIV, and thus HIV prevalence figures.
back to topHigh-income countries
In high-income nations, HIV infections have historically been concentrated principally among injecting drug users and gay men. These groups are still at high risk, but heterosexual intercourse accounts for a growing proportion of cases. In the United States, a quarter of people diagnosed with AIDS in 2008 were female, and three quarters of these women were infected as a result of heterosexual sex.26 In several countries in Western Europe, including the United Kingdom, heterosexual contact is the most frequent cause of newly diagnosed infections. In 2010, the number of people living with HIV in North America and Western and Central Europe reached an estimated 2.2 million.27
Very early in the epidemic, once information and services for prevention had been made available to most of the population, the level of unprotected sex fell in many countries and the demand rose for reproductive health services, HIV counselling and testing and other preventive services.
Prevention work in high-income countries has declined, and sexual-health education in schools is still not universally guaranteed, in spite of the fact that the risks of HIV are well-known to governments. Political factors have been allowed to control the HIV prevention work that is done, and politicians are commonly keen to avoid talking about any sexual issues. Furthermore, it is very hard to show that a number of people are not HIV positive who otherwise would be – and politicians like the electorate to see results.
Among gay men, the virus had spread widely before it was even identified and had established a firm grip on the population by the early 1980s. With massive early prevention campaigns targeted at gay communities, risk behaviour was substantially reduced and the rate of new infections dropped significantly during the mid- and late 1980s. Recent information suggests, however, that risky behaviour may be increasing again in some communities. People think that the danger is over because of lack of media coverage of the issues around HIV and AIDS - and many new infections continue to occur.
Some communities and countries have initiated aggressive HIV prevention efforts, particularly among high-risk groups such as injecting drug users. But in many places the political cost of implementing needle exchange and other prevention programmes has been considered too high for them to be started or maintained.
Many high-income countries suffer from the belief that HIV is something that affects other people, not their own populations. On a national level, this belief prevents policy makers and budget setters from seeing the epidemic on their own doorsteps, looking instead to the situation in areas such as Africa. Some high-income countries fund medication provision for low-income countries whilst failing to provide medicines for their own citizens who have HIV/AIDS. For example, many people cannot afford HIV treatment in America.
back to topWhere do we go from here?
Spending
Significant money is being spent particularly on providing treatment for HIV/AIDS, but there are large numbers of people still needing treatment and funding from many organisations including the Global Fund and PEPFAR, is either being reduced or at best is staying the same.
Prevention and education
HIV education has already been proved to be effective and necessary, both for people who are not infected with HIV - to enable them to protect themselves from HIV - and for people who are HIV positive - to help them to live with the virus. There is a huge wealth of educational resources available around the world, and yet in many places people still lack the knowledge they need to protect themselves.
HIV and AIDS prevention is possible, but to avoid HIV infection people need more than just factual information. People must be able to negotiate safe and responsible sexual relationships; gender inequalities must be confronted; and those who choose to have sex need access to condoms. Needle exchanges should be encouraged, as they have proven highly effective at preventing HIV transmission among injecting drug users.
Medication
Antiretroviral medication has been available through public health programmes since the first few years of the 20th century in high prevalence countries, mainly thanks to generic drugs. However, there must be increasing access to HIV treatment if millions of more deaths are to be avoided. Along with the actual availability of drugs, one of the greatest challenges is a shortage of health workers to carry out HIV tests, administer the medicines, and teach people how to use them.
back to topConclusion
HIV is recognised as a global threat, and funding and resources for the HIV epidemic have increased significantly since the 1990s. However, the global economic recession has led to declining financial commitment.28 Moreover, the availability of treatment is being outpaced by the rate of new infections; two people are infected with HIV for every one put on treatment.29 Much has been achieved but the momentum must be maintained or the hard-won achievements of the past two decades risk being reversed.
In 2011, world leaders gathered to restate their commitment to ending the HIV and AIDS epidemic worldwide. In the Political Declaration, they stated...
“HIV and AIDS constitute a global emergency, pose one of the most formidable challenges to the development, progress and stability of our respective societies and the world at large and require an exceptional and comprehensive global response”30source: Avert
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