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The latest statistics of world AIDS infections and deaths paint a dismal portrait of what life is like on planet Earth during what everyone hopes is the peak of the AIDS epidemic. "In 2000, three million people died from HIV and AIDS, which continues to make it the leading cause-specific death in the world," says Peter Piot, MD, PhD, executive director of UNAIDS of Geneva, Switzerland. Piot discussed the latest trends and statistics at a telephone briefing held by UNAIDS and the World Health Organization (WHO) of Geneva in late November in conjunction with World AIDS Day.
Moreover, there have been 58 million people infected with HIV worldwide, a number that would encompass the entire population of France. And about 22 million people have died of AIDS. "This is more than we thought of [the number] of people who died of the other big epidemic of the 20th century, which was the Spanish flu," Piot says. (See chart on worldwide HIV/ AIDS statistics.)
Even what could be seen as good news is not as hopeful as the numbers would first appear. HIV prevalence in some sub-Saharan African nations is becoming stable, with slightly fewer cases of HIV infection than in 1998. In Uganda and Zambia, the slowing of new infections could be attributed to prevention efforts, but this is unlikely to be the case in other countries, such as Kenya and Tanzania, Piot says. Instead, there probably is epidemic fatigue at work in sub-Saharan Africa, where just about everyone at high risk for HIV probably has it, and therefore fewer people are available to become newly infected, he explains.
"The big question for Africa is what is going to happen in Nigeria, where we have a threshold, I believe, of 5% prevalence in the adult population," Piot says. "Will this go up or remain at that level?"
The infection rate in North Africa and the Middle East has increased dramatically in the past year. At the end of 1999, UNAIDS reported 220,000 people living with HIV/AIDS in that region of the world. At the end of 2000, the number had risen to 400,000. The new infection rate more than quadrupled from 19,000 in 1999 to 80,000 this past year.
UNAIDS officials also are worried about Eastern Europe, where the number of people living with HIV/AIDS climbed from 420,000 to 700,000. In Russia, it’s estimated that the number of people living with the disease has more than doubled from the 130,000 infected at the end of 1999 to 300,000 at the end of 2000. "So there were more new infections [in 2000] in Russia than there were in all previous years combined," Piot says. "Something similar is happening in smaller countries in the region, namely Estonia and Uzbekistan."
Although UNAIDS has had some difficulty estimating HIV rates, particularly in countries where testing and surveillance are uncommon, Piot and other UNAIDS officials say they are confident in the accuracy of the current estimates. Also, they are cautious about predicting when this epidemic will peak because earlier predictions have been proven wrong. "It’s definitely true that the size of the epidemic was heavily underestimated in 1990," Piot says. "I think one of the big mistakes made was [the prediction] that there would be a peak occurring several years ago."
Not only has the world not yet reached that peak, but the number of AIDS cases is nearly twice as large as earlier estimates. "No model predicted that on a countrywide basis one could reach the 35% infection rates like we have now in Botswana," Piot explains.
There is no example in history of an epidemic taking a course like HIV in sub-Saharan Africa, where there’s been a dramatic explosion of HIV infection, says Bernhard Schwartlander, MD, chief epidemiologist for UNAIDS. "The other question is where is this thing going," Schwartlander says. "As we were wrong 10 years ago, you may ask how certain can you be that our estimates are on the nose." The key to the future of the epidemic lies in Nigeria, India, and China, he says.
If Nigeria follows the pattern of South Africa, the epidemic could explode in that large nation. This all depends on the extent to which HIV transmission spreads to the general population through heterosexual contact, Schwartlander says. While there is a potential for that to occur, UNAIDS and WHO officials hope Nigeria will avert disaster by prevention efforts and making use of the world’s knowledge about HIV/AIDS, he adds. If even parts of India and China follow the trend of sub-Saharan Africa, there would be plenty of fuel to keep the epidemic burning for decades. "We don’t believe a whole country like India will have an epidemic," Schwartlander says. "But there are states in India where we have substantial spread already."
As the world has focused on the AIDS pandemic in sub-Saharan Africa, it has become increasingly clear that the disease has entirely different significance in poor nations where there is little or no access to antiretroviral therapies, testing, and treatment of opportunistic infections. In eight African countries, about one-third of the youths who are now age 15 will die of AIDS. About 15% of all adults in these countries are infected with HIV. In South Africa, where one out of every five adults has HIV, AIDS will wipe out the equivalent of $22 billion from its economy. In Botswana, where nearly 36% of adults are HIV-infected, AIDS will consume 20% of the government’s budget and reduce the income of the nation’s poorest citizens by 13%.
In sub-Saharan Africa, the number of deaths from AIDS is about 9.5% of the number of people living with HIV/AIDS infection. By contrast, in North America, the number of AIDS deaths is only about 2.2% of the number of people living with the disease. "HIV shows very much the disparities between rich and poor," says Elhadj Sy, UNAIDS representative in the United States. These disparities can be bridged through partnerships between the nations that have resources and those that do not, Sy says. "We still have an epidemic, and the numbers and figures show that, but we can also say there is hope," he adds. "This hope, we believe, should be the basis for real partnership, for an expanding response, and for a direct response."