Perspective

Global Health

The AIDS Epidemic in 2004

Robert Steinbrook, M.D.

N Engl J Med 2004; 351:115-117July 8, 2004

Article

As the AIDS pandemic enters its 24th year, the number of people living with human immunodeficiency virus (HIV) infection continues to increase steadily (see FigureFigureEstimated Number of Adults Infected with HIV, According to Region, 1980 through 2003.).1 Two thirds of infected persons are in Africa, where the epidemic exploded during the 1990s, and one fifth are in Asia, where the epidemic has been growing rapidly in recent years. As of the end of 2003, an estimated 34.6 million to 42.3 million people throughout the world were living with HIV infection, and more than 20 million had died of AIDS.2 In that year alone, about 4.8 million people became infected with HIV, and about 2.9 million died of AIDS.

The challenge of the epidemic is that despite the increases in funding, global attention, and political will, more infections and more deaths continue to occur. The participants in the 15th International AIDS Conference, which begins in Bangkok, Thailand, on July 11, will once again consider the daunting task of reversing these trends. In preparation for the meeting, the Joint United Nations Program on HIV/AIDS (UNAIDS) has updated its global statistics (see TableTableTable. The Global HIV–AIDS Epidemic at the End of 2003.).2 On the basis of better data than have previously been available from many countries, the estimation of the number of people living with HIV infection as of the end of 2003 has been revised downward — to a point estimate of 37.8 million from an earlier estimate of about 40 million. The estimated number of deaths due to AIDS has also been revised downward. Nonetheless, the statistics are merely estimates that reflect many assumptions and uncertainties; the situation in particular countries, such as those where accurate data are hardest to obtain, may be better or worse. Of all people between 15 and 49 years of age worldwide, 1.1 percent are now infected with HIV.

The global statistics make it clear that the burden remains greatest in Africa, although it is home to only 11 percent of the world's population. On that continent, AIDS has single-handedly reversed gains in life expectancy and reductions in childhood mortality. Botswana, a country of less than 2 million people, has an HIV prevalence rate among adults of 37.3 percent. Of the nine countries that have the most HIV-infected people, eight are in sub-Saharan Africa: South Africa (5.3 million), Nigeria (3.6 million), Zimbabwe (1.8 million), the United Republic of Tanzania (1.6 million), and four others where more than 1 million people are infected (the Democratic Republic of Congo, Ethiopia, Kenya, and Mozambique). An estimated 950,000 people are living with HIV in the United States, 860,000 in the Russian Federation, 840,000 in China, 680,000 in Brazil, 570,000 in Thailand, 400,000 in Sudan, 360,000 in Ukraine, 330,000 in Myanmar, 280,000 in Haiti, and 220,000 in Vietnam. (All these figures are based on a range of high and low estimates, but the estimates for India — which is one of the countries with the most infections — and for China are particularly imprecise: estimates range from 2.2 million to 7.6 million for India and from 430,000 to 1.5 million for China.)

The primary modes of transmission of HIV have changed little over the years: unprotected intercourse, unprotected penetrative sex between men, injection-drug use, unsafe injections and blood transfusions, and transmission from mother to child during pregnancy, labor and delivery, or breast-feeding. Direct blood contact, such as the sharing of drug-injection equipment, is a particularly efficient means of transmitting the virus. The specific nature of the epidemic, however, continues to vary both among regions and within countries. Globally, “unprotected sexual intercourse between men and women is the predominant mode of transmission of the virus,” according to the World Health Report 2004, which the World Health Organization (WHO) released in May.1 “In sub-Saharan Africa and the Caribbean, women are at least as likely as men to become infected.” In India, many infected persons are sex workers and long-distance truck drivers.3 There are parts of China, India, Thailand, and Vietnam where the epidemic is being driven primarily by injection-drug use. In parts of Cambodia, Myanmar, Thailand, and Vietnam, men who have sex with sex workers are a major factor. In his Perspective article in this issue of the Journal (pages 117–120), Field discusses the situation in the countries of the former Soviet Bloc, where the epidemic is also expanding.

The updated statistics highlight the global disparities in deaths due to AIDS. Without treatment, it typically takes 9 to 11 years for HIV infection to progress to full-blown AIDS. A total of 2.2 million people died of AIDS in sub-Saharan Africa in 2003 (accounting for 76 percent of the global total). By comparison, in Western Europe, where effective treatment is widely available, only 6000 people died of AIDS in 2003.2 The same year, there were a total of 12.1 million children in sub-Saharan Africa who had been orphaned by AIDS — an increase of 2.5 million from 2001. Because the epidemic is newer to Asia, fewer people there have died of AIDS than might be expected, given the number of people infected. Nonetheless, in 2003, Thailand had about 58,000 AIDS-related deaths, and China 44,000 (although these estimates are imprecise). UNAIDS is in the process of estimating the number of AIDS-related deaths in India.

AIDS in children remains concentrated in sub-Saharan Africa. More than 2 million women with HIV infection give birth each year.1 Despite the availability of effective antiretroviral treatment, about 630,000 infants contract HIV infection from their mothers each year, including 550,000 in sub-Saharan Africa.2 Of an estimated 2.1 million infected children younger than 15 years of age at the end of 2003, 90 percent were in Africa, where Nigeria alone had 290,000 infected children and South Africa 230,000. In 2003, about 490,000 children in this age group died of AIDS, including 440,000 in sub-Saharan Africa.

The theme of the International AIDS Conference is “access for all.” There are really only two approaches to the epidemic: preventing new HIV infections and providing antiretroviral treatment to people who need it. Because there is no AIDS vaccine, prevention efforts involve education about sexual and other practices, behavioral change, and reaching the groups of people, including injection-drug users and sex workers and their clients, who are at high risk for infection. The public, the medical community, and government officials all need better information about AIDS. Many infected people do not know that they are infected; others may not seek care, even if it is available, because of the stigma or potential repercussions. Cambodia and Thailand are examples of nations that have effective prevention programs, such as programs to increase condom use by sex workers and their clients.1

The WHO has set a goal of providing antiretroviral treatment to 3 million people in developing countries by the end of 2005 — the so-called 3-by-5 initiative. Even if this ambitious plan succeeds — which is by no means assured — only about half the people who need treatment will be receiving it. Despite substantial progress, there remains a large gap between the number of people in developing countries who need treatment (4 to 8 million) and the number being treated (about 400,000, as of the end of 2003, including about 100,000 in sub-Saharan Africa).1 “Dismal” would be a charitable way of describing the treatment-coverage rates in many countries. Botswana, Senegal, and Uganda are three African nations that are doing better. Brazil, which has a large-scale universal program for the distribution of antiretroviral medications, is another developing nation that has made substantial progress against the epidemic. Botswana, which has one of the highest HIV infection rates in the world, has instituted routine HIV testing and is expanding access to treatment.4

The International AIDS Conference will bring new energy, attention, and perhaps resources to the battle against the pandemic. Unfortunately, global control is not in sight.

References

References

1. 1

   The world health report 2004 — changing history. Geneva: World Health Organization, May 2004. (Accessed June 17, 2004, at http://www.who.int/whr.)
   

2. 2

   2004 Report on the global AIDS epidemic. Geneva: Joint United Nations Program on HIV/AIDS, July 2004.
   

3. 3

   Chase M. Gates Foundation bets it can stem India's AIDS crisis. Wall Street Journal. May 3, 2004:A1.
   

4. 4

   LaFraniere S. Mandatory testing bolsters Botswana in combating AIDS. New York Times. June 14, 2004:A1.
   

Citing Articles (23)

Citing Articles

1. 1

   Vitaly A. Kushnir, William Lewis. (2011) Human immunodeficiency virus/acquired immunodeficiency syndrome and infertility: emerging problems in the era of highly active antiretrovirals. Fertility and Sterility 96:3, 546-553
   CrossRef

2. 2

   A.G. Carrión, V.A. Laguna-Torres, G. Soto-Castellares, M. Castillo, E. Salazar, E. Negron, L. Kolevic, S.M. Montano, J.L. Sánchez, C.T. Bautista, R.A. Oberhelman, T.J. Kochel. (2009) Molecular Characterization of the Human Immunodeficiency Virus Type 1 among Children in Lima, Peru. AIDS Research and Human Retroviruses 25:8, 833-835
   CrossRef

3. 3

   Heather J. Zar, Michael R. Bye. 2009. Pulmonary Manifestations of Human Immunodeficiency Virus (HIV) Infection. , 28-48.
   CrossRef

4. 4

   Takatoshi Koujitani, Tai-Vu T. Ton, Stephanie A. Lahousse, Hue-Hua L. Hong, Nobuko Wakamatsu, Robert C. Sills. (2008) K- ras cancer gene mutations in lung tumors from female Swiss (CD-1) mice exposed transplacentally to 3′-azido-3′-deoxythymidine. Environmental and Molecular Mutagenesis 49:9, 720-726
   CrossRef

5. 5

   Duncan G. Fullerton, Nigel Bruce, Stephen B. Gordon. (2008) Indoor air pollution from biomass fuel smoke is a major health concern in the developing world. Transactions of the Royal Society of Tropical Medicine and Hygiene 102:9, 843-851
   CrossRef

6. 6

   Heather J. Zar. (2008) Chronic lung disease in human immunodeficiency virus (HIV) infected children. Pediatric Pulmonology 43:1, 1-10
   CrossRef

7. 7

   Heather J. Zar, Michael R. Bye. 2008. Human Immunodeficiency Virus Infection. , 575-588.
   CrossRef

8. 8

   Charles Feldman, Keith P. Klugman, Victor L. Yu, Ake Ortqvist, Christine C.C. Choiu, Maria Bernadete F. Chedid, Jordi Rello, Marilyn Wagener. (2007) Bacteraemic pneumococcal pneumonia: Impact of HIV on clinical presentation and outcome. Journal of Infection 55:2, 125-135
   CrossRef

9. 9

   Winson Y. Cheung. (2007) Bilateral Leg Swelling as the Initial and Predominant Presentation of HIV and Associated Pulmonary Arterial Hypertension. AIDS Patient Care and STDs 21:5, 293-296
   CrossRef

10. 10

    Hue-Hua L. Hong, June Dunnick, Ronald Herbert, Theodora R. Devereux, Yongbaek Kim, Robert C. Sills. (2007) Genetic alterations in K-ras andp53 cancer genes in lung neoplasms from Swiss (CD-1) male mice exposed transplacentally to AZT. Environmental and Molecular Mutagenesis 48:3-4, 299-306
    CrossRef

11. 11

    Charles Feldman. (2007) Tropical Infections in the Intensive Care Unit. Clinical Pulmonary Medicine 14:2, 65-75
    CrossRef

12. 12

    Galit Aviram, Joel E. Fishman, Phillip M. Boiselle. (2007) Thoracic Infections in Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome. Seminars in Roentgenology 42:1, 23-36
    CrossRef

13. 13

    Lily A. Gutnik, A. Forogh Hakimzada, Nicole A. Yoskowitz, Vimla L. Patel. (2006) The role of emotion in decision-making: A cognitive neuroeconomic approach towards understanding sexual risk behavior. Journal of Biomedical Informatics 39:6, 720-736
    CrossRef

14. 14

    V. L. Patel, L. A. Gutnik, N. A. Yoskowitz, L. F. O'Sullivan, D. R. Kaufman. (2006) Patterns of reasoning and decision making about condom use by urban college students. AIDS Care 18:8, 918-930
    CrossRef

15. 15

    Reinaldo Luis Menéndez Capote, María de los Ángeles Chappotten Delahanty. (2006) Utilidad del departamento de anatomía patológica en un programa de atención a pacientes con infección por el VIH/sida. Atención Primaria 38:6, 367-368
    CrossRef

16. 16

    Robert L. Cook, Kathleen A. McGinnis, Kevin L. Kraemer, Adam J. Gordon, Joseph Conigliaro, Stephen A. Maisto, Jeffrey H. Samet, Stephen Crystal, David Rimland, Kendall J. Bryant, R Scott Braithwaite, Amy C. Justice. (2006) Intoxication Before Intercourse and Risky Sexual Behavior in Male Veterans With and Without Human Immunodeficiency Virus Infection. Medical Care 44:Suppl 2, S31-S36
    CrossRef

17. 17

    E. de Vries, . (2006) Patient-centred screening for primary immunodeficiency: a multi-stage diagnostic protocol designed for non-immunologists. Clinical and Experimental Immunology 145:2, 204-214
    CrossRef

18. 18

    Stephen L. Schensul, Abdelwahed Mekki-Berrada, Bonnie K. Nastasi, Rajendra Singh, Joseph A. Burleson, Martha Bojko. (2006) Men’s Extramarital Sex, Marital Relationships and Sexual Risk in Urban Poor Communities in India. Journal of Urban Health 83:4, 614-624
    CrossRef

19. 19

    Martin A. Makary, Peter J. Pronovost, Eric S. Weiss, E. Anne Millman, David Chang, Susan P. Baker, Edward E. Cornwell, Dora Syin, Julie A. Freischlag. (2006) Sharpless Surgery: A Prospective Study of the Feasibility of Performing Operations using Non-sharp Techniques in an Urban, University-based Surgical Practice. World Journal of Surgery 30:7, 1224-1229
    CrossRef

20. 20

    Reinaldo Luis Menéndez Capote, María de los Ángeles Chappotten Delahanty, Aroldo Ruiz Pérez, Filomena Antonica Costa. (2006) Enfermedades marcadoras de sida en un grupo de pacientes africanos con infección por VIH/sida. Enfermedades Infecciosas y Microbiología Clínica 24:4, 287-288
    CrossRef

21. 21

    Kara Wools-Kaloustian, Silvester Kimaiyo, Lameck Diero, Abraham Siika, John Sidle, Constantin T Yiannoutsos, Beverly Musick, Robert Einterz, Kenneth H Fife, William M Tierney. (2006) Viability and effectiveness of large-scale HIV treatment initiatives in sub-Saharan Africa: experience from western Kenya. AIDS 20:1, 41-48
    CrossRef

22. 22

    Charles Feldman. (2005) Pneumonia associated with HIV infection. Current Opinion in Infectious Diseases 18:2, 165-170
    CrossRef

23. 23

    Rino Rappuoli. (2004) From Pasteur to genomics: progress and challenges in infectious diseases. Nature Medicine 10:11, 1177-1185
    CrossRef