The
Next Wave of HIV/AIDS: Nigeria,
Ethiopia, Russia, India, and China
Intelligence
Community Assessment
September 2002
ICA
2002-04D
Prepared
under the auspices of David F. Gordon, formerly
National Intelligence Officer for Economics and
Global Issues. Additional copies of this assessment
can be downloaded from the NIC public website
at www.odci.gov/nic or obtained from Karen Monaghan,
Acting National Intelligence Officer for Economics
and Global Issues.
Scope
Note
This
Intelligence Community Assessment (ICA) highlights
the rising HIV/AIDS problem through 2010 in
five countries of strategic importance to the
United States that have large populations at
risk for HIV infection: Nigeria, Ethiopia,
Russia, India, and China. The paper does not
attempt to make aggregate projections about
global trends. The five countries were selected
because they are:
- In
the early-to-mid-stages of an HIV/AIDS epidemic.
- Led
by governments that have not yet given the issue
the sustained high priority that has been key
to stemming the tide of the disease in other countries.
This
paper builds on the December 1999 unclassified
National Intelligence Estimate, The Global
Infectious Disease Threat and Its Implications
for the United States, which
focused on the spread of AIDS in the context of
other growing infectious diseases. Excerpts from
the 1999 Estimate presage the expansion of the
HIV/AIDS epidemic beyond the geographic focal
point of southern Africa:
Although
infection and death rates for HIV/AIDS have
slowed considerably in developed countries…the
pandemic continues to spread in much of the
developing world. Sub-Saharan Africa currently
has the biggest regional burden, but the disease
is spreading quickly in India, Russia, China,
and much of the rest of Asia.
According
to UNAIDS, Asia alone is likely to outstrip Sub-Saharan
Africa in the absolute number of HIV carriers
by 2010.
The
National Intelligence Council (NIC) convened a
conference of US Government officials and outside
experts to share their current assessments and
expectations for the future of the disease in
these five countries. Given the range of estimates
of the current numbers of infected people and
the lack of consensus on which infectious disease
models calculate future rates most accurately,
the future projections in this paper represent
consensus estimates by experts. The NIC, in addition
to coordinating the draft within the Intelligence
Community, had the paper reviewed by several leading
experts from outside the Intelligence Community
as part of its effort to seek out expertise from
inside and outside the government. The experts
included Dr. Anthony Fauci, Director of the National
Institute of Allergy and Infectious Diseases at
the National Institutes of Health; Dr. Robert
C. Gallo, Director of the Institute of Human Virology
and Professor of Medicine at the University of
Maryland Biotechnology Institute; Dr.
Phillip Nieburg, Associate Director for Public
Health Practice in the Global AIDS Program for
the Centers for Disease Control; and Dr.
Nicholas Eberstadt of the American Enterprise
Institute.
Contents
|
Page |
Scope
Note |
1 |
Summary |
4 |
Discussion |
7 |
The
Scope of the Next Wave
Country
Profiles |
7
9 |
Prospects
for Control
The Leadership
Challenge
Weak Healthcare
Infrastructure
Treatment |
16
17
20
21 |
Implications
Nigeria and
Ethiopia: Hardest Hit
Russia: HIV/AIDS
Worsening Demographic Situation
India and
China: A Big Problem But Probably Not Devastating
International
Implications |
22
22
24
24
26 |
Summary
The
number of people with HIV/AIDS will grow significantly
by the end of the decade. The increase will be
driven by the spread of the disease in five populous
countries—Nigeria, Ethiopia, Russia, India, and
China—where the number of infected people will
grow from around 14 to 23 million currently to
an estimated 50 to 75 million by 2010.[1]
This estimate eclipses the projected 30 to 35
million cases by the end of the decade in central
and southern Africa, the current focal point of
the pandemic.
- We
project China will have 10 to 15 million HIV/AIDS
cases, and India is likely to have 20 to 25 million
by 2010—the highest estimate for any country.
By 2010, we project Nigeria will have 10 to 15
million cases, Ethiopia 7 to 10 million, and Russia
5 to 8 million.
HIV/AIDS
is spreading at different rates in the five countries,
with the epidemic the most advanced in Nigeria
and Ethiopia. In all countries, however, risky
sexual behaviors are driving infection rates upward
at a precipitous rate.
- Adult
prevalence rates—the total number of people infected
as a percentage of the adult population—are substantially
lower in Russia, India, and China, where the disease
remains concentrated in high-risk groups, such
as intravenous drug users in Russia and people
selling blood plasma in China, where some villages
have reported 60 percent infection rates.
- Nevertheless,
the disease is spreading to wider circles through
heterosexual transmission in India, the movement
of infected migrant workers in China, and frequent
prison amnesty releases of large numbers of infected
prison inmates and rising prostitution in Russia.
It
will be difficult for any of the five countries
to check their epidemics by 2010 without dramatic
shifts in priorities. The disease has built up
significant momentum, health services are inadequate,
and the cost of education and treatment programs
will be overwhelming. Government leaders will
have trouble maintaining a priority on HIV/AIDS—which
has been key to stemming the disease in Uganda,
Thailand, and Brazil—because of other pressing
issues and the lack of AIDS advocacy groups.
- The
governments of Nigeria, India, and China are beginning
to focus more attention on the HIV/AIDS threat.
- Even
if the five next-wave countries devote more resources
to HIV/AIDS programs, implementation is likely
to miss significant portions of the population,
given weak or limited government institutions
and uneven coordination between local and national
levels.
- Nigeria
and Ethiopia have very limited public services
to mobilize. Russia is beset by other major public
health problems. China has decentralized most
responsibility for health and education issues
to local governments that often are corrupt.
- India
has taken some steps to improve its healthcare
infrastructure to combat HIV/AIDS, but the government
has few resources to treat existing infections
and must cope with other major health problems
such as tuberculosis (TB), which has become linked
to the spread of HIV/AIDS.
The
rise of HIV/AIDS in the next-wave countries is
likely to have significant economic, social, political,
and military implications. The impact will vary
substantially among the five countries, however,
because of differences among them in the development
of the disease, likely government responses, available
resources, and demographic profiles.
-
Nigeria
and Ethiopia will be the hardest hit, with the
social and economic impact similar to that in
the hardest hit countries in southern and central
Africa—decimating key government and business
elites, undermining growth, and discouraging
foreign investment. Both countries are key
to regional stability, and the rise in HIV/AIDS
will strain their governments.
-
In Russia, the rise in HIV/AIDS will exacerbate
the population decline and severe health problems
already plaguing the country, creating even greater
difficulty for Russia to rebound economically.
These trends may spark tensions over spending
priorities and sharpen military manpower shortages.
-
HIV/AIDS will drive up social and healthcare costs
in India and China, but the broader economic and
political impact is likely to be readily absorbed
by the huge populations of these countries. We
do not believe the disease will pose a fundamental
threat through 2010 to their status as major regional
players, but it will add to the complex problems
faced by their leaders. The more HIV/AIDS spreads
among young, educated, urban populations, the
greater the economic cost of the disease will
be for these countries, given the impact on, and
the need for, skilled labor.
The
growing AIDS problem in the next-wave countries
probably will spark calls for more financial and
technical support from donor countries. It may
lead to growing tensions over how to disburse
international funds, such as the Global Fund for
AIDS, TB and Malaria.
The
cost of antiretroviral drugs—which can prolong
the lives of infected people—has plunged in recent
years but still may be prohibitively high for
populous, low-income countries. More importantly,
the drug costs are only a portion of HIV/AIDS
treatment costs. Drug-resistant strains are likely
to spread because of the inconsistent use of antiretroviral
therapies and the manufacture overseas of unregulated,
substandard drugs.
-
If an effective vaccine is developed in the coming
years, Western governments and pharmaceutical
companies will come under intense pressure to
make it widely available.
- The
next-wave countries are likely to seek greater
US technical assistance in tracking and combating
the disease.
HIV
Statistics: Official and Unofficial Estimates
Reliable
statistics on HIV/AIDS are difficult or
impossible to get for many countries.
UNAIDS maintains the most comprehensive
databases of information in the world
on AIDS, but the UN organization relies
on official government statistics from
each country—which experts believe sometimes
understate the number of infected people.
Our estimates of infection rates and their
likely trajectories go beyond the official
statistics by incorporating the assessments
of academics and NGOs with field experience.
As a result, all of the numbers in this
assessment should be viewed as rough estimates,
and our projections employ ranges to convey
the general magnitude of the disease within
a relatively high margin of error.
Governments
often do not spend enough money to get
quality infection surveillance because
they have other budget priorities, do
not want to acknowledge the extent of
the epidemic, and the drug users and prostitutes
at high risk of infection are not key
political constituencies.
-
It is difficult to get data on HIV prevalence
rates in foreign military ranks, which
harbor significant numbers of infected
men.
Even
if testing is available, many people do
not get tested because of denial, stigma,
discrimination, or resignation.
- Intravenous
drug users, prostitutes, and homosexuals
usually are reluctant to identify themselves
for fear of punishment.
- Some
avoid testing when healthcare and treatment
for the disease is unavailable.
Infection
surveillance of women attending prenatal
clinics is considered the most reliable
indicator of adult HIV prevalence in the
general population. But even these statistics
can be affected by poor clinic attendance
when fee for services or mandatory HIV
testing is instituted.
|
Discussion
The
Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia,
India, and China
The
Scope of the Next Wave
The
HIV/AIDS pandemic continues to spread around the
world at an alarming rate, and the number of people
with the disease will grow significantly by the
end of the decade, as it becomes more geographically
diffuse. By 2010, we estimate that five countries
of strategic importance to the United States—Nigeria,
Ethiopia, Russia, India, and China—collectively
will have the largest number of HIV/AIDS cases
on earth (see figure 1). These five countries,
which comprise over 40 percent of the world’s
population, are in the early-to-mid-stages of
the epidemic.
- All
five countries are major regional or global players,
and efforts to manage the growing AIDS problem
have the potential to impinge upon their political
and economic outlook.
- The
disease also is a special cause for concern in
these five states because their governments have
yet to demonstrate the kind of sustained commitment
that has been key to managing the spread of HIV/AIDS
in such countries as Uganda, Thailand, and Brazil.
-
HIV
adult prevalence [3] in central and southern Africa currently is the
highest in the world. For example, as of July
2002, UNAIDS estimated that 39 percent of adults
in Botswana (300,000 people) and 20 percent
of adults in South Africa (4.7 million people)
were HIV positive.
Although
current adult prevalence rates in the next-wave
countries range from less than one percent in
China to as high as 18 percent in Ethiopia, the
number of people infected already is substantial,
ranging from 1 to 2 million in China and Russia
to upwards of 5 million in Nigeria and India (see
table 1).
Table:
1 |
Current |
2010 |
Current
and Projected HIV/AIDS Infected Adults |
Number
Infected
(Government Data)
(millions) |
Number
Infected
(Expert
Estimates)
(millions) |
Adult
Prevalence
Rate 2002*
(percent) |
Number
Infected
(Expert
Estimates)
(millions) |
Adult
Prevalence Rate
2010*
(percent) |
Nigeria |
3.50 |
4
– 6 |
6.00
– 10.00 |
10
– 15 |
18
– 26 |
Ethiopia |
2.70 |
3
– 5 |
10.00
– 18.00 |
7
– 10 |
19
– 27 |
Russia |
0.18 |
1
– 2 |
1.30
– 2.50 |
5
– 8 |
6
– 11 |
India |
4.00 |
5
– 8 |
0.90
– 1.40 |
20
– 25 |
3
– 4 |
China |
0.80 |
1
– 2 |
0.14
– 0.27 |
10
– 15 |
1.3
– 2 |
The
spread of HIV/AIDS in the next-wave countries
will be difficult to check by 2010. Treatment
of existing infections and prevention of new infections
is minimal. Even if effective programs could
be implemented in the coming years, such practical
concerns as cost, scale, and experience in health
service delivery probably will result in the omission
of services to a large number of infected individuals,
and the burden of disease will continue to rise.
- We
project that China probably will have 10 to 15
million HIV/AIDS cases by 2010. India is likely
to have 20 to 25 million—higher than projected
for any other country. We estimate Nigeria probably
will have 10 to15 million cases, Russia 5 to 8
million, and Ethiopia 7 to 10 million.
Country
Profiles
Nigeria.
The HIV/AIDS epidemic in Nigeria is significantly
ahead of that in India, China, and Russia—already
advancing well beyond high-risk groups and into
the general population. The official adult prevalence
rate is almost 6 percent, but unofficial estimates
range as high as 10 percent—which represents 4
to 6 million people infected.
Heterosexual
transmission of the HIV virus is the primary mode
of spread in Nigeria, and infections appear to
be as numerous in rural areas as in the cities.
The reported rate of infection apparently varies
significantly by region, with the lowest reported
rate found generally in the predominantly Muslim
northern parts of the country (see figure 3).
Infections are most numerous among men ages 20
through 24, but some experts caution that infection
rates are rising quickly in young women.
Figure
3
Nigeria: HIV Prevalence Among Women Attending
Prenatal
Clinics, 2001
Given
the already advanced state of the disease and
the government’s limited capacity to respond,
we expect HIV/AIDS to infect as many as 10 to
15 million people by 2010. This number would
constitute roughly 18 to 26 percent of adults—close
to the current rates in some of the hardest hit
countries in southern Africa.
Ethiopia.
Ethiopia’s adult prevalence rate—estimated at
between 10 and 18 percent—is the highest among
the five countries, indicating that—like Nigeria—the
disease has moved significantly into the general
population. Government figures cite 2.7 million
Ethiopians currently as HIV positive, although
experts believe the actual number may be between
3 and 5 million. Adult prevalence is much higher
in cities (13 to 20 percent) than in rural areas
(5 percent) (see figure 4). The generally poor
health of Ethiopians as a result of drought, malnutrition,
limited healthcare, and other infectious diseases
has caused HIV to progress rapidly to AIDS. Heterosexual
transmission is the primary mode of spread, and
people with multiple partners—especially those
with sexually transmitted diseases (STDs) and
prostitutes—have significantly higher infection
rates, ranging from 30 to 40 percent in STD-positive
individuals to 50 to 70 percent in prostitutes.
Figure
4
Ethiopia: HIV Prevalence Among Women Attending
Prenatal
Clinics, 1999-2000
Unlike
conditions in other next-wave countries, war has
significantly contributed to the spread of the
disease in Ethiopia. Many soldiers contracted
HIV/AIDS during the civil war in the 1980s by
having contact with multiple sex partners. When
the war ended in 1991, thousands of infected soldiers
and prostitutes returned home, spreading HIV/AIDS
in their villages and towns.
- Another
surge of infections may be underway. Ethiopia
has demobilized 150,000 soldiers over the last
two years as the conflict with Eritrea has wound
down. More troops will be sent home as the border
dispute is settled.
- As
soldiers demobilize, prostitutes—who have even
higher rates of infection—disperse around the
country as well.
Looking
ahead, we expect 7 to 10 million Ethiopians probably
will be infected by 2010 because of the high current
rate of adult prevalence, widespread poverty,
low educational levels, and the government’s limited
capacity to respond more actively.
Russia.
Official statistics list about 200,000 people
in Russia as HIV positive, but the government’s
sampling efforts are poor, especially outside
major cities. Academic and medical experts believe
the actual number probably is between 1 and 2
million, which would indicate an adult prevalence
rate of around 1 to 2 percent.
-
Infection
rates vary significantly across the country,
with the biggest concentrations in cities (see
figure 5). Males comprise 77 percent of all
the infected, and 60 percent of infected men
are between the ages of 17 and 25.
Intravenous
drug use drives the spread of the disease in Russia
more than in any of the other next-wave countries.
An estimated 80 to 90 percent of all infections
in Russia stem from intravenous drug use, which
is rampant and rising.
- In
most countries, the concentration of HIV among
drug users and generally low adult prevalence
rates would suggest the disease still has not
broken out into the general population. Experts
warn, however, that drug use is so widespread
in Russia that many users are integrated into
society with jobs and families, suggesting the
disease is moving into the mainstream.
Prostitutes
and prison inmates—many of whom are intravenous
drug users—are contributing to the spread of the
disease. An estimated 20 to 25 percent of intravenous
drug users in prison, where there is easy access
to drugs, are HIV positive.
- Russia’s
frequent use of prison amnesty programs that release
infected inmates will worsen the HIV/AIDS epidemic
among the general population unless accompanied
by prevention and treatment programs.
Figure
5
Russia: HIV Prevalence Among Various Groups According
to Russian Statistics
- The
growing number of prisoners infected with both
HIV and tuberculosis is compounding the burden;
HIV infection increases the likelihood that a
person with TB will develop the active, contagious
form of TB.
- Moreover,
laws allowing the incarceration of suspects for
up to two years prior to be-ing charged create
a revolving door of inmates who often are intravenous
drug users infected with TB and/or HIV.
HIV/AIDS
also is a growing problem in the Russian military
services. Currently up to one-third of prospective
conscripts are deemed unfit for service owing to
the effects of prior drug use (chronic hepatitis
or HIV infection). Amongst enlisted men, ground
troops have the largest number of infections, while
strategic military forces and airborne troops have
the lowest.
Driven
by widespread drug use, inadequate healthcare infrastructure,
and the government’s limited capability to respond,
the number of HIV positive people probably will
rise to 5 to 8 million by 2010. This condition
would reflect an adult prevalence rate of around
6 to 11 percent, exacerbating Russia’s population
decline.
India.
According to official Indian Government statistics,
4 million people in India are HIV positive. India
also has high rates of TB, however, which may be
indicative of undiagnosed HIV/AIDS. Some experts
believe that 5 to 8 million Indians may be infected.
We
expect
India to have the largest number of people with
HIV/AIDS in the world within the next few years.
But even with the large number of infected people,
India’s adult prevalence rate is only around one
percent.
- Adult
prevalence rates vary across the country, however,
in some areas (Mumbai and Pune) the rate is as
high as 4 percent, according to unofficial estimates
(see figure 6).
Figure
6
India: HIV Prevalence Among Women Attending Prenatal
Clinics, Commercial Sex Workers, and Injecting Drug
Users, 2001
Heterosexual
transmission is the driver of infections, except
in two regions (Nagaland and Manipur) where intravenous
drug use is a serious problem. Thirty to 60 percent
of prostitutes and up to 15 percent of all truck
drivers are infected with HIV/AIDS.
- Sexually
transmitted diseases and reproductive tract infections
are rampant in India, increasing the risk that
HIV/AIDS infections will be transmitted.
The
current trajectory of the disease, limited public
awareness, and the lack of resources for a major
anti-AIDS program will continue to drive the spread
of the disease. Approximately 20 to 25 million
Indians are likely to be infected by 2010—even
if the disease does not break out significantly
into the mainstream population.
China.
China has significantly raised its official estimate
of the number of HIV-positive people over the
last two years from 600,000 to one million. The
UN now estimates that 1.5 million are infected,
while other experts believe the number probably
is closer to 2 million or even higher. Owing
to China’s massive population, even these higher
figures, however, represent an adult prevalence
rate of only 0.15 to 0.25 percent.
HIV:
The Science of the Disease
HIV-1
is a fatal infection acquired by contact
with the blood or body fluids of an
infected person. A transfusion with
infected blood almost always results
in spread of the virus, and children
born to infected mothers have an up
to 40 percent chance of contracting
the virus—prior to birth, during birth,
or through breastfeeding. The transmission
rate of the disease through sexual contact
ranges from 1 to 3 percent. Reusing
infected needles results in infections
less than one percent of the time.
Sexually
transmitted diseases or reproductive
tract infections greatly increase the
risk of contracting HIV, and uncircumcised
men transmit HIV and other STDs to their
partners more frequently than circumcised
men.
As
the disease progresses, a type of infection-fighting
white blood cell—the CD4 positive-t
cell—decreases, leading to an irreversible
loss of immune function. This period
is marked by many illnesses, or unusual
“opportunistic” infections that healthy
immune systems protect against.
HIV-positive
persons are susceptible to opportunistic
and infectious diseases, especially
TB. Once they have contracted TB, the
disease progresses to the highly infectious,
active stage much more quickly and frequently
than in HIV-negative persons and is
often what kills them.
Antimicrobial
medications are used to treat opportunistic
infections of bacterial, viral, and
fungal origin. Frequent or prolonged
use of antimicrobials promotes genetic
mutations that result in drug resistance.
This often makes opportunistic infections
more serious and difficult to treat,
and may drive the spread of resistant
organisms in both HIV-positive and HIV-negative
people.
Antiretroviral
and other antimicrobial medications
can prolong life, but eventually the
immune system becomes so damaged that
HIV progresses to Acquired Immune Deficiency
Syndrome (AIDS), and death usually follows
in a few years. No cure for HIV/AIDS
is available, and no vaccine has proven
a sure way to prevent it; avoidance
of high-risk behavior is the only proven
way to prevent the disease.
A
generally milder form of the virus (HIV-2)
also exists and has limited geographic
reach—primarily in West Africa, including
Nigeria—and is less transmissible and
less lethal than HIV-1. Patients with
HIV-2 have lower viral loads and slower
immune decay but acquire the same opportunistic
infections as those infected with HIV-1.
|
Several
factors are driving the epidemic in China—the
large migrant population, intravenous drug use,
and poor hygiene in plasma sales—increasing
the odds that the disease will continue to spread.
Migration.
An estimated 100 million ruralmigrants are on
the move in China, relocating to cities to find
work. Sexual contact between migrant men and
prostitutes has spread the disease, which advances
over an even wider geographic area if the migrants
return to their villages to visit their families.
Drug
abuse. HIV/AIDS also is rising among intravenous
drug users, especially in southern regions adjacent
to Southeast Asia’s “GoldenTriangle” of heroin
production and distribution routes. Infection
rates also soar as high as 85 percent among intravenous
drug users in the Xinjiang Autonomous Region in
western China (see figure 7).
Figure
7
China: HIV Prevalence Among Injecting Drug Users,
1991-98
Plasma
sales. The practice of plasma selling in
rural areas also has been a major contributor
to the spread of HIV/AIDS (see textbox). Mixing
infected blood plasma causes one of the highest
known transmission rates for HIV/AIDS, and the
practice has infected large numbers of rural,
heterosexual villagers who would otherwise be
considered at low risk for the disease.
Despite
growing concern over the disease among senior
leaders, China’s sheer size, resource constraints,
widespread ignorance of AIDS, cultural taboos
about discussing sex, and coordination problems
between levels of government will make it difficult
to check the spread of the disease.
- Even
if adult prevalence rates rose only to two percent
by the end of the decade, China would have about
15 million infected people by 2010—surpassed only
by India.
Prospects
for Control
We
assess that all five next-wave countries will
have difficulty controlling their HIV epidemics
in the short to medium-term. The disease has
built up significant momentum—especially in Nigeria
and Ethiopia—and the governments have been slow
to respond. None of the five next-wave countries
in this report is on a trajectory to replicate
the success of such countries as Uganda, Thailand,
and Brazil in stemming the spread of the disease.
Several leaders of the next-wave countries are
focusing more attention on the AIDS threat, but
all face a host of competing demands. In addition,
these countries have weak healthcare infrastructures
and severe budget constraints, which will create
difficulty in financing education and treatment
programs for their large populations.
China:
HIV Infections from Blood Selling
Most
of China’s blood supply is purchased
from poor villagers by brokers who
collect only plasma for the manufacture
of therapeutic and diagnostic products.
These brokers often try to save money
and time by mixing the blood of several
donors before spinning out the plasma
in a centrifuge. Reinjecting the
mixed blood back into the donors to
prevent anemia has spread HIV like
wildfire, with infection rates as
high as 60 percent in some villages.
The government has ordered a stop
to the practice, but press reports
suggest that it continues in some
areas. The practice of blood selling
began as a way to raise money for
rural health projects after the central
government cut subsidies to the provinces.
-
·Chinese
media report that people selling blood
in Qinghai, Henan, and Shaanxi claim
that they earn between $12 and $15
for each bag of donated blood—a large
sum of money in these poor provinces.
Some farmers report donating blood
50 times in two months.
|
The
high cost and complexity of treatment programs
probably will continue to feed the debate over
the relative cost/benefit of treatment versus
prevention in addressing HIV/AIDS.
- Pressure
for antiretroviral drugs has jumped in recent
years because such drugs afford one of the most
tangible ways for governments to respond to the
AIDS problem.
- Nonetheless,
successful efforts to combat HIV in Uganda, Thailand,
and other countries suggest that high-profile
education programs to change behaviors remain
key to long-term success, although this approach
requires more time and persistence by senior leaders.
The
Leadership Challenge
The
commitment of senior political leadership to persist
in the struggle against HIV/AIDS has been a key
variable in the few successful programs around
the world. The leaders of Nigeria, Ethiopia,
Russia, India, and China will be challenged to
maintain sustained high-level interest, however,
given the scope and severity of other domestic
and foreign policy issues. Some leaders are beginning
to pay more attention to AIDS, but they have not
given it the sustained priority thus far that
has been needed in other countries to blunt the
spread of the disease.
Overcoming
Social Stigmas
Many
citizens and government officials in
next-wave countries are reluctant to
acknowledge the spread of the disease
owing to strong social and cultural
norms. HIV/AIDS still is associated
with behaviors widely considered taboo,
including prostitution, drug use, and
homosexuality. HIV-positive people
often do not seek testing and treatment
because they fear being ostracized by
their families, neighbors and friends
and losing their jobs or access to public
services.
- In
China, few people publicly acknowledge
HIV-positive status because they might
be barred from school, fired from their
jobs, or even expelled from their community,
according to press reports. Largely as
a result of China’s “one-child” policy
to reduce population growth, Chinese men
are under such pressure to carry on family
lines that some HIV-infected gay men marry
and have families and risk spreading the
disease to their wives and children.
- A
2001 law in one Chinese province prohibits
HIV-infected persons from marrying.
- In
India, recent studies found that HIV-infected
people were refused admission to some
hospitals and denied treatment. Furthermore,
HIV test results often are not kept confidential,
which discourages people from getting
tested. Some experts say that women in
India’s male-dominated society are reluctant
to insist on condom use, and the widows
of men who die from AIDS sometimes are
denied healthcare or contact with their
children.
|
HIV/AIDS:
Success Stories to Model
Uganda,
Thailand, and Brazil have managed
the spread of HIV largely through
active, high-level leadership to increase
awareness, destigmatize the disease,
and treat victims—all of which help
change the behaviors that transmit
the disease. These countries are
widely considered to have the most
successful anti-HIV programs and are
potential models for other countries
ravaged by the disease.
-
Bold
leadership by Uganda’s President
Museveni largely is responsible for
driving down the country’s infection
rate from 30 percent in 1992 to 11
percent in 2000. The HIV/AIDS problem
remains significant, but Museveni
has had success in his relentless
campaign to change behavior by urging
people not to have sex with multiple
partners, publicly acknowledging the
threat posed by AIDS, destigmatizing
the disease, and decentralizing HIV
education programs down to the village
level.
- Thailand
launched a massive HIV/AIDS public awareness
and condom distribution campaign in
the early 1990s—with the support of
several key senior officials—which significantly
reduced the spread of the disease.
More recently, the government announced
it would make antiretroviral drugs available
for less than one dollar a day. AIDS
still is the leading cause of death
in Thailand, but the government probably
has averted millions of HIV infections
(see figure 8).
-
In Brazil, the government has
invested heavily in education and treatment
programs, including providing free antiretroviral
drugs to HIV/AIDS patients distributed
through the public health system. HIV
adult infection prevalence also is declining
among intravenous drug users, suggesting
that programs teaching safer injection
habits also are successful.
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Figure
8
HIV/AIDS in South Africa and Thailand: Effect
of
Behavior Change Programs
Active
leadership will be especially critical given the
widespread public ignorance of AIDS in next-wave
countries. The challenge is especially great
in these countries because of fragile communications
links, numerous government jurisdictions, and
different ethnic and language groups. The five
countries also lack strong domestic advocacy groups
that can raise awareness and increase pressure
for responsive programs.
- In
Nigeria, a healthcare worker was fired after she
tested positive for HIV, although a court ultimately
agreed to hear her appeal.
- Russia
appears to be a major exception. A survey last
year by an independent pollster found that 90
percent of those polled see combating HIV/AIDS
as an important issue.
Nigeria’s
leadership has been the most active of the five
countries in trying to raise AIDS awareness, for
example, by hosting a regional AIDS conference
in 2000 and publicly warning about the risk of
“extinction” on the continent. Nonetheless, the
Obasanjo administration is beset by such other
pressing problems as an approaching election and
rising ethnic and religious tensions. Moreover,
Nigeria’s government institutions have deteriorated
so badly over the last decade that Obasanjo has
few functioning public sector assets left to mobilize
even if he chose to engage fully on the issue.
The
Ethiopian Government does not appear focused
on AIDS, despite occasional statements on the
issue. The government has focused in recent years
on the conflict with Eritrea. Healthcare workers
privately have criticized efforts in recent years
as half hearted, and UN officials have publicly
warned Ethiopian leaders to take more measures
to stem the epidemic.
The
Russian Government has not mounted a sustained
effort up to now to publicize the growing threat
of HIV/AIDS. Russia faces so many other serious
problems that HIV/AIDS is unlikely to receive
high-level attention for an extended period until
the economic and security costs of neglect become
more tangible.
- In
2001, Moscow promised $133 million to fight AIDS
over five years, but it has only appropriated
$80 million ($16 mil-lion per year). Treating
3 million HIV- infected adults would cost $30
billion a year, according Vadim Pokrovsky, the
chief of the Russian Federal AIDS Center.
- In
2001, Moscow refused a World Bank loan to fight
TB and HIV/AIDS, apparently because Russia did
not wish to increase the amount of its debt.
However, Moscow recently re-opened negotiations
for the loan.
The
Indian Government has taken numerous steps
to highlight the risk that AIDS poses to the country,
but tensions with Pakistan and growing religious
strife clearly are considered more pressing issues.
Furthermore, India faces competing priorities
to address such other health challenges as TB.
Nonetheless, the Indian Government did react to
the emergence of HIV/AIDS in 1986 by creating
the National AIDS Control Organization (NACO).
- NACO
faced many difficulties throughout most of its
early years, although new leadership in 1999 has
improved and expanded the HIV/AIDS program.
The
Chinese Government has become significantly
more open over the last year in acknowledging
the rising HIV/AIDS problem after ignoring it
for years. The central government has organized
some public relations events to increase awareness
of the disease, and Beijing has sought bilateral
assistance from the United States and others to
improve its anti-AIDS campaign.
-
The turnaround suggests that senior leaders are
concerned about the potential economic, social,
and political ramifications of the spreading disease.
Nonetheless,
domestic funding to combat the disease remains
low, and Chinese leaders will have difficulty
keeping HIV/AIDS high on the agenda as they struggle
to deal with such challenges as maintaining economic
growth, defusing rural discontent, managing the
Communist Party leadership transition, opening
Chinese markets more widely to trade, and modernizing
the military. Moreover,
decisionmaking has become so decentralized in
China on healthcare and education that senior
leaders in Beijing cannot always count on provincial
and local leaders to follow through.
- Local
government commitment to HIV/AIDS is likely to
be uneven, given the low funding for such programs
from the central government, lack of awareness
of the disease, stigmatization of those infected,
and corruption.
Weak
Healthcare Infrastructure
Although
significant differences in capabilities exist
among next-wave countries, all five have overburdened
and under funded healthcare systems and limited
abilities to provide integrated, nationwide programs
to test people, track infections, and deliver
treatment and education programs. Even within
each of the five next-wave countries there are
disparities in the ability of cities and regions
to deal with the epidemic that are likely to grow
in the coming years.
- Nigeria’s
public healthcare system, which has been deteriorating
for years, is hard pressed to provide even the
most basic public services. Many facilities lack
electricity, water, and soap; even better-equipped
hospitals are beset by strikes by medical staff.
- Ethiopia
has never had a viable national healthcare system
because of overwhelming poverty and years of war.
The government is soliciting international assistance
to build its capabilities, but progress on this
front is likely to take years.
-
Russia’s dwindling health services are unable
to provide treatment for many victims of heart
disease and the skyrocketing number of TB cases.
Since the breakup of the Soviet Union, Russia’s
health infrastructure has deteriorated so much
that most experts believe that the population
is less healthy now than at any time in the past
50 years.
- India
has established nationwide HIV/AIDS centers and
a monitoring system, but access to basic medical
care is not universal and the free public health-
care system often is highly inefficient. Nonetheless,
the government’s AIDS organization was able to
reach an estimated 70 percent of households in
a recent survey of AIDS-related behavior.
- In
China, a growing number of citizens cannot afford
quality healthcare because of privatization of
the public health service. Rural areas, which
have the highest HIV infection rates and where
70 percent of the population lives, suffer from
major shortages of resources. Funds are being
directed toward modernizing urban facilities.
Treatment
Brazil’s
successful emphasis on treatment and the expanded
use of antiretroviral drugs has raised hopes for
improving the length and quality of life for HIV/AIDS
patients. Nonetheless, we believe treatment will
be a
Antiretroviral
Drug Resistance
Natural
viral mutation and improper use of drugs
to control HIV (halting use, intermittent
use, or habitually missed doses) have
caused some strains of HIV to evolve
resistance to antiretroviral medications.
These resistant strains continue to
reproduce and destroy immunity in the
presence of medications meant to control
the virus, and already they have spread
around the world. These drug-resistant
variants are spread less efficiently
than other forms.
- HIV
strains have an amazing ability to recombine
to form mosaic viruses. This pace of
genetic change forces changes in treatment
regimens and has placed unprecedented
pressure on the pharmaceutical industry
to develop new drugs for continued viral
control.
- Most
HIV drug resistance can be traced to improper
use of medications. Weak healthcare infrastructures
in some next-wave countries will lead
to poor distribution and incorrect use
of antiretrovirals, which are likely to
promote drug resistant strains of HIV
and reduce the effectiveness of medicines.
- Treatment
failure rates can be as high as 60 percent
in some countries.
To
help control resistance, therapies now
often employ a combination of several
drugs from different classes. In addition,
some researchers are now trying to curb
the growth of antiretroviral resistance
by having medical workers personally watch
and record patients taking medication—known
as direct observed therapy—a technique
that has slowed the development of resistance
to anti-TB medications.
|
difficult
primary strategy for the next-wave countries
because of the high cost of providing antiretroviral
drugs for such large populations and drug resistance.
- The
cost of antiretroviral drugs has plunged in recent
years—from around $10,000 per year per patient
down to as low as $500 to $600—because of pressure
from many countries on pharmaceutical companies
and the increasing use of generic drug alternatives.
- Pharmaceutical
industries in an increasing number of countries—including
Russia, India, and China—are likely to develop
and produce such drugs in the interest of reducing
the cost of medication.
- A
Chinese government official publicly warned in
September 2002 that Beijing would authorize domestic
firms to manufacture generic drugs in defiance
of patent laws unless prices come down, although
the Ministry of Health later said it would not
violate WTO obligations.
Even
as prices decline, the total cost of providing
drugs for millions of patients is likely to be
prohibitively high for populous, low-income countries.
Moreover, the cost of the drugs is only a small
portion of the overall cost of treatment programs.
Costly laboratory tests and equipment are needed
to determine which combination of drugs is appropriate
for each infected person.
The
effectiveness of antiretroviral drugs also is
being undermined by a growing drug resistance
problem, owing both to the natural mutation of
the virus and improper drug use.
- Scientists
at the July 2002 international AIDS conference
in Barcelona presented numerous research papers
on the challenge of drug resistance and the consequences
of not taking medicines as
prescribed.
Implications
The
rise of HIV/AIDS will have significant economic,
social, political, and military implications in
Nigeria, Ethiopia, Russia, India, and China, although
the percentage of the adult population in each
country that is infected is likely to remain below
the hardest hit countries in southern and central
Africa. The impact of the disease by the end
of the decade will vary among the five countries,
given differences in disease trajectories government
responses, available resources, and demographic
profiles.
Nigeria
and Ethiopia: Hardest Hit
The
social and economic impact of AIDS in Nigeria
and Ethiopia probably will be similar to the hardest
hit countries in Africa. The disease is likely
to negatively impact almost all sectors of society
by 2010. AIDS will take a heavy economic toll
by robbing the countries of many key government
and business elites and by discouraging foreign
investment, although the oil sector is unlikely
to be hurt significantly.
- The
professional classes in Nigeria and Ethiopia—like
other African countries—are more vulnerable in
comparison to other next-wave countries because
adult prevalence rates already are much higher
and relatively fewer elites are concentrated in
a smaller number of key
positions.
- The
drag of AIDS on economic growth will further reduce
the ability of the government to handle the rising
social and healthcare costs.
The
further deterioration of already weak government
institutions by the escalating HIV/AIDS crisis
could leave Nigeria and Ethiopia seriously weakened
states and is likely to reduce their ability to
continue to play a regional leadership role.
-
HIV/AIDS
probably will complicate staffing in the military
officer corps of the two countries as it has
in other African states. Ethiopia is more likely
to suffer military manpower shortages through
the lower ranks, however, because it has a much
larger army and smaller population than Nigeria,
which plans to reduce the size of its force.
- Rising
social tensions over AIDS and related economic
problems could exacerbate regional and ethnic
tensions within Nigeria and Ethiopia while leaving
both governments less able to manage the problem.
AIDS
Vaccines Coming, But Not a Panacea
Many
research and clinical trials are underway
to develop a vaccine against HIV.
Clinical trials of two commercial
vaccines—intended to confer immunity
by introducing a harmless portion
of HIV protein into the body—have
progressed to Phase III human testing
in the United States, Canada, Netherlands,
and Thailand. Results are expected
within the year. Nonetheless, even
if a viable vaccine to protect against
certain viral subtypes of HIV that
are prominent in the test countries
becomes available in the coming years,
it probably will not to be effective
against the most common subtypes of
HIV in Nigeria, Ethiopia, Russia,
India, and China.
Moreover,
first-generation HIV-vaccines probably
would provide lower immunity or shorter-lived
protection than future product iterations
that incorporate what is learned from
wider use. Studies suggest that if
the vaccine is at least 30 percent
effective, delivering it to persons
engaging in high-risk behaviors may
be beneficial, although there is a
danger that it could encourage risky
sexual conduct in individuals who
believe they are protected by the
vaccine. Unless the vaccine was widely
affordable, however, it would remain
beyond the reach of the developing
world—which is likely to fuel intense
political pressure on Western countries
and drug companies to slash prices
or subsidize the cost.
Both
vaccine effectiveness and good distribution
are necessary for HIV transmissibility
to decrease enough for the epidemic
to die out eventually. For example,
some estimates indicate that to stem
the epidemic, the world would need
50 percent coverage with a 75 percent
effective vaccine. Until a highly
effective vaccine is in wide distribution,
anti-AIDS programs aimed at encouraging
behavioral change will remain essential
in controlling HIV/AIDS.
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Researchers
estimated there were 2.6 million AIDS orphans
in Nigeria alone in 2000—higher even than in South
Africa—and the problem will get much worse. AIDS
orphans often are taken in by relatives during
the early stages of the disease, but the phenomenon
in other African countries suggests that Nigeria
and Ethiopia are likely to reach a point before
the end of the decade when the number of caregivers
is insufficient to cope with the burden.
Russia:
HIV/AIDS Worsening Demographic Situation
The
rising AIDS problem in Russia is likely to exacerbate
the significant social, economic, health, and
military problems already facing the country.
These challenges, added together, will complicate
Moscow’s efforts to rebuild Russia.
- A
recent World Bank study projects that HIV/AIDS
could cut annual economic growth in Russia by
half a percentage point by 2010 and a full percentage
point by 2020.
As
the disease spreads, the high cost of treatment
and education programs could drive out other claims
on health systems, leading to a steeper decline
in general health than caused by HIV/AIDS alone.
Even if more resources are committed to combat
HIV/AIDS—either by Russia or outsiders—considerable
time and money would be required to expand and
reform the healthcare infrastructure, suggesting
that the disease will continue to spread at a
rapid pace.
- These
economic problems are likely to fuel social and
political tensions over spending priorities.
Devoting more money to combating HIV/AIDS probably
would just leave that much less for such other
pressing health problems such as heart disease
and TB.
India
and China: A Big Problem but Probably
not Devastating
India
and China are likely to generate the largest number
of people infected with AIDS of any countries
in the world by 2010, but the impact will be lessened
because these individuals will remain diffused
among very large populations. Even if the number
of infected people rises to the upper side of
our projections, the percentage of the adult population
that is infected still would be significantly
lower than in the other next-wave countries at
the end of the decade.
- Fifteen
million HIV-positive people in China would represent
roughly 2 percent of the adult population.
- Twenty-five
million infected Indians would reflect a 4 percent
adult prevalence rate.
Judging
the broader impact on economic growth and productivity
is more difficult, however, because it depends
largely on which demographic groups get hit the
hardest. Several researchers in 1999 estimated
that AIDS cost India roughly 1 percent of GDP
per year because of lost productivity and treatment
of secondary infections. The study did not include
numerous factors—such as the cost of drugs and
retraining workers—however, and there is no consensus
on a formula to calculate the economic costs.[4]
- At
a minimum, AIDS will drive up healthcare costs
in both countries, forcing difficult trade-offs
on spending.
- The
more the disease remains among rural and lower
skilled people, the more likely that the abundant
labor supply of both China and India can fill
the gap.
-
The more the disease spreads among young, educated,
urban professionals, however, the higher the economic
costs will be, given the premium on skilled labor.
- Chinese
leaders are likely to fear that the perception
in global markets of a rising AIDS problem could
discourage the huge flow of foreign investment
into the country that has been vital to growth.
We
believe the HIV/AIDS epidemic, by itself, will
not pose a fundamental threat through 2010 to
the rise of China and India as major regional
players. Given the relatively low current prevalence
rates and the relatively long period from infection
to death, the two countries can manage the impact
of the disease through the end of the decade.
Nonetheless, the mounting AIDS problem will further
add to the complex problems and trade-offs facing
leaders in both countries in the coming years.
There
is no sign that HIV/AIDS will become a lightning
rod for widespread public discontent in either
China or India. Nonetheless, the protests of
rural Chinese who became infected through plasma
sales suggest that anger with the government’s
slow response will add to growing frustration
in rural areas over rising unemployment, widespread
corruption, and poor services.
- For
several days in November, police detained HIV-positive
protesters and a group of reporters who came to
interview them.
- Protests
by Chinese in urban areas almost certainly would
spark deeper concern among Chinese authorities.
- HIV/AIDS
may become more of a political issue in India
as infection rates climb. The debate is likely
to focus on who pays for and receives the antiretroviral
drugs that Indian firms now are producing.
Both
Beijing and New Delhi probably will try to push
the rising cost of dealing with HIV/AIDS down
to state and local governments, as they have on
other issues. Local authorities, however, are
unlikely to have the staff, expertise, or funding
to assume the growing burden.
- Most
Indian state governments already have curbed spending
on healthcare and education to cope with severe
fiscal strains—and some are even struggling just
to pay the wages of government workers.
- Likewise,
Chinese localities already are overburdened with
responsibilities for public health that Beijing
has passed along in decentralizing many government
duties.
HIV/AIDS
is unlikely to undermine general military capabilities
in China and India because of the large pool of
potential recruits for the respective armies.
China began testing conscripts for HIV in 2001.
As
HIV/AIDS moves more into the general population
in China, past experience in other countries suggests
it will exacerbate an already existing gender
imbalance because of the practice of female infanticide.
International
Implications
The
surge in the disease outside southern Africa will
fuel calls for more support from donor countries
to address the problem and intensify the debate
over how to allocate such international resources
as the Global Fund for AIDS, TB, and Malaria.
- A
debate is likely over how much the Global Fund
should focus on heading off AIDS in large, next-wave
countries where it is in the earlier stages, and
how much to devote to the hardest hit countries
in southern Africa. Similarly, differences are
likely to arise between those wanting to allocate
money to programs on the basis of proven success
or greatest need.
- Should
resources be shifted away from central and southern
Africa, Africans there probably will accuse the
West of ignoring them and paying more attention
to large countries that are more economically
and strategically important.
The
rising focus on HIV/AIDS worldwide has the potential
to draw international attention and funding away
from other infectious diseases such as TB, malaria,
hepatitis, as well as other critical non-infectious
health problems.
International
tensions over medical treatment for HIV/AIDS almost
certainly will grow, even though access to antiretrovirals
will
increase.
- The
manufacture of generic antiretroviral drugs by
several next-wave countries will increase pressure
on international pharmaceutical companies to further
lower the price and increase availability of their
drugs. European countries have stated their support
for countries buying AIDS drugs from companies
in India and Brazil that challenge patents.
- The
increasing use of antiretrovirals in next-wave
countries, however, almost certainly will increase
misuse due to their weak healthcare systems, undermining
their effectiveness and fueling resistant HIV
strains throughout the world. If the effectiveness
of antiretrovirals declines, recipient countries
are likely to charge donors with supplying faulty
drugs.
- Developed
countries will face overwhelming pressure to provide
any new vaccines that are discovered to countries
around the world. These countries will complain
bitterly if the early vaccines are not designed
for the HIV subtypes common in their regions or
blame the donors for their limited effectiveness.
Despite
these likely frictions, however, the rising AIDS
crisis probably will make the next-wave countries
more open to seeking technical assistance from
the United States and other donor countries to
help track, prevent, and treat the disease.
Footnotes
[1] These estimates reflect the expected number of HIV
and AIDS cases at that time—not a cumulative
total of all cases over the entire period.
[2] Although the lethal human immunodeficiency virus
(HIV-1) was not characterized until the early
1980s, blood samples from Sub-Saharan Africa
in the 1950s and 1960s have been tested retrospectively
and found to be HIV-positive.
[3] Prevalence refers to the total number of people
infected as a percentage of the adult (ages
15 to 49) population.
[4] Anand K Pandav, CS and Nath LM: The Impact of
HIV/AIDS on the National Economy of India.
Health Policy 47 (1999) pps 195-205. The
costs of antiretroviral therapy, retraining
the work force, strengthening the healthcare
system, R&D, communications and prevention
of mother-to-child transmission were not included
in this model.
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