The epidemiology of HIV and AIDS in the world

Abstract

The worldwide epidemic of HIV continues to expand in many regions of the world, particularly in southern Africa, South and Southeast Asia, East Asia and Eastern Europe and Central Asia. Estimates are that at the end of 2005 there were 38.6 million persons living with HIV infection and that 4.1 million new infections and 2.8 million deaths from HIV occurred during the year. Regionally different patterns predominate from generalized heterosexual epidemics in sub-Saharan Africa and parts of the Caribbean to mixes of epidemics in which transmission among injection drug users, their sexual partners, commercial sex workers and their partners intersect. Multilateral and bilateral antiretroviral access campaigns, such as the World Health Organization's 3 x 5 initiative, have resulted in broader access to live-saving therapy for infected persons in low- and middle-income countries, but several million infected people who are clinically eligible for antiretroviral therapy remain untreated. The public health challenge worldwide is to keep the uninfected and to treat and care for those who have already been infected.

Full text

Coll. Antropol. 30 (2006) Suppl. 2: 3–10
Review
The Epidemiology of HIV and AIDS in the World
Aliya Bokazhanova
1
and George W. Rutherford
1,2
1
Institute for Global Health, University of California, San Francisco, California, USA
2
Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, California, USA
ABSTRACT
The worldwide epidemic of HIV continues to expand in many regions of the world, particularly in southern Africa,
South and Southeast Asia, East Asia and Eastern Europe and Central Asia. Estimates are that at the end of 2005 there
were 38.6 million persons living with HIV infection and that 4.1 million new infections and 2.8 million deaths from HIV
occurred during the year. Regionally different patterns predominate from generalized heterosexual epidemics in sub-Sa
-
haran Africa and parts of the Caribbean to mixes of epidemics in which transmission among injection drug users, their
sexual partners, commercial sex workers and their partners intersect. Multilateral and bilateral antiretroviral access
campaigns, such as the World Health Organization’s3x5initiative, have resulted in broader access to live-saving ther
-
apy for infected persons in low- and middle-income countries, but several million infected people who are clinically eligi
-
ble for antiretroviral therapy remain untreated. The public health challenge worldwide is to keep the uninfected and to
treat and care for those who have already been infected.
Key words: HIV, AIDS, epidemiology, prevalence, Africa, Asia, Europe
Introduction
Since the first description of the acquired immunode-
ficiency syndrome (AIDS) in 1981
1
, the epidemiology of
AIDS and its retroviral causative agent, human immuno-
deficiency virus (HIV), has been well described
2
. AIDS
has come to be viewed not as an isolated syndrome, but
as the most serious manifestation of a range of clinical
and subclinical diseases and conditions caused by HIV.
HIV infection, in turn, is now viewed not as an infection
of isolated groups of people but as an infection that has
spread worldwide in pandemic proportions.
Modes of Transmission
HIV is known to be transmitted through sexual con
-
tact with an infected partner
3
; parenterally through di
-
rect exposure to blood or blood products
4,5
; and vertically
from an infected mother to her offspring
6
(Table 1). The
likelihood of HIV transmission is dependent on the prob
-
ability of exposure and the probability of infection after
exposure
7,8
. Exposure is dependent on the background
prevalence of HIV in a population and the frequency and
nature of contact with sexual or needle-sharing partners
randomly drawn from the population. The probability
that an infectious inoculum of HIV will infect CD4+ T
lymphocytes or a similarly susceptible cell line in a previ-
ously uninfected individual depends on a number of
transmission cofactors such as co-infection with another
sexually transmitted disease (both ulcerative and non-ul
-
cerative), host susceptibility to infection, genetic vari
-
ance in the infectiousness of the particular strain of HIV
and temporal variability in the infectiousness of the
host
3
.
Persons with newly acquired HIV infection have the
highest titers of virus in their blood
9
, and persons with
high titers in blood are more likely to transmit HIV than
those with lower titers. This has been clearly demon
-
strated for blood borne and perinatal transmission
10
, and
there is evidence that at the population level high plasma
or serum viral loads are associated with higher rates of
sexual
11
and postnatal
12
transmission. The result is that
often it is persons who have recently become infected and
have not had sufficient time to develop measurable anti
-
body are the most infectious
13
. This has led to explosive
and sustained epidemics when there are high levels of
sexual mixing and partner exchange
14,15
.
3
Received for publication November 2, 2006
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Epidemiology
The HIV epidemic is extremely dynamic and has
grown rapidly since HIV-1 and later HIV-2 entered hu
-
man populations in the 1920s
16
. Virtually no country in
the world remains unaffected. Joint United Nations
Programme on HIV/AIDS (UNAIDS) and the World
Health Organization (WHO) estimate that the total
number of people living with HIV was 38.6 million with a
confidence bound of 33.4–46.0 million
2
. This is an in-
crease of 200,000 people since 2004. In 2005, 4.1 million
people were estimated to have become newly infected
with HIV, and 2.8 million deaths were attributed to the
infection, more of both than in any previous year
2
.
Regionally the HIV epidemic grew in every region in
the World except one – the Caribbean – in 2005 (Table 2).
Sub-Saharan Africa remains the most affected region in
the world, but there are also rapidly growing epidemics
in Eastern Europe and Central Asia and in East Asia.
Earlier epidemics have left a large burden of disease in
South and Southeast Asia, Latin America and the high-
income nations of North America and Western and Cen
-
tral Europe. The epidemics in Latin America, North
America and Western and Central Europe show some
signs of stabilizing, but, nonetheless, transmission still
occurs in these regions
2
.
Incidence and prevalence by region
Sub-Saharan Africa
Sub-Saharan Africa has just over 10 percent of the
world’s population but is home to 60% of all people living
with HIV
17
. An estimated 24.5 million people were living
with HIV in the region at the end of 2005, and approxi
-
mately 2.7 million new infections, or 66% of all new infec
-
tions worldwide, occurred there during that year
2
. Overall
UNAIDS estimates that 6.1% of the adult population is in
-
fected. Moreover, 50 million Africans have been infected
with HIV since the beginning of the epidemic, and more
than 22 million have died
2
. Eight African countries have
more than 1 million people living with HIV, and estimates
are that among 15 to 24 year-old Africans, 1.9% of men
and 4.6% of women are already infected
17
.
The epidemic in sub-Saharan Africa is not homoge
-
neous; some countries are much more severely affected
than others
18
(Figure 1). In Somalia and Gambia the
prevalence is around 2% of the adult population, whereas
in South Africa and Zambia around 20% of the adult pop-
ulation is infected. In four southern African countries,
the national adult HIV prevalence rate has risen higher
than was thought possible and now exceeds 20%. These
countries are Botswana (24.1%), Lesotho (23.2%), Swazi-
land (33.4%) and Zimbabwe (20.1%). West Africa is rela-
tively less affected by HIV infection, but the prevalence
rates in some countries are creeping up. In West Africa
and Central Africa HIV prevalence is estimated to exceed
5% in several countries including Cameroon (5.4%), Cen-
tral African Republic (10.7%), Côte d’Ivoire (7.1%) and
Nigeria (3.9%). HIV infection in Eastern Africa varies be
-
tween adult prevalence rates of 2.4% in Eritrea to 6.5%
in Tanzania. In Uganda, a country severely affected by
the HIV epidemic in the 1980s and early 1990s, the coun
-
trywide prevalence among the adult population is now
6.7%
2
.
However, declines in the nationwide prevalence of
HIV among adults appear to be underway in three coun
-
tries, Uganda, Kenya and Zambia
19–21
. Within countries
HIV infection can cluster geographically, particularly in
urban and periurban areas. A variety of contextual fac
-
tors contribute to the spread of the epidemic in these ar
-
eas just as surely as do biological factors. Most important
among these are the socioeconomic status of women,
HIV stigma and inadequate knowledge of HIV transmis
-
sion and its prevention. Together these factors lead to
high risk of exposure and, if exposed, high risk of trans
-
mission. These risks are compounded by a hesitancy to
seek counseling and testing and, if positive, to seek ther
-
apy because of stigma.
Sub-Saharan Africa is also home to the world’s largest
pediatric HIV epidemic. Of the 2.3 million children under
15 estimated to be living with HIV infection in 2005, 2.0
A. Bokazhanova and G. W. Rutherford: HIV/AIDS in the World, Coll. Antropol. 30 (2006) Suppl. 2: 3–10
4
TABLE 1
MODES OF HIV TRANSMISSION
Sexual Parenteral Perinatal
•
Heterosexual, male to female
•
Heterosexual, female to male
•
Homosexual, male to male
•
Artificial insemination with
infected semen
•
Sharing of needles and syringes by
injection drug users (heroin, cocaine,
methamphetamines)
•
Transfusion of contaminated blood
•
Administration of contaminated
blood products (e.g., Factor VIII)
•
Organ transplantation with infected
organs
•
Reuse of needles, syringes and intra
-
venous tubing in health-care set
-
tings
•
Occupational injuries
•
Bites
•
Prenatal
•
Perinatal during birth
•
Postnatal from breast milk
Most common forms of transmission are italicized.
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million (90%) lived in sub-Saharan Africa
2
. Similarly
91% of the 570,000 estimated child deaths and 90% of the
estimated 700,000 new infections in 2005 were in the re
-
gion. This is primarily because the predominant mode of
transmission in sub-Saharan Africa is through hetero-
sexual intercourse, which has led to more than half of the
infected population being female. In fact more than three
quarters of all HIV-infected women in the world live in
sub-Saharan Africa.
Asia
Asia has the second largest number of people living
with HIV/AIDS. Until the late 1980s, no Asian country
had experienced a major AIDS epidemic, but by the late
1990s the disease was well established across the region.
UNAIDS reports that in 2005 the total number of people
living with HIV/AIDS in Asia was 8.3 million (confidence
limits 5.7–12.5 million)
2
. The continent includes the
world’s most populous countries – China and India –with
2.25 billion people between them. In both countries, na
-
tional HIV prevalence is low, 0.1% in China and between
0.5% and 1.5% in India
2
.
East Asia
China has the largest HIV epidemic in East Asia. The
latest estimates are that as of the end of 2005, there were
approximately 650,000 people currently living with HIV/
AIDS in China. New HIV cases were being transmitted
primarily through injecting drug use and sex
22,23
.Asa
major drug transshipment country with source drugs
from the »Golden Triangle« area of Southeast Asia,
China has also become an increasingly important drug
consuming market
24,25
. About half of China’s 1.14 mil
-
lion documented drug users inject, and many share nee
-
dles. Injecting with non-sterile needles and syringes has
resulted in 42% of cumulatively reported HIV/AIDS cases
thus far
26
. The potential for even further spread is un
-
derlined by a study that examined drug use practices, in
-
cluding injecting drugs and needle sharing, and unpro
-
tected sex among drugs users in southwestern China.
More than two-thirds of 833 institutionalized drug users
reported that they frequently injected drugs intrave
-
nously or intramuscularly, 78% shared needles, and 73%
had multiple sexual partners
27
.
South and Southeast Asia
In India by the end of May 2004, the total number of
AIDS cases reported was 109,349 of whom 31,982 were
women
28–30
. While the Indian HIV/AIDS epidemic is still
largely concentrated in at-risk populations, including sex
workers, injecting drug users, and truck drivers, surveil
-
lance data suggest that the epidemic is moving beyond
these groups in some regions into the general population.
In northeastern India along the Myanmar border and in
major cities such as Delhi, Chennai and Mumbai drug in
-
jecting is also a major source of new infections, and prev
-
alence has risen rapidly in injection drug users
28,31,32
.
A. Bokazhanova and G. W. Rutherford: HIV/AIDS in the World, Coll. Antropol. 30 (2006) Suppl. 2: 3–10
5
TABLE 2
HIV PREVALENCE, INCIDENCE AND MORALITY BY REGION, 2003 AND 2005
Region
Prevalent cases
Estimated adult
prevalence
Incident cases Mortality
2003 2005 2003 2005 2003 2005 2003 2005
Sub-Saharan Africa 23 500 24 500 6.2% 6.1% 2 600 2 700 1 900 2 000
South and South-East Asia 7 000 7 600 0.6% 0.6% 840 990 470 560
Latin America 1 400 1 600 0.5% 0.5% 130 140 51 59
Eastern Europe and Central Asia 1 100 1 500 0.6% 0.8% 160 220 28 53
North America 1 200 1 300 0.7% 0.8% 43 43 18 18
East Asia 560 680 0.1% 0.1% 100 140 28 33
Western and Central Europe 680 720 0.3% 0.3% 20 22 12 12
North Africa and Middle East 380 440 0.2% 0.2% 54 64 34 37
Caribbean 310 330 1.5% 1.6% 34 37 28 27
Oceania 66 78 0.3% 0.3% 9 7 2 3
Total 36 200 38 600 1.0% 1.0% 3 900 4 100 2 600 2 800
*Estimates x 1,000. UNAIDS, 2005 and 2006.
Fig. 1. HIV prevalence among adults by country, WHO
African Region, December 2003. Source: UNAIDS
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However, the majority (85%) of new infection is due to
heterosexual transmission, particularly among commer
-
cial sex workers, their clients and the sexual contacts of
their clients
33
. Although nationwide HIV prevalence rate
is low (0.9%), in some parts of the country the epidemic
has already »generalised«, with more than 1% of women
accessing antenatal services in public health institutions
testing sero-positive
34
. There are an estimated 2.3 to 8
million female sex workers in India
35
, and HIV informa
-
tion and awareness among sex workers appears to be low,
especially among those working in the streets. Surveys
carried out in various parts of India in 2001 found that
30% of street-based sex workers did not know that con
-
doms prevent HIV infection, and in some states, such as
Haryana, fewer than half of all sex workers (brothel- and
street-based) knew that condoms prevent HIV. Large
proportions of sex workers (42% nationally) also thought
they could tell whether a client had HIV on the basis of
his physical appearance
36
.
Other Southeast Asian countries that have had large
HIV epidemics or are dangerously close to them are Cam
-
bodia, Thailand, Vietnam, and Indonesia due to an explo
-
sive mix of heroin and commercial sex. For example in
Haiphong, Vietnam, in 2000 50% of commercial sex work
-
ers reported sex with a male injection drug user, and an
only slightly smaller percentage of male injection drug
users reported buying sex from a commercial sex work-
er
2
. There is, however, good evidence that the HIV epi-
demic has slowed in Thailand and Cambodia.
Eastern Europe and Central Asia
Eastern Europe and Central Asia is a region in which
the HIV epidemic continues to grow; the number of peo-
ple living with HIV in this region reached 1.5 million in
2005
2
. According to UNAIDS, the total number of newly
reported HIV/AIDS infections in Central Asia grew from
88 in 1995 to 6,706 in 2003, with most new infections oc
-
curring in Kazakhstan, Uzbekistan, and Kyrgyzstan
37
.
However, UNAIDS estimates that there were closer to
50,000 HIV-positive people in the region in 2001, with
20,000 in Kazakhstan alone. Furthermore, the US Cen
-
ters for Disease Control and Prevention (CDC) estimated
the regional total to be 90,000 in 2001, with the potential
to increase to more than 1.6 million in 2005
38
. The explo
-
sive growth of HIV in the region has been fueled primar
-
ily by injection drug use that follows heroin trafficking
routes from Afghanistan across the region into Europe
39
.
This is coupled with reported outbreaks of sexually trans
-
mitted infections, which facilitate HIV transmission. For
instance, the United Nations Office on Drugs and Crime
estimates indicate that Kazakhstan has around 250,000
drug users, almost half of whom are injectors
40
at a time
when the incidence of syphilis increased to 160 cases per
100,000. Knowledge of HIV/AIDS in the country is low
both among high-risk groups and young people; accord
-
ing to a national survey only 15 percent of young people
have adequate knowledge of HIV prevention
41
, and harm
reduction initiatives cover only an estimated 8–10% of
the injecting-drug-using population
42
.
An interesting exception to the rule is Iran, which has
instituted progressive harm reduction policies to combat
a rising epidemic among heroin injectors. Iran has his
-
torically been a major consumer of opium, and as sup
-
plies from Afghanistan waned earlier in the decade,
many users switched from smoking opium to injecting
heroin with a concomitant rise in HIV, hepatitis B and
hepatitis C
43,44
.
In Eastern Europe – notably Estonia, Latvia, Lithua
-
nia, Moldova, Russia and Ukraine – HIV incidence rates
are among the highest in the world
45,46
. Today, Russia
has the largest HIV epidemic in Europe and accounts for
70% of the cases in the Eastern Europe and Central Asia
region
47
. By the end of 2004, almost 300,000 cases of HIV
have been officially registered in the Russian Federation
since the beginning of the epidemic, and this number
continues to grow
47,48
. According to the European Center
for the Epidemiological Monitoring of AIDS, in the Rus
-
sian Federation more than half of the 33,969 cases newly
reported in 2004 had no transmission category reported;
of the remaining cases, 69% were injection drug users
48
.
Many analysts date the sudden explosion of HIV to the
fall of the Soviet Union in the early 1990s and the subse
-
quent economic and social collapse, which in turn led to
unemployment and drug use
50,51
. By some estimates,
there could be as many as 3 million injecting drug users
in the Russian Federation alone and more than 600,000
in Ukraine
37
. Most of these drug users are male and
many are very young; in St. Petersburg, studies found
that 30% of injectors were under 19 years of age, while in
the Ukraine 20% were still in their teens. In a study of
drug use in the city of Togliatti 56% of drug injectors
were infected with HIV, and 36% had injected with used
needles and syringes in the last 4 weeks
50
. The situation
and the trajectory are similar in the Ukraine, where the
national HIV prevalence rate is already higher that 1%
37
.
As in Russia the bulk of HIV infection is among injection
drug users
52
. However, as the epidemic has spread, more
women have been infected, and the number of HIV-in
-
fected infants has tripled in the last five years
53
.
Western and Central Europe
Central Europe in contrast to Eastern Europe has a
much smaller and more stable HIV epidemic. HIV in the
region is largely concentrated in drug injectors, as in
Russia and the former Soviet republics, and three-quar
-
ters of all cases are in Poland and Romania
46
. Southeast
-
ern Europe has a more mixed picture. While the preva
-
lence has in general been low
54
, political instability, the
wars following the disintegration of Yugoslavia and eco
-
nomic depression following the end of the Warsaw Pact
created an environment in which behavioral and cultural
shifts, such as injection drug use, commercial sex work
and migration, created a situation in which HIV could be
rapidly transmitted
55
. In addition conditions, such as
high rates of sexually transmitted diseases, in other
countries in southeastern Europe, such as Romania,
have the potential to facilitate explosive heterosexual
transmission
2
. In only a few countries, such as Slovenia
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and Croatia, are the substantial numbers of cases among
men who have sex with men
48, 56
. Additionally in Croatia,
merchant seamen, in many ways analogous to truck driv
-
ers, appear to have high risk for acquiring HIV infection
sexually and have exposures in hyper-endemic parts of
the world as a result of their voyages
57
. This pattern has
also been seen in commercial fisherman in Cambodia and
Thailand
58,59
.
In Western Europe more than half a million people
are living with HIV, and that number continues to grow
2
.
There are in essence three separate epidemics occurring
in Western Europe – one among men who have sex with
men, one among injection drug users and one among het
-
erosexuals. While there is good evidence that rates of
transmission among men who have sex with men and in
-
jection drug users declined by the late 1980s, by early in
2000 an increase in cases among heterosexuals began to
appear
46
. Data from 11 countries which have provided in
-
dividual HIV data since 1998 (Belgium, Denmark, Fin
-
land, Germany, Greece, Iceland, Luxembourg, Norway,
Sweden, Switzerland, United Kingdom), indicate that
the rise in diagnoses of infections among heterosexuals is
largely due to an increasing number of cases among per
-
sons originating from countries with generalized HIV ep
-
idemics: from 30% of heterosexual infections in 1998 to
53% in 2003, over 90% of which were in migrants from
sub-Saharan Africa
48
. In Germany, the number of new
HIV diagnoses increased in 2002 among heterosexuals
originating from countries with generalized HIV epidem-
ics, most of who were believed to have been infected in
their countries of origin. In Sweden, more than 80% of
reported HIV infections acquired through heterosexual
contact were probably acquired abroad. In Belgium, 73%
of HIV infections ever diagnosed in heterosexually in-
fected people were in non-Belgian individuals – mostly
from Africa
48
. To determine when, where, and how HIV
transmission has occurred is often difficult and further
hindered where language or cultural barriers exist. Most
HIV-infected migrants are unaware of their HIV status
and are diagnosed only when they become symptomatic
or during pregnancy. Their reasons for migration to
Western Europe are economic or political and not con
-
nected with seeking HIV treatment, although this may
sometimes happen
47
.
Despite the increase of new HIV diagnoses in those
infected through heterosexual contact, injection drug us
-
ers and men who have sex with men remain the most af
-
fected groups in Western Europe. Recent studies con
-
ducted among men who have sex with men in England,
Wales and Northern Ireland has found that contrary to
general expectations, recent HIV infections have been
occurring at similar rates in men of all age groups be
-
tween 20 and 44 years. The general opinion has been
continuing HIV transmission is principally due to youn
-
ger men who have sex with men less aware of the safe sex
message of the late 1980s and early 1990s and, as a re
-
sult, adopting high-risk behaviors and practices. In most
years, however, incidence has been highest either in
those aged 35–44 years or those aged 25–34 years. These
data indicate that interventions to reduce risky behavior
and practices need to be intensified and to be targeted at
older, as well as younger, men who have sex with men
60
.
In Italy and Spain, HIV incidence is estimated to have
increased much more rapidly among injection drug users
than among other transmission groups, reaching over 15
per 100 000 population towards the end of the 1980s
61
.
HIV diagnoses among injection drug users have dropped
steeply in the 1990s in Spain after methadone treatment
and needle-exchange projects were introduced. However,
high HIV prevalence is still found among injection drug
users in parts of Spain, such as Catalonia
2
. Italy has a
similarly prominent epidemic among injection drug us
-
ers, with almost 60% of AIDS cases reported among
injectors
48
but also has experienced localized outbreaks
of sexually transmitted diseases reflecting a new rise in
high-risk sexual behavior. As a consequence, HIV is be
-
ing spread sexually. For instance in Rome new HIV infec
-
tions in a sexually transmitted disease clinic have in
-
creased dramatically in the period 2000–2003 compared
to 1996–1999
62
.
North America
UNAIDS estimates that there were 1.3 million people
living with HIV in North America at the end of 2005 and
that the number of new infections (43,000) far outpaces
the number of deaths (18,000). As opposed to less devel-
oped countries, this is because HIV/AIDS survival has in-
creased markedly in the region as the direct result of
highly active antiretroviral therapy
2
.
In the United States of America an estimated 40,000
people have been infected with HIV each year during the
past decade
2
. As in Western Europe, men who have sex
with men, injection drug users and high-risk heterosexu-
als all have experienced high rates of HIV infection.
However, unlike Europe there has been significant trans
-
mission of HIV from injection drug users to non-user het
-
erosexuals. This has been especially pronounced among
persons of African descent in the United States who com
-
prise about 12.5% of the country’s population. Currently
about half of newly reported HIV infections in recent
years have been among African Americans
63
, and Afri
-
can-American women are almost three times as likely to
be infected as women of European descent
2
.
Sex between men is the most common route of HIV
infection in both the United States and Canada, account
-
ing for 63% of newly diagnosed HIV infections in the
United States in 2003
2
, but African Americans are also
disproportionately represented among men who have sex
with men. Analyzing data from 11 states, a recent Cen
-
ters for Disease Control and Prevention study found that
34% of HIV-positive African-American men said they had
sex with both women and men. However, only a small
proportion of HIV-positive African-American women re
-
ported knowing that their partners also had sex with
men
64
.
The HIV epidemic in Canada is more of a hybrid be
-
tween the Western European epidemic, with substantial
numbers of cases among immigrants from countries with
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generalized epidemics, and the United States’ epidemic,
with cases among men who have sex with men, injection
drug users and ethnic and racial minorities
2
.
Latin America
The number of people living with HIV in Latin Amer
-
ica has risen to an estimated 1.8 million
2
. A few countries
in Latin America, such as Honduras, and some areas in
Brazil have reached prevalence rates above 1% in preg
-
nant women and can be considered to have generalized
epidemics
65
. The dominant mode of transmission varies
from country to country, but men who have sex with men
and injection drug users are the predominant groups
that have been affected by HIV in most Latin American
countries. Commercial sex work, especially in Central
America and along the West Coast of South America, has
also been an important amplifier of the epidemic
2
.In
Central America and Brazil, heterosexual transmission
beyond commercial sex work plays an increasing and im
-
portant role for HIV dissemination
65
.
In Latin America, men who have sex with men may
not identify themselves as »gay« and frequently have sex
with women. In Brazil, 11% of the participants in a sex
-
ual practices survey in Fortaleza considered themselves
to be bisexual. The same survey found that a 23% of men
who have sex with men had at least one heterosexual
contact during the previous year. Furthermore, two-
-thirds of men who had unprotected sex with their fe-
male partners also had unprotected anal sex with their
male partners
66
. Similar patterns have been reported in
the Dominican Republic, where sexual contact between
bisexual men and women is common.
Injection drug users are the second group that can act
as a bridge for HIV infection to the general population.
In Brazil 21% of AIDS cases are injection drug users, and
38% of AIDS cases in women resulted from sexual infecti
-
on from injection-drug-using partners or drug use them
-
selves. In the Southern Cone of South America, the pre
-
ferred drug of injection is cocaine, and a band of HIV
infection among cocaine injectors stretches along cocaine
trafficking routes from Bolivia and Paraguay to the At
-
lantic coastal ports of Argentina, Brazil and Uruguay
67
.
Colombia also has a high risk from injecting practices.
The country is currently considered to be one of the most
important producers of opium by-products, ranking fo
-
urth after Myanmar, Laos and Afghanistan
67
. However,
sex between men is the predominant mode of transmis
-
sion. HIV prevalence of 20% was recently reported
among men who have sex with men in Bogotá, while an
-
other survey in the same city found consistently low con
-
dom use in this group
2
.
Caribbean
At the end of 2005, an estimated 330,000 people were
living with HIV and AIDS in the Caribbean. Some 30,000
people were newly infected during 2005, and there were
27,000 deaths due to AIDS. Estimated adult prevalence
is greater than 1% in Barbados, the Dominican Republic,
Jamaica and Suriname; greater than 2% in the Bahamas,
Guyana and Trinidad and Tobago; and greater than 3%
in Haiti
2
. Higher prevalence rates are found only in
sub-Saharan Africa, making the Caribbean the second-
most affected region in the world. More than half of in
-
fected adults are women
2
.
According to U.S. Agency for International Devel
-
opment
68
, AIDS is the leading cause of death among 15 to
44-year-olds in the region; patients with AIDS occupy 25
percent of all hospital beds in the region. Late diagnosis
is common, and few people receive treatment, even for
opportunistic infection. HIV is transmitted primarily
through sexual contact (64% among heterosexuals, 11%
among men who have sex with men) amplified by pov
-
erty, unemployment and gender inequality
2
.
Antiretroviral Therapy
As the incidence of HIV has increased worldwide, so
have the incidence and prevalence of AIDS and the other
advanced clinical stages of HIV infection. We know from
high- and middle-income countries that effective anti-
retroviral therapy can lead to increased survival for indi-
vidual patients and decreased mortality rates at the pop-
ulation level
69–71
. Today, more resources are available for
the fight against HIV than ever before, but at the global
level our treatment efforts have not yet been fully real-
ized. Worldwide in 2005, more people died from AIDS
than in any previous year
2
.
The World Health Organization launched an anti-
retroviral treatment initiative in 2003 to treat 3 million
of the 6 million people living in low- and middle-income
countries who were clinically eligible for antiretroviral
therapy
72
. This initiative, termed 3 x 5 because of the tar
-
get of 3 million people under therapy by 2005, has led to
more than a doubling of antiretroviral therapy to around
1 million patients by June 2005. Moreover, to date, 14 of
target countries are providing antiretroviral therapy to
at least 50 per cent of those who need it, consistent with
the »3 by 5« target, including a remarkable 80% or more
coverage in Brazil, Argentina, Chile and Cuba
2
.
The current momentum to expand treatment access
in sub-Saharan Africa and Asia, where the burden of dis
-
ease is greatest, is especially encouraging. Approximately
500,000 people in the region are receiving treatment, a
three-fold increased in one year from 2003 to 2004. Prog
-
ress in Asia, the region with the second highest need for
treatment, has also been significant, with the number of
people receiving treatment increasing nearly three-fold
–from 55 000 to 155 000 – during this same period. In
Eastern Europe and Central Asia, the number of people
on treatment has almost doubled from 11 000 to 20 000
people. Available data and trends suggest that the goal of
providing antiretroviral therapy to 3 million people by
the end of 2005 was not fully met, but UNAIDS reports
that as the result of antiretroviral access efforts that be
-
gan in 2003, between 250,000 and 350,000 deaths were
averted in 2005
2
.
A. Bokazhanova and G. W. Rutherford: HIV/AIDS in the World, Coll. Antropol. 30 (2006) Suppl. 2: 3–10
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Conclusions
The incidence and prevalence of HIV infection are in
-
creasing worldwide, and the complexity of the pandemic
is increasing with them. As we approach the 25
th
anni
-
versary of the first report of AIDS, the need for primary
prevention of HIV infection is ever more clear, crystal
-
lized by the sobering reality of the depth and breadth of
the pandemic. The need is also clear for treatment and
care of persons who have progressed to AIDS and the less
severe clinical stages of the infection. To achieve these
goals, however, will require a redoubling of scientific ef
-
forts to further refine antiretroviral therapies and care
models; to develop a safe, effective and inexpensive vac
-
cine; and to renew our collective commitment to the be
-
havior changes that have already led to decreasing inci
-
dence in several parts of the world.
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G. W. Rutherford
Institute for Global Health, University of California, San Francisco, 50 Beale Street, Suite 1200,
San Francisco, 94105 California, USA
e-mail: grutherford@psg.ucsf.edu
EPIDEMIOLOGIJA HIV-INFEKCIJE I AIDS-A U SVIJETU
SA@ETAK
Svjetska epidemija zaraze HIV-om nastavlja se {iriti u mnogim dijelovima svijeta, osobito u ju`noj Africi, ju`noj i
jugoisto~noj Aziji, isto~noj Aziji i isto~noj Europi i sredi{njoj Aziji. Procjenjuje se da je krajem 2005. `ivjelo 38,6 milijuna
osoba zara`enih HIV-om i da je bilo 4,1 milijuna novih infekcija i 2,8 milijuna umrlih te godine. Postoje regionalne
razlike od op}e heteroseksualne epidemije u supsaharskoj Africi i dijelova Kariba do mije{ane epidemija u kojoj se
preklapa prijenos me|u korisnicima droga, njihovim seksualnim partnerima, seksualnim radnicama i njihovim part-
nerima. Multilateralni i bilateralni programi provo|enja antiretrovirusnog lije~enja poput incijative 3 x 5 Svjetske
zdravstvene organizacije, rezultirali su ve}om dostupno{}u `ivotno-spa{avaju}eg lije~enja osoba zara`enih HIV-om u
slabo ili srednje razvijenim zemljama, ali vi{e milijuna zara`enih koje bi prema klini~kim mjerilima trebalo lije~iti
ostaju nelije~eni. Svjetski javnozdravstveni izazov jest zadr`ati nezara`ene nezara`enim i lije~iti sve one koji jesu za-
ra`eni.
A. Bokazhanova and G. W. Rutherford: HIV/AIDS in the World, Coll. Antropol. 30 (2006) Suppl. 2: 3–10
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