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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.
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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 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
8
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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
10
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... По оценкам ЮНЭЙДС, в глобальном масштабе удалось стабилизировать ситуацию: число вновь выявленных случаев сократилось с 2000 года на 35% [1,2]. Однако в большинстве стран Центральной Азии и Восточной Европы, включая Россию, эпидемия ВИЧ-инфекции продолжает наступать [1][2][3][4]. Решающую роль во «взрывном» росте заболеваемости ВИЧ-инфекцией, имевшем место в России в конце прошлого века, сыграла эпидемия наркомании [3,5], что отчасти было связано с распадом Советского Союза и последовавшей за этим политической и экономической нестабильностью в регионе [3,[6][7][8]. ...
... Однако в большинстве стран Центральной Азии и Восточной Европы, включая Россию, эпидемия ВИЧ-инфекции продолжает наступать [1][2][3][4]. Решающую роль во «взрывном» росте заболеваемости ВИЧ-инфекцией, имевшем место в России в конце прошлого века, сыграла эпидемия наркомании [3,5], что отчасти было связано с распадом Советского Союза и последовавшей за этим политической и экономической нестабильностью в регионе [3,[6][7][8]. ...
... Однако в большинстве стран Центральной Азии и Восточной Европы, включая Россию, эпидемия ВИЧ-инфекции продолжает наступать [1][2][3][4]. Решающую роль во «взрывном» росте заболеваемости ВИЧ-инфекцией, имевшем место в России в конце прошлого века, сыграла эпидемия наркомании [3,5], что отчасти было связано с распадом Советского Союза и последовавшей за этим политической и экономической нестабильностью в регионе [3,[6][7][8]. ...
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... e primary mode of transmission of HIV in the Caribbean is through heterosexual contact although the virus is also spread through homosexual and bisexual contact, and to a small extent, intravenous drug use [4,5]. Since that time, every country or island in the Caribbean has residents that are either HIV positive or have a diagnosis of AIDS [1,6]. Seventy percent of the HIV/AIDS cases in the English speaking Caribbean occur in the age group 15 to 44 years old [4]. ...
... At pretest, the comparison group had higher scores for knowledge than those in the intervention group ( ). e comparison group had higher scores than those in the intervention on the following variables at pretest, which may be partially accounted for by the differences in age between the two study groups: perceived seriousness about HIV ( ), self-efficacy about speaking on topics about safe sexual practices and using condoms ( ), and attitudes towards abstinence ( 6). See Table 2. Aer controlling for pretest values, and age and gender, the only differences between study groups were as follows: the comparison group had signi�cantly higher knowledge scores at posttest compared to the intervention group ( ) whereas the intervention group had lower intention to delay sexual activity ( 6). ...
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Objective. This study was conducted to determine the effectiveness of an HIV/AIDS educational intervention on adolescents’ knowledge about and perceptions of susceptibility and severity of HIV/AIDS. We also examined whether providing information about assertiveness skills led to an intention to delay initiation of sexual activity. Methods. A quasi-experimental design was used to conduct this study among secondary school students in Trinidad and Tobago. The five constructs of the Health Belief Model were used to design and test the impact of the educational lessons for the intervention group while the comparison group watched one educational video about HIV over four sessions. A total of 196 secondary school students (from nine schools) between the ages of 11 and 18 years participated in the study, 92 in the intervention group and 104 in the comparison group. Results. Those in the comparison group had higher knowledge scores at posttest than the intervention group, controlling for pretest knowledge (), but those in the intervention group were more likely to plan to delay sexual initiation (). Conclusions. While knowledge scores increased for both groups, intention to delay sexual intercourse was only seen among the intervention group and within the younger age groups.
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... In 2011, 34 million people were living with HIV (PLWH) worldwide, of which 2.5 million represented new HIV infections [1]. The United States has about 1.1 million PLWH, and each year close to 50,000 Americans become newly infected [2,3]. Of the 14.8 million PLWH in the world eligible for treatment in 2011, only 8 million received antiretroviral therapy (ART). ...
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Background: Exercise has been associated with improvements in adverse physiological and psychological effects of long-term antiretroviral therapy (ART) in people living with HIV (PLWH). Aim: To summarizes the findings on the effects of aerobic or resistance training alone or combined aerobic and resistance exercise training (CARET) on disease progression, fitness, physical functioning, mental health, and quality of life (QOL) in PLWH receiving ART. A systematic search of articles was performed in several databases, and 20 articles that met inclusion criteria were summarized. Relevance for patients: Aerobic exercise was associated with improvements in aerobic capacity, QOL, and depressive symptoms, while resistance training improved strength. CARET was related to improved aerobic fitness, strength, physical functioning, QOL, and self-efficacy. At least one of the exercise interventions resulted in improvements in CD4+ cell count and HIV RNA viral load. Moreover, another study showed that HIV-specific biomarkers remained unchanged in the exercise intervention group, while they significantly worsened in the non-exercise group. In general, in spite of their well-known benefits, exercise programs have not been extensively utilized or widely recognized as viable therapeutic treatment options for this patient population. Knowing the possible health benefits of increasing physical activity level is important to better recommend exercise programs. However, the prescription must be done carefully and on an individual basis. Additional studies investigating the efficiency and effectiveness of different exercise training regimens for PLWH are needed.
... e population explosion, sex revolution, substance use and globalization have collectively caused an increase in the incidence and prevalence of viral diseases. Recent statistics show that HIV/AIDS is responsible for over 2 million deaths annually across the globe [3]. It is predicted that by year 2020, AIDS would become the deadliest of all the pandemics in human history. ...
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According to UNAIDS estimates, over 25 million people died of AIDS by the end of 2007, and another 33 million are living with the HIV infection. During the last decade, a sudden rise in incidence and prevalence of HIV was recorded in Eastern Europe, mainly in the injecting drug users population, while in Western Europe hetero- and homosexual routes of transmission are dominant. Central Europe is still a region with a low prevalence of this infection. In the Republic of Croatia, 663 infected cases were recorded until the end of 2007. Sexual route of transmission is dominant (43% homosexual and 39% heterosexual), and it is followed by transmission via contaminated equipment for injecting drugs (9%). All other routes of transmission account for less than 5% of cases. Basic epidemic control measures include continuous research and preventive activities among most-at-risk populations, anonymous counseling and testing, therapy for those infected, and reducing stigma associated with HIV infection.
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Chronic viral diseases impose a special responsibility for healthcare workers devoted to obstetric and human reproduction to avoid the risk of infection for the partner or the expected child. Attitudes towards carriers of viral infections are rapidly changing as a result of better medication and, consequently, a better long-term prognosis, which contribute to the progress being made in areas of cell biology and biochemistry. These infections may be transmitted from mother to child at different times not only during pregnancy, but also during intrapartum and postpartum periods. Gynaecologists should be prepared to counsel affected couples about the risks involved with natural and assisted conception and pregnancy and to recognise available testing and treatment options to optimise outcomes. We described the specificities of assisted reproductive techniques for human immunodeficiency virus (HIV)-, hepatitis C virus (HCV)-and hepatitis B virus (VHB)- infected patients, follow-up during pregnancy, recommendations about antiretroviral therapy (ARV) and delivery modes.
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Chronic viral diseases impose a special responsibility for healthcare workers devoted to human reproduction to avoid the risk of infection for the partner or the expected child. Attitudes towards carriers of viral infections are rapidly changing as a result of better medication and, consequently, a better long-term prognosis, in which the progress being made in areas of cell biology and biochemistry has contributed. These infections may be transmitted from mother to child at different times not only during pregnancy, but also during intrapartum and postpartum periods. Gynaecologists should be prepared to counsel affected couples about the risks involved with natural and assisted conception and pregnancy and to recognise available testing and treatment options to optimise outcomes. We described the specificities of assisted reproductive techniques for human immunodeficiency virus (HIV)-, hepatitis C virus (HCV) - and hepatitis B virus (VHB) - infected patients.
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In the United States, transmission of the human immunodeficiency virus (HIV) by blood transfusion occurs almost exclusively when a recently infected blood donor is infectious but before antibodies to HIV become detectable (during the "window period"). We estimated the risk of HIV transmission caused by transfusion on the basis of the window period associated with the use of current, sensitive enzyme immunosorbent assays and recent data on HIV incidence among blood donors. We analyzed demographic and laboratory data on more than 4.1 million blood donations obtained in 1992 and 1993 in 19 regions served by the American National Red Cross, as well as the results of HIV-antibody tests of 4.9 million donations obtained in an additional 23 regions. We estimated that, in the 19 study regions, 1 donation in every 360,000 (95 percent confidence interval, 210,000 to 1,140,000) was made during the window period. In addition, it is estimated that 1 in 2,600,000 donations was HIV-seropositive but was not identified as such because of an error in the laboratory. We estimated that 15 to 42 percent of window-period donations were discarded because they were seropositive on laboratory tests other than the HIV-antibody test. When these results were extrapolated to include the additional 23 Red Cross service regions, there was a risk of one case of HIV transmission for every 450,000 to 660,000 donations of screened blood. If the Red Cross centers are assumed to be representative of all U.S. blood centers, among the 12 million donations collected nationally each year an estimated 18 to 27 infectious donations are available for transfusion. The estimated risk of transmitting HIV by the transfusion of screened blood is very small and nearly half that estimated previously, primarily because the sensitivity of enzyme immunosorbent assays has been improved.
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A high prevalence of human immunodeficiency virus (HIV) infection in female sex workers (FSWs) and men who attend sexually transmitted disease (STD) clinics poses a risk for spread of infection to other populations. To examine spread of HIV to a low-risk population by comparing prevalence of, and risk factors for, HIV and STDs in FSWs and non-FSWs. Women attending STD clinics in Pune, India, were assessed for STDs and HIV from May 13, 1993, to July 11, 1996. Demographic and behavioral information was collected, and clinical and laboratory assessment was performed. Prevalence and risk determinants of HIV infection. Of 916 women enrolled, 525 were FSWs and 391 were non-FSWs. Prevalence of HIV in FSWs and non-FSWs was 49.9% and 13.6%, respectively (P<.001). In multivariate analysis, inconsistent condom use and genital ulcer disease or genital warts were associated with prevalent HIV in FSWs. History of sexual contact with a partner with an STD was associated with HIV in non-FSWs. Infection with HIV is increasing in non-FSWs, previously thought to be at low risk in India. Since history of sexual contact with their only sex partner was the only risk factor significantly associated with HIV infection, it is likely that these women are being infected by their spouses. This underscores the need for strengthening partner-notification strategies and counseling facilities in India.
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To describe and identify sociodemographic and behavioural characteristics and other factors related to high-risk behaviour for HIV infection of men who have sex with men (MSM) living in Fortaleza, Brazil. A survey was carried out among 400 MSM aged 14-65 years and recruited through the snowball technique or in gay-identified venues. A semi-structured questionnaire was conducted among them. Logistic regression analysis was used to model the dichotomous outcome (high risk or low risk). Forty-four per cent of the participants reported engaging in high-risk sexual behaviour in the previous year. MSM less informed about AIDS, reporting more sexual partners, reporting at least one female partner in the previous year, having anal sex as the favourite way to have sex, and having great enjoyment of unprotected anal sex were more likely to be engaged in risky behaviour. Twenty-three per cent of participants reported at least one sexual contact with women during the previous year. Two-thirds of men who had unprotected sex with their female partners also had unprotected anal sex with their male partners. A large proportion of MSM in Fortaleza still remain at elevated risk for contracting HIV infection. The factors predictive of high-risk sexual behaviour are significant in spreading HIV infection among the MSM population and also among their female partners. The lifestyles of these men are different to those of men from other parts of Brazil or outside the country. Preventive interventions need to be culturally and socially specific in order to be effective.
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Emerging epidemics of HIV in Russia, India and China will largely determine the future course of the HIV pandemic. Injecting drug use has been a major source of new infections in these countries. The evolving role of injecting drug use and sexual transmission in driving these emerging epidemics is investigated using a mathematical model. HIV prevalence projections based on behavioural data for urban Russia result in a wide range of possible outcomes, reflecting uncertainty in estimates of adult sexual behaviour. Surveys of adult sexual behaviour in all the three countries are limited, and represent a research priority if the futures of these emerging epidemics are to be better understood. Analysis of behavioural correlates with adult HIV prevalence reveal the central role of unsafe sex in driving HIV prevalence, even among injecting drug users. However, needle sharing can also play a very significant role, particularly when the potential for heterosexual transmission is limited. These emerging epidemics are more likely to cross higher prevalence thresholds when there is extensive sexual mixing between sex workers and the general population, and to a certain extent between injecting drug users and non-users. Both types of sexual mixing have been documented in Russia, India and China. # 2003 Elsevier Science B.V. All rights reserved.
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Manipur, a north-eastern state of India bordering Myanmar, observed introduction of HIV-1 among fairly large number of IDUs in October 1989, followed by rapid spread within the next 6 months. HIV-2 in injectors was not present until recently, though it was detected from other parts of India in 1991. This communication reports for the first time presence of HIV-2 among young injectors of Manipur. All the HIV-2 infected IDUs were also found to be infected with HIV-1. HIV-2 has affected a large number of people in Africa through heterosexual transmission. It remains to be seen whether HIV-2 spreads rapidly also among the drug-injecting population of Manipur. Observation of the disease progression among HIV-2 infected IDUs will also be of interest.
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The results of a questionnaire survey conducted among 243 seafarers in Rijeka in 1989-1990 indicated that the knowledge of ratings among them on AIDS and HIV virus transmission was inadequate. The majority of them had not used condoms for protection against HIV virus infection. More education on AIDS should be given to seafarers, particularly those employed on ships flying flags of developing countries.
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This article focuses on the epidemiology and biology of the host-related factors that affect the sexual transmission of HIV. It discusses host susceptibility and infectiousness environment biologic agent and preventing sexually transmitted HIV infection.
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To reconstruct the HIV epidemic and to provide forecasts of AIDS incidence among adults in the European Union (EU) and in a group of low prevalence (LP) countries of central and eastern Europe (including the Asian republics of the former Soviet Union). An empirical Bayesian back-calculation method was applied to AIDS incidence data reported by 31 March 1994. The HIV-infection curve was modelled as a yearly step function and a seven-stage Markov model of disease progression, incorporating effects of pre-AIDS treatment, was used. Estimation was by penalized maximum likelihood with empirical Bayesian smoothing. Data were analysed by transmission group and, within the EU, by country. Predictions of AIDS cases to 1998 were made assuming constant annual HIV incidence from 1993 onwards. Estimated HIV prevalences per 100,000 population aged 15-59 years were, at 31 December 1993, 198 (n = 447,800) in the EU and 2.7 (n = 6840) in the 22 LP countries, with increases of 41% (EU) and 71% (LP) between 1989 and 1993. Among homo/bisexual men in the EU, prevalence appears to have stabilized since 1989 and AIDS incidence appears to be reaching a peak. Among all prevalent HIV infections in the EU, 42% were estimated to be among injecting drug users, 25% among homo-/bisexual men and 18% among persons infected heterosexually, compared with 29%, 35% and 19%, respectively, in the LP countries. Without allowing for the 1993 revision of the case definition, annual AIDS incidence is predicted to increase, between 1994 and 1998, by 24% in the EU and by 48% in the LP countries, with the largest percentage increases among heterosexually-infected persons. The overall HIV prevalence rate is estimated to have been about 70-fold lower in the LP countries than in the EU in the early 1990s, but to be increasing much more rapidly in the former. Moreover, recent reports of rapidly increasing HIV infection rates suggest that back-calculation may seriously underestimate the size of the epidemic in the LP countries. Implementation of effective preventive measures is urgent if large-scale epidemics are to be avoided in the presently LP countries of the European region.
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Rational application of diagnostic assays in the management of healthcare workers (HCWs) following occupational exposure is needed to rule out pre-existing human immunodeficiency virus (HIV) infection, detect HIV infection or seroconversion as early as possible in the small proportion individuals who become infected, and to rule out infection in the high proportion of individuals who remain uninfected following occupational exposure to HIV. An understanding of the time course of viremia and seroconversion following HIV exposure is essential in developing recommendations for management of occupational exposure among HCWs. Several data sources that address the timing and dynamics of HIV viremia and seroconversion following primary infection are reviewed. The implications of each data source for management of occupational exposure among HCWs is assessed. Although the majority of infected HCWs seroconvert within 2 months of exposure, the possibility of delayed seroconversion is well established, with approximately 5% of infected HCWs estimated to seroconvert >6 months after exposure. In contrast, the period of viremia (detectable by p24 antigen or RNA assays) preceding antibody seroconversion is consistently brief (1-3 weeks). Animal inoculation studies indicate that a variable period of localized viral replication in lymphoid tissue draining inoculation sites exists prior to systemic viremia and subsequent seroconversion.
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The probability of human immunodeficiency virus (HIV) transmission is one of the key epidemiological parameters in the spread of the AIDS epidemic. The understanding of its possible determinants is necessary for a thorough interpretation of epidemic dynamics and for the evaluation of alternative strategies to control the epidemic. We carried out a bibliographic review of the main studies reporting data on the probability of HIV transmission through sexual contacts and parenteral routes (by transfusion of blood and blood products, by occupational exposures among health care workers, by sharing needles among injecting drug users). Different values of probability are associated to different routes of transmission. The observed high variability depends on the viral load, on the biological fluid (blood or mucous secretions) through which the virus is transmitted and on several other factors related to source infectiousness and to individual susceptibility, both common to all routes of exposures and specific to each of them. It is currently too early to forecast how the introduction of highly active antiretroviral treatment, which strongly reduce the viral load in patients with HIV infection, will modify the probability of transmission. Therefore, the compliance with recommended preventive measures still represents an indispensable way to contrast the virus spread.