HIV/Aids: The 21st century plague

More than 40 million people have HIV/Aids, the UN revealed yesterday, with Eastern Europe and sub-Saharan Africa among the worst-hit areas. Jeremy Laurance and Elizabeth Davies report

The global number of people living with HIV has doubled in a decade to exceed 40 million for the first time. The remorseless advance of the disease, the worst in modern times, continued last year, infecting another nine people every minute, and laying waste to families, communities and economies.

It will claim an estimated 3.1 million lives this year, 570,000 of them children, according to the annual report on the epidemic published by UNAIDS and the World Health Organisation (WHO).

Aids experts yesterday tried to put a positive spin on the carnage. " Fortunately, we have some good news," said Purnima Mane, policy director of UNAIDS. "Adult HIV infection rates have declined in some countries, including Kenya, Zimbabwe, and urban parts of Haiti and Burkina Faso."

Changes in behaviour such as increased condom use, delay in the age of first sexual experience and a reduction in the number of sexual partners were playing their parts.

In the Caribbean, the area with the second-highest HIV prevalence in the world after sub-Saharan Africa, there was cause for "guarded optimism", with a decline in infection rates among pregnant women, increased condom use among sex workers and a rise in the numbers coming for voluntary HIV testing.

In Kenya, HIV rates have declined from 10 per cent in the late 1990s to 7 per cent in 2003, partly due to nationwide campaigns to promote condoms and encourage people to go for testing.

It was only the second time in two decades that a country had seen a sustained decrease in infection rates, Ms Mane said. The first was Uganda in the early to mid-1990s.

But the report indicated how fragile these gains are and how easily lost. HIV prevalence rates in Rakai in the south of Uganda fell sharply among women from 20 per cent in 1995 to 13 per cent in 2003. Yet researchers could find no evidence that abstinence or fidelity - two weapons used in the anti-Aids strategy - had increased. Condom use with casual partners had increased - the third weapon in the strategy - and probably contributed to the fall in HIV.

But most of the gain, researchers found, had nothing to do with improved prevention - it came from higher death rates. HIV had spread so far within the community that victims were dying faster than new ones could become infected.

The fall in rates had also led to complacency in the local population with signs of a "possible resurgence" in HIV infection in men and women aged 15 to 24 in Rakai and other parts of the country, the report said.

Peter Piot, executive director of UNAIDS, paid tribute to those countries where sustained prevention programmes had brought down infection rates. "But the reality is that the Aids epidemic continues to outstrip global and national efforts to contain it," he said. "It is clear that a rapid increase in the scale and scope of HIV prevention programmes is urgently needed."

The steepest increase in HIV infections was in eastern Europe and central Asia, where they rose 25 per cent to 1.6 million. Here and in Latin America, injecting drug users and sex workers are the chief drivers of the epidemic. In China, 60 per cent of those infected with HIV contracted the infection through drug use. But sub-Saharan Africa remains the worst-hit region, with three million new HIV infections - almost two-thirds of the global total of 4.9 million.

Key to the success of prevention is increasing access to treatment with antiretroviral drugs. Once treatment is available there is a reason to get tested, and once people know their HIV status they can be counselled to avoid further spread.

"Treatment availability provides a powerful incentive for governments to support and individuals to seek out HIV prevention information and voluntary counselling and testing," said Lee Jong-wook, director general of WHO.

But the experts admitted they had failed to meet the WHO "three by five" target to have three million people on the drugs by 2005. An estimated one million people were taking antiretroviral drugs in low- and middle-income countries by last June, two million below target.

"Of course we are disappointed," said Andrew Ball, senior strategic HIV adviser at the WHO, " but it was an extremely ambitious target." Up to 350,000 deaths had been averted thanks to increased access to drugs, he said. But only one in 10 of those infected was being treated.

"Despite the existence of antiretroviral drugs, three million people died last year. Most of these deaths could have been averted if they had access to these treatments. The message is clear to countries that they must invest in prevention and treatment, because without both we won't halt this epidemic," Mr Ball said.

Anton Kerr, of Christian Aid, called on governments to contribute more to the Global Fund for HIV/Aids, TB and malaria. A conference in September heard that double the £2.1bn donated was needed to fund new prevention, treatment and care programmes in 2006 and 2007.

Adults and children living with HIV in 2005

Average of estimate range

North America - 1.2 million/Western and Central Europe 720,000

These regions - the only ones in the world where antiretroviral treatment is readily available - have seen an increase in HIV-positive cases, with 65,000 newly infected in the past year. The United States exceeded 1m infected for the first time at the end of 2003. Western Europe is home to more than half a million infected people, a growing figure that is due partly to new diagnoses in people originating from countries with serious epidemics. Transmission has been relatively contained in Central Europe.

Caribbean - 300,000

Though it still has the second-highest HIV prevalence levels in the world, there is cause for cautious optimism in the Caribbean, where declines were evident in Barbados, the Bahamas and Bermuda. Haiti, in the past the region's chief victim of Aids, could be turning a corner, with the percentage of pregnant women testing HIV-positive down by half from 1993 to 2004 from 6.2% to 3.1%.

Latin America - 1.8 million

Argentina, Brazil and Colombia are home to the fiercest epidemics in the region, where unsafe sex - particularly between men - and injecting drug use is fuelling HIV transmission. By far the most populous South American country, Brazil is fighting the spread of Aids with a policy of making anti-retroviral therapy accessible on the national health service to all in need.

Eastern Europe/Central Asia - 1.6 million

62,000 people died of Aids-related diseases in the region this year and some 270,000 were newly infected. The majority of those affected were in Russia and the Ukraine; the former also has the worst Aids epidemic in Europe as a whole. Although unsafe sex is one of the main factors for this increase, Russia's primary cause is the widespread use of drug injection. The Ukraine saw an increase of nearly 25% from 2003-2004. Uzbekistan is also experiencing a dramatic increase, from just 28 reported cases in 1999 to 5,600 in 2004.

North Africa/Middle East - 510,000

Awareness of Aids is generally poor and preventive measures rare in this region. 67,000 people were newly infected and 58,000 died of Aids-related diseases last year. The worst affected country is Sudan, where only 5% of women know that condoms can prevent infection and more than two thirds have never heard of them. 53% of drug injectors attending treatment centres in Iran, where 200,000 are thought to be infected, have never used a condom. Drug injection is the main cause of transmission in Libya, where most of the 10,000 HIV cases have occurred since 2000.

Sub-Saharan Africa - 25.8 million

Still by far the region hardest-hit by the Aids pandemic, sub-Saharan Africa is home to more than 60% of all people infected with the virus. Despite apparent declines in HIV prevalence in several countries, including Zimbabwe, Kenya and Uganda, infection levels across the region continue to soar and, where there are seeming success stories, experts fear this is because the numbers dying of Aids are exceeding the number of new HIV infections. And in many other countries, the pandemic continues to evolve at astonishing speed. South Africa, where less than 1% of the population was infected in 1990, has recorded its highest levels to date: in 2004, 29.5% of women attending antenatal clinics tested HIV-positive.

Asia - 8.27 million

Injecting drug users and sex workers are driving the spread of Aids through Asian countries, where more than a million people contracted HIV last year and the disease is infecting people at a quicker rate than anywhere else in the world. While HIV cases have been detected in all 31 Chinese provinces, several different epidemics are spreading throughout India, where 42% of sex workers believed they could tell whether or not a client had Aids by his physical appearance. In the Pakistani city of Karachi, one in five prostitutes were not able to recognise a condom and one-third of those questioned had never heard of Aids. In Indonesia, one of the countries singled out as 'on the brink' of a rapidly worsening epidemic, over 70% of people who requested testing in Pontianak found they were infected.

Oceania - 74,000

An estimated 74,000 people in the region are living with HIV and, although fewer than 4,000 people are thought to have died of Aids in 2005, about 8,200 are believed to have become newly infected with the disease. Australia, which has the oldest epidemic in the region, is starting to see a fresh upward turn in the number of new HIV diagnoses, with 820 new cases detected in 2004. The bulk of HIV transmission- 68% of all cases ever recorded- in Australia still occurs through gay male sex.