- The virus is firmly embedded in the general population, among women whose only risk behaviour is having sex with their own husbands. In a study of nearly 400 women attending STD clinics in Pune, 93% were married and 91% had never had sex with anyone but their husband. All of these women were infected with a sexually transmitted disease, and a shocking 13.6% of them tested positive for HIV.
In Eastern Europe and in Latin America and the Caribbean, infections are concentrated in marginalized groups though clearly not limited to them.
In Latin America the pattern of HIV spread is much the same as in industrialized countries. Men who have unprotected sex with other men and drug injectors who share needles are the focal points of infection. In Mexico studies suggest that up to 30% of men who have sex with men may be infected; among drug injectors in Argentina and Brazil the proportion may be close to half. While transmission through sex between men and women is on the rise, especially in Brazil, heterosexual HIV spread is especially prominent in the Caribbean. Prevalence rates of 8% among pregnant women have been reported from Haiti and one surveillance site in the Dominican Republic.
HIV continues to gallop through drug-injecting communities in Eastern Europe and Central Asia. A region which until the mid-1990s appeared to have been spared the worst of the epidemic, it now holds an estimated 270 000 people living with HIV. For the moment Ukraine remains the worst-affected country, though the Russian Federation, Belarus and Moldova have all registered enormous increases in the past few years. With HIV gaining new footholds as it penetrates new drug-user communities, the potential for continued spread through drugs and sex is undeniable given the known overlap between drug-injecting and sex-worker populations and the dramatic rises in other STDs. In the Russian Federation, for example, syphilis rates have shot up from around 10 cases per 100 000 people in the late 1980s to over 260 cases per 100 000 a decade later.
In North America and Western Europe, new combinations of anti-HIV drugs continue to reduce AIDS deaths significantly. For example, recently-published figures show that in 1997 the death rate for AIDS in the United States was the lowest in a decade–almost two-thirds below rates recorded just two years earlier, before combination therapy came into widespread use. However, because new infections continue to occur while antiretroviral drug cocktails keep already-infected people alive, the proportion of the population living with HIV has actually grown. This obviously increases the demands for care. In a number of less obvious ways, it adds to countries’ prevention challenges.
During 1998, North America and Western Europe recorded no progress in reducing the number of new infections. The early dramatic rises in HIV were successfully reversed by the mid-to-late 1980s thanks to prevention campaigns that raised condom use among gay men from virtually zero to well over 50%. But over the last decade, the rate of new infections has remained stable instead of continuing to decrease. During 1998 alone, nearly 75 000 people became infected with HIV, bringing the total number of North Americans and Western Europeans living with HIV to almost 1.4 million.
Clearly, the epidemic is no longer out of control in these countries. Just as clearly, it has not been stopped. And at this stage the prevention challenges are greater than ever. One reason is that prevention efforts have already reached the easier-to-reach groups, such as the largely well-educated and well-organized white gay communities. Another reason is that HIV infections are increasingly concentrated in the poorer sectors of the population. In the USA, to take one example, HIV has become a disproportionate threat to US citizens of African origin. Although African-Americans represent only 13% of the total US population, they bear an undue share of American poverty, underemployment and inadequate health care access. African-Americans are now more than 8 times as likely as whites to have HIV. According to the Centers for Disease Control and Prevention (CDC), among black males national HIV prevalence is estimated to have reached 2% and AIDS has become the leading killer in the 25-44 age group. For black women in the same age group, AIDS takes second place as cause of death. The US administration has just announced a new $156 million federal effort for minority communities to help curb HIV spread through drug injecting and sex, and to help ensure access to antiretroviral drug therapy for those already living with HIV.
Further details about regional patterns of HIV infection, together with end-1997 estimates of HIV infection and AIDS deaths for 170 individual countries, can be found in the UNAIDS/WHO publication Report on the global HIV/AIDS epidemic-June 1998. 4 These country-specific estimates are the most recent ones available.