Note about UNAIDS/WHO estimates

The estimates concerning HIV and AIDS in this document are based on the information available to UNAIDS and WHO at the current time. They are provisional. WHO and UNAIDS, together with experts from national AIDS programmes and research institutions, keep these estimates under constant review with a view to updating them as improved knowledge about the epidemic becomes available and as advances are made in the methods used for deriving estimates.

For example, knowledge about the epidemic improves not only as better information becomes available about HIV spread (for example, through more representative sentinel surveillance), but also as more is learnt about the factors that help or hinder the spread of the virus (for example, the natural history of HIV infection in different parts of the world, the impact of HIV infection on fertility, and the effects of improved treatment). This improved knowledge together with methodological advances together provide the basis for updated estimates of HIV incidence, prevalence and mortality.

Because of these factors, the 1998 estimates cannot be directly compared with those for 1997 or earlier years, nor with those that may be published subsequently. While they are largely based on the country-specific models prepared for last year’s estimates and published in the joint UNAIDS/WHO publicationReport on the global HIV/AIDS epidemic–June 1998, the December 1998 estimates reflect upward or downward adjustments that were made for a number of countries in the light of updated information.

The purpose of publishing these estimates is to help governments, nongovernmental organizations and others who have a stake in bringing AIDS under control to gauge the status of the epidemic in their country and to monitor the effectiveness of the considerable efforts at prevention and care being made by all partners. 
 

“HIV/AIDS is among us”

South Africa, which in 1998 accounted for nearly 1 in 10 of the new HIV infections estimated to have occurred worldwide, is the latest country in the ranks of those seeking to break through the shroud of stigma and shine a light on the human disaster of AIDS.

“For too long we have closed our eyes as a nation, hoping the truth was not so real,” South African Deputy President Thabo Mbeki told South Africans in October 1998. “For many years, we have allowed the human immunodeficiency virus to spread.. At times we did not know that we were burying people who had died from AIDS. At other times we knew, but chose to remain silent.

“[Now] we face the danger that half of our youth will not reach adulthood. Their education will be wasted,” Mbeki said. “The economy will shrink. There will be a large number of sick people whom the healthy will not be able to maintain. Our dreams as a people will be shattered.”

Appealing to South Africans to change “the way we live and how we love”, Mbeki called for abstinence, fidelity and condom use, and urged a caring, non-discriminatory attitude to those already infected with or affected by HIV. The speech was nationally televised, and the whole nation was urged to stop work to listen to it. Many private companies gave workers a day off. Flags flew at half mast on government buildings and religious leaders, youth, trade unionists, women’s organizations and business leaders committed themselves to the President’s Partnership Against AIDS. 

Silence can continue to reign even when people with HIV are ill and dying. Because AIDS is just the name for a cluster of diseases that immunodeficient people develop, patients and their carers can choose to view the illness as just tuberculosis, or diarrhoea, or pneumonia. An example from southern Africa is telling. In one study of home-based care schemes, fewer than 1 in 10 people who were caring for HIV-infected patients at home acknowledged that their charges were suffering from AIDS. Patients themselves were only slightly more likely to acknowledge their status, and several told researchers that they had not disclosed their HIV-positivity to anyone, including the person caring for them. This self-imposed silence is hard on the patient. It can also be hard on the carers, particularly when they are children or adolescents. If they do not know that their parent or loved one is suffering from a fatal disease, they cannot prepare themselves for the death or acknowledge that it will inevitably come no matter how much effort they put into care. So carers risk compounding their feelings of grief and loss with feelings of failure.

In some countries, leaders have spoken out loudly, clearly and repeatedly about AIDS, have sought to demystify it, and have encouraged discussion about safe sex everywhere from the classroom to the boardroom. It is in such countries–of which Uganda is probably the best-known example in the developing worl–that most progress has been made not just in putting a brake on new infections but in ensuring the well-being of those people who are already living with the virus.
 

Driven by stigma: Shame, silence and denial

It is hard to measure stigma–people with HIV see it in a scornful look in the marketplace, in the refusal of family and friends to visit, care for or even touch them, in the maltreatment of their children or the loss of their job on a flimsy pretext. But stigma is a very real obstacle to both prevention and care. In many of the hardest-hit countries, government officials and ordinary citizens–including those most affected by the epidemic–often continue to look the other way because of the rejection, discrimination and shame attached to AIDS.

Stigma and the fear it engenders both fuel the spread of HIV, since those with risky behaviour in the past may be reluctant to change that behaviour in case the change is interpreted as an admission of infection. Fear of acknowledging HIV infection can stop a married man from raising the subject of condom use with his wife. Fear of advertising her HIV status may prevent an infected woman from giving her baby replacement feeding to avoid transmitting the virus through breastmilk.

The stigma attached to HIV affects both sexes. However, the consequences may be more severe for women, who risk being beaten and even thrown out of the house by their husband if their status is revealed. This is true even when the husband was the source of the woman’s infection. An HIV-infected woman may be blamed for the death of her children, and deprived of care.

In places where shame and stigma are the rule, many people simply do not want to know if they are HIV-infected, even when counselling and testing are offered. And the small minority of people who know their HIV status rarely share it with others, even in confidential support groups. In Zimbabwe’s city of Mutare, for example, surveillance data show that close to 40% of pregnant women are HIV-infected, and infection levels in men are likely to be similarly high. There are probably 30 000 adults living with HIV in Mutare. Yet there is just one HIV support group in the city, and it has just 70 members. Many more people know or fear they are HIV infected: some will find support in their partners or families but many will struggle alone with the implications of their infection.

Driven by danger: Soldiers in Cambodia

Decades of political turmoil and civil war have left much of Cambodia’s infrastructure in tatters. Education, health care, the transport network–all are being rebuilt more or less from scratch as peace gradually returns to the country. In the meantime Cambodian soldiers, many of them teenagers with no schooling, continue to battle Khmer Rouge rebels in the northwest of the country. For them, risk is a way of life, whether from combat, malaria or land mines.

It is understandable that many of these young men view sex as a source of comfort, not of special danger. The risk of HIV infection, which will not in any case kill them for at least a decade, can seem negligible. “The regular troops are there at the front because they have no education and nothing to eat at home,” says a military doctor. “They have no idea of the future. They first think day by day.”

But the HIV risks are not negligible at all. Behavioural research shows that over a third of Cambodian soldiers have visited a brothel just in the last month, including many of the married men in the army and the police force who are separated for long periods from their wives and children. Some 43% of sex workers tested positive in Cambodia’s brothels in 1998, while HIV prevalence in the military was around 7%.

One in five soldiers say that besides visiting prostitutes, they also have girlfriends–often waitresses or “beer girls” who promote various brands of the beverage in restaurants or nightclubs. Both the beer girls and their soldier partners make a distinction between their relationship and an act of commercial sex in a brothel, for condom use with these girlfriends is abysmally low–just 8%. Yet over 20% of beer girls tested positive for HIV in 1998.

To decrease risky behaviour and new infections, Cambodia’s military has trained a number of soldiers about HIV and other STDs and given them support in spreading the prevention message to other soldiers. This system, known as peer education, works well in the military because, as one officer said, “Soldiers live and fight and die together. They have the same problems and the same habits. They are not intellectuals but are very pragmatic and can follow others’ example”.

While it is still early days in the peer education programme, there is already evidence that Cambodian soldiers are reducing their risk of HIV infection. Condom use by soldiers in brothels is now 63%–16% more than in 1997–and visits to brothels in the month preceding the survey fell by 40%, a remarkable change in a single year.

Driven by conflict: Survivors in Rwanda

Before the political turmoil of the mid-1990s, more studies had been done to understand the HIV epidemic in Rwanda than in most developing countries. The pattern of infection recorded there was a familiar one: high rates in urban areas (more than 10% of pregnant women infected) but far lower rates in the rural areas that were home to the bulk of the population (just over 1%).

The political difficulties of recent years not only interrupted HIV surveillance; they changed the shape of the epidemic. By 1997, when a well-designed survey of HIV was carried out in the general population, little difference remained between urban and rural rates. Both were just over 11%. Among teenagers, infection was actually higher in rural areas than in cities. And it was appallingly high at the youngest ages: among 12, 13 and 14 year olds, a full 4% were already HIV-infected.

Many of the changes can be ascribed to the huge population movements during and after the years of ethnic conflict. Nearly three-quarters of the 4700 people surveyed in 1997 had lived elsewhere in the preceding three years–an astonishingly high turnover for this largely rural country. Migrants who had spent the years of conflict outside Rwanda had lower rates of HIV infection than those who endured the troubles inside the country. Most of these people are recently returned from Uganda and Tanzania, countries where HIV prevention campaigns are relatively strong.

HIV prevalence among people who said they had spent the conflict years in refugee camps was 8.5%. Most of these people had fled from rural areas where pre-conflict HIV prevalence was just 1.3%. That suggests a six-fold increase in HIV infection among refugees in the camps. Overcrowding, violence, rape, despair and the need to sell or give away sex to survive are all likely to have contributed to this huge leap in infection.

Wars and armed conflicts generate fertile conditions for the spread of HIV. Rape–inside or outside refugee camps–has doubtless played a part in spreading the virus in Rwanda. Some 3.2% of women surveyed reported being raped, over half of them during the conflict itself. Two-fifths of them were teenagers. Among women who had been raped 17% were HIV-positive, compared with 11% of those who had not. Women who reported rape were three times as likely as those who were not raped to have suffered from genital sores, another STD.

Driven by loneliness: Migrant labourers in South Africa

Nowhere is this more true than in South Africa. Thriving mining industries attract workers not just from rural areas of the nation, but from neighbouring economies where job opportunities are limited and wages are lower. It is hard to know how many people move into and around South Africa in search of work. More than a decade ago 2.5 million South Africans were registered as migrant workers, and that number is likely to have increased. This year, over half a million people will join the country’s growing urban population.

Carltonville, at the heart of South Africa’s gold mining industry, is home to 88 000 mine workers, 60% of them migrants from other parts of South Africa or from nearby countries: Lesotho, Malawi and Mozambique. With the miners come wages. Some US$ 18 million is paid out to workers every month in Carltonville. With the wages come all manner of goods and services, including, of course, drugs and sex. Some 400-500 sex workers service the Carltonville mines. And with drugs and sex comes HIV.

The city has become the HIV hot spot of Gauteng Province. Around 22% of adults in Carltonville are infected with HIV, a rate over two-thirds higher than the national average. A small survey of sex workers found HIV in three-quarters of them, while one mineworker in five is thought to be infected. That count is probably an underestimate because it does not include the men who have dropped out of the mines because they are too sick to work.

Why are infection levels so high in miners? Most men live lonely lives in single-sex dormitories, often hundreds of miles from their families. They also have a dangerous job. A gold-miner in South Africa has a one in forty chance of being killed by a rock-fall underground and a one in three chance of serious injury. Compared with that, the dangers associated with a long, slow infection like HIV might seem remote.

Of course, the HIV dangers are not just to the mineworkers themselves, or to their sex partners around the mining sites. Most migrant workers return home periodically. Increasingly, they are carrying infection back to their wives and their home communities. In Hlabisa, a rural district of KwaZulu/Natal, some 60% of households are estimated to have one or more male migrants. One study here found that sex outside the primary relationship is accepted as almost inevitable in separated families, for both men and women. In this community, HIV rates are rising dramatically, with the prevalence among pregnant women shooting up to 26% in 1997 from 4% just five years earlier. A study in 1995 found that of women whose partners were at home less than a third of the time, 13% were infected. No infections were recorded among women who spent more than two-thirds of the time with their husbands or regular partners.

What drives the epidemic?

The AIDS epidemic has unfolded very differently in different parts of the world, and among different populations. It is not always clear why HIV infection takes off in some places while rates in neighbouring countries remain stable over many years. However, there are several factors which clearly influence the shape of the epidemic. People on the move–escaping from abuse, or even just leaving their families in search of work–are especially likely to be exposed to infection. People whose daily existence is stressful and dangerous may not care about the long-term risks posed by HIV. People in conflict and refugee situations may have little control over their exposure to HIV, indeed even to sex. And the stigma that still attaches to HIV hinders people from protecting themselves and others from infection, or from seeking out care and support.

The different faces of AIDS can be seen in the following country situations, which illustrate some of the factors driving the epidemic.

Young escapees on Brazil’s streets

Brazil is a country of contrasts, of great wealth and of crushing poverty from which young people find it hard to escape. Around a third of the 31 million Brazilians aged between 15 and 24 come from families living below the poverty line. Only one adolescent in 12 completes high school, and many of the rest–half of the boys and as many as three-quarters of the girls–remain jobless. Across the country, some two million people aged 15-19 neither work nor go to school.

Undereducated and underemployed, these young people are easy targets for adults selling drugs or buying sex. In fact, they are easy targets for adults wanting sex but unwilling to pay for it. Research in São Paulo, Brazil’s largest city, indicates that one girl in five has been sexually abused in her own home or in the surrounding community.

Girls who have lived through sexual abuse are more likely than others to drift onto the streets, into prostitution, and onto the waiting list for HIV infection. In Brazil’s impoverished northeast, communities are trying to head off this danger by identifying girls who are at risk of violence or abuse in the home. These girls are invited to join support groups that teach them skills that will help them make a living as well as defend themselves against violence and unwanted sex. Of 850 girls who have been helped by one such programme, so far there are no reports of any of them ending up in prostitution or in a street gang. With HIV rates running as high as 17% among poorer sex workers in some cities, supporting young women with alternatives to a life on the streets is an important way of protecting them from HIV infection. 
 

However, much remains to be done. In the USA, for example, 3 million adolescents a year contract a sexually transmitted disease, a clear indicator of unsafe sex. In developing countries, where the likelihood of encountering a partner infected with a sexually transmitted disease is high, STD infection rates in young people are often much higher.

Young people are vulnerable to HIV for many reasons–they do not know about HIV or STDs, or they know about them but do not know how to avoid infection. Those with the information may be unable to get hold of condoms, or may feel unable to discuss condom use with their partner. Young people, and especially girls, may be unable to defend themselves against unwanted sex. In the Democratic Republic of Congo, nearly a third of young women in a large study reported that they had been forced by their partners into first sex. Similar statistics on coerced sex are reported from many parts of the world.

What is more, adolescence is a time when many people experiment–not only with different forms of sex but with drugs. Apart from the HIV risk connected with needle-sharing, it is known that alcohol and other drugs can affect sexual behaviour and increase young people’s risk of becoming infected with HIV or the other STDs. Excessive drinking, for example, diminishes inhibitions, increases aggression, diminishes the ability to use important information learnt about AIDS prevention, and impairs the capacity to make decisions about protection.

Whether or not young people’s drug-using habits change over time, the consequences of risk behaviour at this age can be irrevocable, as can be seen in data from places as far apart as Asia and Europe. In Myanmar over 60% of teenage drug injectors are infected with HIV–indeed teenagers are the only group of drug users in which HIV prevalence has continued to climb steadily since the early 1990s. In Belarus, over four-fifths of registered HIV infections are in drug users in their teens and twenties. In Lithuania, over half of HIV infections registered in injecting drug users are in people under 25. Regardless of whether these young people continue their drug use or abstain, they will carry HIV with them till their premature death.

HIV–a threat to the world’s young people

This year’s World AIDS Campaign–Young people: Force for change–was prompted in part by the epidemic’s threat to those under 25 years old. Young people are disproportionately affected by HIV and AIDS. Around half of new HIV infections are in people aged 15-24, the range in which most people start their sexual lives. In 1998, nearly 3 million young people became infected with the virus, equivalent to more than five young men and women every minute of the day, every day of the year. And as HIV rates rise in the general population, new infections are increasingly concentrated in the younger age groups. A recent study in Malawi, for instance, found the annual rate of new HIV infections to be as high as 6% in teenage women, compared with under 1% in women over 35.

But the Campaign also highlights the power of young people. The future of the HIV epidemic lies in their hands. The behaviours they adopt now and those they maintain throughout their sexual lives will determine the course of the epidemic for decades to come. Young people will continue to learn from one another, but their behaviour will depend largely on the information, skills and services that the current generation of adults choose to equip their children with.

Research shows that young people adopt safer sexual behaviour provided they have the information, skills and means to do so. In Senegal, 40% of women under 25 and 65% of men used condoms with non-regular partners in 1997, compared with less than 5% for both sexes at the start of the decade. In fact, given the chance, young people are more likely to protect themselves than adults. In Chile, a 1996 study showed that condom use is highest among 15-18-year-olds, and similar patterns have been found in Brazil and Mexico.

Safer sexual behaviour is becoming the norm among young people in developed countries, too. In several studies in Western Europe, some 60% of young people are now using condoms the very first time they ever have se–a six-fold increase since the early 1990s. Among young people in the United States, abstinence is becoming more common and condom use is rising significantly. Among high school students in 1997, 63% of boys reported that they had used a condom the last time they had sex, up from 55% six years earlier. For girls, condom use rose to 51% from 38% over the same period.

AIDS and business: the bottom line suffers

The onslaught of AIDS is denting the prospects for economic development too. In the hard-hit countries of Africa, the epidemic is decimating a limited pool of skilled workers and managers and eating away at the economy. With many economies in the region in flux, it is hard to determine exactly what the impact of HIV is on national economies as a whole. However, it is clear that businesses are already beginning to suffer.

In Zimbabwe, for instance, life insurance premiums quadrupled in just two years because of AIDS deaths. Some companies say that their health bills have doubled. Several report that AIDS costs absorb as much as one-fifth of company earnings. In Tanzania and Zambia, large companies have reported that AIDS illness and death cost more than their total profits for the year. In Botswana, companies estimate that AIDS-related costs will soar from under 1% of the wage bill now to 5% in six years’ time, because of the rapid rise in infection in the last few years.