HIV/AIDS surges in Eastern Europe — Asia-Pacific next?

Twenty years after physicians first spotted the immune deficiency disease that became known as AIDS, the state of the worldwide AIDS epidemic is stirring both dismay and hope, judging from the latest AIDS Epidemic Update released on 28 November by the Joint United Nations Programme on HIV/ AIDS (UNAIDS) and WHO.

In Eastern Europe and Central Asia, HIV infections are rising faster than anywhere in the world — an estimated one million people were living with HIV/AIDS there in 2001, up from 700 000 the year before — and "a huge epidemic may be imminent" in parts of the former Soviet Union, the UNAIDS/WHO report says. In Asia and the Pacific, low national incidence rates hide "serious" local epidemics that could break into the general population, particularly in China, where as many as one million people may already be infected. In the US, Western Europe, Canada and Australia, complacency is replacing the safer-sex ethic "promoted so successfully for much of the 1980s and 1990s", posing the threat of resurgent epidemics.

Worldwide, an estimated five million people were newly infected with HIV in 2001 (vs 5.3 million in 2000) and an estimated 40 million people (vs 36.1 million) are believed to be living with the virus — 70% of them in sub-Saharan Africa, the hardest-hit region.

"This is very bad news," said Dr Gro Harlem Brundtland, Director-General of WHO, in a 29 November statement. "But there is good news, too." On the upside is evidence that prevention programmes work, that aggressive harm-reduction efforts can restrain HIV/AIDS outbreaks. Thailand's "well-funded, politically supported and comprehensive prevention programmes" have trimmed new HIV infections from about 140 000 annually a decade ago to about 30 000 annually today. Cambodia's campaign, too, against high-risk sexual behaviour has reduced HIV prevalence among pregnant women from 3.2% in 1997 to 2.3% in 2000, "suggesting that the country is beginning to bring its epidemic under control".

Similar harm-reduction programmes have curtailed HIV among intravenous (IV) drug users in Poland and have posted successes even in sub-Saharan Africa. Urban men and women in Zambia report fewer sexual contacts and more condom use. HIV prevalence rates among South African adolescents have dropped slightly since 1998. And in Uganda, "the first African country to have subdued a major HIV/AIDS epidemic", prevalence rates among pregnant women in urban areas have fallen for the past eight years running, from a peak of 29.5% in 1992 to 11.25% in 2000.

"When there's the will and commitment from all different sectors — from the political to the religious sectors — it's possible to reverse the epidemic," says Dr Jesus Maria Garcia Calleja, a UNAIDS epidemiologist in Geneva, Switzerland. "It's not a question only of money. It's a question of the country getting involved in the fight against HIV/AIDS."

Massive prevention efforts could avert "a much larger and more generalized epidemic" in Eastern Europe and Central Asia, the UNAIDS/WHO report says, because the outbreak there is still at an early stage. Although diagnosed AIDS cases have risen dramatically over the past two years in the Russian Federation, the epidemic is still centred among IV drug users, not just in Russia but also in Ukraine and several Central Asian countries. However, a high proportion of IV drug users are sexually active young men, raising the prospect that HIV infection might explode into the broader population.

What is needed is "a comprehensive response to reduce risky sexual and drug-injecting behaviour among young people, and to tackle the socioeconomic and other factors that promote the spread of the virus," the report says. It points to signs that governments in the region are planning such an effort.

"The coming year can be the turning point in the fight against this global epidemic," says WHO's Brundtland. But she warns that "it will be a long fight." Dr Peter Piot, UNAIDS executive director, cautions: "It will get worse before it gets better."

Bruce Agnew, Bethesda, Maryland, USA

World Health Organization Genebra - Genebra - Switzerland