Academic journal article Bulletin of the World Health Organization

Commentary: HIV/AIDS in the 1990s and Beyond(*)

Academic journal article Bulletin of the World Health Organization

Commentary: HIV/AIDS in the 1990s and Beyond(*)

Article excerpt


Back in 1988, as they wrote their article on global surveillance and forecasting of acquired immunodeficiency syndrome (AIDS), Jim Chin & Jonathan Mann were careful to list the unknowns that complicated efforts to estimate the scale and direction of the epidemic in the 1990s. Their forecast that the cumulative number of AIDS cases would reach "2 to 3 million" by the mid-to-late 1990s was a tentative one, fully cognisant of underreporting from many of the places where the epidemic was making its most serious inroads. Other daunting obstacles included insufficient information on reported cases and large gaps in both surveillance and behavioural data from many countries.

As we approach the end of the 1990s, three main points of contrast can be seen with the conditions and knowledge base of 10 years ago.

* First, the conditions: the threat to world health presented by HIV/AIDS is much more serious than foreseen. The epidemic is more widespread and considerably more complex, and has resulted in levels of mortality several times greater than those predicted. Close to 12 million people have already died of AIDS around the world, and three times as many are currently infected with human immunodeficiency virus (HIV), the virus that leads to AIDS. Unless an affordable cure is found, most of those infected with HIV will die within a decade.

* Second -- and fortunately -- understanding about what drives the epidemic and about what can be done to prevent it has developed greatly in the past 10 years. In some parts of the world, this understanding has been put into practice with encouraging results. In others, where the lessons have not been learned or lack of knowledge and resources have prevented application of this understanding, the epidemic has advanced unabated. Also, methods of data collection and modelling have improved vastly, not least because of increased political commitment and better technical cooperation between governments and international organizations.

* Third, while prevention remains the most effective response, the emergence of life-prolonging therapies is changing our vision and future estimates of the epidemic. The relationship between new infections, prevalence levels, incidence of AIDS and mortality are no longer as predictable as they were. However, due to the high cost of the drugs involved, it will be some time before significant effects are seen from these therapies in most developing countries, particularly those with the highest incidence of HIV infections.

Global HIV/AIDS estimates at the end of 1997

As of 31 December 1997, a total of 30.6 million people were estimated to be living with HIV/AIDS (Table 1). Since the beginning of the epidemic, deaths from AIDS have reached 2.7 million children under the age of 15 years, 3.9 million women, and 5.1 million men -- about the same numbers as have died from malaria over the same period. The total number of AIDS orphans (children under 15 years of age when their mother or both parents died from AIDS) since the beginning of the epidemic is estimated at 8.2 million. In many places, AIDS is already the leading cause of death among adults aged 15-49 years. About 2.3 million people died of AIDS during 1997. Moreover, HIV continues to spread, with almost 16 000 new infections each day -- corresponding to about 5.8 million new infections in 1997 alone.

Table 1: Estimated number of adults and children living with HIV/AIDS, as of 31 December 1997

Region                             No. of cases

Sub-Saharan Africa                  21 000 000
South and South-East Asia            5 800 000
Latin America                        1 300 000
North America                          860 000
Western Europe                         480 000
East Asia and Pacific (excluding       420 000
 Australia and New Zealand)
Caribbean                              310 000
North Africa and Middle East           210 000
Eastern Europe and Central Asia        190 000
Australia and New Zealand               12 000

The impact of HIV on life expectancy is cancelling out many of the gains made over the last few decades in parts of the developing world. …

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