Care and support for people living with HIV/AIDS

Waking up to devastationThere is no phenomenon apart from the AIDS epidemic that could possibly explain thisrecent drastic rise in mortality after years of declining death rates. Indeed, smaller community-basedstudies with information on the cause of death show that in countrieswhere just under 10% of the adult population has HIV infection, almost 80% of alldeaths in young adults aged 25–45 are associated with HIV. The proportion of HIVrelateddeaths is likely to be even higher in areas with higher HIV prevalence rates.In some countries, over a third of 15-year-olds may die of AIDSHigh and stable HIV prevalence rates are bad news. But there is worse news.Prevalence rates do not reflect the true impact of the epidemic. The 15–49-year-oldage group includes people who are not yet infected with HIV but who will be one day.And it excludes men and women born 15–49 years ago who were infected with HIVbut have already died. If the probability that a person will become infected at any timein his or her life is summed up, the cumulative figure is higher than the “snapshot” providedby current prevalence rates.To give a better idea of the actual risk of dying of HIV-associated disease, researchershave built models to follow people throughout their lives, examining their exposure torisks of infection with HIV at each age. The risks are calculated from patterns of HIVinfection at each age observed in African communities. In general, the rate of newinfections peaks among women in their early 20s and among men slightly later, andtapers off at older ages. The rate of new infections at each age is determined by thecurrent phase of the HIV epidemic in a country. In the model, men and women alsoface the competing risk of dying of other causes at rates similar to those recordedbefore the HIV epidemic.The results of this exercise are illustrated in Figure 10 for men. Along the bottom of thegraph is the current prevalence of HIV in adults aged 15–49. The vertical axis showsthe probability that a boy who is now 15 years old will die of AIDS. Clearly, the likelihoodthat a boy now aged 15 will eventually die of AIDS is much higher than the likelihoodthat a man now aged 15–49 is currently infected with HIV. This sobering factremains true even if the rates of new infection fall in the future. The grey line shows therelationship between current prevalence and the risk of a 15-year-old eventually dyingof AIDS if infection rates stay at current levels – a pessimistic scenario. The red lineshows the relationship if the risk for new HIV infection at each age drops by half overthe next 15 years – in other words, if prevention campaigns are very successful. Evenin this optimistic scenario, however, the proportion of young people who will die ofAIDS is appallingly high in many countries: in virtually any country where 15% or moreof all adults are currently infected with HIV, at least 35% of boys now aged 15 will dieof AIDS.In countries where HIV infection is concentrated in specific sub-populations – forexample, men who have sex with men – there is a similar relationship between currentHIV prevalence in that group and the lifetime risk of dying of HIV-related disease.25