Report on the global <strong>HIV</strong>/<strong>AIDS</strong> epidemic – June 2000PrefaceA decade ago, <strong>HIV</strong>/<strong>AIDS</strong> was regarded primarily as a serious health crisis. Estimates in1991 predicted that in sub-Saharan Africa, by the end of the decade, 9 million <strong>people</strong>would be infected <strong>and</strong> 5 million would die – a threefold underestimation. Today, it is clearthat <strong>AIDS</strong> is a development crisis, <strong>and</strong> in some parts of the world is rapidly becoming asecurity crisis too. There is now compelling evidence, presented in this report, that thetrend in <strong>HIV</strong> infection will have a profound impact on future rates of infant, child <strong>and</strong>maternal mortality, life expectancy <strong>and</strong> economic growth. These unprecedented impactsat the macro-level are matched by the intense burden of suffering among individuals <strong>and</strong>households. <strong>AIDS</strong> is unique in its devastating impact on the social, economic <strong>and</strong> demographicunderpinnings of development.This report also tells another story. It demonstrates that 15 years of action against theepidemic have generated important insights into effective responses. It demonstratesthat, while international political, financial <strong>and</strong> technical <strong>support</strong> are important, loweringincidence <strong>and</strong> mitigating the epidemic’s impacts must be a nationally driven agenda. Tobe effective <strong>and</strong> credible, national responses require the persistent engagement of thehighest levels of government. The report describes the other elements that have provedto be vital: a single, powerful national <strong>AIDS</strong> plan involving a wide range of actors; socialopenness, increasing the visibility of the epidemic <strong>and</strong> countering stigma; social policiesthat address core vulnerabilities; the engagement of all sectors (not just health); a recognitionof the synergy between prevention <strong>and</strong> care; <strong>support</strong> to community participation;<strong>and</strong> targeting interventions to those who are most vulnerable, including young <strong>people</strong>be<strong>for</strong>e they become sexually active. Countries that have adopted <strong>for</strong>ward-looking strategiesto fight the epidemic are reaping the rewards in the <strong>for</strong>m of falling incidence.The task of rolling back the burdens that the <strong>AIDS</strong> epidemic has already brought is enormous.Caring <strong>for</strong> those who are infected remains an enormous national <strong>and</strong> internationalchallenge. Caring <strong>for</strong> the orphans that the epidemic has left behind compounds this task.Protection of another generation of young <strong>people</strong> from premature illness <strong>and</strong> death is aresponsibility of the highest order, <strong>and</strong> is in many countries, the greatest contemporaryleadership challenge.This report sets out our current level of knowledge about the epidemic at the start of the21st century. It lays out the evidence, the success stories <strong>and</strong> the challenges that confrontindividual countries <strong>and</strong> the international community. In doing so, it seeks to convey thetrue seriousness of the global epidemic, but also to keep hope alive. The evidencedemonstrates that we are not powerless against this epidemic, but our response is still ata fraction of what it needs to be. The real task now is to increase, massively, the politicalwill, resources, systems <strong>and</strong> social commitment needed to turn the tide of the epidemic.Peter PiotExecutive DirectorJoint United Nations Programme on <strong>HIV</strong>/<strong>AIDS</strong>7
Report on the global <strong>HIV</strong>/<strong>AIDS</strong> epidemic – June 2000<strong>AIDS</strong> in a new millennium:a grim picture <strong>with</strong> glimmers of hopeWhen <strong>AIDS</strong> emerged from the shadows two decades ago, few <strong>people</strong> could predicthow the epidemic would evolve, <strong>and</strong> fewer still could describe <strong>with</strong> any certainty thebest ways of combating it. Now, at the start of a new millennium, we are past thestage of conjecture. We know from experience that <strong>AIDS</strong> can devastate wholeregions, knock decades off national development, widen the gulf between rich <strong>and</strong>poor nations <strong>and</strong> push already-stigmatized groups closer to the margins of society.Just as clearly, experience shows that the right approaches, applied quickly enough<strong>with</strong> courage <strong>and</strong> resolve, can <strong>and</strong> do result in lower <strong>HIV</strong> infection rates <strong>and</strong> less suffering<strong>for</strong> those affected by the epidemic. An ever-growing <strong>AIDS</strong> epidemic is notinevitable; yet, unless action against the epidemic is scaled up drastically, the damagealready done will seem minor compared <strong>with</strong> what lies ahead. This may sound dramatic,but it is hard to play down the effects of a disease that st<strong>and</strong>s to kill more thanhalf of the young adults in the countries where it has its firmest hold – most of thembe<strong>for</strong>e they finish the work of caring <strong>for</strong> their children or providing <strong>for</strong> their elderly parents.Already, 18.8 million <strong>people</strong> around the world have died of <strong>AIDS</strong>, 3.8 million ofthem children. Nearly twice that many – 34.3 million – are now <strong>living</strong> <strong>with</strong> <strong>HIV</strong>, the virusthat causes <strong>AIDS</strong>. Barring a miracle, most of these will die over the next decade or so.The most recent UN<strong>AIDS</strong>/WHO estimates show that, in 1999 alone, 5.4 million <strong>people</strong>were newly infected <strong>with</strong> <strong>HIV</strong>.Africa: the enormous challenges of a long-lasting epidemicThe African countries south of the Sahara have some of the best <strong>HIV</strong> surveillancesystems in the world. They provide solid evidence that the <strong>HIV</strong> infection rate has stabilizedat a relatively low level in Senegal <strong>and</strong> that the extremely high rates in Ug<strong>and</strong>ahave been reduced. However, in most sub-Saharan countries adults <strong>and</strong> children areacquiring <strong>HIV</strong> at a higher rate than ever be<strong>for</strong>e: the number of new infections in theregion during 1999 was 4.0 million. This acceleration effect is yet another challengeposed by long-st<strong>and</strong>ing epidemics. As the rate of <strong>HIV</strong> infection in the general populationrises, the same patterns of sexual risk result in more new infections simplybecause the chances of encountering an infected partner become higher.8