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AIDS epidemic Receding

'We can say with confidence and conviction that we have broken the trajectory of the HIV/AIDS epidemic,' said Paul De Lay, deputy director of UNAIDS

Washington Post, David Brown, Nov 23, 2010

The AIDS epidemic has crested and started to recede almost everywhere in the world, but it has left behind millions of people who urgently need treatment if they are going to avoid adding to the disease's toll of 30 million dead over the past 30 years.

That is the gist of the annual portrait of the global AIDS epidemic, released Tuesday by UNAIDS, an agency of the United Nations and World Bank.

While AIDS incidence and mortality have been declining for several years, the new report, which includes data through the end of 2009, confirms that the trend is clear and undeniable.

"We can say with confidence and conviction that we have broken the trajectory of the HIV/AIDS epidemic," said Paul De Lay, deputy director of UNAIDS, which is headquartered in Geneva. "There are fewer people infected, and there are fewer people dying."

The downward decline is the consequence of many forces, including sexual behavior change among young people, success in preventing mother-to-child transmission of the virus, and the lower infectious risk of people who are successfully taking AIDS drugs. It also reflects the epidemic's natural history, in which the annual number of new infections peaks and then declines as the disease "saturates" high-risk groups in the population.

In 2009 there were 33.3 million people living with HIV infection, compared with 26.2 million in 1999. However, the number of new infections in 2009 was down 16 percent from a decade ago - 2.6 million versus 3.1 million. The number of AIDS-related deaths peaked in 2004 at 2.1 million, and last year was down to 1.8 million.

Among the hopeful trends is the rapid increase in the number of people in the developing world taking the combination antiretroviral therapy that since 1996 has revolutionized AIDS care in rich countries.

In 2009 there were 5.2 million people in the developing world on the drugs, a 30 percent increase over the previous year. (Treatment of about 2.5 million of those people is paid for by the U.S. government). However, another 10 million people need treatment but aren't getting it.

The report also described some discouraging developments.

In more than a half-dozen countries, HIV infection rates went up more than 25 percent in the past decade. In the United States and Western Europe, an epidemic in gay and bisexual men continues to grow unabated. There are still two new people becoming infected for every one person who starts treatment (although that is better than two years ago, when there were five new infections for every two people starting treatment).

In 2009, about $15.9 billion was spent on the global AIDS response, with slightly more than half the money provided by low- and middle-income countries themselves. However, much more money, about $26.8 billion, is needed annually to fully fund treatment, care and prevention, the report said.

Equally troubling, according to the report, was that in 2009 the amount of money - $7.6 billion - provided by wealthy countries to treat and prevent AIDS overseas was a tad lower than in the previous year.

"This is coming at the wrong moment, just as we are seeing the investment pay off," said Michel Sidibe, UNAIDS's executive director. "For me, it will be immoral to bring more than 5 million people on treatment and to possibly then say, 'We do not have the means to pay for that treatment.' "

Sub-Saharan Africa is home to about two-thirds of the people in the world living with HIV. The continent's total number of infected, about 22.5 million, continues to grow, in part because of the longer survival of people who have started taking antiretroviral drugs. In 22 of the region's nations, however, the annual number of new infections has dropped by more than 25 percent in the last decade.

A dramatically upward trend has occurred in a few places.

In Eastern and Central Europe, the number of people with HIV tripled since 2000, with the most infections acquired through drug use. In Ukraine, 1.1 percent of people age 15 to 49 are infected with the virus, the highest prevalence in the region. HIV incidence has also increased substantially in a few places where the disease is still rare, such as Bangladesh and the Philippines, according to the report.

The number of children infected at birth has fallen nearly 25 percent in five years. The fraction of infected pregnant women who get medicines to prevent passing the virus to their babies is just over 50 percent, up from 35 percent in 2007. But only 15 percent of the women are then put on a permanent course of antiretroviral therapy, which is a big problem, Sidibe said.

"We need make sure that when we save the baby that we don't abandon the mother. That is a major challenge that I am fighting to make sure we change," he said.

One of the welcome changes over the past decade has been the decline in risky sexual behavior. Nine African countries report a decline in the percentage of young people who are sexually active by age 15, or who had sex with more than one partner in the previous year.

"The reduction in partners is clearly a positive trend, and can be linked to the reduction in new infections," said Bernhard Schwartlander, an epidemiologist at UNAIDS.

Condom use and availability has also increased. Of 83 countries reporting statistics on that topic, 32 reported that 60 percent of men with more than one partner used a condom in their last intercourse.

Pope Benedict XVI recently told a reporter that he condones use of condoms under certain circumstances to prevent HIV infection, a view welcomed by Sidibe and other leaders of the global response.

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