The Caribbean is currently the second-most affected region in the world after Sub-Saharan Africa. Nine of the twelve countries with the highest HIV prevalence in the Americas are in the Caribbean, five islands having national prevalence rates of over 2% (these five being the Bahamas, Belize, Guyana, Haiti and Trinidad and Tobago). AIDS has now become the leading cause of death among individuals aged 15-44. Several nations which rely on tourism as a main source of income are among those most affected. Similar to the epidemic in Sub-Saharan Africa, HIV transmission in the Caribbean is largely through heterosexual intercourse with the notable exception of Puerto Rico, in which IV drug use appears to be the major driving force behind the epidemic. Haiti, a nation known for extremely high numbers of citizens living below the poverty line, is the worst affected nation in the region with an adult prevalence rate of 5.6%.
HIV prevalence in East Asian countries is quite low compared to those found in other continents, but the populations of these nations are so large that low prevalence often masks large numbers of people living with HIV. China has by far the largest epidemic in the region. The virus has spread to all of China’s provinces. IV drug use and sex workers currently play a large role in the spread across the nation, up to half of drug injectors testing positive for HIV in some provinces. China has a long history with HIV as a decade ago many rural people were infected when they sold blood plasma to supplement their meager incomes.
Data amongst blood donors in Japan show that HIV prevalence has risen steadily among male blood donors but has remained stable among women. This would indicate that HIV transmission is occurring mainly amongst MSM. There were 340 newly-reported HIV cases among Japanese MSM in 2003, which was over three times the number of reported infections among heterosexual men. There has been a rapid increase in the annual number of HIV infections attributed to homosexuality.
Only Guatemala and Honduras have national prevalence of over 1%, but in terms of raw numbers, Brazil has by far the most infected, accounting for more than one third of the people living with HIV in the region. The epidemic has spread throughout all of Brazil’s regions, at first affection only MSM, and then IV drug users, and now into the heterosexual community. With the exception of Brazil, the HIV epidemic in Latin America has remained largely contained in the large urban centers. Up to 65% of HIV infections in Argentina occurred in the capital, Buenos Aires, and its surrounding areas. This is even more true in Uruguay where up to three quarters of all registered HIV cases have been in the capital, Montevideo. The same is the case in Central America, where the number of HIV infections has been slowly rising in most nations.
The HIV epidemic in the United States disproportionately affects African Americans; though they represent only 12% of the American population, over half of new infections in recent years have been amongst this demographic. African American women are even more disproportionately affected as they account for up to 72% of new HIV diagnoses in American women. Poverty is known to increase vulnerability to HIV infection, and some American studies have shown a close link between higher HIV incidence and lower income. It is estimated that one in four African Americans live in poverty. AIDS is now one of the top three causes of death among African American men aged 25-54 and African American women aged 35-44.
The epidemic for American men is mainly driven by injecting drug use and men having sex with men. Heterosexual intercourse, however, accounts for most new HIV diagnoses in women. The main risk factor for many women appears to be the secret risk behavior of their male partners. The majority of Americans living with HIV are men who have sex with men.
Recent estimates put the number of Canadians infected with HIV at 56,000 at the end of 2002. Most new infections in Canada are among men who have sex with men and injecting drug users.
Southern Asia has the highest total number of HIV infections and AIDS deaths outside of Sub-Saharan Africa. National HIV epidemics are very different due to the diversity of the nations in this region. Some countries such as Cambodia and Thailand were hit hard early, others, such as Pakistan and Bangladesh, are only now beginning to be affected and thus have a great opportunity to prevent large epidemics before they happen. India is the most affected nation with an estimated 5.1 million people living with HIV. Several states across India have epidemics comparable to those in Southern Africa. A prevalence of 50% has been found among sex workers in Tamil Nadu for example. Infection is increasing in Indonesia, Nepal and Viet Nam spurred on both by IV drug use and non drug users who practice various risky behaviors. Condom use is rare in Indonesia for example, with UNAIDS reporting that in some provinces rates of use by brothel-associated sex workers stood at only 4%. IV drug use is the main factor behind the epidemics in both Nepal and Viet Nam, 22%-68% of male injectors across the various provinces in Nepal were found to be HIV positive in 2002. Viet Nam is particularly volatile due to the high rates of IV drug use by sex workers in major urban centers such as Ho Chi Minh. One survey of 1000 sex workers found 38% injected drugs, and nearly 50% of those were infected with HIV. East Timor is particularly disturbing as nearly 6 out of 10 sex workers had never even heard of AIDS as demonstrated in one recent survey, and 4 out of 10 did not recognize a condom when shown one. Southern Asia is not without success stories. Introduction of large-scale prevention programs in both Cambodia and Thailand have been responsible for significant reductions in risk behavior and new HIV infections. Particularly impressive was the “100% condom” program brought to brothels at the beginning of the Thai epidemic. Statistics have shown that these efforts have been quite successful.
A large majority of people in Western European countries have access to anti-retroviral drugs. As a result of this treatment, AIDS related deaths have stayed low since plunging in the mid 1990’s when anti-retrovirals were first introduced. However, a new problem has recently presented itself in many nations, where there is evidence of antiretroviral drug resistance in newly infected individuals.
New HIV infections through heterosexual intercourse have increased by 122% between 1997 and 2002; however this has been largely in immigrant communities from regions with serious epidemics such as Sub-Saharan Africa and the Caribbean. There has also been an increase in diagnoses among MSM, which could indicate a resurgence of risky behaviors. IV drug use is a major factor of epidemics in Spain, Italy and Portugal. Epidemics in the Czech Republic and other central European countries are still largely contained in the MSM communities.
HIV prevalence in East Asian countries is quite low compared to those found in other continents, but the populations of these nations are so large that low prevalence often masks large numbers of people living with HIV. China has by far the largest epidemic in the region. The virus has spread to all of China's provinces. IV drug use and sex workers currently play a large role in the spread across the nation, up to half of drug injectors testing positive for HIV in some provinces. China has a long history with HIV as a decade ago many
rural people were infected when they sold blood plasma to supplement their meager incomes. Data amongst blood donors in Japan show that HIV prevalence has risen steadily among male blood donors but has remained stable among women. This would indicate that HIV transmission is occurring mainly amongst MSM. There were 340 newly-reported HIV cases among Japanese MSM in 2003, which was over three times the number of reported infections among heterosexual men. There has been a rapid increase in the annual number of HIV infections attributed to homosexuality.
This region is very diverse due to the large distances between theislands and the differences in levels of development. Papua New Guinea has the highest HIV prevalence in the region with an estimated 0.6% of adults living with HIV at the end of 2003. New infections have been steadily increasing since the 1990's. The same is the case in
Australia and New Zealand where both of the national adult prevalence rates are estimated at 0.1%. The epidemic is still largely concentrated in the homosexual communities of both nations. Prevalence appears to be low in the many smaller islands throughout Oceania such as Kiribati and Vanuatu, but data is extremely limited so levels may be underestimated.
The number of people living with HIV has increased dramatically over the past decade. Estimates put the figure at 1.4 million at the end of 2004. The most serious epidemic is in Ukraine where the number of infections continues to rise. The largest epidemic by far is in Russia; however it is unevenly distributed across the massive nation. Up to 60% of all HIV infections have been reported in only 10 of the 89 regions of Russia. For the most part epidemics in this region are in their early stages with the exception of a few. Swift interventions can potentially halt and reverse them before they take hold. One interesting note of epidemics in this region is that the vast majority of infections have occurred in people under the age of 30. Also, injecting drug use is a major contributor, but sexual transmission is slowly increasing.
The epidemics in most countries in this region are still in their early stages. This gives an excellent opportunity for preventionmethods to limit further spread of the virus. However, there is a tremendous lack of surveillance throughout the region which may cause data to be unreliable. Evidence points to
heterosexual intercourse being the major route of transmission, but more information is needed as outbreaks of HIV in some populations may be being missed. By far the hardest hit country in the region is Sudan, which has been devastated by famine and civil war. It has hard to provide reliable data due to the instability of the country in recent years.
Sub-Saharan Africa is by far the worst affected region, being home to about 10% of the world's population, and accounting for more than 60% of all people living with HIV. Infection is fact becoming endemic in this region. Even if significant improvements are made in the battle and incident rates are drastically reduced, prevalence levels are high
enough that countries in the region will have to deal with serious AIDS epidemics for many years to come. Adult prevalence rates have stabilized in recent years, which sounds like a good thing but disguises the fact that equally large numbers of people are becoming newly infected with HIV as are dying from AIDS. Women are now disproportionately affected by HIV, especially young women (15-25 years). Recent studies suggest that there are 3.6 young women living with HIV in the region for every young man. Not enough can be said of
how terrible a toll AIDS is taking in this region, serious work must be done to fight it and much help is needed.
Joint United Nations Programme on HIV/AIDS. <www.unaids.org>.
Center for Disease Control. <www.cdc.gov>.