Washington, DC — "The scale of the Aids crisis now outstrips even the worst-case scenarios of a decade ago," according to a new UNAIDS Report on the Global HIV/AIDS Epidemic, and Africa continues as "the worst-affected region in the world."
By 2020, according to UNAIDS numbers, over 25% of the workforce may be lost to Aids in some severely affected countries.
"I wish I could come up with better news," said UNAIDS Executive Director, Peter Piot, briefing reporters Tuesday. "The Aids epidemic continues its expansion. It's now clear to me that we are only at the beginning of the Aids epidemic." This conclusion was unexpected, said Piot. Epidemiological modeling used to project the expansion of Aids had predicted that the spread of the disease would have "peaked" by now.
Southern Africa, the hardest hit region of the continent, was one of the first places where these models suggested that the pandemic might reach a "natural limit" beyond which it would not grow. But among pregnant women in urban areas of Botswana, the latest numbers show a rise from 38.5 percent in 1997 to 44.9 percent in 2001, In Zimbabwe two years ago, one out of four were infected. Today one out of three are infected. In Zambia, nearly two-thirds of deaths among the managerial sector can be attributed to Aids.
"In the 80s and early 90s...obviously the models were wrong. They were all underestimating what is happening now," said Piot. "When we started with UNAIDS [in 1996] there were predictions that by the year 2000 the number of infected individuals in Africa would reach a certain level, and we have gone far beyond that."
Extensive modeling of Southern Africa occurred in the mid-90s, said UNAIDS Senior Epidemiologist Neff Walker, "and in all of those models they predicted prevalence that is roughly one third to one half of what we find now."
As to why: "We missed," said Walker, "the fact that people move in and out of risk groups or being at risk. How you define being at risk for HIV when there is low prevalence is very different once you get higher levels of prevalence. One of the insidious things about HIV/Aids is that people get infected [and] live for nine or ten years. It can be passed across generations. And that's just not something that most of our modeling work in terms of infectious disease has really encountered before."
This means, explained Walker in plainer English, that it is possible not to be at risk at 25 and then be at risk at 35 because the prevalence rate has skyrocketed. "We didn't have, especially in Africa, great behavioral data. And so...every time we tried to do our modeling work we ended up saying, 'the epidemic was at its peak.' Then two years later we got new data and we raised the model again and said they've all peaked again."
Now, says Walker their "new modeling approach" has "a little more epidemiological oomph to it. We have parameters for the size of the population which can vary over time. We even have some factors that deal with behavioral change. So we think now we have a model which more accurately captures what's going on."
Under this new modeling, the "saturation rate" - the point at which Aids begins to level off, is startlingly high. In Botswana, among 25 to 29-year-old women, "We have prevalence rates in the low 60 [percent] among pregnant women in Gaberone and Francistown, the bigger urban centers. So we're assuming now that in some of these countries, in that population, you could reach levels of that kind of prevalence," said Walker.
"We're not saying everyplace in Africa is going to reach Botswana. We generally look at the national country - what's happened there. If the epidemic has slowed down, we assume that that's going to be a fundamentally different kind of model...."
In the end, however, despite all the variations from country to country, the modeling for Africa seems to result in a bleak picture almost everywhere.
Even in Uganda, which continues to show a "downward arc" of prevalence rates - among pregnant women in Kampala from a high of 29.5 percent in 1992 to 11.25 percent in 2000 - "huge challenges remain," according to the report. "New infections continue to occur at a high rate, access to antiretrovirals is limited, and the "orphan crisis will continue to strain society's resources for many decades."
As in Uganda, Senegal's early efforts to fight the disease seem to be paying off. But in general for the [West Africa] region, "there is evidence of recent, rapid HIV spread." In Cameroon, for example, where HIV was under 2 percent in 1988, "the 2000 round of HIV surveillance found national prevalence rates of around 11 percent among pregnant women." Similarly, in Nigeria, national prevalence rates have slowly gown from 1.9 percent in 1993 to 5.8 percent in 2001. "More than 3 million Nigerians are estimated to be living with HIV/Aids."
"In many parts of sub-Saharan Africa, as elsewhere in the world, gender inequality and economic deprivation help drive the epidemic," the report states. UNAIDS estimates that less than 4 percent of people who need treatment are under antiretroviral treatment in the developing world. "When you look at the world overall, 730,000 people are treated [with antiretrovirals]. Of those, half a million are living in western countries, in wealthy countries. And last year there were less than 25,000 deaths. Compare that to Africa: 30,000 people treated and 2.2 million deaths last year."
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The "right responses" can bring the epidemic under control. Less sexual activities with multiple partners by men and use of condoms has caused a significant drop of HIV/Aids among Zambian rural women. Botswana has become the first country to set the goal of making antiretrovirals available to all through its public health system. Nineteen countries have set up HIV/Aids councils at senior levels of government; 34 have completed national strategic HIV/Aids plans.
But it will take money, more money than developing nations, especially poor African nations, can come up with - some US$10bn a year "to provide treatment for those who are infected, to prevent those who are not infected from becoming infected and to take care of the orphans."
Piot said he was "quite disappointed" in the outcome of last week's G-8 Summit. "No commitments were made in terms of supporting Africa to confront Aids."
Piot says they now have "a good idea of what the needs are and it's not a matter of millions but of billions of dollars. If this commitment isn't made, he says, "we'll have to continue to bring out this kind of depressing report and an emerging disaster and it's going to destabilize not only a continent, but I think will have implications for the rest of the world."
