Africa: Next Wave of HIV/AIDS

This posting contains excerpts from a new report by the U.S. National Intelligence Council, identifying five countries including 40% of the world's population as the focus of the next wave of the HIV/AIDS pandemic. These countries include two African countries, Nigeria and Ethiopia, as well as Russia, India, and China. The full study is available at the NIC's web site at: http://www.odci.gov/nic

Note that the projections in the study are even higher than most others currently presented, and are acknowledged to have wide ranges of uncertainty. Note also that the study repeats the conventional assumption that almost all HIV in Africa results from heterosexual transmission. In contrast, a recent article in the Royal Society of Medicines' International Journal of STDs (Sexually Transmitted Diseases) and AIDS, excerpted in another posting today, contends that the proportion of transmission of the virus through unsafe medical care (injections,transfusions, and other procedures) is being grossly underestimated, and may even exceed the proportion transmitted by sexual intercourse.

The new NIC report was featured at a two-day meeting at the Center for Strategic and International Studies, including a luncheon keynote address by Stephen Lewis, special envoy of the UN Secretary-General on HIV/AIDS. See
http://www.csis.org/press/ma_2002_1003.htm Lewis' speech is available at: http://sustainable.allafrica.com/stories/200210040603.html

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The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China

ICA 2002-04D September 2002

National Intelligence Council

The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China

Prepared under the auspices of David F. Gordon, formerly National Intelligence Officer for Economics and Global Issues.

Summary

The number of people with HIV/ AIDS will grow significantly by the end of the decade. The increase will be driven by the spread of the disease in five populous countries Nigeria, Ethiopia, Russia, India, and China where the number of infected people will grow from around 14 to 23 million currently to an estimated 50 to 75 million by 2010. This estimate eclipses the projected 30 to 35 million cases by the end of the decade in central and southern Africa, the current focal point of the pandemic.

* We project China will have 10 to 15 million HIV/ AIDS cases, and India is likely to have 20 to 25 million by 2010 the highest estimate for any country. By 2010, we project Nigeria will have 10 to 15 million cases, Ethiopia 7 to 10 million, and Russia 5 to 8 million.

HIV/AIDS is spreading at different rates in the five countries, with the epidemic the most advanced in Nigeria and Ethiopia. In all countries, however, risky sexual behaviors are driving infection rates upward at a precipitous rate.

* Adult prevalence rates - the total number of people infected as a percentage of the adult population - are substantially lower in Russia, India, and China, where the disease remains concentrated in high- risk groups, such as intravenous drug users in Russia and people selling blood plasma in China, where some villages have reported 60 percent infection rates.

* Nevertheless, the disease is spreading to wider circles through heterosexual transmission in India, the movement of infected migrant workers in China, and frequent prison amnesty releases of large numbers of infected prison inmates and rising prostitution in Russia.

It will be difficult for any of the five countries to check their epidemics by 2010 without dramatic shifts in priorities. The disease has built up significant momentum, health services are inadequate, and the cost of education and treatment programs will be overwhelming. Government leaders will have trouble maintaining a priority on HIV/ AIDS which has been key to stemming the disease in Uganda, Thailand, and Brazil because of other pressing issues and the lack of AIDS advocacy groups.

* The governments of Nigeria, India, and China are beginning to focus more attention on the HIV/ AIDS threat.

* Even if the five next-wave countries devote more resources to HIV/AIDS programs, implementation is likely to miss significant portions of the population, given weak or limited government institutions and uneven coordination between local and national levels.

* Nigeria and Ethiopia have very limited public services to mobilize. Russia is beset by other major public health problems. China has decentralized most responsibility for health and education issues to local governments that often are corrupt.

* India has taken some steps to improve its healthcare infrastructure to combat HIV/AIDS, but the government has few resources to treat existing infections and must cope with other major health problems such as tuberculosis (TB), which has become linked to the spread of HIV/AIDS.

The rise of HIV/AIDS in the next-wave countries is likely to have significant economic, social, political, and military implications. The impact will vary substantially among the five countries, however, because of differences among them in the development of the disease, likely government responses, available resources, and demographic profiles.

* Nigeria and Ethiopia will be the hardest hit, with the social and economic impact similar to that in the hardest hit countries in southern and central Africa decimating key government and business elites, undermining growth, and discouraging foreign investment. Both countries are key to regional stability, and the rise in HIV/AIDS will strain their governments.

* In Russia, the rise in HIV/AIDS will exacerbate the population decline and severe health problems already plaguing the country, creating even greater difficulty for Russia to rebound economically. These trends may spark tensions over spending priorities and sharpen military manpower shortages.

* HIV/AIDS will drive up social and healthcare costs in India and China, but the broader economic and political impact is likely to be readily absorbed by the huge populations of these countries. We do not believe the disease will pose a fundamental threat through 2010 to their status as major regional players, but it will add to the complex problems faced by their leaders. The more HIV/AIDS spreads among young, educated, urban populations, the greater the economic cost of the disease will be for these countries, given the impact on, and the need for, skilled labor.

The growing AIDS problem in the next- wave countries probably will spark calls for more financial and technical support from donor countries. It may lead to growing tensions over how to disburse international funds, such as the Global Fund for AIDS, TB and Malaria.

The cost of antiretroviral drugs which can prolong the lives of infected people has plunged in recent years but still may be prohibitively high for populous, low- income countries. More importantly, the drug costs are only a portion of HIV/AIDS treatment costs. Drug- resistant strains are likely to spread because of the inconsistent use of antiretroviral therapies and the manufacture overseas of unregulated, substandard drugs. 5

* If an effective vaccine is developed in the coming years, Western governments and pharmaceutical companies will come under intense pressure to make it widely available.

* The next-wave countries are likely to seek greater US technical assistance in tracking and combating the disease.

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We project that China probably will have 10 to 15 million HIV/AIDS cases by 2010. India is likely to have 20 to 25 million higher than projected for any other country. We estimate Nigeria probably will have 10 to15 million cases, Russia 5 to 8 million, and Ethiopia 7 to 10 million.

Country Profiles

Nigeria.

The HIV/AIDS epidemic in Nigeria is significantly ahead of that in India, China, and Russia - already advancing well beyond high- risk groups and into the general population. The official adult prevalence rate is almost 6 percent, but unofficial estimates range as high as 10 percent which represents 4 to 6 million people infected.

Heterosexual transmission of the HIV virus is the primary mode of spread in Nigeria, and infections appear to be as numerous in rural areas as in the cities. The reported rate of infection apparently varies significantly by region, with the lowest reported rate found generally in the predominantly Muslim northern parts of the country (see 9 figure 3). Infections are most numerous among men ages 20 through 24, but some experts caution that infection rates are rising quickly in young women.

Given the already advanced state of the disease and the government s limited capacity to respond, we expect HIV/AIDS to infect as many as 10 to 15 million people by 2010. This number would constitute roughly 18 to 26 percent of adults close to the current rates in some of the hardest hit countries in southern Africa.

Ethiopia.

Ethiopia's adult prevalence rate estimated at between 10 and 18 percent is the highest among the five countries, indicating that like Nigeria the disease has moved significantly into the general population. Government figures cite 2.7 million Ethiopians currently as HIV positive, although experts believe the actual number may be between 3 and 5 million. Adult prevalence is much higher in cities (13 to 20 percent) than in rural areas (5 percent) (see figure 4). The generally poor health of Ethiopians as a result of drought, 10 malnutrition, limited healthcare, and other infectious diseases has caused HIV to progress rapidly to AIDS. Heterosexual transmission is the primary mode of spread, and people with multiple partners especially those with sexually transmitted diseases (STDs) and prostitutes have significantly higher infection rates, ranging from 30 to 40 percent in STD- positive individuals to 50 to 70 percent in prostitutes.

Unlike conditions in other next- wave countries, war has significantly contributed to the spread of the disease in Ethiopia. Many soldiers contracted HIV/AIDS during the civil war in the 1980s by having contact with multiple sex partners. When the war ended in 1991, thousands of infected soldiers and prostitutes returned home, spreading HIV/AIDS in their villages and towns.

* Another surge of infections may be underway. Ethiopia has demobilized 150,000 soldiers over the last two years as the conflict with Eritrea has wound down. More troops will be sent home as the border dispute is settled.

* As soldiers demobilize, prostitutes who have even higher rates of infection disperse around the country as well.

Looking ahead, we expect 7 to 10 million Ethiopians probably will be infected by 2010 because of the high current rate of adult prevalence, widespread poverty, low educational levels, and the government's limited capacity to respond more actively.

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HIV: The Science of the Disease

HIV-1 is a fatal infection acquired by contact with the blood or body fluids of an infected person. A transfusion with infected blood almost always results in spread of the virus, and children born to infected mothers have an up to 40 percent chance of contracting the virus prior to birth, during birth, or through breastfeeding. The transmission rate of the disease through sexual contact ranges from 1 to 3 percent. Reusing infected needles results in infections less than one percent of the time.

Sexually transmitted diseases or reproductive tract infections greatly increase the risk of contracting HIV, and uncircumcised men transmit HIV and other STDs to their partners more frequently than circumcised men.

As the disease progresses, a type of infection-fighting white blood cell the CD4 positive-t cell decreases, leading to an irreversible loss of immune function. This period is marked by many illnesses, or unusual opportunistic infections that healthy immune systems protect against.

HIV-positive persons are susceptible to opportunistic and infectious diseases, especially TB. Once they have contracted TB, the disease progresses to the highly infectious, active stage much more quickly and frequently than in HIV-negative persons and is often what kills them. ...

Prospects for Control

We assess that all five next-wave countries will have difficulty controlling their HIV epidemics in the short to medium-term. The disease has built up significant momentum especially in Nigeria and Ethiopia and the governments have been slow to respond. None of the five next-wave countries in this report is on a trajectory to replicate the success of such countries as Uganda, Thailand, and Brazil in stemming the spread of the disease. Several leaders of the nextwave countries are focusing more attention on the AIDS threat, but all face a host of competing demands. In addition, these countries have weak healthcare infrastructures and severe budget constraints, which will create difficulty in financing education and treatment programs for their large populations.

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Nigeria's leadership has been the most active of the five countries in trying to raise AIDS awareness, for example, by hosting a regional AIDS conference in 2000 and publicly warning about the risk of extinction on the continent. Nonetheless, the Obasanjo administration is beset by such other pressing problems as an approaching election and rising ethnic and religious tensions. Moreover, Nigeria s government institutions have deteriorated so badly over the last decade that Obasanjo has few functioning public sector assets left to mobilize even if he chose to engage fully on the issue.

* Nigeria has taken some steps, however, to build domestic monitoring and diagnostic capabilities especially in Lagos and a major study on the economic effects of HIV/AIDS is underway. * The Nigerian military, concerned about the loss of key personnel from AIDS, now mandates training about the disease for soldiers.

* The Ethiopian Government does not appear focused on AIDS, despite occasional statements on the issue. The government has focused in recent years on the conflict with Eritrea. Healthcare workers privately have criticized efforts in recent years as half hearted, and UN officials have publicly warned Ethiopian leaders to take more measures to stem the epidemic.

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Weak Healthcare Infrastructure

Although significant differences in capabilities exist among next- wave countries, all five have overburdened and under funded healthcare systems and limited abilities to provide integrated, nationwide programs to test people, track infections, and deliver treatment and education programs. Even within each of the five next- wave countries there are disparities in the ability of cities and regions to deal with the epidemic that are likely to grow in the coming years.

* Nigeria's public healthcare system, which has been deteriorating for years, is hard pressed to provide even the most basic public services. Many facilities lack electricity, water, and soap; even betterequipped hospitals are beset by strikes by medical staff.

* Ethiopia has never had a viable national healthcare system because of overwhelming poverty and years of war. The government is soliciting international assistance to build its capabilities, but progress on this front is likely to take years.

Implications

The rise of HIV/AIDS will have significant economic, social, political, and military implications in Nigeria, Ethiopia, Russia, India, and China, although the percentage of the adult population in each country that is infected is likely to remain below the hardest hit countries in southern and central Africa. The impact of the disease by the end of the decade will vary among the five countries, given differences in disease trajectories government responses, available resources, and demographic profiles.

Nigeria and Ethiopia: Hardest Hit

The social and economic impact of AIDS in Nigeria and Ethiopia probably will be similar to the hardest hit countries in Africa. The disease is likely to negatively impact almost all sectors of society by 2010. AIDS will take a heavy economic toll by robbing the countries of many key government and business elites and by discouraging foreign investment, although the oil sector is unlikely to be hurt significantly. 22

* The professional classes in Nigeria and Ethiopia like other African countries are more vulnerable in comparison to other next- wave countries because adult prevalence rates already are much higher and relatively fewer elites are concentrated in a smaller number of key positions.

* The drag of AIDS on economic growth will further reduce the ability of the government to handle the rising social and healthcare costs.

The further deterioration of already weak government institutions by the escalating HIV/AIDS crisis could leave Nigeria and Ethiopia seriously weakened states and is likely to reduce their ability to continue to play a regional leadership role.

* HIV/AIDS probably will complicate staffing in the military officer corps of the two countries as it has in other African states. Ethiopia is more likely to suffer military manpower shortages through the lower ranks, however, because it has a much larger army and smaller population than Nigeria, which plans to reduce the size of its force.

* Rising social tensions over AIDS and related economic problems could exacerbate regional and ethnic tensions within Nigeria and Ethiopia while leaving both governments less able to manage the problem.