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The virus

The global epidemiology of in a decline of new infections among children (from an estimated
450,000 in 2001 to 370,000 in 2007).3 Despite considerable prog-

HIV ress in the expansion of ARVs, with almost 3 million people


receiving treatment in 2007, the majority of people in need of
HIV treatment do not have access to ARVs and an estimated
Valerie Delpech 2.0 million people died of AIDS globally in 2007.1
Jacqueline Gahagan
The need for accurate epidemiological information
The quality and availability of HIV data varies widely from coun-
try to country. Many low- and middle-income countries do not
collect case reports of HIV and have a limited number of popula-
Abstract tion-specific studies on which to base prevalence estimates in
An estimated 33 million people were living with HIV worldwide at the both general and vulnerable populations. Furthermore, stigma
end of 2007. Overall global declines in the rate of new HIV infections and discrimination associated with HIV/AIDS leads to significant
and AIDS deaths, notably in sub-Saharan Africa, indicate some successes under-reporting of HIV cases and of deaths due to AIDS. Despite
in prevention and greater access to antiretroviral therapies. Neverthe- the availability of well-established surveillance systems in high-
less, a staggering 2.7 million people became infected with HIV in 2007. income countries, trend data of persons newly diagnosed are
Moreover, the declines in some regions were partially offset by a rise subject to reporting and testing biases. The challenge remains
in new infections in other parts of globe, in particular Asia and eastern to develop technological and statistical tools to measure HIV
Europe. New infections continue to disproportionately impact ­vulnerable ­incidence better and in a more timely fashion*.4
populations, including young women and girls, men who have sex with
men, sex trade workers, people who inject drugs and migrants. Preva-
Modes of transmission
lence rates of HIV infection among these populations, where data exist,
are high. High-quality epidemiological information and robust ­statistical In Africa, the majority of HIV infections are attributed to het-
methods are vital in order to measure accurately the size of the ­epidemic, erosexual contact with an HIV-infected partner,1 whereas sex
identify affected populations and track intervention efforts. Structural between men is the predominant mode of transmission in
barriers, including social inequalities and the lack of prevention and ­western Europe5 and North and South America,1,5 and exposure
intervention efforts aimed at vulnerable populations in many countries to contaminated injecting equipment is the major mode of trans-
continue to hinder efforts to curb the global spread of HIV. mission in Asia and eastern Europe.6 Recent surveys, however,
indicate a greater diversity in the transmission of the virus and
Keywords epidemiology; HIV; international trends; surveillance; overlap in the modes of transmission globally.6–10
­transmission
Unsafe sex between men and women
Heterosexual sex with an HIV-infected partner accounts for the
majority of infections acquired worldwide and over 90% of those
Global trends
acquired in sub-Saharan Africa.1 The likelihood of a woman
In little more than a quarter of a century HIV has caused an acquiring HIV through heterosexual contact with an infected part-
estimated 25 million deaths worldwide and profoundly changed ner is higher than for men11 and as such the prevalence of HIV is
the demographics and social fabric of populations and countries. typically higher and increases more rapidly among women than
According to the Joint United Nations Programme on HIV/AIDS men in countries where heterosexual transmission is dominant.
(UNAIDS), an estimated 33 million (30.3–36.0 million) people Recent national population-based surveys in southern Africa
were living with HIV worldwide by the end of 2007, of which indicate prevalence rates among 20–24-year-old women greater
approximately 16.5 million were women and 2 million were chil- than 20% in Botswana and South Africa, and 38% in Swaziland
dren (<15 years).1 HIV continues to spread worldwide with an in 2006, compared to less than 12% in 20–24-year-old men.2
estimated 2.7 million people infected in the same year. How-
ever, declines in new infections witnessed in some parts of sub- Unsafe sex between men
Saharan Africa suggest that prevention efforts are working.2 In Sex between men occurs in every culture and society, and esti-
particular, greater access to antiretroviral therapies (ARV) to mates of the proportion of men who have had sex with other
­prevent mother-to-child transmission in this region has resulted

* HIV incidence (sometimes referred to as cumulative incidence) is


Valerie Delpech MBBS MPH FPHM is a Public Health Physician and Head the number of new infections arising in a given period in a specified
of national HIV surveillance at the Health Protection Agency Centre for population. UNAIDS normally refers to the number of people (of all
Infections, London, UK. Competing interests: none declared. ages) or children (0–14 years) who have become infected during the
past year. In contrast, HIV prevalence refers to the number of people
Jacqueline Gahagan PhD is Professor, Health Promotion, School of living with HIV at a particular point in time. Prevalence of HIV is likely
Health and Human Performance, Dalhousie University, Halifax, Nova to continue rising given ongoing transmission of the virus and fewer
Scotia, Canada. Competing interests: none declared. AIDS deaths (due to greater access to antiretrovirals).

MEDICINE 37:7 317 Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.
The virus

men at least once vary between 3% and 20% worldwide.6 It is an estimated two-thirds of those living with HIV globally and con-
established as the main mode of transmission in nearly all Latin tinues to experience a disproportionate burden of infections, with
American countries.1 Most HIV-infected men who have sex with a reported 22 million people living with HIV in 2007. Women com-
men (MSM) acquired HIV through unprotected anal sex, which prise 60% of all prevalent cases and this proportion continues to
carries a high risk of HIV transmission.11 Multiple sexual partners rise. Young people, and in particular young women, are at especially
and low condom adherence led to a rapid rise in HIV prevalence high risk of HIV infection due, in part, to social and economic mar-
among MSM in many large cities across Europe, North America ginalization fuelled by gender-based inequalities. Over one-third
and Australia in the 1980s and 1990s. The recent sharp increase (1.9 million) of all new infections and three-quarters of all AIDS
in the incidence of new diagnoses among MSM in these regions deaths worldwide (1.75 million) occurred in sub-Saharan Africa
has been associated with a rise in unprotected sex and sexually in 2007.
transmitted infections.12–15 HIV prevalence is estimated to be above 10% in at least nine
Social stigma and discrimination results in many men who southern African countries.1 An estimated 5.7 million people
may otherwise be exclusively homosexual having heterosexual are living with HIV in South Africa, making it the largest HIV
relationships, thereby potentially also exposing their female ­epidemic in the world.
partners to HIV. Furthermore, because ‘sex between men’ is not Countries in east Africa and west Africa have experienced sig-
included in some national surveillance systems, the full impact of nificantly lower HIV prevalence than those in southern Africa,
HIV transmission among MSM remains largely invisible in many with most having a prevalence below 2%. Some epidemics show
parts of the world. signs of decline, most notably that in Nigeria, the continent’s
Recent studies indicate rates of HIV prevalence among MSM most populous country.1
exceeding 20% in a number of large cities across Africa, Latin
America, the Caribbean, eastern Europe and Asia,7 and the odds Asia
of HIV infection among MSM are at least nine times higher than An estimated 5.0 million people were living with HIV in 2007
in the general population.16 in Asia, including 380,000 new infections and the same number
of AIDS deaths.1 No country in this region has a reported HIV
Exposure to contaminated injecting equipment prevalence exceeding 2%, unlike Africa. The evolution of the
Exposure related to contaminated injecting equipment carries a HIV epidemics varies considerably and show that prevalence is
very high risk of transmission of HIV.11 Reliable estimates of the declining in some countries (Cambodia, Myanmar and Thailand)
number of persons who inject drugs and the prevalence of HIV over the past decade, but rapidly growing in others (Indonesia,
infection among this group, essential in the planning of interven- Pakistan and Vietnam).9 Increases in new HIV infections in popu-
tions, are scarce. Based on data from 78 countries, by the end of lous countries such as China and India are of particular concern.
2003 an estimated 13.2 million individuals (0.3% of the world’s Although the estimated national HIV prevalence rates in India
population) were currently injecting.17 and China are relatively low (0.36% and 0.05%, respectively)
Overall 1 in 10 HIV infections worldwide are attributed to these rates translate into large epidemics, with approximately 2.4
injecting drug use (IDU), a similar proportion to infections attrib- million people living with HIV in India and 700,000 in China.9
utable to sex between men.1 The contribution of IDU to the HIV Although IDU is the predominant mode of transmission in Asia
epidemics varies greatly from region to region. For example, IDU overall, it is important to note that both unsafe sex among sex
is the principal mode of HIV transmission in Asia and eastern trade workers and unsafe injecting are linked and exacerbate the
Europe (accounting for 50–90% of infections) but is also an epidemics in many parts of Asia.9 HIV prevalence among MSM is
important source of HIV spread in parts of the Middle East, Africa very high where data are available.
and the Southern Cone of Latin America.1,9,17
The prevalence of HIV among IDU populations varies widely Europe
but is typically high in established IDU populations, with at least The reported rate of new HIV diagnoses has more than doubled in
25 countries reported as having a prevalence exceeding 20% in a the WHO European Regions§ since 2000.19 Eastern Europe has the
capital city or other major urban area in all regions of the globe.17 highest rate of new diagnoses of HIV (210.8 per million ­population)20
High prevalence among IDU populations is unlikely to change
given inadequate harm reduction and prevention interventions
for IDU in the majority of these countries.18 §Geographical division of World Health Organization European
regions: West, 23 countries: Andorra, Austria*, Belgium*, Denmark*,
Finland*, France*, Germany*, Greece*, Iceland, Ireland*, Israel, Italy*,
Geographical differences
Luxembourg*, Malta*, Monaco, Netherlands*, Norway, Portugal*,
Although global trends indicate an overall decline in new infec- San Marino, Spain*, Sweden*, Switzerland, United Kingdom*. Centre,
tions in recent years (mostly due to a decline in new infections 15 countries: Albania, Bosnia and Herzegovina, Bulgaria*, Croatia,
within sub-Saharan Africa),1 this serves to mask important Cyprus*, Czech Republic*, Hungary*, Former Yugoslav Republic of
­geographical differences in the size, temporal trends and modes Macedonia, Montenegro, Poland*, Romania*, Serbia, Slovakia*,
of transmission of the HIV epidemics. Slovenia*, Turkey. East, 15 countries of the former Soviet Union:
Armenia, Azerbaijan, Belarus, Estonia*, Georgia, Kazakhstan,
Africa Kyrgyzstan, Latvia*, Lithuania*, Republic of Moldova, Russian
The HIV epidemics vary greatly in scale and characteristics across Federation, Tajikistan, Turkmenistan, Ukraine, Uzbekistan. ������������
*Countries
the continent of Africa. Overall, sub-Saharan Africa accounts for which constitute the European Union as of 1 January 2007.

MEDICINE 37:7 318 Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.
The virus

followed by the West (77.0) and the Centre (10.1).19 The three Although effective treatments are available, few people living
regions have remarkable differences in the modes of transmission with HIV in the world’s most affected regions have access to
that drive their epidemics. Current data suggest the HIV epidemics comprehensive HIV care, including access to ARVs. As such, HIV
in the Centre remains low and at relatively stable levels. infection remains the leading cause of death in most sub-­Saharan
Almost 90% of the estimated 1.5 million people living with African countries as well as among many vulnerable popula-
HIV in Eastern Europe were infected in Russia or the Ukraine1 tions worldwide. Furthermore, children remain vulnerable to the
with almost 60,000 persons diagnosed in 200620 (data for Russia cascade effect of HIV and AIDS-related mortality and over 15.2
in 2007 are not available).19 As the epidemic continues to evolve million children have lost one or both parents to AIDS globally
in the region, the proportion of women and young people infected (12 million live in sub-Saharan Africa).3
is increasing. Approximately a quarter (27%) of newly diagnosed The global HIV crisis requires a multi-faceted approach. With
cases are found among young people (15–24 years) and over 40% no proven vaccine in sight, control of the epidemic must rely on
of these are among women.20 Unsafe injecting practices account the establishment of long-term successful prevention and treat-
for two-thirds of new HIV infections in Eastern Europe and these ment interventions. These must include, for example, widespread
numbers continue to increase.21 A rise in the number of infections availability of condoms, clean needles, substitution therapies,
acquired through heterosexual contact has been noted in recent mother-to-child interventions, and universal access to diagnostics
years and now accounts for up to one-third of new diagnoses.20 and effective treatments. Accurate and timely surveillance data,
An estimated 800,000 people were living with HIV in western including estimates of the HIV incidence and prevalence in both
Europe in 20071 and approximately 25,000 new cases of HIV were the general and vulnerable populations, are essential in track-
diagnosed in the same year (representing a rate of diagnosis of 77.0 ing the successes of these interventions. Perhaps most critically,
per million population).19 Whilst MSM continue to be the group a multi-faceted response must address human rights violations
most at risk of acquiring HIV in western Europe (constituting 40% associated with HIV infection and its modes of transmission,
of all new HIV diagnoses in 2007), epidemics in western Europe including gender-based inequalities, testing and treatment access
have diversified over time. Nevertheless, the prevalence of HIV in inequalities, stigma, discrimination and criminalization. ◆
this region has remained well below 0.5% in all countries except
Spain and Portugal (<1%).1 New diagnoses among heterosexuals
has risen sharply in recent years in some countries and in the UK
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The virus

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MEDICINE 37:7 320 Crown Copyright © 2009 Published by Elsevier Ltd. All rights reserved.

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