"With an epidemic of this scale, every new infection adds to the ripple effect, impacting families, communities, households and increasingly, businesses and economies. AIDS has emerged as the single greatest threat to development in many countries of the world," said Peter Piot, Executive Director of UNAIDS.

"We have to ensure that health systems are capable of handling the increasing numbers of HIV-positive people who develop AIDS. De-stigmatization, access to health care and low-cost measures such as the treatment of opportunistic infections become important. WHO is working with Ministries of Health across the world to ensure that adequate facilities and resources are made available to the millions of people likely to develop AIDS in the coming years," said Gro Harlem Brundtland, Director-General of WHO.

AIDS develops in an HIV-positive person after years of infection, as HIV steadily weakens the body's immune system and increases its vulnerability to pneumonia, tuberculosis, diarrhoea, tumours and other illnesses. With the number of people infected with HIV continuing to rise, the number of people falling sick and dying of AIDS will multiply.

HIV-positive women now outnumber HIV-positive men in Africa

In sub-Saharan Africa – still the global epicentre of the epidemic – new evidence shows clearly for the first time that women infected with HIV outnumber men. "Ten years ago, it was hard to make people listen when we were saying AIDS wasn't just a man's disease," said Dr Piot. "Today, we see the evidence of the terrible burden women now carry in Africa's epidemic."

• Fifty-five percent of infected adults in sub-Saharan Africa are women, which means more than six HIV-positive women for every five HIV-positive men. UNAIDS and WHO estimate that 12.2 million African women and 10.1 million African men aged 15-49 are living with HIV at the end of 1999.

• Studies in several countries have found that African girls aged 15-19 are five to six times more likely to be HIV-positive than boys the same age. Ease of male-to-female sexual transmission, and sex with older, infected men appear to be contributing factors to girls' greater vulnerability to HIV.

According to the United Nations Development Programme (UNDP), a number of African nations suffered downward changes this year in the Human Development Index, a ranking based on levels of health, wealth and education. Almost all of the major changes in rank could be attributed to declining life expectancy as a result of AIDS.

• Life expectancy at birth in southern Africa, which climbed from 44 in the early 1950s to 59 in the early 1990s, is expected to drop back to 45 sometime between 2005 and 2010.

• UNDP estimates that fewer than 50% of South Africans currently alive can expect to reach the age of 60, compared with an average of 70% for all developing countries and 90% for industrialized countries.

• According to a survey of commercial farms in Kenya, illness and death have already replaced old-age retirement as the leading reason why employees leave service.

Yet there are reasons for optimism even in this most devastated region: a number of African countries have demonstrated a much stronger commitment to fighting AIDS than ever before. "I believe we are now at a turning point in the 20-year history of the AIDS epidemic in Africa. Everywhere I go, I hear the top African leaders speaking out about AIDS as the major threat to the continent's development", said Dr Piot. "This gives me grounds for hope that in the coming years, we will see stronger, more effective responses to AIDS in many more sub-Saharan African nations – responses to complement the strong programmes that already exist."

Injecting drug use in former USSR fuels world's steepest HIV increases

The report further reveals that the world's steepest HIV curve in 1999 was recorded in the newly independent states of the former Soviet Union, where the proportion of the population living with HIV doubled between 1997 and 1999. In the larger region comprising these nations and the remainder of Central and Eastern Europe, the number of HIV-infected rose by more than a third in 1999 alone, to reach an estimated 360 000.

• In the Russian Federation, nearly half of all reported cases of HIV infection since the start of the epidemic were recorded in the first nine months of 1999 alone.

• In Moscow, three times as many cases were reported in the first nine months of 1999 as in all previous years combined. Towns around Moscow had even sharper rises in HIV, with over five times as many infections reported in the first nine months of 1999 as in all previous years combined.

• Preliminary studies suggest that injecting drug use is becoming increasingly common among unemployed young people in many of the industrial cities of the Russian Federation and Ukraine. HIV is not limited to Russia's major metropolitan regions; in the Siberian city of Irkutsk, nearly 1300 infections have been reported, most of them in 1999.

• Injecting drug use appears to be well established even among Russian schoolchildren. An outreach programme for drug injectors in St Petersburg reported that the caseload for clients under age 14 increased 20-fold between 1997 and the first quarter of 1999.

Strong prevention efforts, care programmes, find success in certain regions

In the report, UNAIDS and WHO also point to some countries and regions which are managing to keep down the number of new infections or improve the well-being of those already infected. For example, evidence continues to mount that the strong prevention programmes of Thailand and the Philippines have had sustained success in reducing HIV risk and lowering or stabilizing HIV rates.

• In India, major efforts to improve the tracking of the epidemic more than tripled the number of HIV surveillance sites in 1998. Estimates now place total HIV infections in the country at around 4 million—more than in any other country, but fewer than projected on the basis of earlier surveillance estimates. Consequently, the regional estimate of HIV infections in Asia has been revised downward by 800 000.

• The AIDS Society in the Indian state of Tamil Nadu has enlisted the support of an advertising agency to encourage safer sexual behaviour, airing television advertisements during major sporting events. Casual sex among factory workers in the state reportedly fell by half between 1996 and 1998, while condom use with casual partners rose from 17% to 50%.

• Some Latin American countries have joined the ranks of those providing antiretroviral drugs to people infected with HIV. Brazil, for example, spent an estimated US $300 million to treat some 75 000 people in 1999. Brazilian health officials said the considerable expense was offset in part by savings in hospitalization and medical care; the country averted an estimated US $136 million in such costs between 1997 and 1998.

"Providing care to growing numbers of HIV-positive people when health systems are already overburdened is no straightforward task. But these examples show how countries around the world can make a difference in fighting the epidemic through both prevention and care. WHO has shown how relatively inexpensive modifications and additions to health-care systems can bring major benefits to people with HIV. Everyone, and every country, can learn and benefit from these examples," said Dr Brundtland.

No room for complacency

Releasing the report, UNAIDS Executive Director Peter Piot also urged industrialized nations to put more emphasis on HIV prevention efforts. "There is no room for complacency in any discussion of this epidemic. The threat of HIV has not diminished in any country. We have even seen evidence from North America and Western Europe suggesting that availability of life-prolonging therapies may be contributing to an erosion of safer sexual behaviour. This is tragic," Dr Piot said.

"While antiretrovirals have brought hope to many people with HIV who are fortunate enough to have access to them, they are not a panacea, and they are not available in most of the world", Dr Piot said. "The key to fighting AIDS is preventing new infections. For this more resources are needed – to implement the prevention strategies we have today, and to develop new and better tools, such as microbicides and a vaccine."

Dr Brundtland added, "While prevention is the most promising strategy for managing the AIDS epidemic in the long term, we cannot lose sight of the fact that millions of people are infected today. For them, we must do a much better job of increasing access to health care and support, including inexpensive antibiotics that can add many months to the lives of people already sick with AIDS, to palliative therapies that can help increase comfort and reduce suffering, and to psychological and social support for patients and their families. WHO and UNAIDS will continue to engage the pharmaceutical industry to make new HIV-related drugs available at affordable prices for those in need."

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