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Confronting the Spread of AIDS

Available in: Français
Press Release No:98/1513

Contacts:  Phil Hay (202) 473-1796
Lawrence MacDonald (202) 473-7465 
Contact, Radio & TV:  Cynthia Case (202) 473-2243 

GENEVA/WASHINGTON, November 3, 1997 — With approximately 90 percent of all HIV infections occurring in developing countries, more intensive government prevention efforts, especially among people who have many sex partners or inject drugs, could save millions of lives and reduce the severe economic and social costs of the epidemic, according to a World Bank report released today in Geneva and Washington.

The report-Confronting AIDS: Public Priorities in a Global Epidemic-says that 23 million people worldwide are now infected with HIV and that 8,500 people are newly infected each day. Two decades after the first appearance of the human immunodeficiency virus, 6 million people have died from AIDS, and new evidence suggests that while Sub-Saharan Africa has most people infected-14 million-the virus may be on the verge of exploding in other regions such as Central and Eastern Europe.

"HIV is continuing to spread and is taking a terrible toll," said Mead Over, co-author of the report. "In many hard-hit countries, HIV has already reduced life expectancy by more than a decade."

The report identifies priorities for developing countries and the international community in responding to the epidemic, the first measure being to help people with the riskiest behavior protect themselves and others from HIV infection. Yet in many countries, government-backed prevention programs do not reach people with the riskiest behavior. Activities that greatly increase the risk of contracting HIV include unprotected sex with many partners and injecting drugs using unsterilized shared needles.

"It is a fundamental responsibility of government to ensure that HIV is prevented among people with the riskiest behavior," Mr. Over said. "This will prevent the largest number of infections among all people--even among people who do not take risks."

For example, in Nairobi, Kenya, treating sexually transmitted diseases among 500 prostitutes and increasing their condom use to 80 percent, prevented 10,000 infections per year among their clients, the clients' wives and other partners. A similar level of condom use among 500 men in the community would have prevented fewer than 100 infections.

"HIV moves through populations in a series of overlapping epidemics," Martha Ainsworth, co-author of the report, said in Washington. "Once the virus has spread widely among people with very risky behavior, preventing its spread to others becomes increasingly difficult."

Programs that make it easier for injecting drug users to get sterile injecting equipment have also been highly effective. Several cities around the world which have needle exchange programs, such as Glasgow, Scotland and Sydney, Australia, have held HIV infection rates among injecting drug users to less than 5 percent; while in nearby cities without these programs, infection rates among injecting drug users have soared to more than 50 percent. Needle exchange programs have also been highly successful in Toronto, Canada; Tacoma (Washington) U.S.A.; Lund, Sweden; and Katmandu, Nepal.

Other people besides sex workers, their clients, and injecting drug users also engage in high risk behavior. Studies have shown that soldiers, police officers, prisoners, long distance truck drivers, migrant workers, and homosexual and bisexual men, often have more sexual partners than others.

Governments need to find out which groups have the riskiest behavior and work with them to prevent the spread of HIV. However, governments are often unwilling to back prevention efforts with such groups because critics argue that these controversial programs will encourage people to have multiple sex partners or to inject drugs. Research has shown this not to be the case.

Non-governmental organizations (NGOs) can sometimes avoid this controversy and are often more effective than governments at working with people with very risky behavior. In Calcutta's Sonagachi red-light district, for example, the Indian government, donor countries, three local NGOs, and sex workers are working together in a prevention program that has held HIV among the sex workers in the area at low levels.

Governments need to act as early as possible. "In every country that now has a serious epidemic, people said 'it can't happen here.' They were wrong," Ms. Ainsworth said. "By the time that many AIDS cases are observed, it is too late to avert a serious epidemic; HIV will already have spread widely." In Honduras, for example, where fewer than 8,000 AIDS cases have been reported, an estimated 50,000 adults are already infected with HIV.

Yet many countries still have an opportunity to prevent a widespread HIV epidemic. In 30 developing countries, and in large areas of China and India, HIV has infected less than 5 percent of people who engage in very high risk behavior. Bangladesh, Indonesia, the Philippines, most countries from the former Soviet Union, and much of Eastern Europe are at this early stage of the epidemic.

For the 2.3 billion people who live in these countries and parts of China and India with "nascent" epidemics, investing in effective prevention now can keep infection rates very low and at relatively low cost.

In other countries, HIV is already widespread among groups with the riskiest behavior but has yet to spread widely among other people. More than 40 developing countries have "concentrated" epidemics, including Pakistan, Ukraine, most of Latin America, parts of Western Africa, and most of Indochina. Parts of India and the southwestern regions of China bordering the "Golden Triangle" of the drug trade also have concentrated epidemics.

Preventing a widespread epidemic in these countries, home to 1.6 billion people, is still possible, but it becomes more difficult and costly than dealing with it at an earlier stage. In Thailand, which has a concentrated epidemic, an extensive campaign promoting universal condom use in brothels is slowing the epidemic. Infection rates among young army conscripts have declined.

Twenty-one countries have "generalized" epidemics in which 5 percent or more of women attending maternity clinics are infected. Most are low-income African countries where the resources needed to cope with the epidemic are most scarce. In these countries, home to 226 million people, it is still crucial to help people with the riskiest behavior protect themselves and others. In addition, prevention among people with fewer partners becomes increasingly important as the epidemic spreads.

Governments in countries with a generalized epidemic also face the problems of deciding how to cope with the increased demand for medical care, and how to respond to the effects of AIDS on poor households. The report recommends that governments in all countries, especially those in the worst-affected regions, ensure that low cost, effective treatments for illnesses that often strike people with HIV are available. For example, treating oral thrush, which makes swallowing extremely painful and affects many people in the early stages of AIDS, costs only about $2.00 per episode.

"Even some quite poor households would readily pay this cost provided that the medicine were available," said Mr. Over. "Sadly, these medicines are often not available."

Tuberculosis, which also often strikes people with HIV, can be treated for as little as $36 per person. Since tuberculosis is highly infectious, governments have an obligation to fund such treatment in any patients who would otherwise go untreated, regardless of their HIV status, the report says. It also cautions that recent medical advances in the treatment of HIV/AIDS involving combinations of expensive drugs are too complex and costly for widespread use in developing countries.

"Antiretroviral therapy costs about $12,000 dollars a year and requires sophisticated clinical support that is rarely available to people in developing countries," Mr. Over said. "To be fair, governments should subsidize expensive HIV treatments at the same rate that they subsidize other treatments that are equally expensive, complex and experimental."

Even if the cost of new HIV/AIDS treatments declined substantially, governments would still need to consider carefully whether scarce government resources should be used for treatment or prevention.

In hard-hit countries, AIDS has greatly increased the number of deaths of adults during their prime working years. Such deaths create particular hardships for the poorest families, who often reduce food consumption and withdraw their children from school to cope with the loss of income. The report suggests that governments can mitigate these impacts of the epidemic by ensuring that anti-poverty programs include poor families affected by HIV/AIDS.

"AIDS presents policymakers with extremely difficult choices in allocating public resources," Joseph Stiglitz, Chief Economist and Senior Vice President of the World Bank said in Washington. "The study helps to identify policies that are fair and cost-effective," he added. The report differs from many other studies of HIV/AIDS by analyzing the epidemic from the perspective of public economics, which focuses on how to allocate government resources.

Speaking at a press briefing in Geneva, Peter Piot, the Executive Director of UNAIDS, said that the World Bank's research in the report is an example of the benefits of international AIDS cooperation. He urged all governments to put AIDS higher on their agendas. "Governments must act now to confront this epidemic and must challenge all sectors of society to become involved," he added. Preparation of the report received extensive support from UNAIDS and the European Commission.

A joint forward to the book signed by Mr. Piot, World Bank President James Wolfensohn, and João de Deus Pinheiro, a member of the European Commission praised the report as "a valuable contribution to the international debate on the role of government in addressing the AIDS epidemic in developing countries."

The World Bank is one of the largest sources of finance of AIDS prevention measures in developing countries. At the end of 1996, the Bank had committed $632 million to 61 HIV/AIDS projects in 41 countries.

For on-line information about the economics of HIV/AIDS, visit

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