The Next Wave of HIV/AIDS: 

Nigeria, Ethiopia, Russia, India, 

and China 

ICA 2002-04 D

September 2002 

National

Intelligence 

Council 

ICA 2002-04D

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. 

Additional copies of this assessment can be downloaded from 

the NIC public website at www.odci.gov/nic or obtained from 

Karen Monaghan, Acting National Intelligence Officer for 

Economics and Global Issues. 

September 2002

Scope Note 

This Intelligence Community Assessment (ICA) highlights the rising HIV/AIDS problem

through 2010 in five countries of strategic importance to the United States that have large 

populations at risk for HIV infection: Nigeria, Ethiopia, Russia, India, and China. The paper 

does not attempt to make aggregate projections about global trends. The five countries were 

selected 

because they are: 

• Among the world’s most populous countries, together representing over 40 percent of the 

world population. 

• In the early-to-mid-stages of an HIV/AIDS epidemic. 

• Led by governments that have not yet given the issue the sustained high priority that has been 

key to stemming the tide of the disease in other countries. 

This paper builds on the December 1999 unclassified National Intelligence Estimate, The Global 

Infectious Disease Threat and Its Implications for the United States, which focused on the 

spread of AIDS in the context of other growing infectious diseases. Excerpts from the 1999 

Estimate presage the expansion of the HIV/AIDS epidemic beyond the geographic focal point of 

southern Africa: 

Although infection and death rates for HIV/AIDS have slowed 

considerably in developed countries...the pandemic continues to 

spread in much of the developing world. Sub-Saharan Africa 

currently has the biggest regional burden, but the disease is 

spreading quickly in India, Russia, China, and much of the rest of 

Asia. 

According to UNAIDS, Asia alone is likely to outstrip Sub-Saharan 

Africa in the absolute number of HIV carriers by 2010. 

The National Intelligence Council (NIC) convened a conference of US Government officials and 

outside experts to share their current assessments and expectations for the future of the disease in 

these five countries. Given the range of estimates of the current numbers of infected people and 

the lack of consensus on which infectious disease models calculate future rates most accurately, 

the future projections in this paper represent consensus estimates by experts. The NIC, in 

addition to coordinating the draft within the Intelligence Community, had the paper reviewed by 

several leading experts from outside the Intelligence Community as part of its effort to seek out 

expertise from inside and outside the government. The experts included Dr. Anthony Fauci, 

Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of

Health; Dr. Robert C. Gallo, Director of the Institute of Human Virology and Professor of 

Medicine at the University of Maryland Biotechnology Institute; Dr. Phillip Nieburg, Associate 

Director for Public Health Practice in the Global AIDS Program for the Centers for Disease 

Control; and Dr. Nicholas Eberstadt of the American Enterprise Institute. 

1 
2
Contents 

Page 

Scope Note 1 

Summary 4 

Discussion 7 

The Scope of the Next Wave 

 Country Profiles 

7 

9 

Prospects for Control 

The Leadership Challenge 

Weak Healthcare Infrastructure 

Treatment 

16 

17 

20 

21 

Implications

Nigeria and Ethiopia: Hardest Hit 

Russia: HIV/AIDS Worsening Demographic Situation 

India and China: A Big Problem But Probably Not Devastating 

 International Implications 

22 

22 

24 

24 

26 

3
Summary 

The Next Wave of HIV/AIDS: 

Nigeria, Ethiopia, Russia, India, and China 

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 2010.1

 

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. 

 

1

 These estimates reflect the expected number of HIV and AIDS cases at that time—not a cumulative total of all 

cases over the entire period. 

4
• 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. 

HIV Statistics: Official and Unofficial Estimates 

Reliable statistics on HIV/AIDS are difficult or impossible to get for many countries. UNAIDS 

maintains the most comprehensive databases of information in the world on AIDS, but the UN 

organization relies on official government statistics from each country—which experts believe

sometimes understate the number of infected people. Our estimates of infection rates and their 

likely trajectories go beyond the official statistics by incorporating the assessments of academics 

and NGOs with field experience. As a result, all of the numbers in this assessment should be 

viewed as rough estimates, and our projections employ ranges to convey the general magnitude 

of the disease within a relatively high margin of error. 

Governments often do not spend enough money to get quality infection surveillance because 

they have other budget priorities, do not want to acknowledge the extent of the epidemic, and the 

drug users and prostitutes at high risk of infection are not key political constituencies. 

• Other hidden pockets of infection include TB patients—some of whom have contracted TB 

because they are HIV positive—and patients with venereal diseases and reproductive tract 

infections. 

• It is difficult to get data on HIV prevalence rates in foreign military ranks, which harbor 

significant numbers of infected men. 

Even if testing is available, many people do not get tested because of denial, stigma, 

discrimination, or resignation. 

• Intravenous drug users, prostitutes, and homosexuals usually are reluctant to identify 

themselves for fear of punishment. 

• Some avoid testing when healthcare and treatment for the disease is unavailable. 

Infection surveillance of women attending prenatal clinics is considered the most reliable 

indicator of adult HIV prevalence in the general population. But even these statistics can be 

affected by poor clinic attendance when fee for services or mandatory HIV testing is instituted. 

6
Discussion 

The Next Wave of 

HIV/AIDS: Nigeria, 

Ethiopia, Russia, India, 

and China 

The Scope of the Next Wave 

The HIV/AIDS pandemic continues to spread 

around the world at an alarming rate, and the 

number of people with the disease will grow 

significantly by the end of the decade, as it 

becomes more geographically diffuse. By 

2010, we estimate that five countries of 

strategic importance to the United States—

Nigeria, Ethiopia, Russia, India, and China—

collectively will have the largest number of

HIV/AIDS cases on earth (see figure 1). 

These five countries, which comprise over 40 

percent of the world’s population, are in the 

early-to-mid-stages of the epidemic. 

• All five countries are major regional or 

global players, and efforts to manage the 

growing AIDS problem have the potential 

to impinge upon their political and 

economic outlook. 

• The disease also is a special cause for 

concern in these five states because their 

governments have yet to demonstrate the 

kind of sustained commitment that has 

been key to managing the spread of 

HIV/AIDS in such countries as Uganda, 

Thailand, and Brazil. 

We project the total number of people with 

HIV/AIDS in these "next-wave" countries is 

likely to soar from 14 to 23 million currently 

to 50 to 75 million by 2010, eclipsing the 

projected 30 to 35 million cases in central and 

southern Africa, the current geographic 

epicenter of the epidemic (see figure 2). 

Through 2010, HIV/AIDS will increase more 

slowly or even decline in southern and central 

7
Table 1 Current 2010 

Current and 

Projected 

HIV/AIDS 

Infected Adults 

Number

Infected 

(Government

Data)

(millions) 

Number

Infected 

(Expert 

Estimates)

(millions) 

 Adult 

 Prevalence 

 Rate 2002* 

 (percent) 

Number 

Infected 

(Expert 

Estimates) 

(millions) 

Adult 

Prevalence 

Rate 

2010* 

(percent) 

Nigeria 3.50 4 – 6 6.00 – 10.00 10 – 15 18 – 26 

Ethiopia 2.70 3 – 5 10.00 – 18.00 7 – 10 19 – 27 

Russia 0.18 1 – 2 1.30 – 2.50 5 – 8 6 – 11 

India 4.00 5 – 8 0.90 – 1.40 20 – 25 3 – 4 

China 0.80 1 – 2 0.14 – 0.27 10 – 15 1.3 – 2 

*Estimates of percent are based on population data from the US Bureau of the Census.

Africa—now in the sixth decade of the 

disease.2

• HIV adult prevalence 3 in central and 

southern Africa currently is the highest 

in the world. For example, as of July 

2002, UNAIDS estimated that 39 

percent of adults in Botswana (300,000 

people) and 20 percent of adults in South 

Africa (4.7 million people) were HIV 

positive. 

Although current adult prevalence rates in 

the next-wave countries range from less than 

one percent in China to as high as 18 percent 

in Ethiopia, the number of people infected 

already is substantial, ranging from 1 to 2 

million in China and Russia to upwards of 5 

million in Nigeria and India (see table 1). 

The spread of HIV/AIDS in the next-wave 

countries will be difficult to check by 2010. 

Treatment of existing infections and 

prevention of new infections is minimal. 

Even if effective programs could be 

implemented in the coming years, such 

practical concerns as cost, scale, and

experience in health service delivery 

probably will result in the omission of 

services to a large number of infected 

individuals, and the burden of disease will 

continue to rise. 

 

2

 Although the lethal human immunodeficiency virus

(HIV-1) was not characterized until the early 1980s, 

blood samples from Sub-Saharan Africa in the 1950s 

and 1960s have been tested retrospectively and found

to be HIV-positive. 3

 Prevalence refers to the total number of people 

infected as a percentage of the adult (ages 15 to 49) 

population.

• 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.

8
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. 

Russia. Official statistics list about 200,000 

people in Russia as HIV positive, but the 

government’s sampling efforts are poor, 

especially outside major cities. Academic 

and medical experts believe the actual 

number probably is between 1 and 2 million, 

which would indicate an adult prevalence 

rate of around 1 to 2 percent. 

• Infection rates vary significantly across 

the country, with the biggest 

concentrations in cities (see figure 5). 

Males comprise 77 percent of all the 

infected, and 60 percent of infected men 

are between the ages of 17 and 25. 

Intravenous drug use drives the spread of the 

disease in Russia more than in any of the 

other next-wave countries. An estimated 80 

to 90 percent of all infections in Russia stem

from intravenous drug use, which is rampant 

and rising. 

• In most countries, the concentration of 

HIV among drug users and generally 

low adult prevalence rates would suggest 

the disease still has not broken out into 

the general population. Experts warn, 

however, that drug use is so widespread 

in Russia that many users are integrated 

into society with jobs and families, 

suggesting the disease is moving into the 

mainstream. 

Prostitutes and prison inmates—many of 

whom are intravenous drug users—are 

contributing to the spread of the disease. An 

estimated 20 to 25 percent of intravenous 

drug users in prison, where there is easy 

access to drugs, are HIV positive. 

• Russia’s frequent use of prison amnesty 

programs that release infected inmates 

will worsen the HIV/AIDS epidemic 

among the general population unless 

accompanied by prevention and 

treatment programs. 

11
The growing number of prisoners infected 

with both HIV and tuberculosis is 

compounding the burden; HIV infection 

increases the likelihood that a person with 

TB will develop the active, contagious 

form of TB. 

• 

• Moreover, laws allowing the incarceration 

of suspects for up to two years prior to being charged create a revolving door of 

inmates who often are intravenous drug 

users infected with TB and/or HIV. 

HIV/AIDS also is a growing problem in the 

Russian military services. Currently up to 

one-third of prospective conscripts are 

deemed unfit for service owing to the effects 

of prior drug use (chronic hepatitis or HIV 

infection). Amongst enlisted men, ground 

troops have the largest number of infections, 

while strategic military forces and airborne 

troops have the lowest. 

Driven by widespread drug use, inadequate 

healthcare infrastructure, and the 

government’s limited capability to respond, 

the number of HIV positive people probably 

will rise to 5 to 8 million by 2010. This 

condition would reflect an adult prevalence 

rate of around 6 to 11 percent, exacerbating 

Russia’s population decline. 

India. According to official Indian 

Government statistics, 4 million people in 

India are HIV positive. India also has high 

rates of TB, however, which may be 

indicative of undiagnosed HIV/AIDS. Some

experts believe that 5 to 8 million Indians 

may be infected. We

12
expect India to have the largest number of 

people with HIV/AIDS in the world within 

the next few years. But even with the large 

number of infected people, India’s adult 

prevalence rate is only around one percent. 

• Adult prevalence rates vary across the 

country, however, in some areas (Mumbai 

and Pune) the rate is as high as 4 percent, 

according to unofficial estimates 

(see figure 6). 

Heterosexual transmission is the driver of

infections, except in two regions (Nagaland 

and Manipur) where intravenous drug use is a 

serious problem. Thirty to 60 percent of 

prostitutes and up to 15 percent of all truck 

drivers are infected with HIV/AIDS. 

• Sexually transmitted diseases and 

reproductive tract infections are rampant 

in India, increasing the risk that 

HIV/AIDS infections will be transmitted. 

13
The current trajectory of the disease, limited 

public awareness, and the lack of resources 

for a major anti-AIDS program will continue 

to drive the spread of the disease. 

Approximately 20 to 25 million Indians are 

likely to be infected by 2010—even if the 

disease does not break out significantly into 

the mainstream population. 

China. China has significantly raised its 

official estimate of the number of HIVpositive people over the last two years from

600,000 to one million. The UN now 

estimates that 1.5 million are infected, while 

other experts believe the number probably is 

closer to 2 million or even higher. Owing to 

China’s massive population, even these 

higher figures, however, represent an adult 

prevalence rate of only 0.15 to 0.25 percent. 

14
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. 

Antimicrobial medications are used to treat opportunistic infections of bacterial, viral, and fungal 

origin. Frequent or prolonged use of antimicrobials promotes genetic mutations that result in 

drug resistance. This often makes opportunistic infections more serious and difficult to treat, and 

may drive the spread of resistant organisms in both HIV-positive and HIV-negative people. 

Antiretroviral and other antimicrobial medications can prolong life, but eventually the immune 

system becomes so damaged that HIV progresses to Acquired Immune Deficiency Syndrome 

(AIDS), and death usually follows in a few years. No cure for HIV/AIDS is available, and no 

vaccine has proven a sure way to prevent it; avoidance of high-risk behavior is the only proven 

way to prevent the disease. 

A generally milder form of the virus (HIV-2) also exists and has limited geographic reach—

primarily in West Africa, including Nigeria—and is less transmissible and less lethal than 

HIV-1. Patients with HIV-2 have lower viral loads and slower immune decay but acquire the 

same opportunistic infections as those infected with HIV-1. 

Several factors are driving the epidemic in 

China—the large migrant population, 

intravenous drug use, and poor hygiene in 

plasma sales—increasing the odds that the 

disease will continue to spread. 

Migration. An estimated 100 million rural 

migrants are on the move in China, relocating 

to cities to find work. Sexual contact between 

migrant men and prostitutes has spread the 

disease, which advances over an even wider 

geographic area if the migrants return to their 

villages to visit their families. 

15
Drug abuse. HIV/AIDS also is rising among 

intravenous drug users, especially in southern 

regions adjacent to Southeast Asia’s 

“GoldenTriangle” of heroin production and 

distribution routes. Infection rates also soar 

as high as 85 percent among intravenous drug 

users in the Xinjiang Autonomous Region in 

western China (see figure 7). 

Plasma sales. The practice of plasma selling 

in rural areas also has been a major 

contributor to the spread of HIV/AIDS (see 

textbox). Mixing infected blood plasma

causes one of the highest known transmission 

rates for HIV/AIDS, and the practice has 

infected large numbers of rural, heterosexual 

villagers who would otherwise be considered 

at low risk for the disease. 

Despite growing concern over the disease 

among senior leaders, China’s sheer size, 

resource constraints, widespread ignorance of 

AIDS, cultural taboos about discussing sex, 

and coordination problems between levels of 

government will make it difficult to check the 

spread of the disease. 

• Even if adult prevalence rates rose only to 

two percent by the end of the decade, 

China would have about 15 million 

infected people by 2010—surpassed only 

by India. 

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. 

China: HIV Infections from Blood Selling 

Most of China’s blood supply is purchased from poor villagers by brokers who collect only 

plasma for the manufacture of therapeutic and diagnostic products. These brokers often try to 

save money and time by mixing the blood of several donors before spinning out the plasma in a 

centrifuge. Reinjecting the mixed blood back into the donors to prevent anemia has spread HIV 

like wildfire, with infection rates as high as 60 percent in some villages. The government has 

ordered a stop to the practice, but press reports suggest that it continues in some areas. The 

practice of blood selling began as a way to raise money for rural health projects after the central 

government cut subsidies to the provinces. 

• Chinese media report that people selling blood in Qinghai, Henan, and Shaanxi claim that 

they earn between $12 and $15 for each bag of donated blood—a large sum of money in 

these poor provinces. Some farmers report donating blood 50 times in two months. 

16
The high cost and complexity of treatment 

programs probably will continue to feed the 

debate over the relative cost/benefit of 

treatment versus prevention in addressing 

HIV/AIDS. 

• Pressure for antiretroviral drugs has 

jumped in recent years because such 

drugs afford one of the most tangible 

ways for governments to respond to the 

AIDS problem. 

• Nonetheless, successful efforts to 

combat HIV in Uganda, Thailand, and 

other countries suggest that high-profile 

education programs to change behaviors 

remain key to long-term success, 

although this approach requires more 

time and persistence by senior leaders. 

The Leadership Challenge 

The commitment of senior political 

leadership to persist in the struggle against 

HIV/AIDS has been a key variable in the 

few successful programs around the world. 

The leaders of Nigeria, Ethiopia, Russia, 

India, and China will be challenged to 

maintain sustained high-level interest,

however, given the scope and severity of 

other domestic and foreign policy issues. 

Some leaders are beginning to pay more 

attention to AIDS, but they have not given it 

the sustained priority thus far that has been 

needed in other countries to blunt the spread 

of the disease. 

Overcoming Social Stigmas 

Many citizens and government officials in next-wave countries are reluctant to acknowledge the 

spread of the disease owing to strong social and cultural norms. HIV/AIDS still is associated 

with behaviors widely considered taboo, including prostitution, drug use, and homosexuality. 

HIV-positive people often do not seek testing and treatment because they fear being ostracized 

by their families, neighbors and friends and losing their jobs or access to public services. 

• In China, few people publicly acknowledge HIV-positive status because they might be barred 

from school, fired from their jobs, or even expelled from their community, according to press 

reports. Largely as a result of China’s “one-child” policy to reduce population growth, 

Chinese men are under such pressure to carry on family lines that some HIV-infected gay 

men marry and have families and risk spreading the disease to their wives and children.

• A 2001 law in one Chinese province prohibits HIV-infected persons from marrying. 

• In India, recent studies found that HIV-infected people were refused admission to some

hospitals and denied treatment. Furthermore, HIV test results often are not kept confidential, 

which discourages people from getting tested. Some experts say that women in India’s maledominated society are reluctant to insist on condom use, and the widows of men who die 

from AIDS sometimes are denied healthcare or contact with their children. 

17
HIV/AIDS: Success Stories to Model 

Uganda, Thailand, and Brazil have managed the spread of HIV largely through active, high-level 

leadership to increase awareness, destigmatize the disease, and treat victims—all of which help 

change the behaviors that transmit the disease. These countries are widely considered to have 

the most successful anti-HIV programs and are potential models for other countries ravaged by 

the disease. 

• Bold leadership by Uganda’s President Museveni largely is responsible for driving down the 

country’s infection rate from 30 percent in 1992 to 11 percent in 2000. The HIV/AIDS 

problem remains significant, but Museveni has had success in his relentless campaign to 

change behavior by urging people not to have sex with multiple partners, publicly 

acknowledging the threat posed by AIDS, destigmatizing the disease, and decentralizing HIV 

education programs down to the village level. 

• Thailand launched a massive HIV/AIDS public awareness and condom distribution 

campaign in the early 1990s—with the support of several key senior officials—which 

significantly reduced the spread of the disease. More recently, the government announced it 

would make antiretroviral drugs available for less than one dollar a day. AIDS still is the 

leading cause of death in Thailand, but the government probably has averted millions of HIV 

infections (see figure 8). 

• In Brazil, the government has invested heavily in education and treatment programs, 

including providing free antiretroviral drugs to HIV/AIDS patients distributed through the 

public health system. HIV adult infection prevalence also is declining among intravenous 

drug users, suggesting that programs teaching safer injection habits also are successful. 

Active leadership will be especially critical

given the widespread public ignorance of 

AIDS in next-wave countries. The challenge 

is especially great in these countries because of 

fragile communications links, numerous 

government jurisdictions, and different ethnic 

and language groups. The five countries also 

lack strong domestic advocacy groups that can 

raise awareness and increase pressure for 

responsive programs. 

• A survey two years ago found that 20 

percent of Chinese respondents had never 

heard of HIV/AIDS, and over 60 percent 

did not know how the disease spreads or 

how to prevent infection.

• A World Bank study in India indicates that 

public awareness of the disease and 

condom use remain low despite 

government education programs.

• In Nigeria, a healthcare worker was 

fired after she tested positive for HIV, 

although a court ultimately agreed to hear 

her appeal. 

• Russia appears to be a major exception. A 

survey last year by an independent pollster 

found that 90 percent of those polled see 

combating HIV/AIDS as an important 

issue. 

18
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. 

The Russian Government has not mounted a 

sustained effort up to now to publicize the 

growing threat of HIV/AIDS. Russia faces so 

many other serious problems that HIV/AIDS is 

unlikely to receive high-level attention for an 

extended period until the economic and 

security costs of neglect become more 

tangible. 

• In 2001, Moscow promised $133 million to 

fight AIDS over five years, but it has only 

appropriated $80 million ($16 mil-lion per 

year). Treating 3 million HIV- infected 

adults would cost $30 billion a year, 

according Vadim Pokrovsky, the chief of 

the Russian Federal AIDS Center. 

• In 2001, Moscow refused a World Bank 

loan to fight TB and HIV/AIDS, apparently 

because Russia did not wish to increase the 

amount of its debt. However, Moscow 

recently re-opened negotiations for the 

loan. 

The Indian Government has taken numerous 

steps to highlight the risk that AIDS poses to 

the country, but tensions with Pakistan and 

growing religious strife clearly are considered 

more pressing issues. Furthermore, India faces 

competing priorities to address such other 

health challenges as TB. Nonetheless, the 

Indian Government did react to the emergence 

of HIV/AIDS in 1986 by creating the National 

AIDS Control Organization (NACO). 

• NACO faced many difficulties throughout 

most of its early years, although new

19
leadership in 1999 has improved and 

expanded the HIV/AIDS program.

The Chinese Government has become

significantly more open over the last year in 

acknowledging the rising HIV/AIDS problem

after ignoring it for years. The central 

government has organized some public 

relations events to increase awareness of the 

disease, and Beijing has sought bilateral 

assistance from the United States and others to 

improve its anti-AIDS campaign. 

• A Chinese government official has publicly 

expressed concern that there could be 10 

million people with AIDS by the end of the 

decade. 

• The turnaround suggests that senior leaders 

are concerned about the potential 

economic, social, and political 

ramifications of the spreading disease. 

Nonetheless, domestic funding to combat the 

disease remains low, and Chinese leaders will 

have difficulty keeping HIV/AIDS high on the 

agenda as they struggle to deal with such 

challenges as maintaining economic growth, 

defusing rural discontent, managing the 

Communist Party leadership transition, 

opening Chinese markets more widely to trade, 

and modernizing the military. Moreover, 

decisionmaking has become so decentralized 

in China on healthcare and education that 

senior leaders in Beijing cannot always count 

on provincial and local leaders to follow 

through. 

• Local government commitment to 

HIV/AIDS is likely to be uneven, given the 

low funding for such programs from the 

central government, lack of awareness of 

the disease, stigmatization of those 

infected, and corruption. 

• Some government leaders probably will be 

especially reluctant to highlight HIV/AIDS 

because they may be linked to the blood 

selling programs that have become a major 

means of transmission. 

• In July 2002, Chinese police detained for 

several months the country’s most 

prominent AIDS activist for circulating a 

“secret” government memo acknowledging 

that poor management of the blood supply 

had contributed to the AIDS problem. 

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. 

• Russia’s dwindling health services are 

unable to provide treatment for many 

victims of heart disease and the 

skyrocketing number of TB cases. Since 

20
the breakup of the Soviet Union, Russia’s 

health infrastructure has deteriorated so 

much that most experts believe that the 

population is less healthy now than at any 

time in the past 50 years. 

• India has established nationwide 

HIV/AIDS centers and a monitoring 

system, but access to basic medical care is 

not universal and the free public healthcare system often is highly inefficient. 

Nonetheless, the government’s AIDS 

organization was able to reach an estimated 

70 percent of households in a recent survey 

of AIDS-related behavior. 

• In China, a growing number of citizens 

cannot afford quality healthcare because of 

privatization of the public health service. 

Rural areas, which have the highest HIV 

infection rates and where 70 percent of the 

population lives, suffer from major 

shortages of resources. Funds are being 

directed toward modernizing urban 

facilities. 

Treatment 

Brazil’s successful emphasis on treatment and 

the expanded use of antiretroviral drugs has 

raised hopes for improving the length and 

quality of life for HIV/AIDS patients. 

Nonetheless, we believe treatment will be a 

Antiretroviral Drug Resistance 

Natural viral mutation and improper use of drugs to control HIV (halting use, intermittent use, or 

habitually missed doses) have caused some strains of HIV to evolve resistance to antiretroviral 

medications. These resistant strains continue to reproduce and destroy immunity in the presence 

of medications meant to control the virus, and already they have spread around the world. These 

drug-resistant variants are spread less efficiently than other forms. 

• HIV strains have an amazing ability to recombine to form mosaic viruses. This pace of

genetic change forces changes in treatment regimens and has placed unprecedented pressure 

on the pharmaceutical industry to develop new drugs for continued viral control. 

• Most HIV drug resistance can be traced to improper use of medications. Weak healthcare 

infrastructures in some next-wave countries will lead to poor distribution and incorrect use of 

antiretrovirals, which are likely to promote drug resistant strains of HIV and reduce the 

effectiveness of medicines. 

• Treatment failure rates can be as high as 60 percent in some countries. 

To help control resistance, therapies now often employ a combination of several drugs from

different classes. In addition, some researchers are now trying to curb the growth of 

antiretroviral resistance by having medical workers personally watch and record patients taking 

medication—known as direct observed therapy—a technique that has slowed the development of 

resistance to anti-TB medications. 

• Important new drugs inhibiting viral entry into healthy cells also are in development, but 

prohibitive costs are likely to limit their distribution in the developing world. 

21
difficult primary strategy for the next-wave 

countries because of the high cost of 

providing antiretroviral drugs for such large 

populations and drug resistance. 

• The cost of antiretroviral drugs has 

plunged in recent years—from around 

$10,000 per year per patient down to as 

low as $500 to $600—because of 

pressure from many countries on 

pharmaceutical companies and the 

increasing use of generic drug 

alternatives. 

• Pharmaceutical industries in an 

increasing number of countries—

including Russia, India, and China—are 

likely 

to develop and produce such drugs in 

the interest of reducing the cost of 

medication. 

• A Chinese government official publicly 

warned in September 2002 that Beijing 

would authorize domestic firms to 

manufacture generic drugs in defiance of 

patent laws unless prices come down, 

although the Ministry of Health later 

said it would not violate WTO 

obligations.

Even as prices decline, the total cost of 

providing drugs for millions of patients is 

likely to be prohibitively high for populous, 

low-income countries. Moreover, the cost 

of the drugs is only a small portion of the 

overall cost of treatment programs. Costly 

laboratory tests and equipment are needed to 

determine which combination of drugs is 

appropriate for each infected person.

• The effectiveness of the drug 

combinations must be monitored and 

adjusted on an ongoing basis as well. 

The effectiveness of antiretroviral drugs also 

is being undermined by a growing drug 

resistance problem, owing both to the 

natural mutation of the virus and improper 

drug use. 

• Weak HIV and TB treatment programs 

in Russian prisons will foster the 

emergence of drug-resistant strains, 

which eventually are likely to appear

outside Russia because of growing 

international travel. 

• Scientists at the July 2002 international 

AIDS conference in Barcelona presented 

numerous research papers on the 

challenge of drug resistance and the 

consequences of not taking medicines as 

prescribed. 

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. 

AIDS Vaccines Coming, But Not a Panacea 

Many research and clinical trials are underway to develop a vaccine against HIV. Clinical trials 

of two commercial vaccines—intended to confer immunity by introducing a harmless portion of 

HIV protein into the body—have progressed to Phase III human testing in the United States, 

Canada, Netherlands, and Thailand. Results are expected within the year. Nonetheless, even if a 

viable vaccine to protect against certain viral subtypes of HIV that are prominent in the test

countries becomes available in the coming years, it probably will not to be effective against the 

most common subtypes of HIV in Nigeria, Ethiopia, Russia, India, and China. 

Moreover, first-generation HIV-vaccines probably would provide lower immunity or shorterlived protection than future product iterations that incorporate what is learned from wider use. 

Studies suggest that if the vaccine is at least 30 percent effective, delivering it to persons engaging

in high-risk behaviors may be beneficial, although there is a danger that it could encourage risky 

sexual conduct in individuals who believe they are protected by the vaccine. Unless the vaccine

was widely affordable, however, it would remain beyond the reach of the developing world—

which is likely to fuel intense political pressure on Western countries and drug companies to slash 

prices or subsidize the cost. 

Both vaccine effectiveness and good distribution are necessary for HIV transmissibility to 

decrease enough for the epidemic to die out eventually. For example, some estimates indicate 

that to stem the epidemic, the world would need 50 percent coverage with a 75 percent effective 

vaccine. Until a highly effective vaccine is in wide distribution, anti-AIDS programs aimed at 

encouraging behavioral change will remain essential in controlling HIV/AIDS. 

23
• If the governments prove unable to 

respond, public confidence in political 

leadership could be weakened further, 

especially if efforts to respond are seen to 

be undermined by corruption. 

Researchers estimated there were 2.6 million 

AIDS orphans in Nigeria alone in 2000—

higher even than in South Africa—and the 

problem will get much worse. AIDS orphans 

often are taken in by relatives during the early 

stages of the disease, but the phenomenon in 

other African countries suggests that Nigeria 

and Ethiopia are likely to reach a point before 

the end of the decade when the number of 

caregivers is insufficient to cope with the 

burden.

Russia: HIV/AIDS Worsening 

Demographic Situation

The rising AIDS problem in Russia is likely 

to exacerbate the significant social, economic, 

health, and military problems already facing 

the country. These challenges, added 

together, will complicate Moscow’s efforts to 

rebuild Russia. 

• HIV/AIDS will accelerate Russia’s 

population decline. A contracting work 

force and exploding healthcare costs will 

be serious counterweights to energydriven economic growth. 

• A recent World Bank study projects that 

HIV/AIDS could cut annual economic 

growth in Russia by half a percentage 

point by 2010 and a full percentage point 

by 2020. 

As the disease spreads, the high cost of 

treatment and education programs could drive 

out other claims on health systems, leading to 

a steeper decline in general health than caused 

by HIV/AIDS alone. Even if more resources 

are committed to combat HIV/AIDS—either

by Russia or outsiders—considerable time 

and money would be required to expand and 

reform the healthcare infrastructure, 

suggesting that the disease will continue to 

spread at a rapid pace. 

• These economic problems are likely to 

fuel social and political tensions over 

spending priorities. Devoting more 

money to combating HIV/AIDS probably 

would just leave that much less for such 

other pressing health problems such as 

heart disease and TB. 

India and China: A Big Problem but 

Probably not Devastating 

India and China are likely to generate the 

largest number of people infected with AIDS 

of any countries in the world by 2010, but the 

impact will be lessened because these 

individuals will remain diffused among very 

large populations. Even if the number of 

infected people rises to the upper side of our 

projections, the percentage of the adult 

population that is infected still would be 

significantly lower than in the other nextwave countries at the end of the decade. 

• Fifteen million HIV-positive people in 

China would represent roughly 2 percent 

of the adult population. 

• Twenty-five million infected Indians 

would reflect a 4 percent adult prevalence 

rate. 

 

Judging the broader impact on economic 

growth and productivity is more difficult, 

however, because it depends largely on which 

demographic groups get hit the hardest. 

Several researchers in 1999 estimated that 

AIDS cost India roughly 1 percent of GDP 

per year because of lost productivity and 

treatment of secondary infections. The study 

did not include numerous factors—such as the 

cost of drugs and retraining workers—

24
however, and there is no consensus on a 

formula to calculate the economic costs.4

• At a minimum, AIDS will drive up 

healthcare costs in both countries, forcing 

difficult trade-offs on spending. 

• The more the disease remains among rural 

and lower skilled people, the more likely 

that the abundant labor supply of both 

China and India can fill the gap. 

• The more the disease spreads among 

young, educated, urban professionals, 

however, the higher the economic costs 

will be, given the premium on skilled 

labor. 

• Chinese leaders are likely to fear that the 

perception in global markets of a rising 

AIDS problem could discourage the huge 

flow of foreign investment into the 

country that has been vital to growth. 

We believe the HIV/AIDS epidemic, by itself, 

will not pose a fundamental threat through 

2010 to the rise of China and India as major 

regional players. Given the relatively low 

current prevalence rates and the relatively 

long period from infection to death, the two 

countries can manage the impact of the 

disease through the end of the decade. 

Nonetheless, the mounting AIDS problem

will further add to the complex problems and 

trade-offs facing leaders in both countries in 

the coming years. 

• Beyond 2010, HIV/AIDS will become an 

even more significant problem for China 

and India if government programs prove 

ineffective and prevalence rates jump

significantly. 

 

4

 Anand K Pandav, CS and Nath LM: The Impact of

HIV/AIDS on the National Economy of India. Health

Policy 47 (1999) pps 195-205. The costs of

antiretroviral therapy, retraining the work force, 

strengthening the healthcare system, R&D, 

communications and prevention of mother-to-child

transmission were not included in this model.

There is no sign that HIV/AIDS will become

a lightning rod for widespread public 

discontent in either China or India. 

Nonetheless, the protests of rural Chinese 

who became infected through plasma sales 

suggest that anger with the government’s 

slow response will add to growing frustration 

in rural areas over rising unemployment, 

widespread corruption, and poor services. 

• Press reports indicate that several smallscale AIDS-related protests have erupted 

in Chinese villages over the last year. 

Journalists report that many villagers 

are angry over the issue but are afraid to 

speak out because of government 

intimidation.

• For several days in November, police 

detained HIV-positive protesters and a 

group of reporters who came to interview 

them. 

• Protests by Chinese in urban areas almost 

certainly would spark deeper concern 

among Chinese authorities. 

• HIV/AIDS may become more of a 

political issue in India as infection rates 

climb. The debate is likely to focus on 

who pays for and receives the 

antiretroviral drugs that Indian firms now 

are producing. 

Both Beijing and New Delhi probably will try 

to push the rising cost of dealing with 

HIV/AIDS down to state and local 

governments, as they have on other issues. 

Local authorities, however, are unlikely to 

have the staff, expertise, or funding to assume

the growing burden. 

25
• Most Indian state governments already 

have curbed spending on healthcare and 

education to cope with severe fiscal 

strains—and some are even struggling just 

to pay the wages of government workers. 

• Likewise, Chinese localities already are 

overburdened with responsibilities for 

public health that Beijing has passed 

along in decentralizing many government 

duties. 

HIV/AIDS is unlikely to undermine general 

military capabilities in China and India 

because of the large pool of potential recruits 

for the respective armies. China began testing 

conscripts for HIV in 2001. 

• China and India increasingly will monitor 

AIDS in the military to ensure that the 

disease does not complicate staffing 

among smaller, more highly trained units 

operating sophisticated weapon systems. 

As HIV/AIDS moves more into the general 

population in China, past experience in other 

countries suggests it will exacerbate an 

already existing gender imbalance because of 

the practice of female infanticide. 

• In India and China, because of cultural 

norms, boys are more likely to be taken 

care of by their relatives than girls. 

International Implications 

The surge in the disease outside southern 

Africa will fuel calls for more support from

donor countries to address the problem and 

intensify the debate over how to allocate such 

international resources as the Global Fund for 

AIDS, TB, and Malaria. 

• UN Secretary General Annan set a goal of 

raising international spending on AIDS to 

$7-10 billion a year when he proposed the 

Global Fund last year. Based on rising 

projections for the next-wave countries, 

pressure will grow to significantly raise 

that amount. 

• A debate is likely over how much the 

Global Fund should focus on heading off 

AIDS in large, next-wave countries where 

it is in the earlier stages, and how much to 

devote to the hardest hit countries in 

southern Africa. Similarly, differences 

are likely to arise between those wanting 

to allocate money to programs on the 

basis of proven success or greatest need. 

• Should resources be shifted away from 

central and southern Africa, Africans 

there probably will accuse the West of

ignoring them and paying more attention 

to large countries that are more 

economically and strategically important. 

The rising focus on HIV/AIDS worldwide has 

the potential to draw international attention 

and funding away from other infectious 

diseases such as TB, malaria, hepatitis, as 

well as other critical non-infectious health 

problems. 

International tensions over medical treatment 

for HIV/AIDS almost certainly will grow, 

even though access to antiretrovirals will 

increase. 

• The manufacture of generic antiretroviral 

drugs by several next-wave countries will 

increase pressure on international 

pharmaceutical companies to further 

lower the price and increase availability of

their drugs. European countries have 

stated their support for countries buying 

AIDS drugs from companies in India and 

Brazil that challenge patents. 

• The increasing use of antiretrovirals in 

next-wave countries, however, almost 

26
certainly will increase misuse due to their 

weak healthcare systems, undermining 

their effectiveness and fueling resistant 

HIV strains throughout the world. If the 

effectiveness of antiretrovirals declines, 

recipient countries are likely to charge 

donors with supplying faulty drugs. 

• Developed countries will face 

overwhelming pressure to provide any 

new vaccines that are discovered to 

countries around the world. These 

countries will complain bitterly if the 

early vaccines are not designed for the 

HIV subtypes common in their regions or 

blame the donors for their limited 

effectiveness. 

Despite these likely frictions, however, the 

rising AIDS crisis probably will make the 

next-wave countries more open to seeking 

technical assistance from the United States 

and other donor countries to help track, 

prevent, and treat the disease. 

27
The National Intelligence Council 

The National Intelligence Council (NIC) manages the Intelligence 

Community’s estimative process, incorporating the best available 

expertise inside and outside the government. It reports to the Director 

of Central Intelligence in his capacity as head of the US Intelligence 

Community and speaks authoritatively on substantive issues for the 

Community as a whole. 

Acting Chairman Stuart A. Cohen 

Vice Chairman for Evaluation Mark Lowenthal 

Acting Director, Senior Review, 

Production, and Analysis 

William R. Heaton 

National Intelligence Officers

Africa Robert Houdek

At-Large Stuart A. Cohen 

Conventional Military Issues John Landry

East Asia Arthur Brown 

Economics & Global Issues Karen Monaghan 

Acting 

Europe Barry F. Lowenkron 

Latin America Fulton T. Armstrong 

Near East and South Asia Paul Pillar 

Russia and Eurasia George Kolt 

Science & Technology Lawrence Gershwin 

Strategic & Nuclear Programs Robert D Walpole 

Warning Robert Vickers

28