An Unequal Epidemic in an Unequal World
Authors: Kevin M. De Cock
Journal: JAMA (2002)

IN JULY 2002, APPROXIMATELY 15000 CLINICIANS, RESEARCHers, and other interested persons will gather once again, this time at the XIV International AIDS Conference in Barcelona, to discuss what is arguably the worst plague the world has ever known. These international conferences and their venues are milestones in the history of this tragic epidemic. In 1985, Atlanta hosted the first meeting; in 1996, the Vancouver meeting introduced combination therapy and viral load testing to the world; and in 2000, Durban drew international attention to Africa’s plight. Barcelona offers further opportunity for dialogue, reflection on epidemiology and response, and strengthening global resolve. The United States is the most heavily affected country in the industrialized world with almost 1 million persons living with HIV (human immunodeficiency virus). Important successes have included the prevention of HIV/AIDS (acquired immunodeficiency syndrome) transmitted through blood and blood products; progress toward elimination of pediatric HIV disease as a result of prevention of motherto-child transmission of HIV; and reductions in AIDS incidence and deaths since 1996 through use of highly active antiretroviral therapy (HAART); however, the trend in incidence and death has now stabilized. Despite some advances, HIV incidence in the United States has not declined significantly over the past decade, with approximately 40000 new infections occurring annually. Unfortunately, HIV infection continues to affect disproportionately communities of color, especially African Americans. Moreover, with unchanged incidence and longer survival, a slow increase has occurred in the total number of persons living with HIV. Because HAART has delayed the development of AIDS, back calculation, a technique used to model HIV incidence from AIDS case surveillance data, is no longer possible. Of note, in part because of the successes of HAART, there has been a recent resurgence of unsafe behavior among men who have sex with men (MSM), resulting in well-characterized outbreaks of sexually transmitted infections such as syphilis, and, perhaps, increased HIV transmission. Three public health priorities for the United States are: (1) to refashion the national HIV/AIDS surveillance system to focus on HIV and obtain insight into HIV incidence; (2) to reinvigorate prevention efforts nationally; and (3) to promote prevention specifically among HIV-infected persons to prevent onward transmission. Among MSM and other populations with high rates of HIV/AIDS, emphasis must be placed on voluntary counseling and testing, medical evaluation and care, prevention services for HIVinfected individuals, and adoption of the philosophy of personal responsibility not to transmit HIV. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that in late 2001 approximately 40 million persons worldwide were living with HIV/AIDS, that 5 million new HIV infections occurred in that year, and that 3 million HIV-infected persons died. In Central and South America, MSM and injecting drug users account for the majority of infected persons in most countries. In western Europe, HIV/AIDS has become endemic, despite major differences between different countries. In some European countries heterosexual transmission now accounts for the majority of new HIV infections, although a substantial proportion of newly reported infections are imported, especially from Africa. The most unpredictable epidemiological situations are in eastern Europe and Asia. Extensive HIV testing has been conducted in eastern Europe, but there have been few systematic prevalence studies. The majority of HIV infections are associated with injecting drug use and occur in men; the male to female ratio of reported infections is more than 3 to 1. The number of new infections in the last few years has increased steeply in Ukraine, the Russian Federation, Latvia, and Estonia, but spread is now occurring throughout most of the region. Eastern Europe needs better surveillance data, interventions to reduce drug use and needle and syringe sharing, and prevention of secondary sexual spread of HIV. Transmission of HIV in Asia remains largely restricted to injection drug users and commercial sex workers and their clients, with secondary sexual transmission from these core groups to their steady partners. Generalized heterosexual spread as seen in Africa has not occurred, and vigorous