Final Report The XI International Conference on AIDS, Official Satellite Symposium, The Status and Trends of the Global HIV/AIDS Pandemic was jointly organized by the AIDS Control and Prevention (AIDSCAP) Project of Family Health International, the François-Xavier Bagnoud Center for Health and Human Rights of the Harvard School of Public Health, the Joint United Nations Programme on HIV/AIDS (UNAIDS); and was partially funded by the United Nations Population Fund (UNFPA) and The United States Agency for International Development.

The Status and Trends of the Global HIV/AIDS Pandemic Satellite Symposium of the XI International Conference on AIDS was jointly organized by the AIDS Control and Prevention (AIDSCAP) Project of Family Health International, the François-Xavier Bagnoud Center for Health and Human Rights of the Harvard School of Public Health and the Joint United Nations Programme on HIV/AIDS (UNAIDS). This two-day Symposium, held on 5-6 July 1996 in Vancouver, Canada, resulted from an extraordinary response to The Status and Trends of the HIV/AIDS Epidemics in Africa Workshop held in Kampala, Uganda, in December 1995 prior to the IX International Conference on AIDS and STD in Africa.

With specific recommendations for urgent action to prevent the further spread of HIV in Africa, the Kampala workshop report raised issues that cut across HIV/AIDS epidemics in developing countries globally and provided a successful model for future action-oriented international HIV/AIDS symposia. The workshop report, released during the Kampala conference and quickly disseminated internationally by the workshop organizers, became available for immediate programmatic reorientation, planning and implementation by policy makers and program managers working on HIV/AIDS-related issues in Africa and around the world.

Seizing on the impact of the Kampala initiative, the workshop's co-chairs, Daniel Tarantola of Harvard's François-Xavier Bagnoud Center and Peter Lamptey of AIDSCAP, quickly convened a larger Symposium on The Status and Trends of the Global HIV/AIDS Pandemic at the XI International Conference on AIDS in Vancouver, Canada, which they also co-chaired. The objectives for the Vancouver Symposium included: reviewing the current status and trends of the global HIV/AIDS pandemic, including the epidemiological and behavioral patterns; identifying the specific data needs for monitoring and forecasting; and producing a consensus report on the global pandemic and on current as well as projected trends for the epidemics in various parts of the world.

Ten regional teams composed of 50 leading epidemiologists, public health and development specialists (see List of Participants at end of this report), each nominated by an international steering committee, were chosen to collect and analyze data and information on the status and trends of HIV/AIDS in their region prior to the Symposium. Regional working group sessions held by each team on site provided the basis for summary presentations to the Symposium participants. Finally, a plenary discussion was held on each region at which the Symposium participants reached conclusions and made their final recommendations for this report.

Released within 24 hours of the Symposium's conclusion, the provisional Vancouver report was amended during the Vancouver conference to the version herein. A day later, the Vancouver Symposium organizers began planning the next Status and Trends of the Global HIV/AIDS Pandemic Symposium to be convened at the 4th International Conference on AIDS in Asia and the Pacific, to be held in Manila, Philippines, in October 1997.

Executive Summary

Globally, the HIV/AIDS pandemic continues to sweep across continents: the number of estimated adult HIV infections worldwide has more than doubled since 1990 from 10 million to a mid-1996 total of 25.5 million. Composed of distinct epidemics, each with its own features and force, the pandemic is disproportionately impacting the developing world. HIV infections, however, are leveling off and even decreasing in some populations. HIV incidence has declined in young women in Uganda, young men in Thailand and in gay men in the U.S., Australia, Canada and western Europe.

From the beginning of the pandemic until mid-1996, an estimated 27.9 million people worldwide were infected with HIV. Of these, 14.9 million were men (58 percent) and 10.5 million were women (42 percent). The majority of HIV infections -- 26 million (93 percent) -- have occurred in developing countries. The largest numbers of HIV-infected individuals were in sub-Saharan Africa, totaling 19 million (68 percent of the global total), and in South and Southeast Asia, totaling 5 million (18 percent of the global total). The number of HIV-infected people in South and Southeast Asia is now more than twice the total number of those infected in the entire industrialized world. Worldwide, 5.8 million people (4.5 million adults and 1.3 million children), 75 percent of all those with AIDS, are estimated to have died from AIDS.

Sub-Saharan Africa, representing about 60 percent of the world's total HIV infections, accounts for almost 90 percent of the current 13.3 million HIV infections in adults and adolescents in Africa. The rates of newly acquired HIV infections are highest in the 15- to 24-year-old group among both females and males in most of sub-Saharan Africa. Of the 3 million HIV-infected infants born in the world with HIV infection since the beginning of the pandemic, over 90 percent have been born in Africa. Many of these children typically develop AIDS and die within a few years.

Eighteen countries in the region have at least 100,000 people living with HIV. Central and East African countries have 37 percent of all current HIV infections on the continent. A second group of countries in southern Africa contributes about 15 percent to the total number of adults and adolescents living with HIV in the region. In other sub-Saharan countries -- mostly in west and central Africa -- HIV epidemics are currently passing through their intermediate stage where between 1 and 10 percent of women attending urban antenatal clinics are HIV-infected. In contrast to the increasing spread of HIV-1, the prevalence of HIV-2 has remained rather stable in West Africa, perhaps the result of the higher transmissibility of HIV-1 compared to HIV-2.

Urban and trading centers generally show substantially higher prevalence of HIV infection than rural areas; however, rates of HIV infection in some rural populations have increased steadily. Open conflicts, environmental degradation, natural disasters and low-intensity wars also have led millions of Africans to leave their homes and, in some situations, to turn to survival strategies that have increased the practice of unsafe sex. Migration and urbanization also have led to high concentrations of predominantly male communities and increased participation in commercial sex.

Demographic surveys in several countries have already noted significant increases in infant and child mortality. Projections for Zambia and Zimbabwe indicate that AIDS may increase child mortality rates nearly threefold by the year 2010. Due to high levels of fertility, populations will generally continue to grow, but critical deficits will affect the economically active age groups.

Asia, home to more than 60 percent of the world's adult population, presents epidemiology and HIV prevalence estimates that are extremely diverse, ranging from countries with low prevalence (Mongolia, DPR Korea) to countries with high prevalence (Cambodia, Myanmar and Thailand). HIV is spreading mostly through heterosexual contact. Infected men probably outnumber infected women by a factor of 3 to 1 or more, and gender inequality and the frequent practice of men visiting sex workers have strongly influenced spread of HIV. Sharing of needles among injecting drug users (IDUs) also played a significant role early in the epidemics, particularly in the Golden Triangle region (from Thailand and Vietnam, across southern China, to Myanmar and Manipur State in India) and in northern Malaysia.

Thailand has an estimated three-quarters of a million people living with HIV. Yet there is evidence that Thailand's active multi-sectoral prevention efforts are taking effect, as HIV infection levels in military conscripts have dropped from 3.6 percent in 1993 to 2.5 percent in 1995. Pediatric HIV infection is difficult to assess regionally, but an estimated 6,400 children are infected annually in Thailand, making up approximately 10 percent of the new infections of HIV.

Evidence in India suggests rapid, extensive and uncontrolled spread of HIV in many parts of the country, and HIV seroprevalence is high in the South and West. In Bombay, prevalence went from 2 to 3 percent in sexually transmitted disease (STD) clinic attendees before 1990 to 36 percent in 1994. Injecting drug use has been a problem in Manipur State, where prevalence reached 60 percent by 1992. Evidence suggests an estimated 2 to 5 million HIV infections nationwide in mid-1996. Low use of condoms and high rates of sexually transmitted disease continue to be a major problem in India, threatening to multiply exponentially the spread of HIV.

In Cambodia data indicate that the current extensive HIV epidemic started during the late 1980s or early 1990s and is predominantly occurring among heterosexuals with multiple sex partners. Myanmar has one of the most serious epidemics in the region, with an estimated half a million people infected with HIV by 1996. In Malaysia HIV infection levels in IDUs have grown rapidly from 0.1 percent in 1988 to 20 percent in 1994.

In Vietnam, evidence shows the HIV epidemic to be growing rapidly, with high levels in IDUs in treatment (32 percent in 1992-95), and increasing levels among young men and women in the south.

China, because of its size and rapid changes in social and sexual behavior, represents another major potential focus of the epidemic in Asia. The majority (about 70 percent) of reported HIV infections and AIDS cases have been among IDUs in Yunnan Province, but infections are believed to be increasing among heterosexuals in southern China, especially in the areas surrounding Hong Kong. An estimated 10,000 persons were infected with HIV in China at the end of 1993, growing to 100,000 by the end of 1995.

HIV transmission may be starting in the heterosexual population in Laos. Bangladesh, Indonesia, Nepal and Sri Lanka show high levels of other STDs, implying a strong possibility for extensive HIV spread. In Hong Kong, Japan, Mongolia and the Republic of Korea, extensive spread has not been documented. No cases of AIDS or HIV have been reported in DPR Korea or Bhutan. In the Philippines the epidemic shows slower growth, and in Singapore, HIV infection levels in sex workers have been growing quite slowly.

In Latin America and the Caribbean the spread of HIV/AIDS has been slower than in other regions, but the pandemic is well-established and some Caribbean countries report AIDS incidence rates among the highest in the world. Dominant modes of transmission vary from one country to the next: mainly through homo- and bisexual contacts in some countries, to epidemics connected to injecting drug use in others, to still others primarily determined by heterosexual transmission. Epidemiological evidence signals a rapid shift of new infections to younger ages, particularly to young people between 15 and 24 years old.

The number of new HIV infections in Mexico, Guatemala, Belize, El Salvador, Honduras, Nicaragua, Costa Rica, Panama, Cuba, Dominican Republic, Haiti and Puerto Rico continues to rise, reflecting increasing HIV/AIDS incidence and accelerated heterosexual transmission.

Haiti is of particular importance because, perhaps alone in the region, it represents a relatively mature epidemic. HIV prevalence is particularly high among sex workers, STD clinic attendees and tuberculosis (TB) patients. High rates of HIV prevalence are found among pregnant women aged 14 to 24.

In the English-speaking Caribbean, the male-to-female ratio of new AIDS cases has fallen dramatically over the past 10 years, under 2 men to 1 woman in 1994. Women aged 15 to 19 now have higher annual incidence rates than men of the same age. AIDS is the leading cause of death among young men in some Caribbean countries, while pediatric AIDS cases have been steadily rising and now account for 5 percent of all new cases. The extremely low incidence of HIV infection through contaminated blood represents a partial success story for the Caribbean region.

HIV infections and AIDS cases in South America are rising steadily. Brazil accounts for 75 percent of AIDS cases reported and is followed by the Andean Region (15 percent) and the Southern Cone (10 percent). Sexual transmission of HIV accounts for 74 percent of all infections (51 percent homo/bisexual and 23 percent heterosexual), injecting drug use 19 percent (although recent data in Brazil suggests that the HIV transmission through injecting drug use seems to be leveling off) and 7 percent for blood and vertical transmission and undocumented cases.

The impact of HIV/AIDS on morbidity and mortality is being seen in major urban centers, such as in São Paulo, Brazil, where AIDS is now the leading cause of death in women of reproductive age.

North America has seen the HIV epidemic slow in recent years as new infections start to level off, largely due to the decline in sexual transmission between men as a result of behavior change. Nevertheless, HIV prevalence in gay men remains high on the continent. In the United States, HIV prevalence among IDUs has decreased. AIDS cases related to heterosexual contact represent an increasing proportion of newly diagnosed cases in North America.

Since the start of the epidemic from 1 to 1.5 million cumulative HIV infections have occurred in North America, and HIV infection has been one of the major causes of death for individuals between the ages of 25 and 44. Among men in this age group, it was the leading cause of death in the U.S. and the second leading cause of death in Canada in 1994. In the same year, HIV infection was the third leading cause of death among 25- to 44-year-old women in the U.S. An estimated 12,000 children in the U.S. are living with HIV, although AIDS incidence among children under 13 has declined annually since 1990.

Although there has been an overall slowing in AIDS incidence, there has been substantive shift in the populations affected. In 1995 AIDS incidence was 6.5 times greater for blacks and 4 times greater for Hispanics than for whites, 20 percent of persons diagnosed with AIDS were women, and 15 percent were infected heterosexually. AIDS among prisoners was 7 times the rate of the non-incarcerated population, and AIDS was the second leading cause of death among prisoners.

In Europe an estimated 450,000 adults were living with HIV in western Europe at the end of 1993, with an annual incidence of around 40,000 since 1990. Over the past 2 to 3 years, AIDS incidence appears to have stabilized in several countries in northwestern Europe and condom use increased markedly, particularly for the most sexually active population groups. In contrast, countries in southwestern Europe show no indication of AIDS leveling off.

Transmission of HIV through injecting drug use continues to play a major role in the dynamics of the epidemic. It is responsible for the majority of AIDS cases in some of the western countries with highest incidence (Spain and Italy) and is strongly associated with AIDS cases occurring among heterosexual adults and among children in these countries.

In central and eastern Europe (with the exception of Romania) and central Asia, the HIV/AIDS epidemic is much more recent and AIDS incidence much lower than in western Europe. In some countries, a rapid spread of HIV is indicated, mainly linked with injecting drug use. In Poland and the Federal Republic of Yugoslavia, where IDUs account for the largest proportion of cases, the incidence of AIDS is rising rapidly.

Before 1990, most AIDS cases were diagnosed in men who have sex with men (MSM). Since 1990, however, IDUs account for the highest proportion of yearly diagnosed cases in the region (43 percent of adult and adolescent cases in 1995). The shift in transmission patterns is accompanied by an increase in the proportion of female cases, which rose from 11 percent in 1986 to 20 percent in 1995.

The vast majority of children have been infected through mother-to-child transmission, and HIV prevalence in pregnant women has been much higher in urban than in rural areas. The epidemic among children is dominated by the epidemic in Romanian hospitals, which was detected in 1989 and accounts for over 50 percent of the 6,060 pediatric cases reported in the European region. Another, though much smaller, epidemic among children in hospitals occurred in the Russian Federation in the late 1980s. The most worrisome information coming from STD surveillance arose recently from the independent republics of the former Soviet Union. Substantial increases in syphilis rates have been seen since 1990 in several of these states.

In the North and South Pacific around 7,400 cases of AIDS had been reported by the end of 1995, with over 7,000 of them in Australia and New Zealand, where the major pathway of HIV transmission (about 85 percent of HIV infections) has been through sexual contact between men. This pattern also has been reflected in the French Territories of New Caledonia and French Polynesia. The HIV epidemic in Papua New Guinea (PNG) has developed more recently and appears to involve a major component of heterosexual transmission; by the end of 1994 PNG had an estimated 4,000 adults living with HIV, overtaking Australia on a per-capita basis to give the highest prevalence in the region.

The incidence of AIDS has reached a plateau in Australia, and appears to be declining in New Zealand, due to the drop in the rate of sexual transmission of HIV between men that mostly occurred ten years earlier. In Australia, and to a lesser extent New Zealand, high rates of STDs other than HIV in indigenous people have led to mounting concern about the potential for a major heterosexual epidemic of HIV infection in these populations, among whom the rate of HIV diagnosis has increased in the past six years.

In conclusion, the HIV/AIDS pandemic is as powerful as ever: HIV continues to spread in the industrialized world, where, increasingly, it affects people who, for reasons of race, sex, behavior or social and economic status, have lesser access to services. From a global perspective, the pandemic disproportionately affects the developing world, where the needs for effective prevention and care are escalating. But the pandemic has now become immensely complex. It has become fragmented and is now a mosaic composed of a multitude of epidemics, which can be distinguished on the basis of: predominant modes of transmission; geographic focus; HIV sub-types; age, sex, socioeconomic or behavioral characteristics of the populations most affected; rapidity of or potential for HIV spread; stage of maturity and, in some communities and countries, declining HIV incidence.

As the HIV epidemics pursue their course, the social, economic and demographic impacts of HIV/AIDS in particular in the developing world are likely to exacerbate the burden on individuals, communities and countries, which will challenge the stability of entire regions.

Current evidence of the effectiveness of HIV prevention and recent progress achieved in the development of new therapies provide the scientific basis on which an expanded response to growing prevention and care needs can be built.

Existing epidemiological surveillance systems are inadequate to monitor the HIV epidemics effectively. Creativity and sustained effort must be applied to collect and analyze data that better reflect and will help understand, predict and prevent the dynamic spread of HIV in vulnerable populations worldwide.

Global Overview

In mid-July 1996, an estimated 21.8 million adults and children worldwide were living with HIV/AIDS, of whom 20.4 million (94 percent) were in the developing world. Of the adults, 12.2 million (58 percent) were male and 8.8 million (42 percent) were female.1 Close to 19 million adults and children (86 percent of the world total) were living with HIV/AIDS in sub-Saharan Africa and in South and Southeast Asia.

Worldwide during 1995, 2.7 million adult HIV infections occurred in adults (averaging more than 7,000 new infections each day). Of these, about 1 million (an average of nearly 3,000 new infections per day) occurred in Southeast Asia and 1.4 million infections (close to 4,000 new infections per day) were in sub-Saharan Africa. The industrialized world accounted for about 55,000 new HIV infections in 1995 (nearly 150 new infections per day; about 2 percent of the global total).

In 1995 approximately 500,000 children were born with HIV infection (about 1,400 per day); of these children 67 percent were in sub-Saharan Africa, 30 percent in South and Southeast Asia, and over 2 percent in Latin America and the Caribbean.

From the beginning of the pandemic until mid-1996, an estimated 27.9 million people worldwide have been infected with HIV. The largest numbers of individuals ever infected with HIV were in sub-Saharan Africa, totaling 19 million (68 percent of the global total), and in South and Southeast Asia, totaling 5 million (18 percent of the global total).

Since the beginning of the pandemic, the majority of HIV infections-26 million (93 percent)- have occurred in the developing world. The number of HIV-infected people in South and Southeast Asia is now more than twice the total number of infected people in the entire industrialized world.

The global cumulative number of HIV infections among adults has more than doubled since the beginning of the decade, from about 10 million in 1990 to almost 25.5 million by mid-1996. Of these, 14.9 million were men (58 percent) and 10.5 million were women (42 percent).

More than 6 million adults have developed AIDS from the beginning of the pandemic to July 1996, and of these 4.5 million (close to 75 percent) were in sub-Saharan Africa; 0.4 million were in Latin America and the Caribbean (7 percent); and 0.75 million were in North America, Europe and North and South Pacific combined (12 percent). In South and Southeast Asia, where the pandemic gained intensity more recently, it is estimated that 330,000 adults have developed AIDS. Of the 1.6 million children with AIDS, the majority -- 1.4 million (85 percent) -- were in sub-Saharan Africa.

By July 1996, 5.8 million people (4.5 million adults and 1.3 million children), 75 percent of all people with AIDS, are estimated to have died from AIDS worldwide.

In summary, the HIV/AIDS pandemic is as powerful as ever. This report will show that the pandemic is now composed of distinct epidemics each with their own features and force, and disproportionately impacting on the developing world. The following sections of this report will show that as the HIV/AIDS epidemics within each region and country have become increasingly diverse and fragmented, they have created a multifaceted and devastating pandemic.