The Demographics of HIV/AIDS

Who is Infected?

At the end of 2010, there were 34 million people living with HIV, half of them women. In 2010 alone, 2.7 million people were newly infected. That same year, an estimated 390,000 children under the age of 15 contracted the virus, bringing the global total of infected children to 3.4 million.

The disease is disproportionately concentrated in sub-Saharan Africa, which is home to 67 percent of all infected people. Within sub-Saharan Africa, infection rates vary widely between nations, from 0.2 percent in Madagascar to 25.9 percent in Swaziland. In most sub-Saharan African countries the rate of new infections has either stabilized or declined. However, population growth keeps the absolute number of infected people climbing.

Demographic Consequences

Four young boys orphaned by HIV/AIDS help their grandmother prepare manioc to sell inNgaoundere, Cameroon. Photo: Ted Alcorn, Courtesy of Photoshare

Worldwide, the number of children orphaned by AIDS is estimated at 16.6 million. Nearly 90 percent of them live in sub-Saharan Africa—14.8 million children in that region have lost one or both parents to HIV/AIDS.

But breaking apart families is just one of the myriad ways that HIV/AIDS dramatically destabilizes communities. The disease kills mostly working-aged adults. This means that countries with a high HIV/AIDS prevalence lose a staggeringly large number of experienced workers, whose roles in society cannot easily be filled by children or the elderly. Thus, families lose their primary caretakers and governments lose their primary wage earners. “At the peak of the AIDS epidemic in Africa, HIV accounted for two-thirds of all adult deaths. Can you imagine what that would be like in our own village, our own community? There were communities in which the only business that was increasing was the funeral business,” said Dr. Thomas Frieden, director of the CDC.

Because HIV/AIDS primarily affects adults between the ages of 15 and 49, it has distorted country age distributions and stunted life expectancies. In fact, the life expectancy in sub-Saharan Africa is only 55 years. In the two most heavily affected countries in the region, Lesotho and Swaziland, life expectancy is only 49 years.

Despite the devastatingly destabilizing demographic consequences of AIDS, the population continues to grow rapidly, even in many of the countries worst affected by the epidemic. For example, in Botswana, despite an HIV/AIDS prevalence rate of 24.8 percent, the population is projected to grow by up to 59 percent between now and 2050, depending on fertility trends.

Six orphan children outside their grandmother’s hut in Kano, Kisumu District, Kenya. Photo: MaryAtieno Otieno/Rural-Kenya World Cultural Link (CULINKE), Courtesy of Photoshare

New Victims

HIV/AIDS was once considered a “homosexual problem.” However, today the virus is spread primarily through heterosexual contact, and in sub-Saharan Africa and the Caribbean the number of infected women exceeds the number of infected men. Women who abstain from premarital sex and stay faithful to their husbands once married can still contract HIV if their husbands have the virus.

Mother-to-child transmission of HIV is a concern during pregnancy, delivery, and breastfeeding, as there is a 15-45 percent chance of an HIV-positive mother passing along her infection to her child during this time. More than 90 percent of children with HIV were infected through motherto- child transmission. Countries that already have high rates of infant and child mortality must redouble their efforts to improve child survival when dealing with antenatal transmission. In Swaziland, the under-five mortality rate is 92 deaths per 1,000 live births. In comparison, in Madagascar, the under-five mortality rate is 58 deaths per 1,000 live births.

Antiretroviral (ARV) drugs given to pregnant women can reduce the risk of mother-to-child transmission, down to levels below 5 percent. Between 2008 and 2009, the percentage of HIV-infected pregnant women receiving ARVs increased from 58 percent to 68 percent in Eastern and Southern Africa, and from 16 percent to 23 percent in West and Central Africa. Despite these increases, in 2010 ARVs were provided to only half of pregnant women living with HIV in low and middle income countries.

Preventing unintended pregnancy is another means of reducing mother-tochild transmission. The new guidelines for PEPFAR (described below) state that family planning “is an important component of the preventive care package of services for people living with HIV/AIDS and for women accessing PMTCT [preventing mother to child transmission] services.”

Policy and Funding Response

An infant receives ARV drugs and micronutrientdrops in Chennai, India. Photo: Jpaul/Buds ofChrist, Courtesy of Photoshare

Between 2003 and 2008 (Phase I), the Bush Administration committed $15 billion to HIV/AIDS prevention and treatment under the President’s Emergency Plan For AIDS Relief (PEPFAR). Congress reauthorized the program in 2008 for another five years at $48 billion (2009- 2013—Phase II) and President Obama made PEPFAR the cornerstone of his new Global Health Initiative shortly thereafter.

PEPFAR has experienced marked success. Between 2004 and 2008, odds of death were approximately 20 percent lower in countries in which PEPFAR was most active. Additionally, nearly 240,000 mother-to-child infections were averted during Phase I. According to Dr. Peter Piot, former executive director of UNAIDS, “There are probably very few examples in international aid that can demonstrate such direct, dramatic impact.”

However, challenges persist.

In Phase I, organizations were required to spend 33 percent of all PEPFAR grants on “Abstinence and Be Faithful” programs, which failed to address all methods of prevention, i.e. condoms. Although the requirement was removed for Phase II, aid recipients must send a report to Congress “if less than half of prevention funds go to abstinence, delay of sexual debut, monogamy, fidelity and partner reduction in any host country with a generalized epidemic.” One organization admitted, “There are perceived restrictions in PEPFAR about what you can discuss with whom, so everyone is being very cautious… People are afraid to discuss family planning, condoms, abortion—so many groups don’t address them at all.”

PEPFAR was first introduced as an emergency response to the AIDS epidemic. As such, its foremost emphasis was originally on treatment, rather than prevention of new cases. Experts like Dr. Stefano Bertozzi of the Bill and Melinda Gates Foundation have since acknowledged that “there’s no way we can treat ourselves out of this epidemic.” In response, Phase II includes the target of preventing 12 million new HIV infections and providing at least 80 percent of HIV positive pregnant women with treatment to prevent motherto- child transmission.

Despite huge strides in the fight against HIV, millions of infections still occur annually. It is too soon to slow our offensive. As former UN Secretary-General Kofi Annan said, “In this effort, there is no us and them, no developed and developing countries, no rich and poor—only a common enemy that knows no frontiers and threatens all people.”

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