The Future of AIDS

Nicholas Eberstadt

From Foreign Affairs, November/December 2002

Summary:  In the decades ahead, the center of the global HIV/AIDS pandemic is set to shift from Africa to Eurasia. The death toll in that region's three pivotal countries--Russia, India, and China--could be staggering. This will assuredly be a humanitarian tragedy, but it will be much more than that. The disease will alter the economic potential of the region's major states and the global balance of power. Moscow, New Delhi, and Beijing could take steps to mitigate the disaster--but so far they have not.

Nicholas Eberstadt holds the Henry Wendt Chair in Political Economy at the American Enterprise Institute and is Senior Adviser to the National Bureau of Asian Research. This essay draws on a longer study prepared with the assistance of Lisa Howie; for more detailed results see www.AEI.org/scholars/eberstadt.htm.

A TRYST WITH DISEASE

In India, as elsewhere, current numbers are uncertain. UNAIDS has suggested that about four million Indians were HIV positive in 2001 -- a figure that squares with New Delhi's official estimates. In August 2002, however, Health Minister Shatrughan Sinha publicly warned that the true numbers might be much higher, owing to the sketchy disease-surveillance capabilities of several large Indian states. This view is corroborated by a U.S. National Intelligence Council estimate that India has between five and eight million HIV sufferers.

HIV was first diagnosed in India in the mid-1980s. As in Russia (and in most other countries), HIV first emerged in India's urban centers; Mumbai (Bombay), Chennai (Madras), and Bangalore were among the early high-risk cities. Studies suggest that the disease has spread through two geographic pathways: first, along the main trunk roads that serve as the transport network for this enormous country, and second, along the border regions near Burma, where drug use is widespread.

Firm conclusions are difficult since epidemiological surveys (which calculate the incidence, distribution, and control of disease) are still very limited in scope and scale in India. In most of the country, moreover, people are still reluctant to discuss behavior that contributes to the spread of the disease. Homosexual sex, for instance, is an apparent vector for HIV transmission in India, but public sensibilities preclude a discussion of this factor. Drug use has also grown over the past decade, but is mostly confined to the border with Burma. Reports indicate, however, that most of the Indian HIV/AIDS epidemic today is heterosexual -- and is transmitted by commercial sex workers and commercial truckers. (Prostitution in India appears to be widespread: in the early 1990s, Indian social scientists estimated that 2 million prostitutes were at work in the country, and demand has only grown during the intervening decade.) Furthermore, if current accounts are accurate, many monogamous women in India are being infected by husbands having extramarital affairs. And given the high levels of illiteracy among women in India and the taboos concerning sexually transmitted diseases more generally, very little information seems to be available to India's adult female population about HIV risks.

The Indian government has responded to the country's HIV epidemic unevenly. New Delhi announced a National AIDS Control Program in 1987, but follow-through was haphazard and the government's own anti-AIDS organization devoted a considerable portion of its energies to arguing that outside groups were overestimating the prevalence of HIV in India. India is currently in the second phase of a ten-year government program for combating the spread of HIV. India's federal system, however, grants wide latitude to states, and these have shown varying levels of interest (and competence) in dealing with the problem. In April 2002, New Delhi announced a nationwide target of "zero ... new [HIV] infections by 2007." But barring a miracle cure, that goal is utterly fanciful -- and only raises questions about the seriousness of the effort overall.

GREAT LEAP BACKWARD

Of the three countries under consideration, the uncertainties are greatest for China. The overwhelming majority of HIV cases in the country are undocumented and untreated: as of 2001, a cumulative total of only 30,000 HIV cases had been registered. Consequently, estimates of the total current cases and the number of new cases of HIV in China rely heavily on guesswork.

In August 2001, health authorities in Beijing announced that 600,000 Chinese were HIV positive as of 2000. A little later, in July 2002, UNAIDS estimated that the total number of people living with HIV/AIDS in China was 850,000 -- a figure with which Beijing, at the time, concurred. Just two months thereafter, however, the Chinese Health Ministry raised the official estimate to one million.

Other sources suggest that the total may be even higher. (Indeed, according to some claims, the province of Henan alone might already have 1.2 million HIV carriers.) A June 2002 UN report suggested that China's HIV population was between 800,000 and 1.5 million people. The U.S. intelligence community, for its part, estimates that China has one million to two million HIV carriers. Nor is this the upper boundary of informed guesswork. In June 2002, an unnamed un official told The New York Times that there could be as many as 6 million HIV cases in China today; if that claim proves accurate, China would currently have the largest HIV population of any country in the world.

Given China's enormous population, these huge HIV numbers still translate into relatively low rates of prevalence: a million HIV carriers would mean a rate of about 0.13 percent; 2 million, about 0.25 percent; and even with the astronomical figure of 6 million, China's HIV prevalence rate would be only somewhat higher than the current 0.7 percent rate in the United States. But whatever the true rate is, there can be no doubt that totals are rising swiftly. Chinese authorities and UNAIDS, for instance, both suggest that the prevalence of HIV in China has been increasing recently by about 20-30 percent per year; the U.S. Centers for Disease Control and Prevention also note that at current rates the number of victims could double in 30 months.