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.

Conversely, it is worth noting why HIV has made relatively limited inroads into the populations of wealthy Western countries. This seems to be due to their favorable "ecological" advantages (better nutrition and minimal endemic disease fortify their residents' immune systems), their particular "behaviorial" dispositions (risky practices, such as drug use and prostitution, have not proliferated catastrophically), and public health infrastructures that have successfully contained potentially lethal risk factors.

Given what is known about the ecological and behavioral HIV risks in Eurasia, it seems safe to suggest that China, India, and Russia today are susceptible to distinctly greater HIV/AIDS risks than are the affluent Western countries -- but distinctly lower risks than those in much of sub-Saharan Africa. Where Eurasia will fall between these two poles is not yet clear, but expert opinion has already hazarded some predictions. China's health minister, Zhang Wenkang, warned last year of 10 million HIV infections by 2010; the head of UNAIDS, Peter Piot, has set the figure at 20 million. The former figure would correspond with an HIV prevalence of 1.3 percent among adults; the latter figure would suggest 2.5 percent. For India, the U.S. intelligence community has predicted 20 million to 25 million HIV carriers by 2010 -- numbers consistent with a prevalence rate of 3-4 percent. And in Russia, that country's leading AIDS authority, Dr. Vadim Pokrovsky, expects 5 million HIV sufferers by 2005, corresponding to an HIV prevalence rate of 6 percent among adults. U.S. intelligence estimates run as high as 8 million by 2010, implying a virtually sub-Saharan infection rate of 11 percent.

With these figures in mind, it is possible to map out prospective paths for HIV/AIDS in Russia, India, and China over the next quarter-century, using demographic and epidemiological modeling techniques. The assumptions behind any model drive its results -- and so any projections can only be illustrative. And from what we know about the record of past HIV/AIDS projections, no one should expect this exercise to be profoundly prescient. But such modeling can nonetheless help to clarify thinking, for it has the virtue of internal consistency.

At the risk of making eyes glaze, let me briefly review the components of this "model." After all, I do not want to seem to be pulling results out of a magical black box.

First, I needed a "baseline" to describe the expected demographic trends in the absence of HIV/AIDS: for this baseline, I chose the U.S. Census Bureau's most recent population projections for the period from 2000 to 2025 for China, India, and Russia. Then, I had to make some basic presumptions about the nature of the local HIV/AIDS epidemics themselves.1 These particular assumptions affect all subsequent calculations -- but the only truly critical one was that the epidemics would be essentially "heterosexual" in nature. (As the previous discussion showed, that view is not the least bit unrealistic.) I assumed the HIV-positive population to be one million as of 2002 in Russia, two million in China, and four million in India -- necessarily arbitrary figures, to be sure, but ones well within the range of informed assessments today.

Finally, I had to make conjectures about distinct future HIV "prevalence scenarios" for each of the three countries. That is to say, how bad would the epidemic become over time? Clearly, this was the trickiest -- and most arbitrary -- facet of the effort. I identified three "families" of scenarios for the disease, which I termed "severe," "intermediate," and "mild" -- corresponding to high, medium, and low levels of HIV infection. ("Severe" is taken here to mean adult HIV prevalence by 2025 reaching as high as 10 percent in Russia, 7 percent in India, and 5 percent in China; "intermediate," 6 percent, 5 percent, and 3.5 percent, respectively; and "mild," 2 percent, 1.5 percent, and 1.5 percent.) These different scenarios, though quite arbitrary, fall well within the expectations of informed independent observers today.

CHRONICLE OF DEATHS FORETOLD

The model lays out a series of specific and staggering implications for the spread of HIV/AIDS in Russia, China, and India.

The magnitude of infection. First, the absolute magnitude of the Eurasian HIV/AIDS epidemic over the coming quarter-century will match or exceed that of the entire worldwide HIV crisis up to now. For example, under the assumptions of even a mild epidemic, the cumulative total of new HIV cases in China, India, and Russia from 2000 to 2025 would be about 66 million, compared to UNAIDS estimates of about 65 million infected worldwide to date. The other scenarios predict even higher HIV totals: an intermediate epidemic would suggest nearly 200 million new HIV cases in the next 25 years, and a severe epidemic would lead to more than 250 million new cases (see Table 1).

The death toll. In each scenario, the cumulative death toll from AIDS over the next 25 years for Russia, China, and India vastly exceeds the total number of people killed by AIDS globally so far. UNAIDS estimates that AIDS -- from its onset to the present day -- has taken about 25 million lives. By contrast, a mild epidemic would project a cumulative total of about 43 million AIDS deaths for these three countries from 2000 to 2025. And the other projections look far worse. During an intermediate epidemic, for example, the hypothetical toll would be about 105 million, more than four times as many as have died to date (see Table 2).