The Next Wave of HIV/AIDS: Nigeria,
Ethiopia, Russia, India, and China

Intelligence Community Assessment
September 2002

ICA 2002-04D
Prepared under the auspices of David F. Gordon, formerly National Intelligence Officer for Economics and Global Issues. Additional copies of this assessment can be downloaded from the NIC public website at www.odci.gov/nic or obtained from Karen Monaghan, Acting National Intelligence Officer for Economics and Global Issues.

This paper builds on the December 1999 unclassified National Intelligence Estimate, The Global Infectious Disease Threat and Its Implications for the United States, which focused on the spread of AIDS in the context of other growing infectious diseases.  Excerpts from the 1999 Estimate presage the expansion of the HIV/AIDS epidemic beyond the geographic focal point of southern Africa:

The National Intelligence Council (NIC) convened a conference of US Government officials and outside experts to share their current assessments and expectations for the future of the disease in these five countries.  Given the range of estimates of the current numbers of infected people and the lack of consensus on which infectious disease models calculate future rates most accurately, the future projections in this paper represent consensus estimates by experts.  The NIC, in addition to coordinating the draft within the Intelligence Community, had the paper reviewed by several leading experts from outside the Intelligence Community as part of its effort to seek out expertise from inside and outside the government.  The experts included Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health; Dr. Robert C. Gallo, Director of the Institute of Human Virology and Professor of Medicine at the University of Maryland Biotechnology Institute; Dr. Phillip Nieburg, Associate Director for Public Health Practice in the Global AIDS Program for the Centers for Disease Control; and Dr. Nicholas Eberstadt of the American Enterprise Institute.

Contents

Summary

The number of people with HIV/AIDS will grow significantly by the end of the decade.  The increase will be driven by the spread of the disease in five populous countries—Nigeria, Ethiopia, Russia, India, and China—where the number of infected people will grow from around 14 to 23 million currently to an estimated 50 to 75 million by 2010.[1]  This estimate eclipses the projected 30 to 35 million cases by the end of the decade in central and southern Africa, the current focal point of the pandemic.

HIV/AIDS is spreading at different rates in the five countries, with the epidemic the most advanced in Nigeria and Ethiopia.  In all countries, however, risky sexual behaviors are driving infection rates upward at a precipitous rate.

It will be difficult for any of the five countries to check their epidemics by 2010 without dramatic shifts in priorities.  The disease has built up significant momentum, health services are inadequate, and the cost of education and treatment programs will be overwhelming.  Government leaders will have trouble maintaining a priority on HIV/AIDS—which has been key to stemming the disease in Uganda, Thailand, and Brazil—because of other pressing issues and the lack of AIDS advocacy groups.

The rise of HIV/AIDS in the next-wave countries is likely to have significant economic, social, political, and military implications.  The impact will vary substantially among the five countries, however, because of differences among them in the development of the disease, likely government responses, available resources, and demographic profiles.

The growing AIDS problem in the next-wave countries probably will spark calls for more financial and technical support from donor countries.  It may lead to growing tensions over how to disburse international funds, such as the Global Fund for AIDS, TB and Malaria.

The cost of antiretroviral drugs—which can prolong the lives of infected people—has plunged in recent years but still may be prohibitively high for populous, low-income countries.  More importantly, the drug costs are only a portion of HIV/AIDS treatment costs.  Drug-resistant strains are likely to spread because of the inconsistent use of antiretroviral therapies and the manufacture overseas of unregulated, substandard drugs.

Discussion

The Scope of the Next Wave
The HIV/AIDS pandemic continues to spread around the world at an alarming rate, and the number of people with the disease will grow significantly by the end of the decade, as it becomes more geographically diffuse. By 2010, we estimate that five countries of strategic importance to the United States—Nigeria, Ethiopia, Russia, India, and China—collectively will have the largest number of HIV/AIDS cases on earth (see figure 1).  These five countries, which comprise over 40 percent of the world’s population, are in the early-to-mid-stages of the epidemic.

Figure 1
High and Low Estimates of Current and Future HIV/AIDS-Infected
Adults in Next-Wave Countries, 2002 and 2010

We project the total number of people with HIV/AIDS in these "next-wave" countries is likely to soar from 14 to 23 million currently to 50 to 75 million by 2010, eclipsing the projected 30 to 35 million cases in central and southern Africa, the current geographic epicenter of the epidemic (see figure 2).

Figure 2
High and Low Estimates of Current and Future HIV/AIDS-Infected
Adults in Central and Southern Aftrica and in Next-Wave Countries

Through 2010, HIV/AIDS will increase more slowly or even decline in southern and central Africa—now in the sixth decade of the disease.[2]

Although current adult prevalence rates in the next-wave countries range from less than one percent in China to as high as 18 percent in Ethiopia, the number of people infected already is substantial, ranging from 1 to 2 million in China and Russia to upwards of 5 million in Nigeria and India (see table 1).

The spread of HIV/AIDS in the next-wave countries will be difficult to check by 2010.  Treatment of existing infections and prevention of new infections is minimal.  Even if effective programs could be implemented in the coming years, such practical concerns as cost, scale, and experience in health service delivery probably will result in the omission of services to a large number of infected individuals, and the burden of disease will continue to rise.

Country Profiles

Nigeria.  The HIV/AIDS epidemic in Nigeria is significantly ahead of that in India, China, and Russia—already advancing well beyond high-risk groups and into the general population.  The official adult prevalence rate is almost 6 percent, but unofficial estimates range as high as 10 percent—which represents 4 to 6 million people infected.

Heterosexual transmission of the HIV virus is the primary mode of spread in Nigeria, and infections appear to be as numerous in rural areas as in the cities.  The reported rate of infection apparently varies significantly by region, with the lowest reported rate found generally in the predominantly Muslim northern parts of the country (see figure 3).  Infections are most numerous among men ages 20 through 24, but some experts caution that infection rates are rising quickly in young women.

Figure 3
Nigeria: HIV Prevalence Among Women Attending Prenatal
Clinics, 2001

Given the already advanced state of the disease and the government’s limited capacity to respond, we expect HIV/AIDS to infect as many as 10 to 15 million people by 2010.  This number would constitute roughly 18 to 26 percent of adults—close to the current rates in some of the hardest hit countries in southern Africa. 

Ethiopia.  Ethiopia’s adult prevalence rate—estimated at between 10 and 18 percent—is the highest among the five countries, indicating that—like Nigeria—the disease has moved significantly into the general population.  Government figures cite 2.7 million Ethiopians currently as HIV positive, although experts believe the actual number may be between 3 and 5 million.  Adult prevalence is much higher in cities (13 to 20 percent) than in rural areas (5 percent) (see figure 4).  The generally poor health of Ethiopians as a result of drought, malnutrition, limited healthcare, and other infectious diseases has caused HIV to progress rapidly to AIDS.  Heterosexual transmission is the primary mode of spread, and people with multiple partners—especially those with sexually transmitted diseases (STDs) and prostitutes—have significantly higher infection rates, ranging from 30 to 40 percent in STD-positive individuals to 50 to 70 percent in prostitutes.

Figure 4
Ethiopia: HIV Prevalence Among Women Attending Prenatal
Clinics, 1999-2000

Unlike conditions in other next-wave countries, war has significantly contributed to the spread of the disease in Ethiopia.  Many soldiers contracted HIV/AIDS during the civil war in the 1980s by having contact with multiple sex partners.  When the war ended in 1991, thousands of infected soldiers and prostitutes returned home, spreading HIV/AIDS in their villages and towns.

Looking ahead, we expect 7 to 10 million Ethiopians probably will be infected by 2010 because of the high current rate of adult prevalence, widespread poverty, low educational levels, and the government’s limited capacity to respond more actively.

Russia.  Official statistics list about 200,000 people in Russia as HIV positive, but the government’s sampling efforts are poor, especially outside major cities.  Academic and medical experts believe the actual number probably is between 1 and 2 million, which would indicate an adult prevalence rate of around 1 to 2 percent.

Intravenous drug use drives the spread of the disease in Russia more than in any of the other next-wave countries.  An estimated 80 to 90 percent of all infections in Russia stem from intravenous drug use, which is rampant and rising. 

Prostitutes and prison inmates—many of whom are intravenous drug users—are contributing to the spread of the disease.  An estimated 20 to 25 percent of intravenous drug users in prison, where there is easy access to drugs, are HIV positive. 

The current trajectory of the disease, limited public awareness, and the lack of resources for a major anti-AIDS program will continue to drive the spread of the disease.  Approximately 20 to 25 million Indians are likely to be infected by 2010—even if the disease does not break out significantly into the mainstream population. 

China.  China has significantly raised its official estimate of the number of HIV-positive people over the last two years from 600,000 to one million.  The UN now estimates that 1.5 million are infected, while other experts believe the number probably is closer to 2 million or even higher.  Owing to China’s massive population, even these higher figures, however, represent an adult prevalence rate of only 0.15 to 0.25 percent.

Migration.  An estimated 100 million ruralmigrants are on the move in China, relocating to cities to find work.  Sexual contact between migrant men and prostitutes has spread the disease, which advances over an even wider geographic area if the migrants return to their villages to visit their families.

Drug abuse.  HIV/AIDS also is rising among intravenous drug users, especially in southern regions adjacent to Southeast Asia’s “GoldenTriangle” of heroin production and distribution routes.  Infection rates also soar as high as 85 percent among intravenous drug users in the Xinjiang Autonomous Region in western China  (see figure 7).

Figure 7
China: HIV Prevalence Among Injecting Drug Users, 1991-98

Plasma sales.  The practice of plasma selling in rural areas also has been a major contributor to the spread of HIV/AIDS (see textbox).  Mixing infected blood plasma causes one of the highest known transmission rates for HIV/AIDS, and the practice has infected large numbers of rural, heterosexual villagers who would otherwise be considered at low risk for the disease.

Despite growing concern over the disease among senior leaders, China’s sheer size, resource constraints, widespread ignorance of AIDS, cultural taboos about discussing sex, and coordination problems between levels of government will make it difficult to check the spread of the disease. 

Prospects for Control
We assess that all five next-wave countries will have difficulty controlling their HIV epidemics in the short to medium-term.  The disease has built up significant momentum—especially in Nigeria and Ethiopia—and the governments have been slow to respond.  None of the five next-wave countries in this report is on a trajectory to replicate the success of such countries as Uganda, Thailand, and Brazil in stemming the spread of the disease.  Several leaders of the next-wave countries are focusing more attention on the AIDS threat, but all face a host of competing demands.  In addition, these countries have weak healthcare infrastructures and severe budget constraints, which will create difficulty in financing education and treatment programs for their large populations.

The Leadership Challenge
The commitment of senior political leadership to persist in the struggle against HIV/AIDS has been a key variable in the few successful programs around the world.  The leaders of Nigeria, Ethiopia, Russia, India, and China will be challenged to maintain sustained high-level interest, however, given the scope and severity of other domestic and foreign policy issues.  Some leaders are beginning to pay more attention to AIDS, but they have not given it the sustained priority thus far that has been needed in other countries to blunt the spread of the disease.

Figure 8
HIV/AIDS in South Africa and Thailand: Effect of
Behavior Change Programs

Active leadership will be especially critical given the widespread public ignorance of AIDS in next-wave countries.  The challenge is especially great in these countries because of fragile communications links, numerous government jurisdictions, and different ethnic and language groups.  The five countries also lack strong domestic advocacy groups that can raise awareness and increase pressure for responsive programs.

Nigeria’s leadership has been the most active of the five countries in trying to raise AIDS awareness, for example, by hosting a regional AIDS conference in 2000 and publicly warning about the risk of “extinction” on the continent.  Nonetheless, the Obasanjo administration is beset by such other pressing problems as an approaching election and rising ethnic and religious tensions.  Moreover, Nigeria’s government institutions have deteriorated so badly over the last decade that Obasanjo has few functioning public sector assets left to mobilize even if he chose to engage fully on the issue.

The Ethiopian Government does not appear focused on AIDS, despite occasional statements on the issue.  The government has focused in recent years on the conflict with Eritrea.  Healthcare workers privately have criticized efforts in recent years as half hearted, and UN officials have publicly warned Ethiopian leaders to take more measures to stem the epidemic.

The Russian Government has not mounted a sustained effort up to now to publicize the growing threat of HIV/AIDS.  Russia faces so many other serious problems that HIV/AIDS is unlikely to receive high-level attention for an extended period until the economic and security costs of neglect become more tangible.

The Indian Government has taken numerous steps to highlight the risk that AIDS poses to the country, but tensions with Pakistan and growing religious strife clearly are considered more pressing issues.  Furthermore, India faces competing priorities to address such other health challenges as TB.  Nonetheless, the Indian Government did react to the emergence of HIV/AIDS in 1986 by creating the National AIDS Control Organization (NACO).

The Chinese Government has become significantly more open over the last year in acknowledging the rising HIV/AIDS problem after ignoring it for years.  The central government has organized some public relations events to increase awareness of the disease, and Beijing has sought bilateral assistance from the United States and others to improve its anti-AIDS campaign. 

Nonetheless, domestic funding to combat the disease remains low, and Chinese leaders will have difficulty keeping HIV/AIDS high on the agenda as they struggle to deal with such challenges as maintaining economic growth, defusing rural discontent, managing the Communist Party leadership transition, opening Chinese markets more widely to trade, and modernizing the military.  Moreover,
decisionmaking has become so decentralized in China on healthcare and education that senior leaders in Beijing cannot always count on provincial and local leaders to follow through.

Weak Healthcare Infrastructure
Although significant differences in capabilities exist among next-wave countries, all five have overburdened and under funded healthcare systems and limited abilities to provide integrated, nationwide programs to test people, track infections, and deliver treatment and education programs.  Even within each of the five next-wave countries there are disparities in the ability of cities and regions to deal with the epidemic that are likely to grow in the coming years.