Chapter 6a


Things go badly wrong, 1989-2009

 

By 1988, the world’s public health experts had studied HIV and had settled on strategies to stop it. Knowledge of HIV led to dramatic slowing of epidemic expansion in some countries, but not in others. From 1989, new generalized epidemics emerged in Africa and Asia. New epidemics in relatively wealthy African countries became much worse than anything that had developed in the fifty or so years to 1981, when no one knew anything about AIDS or HIV.

 

Table 6.1: World overview of HIV epidemic expansion, 1988-2007

Epidemic type, region, country

HIV infections (1,000s)

1988[i]

 

2007[ii]

Concentrated epidemics, of which:

2,500

 

6,900

    North and South America

2,000

 

2,900

    Western and Central Europe

 500

 

 730

    Eastern Europe and Central Asia

 

1,500

    East Asia, Southeast Asia, South Asia, and Oceania

 

1,700

   Middle East and North Africa

 

100

Generalized epidemics, of which:

2,500

 

26,000

    Sub-Saharan Africa

2,500

 

22,000

    Caribbean region (Haiti, 9 other small countries)

*

 

  240

    Asia and Oceania (Cambodia, India, Myanmar,

    Papua New Guinea, Thailand) 

 

 3,400

Total

5,100

 

33,000

* Included in the estimate for Africa.

† In 1988, WHO estimated 100,000 HIV infections in Asia, Central and Eastern Europe, the Middle East, and North Africa.

Sources: See references by column.

 

Concentrated epidemics        

 

As of 1988, WHO estimated circa 2.5 million HIV infections in Pattern 1 (concentrated) epidemics in the Americas, Western Europe, Australia, and New Zealand, which was about half of all HIV infections in the world (Table 6.1). During 1989-2007, most new epidemics outside Africa developed as concentrated epidemics. In 2007, countries with concentrated epidemics accounted for an estimated 6.9 million infections – about one-fifth of HIV infections in the world. Estimated adult HIV prevalence varied across countries from near 0.01 percent (1 in 10,000), as in Bangladesh and Bulgaria, to 1.1-1.6 percent in Estonia, Russia, and Ukraine (these estimates exceeding 1 percent may be too high).

 

Stabilizing old concentrated epidemics          

 

Beginning from the early 1980s, most of the MSMs and IDUs who were infected or at risk in old concentrated epidemics progressively changed their behavior. By the early 1990s, an average HIV-positive person infected less than one other person in their life. Deaths matched or exceeded new infections. Most of the modest expansion in old concentrated epidemics during 1989-2007 occurred in South America.

During the 1980s, some AIDS experts hypothesized that concentrated epidemics in the US and Europe would progress naturally to generalized epidemics, as in Africa. This has not happened. In the US, Western Europe, Canada, and Australia, MSMs and IDUs accounted for 75-88 percent of cumulative adult and adolescent AIDS cases through mid- to end-2005, and the proportion attributed to heterosexual risk ranged from 7 percent to 16 percent (excluding persons born in countries with generalized epidemics).[iii]

Although many HIV-positive bisexuals and IDUs have been heterosexually active, only a minority has infected heterosexual partners through sex, and subsequent heterosexual spread from these partners to others has been limited. Studies estimate that heterosexual transmission has been too slow to sustain HIV epidemics in the US[iv] and Norway.[v] Although HIV ‘leaks’ into the general population, people who are neither IDUs nor MSMs on average die before passing HIV to anyone else.

 

IDUs drive new concentrated epidemics

 

While MSMs dominate most of the old concentrated epidemics, IDUs drive the new ones. The five largest new epidemics emerged in Russia (940,000 infections estimated in 2007), China (700,000 infections, with less than 0.1 percent HIV prevalence in adults), Ukraine (440,000 infections), Vietnam (290,000 infections), and Indonesia (270,000 infections).[vi]

HIV circulated among MSMs in Russia in the 1980s, but infections were rare. Through 1995, only 1,062 infections had been detected, and only 7 were in IDUs.[vii] From 1996, HIV infection took off among IDUs, and so did Russia’s epidemic. For Russia and for all Eastern Europe through 2005, IDUs accounted for more than 80 percent of cumulative reported infections with information on risk.[viii]

The first AIDS case in China was reported in 1985 from Yunnan Province near Myanmar. IDUs spread HIV throughout China, reaching all of China’s 31 provinces by 1998. A 2002 assessment of China’s HIV epidemic attributed 60-70 percent of infections to IDUs,[ix] while a later UNAIDS and government estimate in 2005 attributed 44 percent to IDUs, 7 percent to MSMs, and 11 percent to blood or plasma donors and transfusions recipients.[x]

Vietnam’s HIV epidemic similarly began in the 1980s. Through 1999, IDUs accounted for 88 percent of identified infections.[xi] Indonesia’s epidemic took off among IDUs in the late 1990s. During 1997-2001, HIV prevalence among IDUs in a rehabilitation center in Jakarta, the capital, increased from 0 percent to 48 percent.[xii]

 

Are there other kinds of concentrated HIV epidemics?

 

Currently, UNAIDS and WHO classify HIV epidemics into three categories: generalized epidemics, in which HIV prevalence exceeds 1 percent in the general population; concentrated epidemics, in which prevalence is less than 1 percent in the general population but exceeds 5 percent in at least one high risk group; and low-level epidemics, in which HIV prevalence does not exceed 5 percent in any group.[xiii]

These categories extend the concept of a concentrated epidemic beyond MSMs and IDUs to include epidemics in which HIV infections concentrate in groups that are heterosexually promiscuous – especially women in sex work and clients. This poses an empirical question: does a small group of heterosexually promiscuous men and women account for most HIV infections in any country? From available evidence (presented later in this chapter, and in Chapter 7), the answer is ‘no.’ In countries where HIV does not concentrate in MSMs and IDUs, most HIV-positive people report average to conservative sexual behaviors (see Table 7.1).

Futhermore, these categories obscure an important distinction. In the 1980s WHO recognized different sex ratios among those with HIV infections in Pattern 1 vs. Pattern 2 epidemics. Pattern 1 epidemics infected mostly men, while Pattern 2 epidemics afflicted women as often or more often than men. This distinction based on the sexual distribution of infections is lost if the category of concentrated epidemics is extended to include epidemics with high HIV prevalence in sex workers. If one is trying to understand differences among HIV epidemics, it is arguably important to use categories which preserve attention to vastly different sex ratios among HIV-positive people.

Thus, in this book, ‘concentrated epidemics’ refers to those in which infections concentrate in MSMs and/or IDUs, while ‘generalized epidemics’ refers to those in which HIV prevalence in women is greater than or comparable to prevalence in men. With these definitions, low-level epidemics may be low-level concentrated or generalized epidemics, depending on the proportion of infections in MSMs and IDUs and on the sex ratio among those who are infected. With these terms, there may also be mixed epidemics, where MSMs and IDUs account for a large minority of infections, but HIV also infects many non-IDU women.

             

Generalized epidemics in Africa     

 

Whereas awareness of HIV led to limited growth of concentrated epidemics after 1988, awareness had less impact on generalized epidemics. During 1988-2007, the total number of HIV infections in generalized epidemics increased by an estimated 23 million – from 2.5 million to 26 million. Most of this increase occurred in Africa (Table 6.1 and Statistical Annex).

One of the difficulties in tracking generalized HIV epidemics over the years has been that official estimates of HIV prevalence have often been far off the mark. Consider Ethiopia. In 1994, WHO estimated that 2.5 percent of Ethiopian adults were HIV-positive. By 2000, UNAIDS reported that HIV prevalence had increased to 10.6 percent. In 2005, the Ethiopian government conducted a national survey – and found that only 1.4 percent of adults were infected![xiv]

During 2001-08, more than thirty governments of countries with generalized epidemics implemented national surveys of HIV infection. In these countries, estimates of HIV prevalence are on solid ground. As of early 2009, only a few countries with generalized epidemics and without surveys – especially Nigeria and Mozambique have sufficient estimated infections that future surveys could have more than a small impact on regional and world estimates of HIV infections.

After 1989, Africa’s HIV epidemics took several paths. Many of the countries with the worst epidemics in 1988 showed little or no epidemic expansion, while terrible new epidemics emerged in Southern Africa. Outside of Southern Africa, the most serious new epidemics developed in three relatively wealthy countries in East and Central Africa (Kenya, Cameroon, and Gabon). At the same time, many African countries, including countries at war, continued to have only low-level generalized epidemics. The following subsections describe these different paths.

 

What happened to Africa’s worst epidemics from 1988?       

 

In 1988, WHO had identified 12 countries in Africa with at least 0.5 percent of the population infected (children and adults). Three of these 12 countries – Malawi, Zambia, and Zimbabwe – are in Southern Africa. Epidemics in these three countries developed into some of the worst in the world (see next subsection). In the remaining nine countries in Central Africa (CAR, Congo, and DRC), West Africa (Cote d’Ivoire and Guinea-Bissau), and East Africa (Burundi, Rwanda, Tanzania, and Uganda), HIV epidemics expanded more slowly or not at all during 1989-2007.

In 1988, these nine countries probably had roughly two-thirds of WHO’s estimated 2.5 million infections in Africa. Through 2007, the estimated number of infections in these nine countries more than doubled to about 4.0 million. The figure for 2007 is close to accurate – it is based on national surveys in seven of the nine countries with more than 95 percent of estimated infections. In 2006, the total population in these nine countries was 170 million, and the weighted average adult HIV prevalence was 4 percent.

Some countries did better than others. In DRC, HIV prevalence among women in urban antenatal clinics fell from the late 1980s, and a 2007 national survey found only 1.3 percent of adults to be HIV-positive. National surveys in Rwanda in 1986 and 2005 found, respectively, 2.7 percent and 3.0 percent adult HIV prevalence, showing little epidemic expansion over 19 years. Cote d’Ivoire’s 1989 and 2005 national surveys showed adult HIV prevalence falling from 6 percent to 4.7 percent over 16 years. Even if errors in the 1989 survey (such as false positive tests) had inflated estimated prevalence, Cote d’Ivoire’s epidemic likely grew little if at all after 1989. Burundi’s national survey in 2002 reported 3.6 percent of adults to be HIV-positive, so that HIV prevalence may have doubled from roughly 2 percent in a 1989 survey.

More than half the estimated infections in these nine countries are found in Tanzania and Uganda, with an estimated 1.3 million and 1.1 million infections, respectively, in 2007. In Tanzania, HIV prevalence fell from the late 1980s in heavily infected regions west of Lake Victoria. Surveys in Bukoba town, for example, found 24 percent of adults to be HIV-positive in 1987, but only 13 percent in 1996.[xv] However, these reductions were offset by gains elsewhere, so that Tanzania’s HIV prevalence increased from 1988. Tanzania’s first and second national surveys in 2003 and 2007-08 found 7.0 percent and then 5.7 percent adult HIV prevalence, which are among the highest rates outside Southern Africa.

In Uganda, several estimates based on the 1987-88 national survey suggest adult HIV prevalence of 7-10 percent, which may have been misleadingly high (see Chapter 5). Uganda’s second and more complete national survey in 2004-05 reported 6.3 percent HIV prevalence in adults aged 15-59 years. For some years around 1990, Uganda probably had the highest HIV prevalence in Africa – but how high? In any case, Uganda’s current HIV prevalence is one of the highest outside Southern Africa.

From the mid-1990s, many AIDS experts have presented Uganda as the country with the best success against HIV in Africa. For example, an article in Science in 2004 declared, ‘Uganda has shown a 70 percent decline in HIV prevalence since the early 1990s…’[xvi] This and similar claims of success are based largely on data from selected urban antenatal clinics, where HIV prevalence often topped 20 percent during 1987-1996.[xvii] However, HIV prevalence in these clinics was not only far greater than in Uganda’s rural population, but falling prevalence in these clinics also did not reflect what was happening in rural areas. For example, in 15 villages in rural Masaka west of Lake Victoria, adult HIV prevalence fell only modestly during 1989-99 from 7.8 percent to 6.4 percent.[xviii]

 

Table 6.2: Recent distribution of HIV infections in African countries* with the worst epidemics in 1988

Country, year of survey

HIV prevalence (%) in adults

HIV prevalence (%) in women by education

HIV prevalence (%) in women by wealth quintiles

Urban

Rural

None

Prim-ary

Secondary or higher

Low-est

2nd

3rd

4th

High-est

Cote d’Ivoire, 2005

 

 

    Women

7.4

5.5

5.2

8.2

7.0

3.6

3.8

6.5

8.0

8.8

    Men

3.2

2.5

 

 

 

 

 

 

 

 

DRC, 2007

 

 

    Women

2.4

1.0

0.6

2.1

1.7

1.2

1.4

1.2

1.8

2.3

    Men

1.3

0.6

 

 

 

 

 

 

 

 

Rwanda, 2005

 

 

    Women

8.6

2.6

3.3

2.8

6.4

2.6

2.2

3.6

3.4

6.5

    Men

5.8

1.6

 

 

 

 

 

 

 

 

Tanzania, 2007-08

 

 

    Women

10.6

5.3

6.0

7.0

4.9

5.0

6.6

5.1

6.0

9.5

    Men

6.4

4.0

 

 

 

 

 

 

 

 

Uganda, 2004-05

 

 

    Women

12.8

6.5

5.8

8.1

7.6

4.8

6.6

6.7

7.0

11.0

    Men

6.7

4.7

 

 

 

 

 

 

 

 

*All countries for which survey data are available.

Sources: See the Statistical Annex.

 

AIDS experts argue about whether Uganda’s success was due to more condom use or to fewer sexual partners. These arguments ignore possible reductions in non-sexual transmission. From 1987, the Ugandan government promoted infection control for AIDS prevention, and warned the public about HIV from unsafe injections. In any case, the presentation of Uganda as the county with the best success against AIDS in Africa overlooks other African countries with lower and/or falling HIV prevalence, such as Cote d’Ivoire, DRC, and Rwanda. As Tim Allen documents in a 2006 review, ‘Interpretations of HIV/AIDS in Uganda have taken on lives of their own, in which evidence of all kinds plays a secondary role.’[xix]

Across all nine countries in Central, East, and West Africa with the worst epidemics in 1988, HIV prevalence in the early 2000s was, of course, higher in women than in men. It was also much higher in urban than in rural populations. In the five countries for which we have data, HIV prevalence in women increased with wealth, and (less consistently) with education (Table 6.2). Rich, educated, urban women were several times more likely to be HIV-positive than poor, illiterate, rural men.

 

The world’s worst epidemics in Southern Africa          

 

Most of the countries in Southern Africa are wealthy by African standards. In the 1990s, per capita gross national products in South Africa and Botswana were 10 times the average for the rest of sub-Saharan Africa. Per capita gross national products in Lesotho, Namibia, Swaziland, and Zimbabwe were several times the average for the rest of sub-Saharan Africa (excluding South Africa).[xx]

In 1988, WHO estimated that more than 1 percent of the population (2 percent of adults) was HIV-positive in Malawi and Zambia, and more than 0.5 percent was HIV-positive in Zimbabwe. Through 1989, Mozambique was the only other county in Southern Africa with evidence for substantial numbers of HIV infections. A 1989 survey among women attending an antenatal clinic in Maputo, the capital, reported 0.6 percent HIV prevalence (see Figure 6.1), but most people lived in rural areas with lower prevalence.

Elsewhere in Southern Africa, HIV infections were rare through 1988. The 50 South Africans recognized with AIDS through March 1987 were all white men with risks found in concentrated epidemics.[xxi] In 1988, HIV was just beginning to spread among South Africa’s majority black population. In Natal Province of South Africa, HIV prevalence among black blood donors passed 0.1 percent in late 1988 and 0.2 percent in early 1989.[xxii] In Lesotho, none of more than 5,000 blood donors was HIV-positive in 1988.[xxiii]

Throughout Southern Africa, HIV prevalence in pregnant women attending urban antenatal clinics soared in the early 1990s (Figure 6.1). From 1988 to 2007, the number of HIV infections in nine countries in Southern Africa – Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe – increased from possibly around 300,000 to 11 million. Estimates for 2007 are based on recent national surveys in seven of the nine countries. As of 2007, across these nine countries, the weighted average adult HIV prevalence was 16 percent.(For reasons that are not well understood, Madagascar escaped this regional disaster, sustaining very low adult HIV prevalence – estimated at 0.1 percent in 2007.)

The explosion of the region’s HIV epidemic occurred in the face of well-funded public health programs. By the early 1980s, the government of Botswana, with its own money from diamonds and with donor support, had constructed a public health post or clinic within 15 kilometers of more than 90 percent of the population, and provided mobile services to reach the rest.[xxiv] In the 1990s, the South African government expanded public health services to the black majority. During 1990-95, public expenditures on health in the nine countries in Southern Africa with the emerging worst AIDS epidemics ranged from 1.9 percent to 4.6 percent (with a median of 3.0 percent) of gross domestic product, far exceeding the average of less than 1.3 percent for the rest of Africa.[xxv]

 

Figure 6.1: HIV prevalence in pregnant women* attending urban antenatal clinics, for nine countries in Southern Africa, 1985-2005

* Median HIV prevalence among selected (sentinel) urban antenatal clinics.

Source: WHO's Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections for varioius countries and years.

 

During the 1990s, countries in the region implemented HIV prevention programs guided by international advice. In 2001, the Harvard AIDS Institute honored Botswana’s President Festus Mogae with its Leadership Award. Harvard’s publicity surrounding the event lauded Botswana’s response to the epidemic.[xxvi] In 2003, an international team judged that Swaziland’s response to the AIDS epidemic ‘has been in accordance with international norms, and indeed in many places has gone beyond them…Swaziland was one of the earliest countries to make mention of HIV in its national development plans…’[xxvii]

AIDS experts criticized Thabo Mbeki, the president of South Africa during 1999-2008, for his dialogue with denialists, who say HIV does not cause AIDS. Under Mbeki, the South African government opposed and slowed the introduction of antiretroviral drugs to reduce mother-to-child HIV transmission and to treat people with AIDS. These controversies focused on treatment, and began after HIV had already overrun the country. During the 1990s,[xxviii] and continuing, programs to prevent HIV infections among adults followed international advice, promoting sexual behavior change, condoms, and treatment of sexually transmitted disease.

Even within relatively wealthy countries in Southern Africa, women’s HIV prevalence often increased with wealth (but generally did not increase with education). As in most countries in Africa, women were more heavily infected than men. However, in some countries, there was little difference between urban and rural adults (Table 6.3).

 

 

Table 6.3: Distribution of HIV infections in Southern African countries* with the worst current epidemics

Country, year of survey

HIV prevalence (%) in adults

HIV prevalence (%) in women by education

HIV prevalence (%) in women by wealth quintiles

Urban

Rural

None

Prim-ary

Secondary or higher

Low-est

2nd

3rd

4th

High-est

Lesotho, 2004

 

 

    Women

33.0

24.3

30.4

26.5

26.0

19.6

27.9

25.5

27.3

28.9

    Men

22.0

18.6

 

 

 

 

 

 

 

 

Malawi, 2004

 

 

    Women

18.0

12.5

13.6

12.8

15.1

10.9

10.3

12.7

14.6

18.0

    Men

16.3

8.8

 

 

 

 

 

 

 

 

Swaziland, 2006-07

 

 

    Women

36.8

29.1

29.6

33.5

30.0

31.6

32.1

31.5

31.8

29.4

    Men

25.5

17.3

 

 

 

 

 

 

 

 

Zambia, 2007

 

 

    Women

23.1

11.0

10.8

15.8

18.0

8.8

9.6

13.3

22.9

21.6

    Men

15.9

9.4

 

 

 

 

 

 

 

 

Zimbabwe, 2005-06

 

 

    Women

21.6

20.8

20.0

22.4

20.4

17.7

21.1

22.7

26.8

17.1

    Men

15.7

13.8

 

 

 

 

 

 

 

 

* All countries for which survey data are available.

Sources: See the Statistical Annex.

 

Other Africa countries with severe epidemics              

 

Aside from the countries already discussed – countries with the worst epidemics in 1988, and countries in Southern Africa with the worst epidemics in 2007 – generalized epidemics developed in most if not all other African countries. In most of these countries, adult HIV prevalence ranged from 1 percent to 4 percent. Through 2007, estimated adult prevalence exceeded 5 percent in only three other countries – Kenya in East Africa, and Cameroon and Gabon in Central Africa.

Kenya is the wealthiest and most developed country in East Africa. Although its HIV epidemic began later than epidemics in Tanzania and Uganda, a 2007 national survey found 7.8 percent of Kenyan adults to be HIV-positive, more than in Tanzania or Uganda. Kenya’s epidemic is much worse than what is found in poorer neighbors to the north – Southern Sudan, Ethiopia, and Somalia.

Adult HIV prevalence was likely less than 0.5 percent in Cameroon and somewhat higher in Gabon in the mid-1980s, an estimated 50 years after HIV began to circulate in the region. Some scientists saw ‘a paradoxical discrepancy between high genetic diversity,’ which was what one would expect to find in an old epidemic, ‘and low prevalence.’[xxix] In both countries, old epidemics expanded in the 1990s. A national survey in Cameroon in 2004 found 5.5 percent of adults to be HIV-positive. For Gabon, UNAIDS estimated 5.9 percent adult HIV prevalence in 2007. Both Cameroon and Gabon are relatively wealthy and developed by African standards, and their HIV prevention programs have cooperated with international advice. Why did their epidemics do so little for so long, and then expand in the 1990s, when prevention programs were in place?

 

Table 6.4: Distribution of HIV infections in other African countries* with at least 5 percent HIV prevalence in adults

Country, year of survey

HIV prevalence (%) in adults

HIV prevalence (%) in women by education

HIV prevalence (%) in women by wealth quintiles

Urban

Rural

None

Prim-ary

Secondary or higher

Low-est

2nd

3rd

4th

High-est

Cameroon, 2004

 

 

    Women

8.4

4.8

3.4

7.2

8.2

3.1

4.1

8.1

9.4

8.0

    Men

4.9

3.0

 

 

 

 

 

 

 

 

Kenya, 2003

 

 

    Women

12.3

7.5

4.4

9.9

8.2

3.9

8.5

7.1

9.7

12.2

    Men

7.5

3.6

 

 

 

 

 

 

 

 

*All countries for which survey data are available.

Sources: See the Statistical Annex.

 

Chapter 6 continues at 6b...

 



[i] Table 6.1, estimates of HIV infections in 1988 are from: Sato PA, Chin J, Mann JM. ‘Review of AIDS and HIV infection: Global epidemiology and statistics’, AIDS, 1989, 3 (suppl 1): S301-7; Chin J, Sato PA, Mann JM. ‘Projections of HIV infections and AIDS cases to the year 2000’, Bull WHO, 1990, 68: 1-11.

[ii] Table 6.1, estimates of HIV infections in 2007 are from: UNAIDS. 2008 Report on the Global AIDS Epidemic. Geneva: UNAIDS, 2008. Table 6.1 includes Sudan in sub-Saharan Africa; includes Belize, Guyana, Honduras, and Suriname as countries with generalized epidemics in the Caribbean region; and includes information on HIV prevalence from recent national surveys (see the Statistical Annex in this book).

[iii] CDC. HIV/AIDS Surveillance Report, 2005, vol. 17, rev. ed. Atlanta: CDC, 2007; Health Canada. HIV and AIDS in Canada: Surveillance report to June 30, 2005. Ottawa: Health Canada, 2005; National Centre in HIV Epidemiology and Clinical Research. HIV/AIDS, Viral Hepatitis and Sexually Transmissible Infections in Australia: Annual Surveillance Report 2006. Sydney: National Centre in HIV Epidemiology and Clinical Research, 2006; European Centre for the Epidemiological Monitoring of AIDS. HIV/AIDS Surveillance in Europe, end-year report 2005, no. 73. Saint-Maurice, France: EuroHIV, 2005.

[iv] Pinkerton SD, Abramson PR, Kalichman SC, et al. ‘Secondary HIV transmission rates in a mixed-gender sample’, Int J STD AIDS, 2000, 11: 38-44.

[v] Aavitsland P, Nilsen O, Lystad AA. ’No evidence of an epidemic of locally acquired heterosexual HIV infection in Norway’, Sex Transm Dis, 2002, 29: 222-7.

[vi] UNAIDS. 2008 Report on the Global AIDS Epidemic. Geneva: UNAIDS, 2008.

[vii] Twigg JL, Skolnik R. Evaluation of the World Bank’s assistance in responding to the AIDS epidemic: Russia case study. Washington DC: World Bank, 2005.

[viii] European Centre for the Epidemiological Monitoring of AIDS. HIV/AIDS Surveillance in Europe, mid-year report 2006, no. 74. Saint-Maurice, France: EuroHIV, 2006.

[ix] Zhang K-L, Ma S-J. ‘Epidemiology of HIV in China’, BMJ, 2002, 324: 803-4.

[x] Ministry of Health, China, UNAIDS, WHO. 2005 Update on the HIV/AIDS epidemic and response in China. Geneva: WHO, 2006.

[xi] Quan VM, Chung A, Long HT, et al. ‘HIV in Vietnam: The evolving epidemic and the prevention response, 1996 through 1999’, J Acquir Immune Defic Syndr, 2000, 25: 360-9.

[xii] Riono P, Jazant S. ‘The current situation of the HIV/AIDS epidemic in Indonesia’, AIDS Educ Prev, 2004, 16 (suppl A), 78-90.

[xiii] Pisani E, Lazzari S, Walker N, et al. ‘HIV surveillance: A global perspective’, J Acquir Immune Defic Syndr, 2001, 32 (suppl 1): S3-11.

[xiv] ORC MACRO. Ethiopia Demographic and Health Survey 2005. Calverton, Maryland: ORC MACRO, 2006.

[xv] Kwesigabo G, Killewo J, Urassa W, et al. ‘HIV-1 infection prevalence and incidence trends in areas of contrasting levels of infection in the Kagera Region, Tanzania, 1987-2000’, J Acquir Immune Defic Syndr, 2005, 40: 585-91.

[xvi] Stoneburner RL, Low-Beer D. ‘Population-level HIV declines and behavioral risk avoidance in Uganda’, Science, 2004, 304: 714-18. p. 714.

[xvii] UNAIDS, WHO. Uganda: Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections, 2002 update. Geneva: WHO, 2002.

[xviii] Whitworth JAG, Mahe C, Mbulaiteye SM, et al. ‘HIV-1 epidemic trends in rural south-west Uganda over a 10-year period’, Trop Med Inter Health, 2002, 7: 1047-52.

[xix] Allen T. ‘AIDS and evidence: Interrogating some Ugandan myths’, J biosoc Sci, 2006, 38: 7-28. p. 11.

[xx] World Bank. African Development Indicators 1998/99. Washington DC: World Bank, 1998.

[xxi] Shoub BD, Lyons SF, McGillivray GM, et al. ‘Absence of HIV infection in prostitutes and women attending sexually-transmitted disease clinics in South Africa’, Trans R Soc Trop Med Hygiene, 1987, 81: 874-5.

[xxii] Prior CRB, Buckle GC. ‘Blood donors with antibody to the human immunodeficiency virus – the Natal experience’, S Afr Med J, 1990, 77: 623-5.

[xxiii] US Census Bureau. HIV/AIDS Surveillance Data Base, June 2003 release. Washington, DC: US Census Bureau, 2003.

[xxiv] World Bank. Staff Appraisal Report: Botswana Family Health Project. Report No. 4820-BT. Washington, DC: World Bank, 1984. p. 6.

[xxv] World Bank. African Development Indicators 1998/99.

[xxvi] ‘Botswana President Receives 2001 Harvard AIDS Institute Leadership Award’, Update, 2002; 3(1): p. 1. Available at:

http://www.aids.harvard.edu/news_publications/update/vol3iss1/update3.html (accessed 11 September).

[xxvii] Whiteside A, Hickey A, Ngcobo N, et al. What is driving the HIV/AIDS epidemic in Swaziland, and what more can we do about it? Mbabane: National Emergency Response Committee on HIV/AIDS, 2003. p. 6.

[xxviii] Heywood M. ‘The price of denial’, Development Update 2005; 5: 93-122. Available at:

http://www.alp.org.za/modules.php?op=modload&name=News&file=article&sid=236 (accessed 5 November 2007).

[xxix] Makuwa M, Souquiere S, Apetrei C, et al. ‘HIV prevalence and strain diversity in Gabon: the end of a paradox [letter]’, AIDS, 2000, 14: 1275.