million lives, and close to 40 million people worldwide harbor HIV (UNAIDS, 2004). Of the latter, 30 million are Africans, concentrated in southern and eastern Africa where HIV prevalence among adults now exceeds 15 percent in many countries and 30 percent in at least four countries (Botswana, Lesotho, Swaziland, and Zimbabwe). In less than 10 years, HIV/AIDS has reversed the gains in life expectancy achieved by Africa over 50 years and orphaned 12 million children, half of whom are between the ages of 10 and 14 (UNAIDS, 2004). Girls and women are especially vulnerable to HIV, and now account for 50 percent of people living with HIV worldwide and 57 percent of those in sub-Saharan Africa (UNAIDS, 2004).

At the same time, HIV/AIDS increasingly threatens other regions of the world. According to the National Intelligence Council, by 2010 China will likely have 10–15 million people living with HIV, India 20–25 million, and Russia 5–8 million (Morrison, 2004).

Viewed from the perspective of the wreckage of human lives, there is nothing positive about HIV/AIDS. However, unlike earlier pandemics that took place in the absence of knowledge, tools, and connectivity, today’s crisis offers one opportunity: a decisive global response. What form should this response take? Rich countries have a moral and political imperative to invest heavily in effective treatments and other material assistance to poor countries highly impacted by HIV/AIDS. Yet no amount of money can fully substitute for experienced professionals with a variety of skills assisting counterparts on the ground in fighting the epidemic.

This chapter begins by examining the linkages between HIV/AIDS and two other infectious diseases—TB and malaria—that have a major impact on the developing world, as well as the resulting health care challenges. This is followed by an overview of the impacts of HIV/AIDS at the individual, household, and societal levels. Next, the chapter provides a closer look at HIV/AIDS, itself, including its pathophysiology, transmission, and natural course, and comorbidities and cofactors in disease progression. Finally, the chapter reviews treatment and care for HIV/AIDS, addressing in turn antiretroviral therapy (ART), the problem of drug resistance, elements of a comprehensive care model for those infected in developing countries, clinical entry points for treatment and care, and issues in providing ART and HIV/AIDS care in resource-limited settings.

HIV/AIDS, TUBERCULOSIS, AND MALARIA

Linkages Among the Three Diseases

In an attempt to target high-risk individuals, health programs addressing malaria, TB, and HIV infection often focus on biologically vulnerable groups. Table 2-1 summarizes the available evidence on biological and



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