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7 International Aspects of AIDS and HIV Infection As of March 1988, 133 of the 158 countries or territories reporting to the World Health Organization (WHO) had listed one or more cases of AIDS. A total of more than 81,000 cases has been reported from countries on all continents. However, AIDS case reporting to WHO is incomplete. In the United States, for example, the reporting system is estimated to capture approximately 80 percent of AIDS cases, a proportion that probably applies to other industrialized nations. Countries whose reporting sys- tems are less well established or nonexistent capture a much smaller percentage of cases. A further complication in data collection is the considerable lag in reporting in many countries. In light of these consid- erations, a more accurate estimate of the number of AIDS cases world- wide is at least 150,000 as of April 1988. Because of the relatively long interval between infection and the appearance of AIDS, increasing reliance is being placed on seroepide- miology to assess the spread of the epidemic. On the basis of seropreval- ence surveys or estimates that have been made in a wide variety of countries, WHO currently estimates that the number of infected persons worldwide is at the lower end of the earlier range of estimates, which was 5 to 10 million. Considering the data that have accumulated in the past 2 years, this estimate can now be viewed as much more reliable than it was when it was first offered in 1986. Three different patterns of AIDS can be seen in the various countries, and although these patterns are necessarily generalizations, they never- theless describe the worldwide epidemiology of the disease (Plot et al., 159

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160 CONFRONTING MDS: UPDATE Eggs 19881. The first pattern, in which most AIDS cases have occurred among homosexual or bisexual men and urban IV drug abusers, is found in North America, many Western European countries, Australia, New Zealand, and parts of South America. In these areas, heterosexual transmission of the infection is responsible for only a small percentage of cases, but it is increasing, as is perinatal transmission. Transmission through HIV- contaminated blood and blood products has now been largely controlled by routine screening for HIV antibodies and a campaign to encourage persons with known risk factors to refrain from donating blood. The male-to-female ratio in countries with this pattern of AIDS cases ranges from 10:1 to 15:1. The prevalence of HIV infection in their overall populations is estimated to be less than 1 percent, but it has been reported to exceed 50 percent in some high-risk groups (e.g., homosexual men with multiple sexual partners who practice receptive anal intercourse, and IV drug abusers). The second pattern applies to some areas of southern, central, and eastern Africa and some areas of the Caribbean, where most AIDS cases occur among heterosexuals and the male-female ratio is approximately 1:1. As a consequence, perinatal transmission is relatively common, but transmission through IV drug abuse and homosexual activity appears to be infrequent. In a number of these countries, it is estimated that the prevalence of HIV infection in the overall population is more than 1 percent; in some urban areas, the prevalence of infection may be as high as 15 percent in the young and early middle-aged population (15 to 40 years of age). Transmission of the infection through contaminated blood remains a significant problem in countries that have not yet begun nationwide blood screening, and the possibility of HIV transmission through the medical use of unsterilized needles and syringes or other skin-piercing instruments is thought to be substantial. The third pattern is found in Eastern Europe, the eastern Mediterra- nean area, Asia, and most of the Pacific, where HIV appears to have been introduced in the early to mid-1980s and only small numbers of cases have been reported thus far. Both homosexual and heterosexual transmission paths have been documented in cases that, in general, have occurred in persons who traveled to or had sexual contact with persons from endemic areas. In these countries, some AIDS cases are also attributed to the use of imported blood or blood products. The prevalence of infection has not been estimated. THE WHO GLOBAL PROGRAMME ON AIDS The WHO Global Programme on AIDS has worked extensively during the past year in two general directions: (1) providing support to various

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INTERNATIONAL ASPECTS 161 national AIDS control and prevention programs and (2) conducting global AIDS-related activities such as surveillance; biomedical, social, behav- ioral, and epidemiological research; forecasting; and impact assessment. In addition, the Global Programme and the United Nations Development Programme (UNDP) recently concluded an agreement whereby UNDP country resident representatives will provide additional support to na- tional AIDS control and prevention programs in accordance with the general scientific and technical strategies laid out by WHO. To launch a global blood safety initiative, WHO has drawn together various organizations such as the International Society for Blood Trans- fusion, UNDP, the International League of Red Cross and Red Crescent Societies, and its own Global Programme on AIDS and Health Labora- tory Technology Units. The blood safety initiative is intended to reduce the risks of transmission of HIV and other pathogens by establishing or strengthening blood transfusion systems in all countries. The goal is to establish a system in each country that is capable of employing quality control procedures, including screening, on a sustained, routine basis. National AIDS committees have been established in over 150 coun- tries; WHO has provided technical assistance to at least 115 of them. Of the countries to which WHO has given assistance, 78 have established short-term AIDS control and prevention programs and 22 have medium- term plans (3 to 5 years) in place. Nearly $30 million has been raised for these medium-term plans through meetings convened to elicit support from bilateral development funds and international agencies. In addition, WHO's Global Programme on AIDS has provided an amount approxi- mately equal to that raised by national efforts thus far. WHO anticipates that two-thirds of the Global Programme's 1988 budget of $66 million will be spent on direct assistance to countries. More than 30 consensus meetings were held during 1987 by the program to provide guidance to national efforts in such areas as criteria for HIV screening and HIV in relation to breastfeeding and breastmilk, contraceptive methods, routine childhood immunizations, and HIV testing of international travelers. RATIONALE FOR U.S. INTERNATIONAL INVOLVEMENT The past year has seen an appreciable increase in information that confirms or strengthens the rationale for U.S. involvement in interna- tional AIDS activities. The rationale is threefold, involving foreign policy considerations, health improvement assistance issues, and opportunities for mutually beneficial research. Foreign Policy Considerations Recent economic analyses con- ducted by the World Bank and others (Over et al., 1988) indicate that

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162 CONFRONTING AIDS: UPDATE eggs combating AIDS will impose a considerable economic burden on a large number of substantially affected countries. The adverse economic effects of AIDS are clearly unavoidable in certain countries of central, eastern, and southern Africa, and there is likewise a potential for significant economic impacts in those countries in which HIV infection is established or is becoming established in the heterosexual population (e.g., countries of the Caribbean and Latin America). In industrialized countries, the economic burden of AIDS will continue to be heavy in such high-risk groups as male homosexuals and IV drug abusers. For young and middle-aged adults in certain developing countries, it is estimated that, by 1991, AIDS-related deaths will double the mortality rates (from 500 to 1,000 deaths per 100,000 inhabitants). In addition to the toll exacted by the large numbers of casualties, the many deaths among young, highly educated urban dwellers who are normally very productive members of the society will exacerbate the disease's economic impact. The increase in AIDS-related deaths undoubtedly will adversely affect development in such countries, toward whose welfare the United States contributes. Health Improvement AssistanceIt has become increasingly appar- ent during the last year that perinatal transmission of HIV has the potential to raise infant and child mortality to such a level that recent advances in child survival may well be reversed in some countries (Mann, 19881. Such reverses are particularly feared in those countries in which heterosexual transmission is the predominant mode of spreading the infection. Opportunities for Mutually Beneficial Research As the epidemic spreads, the need for international collaboration in pursuing biomedical, epidemiological, and behavioral research opportunities in relation to AIDS becomes more apparent. Important research directions include aspects of perinatal and heterosexual transmission, as well as the influ- ence of cofactors for the acquisition or progression of HIV infection and the pathogenicity of related viruses (e.g., HIV-2) that are not prevalent in the United States (see Chapter 6~. THE U.S. CONTRIBUTION TO INTERNATIONAL EFFORTS The United States contributes to international AIDS activities through a variety of agencies. Specific international activities are part of the programs of CDC, various agencies of NIH (e.g., the National Institute of Allergy and Infectious Diseases, the National Cancer Institute, and the Fogarty International Center), and the Department of Defense. The U.S. Agency for International Development (USAID), part of the State De- partment, has provided considerable technical and financial support to the WHO Global Programme on AIDS. U.S. contributions to the WHO

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INTERNATIONAL ASPECTS 163 program totaled $1 million in 1986 and $5 million in 1987; they are anticipated to be $15 million in 1988. In addition, funds have been provided through USAID country missions in support of specific national AIDS efforts. Recently, a number of philanthropic foundations (e.g., the Rockefeller and Ford Foundations) have also begun to fund AIDS-related activities outside the United States or have indicated their intention to consider such support. In addition to these contributions, however, the United States has a special responsibility in international health efforts to control AIDS because of our exceptional resources in public health specialists and biomedical scientists, the large number of infected persons in the United States, and our relative affluence. Cooperation with other countries should occur both through WHO and in bilateral arrangements, making full use of the expertise of the U.S. Public Health Service. Emphasis should be given to helping severely affected countries in central Africa implement educa- tional efforts, test and counsel sexually active persons, conduct serologic screening of blood donors, eliminate inappropriate or unnecessary blood transfusions, improve indigenous epidemiological and surveillance capa- bilities, and prepare for consequent increases in the incidence of tuber- culosis. U.S. responsibility also extends to less direct aspects of support for AIDS prevention and control activities. WHO's Global Programme on AIDS is mainly funded by extrabudgetary monies, those contributed in addition to the regular assessed contributions of each nation. Yet the AIDS program is also supported, in a sense, by regular budget contribu- tions to WHO in that the program interacts to a considerable extent with other WHO units for example, the divisions of mental health and communicable diseases. The AIDS program also draws on the adminis- trative structures of WHO as a whole. As of May 1988 the United States was in arrears on its regular WHO budget assessment approximately $38 million for 1987 and $75 million for 1988. Although the United States has indicated its intention to honor those assessments, payment delays are having severely deleterious erects on WHO's capacity to support the Global Programme on AIDS. The committee strongly urges that the United States pay its assessed contributions to WHO in total as soon as possible. Finally, U.S. commitment to the long-term support of international AIDS activities is essential. Although the future course of the AIDS epidemic is not known, the death toll thus far and its rate of increase identify the disease as a major global health problem that will require sustained international efforts in the search for a solution and substantial U.S. support of those efforts. Some predictions (Anderson et al., 1988) are that it may be at least several decades before the full effects of AIDS and HIV infection are seen, even in those countries in which the disease

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]~ CONFRONTING AIDS: UPDATE 1988 currently is most prevalent. Politicians and policymakers should plan now to provide a substantial increase in resources over the next few years, or perhaps over the next few decades, to be devoted to AIDS prevention and control. Funds will also be needed to ensure that today's predominantly educational methods for preventing HIV transmission can be supple- mented with appropriate vaccines and drugs when and if they become available. The committee is encouraged by the United States' response to the needs of the international campaign against AIDS and HIV infection. U.S. support at present is adequate to the requirements of well-planned programs; future support should be based on demonstrated needs. The committee urges policymakers to be sensitive to the public concern about the AIDS epidemic elsewhere in the world and its relevance to U.S. interests. Effective planning for U.S. participation requires that we know the detail and extent of international AIDS research activities in which we are already engaged. The committee responsible for Confronting AIDS could find no such data base 2 years ago. The present committee has also failed to find such a source. These data are crucial to the coordination of U.S. endeavors worldwide. The committee urges that a data base for interna- tional AIDS research activities be established and maintained. REFERENCES Anderson, R. M., R. M. May, and A. R. McLean. 1988. Possible demographic conse- quences of AIDS in developing countries. Nature 332:228-234. Mann, J. 1988. Global AIDS: Epidemiology, impact, projections, and the global strategy. Paper presented at the World Summit of Ministers of Health on Programs for AIDS Prevention, London, January 26-28. Over, M., S. Bertozzi, J. Chin, B. N'Galy, and K. Nyamuryekung'e. 1988. The direct and indirect costs of HIV infection in developing countries: The cases of Zaire and Tanzania. Paper presented at the International Conference on the Global Impact of AIDS, London, March 8-10. Plot, P., F. A. Plummer, F. S. Mhalu, J.-L. Lamboray, J. Chin, and J. M. Mann. 1988. AIDS: An international perspective. Science 239:573-579.