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Section A - Analysis of HIV/AIDS Numbers and Trends

This section, provides analyzes and commentary on reports from UNAIDS and other official agencies, as well as news media coverage of estimated or projected HIV/AIDS numbers and trends. These commentaries will point out inaccuracies in the numbers and incorrect conclusions whenever they are identified.

Sept 5, 2008 - I have not updated this site for close to a half year because: (1) I have been lazy; and (2) my major epidemiological differences with UNAIDS have been mostly resolved because now UNAIDS' numbers and estimates of the pandemic's trajectory are almost identical to mine. In early June, Dr Kevin de Cock, head of WHO's HIV/AIDS department, said that there has been a shift in the understanding of the risks posed by the HIV. Speaking to an Indian newspaper, Dr Kevin de Cock said that if the virus had to cause an epidemic among the general population in India and China, as originally feared, why hasn't it happened till now? It doesn't look likely anymore. Further, he added, India needs to look at who are getting infected more often and then target that section of society. Countries need to go where transmission is occurring, which they have not always been good at. Kevin got a lot of flak from UNAIDS for his truthful assessment of the low potential for "generalized" HIV epidemics in Asia and was, in my opinion, forced to issue a joint press statement with UNAIDS to say that the AIDS pandemic is definitely not over! Nobody, including Kevin has ever said this, but this press release seems to have appeased UNAIDS' mind set. Now, I have very little to be critical about with regards to WHO/UNAIDS' understanding of the AIDS pandemic except to say - why has it taken them so long to finally get it right!

I have not been idle since late March. I was in London in May to promote my book and gave a couple of talks on the status of the AIDS pandemic. I also was in Geneva in June to give similar presentations and I had an opportunity to meet with senior staff of WHO's HIV/AIDS Department.

The following website www.criticalopinion.org/authors/10 lists all of my OP-ED articles from Mar 5, 2007 to the most recent - May 18, 2008, and Aug 11, 2008.

I'm now in transit (in Honolulu for a few days) to Taipei where I'll be a Visiting Professor at the Graduate Institute of Epidemiology, Taiwan National University, Taipei, Taiwan. I'll be there until about mid-December to teach an undergraduate and a graduate course on the past, present and future of the AIDS pandemic and to begin preparing an Internet course on HIV/AIDS epidemiology.

March 27, 2008 - Redefining AIDS in Asia, a report from the Commission on AIDS in Asia - supported primarily by UNAIDS

The Commission on AIDS in Asia reported Wednesday that if Asian governments do not boost prevention funding, the region would see increases in AIDS mortality and HIV infections. The UNAIDS-commissioned study predicted that, without additional action, AIDS deaths in Asia could rise from 440,000 each year currently to nearly 500,000 annually by 2020, and total infections could double from 4.9 million to 10 million.

Despite declines in new HIV infections in some countries, "AIDS still accounts for more deaths annually among 15 to 44 year-olds than do tuberculosis and other diseases," the report said.

The report also said: "...currently, HIV epidemics in Asia are highly unlikely to sustain themselves in the "general population" independently of commercial sex, drug injecting, and sex among men. And, most critically, it means that prevention efforts that drastically reduce HIV transmission among and between those most at risk populations will bring the epidemics under control."

Comment - This report finally tones down the doom and gloom HIV scenarios that Peter Piot and pseudo AIDS experts like the US National Intelligence Council, Nicholas Eberstadt, and Susan Hunter have been shouting about during the past decade. However, use of Tim Brown's Asian Epidemic model has resulted in decreasing HIV incidence and prevalence in Asia until close to 2010 when for unclear reasons both HIV incidence and prevalence will begin to increase due to increased transmission in commercial sex networks. Overall, according to this model, HIV prevalence in Asia will slowly increase from the current close to 5 million to over 10 million by 2020. This projection makes no epidemiologic sense to me, but UNAIDS apparently has swallowed this modeling, hook, line, and sinker!

It's shameful that this report asserted that "Regionally, AIDS is estimated to be the single largest cause of death and morbidity due to disease for adults age 15-44 years." This is absolutely wrong - by almost an order of magnitude! The epidemiologists who supplied the HIV/AIDS estimates and data for this report should have known that the global burden of disease study by Colin Mathers clearly showed that because of the huge numbers of AIDS deaths in sub-Saharan Africa, AIDS was the leading cause of adult (15-59 years of age) deaths in 2001 on a global basis. However, for Asia, AIDS was not even in the top 10 leading causes of adult deaths in 2001! I would respectfully ask the authors of this Commission report to put out a correction for this gross error. Ban Ki-moon, UN Secretary-General was not well served by his UN staff when they drafted the following statement for him regarding the Commission's report:

"As a Korean, and the first UN Secretary-General from Asia in more than 30 years, it's no surprise that I often speak of my home continent as a model for economic development. Yet when it comes to the AIDS epidemic, I am more disheartened than proud. Across Asia, AIDS remains the most likely cause of death of people in their most productive years. At the rate we are going, the current 5 million Asians infected with HIV will grow to 13 million by 2020. Meanwhile the death toll mounts, with some 440,000 people succumbing to AIDS each year."

Although this report was from an independent study, the HIV/AIDS estimates and data continue to be supplied by UNAIDS staff or UNAIDS advisors. One of these days, they may actually report accurate numbers, even if it may be by accident! There is no doubt that AIDS is not the leading cause of adult deaths in Asia - nor even within the top 10 causes of adult deaths in Asia - is this error again an indication of epidemiologic incompetence or deliberate distortion of the data by UNAIDS!

However, aside from not agreeing with the HIV/AIDS numbers and projections in this report, I do agree with most of the recommendations in this report.

Jan 27, 2008 - Experts call for rethinking AIDS money by MARIA CHENG, AP Medical Writer, Fri Jan 18, 12:38 PM ET

LONDON - In the two decades since AIDS began sweeping the globe, it has often been labeled as the biggest threat to international health. But with revised numbers downsizing the pandemic - along with an admission that AIDS peaked in the late 1990s - some AIDS experts are now wondering if it might be wise to shift some of the billions of dollars of AIDS money to basic health problems like clean water, family planning or diarrhea...

Comment - The following is the last section of my op-ed article that was requested by the Frankfurter Allgemeine Sonntagszeitung, one of the larger German newspapers. This article is scheduled to be published in German by mid-to-late February, 2008.

"...There have been several OP-ED articles recently that have decried the huge gap between global funding for AIDS compared with other urgent public health needs such as clean water in resource poor countries. There are no excuses for the inadequate international funding for basic public health programs in resource poor countries. However, aside from minimizing the waste of funds inherent in a rapidly evolving and massive prevention and treatment program, the redirection of major support from AIDS programs is not necessarily the most appropriate solution. The ultimate solution would be to increase the global budget to provide adequate funding for all major public health programs in resource poor countries. Although such an increase would only constitute a fraction of the current global cost for the war on human terrorism, the current political and economic realities are that such a solution will require more time and more forceful advocacy efforts to achieve.

The AIDS pandemic has clearly received unprecedented global priority and funding, most of which I believe were and are needed. I also believe that UNAIDS' epidemiologic incompetence and distortions of the scope and trend of the AIDS pandemic should not be allowed to compromise the needed global response to this unprecedented pandemic. Since recognition of the AIDS pandemic in the early 1980s, annual AIDS deaths have been steadily increasing and, as of the new millennium, have become the leading cause of annual global adult deaths. The current global impact of about 30 million persons living with HIV and at least 2 million new infections and 2 to 3 million AIDS deaths annually requires a massive global response. If there was a pandemic of a new disease similar to human "mad cow's disease" with a global prevalence of a few million and an annual incidence of several hundred thousand, how many billions of dollars for research, prevention, and treatment would be considered too much?

In evaluating the global AIDS budget, it also needs to be noted that prior to AIDS, no international agency provided routine treatment for any disease since treatment was considered to be a bottomless pit. However, at the G8 Heads of Government Summit in July 2005, G8 leaders promised: to "develop and implement a package for HIV prevention, treatment, and care with the aim of as close as possible to universal access to treatment for all those who need it by 2010." To keep this commitment, the global AIDS budget will have to be significantly increased because, as of 2008, less than a quarter of persons in low and middle-income countries who need HIV treatment have received it. Hopefully, the global commitment to support routine HIV treatment programs will be just the first of additional commitments to provide routine treatment for other major diseases.

I believe there will be significant shortfalls in keeping this moral commitment over the next decade. However, I'm optimistic that as the concepts of global health and social justice takes firmer root, there will eventually be a comprehensive and equitable international commitment to support prevention and treatment programs in resource poor countries for most major human diseases. This will not be accomplished in my life time - and for this failure, shame on my generation! This is a commitment that I believe that my grandchildren's generation can and will accomplish - if not, shame on them!

Jan 12, 2008 - MSM in Kenya urgently require targeted HIV prevention
AIDSMap News - Rob Dawson, Friday, January 11, 2008

Men who have sex with men (MSM)in Kenya urgently need targeted, HIV risk-reduction prevention information, according to the first study describing HIV prevalence and risk factors in a large group of East African MSM. The study is published in the November 2007 edition of AIDS. [Sanders EJ et al. HIV-1 infection in high risk men who have sex with men in Mombasa, Kenya. AIDS 21: 2513 - 2520, 2007]

Between August 2005 and April 2007, 285 MSM were identified; 114 men reported sex with men exclusively(MSME) and 171 men reported sex with both men and women (MSMW). MSM formed approximately one-third of the vaccine-feasibility enrollment population screened; other risk groups screened included 339 women and 210 men at high risk of heterosexually acquired HIV infection.

HIV prevalence was 43.0%(95% confidence interval(CI), 34-52%) for MSME and 12.3% (95% CI, 7-17%) for MSMW. Overall HIV prevalence for MSM at enrollment was 24.5% (95% CI, 19.7-30.7%). By contrast, HIV prevalence at cohort enrollment was 31.5% (95% CI, 27-36%) for female sex workers and 12.4% (95% CI, 8-17%) for high risk heterosexual men. Overall, 25.3% of MSM reported previous HIV testing, of whom five MSME and two MSMW disclosed that they had tested HIV positive...

Comment - In Chapter 8 (HIV Prevention) of my book published in early 2007, I said - "MSM and IDU networks should be considered to be present in all regions and countries. The specific behavioral patterns and size of these sex and injecting drug networks have not yet been adequately described in most SSA populations primarily because they are overshadowed by the preponderance of heterosexual transmission. HIV/AIDS programs need to develop specific public health interventions for each of these modes of transmission based on local surveillance data on the patterns and prevalence of these risk factors and risk behaviors."

Jan 9, 2008 - INDONESIA: "Building Boom Drives Rapid AIDS Spread in Indonesia: Asian Development Bank" Agence France Presse (01/08/08)

The Manila-based Asian Development Bank(ADB)today warned of an "exponential" rise in HIV/AIDS in Indonesia driven primarily by the country's construction boom.

Last year, the Health Ministry estimated some 220,000 Indonesians of working age were living with HIV/AIDS; another 8.2 million were considered at high risk. "By 2010, the number of people with HIV and AIDS is projected to reach 400,000, and it is expected that 100,000 will have died of AIDS," said ADB....

Comment - I don't know how these HIV/AIDS numbers were projected, but they are totally unrealistic. If HIV prevalence (including living AIDS cases) were to increase to 400,000 by 2010 and there were also 100,00 AIDS deaths during these two years, then annual HIV incidence would have to be close to 150,000. If what they meant was by the end of 2010 (a three year period), then annual HIV incidence would have to be about 90,000. Either way, no way!

Dec 17 - MyPressportal [Free press releases South Africa] - HIV/Aids infections in SA continue to rise - Submitted by Lancet Laboratories, Monday, 17 December 2007 - http://www.pressportal.co.za/content/view/976/56/

...Despite a worldwide adjustment from 40 million to 33 million people living with HIV and AIDS, U.N. officials say the revisions stemmed mainly from better measurements rather than fundamental shifts in the epidemic according to the Washington Post, while local statistician Debbie Bradshaw warned in the Cape Argus last week that South African statistics were as high as ever, and that South Africa was not one of the countries responsible for pushing down the numbers. "At our laboratories alone we do about three thousand tests a day and the percentage of positive HIV results has risen from 8 percent to between ten and fifteen percent within the last five years", says Dr Lynne Webber leading South African Virologist from Lancet Laboratories..."We urgently need a comprehensive and effective consensus on AIDS in South Africa that works with the same determination as Uganda and encompasses all sectors of the South African population lead by the government based on facts rather than misguided, bias and dangerous beliefs, if we want to curb this catastrophic dying of our people" says Dr Webber...

Comment - Dr. Webber is right on target regarding what is needed to effectively respond to the severe HIV/AIDS disaster in South Africa. However, her conclusion that HIV prevalence may be increasing in SA because the percent of HIV positive tests from several thousand daily tests has risen from 8% to 10-15% within the last 5 years is probably wrong. Most of these daily tests are probably carried out for clinical purposes - i.e., to confirm a clinical diagnosis of HIV related disease. Over a 5 year period, even if HIV prevalence in SA was stable (level) or even slowly decreasing, the percent of HIV-positive blood specimens submitted for mainly clinical reasons could be expected to increase as more HIV-infected persons begin to develop some clinical illness and as clinicians improve their recognition of HIV-related illnesses.

Uploaded Dec 16 - Nov 29 - AP BEIJING: "The number of people estimated to be living with HIV in China has risen to 700,000, says a report released Thursday by the United Nations and the Chinese government. The government had previously estimated that [in 2005] 650,000 people were living with HIV, the virus that causes AIDS. There were 50,000 new cases in 2007, mainly among intravenous drug users and sex workers, says the report by Unaids, the United Nations' AIDS-fighting agency, and a committee of the State Council, the Chinese cabinet..."

Comments [Dec 16] - I was at a week long field epidemiology conference in Taipei when this report was released and since then I have been laid up by a persistent URI that started a day before I delivered my keynote talk on the Most Probable Past, Present, and Future of AIDS in Asian and Pacific Countries. My PowerPoint presentation can be accessed at:

http://www.elitepco.com.tw/tephinet2007taiwan/index-19e.html

I had to whisper into the microphone since I totally "lost" my voice for about a week. I have the following comments on the new China HIV prevalence estimate and I will be preparing another OP-ED article to respond to UNAIDS and its defenders about my criticism of UNAIDS' gross miscalculations of the scope and trend of the AIDS pandemic - stay tuned!

1. With the vagaries of the HIV data and the limitations of the available methods for estimating HIV prevalence, especially for such a very large population as mainland China, estimation of HIV prevalence cannot be very accurate. Such estimates are very susceptible to biased manipulation - regardless of UNAIDS' disclaimer that it is absurd or ridiculous to even think that anyone would be capable of such a deed!

2. My understanding of the epidemiologic trend of HIV epidemics in China suggests that annual HIV incidence in the major HIV epidemic in paid plasma donors peaked before the mid-1990s and annual HIV incidence also peaked during the early-to-mid-1990s in most of the dozen or so IDU epidemics. Thus, from my perspective, HIV prevalence in China should have been decreasing since the late 1990s.

3. In 2006, a detailed analysis (with the participation of invited external experts) of all available HIV data concluded that HIV prevalence in 2005 was 650,000, a significant decrease from the 2003 estimate of about 850,000. However, instead of accepting that HIV prevalence may have decreased from 2003 to 2005, the estimators revised the 2003 estimate down to 530,000, thereby showing an increasing HIV prevalence trend instead of a decreasing prevalence trend.

4. For 2007, another detailed analysis of all available HIV data was also carried out with the participation of invited external experts. The new estimate of 700,000 maintained the increasing prevalence trend - an increase of 50,000 compared to the estimate of 650,000 for 2005.

5. Whoever prepared the press release to announce the 2007 estimate is good at simple math, but clearly he/she does not understand the dynamics of HIV numbers. If, there were in fact, about 650,000 persons living with HIV in 2005, at least 100,000 or more would have died because of AIDS by the end of 2007 - a two year span. Thus, to have a prevalence of 700,000 at the end of 2007 the incidence of HIV infections during this time period would have had to be at least 150,000.

6. Although I have never seen any of the Chinese HIV data, I seriously doubt that HIV incidence in China has been increasing in recent years and I seriously doubt that HIV prevalence has increased over the last couple of years, but these are the "officially" approved estimates by the Chinese government and supported by UNAIDS.

7. An official report describing the data, methods and assumptions used for developing the latest China HIV prevalence estimate is apparently being prepared. I'm looking forward to reviewing this report whenever it may be released.

Posted Dec 16 - Nov 21 - UNAIDS press release: Revised HIV estimates - "As published in the 2007 AIDS epidemic update, WHO and UNAIDS have revised the estimated number of people living with HIV downwards from 39.5 million [34.1-47.1 million] in 2006 to 33.2 million [30.6-36.1 million], in 2007. The revisions are due mainly to improved methodology, better surveillance by countries and changes in the key epidemiological assumptions used to calculate the estimates..."

Comment - I did not update my website in late November because my computer crashed the week before UNAIDS released its 2007 update report. My comments and those of others such as Stephen Lewis regarding UNAIDS' delays and excuses for finally acknowledging more realistic and lower estimates of HIV prevalence as well as admitting that the trend of global HIV incidence has been decreasing for the past decade instead of ever-increasing and ever-expanding as all UNAIDS reports have proclaimed up to mid-2006, have been well covered by the news media.

However, UNAIDS has attributed its acceptance of the lower estimates and the decreasing incidence trend to "a better understanding of the AIDS pandemic" resulting from their improved data and methods. UNAIDS and their staunch defenders would have us believe that they have been in the forefront of collecting better HIV data and developing better methods for estimating HIV prevalence. However, from my perspective they have been literally dragged kicking and screaming to accept more realistic HIV numbers and trends that were obvious even using their prior datasets and methods if they were objectively and critically analyzed. For some reason, UNAIDS cannot simply admit that it had seriously misgauged both the scope and trend of the AIDS pandemic, although it is very clear from their report last month that they did.

I'm angry that my criticizing UNAIDS' misunderstanding or distortion of the AIDS pandemic has been considered petty and unnecessary by the International AIDS Society (IAS). My objective in persistently harping about UNAIDS' gross overestimation of the scope and trend of the AIDS pandemic over the past decade was to try to focus prevention efforts more on persons with the highest HIV-risk behaviors and not continue to waste limited public health resources on general populations and all youth, who are at no measurable risk of epidemic HIV transmission. I will be preparing an OP-ED article to respond to UNAIDS and its defenders!

Nov 1 - Zimbabwe AIDS deaths, infection rate dropping, government says - The AP - Thursday, November 1, 2007, JOHANNESBURG,South Africa:
http://www.iht.com/bin/printfriendly.php?id=8157131

Zimbabwe has registered a 2.5 percent decline in HIV infection rates, and the number of AIDS deaths also is dropping, but analysts were skeptical given the lack of medical care in the country in crisis. The HIV rate dropped from 18.1 percent in people aged 15 to 49 years last year to 15.6 percent this year, Zimbabwe's Ministry of Health said Thursday. AIDS deaths also have decreased, down to 2,214 a week from around 2,500 a week, according to the new statistics. The government said its figures had been verified by the United Nations. But UNAIDS said that was not the case. "It looks like they've used the methodology that we recommended, however, as we haven't received this data officially, we cannot validate it," said spokeswoman Sophie Barton-Knott.

"...Others were doubtful of the figures and the assumptions, pointing to Zimbabwe's economic and infrastructural meltdown, lack of medical care and medication, and the difficulties of relying on statistics when as much as a third of the population has abandoned the country. "I think with the current state of affairs in Zimbabwe, one would be kind of skeptical about statistics, which could also be caused by an undercount, by mass migration ...," said Dr. David Bourne, an epidemiologist at the University of Cape Town in South Africa....Bourne said experts expected to see a peak and decline in prevalence rates, which would occur naturally even without intervention, but the fact that the number of deaths was declining was "very surprising."...

[Comment - As indicated in the prior comment (below), it is not clear how the latest HIV prevalence estimate was made. Estimates of weekly AIDS deaths had to have been derived from modeling and this likely account for the decreasing estimate of AIDS deaths because the most recent model runs are using the lowered HIV prevalence estimates. Annual HIV incidence in Zimbabwe probably peaked by the late 1990s and thus Zimbabwe has been in the post-peak phase of its HIV epidemic for about a decade or more and annual AIDS deaths should still be increasing and not decreasing. Annual AIDS deaths in Zimbabwe can only be decreasing if peak HIV incidence in Zimbabwe occurred prior to the mid-1990s.]

Oct 31 - Zimbabwe's HIV Prevalence Rate In Further Decline To 15.6% - Voice of America, Reported by Sylvia Manika
http://www.voanews.com/english/Africa/Zimbabwe/2007-10-31-voa82.cfm

[Comment - According to the UNAIDS 2006 Report on the Global AIDS Epidemic, the estimated HIV prevalence in the 15-49 year old population was listed as 20.1%. In late 2006, the result of the 2005/2006 DHS+ survey indicated that HIV prevalence in adults in Zimbabwe was 18.1%. No details were provided in this brief news report and it is not clear whether the latest "official" Zimbabwean HIV prevalence estimate was derived from another DHS type survey or not. However, the general trend of decreasing HIV prevalence in high HIV prevalence countries in sub-Saharan Africa (SSA) continues as a result of: (1) prior overestimation; and (2) the reality that virtually all SSA HIV epidemics have been in their post peak phase since the 1990s!]

Oct 15 - Indian Government Releases Final Report for New National Health Survey - Press release
The much-awaited final report of the 2005-06 National Family Health Survey (NFHS-3) was released on Thursday, October 11th, by the Ministry of Health and Family Welfare at an official ceremony at the Ashok Hotel, New Delhi....For the first time, the survey measured HIV prevalence at the national level and for selected states (Andhra Pradesh, Karnataka, Maharashtra, Manipur, Tamil Nadu, and Uttar Pradesh). The NFHS-3 survey found an HIV prevalence rate of 0.28 percent for the population age 15-49. The important new information about HIV prevalence from NFHS-3 has spurred the Government of India and international agencies to greatly reduce the official estimate of Indians living with HIV from more than 5 million persons to 2.47 million...

[Comment - HIV prevalence in India is still probably overestimated!

The NFHS-3 studies carried out in India in 2005-2006 estimated HIV prevalence in the 15-49 year old population at 0.28%, more than two-thirds less than the previous NACO estimate of 0.9% in 2005. However, it is quite likely that population based HIV sero-surveys such as the NFHS-3 surveys, in Asian HIV epidemics, may underestimate national HIV prevalence because HIV in India is concentrated in high HIV-risk populations. Professor Lalit Dandona's seminal HIV study in 2005 in Guntur district in Andrea Pradesh recognized the need to supplement the findings from random sampling of the adult population with findings from surveys in known high risk populations. His adjustments included estimated HIV prevalence in female sex workers and single men who would not have been included in a "family" oriented survey. Collectively, these additional data sources increased the total adult estimate in his study by less than 10%. Similarly, NACO apparently used HIV sentinel surveillance data to adjust the findings from the NFHS-3 survey and increased the NFHS-3 estimated prevalence rate by about 25% to 0.36%. I believe that this "adjustment" is too large and needs to be justified by NACO, but no details of what data and assumptions were used to obtain this increase have been released by NACO or UNAIDS.

In addition, NACO is now estimating HIV prevalence in the 15+ population (close to 750 million) and not just in the 15-49 year old population (580 million). All studies of the age distribution of adult HIV prevalence over the past decade have shown that about 95% of all adult HIV infections are within the 15-49 year old population, i.e., the most sexually active age group. If the NFHS-3 finding of 0.28% in the 15-49 year old population is used, then the estimated number of HIV-infected 15-49 year olds in India is now about 1.6 million compared to the 5.2 million estimated by NACO in 2005 when they had estimated the HIV prevalence rate to be 0.9%. If the estimate of 0.36% developed by NACO is used, the estimated number of HIV infections in the 15-49 year old population is just about 2 million. The new NACO estimate now includes the 50+ population, but this should only add an additional 100,000 HIV infections (i.e., about an additional 5% to the 2 million in the 15-49 year old population) since the 0.36% prevalence rate cannot be applied to the 50+ population. Therefore, even if the 0.36% prevalence rate is applied to the 15-49 year old population, the revised estimate for the 15+ population should be, at most, less than 2.2 million. It will be interesting to see what specific numerator and denominator numbers NACO and UNAIDS used to calculate their 2.5 million estimate! I suspect that NACO may have used the 0.28% prevalence rate for the 50+ population of 170 million since this calculation would add 0.47 million to the 2 million calculated for the 15-49 year old population. Only NACO and/or their scientific advisors can fully explain how they arrived at an estimate of about 2.5 million persons age 15+ who were living with an HIV infection in India in 2006.]

Oct 15 - New HIV Cases Among Married Couples in Thailand Increasing, Survey Says - Kaiser Daily HIV/AIDS report - October 15, 2007

The percentage of new HIV cases recorded among married couples in Thailand has increased from 38.7% of new diagnoses in 2005 to 40% of new diagnoses in 2006, according to a recent survey by Thailand's Department of Disease Control, Thailand's Nation reports.

According to the survey, between 44% and 52% of married couples in the country engage in unprotected sex. The survey also found that 22% of new HIV diagnoses were among men who have sex with men. In addition, 11% of men who are newly diagnosed contracted the virus from commercial sex workers, and 10% contracted the virus from their partners, the survey found....

[Comment - The findings from this survey just confirms the observed steady trend in Thailand over the past decade of increasing HIV transmission from males who were infected during the late 1980s and early 1990s, as a result of their HIV-risk behaviors, to their wives or steady girlfriends. This trend was modeled a few years ago and according to the modelers, by the year 2010, about half of all new HIV infections will be occurring within HIV-discordant couples. This is a global trend and has also been well documented in most sub-Saharan African populations. This "nonepidemic" HIV transmission will inevitably occur following any HIV epidemic transmission in IDU, MSM, FSW, and persons infected because of faulty plasma collection methods (as in China up to the mid-1990s). However, these HIV "bridges" to the "general population" are "bridges to nowhere" since most of the regular sex partners of persons infected in HIV epidemics do not have any significant HIV-risk behaviors. As a result there is no significant HIV spread or penetration into the "general population."]

Oct 6 - Kenya: Country Needs New Aids Plan, The Nation (Nariobi), Daniel Mwaura http://allafrica.com/stories/200710051258.html

...Kenyans recently celebrated the achievement of reduced HIV prevalence from 13 per cent to 5.1 per cent through the efforts of the Government, the private sector, NGOs and others...

[Comment - The vast majority of the marked decrease in HIV prevalence was due to the gross overestimation of the prior estimate that was cut from close to 2.3 million to 1.2 million as a result of more accurate HIV data from population based HIV serosrveys in 2001. Thus, most of the generally decreasing HIV prevalence in sub-Saharan African countries such as Kenya can be attributed to prior overestimation and also to increasing numbers of AIDS deaths during the past decade. How much of this decreasing HIV prevalence can be attributed to "sucessful" HIV prevention programs will be open to heated debate!]

Sept 22 - Karnataka - Bangalore - Rs. 39 crore for AIDS prevention programme Special Correspondent - The Hindu http://www.thehindu.com/2007/09/22/stories/2007092254260500.htm

...NACO has been implementing the Third National HIV/AIDS Control Project, for which the World Bank agreed to provide credit of $ 250 million. The Union Government has embarked on an ambitious goal of halting and reversing the HIV/AIDS epidemic by 2011, ahead of the 2015 target of the eighth Millennium Development Goals of the United Nations.
According to NACO's Annual Sentinel Surveillance Data, the prevalence of HIV/AIDS cases in the State declined by 7 per cent during 1998-2006. Cases also declined in Tamil Nadu, Maharashtra and Andhra Pradesh during the same period....According to estimates, India had 5.2 million HIV/AIDS patients (people aged between 15-49 years) in 2005.

[Comment - I just copied the last paragraphs of this report that provided some of the HIV/AIDS data and estimates for India. According to the data and trends, HIV prevalence has been decreasing since the late 1990s and therefore annual HIV incidence (new infections) had to have peaked prior to the late 1990s. The goal of halting and reversing the HIV/AIDS epidemic was met by the mid-1990s, but UNAIDS, NACO, and all AIDS programs have yet to acknowledge this! Note that the old high HIV prevalence of 5.2 million for India continues to be cited!

The UN Millennium goal was clearly not drafted by an epidemiologist who understands the natural history and epidemiology of HIV infections. HIV prevalence (persons living with an HIV infection) will decrease when there are more AIDS deaths than new HIV infections (HIV incidence). HIV prevalence in India started to level off and then started to decrease slowly by the late 1990s because annual HIV incidence in India peaked around the early to mid-1990s. UNAIDS will have to specify what is meant by "halting and reversing the spread of HIV/AIDS" if it does not accept that peaking and decreasing trends of HIV incidence and HIV prevalence meets this Millennium goal!]

Sept 20 - ICAAC: Sharp decline in HIV prevalence reported in pregnant women in rural northern Zimbabwe Derek Thaczuk & Michael Carter

A dramatic 41% decline in HIV prevalence has been reported in pregnant women in Zimbabwe, according to the latest survey done in this population. The results were reported in a poster presentation at the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy in Chicago this week. [Silverman MS et al. Declining prevalence of HIV in pregnant women in Zimbabwe. 47th Interscience Conference on Antimicrobial Agents and Chemotherapy, abstract H-1728, Chicago, 2007.]
...The investigators presented data on 15,555 women tested, of whom a total of 3.121 tested HIV positive. Analysis showed that HIV prevalence amongst pregnant women was declining in a linear fashion by 1.4% per month (95% CI: 1.1 - 1.7% per month). During the eight year observation period, prevalence dropped from 26.6% (95% CI: 24.2 - 29.2%) to an estimated mean of 15.6% (95% CI: 13.1 - 18.1%). This represents a 41% drop in estimated prevalence from the original rate, which began as early as 1999, and continues through to August 2007. In comparison, HIV prevalence among pregnant women in South Africa has declined only slightly in the past two years after a long pattern of increase, and still remains close to 30%.
Discussing the possible reasons for this decline, the researchers note that "although a natural fall in the HIV epidemic curve through patient deaths may explain the observed decrease, decreased sexual "mixing" due to decreased disposable income of working class men, and collapse of transportation infrastructure may be relevant." The researchers also note that incidence rates - the rates of new infections - were not assessed.
Local prevention programmes include voluntary counselling and testing, condom distribution campaigns, community education including puppet shows and AIDS clubs for students, and mother-to child prevention programs. However, "It is unclear if [these] local education, prevention programs and behaviour change are likely to have also contributed to this trend." But a review of the evidence on changes in HIV prevalence in Zimbabwe carried out by an expert group for UNAIDS in 2005 concluded that it was prevention activities - particularly condom promotion and partner reduction - starting from the mid-1990s, that had contributed most to the decline in HIV prevalence in Zimbabwe since 2000.

[Comment - The overall HIV prevalence trend in sub-Saharan Africa is level and then decreasing since the late 1990s. How much of this decrease can be attributed to public health interventions and how much to a natural decrease because of lower annual HIV incidence and increasing numbers of AIDS deaths will be the topic of heated debate. My bias is that AIDS programs will try to "ride to glory" on the down slope of the HIV epidemic curve!]

Sept 20 - Donors to cut AIDS assistance for Cambodia. People's Daily Online, China
Three international donors have decided to reduce aid for AIDS prevention in Cambodia as the country has reportedly achieved satisfactory progress on the issue, local media said on Thursday. The Global Fund, the Department for International Development ( DFID), and the United States Agency for International Development (USAID) will cut funds targeted at reducing the transmission of HIV/AIDS in Cambodia as nationwide rates have declined from 3.3 percent in the 1990s to only 0.9 percent in 2005, reported Cambodian-language newspaper the Koh Santepheap. "The reduction in aid does not mean they have to end HIV/AIDS prevention activities. In fact, it is observed that the Royal Government of Cambodia has enough capacity to carry out on their own the fight against the spread of HIV/AIDS in Cambodia," said UNAIDS representative Pasi Rajander during a training course on AIDS prevention and labor law held through Sept. 18-20 at the National Center for Tuberculosis and Leprosy Control.

[Comment - It appears that funding from major donors is greatly influenced by how large the numbers may be. HIV prevalence in Cambodia did not drop from 3.3 percent in the 1990s to 0.9 percent in 2005 - it is likely that much of this decrease can be attributed to prior overestimation, but also, HIV incidence in Cambodia peaked around the mid-1990s and HIV prevalence peaked by the late 1990s. Thus, there has been a decreasing HIV prevalence since the new millennium. How much of this decrease can be attributed to the 100% condom program that was started in 2000 by WHO for all commercial sex contact and how much to a natural decrease in HIV prevalence due to increasing AIDS deaths is unclear. The recent decision by major donors to withdraw funding for HIV prevention programs in Cambodia is, in my opinion, a terrible mistake since the cost of HIV prevention is about the same regardless of whether HIV prevalence is high or low. In addition, the assumption that Cambodia has enough capacity without any external donor funds to support HIV prevention is also dead wrong! This decision by all of the major donors will just motivate other resource poor countries to continue to overestimate their HIV prevalence in order to continue to receive external support.]

 Sept 17 - Researchers Say Africa's Declining HIV/AIDS Prevalence Dangerous" Xinhua News Agency

On the sidelines of a reproductive health conference in Nairobi over the weekend, an expert warned that reductions in HIV/AIDS figures in some African countries are likely the result of more people dying of the disease rather than effective campaigns to reduce the number of new infections. Dr. Joachim Osur, senior reproductive health expert with IPAS, an international organization specializing in women's health issues, said reported reductions in Kenya, Uganda, and Rwanda are not good news.

There is no indication that many more people have begun HIV/AIDS treatment, while new infections have continued to soar. "The reducing HIV/AIDS prevalence means many infected people are dying from the disease. It does not mean the situation is getting better," said Osur . . . . Uganda has cut its prevalence rate by almost 70 percent since the 1990s to the current 6.6 percent. While UNAIDS has attributed the decline to "specific interventions," it warns that the failure to distribute antiretrovirals remains a challenge on the continent.

Dr. Patrick Orege, former director of Kenya's National AIDS Control Council, said new infections continue unabated among adolescents and women. Meanwhile, he said, policies have failed to address the issues involving increasing treatment access. Arthur Okwemba, a Kenyan media analyst, urged African governments not to rely on falling prevalence rates to measure successes in combating HIV/AIDS. "We should not rely on prevalence because of its volatility; we need to move to HIV/AIDS incidence studies to determine the number of new infections from every locality," he said.

[Comment - HIV prevalence can only decrease when there are more AIDS deaths compared to new HIV infections (HIV incidence). Thus, at this post-peak stage of HIV epidemics in Kenya, an indicator of a "sucessful" anti-retroviral treatment (ART) program would be a level or even increasing HIV prevalence. The suggestion by Dr. Orege to begin to determine the number of new HIV infections (incidence) is a good one, but unfortunately no reliable method is available to directly measure HIV incidence. The only fairly "reliable" method for estimating HIV incidence is simple modeling that depends on unchanged progression rates from HIV infection to AIDS and death -- a sucessful ART program will make such modeling invalid.]

Sept 12 - "Indonesia Faces Rising Tide of HIV" Voice of America News :: Trish Anderton
According to the UN, nearly 1 million Asians contract HIV each year. The virus is spreading quickly in Indonesia, mainly through prostitution…..Some 7 million to 10 million men visit sex workers each year in Indonesia. According to the UN, prevention efforts in 2004 reached about 18 percent of female sex workers and less than 7 percent of their clients. However, data suggest that the level of knowledge about HIV is improving both among prostitutes and their clients….Indonesia has a high level of poverty, and the poor have limited access to education, health care, and shelter.

[Comment - This reporter has doubled UNAIDS' gross overestimation of annual HIV incidence in the Asia-Pacific region - from 500,000 to a million! She also invokes the false litany of poverty and limited access to education, health care, and shelter as important determinants for HIV transmission.]

Sept 5 - Papua New Guinea AIDS Crisis May Mirror Africa's, UN Says"
Bloomberg News: Emma O'Brien
Tim Rwabuhemba, Papua New Guinea's coordinator for UNAIDS, said in an interview that the country's HIV/AIDS epidemic may mirror the crisis in Africa. Infections are surging, and more than 75 percent of patients are unable to access AIDS drugs. "There is an urgent need for more HIV services across the board here," he said. The nation of 6 million accounts for 90 percent of the Pacific region's HIV cases. It is one of four Asia-Pacific countries experiencing an AIDS epidemic, according to the UN.

[Comment - The HIV/AIDS epidemic in PNG is most similar to those in the Caribbean (Haiti, etc.) and less Asian-like (i.e, large brothel type sex networks). It is definitely one of the most severe HIV epidemics in the Asia-Pacific region, but if HIV prevention is aggressively targeted to persons who have multiple and concurrent sex partners, HIV prevalence should not exceed 1 to 2 percent of the adult population.]

Sept 5 - New Delhi Records Increasing Number of AIDS Cases Despite Decrease in India's National Estimate, Report Says. Kaiser network daily reports
Although India recently reduced its HIV/AIDS caseload estimate, the number of AIDS cases in New Delhi has been increasing since 2000, according to a recent Ministry of Health and Family Welfare report, the IANS/Economic Times reports (IANS/Economic Times, 9/2) . . . . According to the report, the number of recorded AIDS cases in New Delhi has increased from 498 in 2000 to 5,082 in 2007 . . . .

[Comment - This report is very misleading because reported numbers of AIDS cases in India have to be increasing regardless of whether HIV prevalence in India is 5 million or 2.5 million. In addition, only a very small percent (probably less than 5%) of AIDS cases that occurred in India have been reported. Thus, a 10 fold increase of reported AIDS cases from about 500 to over 5,000 in a 6-7 year period can easily be attributed to (1) a natural increase of AIDS cases and (2) an increased rate of reporting. The actual number of AIDS cases in New Delhi in 2007 is much, much higher than about 5,000!

]Aug 24 - HIV in Rwanda drops to 3% by Ampaire Loice
http://www.newvision.co.ug/D/8/13/583113

The number of people infected with HIV/AIDS in Rwanda dropped from seven percent in 2004 to three percent today, new statistics have revealed. The Demographic and Health Survey shows that the HIV prevalence is higher among men than women at 3.6% versus 2.3% respectively. It also indicated that 7.3% of urban dwellers are infected, compared to 2.2% of the rural population. Kigali has the highest HIV/AIDS prevalence. About 8% of the city's women are infected and 5.2% of the men. The Rwandan Health Minister, Jean Damascene Ntawukuriryayo, said the success in the fight against AIDS was due to the increased awareness and reliable preventive mechanisms. "Almost every person, old and young in Rwanda, has heard of AIDS and its dangers."

[Comment - Rwanda's HIV prevalence was lowered from almost 9 percent in 2001 to about 5 percent in 2003 and then to 3 percent in 2005.  Thus, it is not clear as to why the results of the 2005 DHS survey were "revealed" as new statistics. How much of this marked decrease in estimated HIV prevalence from 2001 to 2007 can be attributed to "successful" prevention programs, how much to initial gross overestimation, and how much to “natural” decreasing annual incidence is not clear.]

Aug 24 - Malawi
http://www.dailytimes.bppmw.com/article.asp?ArticleID=6360

The VCT [voluntary counseling and testing] week this year put up 1,367 sites where people could have their blood tested...the highest rates of HIV ranging between 10 and 14.3 percent. The minister, however, said the results only capture those that voluntarily had their blood tested. "The HIV rates reported in the campaign are for people that voluntarily responded to this campaign which means they are not a scientific representation of all the people in Malawi," Ngaunje warned. She added that the official prevalence rate of HIV cases in the country still remained at 14.1 percent.

[Comment - This may be nit-picking, but a DHS+ study in Malawi in 2005 estimated HIV prevalence in Malawi at about 11 to 12 percent!]

Aug 23 - MONROVIA (PLUSNEWS) - LIBERIA: HIV rates lower than feared
http://www.plusnews.org/PrintReport.aspx?ReportId=73904

Reliable statistics on HIV/AIDS have been hard to come by in Liberia, slowly recovering from years of conflict, but two recently released surveys indicate a much lower HIV/AIDS prevalence rate than was previously thought. "This is a reliable survey, involving 7,000 households across the country, where individual blood samples were collected and tested for HIV, and this exercise is the first in 25 years," said Edward Liberty, head of the Liberia Institute of Statistics and Geo-Information Services (LISGIS). Respondents sampled were in the age range of 15 to 49. The first post-war demographic and health survey, conducted by the LISGIS from December 2006 to July 2007 in nine of the country's 15 counties, indicated an HIV prevalence rate of 1.5 percent of the country's 3.2 million people. The civil war made most rural areas inaccessible, but when it ended in 2003, UNAIDS put HIV infection at 5.9 percent, while a 2002 Liberian government study estimated 8.2 percent.

[Comment - Yet another example of gross overestimation of HIV prevalence. However UNAIDS estimated prevalence in the 15-49 year old population in 2003 to be close to 6 percent and the 2006-07 household survey estimated HIV prevalence in the total population at 1.5 percent. Thus, estimated HIV prevalence in the 15-49 year old population in 2006-07 is close to 3 percent - about half of the 2003 UNAIDS estimate.]

Aug 23 - Voice of America - AIDS Budgets in Asian Countries Called Insufficient by Melinda Smith - http://www.voanews.com/english/2007-08-23-voa48.cfm

"At least eight and a half million people living in Asia have been infected with the HIV virus. Small numbers, perhaps, compared to the 25 million people living and dying from the disease in sub-Saharan Africa. But while most Asian countries have a low prevalence of HIV, there are large numbers of people infected. India, for example, has almost the same number of infections as South Africa..."

[Comment - This reporter, writing her report from Washington DC, is quite sloppy with her HIV numbers - something that is unfortunately all too frequently seen with many news reports. At the International Congress on AIDS in Asia and the Pacific that was held in Colombo, Sri Lanka this week, most speakers were quite careful to use the revised HIV prevalence estimate in Asia of just over 5 million and not the old estimate of more than 8 million. This reporter also was apparently oblivious to the fact that India's HIV prevalence had been slashed drastically in early July and now stands at less than 2.5 million which is much less than South Africa.]

Aug 22 - Myanmar HIV Rates Falling As Funds Dry Up - Experts - by Johanna Son* - IPS/TerraViva - http://www.irrawaddy.org/article.php?art_id=8317

At a discussion at the 8th International Congress on AIDS in Asia and the Pacific (ICAAP) here, participants heard information showing that HIV prevalence rates in Burma have been falling among some groups -- intravenous drug users, mothers who passed on the virus to their babies, military recruits...Citing preliminary results, Wiwat Peerapatanapokin, an epidemiologist with the Policy Research and Development Institute in Thailand who has been part of estimation exercises of HIV and AIDS in Burma, put the HIV prevalence rate there at 0.67 percent as of 2007, after reaching a peak in 2000. This translates into 230,000 adults living with HIV and AIDS, 6,000 children and 13,000 new infections among adults, he added. These new figures are in contrast to previous estimates of up to 2.2 percent HIV prevalence rates in the country of 50 million.

[Comment - In this report, only preliminary estimates are provided, yet from my biased perspective, the lower estimates for Myanmar are consistent with: (1) Formerly, gross overestimation of HIV prevalence; and (2) decreasing HIV prevalence as a result of lower annual HIV incidence and increasing annual AIDS deaths! Who wants to bet that the new HIV estimate in China will be higher or lower than the 650,000 estimated last year - my money is on the lower side!]

Aug 21 - COLOMBO (Reuters) - Drugs, conflict spur HIV in Asia Pacific region by Simon Gardner http://africa.reuters.com/wire/news/usnCOL141335.html

HIV infections are increasing at a worrying 10 percent a year in the Asia Pacific region, a top UN AIDS official said on Tuesday, putting the rise down to intravenous drug use, sex workers and conflicts..."In the last two years we have seen about a million infections coming in, that means half a million every year," Rao told Reuters in an interview at the International Congress on AIDS in Asia and the Pacific being hosted in Colombo. "Ten percent is a worrying figure." "If you take out Southern India and Thailand and Cambodia, where you have a declining rate, in the remaining Asia Pacific region it is still an increasing epidemic," he added. "It is still accelerating." UNAIDS estimates 5.4 million people were living with HIV in the Asia Pacific region in 2006, with anywhere between 140,000 and 610,000 people dying from AIDS-related illnesses.

[Comment - At least Rao used the more recent estimate for India to get the 5.4 million total, but I'll bet the current total is less than 4 million! I for one would like to see where he would distribute the 1 million new HIV infections he claims during the past 2 years! It needs to be recognized that annual HIV incidence cannot be directly measured but has to be modeled and such modeling is dependent on: (1) the estimated HIV prevalence; and (2) where on the HIV prevalence curve (pre-peak, peak, or post-peak) the current year may be. If HIV prevalence is overestimated, then annual HIV incidence will be proportionally overestimated and if the current year is placed at a pre-peak or peak point on the HIV prevalence curve selected for modeling, then annual HIV incidence will be much higher than if the current year is placed at a post-peak position of the prevalence curve. UNAIDS has clearly (1) overestimated HIV prevalence in Asia, and (2) inappropriately assumed that the Asia region is still at the pre-peak or peak position on the Asian HIV prevalence curve! How long will UNAIDS continue with such blatant overestimation of annual HIV incidence, especially since UNAIDS was forced to acknowledge last year that global HIV incidence peaked during the late 1990s! Any challenge or rebuttal by UNAIDS or any of their scientific advisors to my evaluation their annual HIV incidence estimate for Asia would be welcomed!]

Aug 20 - Colombo (PLUSNEWS) - ASIA: "Seize the opportunities of hope"

http://www.plusnews.org/PrintReport.aspx?ReportId=73821

UNAIDS, co-sponsor of the congress, along with the AIDS Society of Asia and the Pacific (ASAP), recently revised its estimate of HIV-positive people in the region from 8.3 million to 5.4 million. Nevertheless, the epidemic in Asia and the Pacific is still increasing, with approximately one million new infections in the last two years. J V R Prasado Rao, director of the UNAIDS regional support team in Asia, explained that the new figures were drawn from a combination of household and antenatal surveillance figures, whereas previous estimates had relied solely on tests of pregnant women. "UNAIDS advocates looking at trends, not figures," Prasado Rao told delegates on Monday, "and the overall trends remain the same." Summarising these, he noted that HIV infections were rising in a number of countries, including China, Vietnam, Bangladesh, Nepal, Pakistan and Indonesia, but had declined in Thailand, Cambodia and several parts of India.

[Comment - I would like everyone to take note of UNAIDS' persistent claims/conclusions that HIV infections (I presume they mean both HIV incidence and prevalence) in China, Vietnam, Bangladesh, etc., are increasing. I haven't been involved with HIV estimation in these countries for several years, but I doubt that HIV incdence and prevalence are still increasing in these countries!]

Aug 19 COLOMBO (Economic Times - India) India, UN help AIDS figures come down globally - Economic Times

Some 25 years after the discovery of the first case of AIDS, the global figure for people living with the virus will come down when fresh figures are released in November, a senior official of the United Nations AIDS umbrella disclosed Sunday. The scale-down in the epidemic is being attributed to a new counting methodology pioneered jointly by the Indian government and the UN - which saw the figures for Indians living with HIV/AIDS decline from 5.7 million to around three million two months ago...Landey's startling disclosure about the expected decline in numbers comes at a crucial juncture in the global fight against HIV/AIDS...The danger, say health experts in Colombo, is that news about declining numbers will lead to governments becoming complacent in the fight against HIV/AIDS. "We are worried about complacency," said Landey. "Countries that have become complacent have seen the epidemic go up."

[Comment - In this report, UNAIDS has assumed, or at least accepted, credit for "pioneering" along with the Indian government a new counting methodology, i.e., using population based sampling survey data rather than relying on mostly urban based sentinel surveillance samples. In fact, UNAIDS had been, up to a year or two ago, quite reluctant to accept the lower estimates that were made by the first demographic and health surveys (DHS) that included HIV testing - in Zambia (2001) and Kenya in 2003. Now, that it has been amply shown that DHS type data provides more accurate HIV prevalence estimates, UNAIDS is singing a far different tune. UNAIDS also needs to abandon their rhetoric that the AIDS pandemic is ever-increasing and ever expanding and HIV epidemics will inevitably erupt in "general" populations if governments become "complacent." I fully agree with UNAIDS that HIV prevention outreach to persons with the highest HIV-risk behaviors, must be intensified in all countries, regardless of whether HIV prevalence is currently high or low. However, it needs to be understood that even if the vast majority of general populations, especially all youth, in countries like Bangladesh, the Philippines, Mongolia, etc., are not aware of at least three ways that HIV infections can be prevented and the government and public has become "complacent" about the AIDS pandemic, that HIV epidemic spread cannot occur in these "general" populations! I for one would like to know where HIV epidemics have gone up where a country had become complacent!]

Aug 16 (Nigeria) - Vulnerable Women As Face of HIV/AIDS by Godwin Haruna http://allafrica.com/stories/200708170153.html

"...United Nations Development Fund for Women (UNIFEM)'s executive director, Noeleen Heyer, declared in June 2001 that there is indeed a direct correlation between women's low status, the violation of their human rights and HIV transmission. The reason that AIDS has escalated into a pandemic is because inequality between women and men continues to be pervasive and persistent. She asserts that the time has come for the AIDS community to join hands with the women's community to hold governments accountable...

[Comment - Female inequity continues to be perceived as an established major determinant of high HIV prevalence in sub-Saharan Africa by most groups advocating gender equality. However, a recent study of the determinants of risky sexual behavior by Linda Tawfik and Susan Watkins indicate that this may not be a major reason for high HIV infection rates in females in Africa. "[The prevailing] perspective of women as poor, passionless and powerless is similar to that of academic feminists in the 1960s and 1970s; although now largely replaced in academia, it survives in Geneva and Lilongwe. From rural Balaka [in Malawi], the perspective is different. Women are said to be poorer than men, but they are motivated to seek other partners not only by survival but also by aspirations for a higher standard of living, by love and lust, and by revenge for a husband's infidelity...We conclude that from the Balaka perspective [females in a rural district of Malawi], women's extramarital sexual partnerships...is motivated not only by a need for resources to survive but also by aspirations for attractive consumer goods and by sexual desire; moreover, both men and women acknowledge specific points of a sexual relationship where women have considerable power and autonomy..."

In addition, there are a couple of epidemiologic observations that do not support the contention that female inequity is a major determinant of high HIV prevalence. Women in Moslem countries face far more gender inequity compared to theircounterparts in non-Moslem countries, but HIV prevalence in Moslem populations in Africa has remained relatively low compared to non-Moslem countries. Study of HIV discordant couple in sub-Saharan Africa has consistently shown that there are more HIV-infected females than infected males - thus, it is not always the "dominant male" who will infect his "submissive female" sex partner!

Aug 16 - (Nepal)- Study: Sex trafficking contributes to AIDS epidemic by Erin Roach - http://www.sbcbaptistpress.org/BPnews.asp?ID=26256

Intervention to release sex-trafficked girls and women from forced prostitution may be an important strategy in preventing the spread of HIV/AIDS, according to a study released in August by the Journal of the American Medical Association. Researchers called for strengthened efforts to prevent sex trafficking and to protect trafficking survivors after they found that victims of forced prostitution in India contributed to the HIV/AIDS epidemic when they were repatriated into their native country of Nepal...

[Comment - "We" were all aware of the Nepal to India and return of female prostitutes (trafficked or voluntary) and the great potential risk for the introduction and start of heterosexual HIV epidemics in Nepal from the early 1990s. I was in Nepal on several visits in the 1990s to evaluate the HIV/AIDS situation there. No HIV epidemics have been detected except in IDU networks in the Katmandu valley and other parts of Nepal. We "knew" that some (many?) HIV-infected trafficked sex workers were being returned home and there was great concern that they would be the start of epidemic heterosexual HIV transmission in rural areas of Nepal. Such has not occurred, primarily because they did not return to any large commercial sex networks. "We" are still awaiting the other shoe to drop and it may never drop because of the generally low infectivity of HIV from an infected female to a susceptible male.]

Aug 16 (Somalia) - Increased sexual violence raises HIV concerns (PLUSNEWS)
http://www.reliefweb.int/rw/RWB.NSF/db900SID/EMAE-765PG2?OpenDocument

Escalating violence in Somalia is increasing the incidence of sexual attacks against women and girls and heightening their risk of HIV infection, say humanitarian workers based in the region..."We are convinced that sexual and gender-based violence, which is a symptom of the lowly status of women and their lack of negotiating power, is a driver of the Somali HIV epidemic," said Leo Kenny, country director of UNAIDS Somalia...

[Comment - Sexual violence is a terrible problem in its own right and may often result in HIV transmission, but such reprehensible behavior is not the primary or even a major driver of HIV epidemics in sub-Saharan Africa. A recent study found that regions in Africa suffering from conflict, genocide and mass rape, such as Rwanda, Congo and Angola, are no more likely to be affected by HIV than peaceful countries such as Botswana or Swaziland, which have the world's highest rates of HIV (Spiegel et al. Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review. Lancet 2007; 369:2187-2195).]

Aug 16 - Pakistan's "window of opportunity" to prevent HIV
http://www.dailytimes.com.pk/default.asp?page=2007%5C08%5C16%5Cstory_16-8-2007_pg7_21

As a major World Bank-sponsored conference on AIDS-HIV in South Asia gets underway in Sri Lanka this month, the bank says Pakistan still has a "window of opportunity" to act decisively to prevent the spread of HIV. The banks says that although the estimated HIV burden is still low at around 0.1 percent of the adult population, there has been an outbreak of HIV among injecting drug users (IDUs) in Sindh. Without vigorous and sustained action, Pakistan runs the risk of experiencing the rapid increase in HIV among vulnerable groups seen elsewhere. According to UNAIDS estimates, about 85,000 people, or 0.1 percent of the adult population in Pakistan, are infected with HIV...There are serious risk factors that put Pakistan in danger of facing a rapid spread of the epidemic if immediate and vigorous action is not taken, the bank warns...

[Comment - I recall a trip in 1988 to the WHO regional offices in Manila (WPRO) and Delhi (SEARO) with Jon Mann to try to kick-start some aggressive HIV prevention programs in Asia with the rhetoric that "the window of opportunity" for AIDS prevention in Asia was fast closing. Apparently, the window is still open almost a couple of decades later - OR - the potential for HIV to jump into the "general" population and spread extensively is slim to none, even though there clearly has been some epidemic HIV transmission in IDU and MSM networks in Pakistan. Perhaps Pakistan did not get the message in 1988 because even though it is geographically in Asia, it is assigned to the Eastern Mediterranean regional office (EMRO) of WHO. I have never been to Pakistan, and I haven't ever reviewed or evaluated the HIV/AIDS situation there in any detail, but I'll bet that the estimated 85,000 HIV infections is a tad high!]

Aug 14 - Kenya's HIV Prevalence Decreases, National AIDS Control Council Says - http://www.medicalnewstoday.com/articles/79802.php

 "Kenya's Aids prevalence rate dropped to 5,1% last year from 5,9% in 2005, mainly due to the increased roll-out of antiretrovirals (ARV), the national Aids council said Tuesday.  The state-run National Aids Control Council (NACC) said the growing use of life prolonging therapy averted about 57 000 deaths in 2006..."

[Comment - It's clear that the Kenyan National AIDS council does not understand the epidemiologic significance of a decreasing HIV prevalence rate. The prevention of 57,000 AIDS deaths would increase HIV prevalence not decrease prevalence!

Aug 12 - (India) - Crippling Corporate (Economic Times India)
Crippling Corporate

"...even if the present prevalence rate is taken into account, the potential costs to the economy arising from the continued and unchecked march of the HIV epidemic could be quite high, according to a report on the macro-economics and sectorial impacts of HIV and AIDS in India... The study, based on a CGE (computable general equilibrium) analysis of the likely impact of the epidemic over a 14-year period between 2002-03 and 2015-16, shows that with an unchecked spread of the HIV and AIDS epidemic in India, the country's achievements in terms of economic growth in the next 10-15 years will be noticeably less than its potential."

[Comment - A few years ago, when HIV prevalence in Thailand was estimated at close to 3% of the 15-49 year old population, a well respected American academic economist projected the economic impact of AIDS on the Thai economy. His conclusion was that AIDS would have minimal impact on the macro-economy of Thailand, BUT he also said that if HIV prevalence in Thailand were to increase 10 fold (by an order of magnitude!), then AIDS would have a severe impact on the Thai economy. This Indian economic report is almost the same as the Thai report. Economists have taught me that if you multiply two small numbers you get a relatively small sum, BUT, if you multiply two very large numbers, you will surely get a much larger sum! I now know why the World Bank chose not to use my report (which they paid me to prepare in 2003) analyzing the prospects for severe HIV epidemics in the Bank's Asia region. I said that the prospects for severe HIV epidemics (other than those that had already occurred during the 1980s and 1990s) were slim to none. Their staff preferred the "gathering storm" or "next wave" HIV scenarios for Asia!]

Aug 9 - (PNG) - Outgoing PNG Health Minister calls new HIV figures unrealistic
http://www.rnzi.com/pages/news.php?op=read&id=34296

Papua New Guinea's outgoing health minister, Sir Peter Barter, says new figures showing a decrease in the prevalence of HIV are unrealistic. Estimates by government health agencies and overseas partners show an HIV prevalence rate among adults aged 15 to 49 years of just under 1.3 percent. Sir Peter says while the new data is better than any previous data collected, it was taken over too few testings to produce a realistic figure. He says the rate could be as high as three percent. "The actual figures that we've been able to obtain through fairly accurate means over the limited number of people being tested comes down to 1.28, which unfortunately whilst it sounds good because it's lower than the 1.7 that's been commonly thought - we don't believe that the figures are, in reality, true because we need to do a lot more testing." Sir Peter says the new figures show the prevalence rate is levelling off in urban areas but spiralling in rural areas.

[Comment - Papua New Guinea (PNG), had up to early August of this year, the dubious distinction of having the highest estimated HIV prevalence rate in the Asia-Pacific region. In 2005, UNAIDS made or accepted HIV prevalence estimates of 1.8% for the adult population in PNG, 1.6% for Cambodia, and 1.4% for Thailand. As a result of a recent national HIV prevalence estimation meeting or workshop with invited international experts, the HIV prevalence rate in PNG was lowered to 1.28% (a decrease of almost 30%). Unless Thailand can somehow lower its HIV prevalence estimate below 1% as Cambodia did last year because of the findings of a 2006 DHS+ study, PNG has for now slipped below the Thai prevalence rate of 1.4%.

The PNG revision of its HIV prevalence estimate was not due to any population based survey data but more likely due to more careful extrapolation of the available HIV data, i.e., by paying close attention to the overestimation bias inherent in mostly urban HIV data. However, the outgoing Minister of Health, Sir Peter Barter was clearly skeptical about the lowered estimate.

Last year, UNAIDS had to acknowledge that annual global HIV incidence (i.e., new HIV infections) peaked by the late 1990s. In fact, annual HIV incidence peaked in most regions by the mid-to-late 1980s or by the mid-1990s, and annual incidence in sub-Saharan Africa (SSA) was the last to peak - by the late 1990s. As a result, HIV prevalence in most countries has been either relatively level/stable or decreasing since the mid-1990s and in most countries in SSA since about the year 2000. There may be some exceptions and PNG may be one of them if sexual risk behaviors in rural areas are higher than they are in urban areas. I'm skeptical of Sir Peter's skepticism, but only future estimation of HIV prevalence in PNG using a consistent methodology will answer the question of whether HIV prevalence is increasing or decreasing.

The PNG situation is similar to that in China, where there has also been a marked reduction of the estimated HIV prevalence as a result of more and more reliable HIV data. Nevertheless, an unshaken belief persists among some Chinese and international AIDS "experts" that HIV prevalence in China is still increasing and HIV is "on the brink" of spreading into the "general" population! It is difficult for most AIDS advocates and activists to accept the reality that the patterns and prevalence of sexual risk behaviors in most general populations are insufficient to start or sustain epidemic (Ro >1) heterosexual HIV transmission.]

Aug 8 - South Africa reports slight decline in HIV prevalence among pregnant women (Reproduced from PLUS NEWS)
http://www.aidsmap.com/en/news/046870C1-4950-4188-8517-43A6BCBD76B0.asp

- After a steep increase in the 1990s, and several years of plateauing, South Africa's HIV prevalence may finally have entered a phase of decline. The first evidence of this downward trend comes from the government's 2006 National HIV and Syphilis Survey, which tested more than 33,000 pregnant women at antenatal clinics in all nine of the country's provinces....Introducing the report at a press conference in Johannesburg, Tshabalala-Msimang described the new figures, as "a good indicator of the impact of the country's prevention programmes".

[Comment - When HIV prevalence plateaus (i.e., peaks and is then relatively level or stable), annual HIV incidence (new infections) had to have peaked at least several years before. There are many reasons why HIV incidence peaks and one of the major reasons is saturation of infection in those persons in the population with the highest HIV risk behaviors. As detailed in the last section of my Chapter on HIV Prevention in my book, "How much of any decrease in annual HIV incidence might be attributed to public health prevention programs and how much to a natural decrease can and will definitely be the subject for heated debate for the rest of this decade." South Africa's Minister of Health is trying to "ride to glory on the down slope of the HIV epidemic curve."]