Introduction

IN THE FIVE YEARS since the International Conference on Population and Development (ICPD) held in Cairo, the AIDS epidemic has worsened dramatically. The numbers infected with HIV to date are even greater than was predicted at that time, and in some countries the epidemic is frankly out of control.

A cumulative total of 47 million people have contracted HIV since the pandemic began, and some 14 million people have died of AIDS, leaving more than 33 million living with the virus by the end of 1998. Last year alone, there were nearly 6 million new infections, which means that every minute of every day 11 people contracted the virus.

Sub-Saharan Africa remains the epicentre of the pandemic, with nearly 23 million men, women and children infected with HIV. But the spotlight is now turning on the Asian continent, where an estimated 7 million people are already infected and the virus has begun to take off in earnest in the world’s most populous countries, India and China. Eastern Europe too presents an extremely alarming picture. At the time of the Cairo conference, only an estimated 30,000 of the region’s 450 million people were HIV-infected, compared with 15 times that number in Western Europe and 400 times as many in sub-Saharan Africa. But in the last four years there has been a six-fold increase in HIV infections in the region as a whole - and an astronomical 70-fold increase in Ukraine alone. In the Russian Federation, too, the number of infected people has increased - 27-fold between 1994 and 1997.

At the same time there have been marked changes in the pattern of spread of HIV. The proportion of women among those infected has been rising inexorably, so that, on a global scale, women accounted for 43% of all infected people in 1998. The risk is increasing for women in developed and developing countries alike.

Thus in France, women’s share of reported AIDS cases rose from 12% in 1985 to 20% ten years later. In Spain, female AIDS cases rose from 7% to 19% of all AIDS cases during the same period. And in Brazil, the proportion rose from just 1% in 1984 to 25% ten years later. Not surprisingly perhaps, the number of babies who acquire HIV from their infected mothers before or during birth or from breastfeeding has also been rising dramatically. Globally, one in ten of those who became newly infected during 1998 was a child under the age of 15 years.

However, in countries where HIV has its strongest stranglehold the virus is now spreading fastest among young people between the ages of 10 and 25 years. This is partly because high rates of infection in the general population mean that young people are likely to encounter infected partners early in their sexual careers. On a global scale, over half of all new infections past infancy today are in people under 25 years, very many of them still teenagers.

Despite this grim picture, the global response has increased enormously in sophistication, effectiveness and scope over recent years. This has been made possible by an expansion in the numbers of people who have joined the fight against AIDS and the great diversity of skills and expertise they have contributed to the effort. It has relied on imaginative partnerships, close collaboration and dynamic leadership. During this period, the Joint United Nations Programme on HIV/AIDS (UNAIDS) itself was created, to focus and strengthen the work of the six UN agencies most active in the field of HIV/AIDS, and to drive and support the global response (see box).

Today AIDS is being tackled on a multitude of fronts. Because mother-to-child transmission (MTCT) of HIV and infection among young people are the epidemic’s new trends, UNAIDS is giving these issues the highest priority for action. This report will discuss these trends and the strategies we must adopt to reverse them. Moreover, many of the issues raised in the ICPD Programme of Action as being central to the quest for reproductive health also carry high priority for UNAIDS because they are of direct relevance to AIDS prevention and care for mothers, infants and young people. They include:

· the empowerment of women and other measures to improve their social and economic status;

· the importance of gender influences, and the role of men in promoting reproductive health and rights;

· the reproductive health and rights of adolescents and young people;

· the need to expand coverage of primary health care, with special attention to quality of services, equity of access, and relevance to women and young people;

· the central role of human rights, especially reproductive rights, in protecting and promoting health;

· the role of civil society and imaginative partnerships in reproductive health.

This report will discuss what makes women, babies and young people specially vulnerable to HIV, and describe the strategies that have been developed to meet their needs, the work going on at present, and the future challenges. And drawing lessons from experience and examples from the field, it will identify successful approaches to HIV prevention. It is clear today, however, that HIV/AIDS is a social and development problem as well as a medical one: fighting this most complex of diseases requires constant reappraisal of strategies in the light of new knowledge.

THE BIRTH OF UNAIDS