Global Policy Forum

By David Brown

The head of the United Nations' AIDS program warned yesterday that India, China and Russia are "perilously close to a tipping point" that could turn their small, localized AIDS epidemics into gigantic ones capable of disrupting the world's response to the disease. The situation in those three countries "bears alarming similarities to the situation we faced 20 years ago in Africa," Peter Piot, a Belgian physician and epidemiologist, told policymakers in Washington. It could transform "from a series of concentrated outbreaks and hot spots into a generalized explosion across the entire population -- spreading like a wildfire from there." If that happens, affecting both the global economy and international security, "no country on Earth will escape the impact," said Piot, who heads UNAIDS, a program run by U.N. agencies, the World Bank and the World Health Organization.

Many experts in recent years have publicly worried about the emerging AIDS epidemics in China and India, but Piot's warning was unusually ominous and concrete. He also drew a connection between AIDS prevention efforts in Asia and AIDS treatment efforts in Africa, which have sometimes been viewed as potential competitors for scarce resources. Specifically, he said, the laborious, expensive and overdue effort to bring antiretroviral therapy to millions on the continent where AIDS began could unravel if Africa-scale epidemics in India and China steal the world's attention.

Piot, who spoke at the Woodrow Wilson International Center on the eve of World AIDS Day, has observed the AIDS epidemic firsthand virtually from its start. In the early 1980s, he helped lead an international team of researchers in Zaire (now the Democratic Republic of Congo) that figured out -- even before the AIDS virus was discovered -- that the disease could be spread by heterosexual intercourse. In making his remarks yesterday, he shared a podium with Randall L. Tobias, director of the Bush administration's global AIDS activities. None of the three large countries Piot discussed is among the 15 "focus countries" targeted by the $15 billion President's Emergency Plan for AIDS Relief.

In emphasizing the importance of China, India and Russia, Piot said he intended no slight to the administration's AIDS effort in 12 countries in sub-Saharan Africa, Haiti and Guyana in the Americas, and Vietnam. He called "the leadership and generosity of America . . . one of the most promising and heartening developments in years." But he warned: "If the epidemic gains a foothold in even a few states or provinces in China and India, and spreads there as it has in some African countries, the global resources now available for Africa could easily diminish, perhaps even vanish. If we hope to have the resources to treat the epidemic in the hardest-hit countries, we must prevent major epidemics in the most populous countries."

Piot noted that the prevalence of HIV infection among adults (people ages 15 to 49) is 0.1 percent in China, compared with 7.5 percent in sub-Saharan Africa. India also has extremely low prevalence, although it is second only to South Africa in the number of people infected -- 5.1 million vs. 5.3 million. Russia has about 860,000 people infected, out of the global total of 39.4 million people living with HIV. In all three countries, the HIV epidemic is confined almost entirely to high-risk groups -- injecting drug users, and prostitutes and their customers. When it breaks out of those groups into the general population of heterosexual adults is when the number of infected people begins to rise exponentially. "The tipping point is not a hypothetical construct," Piot told the audience at the Wilson Center. "In South Africa, it took five years for prevalence rates to move from 0.5 percent to 1 percent. Then, in only seven years, it jumped from 1 percent to 20 percent."

Tobias said the U.S. government has spent money on AIDS programs in all three countries Piot spoke of, including at least $30 million in India. Tobias does not believe the administration's program needs to be refocused to include them in larger ways, he said. "All three of those countries have the capacity to do a great deal for themselves," he said. "I think we need to encourage that to happen. We need to encourage the leadership, and make sure that each of those countries is doing everything it can to put this issue at the very top of the agenda." In particular, Tobias said, China, India and Russia need to work on destigmatizing HIV infection, a change that first requires government leaders to openly acknowledge the importance of AIDS. He said that, in his experience, how willing a taxi driver is to discuss AIDS on a ride from the airport "is one indicator of the degree to which the country at large has internalized the seriousness of the problem."

A study by UNAIDS and the Asian Development Bank released in July estimated that direct and indirect costs of HIV in India, Cambodia, Thailand and Vietnam totaled $7.3 billion in 2001. They will increase to $18 billion by 2010 if comprehensive prevention efforts do not begin now, the authors of the report wrote. With a comprehensive program, the number of new infections by 2010 can be reduced from 10 million to 4 million, and deaths could be cut from 760,000 to 660,000, they said.

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