By Charlene Laino
MSNBC

At a time when many young adults who didn’t live through the first devastating years of the AIDS epidemic are growing complacent about the disease, the United Nations warned Tuesday that the worst is yet to come.

TWENTY-ONE YEARS into the epidemic, AIDS has yet to peak, according to the report, which UNAIDS called its first official projection of the extent of the pandemic.
The virus continues its rampant spread into many of the world’s most populous countries, including India, China and Indonesia, the report said. Meanwhile, a return to unsafe sex among younger adults in Europe and North America is leading to higher rates of infection there.
Already, the number of people infected with HIV in the hardest hit countries of southern Africa is higher than believed possible, the report said. Russia and Eastern Europe are suffering from the greatest increase in new infections.
“We have grossly underestimated how bad this was going to be,” said Dr. Peter Piot, executive director of UNAIDS.
The bottom line: Unless the tide is turned, nearly 70 million people will die of AIDS-related diseases in the next 20 years — more than five times the number of deaths in the first two decades of the epidemic, the report said.

BETTER STATISTICAL MODELS
How could the United Nations so vastly underestimated the extent of the epidemic in the past?
Traditional statistical modeling techniques just didn’t work, said Neff Walker, senior epidemiologist at UNAIDS. “Everytime we did our modeling work, we’d say, ‘The epidemic has reached its peak.’ And then the next year, there would be even more cases.
“What we failed to capture were things like people moving in and out of risk categories,” Walker said. “For example, a 25-year-old-man who is happily married was not at risk; he turns 30 or 35, his spouse dies and he is at risk, just because the HIV prevalence is so high.
“Now that we better understand the epidemic, we can better predict its extent.”
The report was released Tuesday in advance of the International AIDS Conference, which begins this weekend in Barcelona.
Please check back for MSNBC.com’s and NBC’s onsite coverage of the International AIDS Meeting in Barcelona, beginning Saturday July 6.
Many of the 40 million people now infected worldwide live in developing nations, where only 4 percent of those who need antiviral drugs have access to them, according to UNAIDS.

SOME ENCOURAGING NEWS
Not all the news is bad: The world is finally waking up to what it will take to bring the epidemic under control, Piot said.
Almost 100 countries now have national AIDS strategies in place, and dozens have established national AIDS commissions. Several nations have achieved success in slowing the spread of HIV within their borders, the report said.

In Zambia, for example, the number of new infections is falling among young women. And in Uganda, Africa’s greatest success story in the fight against AIDS, the number of new annual infections decreased from 8.3 percent in 1999 to 5 percent in 2001.
By mounting a strong national response, Poland has successfully curtailed the epidemic among IV drug users and prevented it from gaining a foothold in the wider population, Piot said.

FUNDING STILL FALLS SHORT
But outside of Poland, Eastern Europe has the world’s fastest growing rate of infection, with 250,000 new cases last year.
Overall, funding earmarked for fighting the epidemic has increased six-fold since 1998. But it still falls short: About $3 billion in 2002, compared with the $10 billion a year Piot said is needed to combat AIDS.
The report also downplayed theories that the number of infected people is leveling off in the hardest hit countries of southern Africa.

In Botswana, the country with the world’s highest infection rates, 39 percent of adults are now living with HIV, up from less than 36 percent two years ago. In Zimbabwe, one in four adults was HIV-positive in 1997; now, one in three is infected. And, in a number of southern African countries, up to one half of new mothers could die of AIDS.
Elsewhere, the report said India is now home to more infected people than any other country except South Africa — almost 4 million.
In Indonesia, the world’s fourth-most populous country, infection rates are rising rapidly, following a decade of negligible HIV prevalence. At one Jakarta drug treatment center, for example, four in 10 tested positive.

In a separate report released last week, UNAIDS warned that China is on the brink of an explosive HIV epidemic, with 10 million people projected to be infected by the end of the decade.

YOUNG PEOPLE AT RISK
As AIDS continues its grim march around the planet, young people are at greatest risk, Piot said. Today, approximately half of all new adult infections are among those ages 15 to 24.
Already, 12 million young people are living with HIV, Piot said, and 6,000 more become infected every day. Additionally, 14 million children living today have lost one or both parents to AIDS — a number that continues to grow.
A separate UNICEF survey, also released Tuesday, found that more than half of those ages 15 to 24 don’t know how HIV is spread or how to how to protect themselves.

A RETURN TO UNSAFE SEX
In the United States, Australia and countries of Western Europe, an apparent increase in unsafe sex is triggering higher rates of sexually transmitted infections and in some cases, of HIV disease as well, the report said.

In the United Kingdom, for example, nearly half of the 3,400 new HIV infections diagnosed in 2000 — an increase over previous years — resulted from heterosexual sex, the report said.
In Los Angeles, a syphilis outbreak among homosexuals confirmed warnings that safe sex was on the decline there.
“Widespread risk taking is eclipsing the safer-sex ethic promoted so effectively for much of the 1980s and 1990s,” he said.

The findings are consistent with those of the U.S. government, which has reported that HIV is spreading at alarming rates among urban gays who are too young to recall the beginnings of the AIDS epidemic.
The culprit, U.S. officials said, appears to be a growing complacency among young American men growing up in an era when potent drug combinations can keep the virus in check.
“There’s a rekindled sense of urgency,” said Dr. Ronald Valdiserri, deputy director of the U.S. Center for Disease Control and Prevention’s HIV, STD and TB programs. “We face new challenges in stemming the tide, challenges that point to the need for collaborative efforts.”

Charlene Laino is Executive Health Editor of MSNBC.com.

HIV/Aids has had a devastating impact on millions of lives worldwide over the past 20 years. However, a United Nations expert tells BBC News Online's Mangai Balasegaram that the virus is likely to tighten its grip still further.

Few people took note when, on 5 June 1981, a US Government bulletin noted a strange disease ravaging a number of gay men in Los Angeles.

Nobody could have foreseen then how the disease, soon to be named Acquired Immunodeficiency Syndrome (Aids), would take its grip on the world.

Within months of that report, the US Centers for Disease Control (CDC) had already declared it had an epidemic on its hands.

And now, 20 years later, with no real cure and no vaccine still, the toll of Aids has been staggering - 22 million people are known to be dead, and that figure is just a fraction of those living with the virus.

And the huge majority of those infected don't even know it, says the United Nations' Aids agency (UNAids), meaning they may unknowingly infect others.

According to the CDC, almost half a million Americans have died from Aids - almost 10 times as many as those who lost their lives in Vietnam.

Last year, the US government declared Aids a threat to national security.

But the brunt of the disease has been borne in Africa, where Aids has etched such a deep impression that it has reshaped economies and populations.

Up to 30% of adults are infected in many sub-Saharan countries, and one in nine of all South Africans is infected.

"The worst is yet to come," says Dr J Garcia Calleja, an epidemiologist with UNAids.

"There's no reason to think the situation is going to improve [in the short term]."

Behaviour change

The tremendous impact of the disease has not been confined to death tolls but has also altered the social landscape through behaviour change.

The carefree abandon of the sexual revolution of the '60s has given way to a generation grilled with safe sex messages.

Countries that once shied from discussing sex publicly, such as Thailand, now routinely talk about condoms.

Like a Pandora's box, Aids has also exposed deeply-hidden or marginalised behaviour, including drug injection, prostitution and homosexual sex.

And the disease has also helped spur huge advancements in the understanding of the immune system and viruses.

Politics and inequality

The scientific progress has not been enough to tackle Aids however, becausethe shape and scale of the epidemic has driven by social inequalities and directed by politics.

Poverty, large-scale migration, war, poor educational levels and untreated sexually transmitted diseases have all fuelled the epidemic.

Governments have also been deeply reluctant to grapple with certain social problems, such as drug use, which lies behind the bulk of new HIV infections in many countries, including Russia, Vietnam and Malaysia.

The epidemic in most Asian countries also first began among drug users, where infection rates soared from 1% to 40% among some drug injecting communities in just one year.

Africa's burden

Africa though, has been the most blighted by Aids.

"Everybody [there] has some relative who is affected with HIV," says Dr. Calleja.

"It has strained health services and reduced life expectancy."

Zimbabwe will have zero percent population growth next year due to Aids.

As Aids affects young and mobile adults, the disease has a socioeconomic impact, which has been felt by some industries, such as mining and banking, where there has been a problem with labour supply.

In some villages in the continent, a generation of adults has almost been wiped out; with their children made into orphans.

Experts say what has happened in Africa, which took two decades, is only just beginning in Asia, where the disease is still very young.

New infections in China, for example, have only been seen in the last two years. A huge blood scandal which has infected hundreds of thousands in the country is now only unfolding.

Twenty years after the advent of Aids, we may be only seeing the beginning