James Chin* explains the current erroneous figures and prevailing assumptions about the HIV/AIDS pandemic Many controversies concerning the AIDS pandemic are spread by the Joint United Nations Programme on HIV/ AIDS (UNAIDS) and other mainstream AIDS agencies and activists, either unintentionally out of ignorance or intentionally by distortion or exaggeration, including fear of a generalised epidemic. UNAIDS continues to perpetuate the fallacy that only aggressive HIV/AIDS prevention programmes -- especially directed at youth -- can prevent the eruption of heterosexual HIV epidemics where prevalence is currently low. More than two decades of observation and analysis point to far different conclusions -- there are no "next waves" of HIV epidemics just around the corner and the AIDS pandemic is now in its post-epidemic phase. The highest HIV infection rates are found in many sub- Saharan African populations because up to 40 per cent of adolescent and adult males and females in these populations routinely have multiple and concurrent sex partners, and they also have the highest prevalence of factors that can greatly facilitate sexual HIV transmission. In most other heterosexual populations the patterns and frequency of sex-partner exchanges are not sufficient to sustain epidemic sexual HIV transmission. UNAIDS and most AIDS activists reject this analysis as socially and politically incorrect, saying it further stigmatises groups such as injecting drug users (IDU), sex workers and male homosexuals (MSM). However, all available epidemiologic data show that only the highest-risk sexual behaviour (multiple, concurrent and a high frequency of changing partners) drives HIV epidemics amongst heterosexuals or MSM, anywhere in the world. Most AIDS activists claim, without any supporting data, that high HIV prevalence in MSM and IDU groups will inevitably "bridge" over to the rest of the population and lead to "generalised" HIV epidemics. This entrenched myth persists even though there is little, if any, HIV spread into any "general" population except from infected IDU and MSM or bisexuals to their regular sex partners. Without a constant flow of alarming news releases warning about HIV being on the brink of spreading into general populations, AIDS activists fear that the public and policy- makers will not continue to give AIDS programmes the highest priority -- hence these "glorious myths", lies told for a noble cause. This alarmism goes against all the evidence. Global and regional HIV rates have remained stable or have been decreasing during the past decade (except possibly among drug users in Eastern Europe). HIV has remained concentrated in groups with the riskiest behaviour. Several decades of experience support the conclusion that HIV is incapable of epidemic spread among the vast majority of heterosexuals. Most of the public, policy- makers and media have no inkling that the UNAIDS working assumption is inconsistent with established facts -- indeed, until 2006, no major public health or international development agency had openly challenged this assumption. Some cracks in this wall of silence began to appear during 2006 with the publication of several studies which questioned the UNAIDS view. Since 2000, dozens of population-based HIV sero-surveys have forced UNAIDS to reduce its overestimates in most high-HIV-prevalence countries by around 50 per cent or more: examples include Kenya's estimate in 2001 of 14 per cent reduced to 6.7 per cent and Haiti's 2001 estimate of 6.1per cent reduced to 2.2 per cent in 2006. Estimates of HIV prevalence in China indicated a decrease and the current estimate of over five million HIV infections in India is likely to be cut by half or more as the result of recent, more accurate, studies. In 2007 UNAIDS needs to come up with more realistic HIV estimates and projections, especially when more mainstream epidemiologists and the news media begin to question the basis of the UNAIDS assumption. Continued denial of these realities will lead to further erosion of the credibility of UNAIDS and other mainstream AIDS agencies, raising the danger of people underestimating the real threats. Regardless of my epidemiologic disagreements with UNAIDS, I totally agree with mainstream AIDS experts who declare that this is no time to be complacent about strengthening HIV treatment and, above all, HIV prevention programmes. Although many countries have overestimated their numbers, there are now at least 20 million HIV-infected people in sub-Saharan Africa and several million in Asia and these numbers can be expected to remain close to these levels for a decade or more. AIDS is a severe problem in sub-Saharan Africa and to a lesser extent in Caribbean countries and a few South East Asian countries, as well as among MSM, IDU and sex workers throughout the world. This means that scarce health resources in countries with low HIV prevalence should be targeted primarily at those who are at the highest HIV risk instead of being misdirected to the wider public. We must cut through the overestimates of HIV prevalence and the exaggerated potential for generalised HIV epidemics so we can concentrate money and efforts on prevention and palliative care where it really matters. * The writer of the University of California at Berkeley is a former chief of the Surveillance, Forecasting, and Impact Assessment Unit of the Global Programme on AIDS of the World Health Organisation. His book The AIDS Pandemic: The Collision of Epidemiology with Political Correctness (Radcliffe, Oxford) was published in January.
