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In most countries human immunodeficiency virus (HIV) infection initially spreads primarily through a group of core transmitters who are at particular risk. Sex between men may have a transmission rate as high as one in ten, depending on sexual practices. Transmission rates among intravenous drug users are high because a contaminated needle can introduce HIV directly into the bloodstream. Sex workers also have an elevated risk of contracting and transmitting HIV. HIV/AIDS (acquired immunodeficiency syndrome) often establishes itself in those highrisk groups before moving into the general population. As the mode of transmission shifts from sex between men and the sharing of needles by intravenous drug users, the rate of HIV diagnosis among women often increases dramatically, leading to greater numbers of children being born with HIV or orphaned by AIDS. HIV is most likely to be a generalized epidemic in poorer countries, which may lack the infrastructure, money, and political stability for effective wide-scale treatment and prevention.

In the United States HIV/AIDS first became widespread among populations of homosexual men, which suffered widespread fatalities in the early years of the epidemic. As a result AIDS long was considered a ''gay'' disease, and there is still a lingering perception that AIDS victims are most likely to be homosexual men. In later years, however, the nature of the epidemic changed noticeably. More than 50 percent of new HIV diagnoses have been among African Americans, and some three-quarters of women diagnosed with HIV are African American. The wide availability of antiretroviral therapy has led to a substantial decrease in AIDS deaths; African Americans, however, have substantially lower survival rates than does the white population. In 2002 the death rate of African Americans with AIDS was twice that of whites.

Sub-Saharan Africa bears a disproportionate burden from the AIDS epidemic; it is home to about 10 percent of world population but contains 60 percent of HIV cases worldwide. In Africa the epidemic is widespread and generalized, with most transmission occurring through heterosexual sex.

Widespread poverty, lack of infrastructure, inconsistent or ineffective prevention programs, expensive or unavailable treatment, and social and political upheaval have contributed to the spread of infection in many countries in that region. As a result the areas hardest hit by HIV/AIDS are often the least able to respond effectively. Because AIDS is most likely to kill people in the prime of life, local and national productivity has been affected seriously. Households with one or more AIDS victims often are strained by the loss of income and the need to provide care and treatment to the afflicted member; young children and the elderly often end up shouldering much of the burden. Local communities also are strained by AIDS deaths because extended families and elderly grandparents with limited resources often take in children orphaned by AIDS.

In many countries in Eastern Europe and Asia, HIV infections have been on the rise. The Ukraine experienced a tremendous upsurge in HIV diagnoses after 2000, with a significant incidence in women and the heterosexual population. Russia also has seen an increase in HIV cases, apparently linked to widespread intravenous drug use in its population. In several other countries in Eastern Europe, AIDS is spreading rapidly through intravenous drug users. The epidemic is expected to become more generalized as drug users begin transmitting the virus to their partners.

In many East Asian countries most new infections are transmitted by sex workers, who often cannot insist on condom use. In Thailand, however, a government mandate requiring universal condom use among sex workers has slowed the advance of HIV/AIDS dramatically. Because of the sheer size of many Asian nations, the raw number of HIV-infected individuals in that region is expected by some to overtake that of sub-Saharan Africa.

As HIV infection becomes increasingly generalized in a population, women tend to be affected disproportionately. Of the estimated 39.4 million HIV cases worldwide at the end of 2004, some 17.6 million were women. Almost 75 percent of those women lived in sub-Saharan Africa, where women accounted for 57 percent of HIV infections. Among young women in that region, the gap between male and female infections has been even more striking: It has been estimated that some thirty-six women between the ages of fifteen and twenty-four are infected for every ten men in the same age group.

The increased infection rates among women may be in part biological--evidence suggests that it may be easier for men to transmit HIV to women than vice versa--but it is often also a reflection of the relative status and power of women in a society. Researchers in sub-Saharan Africa, for example, have noted that HIV transmission among women is accelerated in societies in which large numbers of women are not in a position to refuse sex or to insist on safe sex, for example, when they are physically or economically dependent on a male head of household's earnings, gifts from a lover, or earnings from prostitution. In countries stricken by warfare increases in the number of rapes also help spread infection. In societies in which the economic and social status of women has risen, researchers have found that transmission rates tend to drop.

As of the end of 2004 some 2.2 million children were infected with HIV. Although many children are infected by their mothers, several countries have seen a marked increase in early sexual activity among children, making that population more vulnerable to HIV infection. Additionally, some children are infected in the course of sexual molestation and abuse by adults. In addition to those directly infected by HIV, millions of children worldwide have been orphaned by AIDS. It appears that some 11 million children or more are AIDS orphans; that number was projected to more than triple by 2020.

Societies that have large numbers of orphans are also those which have few institutional structures to help care for them. In sub-Saharan Africa, which is home to some 12 percent of orphans worldwide, extended families traditionally have shouldered the burden of caring for the children of deceased relatives, often straining already tight resources. Members of families that have taken in orphans are more likely to be malnourished and their children and foster children are more likely to be stunted. Orphans often have increased responsibilities at home, are less likely to attend school, and are more likely to do poorly when they do attend. Lack of resources to care for orphaned children probably will affect a region or nation over the long term as malnourished and uneducated children grow into an unskilled adult population with a variety of health problems.

Reference:

Barnett, Tony, and Alan Whitehead. 2006. AIDS in the Twenty-First Century: Disease and Globalization. 2nd edition. New York: Palgrave Macmillan.

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