HIV/AIDS in the Developing World U.S. Agency for International Develop -ureaii for Global Programs. Field Support, arid Researc, - Office ol Health andvNutritJOT economics ana i>tatist« BUREAU Acknowledgments HIV/AIDS in the Developing World was prepared in the International Programs Center (IPC), Population Division, Bu- reau of the Census, under a Participating Agency Service Agreement with the U.S. Agency for International Development. The report was produced under the gen- eral direction of James C. Gibbs, As- sistant Center Chief for Demographic and Economic Studies. Many persons on the Center's staff shared in the preparation of the demo- graphic estimates and projections, as well as other activities, upon which this report is based. Eduardo E. Arriaga, Special Assistant for International Demographic Meth- ods, provided guidance in determining the method used for incorporating AIDS mortality into population estimates and projections. Staff of the Health Studies Branch as- sisted in the preparation of this report including Jinkie Corbin, John Gibson, Lisa Mayberry and Anne Ross. The HIV/AIDS Surveillance Data Base, which provides the basis for incorporat- ing AIDS mortality into population pro- jections, is maintained by the Health Studies branch under the direction of Karen A. Stanecki. The discussion in Appendix A of the methodology for incorporating AIDS mortality into projections was written by Peter O. Way Under the direction of Walter C. Odom, the staff of the Administrative and Cus- tomer Services Division performed publi- cation planning, editorial review, design, composition, and printing planning and procurement. Nelsa Brown provided pub- lication coordination and editing. Janet Sweeney prepared the graphics and docu- ment design. We are grateful to national AIDS con- trol programs, national statistical of- fices and other national and interna- tional organizations worldwide, without whose generous collaboration this kind of report would not be pos- sible. Recognition is due to the United Nations Joint Programme on HIV/ AIDS. Finally, we wish to express our grati- tude to colleagues at the U.S. Agency for International Development for their support throughout the various stages of this project. We acknowledge with thanks the contributions of Paul DeLay, Chief of HIV- AIDS Division, Elizabeth S. Maguire, Director, Office of Population; Scott Radloff. Deputy Director; and Ellen Starbird, Chief, Policy and Evaluation Division. Special thanks are due to the Cognizant Technical Officer (CTO) on this project. David Stanton. WP/98-2 HIV/AIDS in the Developing World Pennsylvania State Univers% Libraries AUG 2 6 1999 Documents CoHectkw VS. Depository Cop? Issued May 1999 USAID ^<° F >, rXTTTXTl U.S. Agency for International Development Bureau for Global Programs, Field Support, and Research Sally Shelton-Colby, Assistant Administrator CENTER FOR POPULATION, HEALTH AND NUTRITION Duff Gillespie, Deputy Assistant Administrator \ LT: "^TES 0* ' U.S. Department of Commerce William M. Daley, Secretary Economics and Statistics Administration Robert J. Shapiro, Under Secretary for Economic Affairs BUREAU OF THE CENSUS Kenneth Prewitt, Director JSaa ECONOMICS AND STATISTICS ADMINISTRATION USAID mania Economics and Statistics Administration Robert J. Shapiro, Under Secretary for Economic Affairs BUREAU OF THE CENSUS Kenneth Prewitt, Director William Barron, Deputy Director Paula J. Schneider, Principal Associate Director for Programs Nancy M. Gordon, Associate Director for Demographic Programs POPULATION DIVISION John F. Long, Chief Bureau for Global Programs, Field Support, and Research Sally Shelton-Colby, Assistant Administrator CENTER FOR POPULATION, HEALTH AND NUTRITION Duff Gillespie, Deputy Assistant Administrator Suggested Citation U.S. Bureau of the Census, Report WP/98-2, HIV/AIDS in the Developing World, U.S. Government Printing Office, Washington, DC, 1999. For sale by Superintendent of Doeuments. U.S. Government Printing Office. Washington. DC 20402. Contents Highlights 1 Introduction 3 HIV/AIDS in the Developing World 5 Appendix A. Population Projections Incorporating AIDS A-l Appendix B. References B-l Appendix C. Glossary C-l Figures 1. Crude Death Rate With and Without AIDS for Selected Countries: 1998 and 2010 10 2. Infant Mortality Rate With and Without AIDS for Selected Countries: 1998 and 2010 1 1 3. Child Mortality Rate With and Without AIDS for Selected Countries: 1998 and 2010 12 4. Growth Rate With and Without AIDS for Selected Countries: 1998 and 2010 13 5. Population Size With and Without AIDS for Selected Countries: 1998 and 2010 14 6. Life Expectancy With and Without AIDS for Selected Countries: 1998 and 2010 15 7. HIV Seroprevalence for Pregnant Women in Selected Urban Areas of Africa: 1985-1997 16 8. HIV Seroprevalence for Pregnant Women in Selected Urban Areas of Asia: 1990-1997 16 9. HIV Seroprevalence for Pregnant Women in Selected Urban Areas of Latin America: 1986-1997 17 Appendix A. Population Projections Incorporating AIDS A-l. Three Scenarios and Empirical Trend in Urban Female HIV Seroprevalence A-9 A-2. Three Scenarios and Empirical Trend in Total Female HIV Seroprevalence A-9 A-3. Projected HIV Seroprevalence for Selected Countries of Africa A-10 A-4. Projected HIV Seroprevalence for Uganda A-10 Tables 1. Demographic Indicators With and Without AIDS: 1998 8 2. Demographic Indicators With and Without AIDS: 2010 9 Appendix A. Population Projections Incorporating AIDS A-l. Empirical Seroprevalence Data for Selected Countries A-l U.S. Census Bureau U.S. Census Bureau Highlights As of the end of 1997, the United Nations Joint Programme on HIV/ AIDS estimated that over 40 million people had become infected with HIV since the beginning of the pan- demic in the late 1970s and that over 1 1 million of these people had al- ready died. AIDS has cut life expectancy by 4 years in Nigeria, 18 years in Kenya and 26 years in Zimbabwe-only a few of the countries where mortality from the disease is having a major demographic impact. AIDS results in higher mortality rates in childhood, as well as among young adults where mortality otherwise is low. As a re- sult, AIDS deaths will have a larger impact on life expectancies than on some other demographic indicators in these nations. Infant and child mortality rates in the most severely affected countries are higher due to AIDS, reversing the declines that had been occurring in many countries during the 1970s and 1980s. Over 30 percent of all children born to HIV-infected moth- ers in Sub-Saharan Africa will them- selves become HIV infected. In spite of the massive impact on the numbers of deaths in the most se- verely affected countries, population growth rates will remain positive in the year 2010 although some will be near zero. In 21 African countries more than 5 percent of the urban population is HIV positive. HIV/AIDS epidemics continue to spread in Sub-Saharan Africa, particularly in Botswana and South Africa. Other severely affected countries include Namibia, Swaziland, Zambia and Zimbabwe, where 19 to 25 percent of all adults are HIV-positive. The HIV pandemic in Asia is ex- tremely diverse ranging from no evi- dence of HIV epidemics in some countries such as Mongolia and South Korea to countries such as Thailand and Burma with 2 percent of adult populations now HIV posi- tive. In Latin America and the Caribbean, Guyana, Haiti, Honduras and Brazil are also seeing the impacts of AIDS mortality. U.S. Census Bureau U.S. Census Bureau Introduction Two demographic events have occurred in the second half of the twentieth century that have softened the surge in human numbers. The first is the progressive decline in fertility levels that has occurred, particularly in the world's developing regions, since the early 1960s. The second event is the emergence of the global HIV/ AIDS pandemic, which has raised mortality and slowed growth in every world region, but with the greatest impacts in a number of Sub-Saharan African, Asian and Latin American nations. HIV/ AIDS has had, and continues to have, substantial and sometimes dramatic impacts on mortality levels in countries most seriously affected. However, AIDS will not overcome the momentum of population growth at the regional level, even in Sub-Saharan Africa. This will be true particularly if changes in behavior, already observed in some settings, bring about an early curtailment of HIV infections in affected countries. Current estimates indicate over 40 million people have become infected with HIV since the beginning of the pandemic in the late 1970s, and over 11 million of these people have already died. While the majority of the infections have occurred in Sub-Saharan Africa up to now, the spread of the disease in Asia during the coming years may result in many more infections in that region than in Sub-Saharan Africa. This report provides an update on one of the key international health and demographic events of our time, and a source of some of the uncertainty associated with demographic change in the coming decades— the worldwide HIV/ AIDS pandemic. Originally proposed as the focus chapter of the Census Bureau's World Population Profile: 1998, this report includes information on the impact of AIDS on mortality and population. In addition, the report reviews the current status of the HIV/ AIDS epidemics in Africa, Asia, and Latin America. This report presents the methodology and results of incorporating AIDS mortality into the U.S. Census Bureau's population estimates and projections for severely affected countries of the world. The available information and the methodology and assumptions used for incorporating AIDS mortality into the population estimates and projections are described in Appendix A. Questions about the demographic impacts of the HIV/ AIDS pandemic, presented in this report, or about the methodology employed in estimating those impacts may be directed to: Chief, Health Studies Branch, International Programs Center, Census Bureau, Washington, DC 20233-8860. U.S. Census Bureau This report is available on the Census Bureau web site as the focus chapter in World Population Profile: 1998. The web address is: http://www.census.gov/IPC/www/wp98.html. The data presented in this report draw upon informa- tion stored in two databases maintained and annually updated by the International Programs Center of the U.S. Bu- reau of the Census (IPC). IPC compiles, evaluates, electronically stores and analyzes selected demographic and health data for all countries. IPC's Health Studies branch maintains the HIV/AIDS Surveillance Data Base, a compi- lation of information on HIV prevalence from all available studies from Africa, Asia, and Latin America. The Interna- tional Data Base (IDB) contains statistical tables providing demographic and socioeconomic data for all countries of the world. • The HIV/AIDS Surveillance Data Base includes all available epidemiological information on HIV/AIDS seroprevalence and incidence for countries in Africa, Asia, Latin America and from select New Independent States taken from the scientific literature and from unpublished reports prepared for international conferences and vari- ous workshops. The current update of the data base contains nearly 40,000 individual data records drawn from over 4,000 publications and presentations. The HIV/ AIDS Surveillance Data Base can be obtained free of charge on CD-ROM or diskette from the Health Studies Branch, or downloaded from the Internet at: http://www.census.gov/ipc/www/hivaidsn.html Requests for specific data items, CD-ROM or diskettes, or questions about the HIV/AIDS Surveillance Data Base should be directed to: Chief, Health Studies Branch International Programs Center Bureau of the Census Washington, DC 20233-8860 USA Telephone: 301-457-1406; FAX: 301-457-3034 Internet e-mail: ipc-hiv@census.gov • The International Data Base contains information derived from censuses and surveys (for example, population by age and sex, labor force, and contraceptive use) and administrative records (for example, registered births and deaths) for selected years from 1950 to the present. Some variables are available by urban/rural residence. The IDB contains the International Programs Center's current estimates and projections of fertility, mortality, migration and population on a single-year basis to the year 2020, and for every fifth year from 2025 through 2050. IDB esti- mates and projections may be more recent than those presented in this report, which are current to September 1997. Direct access and further information about the IDB are available through the Internet at: http://www.census.gov/ipc/www/idbnew.html Requests for specific data items from, or questions about, the IDB should be directed to: Chief, Information and Research Branch Bureau of the Census Washington, DC 20233-8860 USA U.S. Census Bureau HIV/AIDS in the Developing World U.S. Census Bureau U.S. Census Bureau HTV/AIDS in the Developing World Well into the second decade of the HIV/ AIDS pandemic, AIDS mortality is hav- ing major demographic impacts on populations in countries where the epi- demic is most severe. • Crude death rates are higher • Improvements in infant and child mortality rates have been reversed • Population growth has slowed • Life expectancies have fallen The HIV/AIDS epidemics continue to develop in Sub-Saharan Africa. Many can be described as generalized with high (over 5 percent) HIV prevalence in general adult population and increasing urban to rural equalization of HIV prevalence. Although HIV seroprevalence levels have stabilized or declined in some urban areas (Uganda), in others the epidemics are increasing rapidly (Botswana, South Africa). Some countries initially spared are now see- ing increases in HIV seroprevalence (Nigeria, Cameroon). The most dramatic impacts will be in countries which had seen the most improvements in these in- dicators over the past two decades (Botswana and Zimbabwe). The HIV epidemics in Asia are ex- tremely diverse, ranging from countries with no evidence of an epidemic (Mongolia, South Korea) to countries with high HIV prevalence among popu- lations exhibiting high-risk behaviors as well as evidence of HIV prevalence in the general population (Cambodia, Burma, and Thailand). The HIV epi- demic in India varies from state to state, with high HIV prevalence levels in west and southern India, but low HIV seroprevalence levels in east and north- ern India. However, more data on HIV prevalence and trends, particularly from India and China, will be required to de- termine the scope of the epidemic and its demographic consequences in this region. HIV/AIDS is well established in the Caribbean and Latin American region but information is scarce. Current levels of HIV prevalence and subsequent AIDS mortality are having impacts on popu- lations in Guyana, Haiti, Honduras, and Brazil. The level of HIV prevalence in Guyana is similar to that seen in some Sub-Saharan African countries. HIV prevalence in Haiti has remained stable for several years — a pattern similar to the trends seen in the Democratic Re- public of Congo (Congo (Kinshasa), formerly Zaire). HIV epidemics in other countries can be described as either na- scent: few cases of AIDS and low HIV prevalence in high-risk groups in urban centers or as concentrated: high HIV prevalence in high-risk groups and low prevalence in general adult popula- tions. By the end of 1997, the United Nations Joint Programme on HIV/AIDS (UN AIDS) estimated that over 40 million people had become infected with HIV since the be- ginning of the pandemic in the late 1970s and that over 1 1 million of these people had already died. 1 The majority of the in- fections have occurred in Sub-Saharan Af- rica, but the increases that are occurring in Asia may result in more infections in that region than in Sub-Saharan Africa. AIDS Mortality Will Have Major Demographic Impacts The particular pattern of mortality due to AIDS is the reason for these major im- pacts. 23 All mortality indicators will be affected. Crude death rates and infant and child mortality rates will be higher than would have been expected without HIV/AIDS. The most dramatic differ- ence will occur in life expectancies, due to the increases in mortality in the young adult ages. For the 1998 round of population estimates and projections prepared by the Census Bureau, AIDS mortality was incorporated into those countries most severely affected by the AIDS pandemic: 21 African countries, 3 Asian countries and 4 countries in Latin America and the Caribbean. This report describes the impact of the HIV/AIDS pandemic on populations and the cur- rent status of the HIV/AIDS epidemics in selected countries in these regions of the world. 4 Crude Death Rates Are Higher The most direct impact of AIDS is to in- crease the number of deaths in popula- tions affected. Crude death rates, the number of people dying per 1,000 population, have already been affected by AIDS. By the year 2010, crude death rates will be considerably higher in those countries severely affected by HIV/AIDS epidemics than would have been expected without AIDS (Tables 1 and 2). : Bureau of the Census (1994). 'Stanecki and Way (1991). 4 See Appendix A for discussion of popula- tion projections incorporating AIDS. 'UNAIDS/WHO (1998:6). U.S. Census Bureau Table 1 . Demographic Indicators With and Without AIDS: 1998 Country Botswana Burkina Faso Burundi Cameroon Central African Republic Congo (Brazzaville) Congo (Kinshasa) CotedTvoire Ethiopia Kenya Lesotho Malawi Namibia Nigeria Rwanda South Africa Swaziland Tanzania Uganda Zambia Zimbabwe Brazil Guyana Haiti Honduras Burma Cambodia Thailand Growth Life Crude death Infant mortality Child mortality rate expectancy With Without rate rate (underage 5) With Without With Without With Without With Without AIDS AIDS AIDS AIDS AIDS AIDS AIDS AIDS AIDS AIDS 1.1 2.4 40.1 61.5 20.9 8.6 59.3 36.4 121.1 57.4 2.7 3.2 46.1 55.4 17.7 13.1 109.2 101.1 179.1 156.5 3.5 4.0 45.6 55.4 17.4 12.2 101.2 92.1 157.1 131.0 2.8 3.2 51.4 58.6 14.0 10.6 76.9 70.7 128.1 109.6 2.0 2.5 46.8 56.3 16.8 12.0 105.7 97.7 162.6 140.2 2.2 2.7 47.1 57.2 16.5 11.3 102.7 94.0 166.3 142.5 3.0 3.3 49.3 54.4 15.2 12.7 101.6 97.1 152.7 139.3 2.4 3.0 46.2 56.5 16.1 10.7 95.9 86.7 149.2 122.7 2.2 2.9 40.9 50.9 21.3 15.0 125.7 115.4 197.6 169.2 1.7 2.5 47.6 65.6 14.2 6.2 59.4 44.7 107.0 64.9 1.9 2.3 54.0 62.0 12.8 9.2 78.3 71.2 120.2 98.3 1.7 2.7 36.6 51.1 23.7 14.4 133.8 117.9 231.6 190.3 1.6 2.9 41.5 65.3 19.8 7.5 66.8 44.0 125.5 62.1 3.0 3.2 53.6 57.8 13.0 10.9 70.7 65.9 139.0 124.4 2.5 3.2 41.9 53.9 19.0 12.2 113.3 101.3 181.9 148.5 1.4 1.9 55.7 65.4 12.3 7.8 52.0 43.3 95.5 69.7 2.0 3.2 38.5 58.1 21.4 10.1 103.4 83.8 168.1 114.4 2.1 2.6 46.4 55.2 16.7 12.1 96.9 89.2 160.1 137.8 2.8 3.5 42.6 54.1 19.0 12.5 92.9 81.3 164.5 132.9 2.1 3.3 37.1 56.2 22.6 11.4 92.6 72.0 181.2 125.7 1.1 2.5 39.2 64.9 20.1 6.2 61.8 35.9 123.4 50.5 1.2 1.5 64.4 71.4 8.5 5.6 37.0 33.5 47.3 37.5 -0.5 -0.3 62.3 65.7 8.7 7.3 48.7 45.4 71.4 61.3 1.5 2.0 51.4 55.5 14.2 12.6 99.0 95.6 155.7 145.9 2.3 2 3 65.0 69.2 7.0 3.5 41.9 38.6 61.2 50.4 1.6 L.8 54.5 57.1 12.5 11.2 78.4 76.3 113.1 106.4 2.5 2.7 48.0 50.7 16.5 15.0 106.8 104.2 179.7 171.9 1.0 I.I 69.0 71.3 7.1 6.1 30.8 29.7 40.8 36.2 Note: Life expectancy (e ), infant mortality, and child mortality (,.q ) are for both sexes combined. Growth rate is given as a percent. Crude death rate is deaths per 1,000 population. Source: U.S. Bureau of the Census, International Data Base and unpublished tables. U.S. Census Bureau Table 2. Demographic Indicators With and Without AIDS: 2010 Country Botswana Burkina Faso Burundi Cameroon Centra] African Republic Congo (Brazzaville) Congo (Kinshasa) CotedTvoire Ethiopia Kenya Lesotho Malawi Namibia Nigeria Rwanda South Africa Swaziland Tanzania Uganda Zambia Zimbabwe Brazil Guyana Haiti Honduras Burma Cambodia Thailand Growth L fe Crude death Infant mortality Child mortality rate expectancy With Without rate rate (underage 5) With Without With Without With Without With Without AIDS AIDS AIDS AIDS AIDS AIDS AIDS AIDS AIDS AIDS 0.2 1.9 37.8 66.3 23.8 6.4 55.2 26.3 119.5 38.3 2.4 3.1 45.6 60.7 16.3 9.0 86.6 73.7 144.7 108.7 2.3 3.0 45.3 60.8 16.4 8.6 79.6 66.3 128.6 90.9 2.5 3.0 49.8 63.2 14.1 8.2 63.8 52.9 108.3 78.0 L.9 2.3 50.9 61.9 14.1 9.1 79.8 71.6 122.7 99.1 1.7 2.3 49.0 62.4 14.8 8.2 77.5 67.3 125.9 97.1 2.9 3.3 51.9 59.8 12.6 4.1 77.0 70.4 116.2 97.3 2.2 2.9 46.7 61.8 15.4 8.0 74.8 61.8 120.9 84.2 1.9 2.9 38.6 54.7 21.8 12.1 112.4 95.4 183.4 136.7 0.6 1.8 43.7 69.2 18.6 5.2 53.9 32.9 105.2 45.4 0.8 1.9 44.7 65.9 18.7 7.4 71.1 52.8 121.9 70.7 0.7 2.2 34.8 56.8 25.3 10.4 113.1 88.4 202.6 136.0 1.2 2.8 38.9 70.1 21.9 5.2 57.2 28.3 118.8 37.5 2.1 3.0 46.3 64.9 16.1 7.1 57.4 41.4 112.7 68.2 1.4 2.9 37.6 59.2 23.1 9.4 97.1 74.7 166.4 105.5 0.4 1.4 48.0 68.2 17.8 7.1 50.7 32.3 99.5 48.5 1.7 3.1 37.1 63.2 22.6 7.5 85.3 58.6 152.2 77.5 1.8 2.6 46.1 60.7 16.3 8.9 77.8 65.2 131.3 95.8 3.1 3.5 47.6 59.5 14.4 8.S 68.6 58.5 120.6 92.2 2.0 3.1 37.8 60.1 21.5 9.0 81.7 58.4 160.7 96.9 0.3 1.9 38.8 69.5 22.5 4.9 53.7 24.0 115.6 31.8 0.8 1.1 67.7 75.5 8.5 5.4 22.3 18.4 31.4 20.6 0.0 1.0 51.1 67.9 16.9 7.5 50.1 36.9 86.6 48.7 1.7 2.1 54.4 58.8 12.5 10.2 83.4 80.1 129.1 119.0 1.3 1.9 59.7 73.4 9.7 4.4 32.1 23.5 55.2 29.3 1.4 1.6 58.8 62.8 10.7 8.8 55.7 52.4 80.3 70.1 2.4 2.6 52.8 56.7 12.8 10.9 81.7 78.1 133.9 123.9 0.6 0.7 72.9 75.1 7.4 6.5 18.7 17.8 25.0 21.2 Note: Life expectancy (e ), infant mortality, and child mortality ( 5 q ) are for both sexes combined. Growth rate is given as a percent. Crude death rate is deaths per 1,000 population. Source: U.S. Bureau of the Census, International Data Base and unpublished tables. U.S. Census Bureau 10 In Sub-Saharan Africa, crude death rates are dramatically higher over what would have been expected without AIDS due to the additional AIDS mor- tality. For example, in Cameroon and Nigeria, where HIV prevalence was ap- proaching 5 percent of the total adult population in 1995, crude death rates in 1998 are 20 to 30 percent higher. By the year 2010, the crude death rate will be nearly twice as high in Cameroon and over twice as high in Nigeria. In Zimbabwe the crude death rate in 1998 is over three times as high as it would have been without AIDS and will be more than four times as high by the year 2010 (Figure 1). Because of AIDS mortality, crude death rates are at least 10 percent higher in 1998 in Burma, Cambodia and Thai- land. By 2010, the crude death rate will be 20 percent higher than it would have been without AIDS in Burma and approximately 15 percent higher in Cambodia and Thailand. In Latin America, AIDS mortality will have varying impacts on crude death rates. In Brazil, AIDS mortality has re- sulted in a crude death rate that is 50 percent higher. By the year 2010, the crude death rate will continue to be about 50 percent higher. In Haiti, AIDS mortality will result in a crude death rate that is about 13 percent higher in 1998 and by the year 2010, the crude death rate will be about 20 percent higher than it would have been without AIDS. In Guyana and Honduras, how- ever, by the year 2010, crude death rates will be more than twice as high as they would have been without AIDS. AIDS is Affecting Infant Mortality Rates Infant mortality rates are higher due to AIDS, reversing the declines that had been occurring in many countries dur- ing the 1970s and 1980s. Over 30 per- cent of all children born to HIV-infected mothers in Sub-Saharan Africa will themselves become HIV infected. The Figure 1. Crude Death Rate With and Without AIDS for Selected Countries: 1998 and 2010 1998 I 1 Without AIDS » With AIDS Africa South Africa Zimbabwe Asia Cambodia Thailand Latin America Haiti Honduras I 1 1 ■--:■: ' . i i .v..-- ■•■ . .' J 2010 Africa Asia 1 1 " 1 atin America Haiti ■ 1 "1 Source: U.S. Bu 10 15 20 25 Deaths per 1 .000 population i of the Census, International Data Base and unpublished tables. 30 35 relative impact of AIDS on infant mor- tality will depend on both the level of HIV in the population and the infant mortality rates from other causes. Those countries that had significantly reduced non-AIDS infant mortality and have high HIV prevalence rates will see a greater relative impact. In West Africa, AIDS mortality has already resulted in higher infant mortality rates. In Cameroon and Cote dTvoire, infant mortality rates are already 10 percent higher and are projected to be 20 percent higher over what they would have been without AIDS in 2010. In Nigeria, the in- fant mortality rate is estimated to be 7 percent higher in 1998 and is projected to be nearly 40 percent higher over what would have been expected by the year 2010 without AIDS. In East and Southern Africa, the regions most affected by the AIDS epidemic, in- fant mortality rates are nearly 70 per- cent higher over what they might have been without AIDS. In Kenya, the in- fant mortality rate is estimated to be 33 percent higher. By the year 2010, it will be over 60 percent higher. In South Africa, the infant mortality rate is esti- mated to be 20 percent higher. And in Zimbabwe, perhaps the most severely affected country in Sub-Saharan Africa, the infant mortality rate is now esti- mated to be 72 percent higher than it U.S. Census Bureau 1 1 Figure 2. Infant Mortality Rate With and Without AIDS for Selected Countries: 1998 and 2010 1998 I 1 Without AIDS in With AIDS Africa ■v"- < "" v ■ .' - •■'■■■^ ~1 ■:■ • Asia 1 ! ■ . - 1 Latin America Haiti ■:■■■<■: ' ' . . . 1 1 -:■-.- = 1 2010 Africa 1 1 ! Asia ' ■ : ■■;■■■-■■■ ■'■■--: ■■■■--■■"■■■'..■:■:•■■■■■ 1 ! Latin America Haiti • : "-:':■' .v,.-' ■":':'/ , . . | 1 ,-;;:.::-,,,-•: ; ■■.■.■-x; : i 20 40 60 80 Infant deaths per 1.000 live births Source: U.S. Bureau of the Census, International Data Base and unpublished tables 100 120 would have been without AIDS (Figure 2). By the year 2010, the infant mortal- ity rate in Zimbabwe will be more than twice as high as it would have been without AIDS. Since the HIV epidemics in Asia occurred later than in Africa, and prevalence rates have not yet reached the same levels as have been seen in Africa, the impacts on infant mortality rates are not yet as severe. In Burma, Cambodia and Thailand, infant mortality rates are estimated to be 3 per- cent higher than they would have been without AIDS. By the year 2010, they will be 5 to 6 percent higher. In Latin America, the infant mortality rate is 10 percent higher in Brazil, 9 percent higher in Honduras, 7 percent higher in Guyana, and 4 percent higher in Haiti. By the year 2010, the infant mortality rate will be over 21 percent higher in Brazil than it would have been without AIDS, over 35 percent higher in both Honduras and Guyana, and 4 percent higher in Haiti. Again, the relative impact will be affected by the level of deaths due to other causes as well as the level of HIV prevalence in the population. Two-thirds of AIDS Deaths Among Children Will Occur After the Age of One Child mortality rates will be higher due to AIDS mortality since many HIV in- fected children survive beyond their first birthday. Those countries with el- evated levels of HIV prevalence and low non-AIDS child mortality will see child mortality rates higher than would have been without AIDS. For example, child mortality rates are estimated to be about 20 percent higher than they would have been without AIDS in Cameroon and in Cote dTvoire. By the year 2010, child mor- tality rates are expected to be 40 per- cent higher. In Nigeria, the current child mortality rate is estimated to be 12 percent higher and by 2010, it will be 65 percent higher. In East and Southern Africa, the impact on child mortality rates will be even greater, particularly among those coun- tries that had greatly reduced child mor- tality. In Kenya, the child mortality rate is estimated to be 65 percent higher than it would have been without AIDS and by the year 2010, it will be over twice as high. In South Africa, the cur- rent child mortality rate is estimated to be 27 percent higher, and in Zimbabwe, the current rate is estimated to be nearly three times as high (Figure 3). By the year 2010, the child mortality rate in South Africa will be more than twice as high as it would have been without AIDS and in Zimbabwe it will be three and a half times as high. The impact on child mortality rates in Asia are not yet as severe as they are in Africa, since the HIV/AIDS epidemics started later there and the present na- tional prevalence rates are still low. Currently, child mortality rates are six percent higher in Burma and in Cambo- dia. In Thailand, where non-AIDS child U.S. Census Bureau 12 mortality is much lower, AIDS is cur- rently resulting in a child mortality rate 13 percent over what it would have been without AIDS. By the year 2010, AIDS mortality will result in even higher child mortality rates: 15 percent higher in Burma, 8 percent in Cambo- dia and 18 percent in Thailand. In Latin America and the Caribbean, AIDS mortality again is having differ- ent impacts on countries due to the un- derlying non-AIDS childhood mortality and the HIV prevalence levels. In Bra- zil, where non-AIDS child mortality is among the lowest in the region, the child mortality rate is estimated to be 26 percent higher because of the AIDS epidemic. In contrast, the AIDS epi- demic in Haiti has resulted in a child mortality rate 7 percent higher. In Guyana, which may have an HIV/AIDS epidemic similar to those seen in Sub- Saharan Africa, the child mortality rate is 16 percent higher. And in Honduras, the current child mortality rate is 21 percent higher. By the year 2010, the AIDS epidemics will have even greater impacts on the child mortality rates in countries in Latin America and the Caribbean. In Brazil, the child mortality rate is pro- jected to be 52 percent higher. In Guyana and Honduras, child mortality rates will be around 80 percent higher. And in Haiti, the rate again will only be about 8 percent higher. This is again due to the underlying higher rates of non-AIDS child mortality rate in Haiti. Figure 3. Child Mortality Rate With and Without AIDS for Selected Countries: 1998 and 2010 ] 1998 1 1 Without AIDS □ With AIDS Africa 1 Asia ! 1 1 Latin America Haiti J 2010 Africa South Africa Zimbabwe Asia Cambodia Thailand Latin America Haiti Honduras ■ I I so 100 150 Deaths under age 5 per 1.000 live births Source: U.S. Bureau of the Census, International Dala Base and unpublished tables- 2(1(1 250 U.S. Census Bureau 13 Figure 4. Growth Rate With and Without AIDS for Selected Countries: 1998 and 2010 1998 1 1 Without AIDS EZD With AIDS Africa 1 . ,,,, , , ( Asia 1 1 Latin America Haiti " -1 1 1 2010 Africa South Africa Zimbabwe Asia Cambodia Thailand Latin America Haiti Honduras Percent Source: U.S. Bureau of the Census. International Data Base and unpublished tables Even With Higher Mortality Rates Due to AIDS, Growth Rates Will Remain Positive in the Year 2010 Although Some Will be Near Zero In some of the countries most severely affected by the AIDS epidemics, low projected total fertility rates combined with high expected mortality from AIDS will result in projected zero or near zero population growth. AIDS mortality, however, will reduce the growth rates in all countries. Currently, growth rates are estimated to be 6 percent lower in Nigeria, 20 per- cent lower in Cote d'lvoire and Uganda, and over 50 percent lower in Zimbabwe (Figure 4). By the year 2010, growth rates are projected to be reduced 75 per- cent or more in South Africa and in Zimbabwe (Figure 4 second panel). In Kenya, growth rates will be reduced 66 percent. In Nigeria, growth rates are projected to be over 40 percent lower. In Asia, growth rates have been reduced about 10 percent in Burma and in Thai- land. In Cambodia, growth rates are currently estimated to be about 7 per- cent lower. By the year 2010, growth rates are projected to be reduced by 14 percent in Thailand, 13 percent in Burma, and 8 percent in Cambodia. Guyana has been experiencing negative population growth from high out-mi- gration. AIDS mortality is further in- creasing that negative population growth. In Brazil and Haiti, growth rates have been reduced by 20 and 25 percent, respectively. In Honduras, cur- rent growth rates are estimated to be 8 percent lower due to AIDS mortality. Future migration patterns for Guyana are difficult to project. However, AIDS mortality in Guyana is projected to re- duce an estimated 1 percent growth rate for the year 2010 to nearly zero. In Bra- zil and Honduras, future growth rates are projected to be about 30 percent lower in the year 2010. Growth rates in Haiti are projected to be about 20 per- cent lower. 16 Million Fewer People Today in the 21 Most Affected Countries in Sub-Saharan Africa Differences in population size between the AIDS-adjusted and the non-AIDS scenarios are often substantial, amount- ing to millions of persons. Some, but not all of these differences are due to AIDS mortality. The balance of the dif- ferences in population size is because of decreased population resulting from premature female deaths and the lost fu- ture population growth resulting from that deficit. Although Nigeria probably has a rela- tively lower HIV prevalence rate com- pared to other countries in Sub-Saharan Africa, there are currently nearly 1 mil- lion fewer people there due to the AIDS epidemic, 110.5 million instead of 1 1 1.3 million. It is estimated that there U.S. Census Bureau 14 are 900,000 fewer people in South Af- rica, 1.3 million fewer people in Uganda, and 1.6 million fewer people in Zimbabwe directly and indirectly due to AIDS (Figure 5). By the year 2010, there will be a total of 71 million fewer people in the re- gion. Kenya will have 6.7 million fewer people, South Africa will have 5.6 million fewer people, Nigeria will have 11.7 million fewer people, Uganda will have 4.2 million fewer people, and Zim- babwe will have 4.4 million fewer people than there would have been without the effect of AIDS (Figure 5 sec- ond panel). In Asia, current estimates indicate that there are 400,000 fewer people in Burma, 200,000 people less in Cambo- dia, and 300,000 fewer people in Thai- land. By the year 2010, Burma will have 1.6 million fewer people, Cambodia's population will have been reduced by a potential 500,000 people and Thailand will have 1.1 million fewer people. The population of Brazil is one of the largest in Latin America, and with the AIDS epidemics, will lose the most people. Current estimates show 2.3 mil- lion fewer people in Brazil with a pro- jected loss of population of 10 million people by the year 2010. Current esti- mates only indicate a population loss in Haiti, with 400,000 fewer people. By the year 2010, Haiti will have 900,000 fewer people. Perhaps the Largest Demographic Impact of AIDS Mortality Will Be on Life Expectancies Many potential years of life will be lost due to the AIDS epidemics. AIDS will re- sult in higher mortality rates in child- hood, as well as among young adults where normal mortality is quite low. As a result, AIDS deaths will have a rela- tively larger impact on life expectancies Figure 5. Population Size With and Without AIDS for Selected Countries: 1998 and 2010 1998 1 I Without AIDS □ With AIDS Africa 1 1 Asia 1 tin America Haiti Honduras 2010 Africa :.: 1 Asia 1 '"! itin America Haiti ~ 1 «-.-... y 1 2(1 40 60 Millions ion Source: U.S. Bureau of the Census, International Data Base and unpublished tables. than on perhaps any other demographic indicator. In those countries most seri- ously affected by AIDS, life expectancies have been reduced by 4 to 26 years. In Kenya, the AIDS epidemic has resulted in 18 years of life lost. In Nigeria, current estimated life expectancy has been re- duced 4 years and in Zimbabwe, 26 years of life have been lost (Figure 6). By the year 2010, 8 to 31 years of life will have been lost in those countries most seriously affected by AIDS in Sub- Saharan Africa. Without AIDS, life ex- pectancies would have reached 69.5 in Zimbabwe, but with the AIDS epidemic, life expectancy has been reduced by 3 1 years. In Kenya, 26 years of life will have been lost, in Nigeria 19 years and in Uganda, 12 years (Figure 6 second panel). In Asia, life expectancy has been re- duced by 2 to 3 years. In Burma and Cambodia nearly 3 years of life have been lost and in Thailand life expect- ancy has been reduced 2 years. By the year 2010, life expectancies will be re- duced by 2 to 4 years in these Asian countries. In Latin America and the Caribbean, ADDS deaths have reduced current life expect- ancies from 3 to 7 years. Life expectancy in Brazil has been reduced 7 years, Hon- duras and Haiti are now experiencing 4 U.S. Census Bureau 15 Figure 6. Life Expectancy With and Without AIDS for Selected Countries: 1998 and 2010 ] 1998 1 1 Without AIDS H With AIDS Africa . . ' ' ,v'.-.vr.- •-■■- ' '1 •-'■.'■••■-. Asia 1 ■■•■.'■ ■ ' . ■ 1 .',;:-.;-.V.V >■-■•':■,:,■ tin America Haiti 1 1 1 2010 Africa South Africa Zimbabwe Asia Cambodia Thailand Latin America Haiti Honduras ; ..■-'1 1 ! ' ./:i;/,..,v.' f :.=^-.::,,.-v.. v ...-v. „■.-,;. ' .:.,-,. :,.,,.-, -m i ,. , ,.•■■■. • , , - , ';•, J 1 10 :o 30 40 50 60 Life expectancy at birth (years) Source: U.S. Bureau of the Census. International Data Base and unpublished tables. 70 go years of life lost and in Guyana, life ex- pectancy is now 3 years lower. By the year 2010, life expectancies will have been reduced by 4 to 17 years in these countries. In 21 African Countries More Than 5 Percent of the Urban Population Is HIV Positive 5 Many of the epidemics in Africa can be described as generalized, with high (over 5 percent) HIV prevalence in the general adult population and increasing 5 A11 HIV prevalence data sited in this re- port can be found in the HIV/AIDS Surveil- lance Data Base. 1998 version, U.S. Bureau of the Census. urban to rural equalization of HIV prevalence. 6 In 21 African countries, HIV prevalence among low-risk urban adult populations (15-49 year olds) has reached 5 percent. The most severely affected countries are Botswana, Namibia, Swaziland, Zambia, and Zim- babwe, where 18 to 25 percent of all adults are HIV positive. Over 2 million adults are HIV positive in each of the following countries: Ethiopia, Kenya, Nigeria, and South Africa. Although HIV epidemics have stabi- lized or declined in some urban areas, in others the epidemics are increasing rapidly (Figure 7). HIV seropre valence levels among antenatal clinic women have declined in Kampala, Uganda from a peak of 30 percent in 1992 to 15 percent in 1996. And in Lusaka, Zam- bia, HIV prevalence among antenatal women tested remained around 25 per- cent between 1990 and 1994. In Francistown, Botswana, however, HIV prevalence among antenatal clinic women increased from 8 percent in 1991 to 43 percent in 1996. Similarly, HIV prevalence among antenatal clinic women tested in Kwazulu-Natal, South Africa, increased from 2 percent in 1990 to 20 percent in 1996. High prevalence levels among antenatal clinic attendees have also been reported in other provinces of South Africa: Free State, 17 percent; North West, 25 per- cent; and Mpumalanga, 16 percent. Some countries initially spared are now seeing increases in HIV seroprevalence. In Nigeria, median prevalence among antenatal clinic women tested in urban sites increased from less than 1 percent in 1991-92 to 4 percent in 1993-94. In Lagos State, 7 percent of antenatal clinic women tested in 1993-94 were HIV positive. In Yaounde, Cameroon, HIV prevalence among antenatal clinic women increased from 1 percent in 1989 to 3 percent in 1995 and in Douala, HIV prevalence increased from 1 percent in 1990 to 6 percent in 1994. The HIV Pandemic in Asia is Extremely Diverse There is no evidence of an HIV epi- demic in some countries of Asia such as Mongolia and South Korea. In other countries, such as Thailand and Burma, 2 percent of the adult population are now HIV positive. In Cambodia, nearly 5 percent of the adult population is HIV positive. In Asia, HIV transmission oc- curs mainly through heterosexual con- tact, from mother to child, and through injecting drug use. Rapid increases in HIV prevalence have "World Bank (1997). U.S. Census Bureau 16 Sub-Saharan African Countries Most Affected by the HIV/AIDS Epidemic Botswana Burkina Faso Burundi Cameroon Central African Republic Congo (Brazzaville) Cote d'lvoire Congo (Kinshasa) Ethiopia Kenya Lesotho Malawi Namibia Nigeria Rwanda South Africa Swaziland Tanzania Uganda Zambia Zimbabwe been occurring in Cambodia over the last few years (Figure 8). HIV preva- lence among sex workers tested in Phnom Penh increased from 10 percent in 1992 to 42 percent in 1996. Among sex workers tested in 17 sites in 1996, HIV prevalence ranged from 13 percent in Kandal province to nearly 60 percent Figure 7. HIV Seroprevalence for Pregnant Women in Selected Urban Areas of Africa: 1985-1997 HIV seroprevalence (percent) 1985 1986 1987 1989 1990 1991 1992 1993 1994 1995 1996 1997 Note: Includes infection front HIV-1 and/or HIV-2. Source: U.S. Bureau of the Census, HIV/AIDS Surveillance Data Base. 19 Figure 8. HIV Seroprevalence for Pregnant Women in Selected Urban Areas of Asia: 1990-1997 HIV seroprevalence (percent) 0L_ 1990 1497 lis Hnieiil K- I ill-., is. Ill\ AIDS Sun. ulhiui' UiU Base. I'l'LS U.S. Census Bureau 17 L5 12 Figure 9. HIV Seroprevalence for Pregnant Women in Selected Urban Areas of Latin America: 1986- 1997 HIV seroprevalence (percent) A / \ • Guyana San Pedro Sula Sao Paulo 1 1 1 1 1 ^r Rio de Janeiro 1 — i "'"" r i i 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Source: U.S. Bureau of the Census, HIV/ AIDS Surveillance Data Base, 1998. in Battambang province. HIV preva- lence among antenatal clinic attendees in Phnom Penh increased from no evi- dence of HIV infection in 1992 to 3 per- cent of women tested in 1996. In the 17 sentinel surveillance sites outside of Phnom Penh, HIV prevalence ranged from less than 1 to 6 percent of antena- tal clinic attendees tested. In Thailand and Burma, the HIV epi- demic continues to affect the popula- tion. As in other parts of Asia, HIV transmission occurs through hetero- sexual contact, from mother to child, and via injecting drug use. In Rangoon and Mandalay, HIV prevalence among sex workers increased from 4 percent in 1992 to 21 percent in 1996. Among an- tenatal clinic women tested in Rangoon and Mandalay in 1995, less than 1 per- cent were HIV positive. However, HIV prevalence among antenatal clinic women in Tachileik had reached 8 per- cent by 1995. In Thailand, HIV prevalence among sex workers in Bangkok reached a peak of 18 percent in 1992 but appears to be declining. Seven percent of sex work- ers tested in Bangkok in 1996 were HIV positive. Declines are also being seen among antenatal clinic women in Bangkok (Figure 8). In other areas of the country, HIV prevalence among sex workers appears to have stabilized be- tween 18 and 20 percent between 1993 and 1996. Among antenatal clinic at- tendees tested in 1996, HIV prevalence ranged from 2 to 8 percent with the highest prevalence in the Northern re- gion. The epidemic in India differs from state to state, with high HIV prevalence in west and southern India to low levels of HIV in east and northern India. In Mumbai (Bombay), HIV prevalence in- creased from 2 to 3 percent in sexually transmitted disease (STD) clinic attend- ees before 1990 to 36 percent in 1994. HIV prevalence among sex workers tested in Mumbai rose from 1 to 5 1 per- cent between 1987 and 1993. Studies among sex workers in Calcutta, in con- trast, show clear and consistently low prevalence of one percent. Among an- tenatal clinic attendees tested in Mumbai, two percent tested positive for HIV in 1995. In Manipur, in the north, an HIV epidemic is occurring among in- jecting drug users, where 60 to 70 per- cent of injecting drug users tested in 1996 were HIV positive. A concurrent epidemic is now occurring among the antenatal clinic attendees in that area. However, there is a general lack of con- sistent HIV seroprevalence information making it difficult to analyze the extent of the spread of the HIV epidemic in In- dia. HTV/AroS is Well Established In the Caribbean and Latin American Region but Information is Scarce The spread of HIV/AIDS has been slower in Latin America and the Carib- bean than in other developing regions of the world, but sentinel surveillance data are rare and information on HIV prevalence is difficult to find. What can be determined to date is that the HIV epidemic varies from country to country, with some countries in the na- scent stage, with few cases of AIDS and low HIV prevalence in high-risk groups; and others in the concentrated stage, with high prevalence in predomi- nantly homosexual/bisexual or inject- ing drug user groups with low preva- lence in general adult population. In some countries, transmission through injecting drug use has had an important impact on the epidemic. In the Caribbean the HIV epidemic has been characterized as mostly a hetero- sexual epidemic. In Haiti, HIV preva- lence has remained stable over the past several years at around 5 percent of the adult population. In Guyana, among antenatal clinic women tested in 1992, 7 percent were HIV positive (Figure 9). The epidemic increased from 1 percent of adults infected in 1994 to 2 percent in 1997 and is projected to increase to 13 percent by 2010. U.S. Census Bureau The epidemics in Central America also appear to be mostly caused by hetero- sexual transmission. Recent data from Honduras indicate an increase in HIV prevalence in the major urban centers. HIV prevalence among sex workers in- creased in Tegucigalpa from 6 percent in 1989 to 8 percent in 1996. In San Pedro Sula, HIV prevalence among sex workers has ranged from 15 to 20 per- cent since 1989. HIV prevalence among antenatal clinic attendees in Tegucigalpa increased from 0.2 -0.3 percent in 1991-1993 to 1 percent in 1996. In San Pedro Sula, HIV preva- lence among antenatal clinic attendees had increased to 4 percent by 1994. In Brazil, there is considerable HIV transmission due to injecting drug use and the epidemic has progressed since the early 1980s from one predominated by homosexual/bisexual transmission to one with an increasing heterosexual component. High rates of HIV infection among injecting drug users in Brazil have been found since the late 1980s. Fifty percent of injecting drug users tested in two sites in Sao Paulo were HIV positive in 1989. Since 1990, a third of all injecting drug users tested in major urban areas tested positive for HIV. In 1990, 1 percent of antenatal women in Sao Paulo tested positive for HIV. As more sentinel sites began re- porting, the median HIV prevalence rate among antenatal clinic attendees varied around 1 percent of women tested. In 1995, nearly 3 percent of antenatal women tested in Porto Alegre and Rio de Janeiro tested positive for HIV and in 1996, 5 percent of women in Santos tested positive for HIV. The HTV/AIDS Pandemic Continues to Evolve By the end of 1997, the United Nations Joint Programme on HIV/AIDS (UNAIDS) estimated that over 40 mil- lion people had become infected with HIV since the beginning of the pan- demic and that over 1 1 million of these people have already died. The majority of the infections have occurred in Sub- Saharan Africa, but the increases that are occurring in Asia may result in more infections in that region than in Sub- Saharan Africa. This is the third round of population es- timates and projections in which the Census Bureau has incorporated AIDS mortality. Some of our original conclu- sions have remained the same: • AIDS will not overcome the momen- tum of population growth in the most affected countries, particularly in Sub-Saharan Africa. The region's current high fertility rate ensures that the population will continue to increase. • Changes in behavior, both spontane- ous and induced, may help to create an early plateau in some epidemics and ultimately may result in declines in HIV infection levels. We are clearly seeing this in Thailand and in certain areas of Uganda. • Given the uncertainties surrounding the course of AIDS epidemics, it is probable that refinements and ad- justments in the method for the in- corporation of AIDS-related mortal- ity into these population projections will be adopted in future rounds of the projection process. Uganda: A Rare Example of Success When the general public thinks about the AIDS epidemic in Af- rica, they usually think of Uganda first, and they assume that the epidemic is worse there than in any other country. How- ever, HIV surveillance data show that the AIDS epidemics are far worse in some of the countries in Southern Africa such as in Botswana, Zimbabwe, and Zam- bia. HIV prevalence among Ugandan antenatal women in Kampala and the Rakai district have been high, as high as 30 per- cent. However, in other areas of the country prevalence is much lower. Since 1993, prevalence rates have fallen to 15 percent among antenatal women in Kampala. Uganda, however, was the first country in Africa to admit they had an AIDS epidemic and, with the strong backing of President Museveni, AIDS prevention pro- grams are making an impact. At the opening ceremony of the IXth International Conference on AIDS and STDs in Africa held in Kampala, President Museveni stressed the importance of politi- cal leadership in the fight against AIDS. The results of this leader- ship are showing in Uganda. U.S. Census Bureau Appendix A. Population Projections Incorporating AIDS U.S. Census Bureau U.S. Census Bureau Population Projections Incorporating AIDS A-3 Background Although it has been clear for a number of years that mortality estimates and projections for many countries would have to be revised due to AIDS mortal- ity, the lack of accurate empirical data on AIDS deaths, the paucity of data on HIV infection among the general popu- lation, and the absence of tools to project the impact of AIDS epidemics into the future have all hampered these efforts. While the accuracy of data on AIDS deaths has not substantially im- proved, knowledge of HIV infection has expanded and modeling tools have become available to project current epi- demics into the future. The methodology used to project AIDS mortality into the future for this report follows generally the method adopted for World Population Profile: 1994, and World Population Profile: 1996 with continuing modifications. The method consists of the following steps: 1. Establish criteria for selecting coun- tries for which AIDS mortality will be incorporated into the projections. 2. For each selected country, determine the empirical epidemic trend and a point estimate of national HIV prevalence. 3. Model the spread of HIV infection and the development of AIDS in the population, generating alternative scenarios ranging from high to low AIDS epidemics, and produce the seroprevalence rates and AIDS-re- lated age-specific mortality rates which correspond to each epidemic. 4. Use the empirical levels and trends (from step 2) to establish a factor representing each country's position on a continuum between high and low epidemics (from step 3). Use the derived factor to generate a unique interpolated epidemic. 5. Use weighted country total adult seroprevalence to determine an appropriate location on the total country epidemic curve implied by the interpolation factor. This projects adult HIV seroprevalence for the total country. 6. Interpolate AIDS-related mortality rates, by age and sex, associated with the estimated speed and level of HIV from epidemic results for the period 1990 to 2010. In the sections that follow, each of these steps is described, and the method is il- lustrated. Country Selection Criteria The International Programs Center, U.S. Bureau of the Census, maintains an HIV/AIDS Surveillance Data Base. This data base is a compilation of aggregate data from HIV seroprevalence studies in developing countries. Currently, it con- tains over 30,000 data items drawn from nearly 3,800 publications and presenta- tions. As a part of the biannual updat- ing of the data base, new data are re- viewed for inclusion into a summary table which, for each country, lists the most recent and best study of seroprevalence levels for high- and low-risk populations in urban and rural areas. 7 A review of the data in the summary table suggested that a reasonable cut- off point for selection would be coun- tries which had reached 5 percent HIV prevalence among their low-risk urban populations, or, based on recent trends, appeared to be likely to reach this level in the near future. A total of 26 countries now meet these criteria for the incorporation of AIDS mortality in the projections. Twenty- one of these countries are in Africa. The African countries are as follows (newly added countries are shown in italics): Botswana Burkina Faso Burundi Cameroon Central African Republic Congo (Brazzaville) Congo (Kinshasa) Cote dTvoire Ethiopia Kenya Lesotho Malawi Namibia Nigeria Rwanda South Africa Swaziland Tanzania Uganda Zambia Zimbabwe Outside of Africa, the following coun- tries meet the criteria: Guyana Burma Haiti Cambodia Honduras Two other countries, Brazil and Thai- land, have also been included since 1994 because country-specific model- ing work had already been completed. The simplified approach taken in these special cases is described in a later section. 'High risk includes samples of prostitutes and their clients, sexually-transmitted disease patients, or other persons with known risk factors. Low risk includes samples of preg- nant women, volunteer blood donors, or oth- ers with no known risk factors. For a more complete description of the selection criteria, see U.S. Bureau of the Census (1995). U.S. Census Bureau A-4 Table A- 1. Empirical Seroprevalence Data for Selected Countries Urban trend, pregnant women Estimated total country Country Percent Percent Percent Date seropositive Date seropositive seropositive Jan. 1. Year 1995 27.8 1997 31.4 18.0 1995 1991 7.8 1994 11 9 6.7 1995 1986 14.7 1993 20.0 7.6 1995 1993 4.0 1995 5.7 4.8 1995 1987 4.7 1995 9.3 6.9 1995 1988 3.1 1994 7.2 7.2 1995 1986 6.9 1992 9.2 3.7 1995 1994 10.3 1996 12.4 7.7 1995 1991 10.7 1997 17.9 8.7 1995 1993 14.4 1996 18.5 11.6 1995 1993 3.4 1994 4.1 44 1995 1992 22.0 1996 27.6 13.6 1995 1992 4.2 1997 16.0 19.8 1998 1992 2.9 1994 5.4 2.2 1995 1991 26.2 1997 32.7 12.2 1998 1994 3.0 1997 11.8 10.0 1998 1994 21 9 1997 26.0 18.0 1998 1987 3.7 1997 13.7 6.4 1995 1988 24.0 1992 29.5 12.0 1995 1986 10.7 1997 15.3 8.8 1998 1990 24.5 1995 27.5 17.1 1995 1991 18.7 1996 31.0 22.0 0.7 1998 1995 1991 1.5 1992 [.9 1.3 1995 1990 8.0 1994 8.5 4.4 1995 1992 2.0 1996 4 1 1.6 1995 1993 0.6 1997 0. 9 2 1.5 1995 1996 3.0 1996 3.2 1.9 2.1 1995 1995 Botswana Burkina Faso Burundi Cameroon Central African Republic . Congo (Brazzaville) Congo (Kinshasa) Cote d'lvoire Ethiopia Kenya Lesotho Malawi Namibia Nigeria Rwanda South Africa Swaziland Tanzania Uganda — High Uganda — Low Stable. . . . Zambia Zimbabwe Brazil 1 Guyana Haiti Honduras Burma Cambodia Thailand 1 1 Country-specific modeling was undertaken for Brazil and Thailand. 3 Burma military recruit data. Source: HIV/AIDS Surveillance Data Base, International Programs Center, U.S. Bureau of the Census, January 1997. U.S. Census Bureau A-5 Empirical Epidemic Trends For each of the 26 countries meeting the selection criteria, staff members re- viewed the HIV seroprevalence infor- mation available in the HIV/AIDS Sur- veillance Data Base to establish urban seroprevalence trends over time (Table A-l, col. 1-5) and to establish the esti- mated prevalence for the whole country (Table A-l, col. 6-7). The two data points judged to be most representative for the urban low-risk population were identified and used to calculate the an- nual change between the dates of the two studies. National prevalence figures were based on year-end 1994 and 1997 estimates prepared by the World Health Organization and the United Nations Joint Programme on HIV/AIDS. Alternative Scenarios To project the impact in the selected countries, three alternative epidemic scenarios were developed, correspond- ing to low-, medium-, and high-impact AIDS epidemics. These scenarios were developed using iwgAIDS, which is a complex deterministic model of the spread of HIV infection and the devel- opment of AIDS in a population. This model was developed under the spon- sorship of the Interagency Working Group (iwg) on AIDS Models and Meth- ods of the U.S. Department of State (Stanley et al. 1991). All three of these epidemic scenarios in- corporate increasing levels of behavior change in the form of increased condom use. This assumption corresponds to ac- tual changes in behavior that are now beginning to occur in some countries. In addition, all three epidemics exhibit plateauing and subsequent declines in prevalence in the later stages of the epi- demic, particularly in urban areas. Figure A- 1 . Three Scenarios and Empirical Trend in Urban Female HIV Seroprevalence HIV seroprevalence (in percent) I I I i I 5 10 15 20 25 30 35 40 45 50 Years from onset of epidemic Source: U.S. Bureau of the Census, unpublished tables. Figure A-2. Three Scenarios and Empirical Trend in Total Female HIV Seroprevalence HIV seroprevalence (in percent) 411 35 30 High scenario 25 ^^— 20 >^ A A a Interpolated epidemic 15 ^^ a A jrf ^"*** - *"^ Medium scenario 10 S^s