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Introduction
In this review, we describe the epidemiology of the
HIV/AIDS epidemic, both chronologically and by HIV
transmission route, and highlight prevention interventions and other factors potentially affecting transmission
and spread. We first discuss recognition of the epidemic,
discovery of HIV transmission routes, and initial
prevention efforts during the early to mid-1980s. We
then examine how the epidemic and prevention
approaches evolved during the pre-antiretroviral therapy
(ART) era, and conclude by describing the current
epidemic and prospects for control. In an earlier
A medical mystery
What became known as AIDS was first described in a
report published on 5 June 1981. Gottlieb and colleagues
reported five young, previously healthy, homosexual men
treated for Pneumocystis carinii (now Pneumocystis jiroveci)
pneumonia (PCP) in three Los Angeles hospitals [2].
Those tested had evidence of T-lymphocyte depletion,
and two had died. Over the following months, additional
cases of PCP, other opportunistic infections, and Kaposis
Centers for Disease Control and Prevention, and bRollins School of Public Health, Emory University, Atlanta, Georgia, USA.
Correspondence to Kevin M. De Cock, MD, Centers for Disease Control and Prevention (MS D-69), 1600 Clifton Road, Atlanta,
GA 30333, USA.
Tel: +1 404 639 7420; e-mail: kmd2@cdc.gov
Received: 3 April 2012; accepted: 3 April 2012.
DOI:10.1097/QAD.0b013e328354622a
ISSN 0269-9370 Q 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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An evolving epidemic
Over the next decade, perceptions of HIV/AIDS evolved
from a medical quandary primarily affecting MSM in the
United States to a pandemic of uncertain magnitude
threatening diverse populations around the world. The
pandemic was not one phenomenon but a patchwork of
epidemics moving through different groups and countries
at different times. They were characterized by waves of
unapparent HIV infections followed by visible epidemics
of disease and death. Peak HIV prevalence was useful as an
indicator to compare the severity of epidemics between
locations and over time [24].
Molecular epidemiologic studies have provided insights
into the origin and broad geographic transmission
patterns of HIV-1 [25]. The virus is thought to have
entered human populations in the early twentieth century
through cross-species transmission of related chimpanzee
retroviruses found in western equatorial Africa [26,27].
By the early 1980s, multiple genetic subtypes of HIV-1
were present in Kinshasa, Zaire [28]. Examination of
genetic sequences of HIV-1 recovered from early Haitian
patients suggested spread of HIV-1 infection from Africa
to Haiti in the 1960s and later introduction to the United
States [29], although multiple introductions were likely.
By the mid-1990s, more than 20 million persons were
estimated to be living with HIV/AIDS, the vast majority
in sub-Saharan Africa [30]. Largely reflecting the African
epidemic, sexual transmission accounted for at least three
quarters of all new infections, most in heterosexuals.
Overall, women accounted for about 40% of infected
adults. With exceptions of sub-Saharan Africa and Haiti,
however, fears of a generalized, self-sustaining, heterosexual epidemic throughout the world did not materialize. In retrospect, lack of generalized heterosexual
spread in the large populations of Asia was one of the
most important observations for understanding global
HIV/AIDS epidemiology [31]. In the United States,
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1207
[51,52]. Other, nonulcerative, infections such as gonorrhea also appeared to increase transmissibility by
increasing HIV shedding [53]. As chancroid became
less common in many locations, herpes simplex type 2
(HSV-2) emerged as the predominant cause of genital
ulcer disease associated with HIV [54]. Ecologic studies
also demonstrated that African countries with low
male circumcision rates (southern and, to a lesser extent,
eastern Africa) generally had high HIV infection rates and
vice versa (highly circumcised west African populations
were less heavily infected with HIV) [55]. These studies
and analytic observations [51,52] provided evidence that
lack of circumcision increased the risk for males acquiring
HIV infection and prompted later research that culminated in intervention trials and subsequent programmatic implementation.
An additional complexity in the African epidemic was a
second AIDS virus, HIV-2, first reported from west
Africa in 1986 [56]. Like HIV-1, this virus is thought to
have entered human populations through cross-species
transmission: a highly related retrovirus is present in sooty
mangabeys in this geographic area [26,27]. HIV-2 is
transmitted through sexual contact and blood, but very
rarely from mother to child [57]. Although the virus
causes AIDS, it has a slower rate of disease progression
than HIV-1 [5860] and is overall less transmissible [61].
Initial prevention efforts in sub-Saharan Africa concentrated on limiting heterosexual transmission through the
ABC strategy: abstain, be faithful, and use condoms, a
message communicated in culturally meaningful or
colorful phrases such as zero grazing and condomize
([62], this issue). The fall in HIV prevalence in childbearing
women in Uganda during the early 1990s has been
attributed to this approach, although this interpretation is
controversial [63,64]. But, as in the United States, massive
numbers of deaths of potential HIV transmitters must have
influenced epidemiology. A more clear-cut prevention
success was Thailands 100% condom campaign, which
targeted female sex workers and their clients [31,65,66].
Another early, oft-cited prevention success occurred in
Senegal, where HIV/AIDS never spread widely [65].
Senegal was exemplary in its openness and political
commitment. However, the predominance of HIV-2,
concentration of HIV-1 in high-risk groups, universal
nature of male circumcision, and traditional and religious
cultures in the country may have been more powerful
factors than specific HIV prevention campaigns.
In the late 1980s, studies in the former Zaire showed a
21% risk of HIV transmission from an infected mother to
her infant in the perinatal period [67]. Prolonged breast
feeding, the norm in sub-Saharan Africa for cultural and
socio-economic reasons, increased transmission by an
additional 14% [68], resulting in an overall transmission
risk of 3045% [69]. These breastfeeding findings caused
difficult policy choices between advocating replacement
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this issue). In the United States, for example, nearuniversal testing of pregnant women, provision of
appropriate antiretroviral treatment or prophylaxis, and
avoidance of breastfeeding by HIV-infected mothers have
virtually eliminated new pediatric HIV infections [109].
The concern that the findings of the ACTG 076 study
[110], which showed the benefits of zidovudine
monotherapy, could not be implemented in Africa led
to the search for simpler regimens. The HIVNET 012
study [111], which used single-dose nevirapine, was
initially greeted with enthusiasm because of the simplicity,
low cost, and relatively high efficacy of the regimen
(about 50%). Unfortunately, challenges to program
adherence, transmission through breastfeeding, and
recognition that monotherapy was a risk factor for later
drug resistance all became apparent, and single-dose
nevirapine is now considered a suboptimal approach.
The most important intervention for preventing motherto-child transmission of HIV is to identify and treat
pregnant women who need ART for their own health,
currently defined as those with CD4 cell counts less than
350 cells/ml [112]. Discussion continues about
approaches that could replace WHOs complex current
recommendations for pregnant women and infants [113],
but a pragmatic approach being considered by some
countries (e.g., Malawi) would be to provide immediate
and lifelong combination ART for all HIV-infected
pregnant women irrespective of CD4 cell count.
United Nations Agencies have set a goal of reducing new
pediatric HIV infections from the 2009 baseline of
approximately 400 000 infections to less than 40 000
infections by 2015, a 90% reduction [114]. Currently,
available interventions can lower mother-to-child transmission rates in breastfeeding populations to less than 5%,
and success will require much more aggressive uptake of
HIV testing and provision of ART. Linkage of these
interventions to other efforts to improve maternal and
child health, including safe delivery in health facilities,
will be essential, especially in Africa.
Globally, about 3 million IDUs are estimated to be
infected with HIV, and drug injection accounts for almost
one-third of HIV incidence outside of sub-Saharan
Africa. The greatest number of HIV-infected IDUs
resides in eastern Europe and south-east Asia [89], where
their access to services is limited because of stigma,
discrimination, and the definition of drug dependence as
a law enforcement rather than public health issue. Along
with HIV, IDUs suffer high rates of hepatitis B and C
infections as well as tuberculosis, and can be an important
source of sexual transmission of HIV. Experience in other
parts of the world where HIV has been successfully
controlled in IDUs illustrates that currently available
interventions can be effective [115]. Ecologic evidence
also suggests that expansion of ART among HIV-infected
drug injectors has a prevention benefit [97].
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Acknowledgements
Conflicts of interest
There are no conflicts of interest.
References
Conclusions
Although heterosexual transmission remains the dominant mode of spread worldwide, we have witnessed
encouraging trends in Africas generalized epidemics
[120,121], evidence of efficacy of biomedical interventions (especially ART-based prevention and male
circumcision) [122], and successful prevention program
scale-up [104]. ART-based prevention approaches have
the potential to reduce all modes of transmission ([75],
this issue). Cautious optimism is justified when this reality
and the tools available are contrasted to the history of the
pre-ART era. However, continued funding, intensified
program implementation, massive scale-up of HIV
testing, surveillance, and appropriate intervention and
implementation science are critical to success.
Much more can be done to prevent and treat HIV
infection in IDUs and sex workers, whose needs remain
neglected and for whom targeted services can substantially reduce HIV transmission. Mother-to-child
transmission of HIV is largely preventable, trends are
encouraging, and the worlds attention is now focused on
this problem. Although continued efforts are needed
to improve blood safety [123] and reduce healthcareassociated infections, blood transfusion and medical
injections are not major modes of HIV transmission.
Strikingly, HIV among MSM, the issue that first brought
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