This Intelligence Community Assessment (ICA) highlights the rising HIV/AIDS problem through 2010 in five countries of strategic importance to the United States that have large populations at risk for HIV infection: Nigeria, Ethiopia, Russia, India, and China. The paper does not attempt to make aggregate projections about global trends. The five countries were selected because they are:
· Among the world’s most populous countries, together representing over 40 percent of the world population.
· In the early-to-mid-stages of an HIV/AIDS epidemic.
· Led by governments that have not yet given the issue the sustained high priority that has been key to stemming the tide of the disease in other countries.
This paper builds on the December 1999 unclassified National Intelligence Estimate, The Global Infectious Disease Threat and Its Implications for the United States, which focused on the spread of AIDS in the context of other growing infectious diseases. Excerpts from the 1999 Estimate presage the expansion of the HIV/AIDS epidemic beyond the geographic focal point of southern Africa.
Although infection and death rates for HIV/AIDS have slowed considerably in developed countries…the pandemic continues to spread in much of the developing world. Sub-Saharan Africa currently has the biggest regional burden, but the disease is spreading quickly in India, Russia, China, and much of the rest of Asia.
According to UNAIDS, Asia alone is likely to outstrip Sub-Saharan Africa in the absolute number of HIV carriers by 2010.
The National Intelligence Council (NIC) convened a conference of US Government officials and outside experts to share their current assessments and expectations for the future of the disease in these five countries. Given the range of estimates of the current numbers of infected people and the lack of consensus on which infectious disease models calculate future rates most accurately, the future projections in this paper represent consensus estimates by experts. The NIC, in addition to coordinating the draft within the Intelligence Community, had the paper reviewed by several leading experts from outside the Intelligence Community as part of its effort to seek out expertise from inside and outside the government. The experts included Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health; Dr. Robert C. Gallo, Director of the Institute of Human Virology and Professor of Medicine at the University of Maryland Biotechnology Institute; Dr. Phillip Nieburg, Associate Director for Public Health Practice in the Global AIDS Program for the Centers for Disease Control; and Dr. Nicholas Eberstadt of the American Enterprise Institute.

Scope Note
Summary
Discussion
The Scope of the Next Wave
Country Profiles
Prospects for Control
The Leadership Challenge
Weak Healthcare Infrastructure
Treatment
Implications
Nigeria and Ethiopia: Hardest Hit
Russia: HIV/AIDS Worsening Demographic Situation
India and China: A Big Problem But Probably Not Devastating
International Implications

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The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China
The number of people with HIV/AIDS will grow significantly by the end of the decade. The increase will be driven by the spread of the disease in five populous countries—Nigeria, Ethiopia, Russia, India, and China—where the number of infected people will grow from around 14 to 23 million currently to an estimated 50 to 75 million by 2010 (1) . This estimate eclipses the projected 30 to 35 million cases by the end of the decade in central and southern Africa, the current focal point of the pandemic.
· We project China will have 10 to 15 million HIV/AIDS cases, and India is likely to have 20 to 25 million by 2010—the highest estimate for any country. By 2010, we project Nigeria will have 10 to 15 million cases, Ethiopia 7 to 10 million, and Russia 5 to 8 million.
HIV/AIDS is spreading at different rates in the five countries, with the epidemic the most advanced in Nigeria and Ethiopia. In all countries, however, risky sexual behaviors are driving infection rates upward at a precipitous rate.
· Adult prevalence rates—the total number of people infected as a percentage of the adult population—are substantially lower in Russia, India, and China, where the disease remains concentrated in high-risk groups, such as intravenous drug users in Russia and people selling blood plasma in China, where some villages have reported 60 percent infection rates.
· Nevertheless, the disease is spreading to wider circles through heterosexual transmission in India, the movement of infected migrant workers in China, and frequent prison amnesty releases of large numbers of infected prison inmates and rising prostitution in Russia.
It will be difficult for any of the five countries to check their epidemics by 2010 without dramatic shifts in priorities. The disease has built up significant momentum, health services are inadequate, and the cost of education and treatment programs will be overwhelming. Government leaders will have trouble maintaining a priority on HIV/AIDS—which has been key to stemming the disease in Uganda, Thailand, and Brazil—because of other pressing issues and the lack of AIDS advocacy groups.
· The governments of Nigeria, India, and China are beginning to focus more attention on the HIV/AIDS threat.
· Even if the five next-wave countries devote more resources to HIV/AIDS programs, implementation is likely to miss significant portions of the population, given weak or limited government institutions and uneven coordination between local and national levels.
· Nigeria and Ethiopia have very limited public services to mobilize. Russia is beset by other major public health problems. China has decentralized most responsibility for health and education issues to local governments that often are corrupt.
· India has taken some steps to improve its healthcare infrastructure to combat HIV/AIDS, but the government has few resources to treat existing infections and must cope with other major health problems such as tuberculosis (TB), which has become linked to the spread of HIV/AIDS.
The rise of HIV/AIDS in the next-wave countries is likely to have significant economic, social, political, and military implications. The impact will vary substantially among the five countries, however, because of differences among them in the development of the disease, likely government responses, available resources, and demographic profiles.
· Nigeria and Ethiopia will be the hardest hit, with the social and economic impact similar to that in the hardest hit countries in southern and central Africa—decimating key government and business elites, undermining growth, and discouraging foreign investment. Both countries are key to regional stability, and the rise in HIV/AIDS will strain their governments.
· In Russia, the rise in HIV/AIDS will exacerbate the population decline and severe health problems already plaguing the country, creating even greater difficulty for Russia to rebound economically. These trends may spark tensions over spending priorities and sharpen military manpower shortages.
· HIV/AIDS will drive up social and healthcare costs in India and China, but the broader economic and political impact is likely to be readily absorbed by the huge populations of these countries. We do not believe the disease will pose a fundamental threat through 2010 to their status as major regional players, but it will add to the complex problems faced by their leaders. The more HIV/AIDS spreads among young, educated, urban populations, the greater the economic cost of the disease will be for these countries, given the impact on, and the need for, skilled labor.
The growing AIDS problem in the next-wave countries probably will spark calls for more financial and technical support from donor countries. It may lead to growing tensions over how to disburse international funds, such as the Global Fund for AIDS, TB and Malaria.
The cost of antiretroviral drugs—which can prolong the lives of infected people—has plunged in recent years but still may be prohibitively high for populous, low-income countries. More importantly, the drug costs are only a portion of HIV/AIDS treatment costs. Drug-resistant strains are likely to spread because of the inconsistent use of antiretroviral therapies and the manufacture overseas of unregulated, substandard drugs.
· If an effective vaccine is developed in the coming years, Western governments and pharmaceutical companies will come under intense pressure to make it widely available.
· The next-wave countries are likely to seek greater US technical assistance in tracking and combating the disease.

Reliable statistics on HIV/AIDS are difficult or impossible to get for many countries. UNAIDS maintains the most comprehensive databases of information in the world on AIDS, but the UN organization relies on official government statistics from each country—which experts believe sometimes understate the number of infected people. Our estimates of infection rates and their likely trajectories go beyond the official statistics by incorporating the assessments of academics and NGOs with field experience. As a result, all of the numbers in this assessment should be viewed as rough estimates, and our projections employ ranges to convey the general magnitude of the disease within a relatively high margin of error.
Governments often do not spend enough money to get quality infection surveillance because they have other budget priorities, do not want to acknowledge the extent of the epidemic, and the drug users and prostitutes at high risk of infection are not key political constituencies.
· Other hidden pockets of infection include TB patients—some of whom have contracted TB because they are HIV positive—and patients with venereal diseases and reproductive tract infections.
· It is difficult to get data on HIV prevalence rates in foreign military ranks, which harbor significant numbers of infected men.
Even if testing is available, many people do not get tested because of denial, stigma, discrimination, or resignation.
· Intravenous drug users, prostitutes, and homosexuals usually are reluctant to identify themselves for fear of punishment.
· Some avoid testing when healthcare and treatment for the disease is unavailable.
Infection surveillance of women attending prenatal clinics is considered the most reliable indicator of adult HIV prevalence in the general population. But even these statistics can be affected by poor clinic attendance when fee for services or mandatory HIV testing is instituted.

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India and China are likely to generate the largest number of people infected with AIDS of any countries in the world by 2010, but the impact will be lessened because these individuals will remain diffused among very large populations. Even if the number of infected people rises to the upper side of our projections, the percentage of the adult population that is infected still would be significantly lower than in the other next-wave countries at the end of the decade.
· Fifteen million HIV-positive people in China would represent roughly 2 percent of the adult population.
· Twenty-five million infected Indians would reflect a 4 percent adult prevalence rate.
Judging the broader impact on economic growth and productivity is more difficult, however, because it depends largely on which demographic groups get hit the hardest. Several researchers in 1999 estimated that AIDS cost India roughly 1 percent of GDP per year because of lost productivity and treatment of secondary infections. The study did not include numerous factors—such as the cost of drugs and retraining workers—however, and there is no consensus on a formula to calculate the economic costs (2) · At a minimum, AIDS will drive up healthcare costs in both countries, forcing difficult trade-offs on spending.
· The more the disease remains among rural and lower skilled people, the more likely that the abundant labor supply of both China and India can fill the gap.
· The more the disease spreads among young, educated, urban professionals, however, the higher the economic costs will be, given the premium on skilled labor.
· Chinese leaders are likely to fear that the perception in global markets of a rising AIDS problem could discourage the huge flow of foreign investment into the country that has been vital to growth.
We believe the HIV/AIDS epidemic, by itself, will not pose a fundamental threat through 2010 to the rise of China and India as major regional players. Given the relatively low current prevalence rates and the relatively long period from infection to death, the two countries can manage the impact of the disease through the end of the decade. Nonetheless, the mounting AIDS problem will further add to the complex problems and trade-offs facing leaders in both countries in the coming years.
· Beyond 2010, HIV/AIDS will become an even more significant problem for China and India if government programs prove ineffective and prevalence rates jump significantly.
There is no sign that HIV/AIDS will become a lightning rod for widespread public discontent in either China or India. Nonetheless, the protests of rural Chinese who became infected through plasma sales suggest that anger with the government’s slow response will add to growing frustration in rural areas over rising unemployment, widespread corruption, and poor services.
· Press reports indicate that several small-scale AIDS-related protests have erupted in Chinese villages over the last year. Journalists report that many villagers are angry over the issue but are afraid to speak out because of government intimidation.
· For several days in November, police detained HIV-positive protesters and a group of reporters who came to interview them.
· Protests by Chinese in urban areas almost certainly would spark deeper concern among Chinese authorities.
· HIV/AIDS may become more of a political issue in India as infection rates climb. The debate is likely to focus on who pays for and receives the antiretroviral drugs that Indian firms now are producing.
Both Beijing and New Delhi probably will try to push the rising cost of dealing with HIV/AIDS down to state and local governments, as they have on other issues. Local authorities, however, are unlikely to have the staff, expertise, or funding to assume the growing burden.
· Most Indian state governments already have curbed spending on healthcare and education to cope with severe fiscal strains—and some are even struggling just to pay the wages of government workers.
· Likewise, Chinese localities already are overburdened with responsibilities for public health that Beijing has passed along in decentralizing many government duties.
HIV/AIDS is unlikely to undermine general military capabilities in China and India because of the large pool of potential recruits for the respective armies. China began testing conscripts for HIV in 2001.
· China and India increasingly will monitor AIDS in the military to ensure that the disease does not complicate staffing among smaller, more highly trained units operating sophisticated weapon systems.
As HIV/AIDS moves more into the general population in China, past experience in other countries suggests it will exacerbate an already existing gender imbalance because of the practice of female infanticide.
· In India and China, because of cultural norms, boys are more likely to be taken care of by their relatives than girls.

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