The extent of the AIDS epidemic underscores the urgent need for condoms. Worldwide, nearly 1 adult in every 100 between the ages of 15 and 50 is infected with HIV. At the end of 1998 at least 33 million people had HIV/AIDS, and another 14 million people had died as a result of HIV/AIDS (269).

HIV/AIDS is especially widespread in the developing world. In some sub-Saharan countries AIDS has more than doubled the death rate. In Namibia AIDS already has become the single greatest cause of death (266, 355). As a result of AIDS, life expectancy also is falling substantially in Botswana, Ethiopia, Malawi, Swaziland, Zambia, and Zimbabwe (391).

HIV infects certain body cells, especially CD4 lymphocytes ("T-cells"), thereby destroying the body's immune system and reducing its ability to fight certain diseases. People who are infected with HIV get sick easily with such diseases as pneumonia, tuberculosis, aggressive Kaposi's sarcoma (a type of cancer), brain infections, persistent diarrhea, and herpes infections.

An HIV-infected person whose immune system is severely compromised and/or who has one or more HIV-related diseases is defined as having AIDS. Because HIV damages the immune system, most people with AIDS die from dis-eases that their bodies no longer can fight (246, 555, 587).

How HIV/AIDS spreads. HIV is carried in body fluids. The most important are semen, blood, breastmilk, and vaginal fluid (246, 558). HIV is spread primarily through sexual contact that passes body fluids from one person to another. It also can be spread by contaminated blood or blood products, by hypodermic needles contaminated with such blood, and from an infected woman to her child during pregnancy, childbirth, or breastfeeding. A person may have HIV for years before any symptoms appear. Although people may not know that they are infected, and they do not look or feel sick, they still can pass HIV to others.

For physiological reasons, a woman is more likely to contract HIV/AIDS sexually from an infected man than a woman is to infect a man (23, 129, 394). The percentage of HIV-positive adults who are women has risen from 25% estimated in 1990 to 43% in late 1997 and appears to be still rising (12, 266).

HIV also has spread to children born to infected mothers, a trend that is eroding previous gains in child survival. The majority of infections occur during or close to birth; in developing countries breastfeeding accounts for an estimated one-third of HIV transmission from mother to child (269).

Treatment is not enough. Recently developed antiviral drugs reduce the amount of HIV in the body, delay the onset of symptoms of AIDS, significantly improve the quality of life for HIV-infected people, and can reduce the likelihood that HIV-infected mothers will pass HIV to their children (266, 498). These drugs are unlikely to play a major role in controlling the epidemic, however. Most are expensive, even if subsidized for developing countries. They require lengthy treatment and regular medical supervision; they have serious side effects; and they do not work for everyone (269, 408, 498).

Furthermore, widespread use of antiviral drugs would not eliminate new infections among adults (183). In North America and Western Europe, because new infections have continued to occur while the drugs have kept already infected people alive, the proportion of the population living with HIV has grown (266). Moreover, if people do not take the drugs as directed, drug-resistant strains of HIV can survive the treatment and be transmitted to others (498).

Less expensive drug treatments that can help prevent mother-to-child transmission of HIV may have a role to play in developing countries. A recent study conducted at five sites in South Africa, Tanzania, and Uganda indicates that a short, relatively inexpensive course of drug treatment could cut in half the risk that HIV will be transmitted from an infected woman to her fetus (379, 523).

Other STIs. Some 25 infections besides HIV can be spread through sexual contact (155). These share many characteristics with HIV/AIDS: They are often asymptomatic for years after initial infection, particularly in women. Many carry a social stigma. Rates of infection are higher in conditions of poverty and poor access to health care (12, 155, 590).

People generally have a higher risk of HIV infection if they have other STIs (559). STIs that have been linked to an increased risk of HIV/AIDS include bacterial vaginosis, chancroid, chlamydia trachomatis, herpes simplex, syphilis, and trichomoniasis (161, 390, 559). One study estimated that preventing or curing 100 cases of syphilis in a high-risk group would prevent 109 new HIV infections as well as more than 4,100 new cases of syphilis in the following 10 years (393).

Globally, an estimated 333 million new cases of the four major curable STIs—gonorrhea, chlamydia, syphilis, and trichomoniasis—occur each year among adults, with at least one-third of these in adults under 25 years of age (594). Prevalence and incidence of curable STIs are particularly high in developing countries (129, 596). Among women of reproductive age in developing countries, STIs are the second most frequent cause of sickness and death, behind only maternal causes (589). Many of these cases of STIs could be prevented through correct and consistent use of condoms.

Regional Prospects for AIDS

Sub-Saharan Africa. Two-thirds of all adults living with AIDS are in sub-Saharan Africa, and 70% of all new HIV infections in 1998 occurred there (266). In sub-Saharan Africa 7% of adults ages 15 to 49 are infected with HIV, and in 13 countries at least 10% of the adult population is infected (266, 271).

The southern countries of Africa have the highest HIV infection rates in the world. In Botswana, Namibia, Swaziland, Zambia, and Zimbabwe, between 18% and 26% of adults ages 15 to 49 are infected (266).

About 10% of African adults infected with HIV live in Nigeria, the region's most populous country (269). Nigeria's adult infection rate is now about 4% and is continuing to rise (269).

About 4 of every 5 women and nearly 9 of every 10 children infected with HIV live in Africa. Because the HIV/AIDS epidemic in sub-Saharan Africa has from its start spread primarily through heterosexual relations, women and children have been more affected than in countries where HIV initially spread largely through male-to-male sex or sharing of intravenous drug injecting equipment (269).

There are signs that AIDS prevention programs are beginning to make a difference in some parts of Africa. In areasof Tanzania with active AIDS prevention programs, for example, infection rates have started to decline among young people. In Uganda infection rates have fallen substantially among young adults (269, 369).

Asia. In Asia there are many cases of HIV/AIDS because of the region's large population, but fewer than 1% of adults are infected with HIV, and in most countries infection rates are less than 0.5%. Infection rates are higher in certain countries, particularly Thailand, Cambodia, and Myanmar, where about 2% of adults are infected. In Thailand, however, after a period of rapidly increasing prevalence, new infections have been decreasing in response to AIDS prevention programs.

In India an estimated 4 million people are infected with HIV, the largest number of HIV-infected people in any country in the world. HIV is spreading so fast in India that the number of infections could reach 12 million in the year 2000 (524). In China infection rates are low, but HIV appears to have begun spreading rapidly in southwestern China through intravenous drug use and in relatively prosperous eastern areas through sex workers (269).

Latin America and the Caribbean. In Latin America only about 0.5% of adults are infected with HIV, but in the Caribbean the infection rate is about 2%. Rates are highest in Haiti, at about 5% of adults; the Bahamas, at about 4%; and Barbados, at about 3%. In Latin America and the Caribbean HIV is predominantly spread by men having unprotected sex with men and by intravenous drug users who share needles. In Mexico, for example, up to 30% of men who have sex with men and between 3% and 11% of intravenous drug users are infected with HIV (269).

Other regions. In Eastern Europe and Central Asia, HIV infection rates are low; currently only about 0.1% of the population is infected. Nevertheless, in Belarus, Moldova, the Russian Federation, and Ukraine, HIV infection rates have risen dramatically since 1994, largely due to unsafe drug injecting. In Kaliningrad, Russia, for example, a study found that one-third of sex workers were intravenous drug users infected with HIV (269).

Little is known about HIV infection rates in North Africa and the Near East. The best evidence is that only about 0.1% of adults are infected. Within the region, the infection rate is highest in Sudan, at 1% (269).

In developed countries the AIDS epidemic may be peaking. In Western Europe infection rates appear to be dropping. In the US infection rates have not dropped, but the number of AIDS-related deaths is falling due to improved treatment. HIV prevalence in the US has dropped among white men but has changed little among Hispanic and African-American men, and it has increased among women (460, 556).

PATH/FHI/USAID/NGO AIDS Consortium, Kenya

In Kenya, as elsewhaere, many myths surround the spread of AIDS. Globally, by the end of 1998, 33 million people had HIV/AIDS, and another 14 million had already died as a result of HIV/AIDS. The extent of the epidemic underscores the need for condoms.

People are more likely to use condoms when they think others do, too. Often, however, condoms suffer from a poor image and negative attitudes (309). For young women in Ghana, for example, buying or suggesting condoms carried a social cost that exceeded the health risks of not buying or suggesting them. In focus groups, many said they associated condoms with "bad girls" and "sex maniacs" (214).

Furthermore, there is some organized opposition to condom use. Some groups advocate abstinence from sex as the only sure protection (366, 373, 491). Some say that promoting and distributing condoms lures people into unsafe sexual behavior (21). For example, in Zambia the Unity Party has argued that monogamy is the only protection against HIV (529) and that condoms only encourage promiscuity and immorality (288). While such opinions have been demonstrated to be unfounded (see Lesson Learned in siderbar below), they often are widespread, along with other false rumors and myths about condoms.

Ghana Social Marketing Foundation

Creating a positive image of condom use, as in this Ghanaian advertisement, is often more effective than citing frightening health statistics.

How Can Programs Change Attitudes?

Political and religious leaders can speak out in favor of condoms. In Bermuda, for example, the Anglican Archdeacon has placed baskets of condoms at the rear of his church and urged distribution in schools (71). In Mauritania a Muslim imam has been named president of Stop SIDA, an organization that promotes HIV/AIDS awareness. He explains that condoms do not encourage prostitution but rather they prevent AIDS (585). In the Philippines Juan Flavier's frank approach to AIDS prevention while Secretary of Health attracted news coverage and increased public approval of condoms (13).

Mass-media campaigns can overcome negative norms toward condoms, improve the image of condoms, and desensitize them as a topic of discussion (36, 74, 136, 155, 282, 356, 420, 599). For example, serial dramas (soap operas) on television and radio in Uganda, India, and elsewhere have helped people to identify with characters whose behavior changes positively as the dramas progress (286, 469, 495).

Condom promotion for family planning or for AIDS prevention should present condom use as a responsible expression of love and as part of modern life. Such a positive approach often changes minds better than citing frightening health statistics.