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Confronting the HIV/AIDS Crisis in Post-Military Nigeria.


AIDS or acquired immunodeficiency syndrome is caused by the presence of the human immunodeficiency virus or HIV in the body. Global epidemiologic studies have so far identified two types of HIV; type 1 is found worldwide while type 2 is restricted to West Africa though it could be transmitted to outsiders with ties to the region. Almost all persons infected with HIV-1 suffer from severe depletion of CD4+ lymphocyte, a component of the immune system that fights off infections. An infected person invariably becomes highly susceptible to various opportunistic organisms that would not normally cause serious disease to uninfected individuals. AIDS opportunistic infections (AIDS-OIs) or diseases caused by such organisms include recurrent pneumonia, pulmonary tuberculosis, histoplasmosis, invasive cervical cancer, and cytomegalovirus (CMV), to name a few. Although HIV-1 is more virulent, the median time from infection to development of the disease to full blown AIDS in adults is approximately 10 years; with HIV-2, the median time is about 5 years (Gallo & Montagnier, 1988). In other words, a person infected with HIV may show no symptoms of AIDS for a few years, but can transmit the virus to uninfected persons through sexual contact, blood transfusion and contaminated needles. Infected women can transmit the disease to an unborn fetus and to an infant through breast-feeding. Clinical expression of AIDS-OIs is exacerbated by a broad spectrum of parasitic and viral diseases that occur in epidemic proportions in sub-Saharan Africa.

The primary purpose of this study is to examine the prospects for sustained international intervention against Africa's AIDS crisis. When the AIDS virus was discovered in early 1980s, there were speculations that it originated in Africa. But it was its pandemic nature that raised alarm in the global community; not only did AIDS prove to be a highly virulent disease, but also a trans-boundary health problem because of its infectious nature. Two decades after the HIV virus made the headlines as a major killer, the debate about its origin has lost much significance in view of what has been revealed by the global struggle against AIDS; not only does Sub-Saharan Africa account for a disproportionate number of the world's AIDS victims, the region lags behind the rest of the global community in terms of its ability to combat the epidemic. The authors argue that the African situation reflects the existing global inequalities in terms of the technological and financial resources necessary to combat AIDS. However, as has been demonstrated by the experiences of the industrial nations of Europe and North America, African countries will need more than those critical medical resources to reverse the present AIDS/HIV trends in the region. Toward that end, the authors conclude with suggestions for more aggressive inward looking approaches to combating the epidemic.

Transmission and Spread of AIDS in Africa

In a recent study entitled Population and Reproductive Health in Sub-Saharan Africa, Thomas Goliber stated that while the HIV/AIDS epidemic is serious in many world regions, it is especially severe in Africa which accounts for a disproportionate number of the world's HIV infections and AIDS deaths (Goliber, 1997). The extent of the HIV/AIDS epidemic in Sub-Saharan Africa is difficult to gauge because many cases are not reported. National estimates of HIV/AIDS prevalence reflect data from sentinel surveillance systems. These are health facilities designated to conduct tests on anonymous blood samples from sexually transmitted disease (STD) clients and from pregnant women who seek antenatal care (ANC). Since these groups are not representative of the entire populations, the statistical data used to analyze the status of the epidemic in sub-Saharan Africa are grossly inadequate. Furthermore, not only do most health facilities lack the diagnostic tools to test for HIV infection, infected persons do not die directly from HIV but rather from the opportunistic infections that invade the body as the immune system breaks down. Consequently, AIDS may not be reported as the underlying cause of death. Furthermore, many infected persons don't seek care and are never reported because of the social stigma attached to the disease. Some health-care providers and families prefer not to report an AIDS diagnosis for the same reason.

As shown in table 1 (see appendix 1), by December 1997 the cumulative HIV/AIDS cases since the outbreak of the epidemic in the mid-1970s were estimated at 30,300,000. Also, in December 1997 the cumulative HIV/AIDS cases in the region were estimated at 30,000,000. According to table 2 (see appendix 2), cumulative AIDS deaths worldwide was 11,700,000 by December 1997 while Sub-Saharan Africa accounted for 21,000,000 or 82 percent of cumulative global AIDS deaths in the same year.

Several factors contribute to the high level of HIV prevalence in sub-Saharan Africa. The major mode of HIV transmission in sub-Saharan Africa is heterosexual transmission, followed by transmission from mother to infant before, during, or after birth. Contact with contaminated blood through medical procedures or use of unsanitary needles are relatively unimportant means of HIV transmission in the region. The appalling number of HIV/AIDS cases in the region is a function of multiple factors which are outlined below.

* Sexually transmitted diseases or STDs: The presence of a sexually transmitted disease such as gonorrhea, chanchroid, and syphyllis greatly increases the chances of HIV transmission during an unprotected act of sexual intercourse. STDs tend to remain asymptomatic in women for a long time while subjecting the cubical epithelial cells to lacerations. There is a high prevalence of STDs among female sex workers in sub-Saharan Africa due to poor sanitary conditions and lack of medical care. As a result many of them contract HIV infection through unprotected sexual intercourse with infected male clients.

* Multiple concurrent sexual partners: There is a high incidence of multiple concurrent sex partners in sub-Saharan Africa, especially because polygamy is a common practice in many parts of the region. In Sub-Saharan Africa as well as in other parts of the world, marital infidelity on the part of the men does not attract serious social sanction. For instance, among the Fulani of Northern Cameroon young men are not expected to remain celibate until marriage. Nor is any great value attached to fidelity among married men, particularly when they are away from home. Unfortunately, as often happens, the wives may be infected by their husbands if the latter have outside sex partners. The age and sex profiles of reported AIDs cases suggest that many young women are being infected with HIV from older men (David and Voas, 1981).

* Commercial sex workers: High incidence of commercial sex and other transactional sexual relationships in the region also facilitate the transmission of HIV. Prostitution and associated STDs increase the transmission of HIV in African women. High incidence of HIV seropositivity among sex workers has been confirmed in East, Central, and West Africa. For instance, Obolea noted a high affinity for prostitution among the Haya women of Tanzania, Nandi of Kenya, and Hausa Women of Nigeria. The author further pointed out that the geographic mobility of sex workers and migration of young females to urban communities increase the occurrence of prostitution. Similarly, the involvement of married men in multiple sexual relationships facilitate the transmission of HIV infection (Williams, 1991).

* Low condom use: Anti-HIV and STD campaigns and social marketing have increased the availability of and use of condoms in sub-Sahara Africa in the late 1990s. But owing to high cost of condoms and inadequate sex education, availability and use of condoms have not increased sufficiently to slow the spread of HIV. Furthermore, as demonstrated by a study on Chitipa residents in Malawi, there is still significant resistance to use of condoms among the men due to alleged inconvenience and cultural misconceptions (Waldorf, 1997).

* Circumcision: Female circumcision is still common in parts of sub-Saharan Africa despite public outrage against the practice. The process can result in profuse bleeding, with the danger of viral infection. The risk of HIV transmission is high when, as is often the case, local healers use unsterilized surgical instruments to perform multiple circumcisions. While generally considered necessary for sanitary and cosmetic reasons, male circumcision is not practiced in parts of sub-Saharan Africa because of cultural reasons (Ebomoyi, 1987). Unfortunately, uncircumcized heterosexual men are susceptible to HIV transmission when the prepuce comes into contact with the smegma of an infected female sexual partner. The likelihood of spreading HIV virus to a larger group is increased if such men engage in concurrent sexual intercourse (Goliber, 1997; Toubia, 1994). Notably, scarification and similar cultural practices in sub-Saharan Africa carry additional risk of HIV infection.

* Urbanization: Sub-Saharan Africa is the least urban but most rapidly urbanizing part of the world. While in 1950 only 11 percent of the population lived in the cities, urban residents made up nearly one-third or 32 percent of the population in 1996. The UN projects that nearly one-half of sub-Saharan Africa's population will be urban by 2025. Urban growth is driven by a constant flow of migrants from the countryside and persistently high birth rates within the cities. Although urbanization in sub-Saharan Africa is not accompanied by significant industrial expansion, the cities are increasingly attractive to an ever growing population of young job seekers because of the amenities of urban life and the deterioration of agriculture in the rural areas. Another factor contributing to the high rates of urbanization is that many African countries, especially the smaller ones, have a dominant or primary city that serves as the administrative, economic and political center of the country. These primary cities account for 30 to 40 percent of the urban population of the region. The inability of these countries to provide adequate sanitation, transportation, education, housing, health care, energy and a host of other basic needs for urban residents has created structural conditions that exacerbate the AIDS/HIV epidemic. For instance, many unemployed or unemployable urbandwelling females take to prostitution while large numbers of working-age males often migrate to cities without their wives or families and become involved in multiple sexual relationships. Furthermore, the prevalence of HIV and other STDs is high in the cities because of the large concentration of people, and because many of the social norms that limit sexual contacts in the countryside break down in the city environment (Goliber, 1997).

* Refugee movement: Sub-Saharan Africa has one of the largest refugee populations in the world. According to the U.S. Committee for Refugees, about 3.5 million of the 14.5 million refugees in the word were in the region in 1996. Massive population movements generated by civil unrest and war, economic distress, and environmental disasters force thousands of dislocated people into unsanitary living conditions that increase the risk of HIV infection as well as the spread of other STDS. In fact, the generally low health status of refugees makes them particularly vulnerable. Without doubt, civil war and refugee movement contributed to HIV prevalence in Congo (Zaire), Rwanda, Burundi, and Sudan (Goliber, 1997).

* Poverty and malnutrition: Finally, HIV prevalence in sub-Saharan Africa is a function of the people's standard of living which has undergone a steady decline in recent years. One in five children in the region dies before the age of five. Fifty percent live below the poverty line; 40 percent live on less than $1.00 a day while forty percent suffer from malnutrition and hunger. Over 44 million children are not in primary school. Africa is the only developing region where the rate of school attendance is in decline. During the 1990s, the ability of African governments to provide basic needs is hamstrung by dwindling foreign aid and heavy debt service which takes 80 percent of the regions's export earnings. Against this backdrop, AIDS patients in sub-Saharan Africa cannot afford the high costs of treatments (with protease inhibitors) which can boost the immune system and prolong their life. Furthermore, the low health status in the region makes it difficult for many people to resist infections of many kinds, including STDs and other AIDS opportunistic diseases (Goliber, 1997: 28-31).

* Breast-feeding: Breast-feeding is a major means of HIV transmission from infected mothers to their infants. It is a common practice both in the rural and urban parts of sub-Saharan Africa. It is often used as a contraceptive device since many postpartum women do not easily become pregnant while they are lactating. Furthermore, breast-feeding is encouraged by the WHO as one of the key elements of maternal and child health in primary health care. In several African communities, children are breast-fed to the age of 24 months to facilitate child spacing, foster maternal-child bonding, and to improve the health status of the infant (Williams, 1991; Oni, 1986).

* High fertility rates: The total fertility rate (TFR) in sub-Saharan Africa was about 6.6 children per woman in the 1950s. In the 1990s, the region continues to have the highest birth rates in the world, with a TFR of about 6.0 children per woman. However, fertility rates vary dramatically among countries in the region. For instance, in 1997 Nigeria had a TFR of 6.2 children per woman while Kenya and South Africa had a TFR of 5.4 and 3.4 respectively. High fertility rates are due to a combination of cultural and economic factors that militate against family planning through modern contraception. High birth rates have kept sub-Saharan African countries young. In 1997, the population under age 15 exceeded 40 percent in every country except of Gabon and South Africa which have relatively low fertility rates. High fertility rates (a youthful population structure) put a great strain on available resources, thus constraining the ability of sub-Saharan Africa's impoverished countries to fight the HIV/AIDS epidemic. More importantly, their youthful population structures invariably translate to a large pool of potentially at risk persons in each country. Not only that, the tendency for African mothers to procreate until menopause may aggravate the clinical expression of HIV and increase maternal upsurge of infectious virus. This will not only give rise to vertical transmission but also increase the portion of Pediatric AIDS cases (PAIDS) (Goliber, 1997; Williams, 1991).

* Ecology: Sub-Saharan Africa is a tropical region with ecological conditions that are conducive to the proliferation of parasitic and viral diseases, including HIV opportunistic diseases. Furthermore, in many areas inclement climatic conditions have a negative effect on food production and sanitation which in turn impact negatively on the health status of the people (Bethel, 1995).

Barriers to Treatment of AIDS in Africa

From the standpoint of neomalthusian theorists, AIDS may be the ecological solution to the rapid population explosion in Africa and the rest of the developing world. For instance, in 1997 the Population Reference Bureau estimated world census at 5,840,433,000; developing nations made up 79.9% while the developed nations made up 20.1% (Population Today, 1998). Medical scientists and WHO epidemiologists have predicted that HIV will infect more than 200 million people by the year 2010. Africa's share of this demographic disruption could approach 100 million (Mann, 1996). To what extent this demographic imbalance has contributed to the ambivalence of the international community toward the challenge of combating the epidemic in areas where population growth is highest but confronted with the trinity of AIDS, ignorance may not be clear. However, the vicious nature of the HIV/AIDS epidemic and its capacity to decimate families and communities in Africa and other developing regions has become very blatant.

In 1996, the United States Food and Drag Administration approved many protease inhibitors, members of a new class of antiretrovirals. By July 10, 1996, the American Medical Association (13) issued a consensus statement approving several antiretroviral therapies for HIV infection. These expensive drugs include Ziovudine (AZT), Zalcitabine (ddc), Didanosine (ddi), Stavudine (d4t), Nevirapine, Lamivudine 3TC, Saquinavir Mesylate, Indinavir Sulphate, and Ritonavir (Fishel et al, 1996). With this medical breakthrough, there has been a progressive decline in AIDS deaths and incidence of AIDS cases in the United States. The number of AIDS deaths in the US fell from 45,765 in 1995 to 25,695 in 1996 (CDC, 1997). It is expected that by the year 2000, AIDS deaths in the United States will be quite minimal. In contrast, AIDS deaths are expected to rise steadily in the African AIDS epicenters such as Zaire, Tanzania, Rwanda, Malawi, and South Africa.

Notably, the United States Center for Disease Control (CDC) has also warned that the new drags were extremely expensive (approximately $12,000 per patient per year) and many infected persons in the United States would not be able to afford them. If America with one of the highest per capita incomes in the world cannot afford combination therapy for all of its AIDS victims, the implication is that patients from highly impoverished parts of the world are confronted with a far more uncertain future. Inadequate diagnosis, under-reporting and the prohibitive cost of the combination therapy constitute monumental barriers to the treatment of AIDS patients in Africa and other developing regions (CDC, 1997). This situation can be further understood in the context of prevailing political and economic crises, official corruption and waste which act as impediments to government-sponsored pharmaceutical research in Africa. With the exception of few African countries such as Uganda and the Ivory Coast, governments that lack the resources to deal with the HIV/AIDS epidemic are reluctant to admit the magnitude of the problem and alert the public accordingly. The failure of African governments to contend with the AIDS/HIV epidemic tends to reinforce other barriers to controlling and treating the disease. For instance, ignorance, poverty and social stigmatization of AIDS victims in Malawi force the latter to hide their seropositivity status or to rely on ineffective treatment by traditional healers. This state of affairs is compounded by the fact that some infected individuals, frustrated with their condition, surreptitiously infect unsuspecting sexual partners.

Against this background, AIDS death has become the modern day sword of Damocles hanging menacingly over the heads of Africans. AIDS has the potential to decimate whole villages, towns, and hamlets. As pointed out earlier, AIDS-related deaths of adults has resulted to massive orphanization of African children. It has also contributed to the undermining of time-tested cultural observances that are only internalized through traditional processes of socialization.

Prospects for International Intervention

In 1998, one in five African children died before the age of five while 50 percent of the people lived below the poverty line, with 40 percent living on less than $1.00 a day. In the same year, forty percent of the African people suffered from hunger and malnutrition. Over 44 million children were unable to attend primary school. In fact, Africa was the only developing region where school attendance rates were in decline. The continent's economic crisis is further compounded by falling commodity prices, dwindling foreign aid, and a heavy debt service which takes 80 percent of the region's export earnings. This dismal picture suggests that, left on their own African governments will not be able to shoulder the AIDS burden in addition to the present challenges of achieving sustainable development in the region. Although this reality appears to have stimulated some international intervention, the outcome has been minimal as relatively meager resources have been devoted to Africa's HIV/AIDS crisis by foreign donors. Specifically, Uganda and the Ivory Coast are the two most prominent recipients of international assistance with regard to their efforts to combat the epidemic. The WHO and UNAIDS have been conducting clinical trials with protease inhibitors in the above countries. These experimental programs are designed to assist a handful of individuals infected with the AIDS virus in these countries. The limited nature of support from the multilateral agencies is due partly to the fact that they were primarily designed to provide consultancy services to member nations as opposed to serving as international providers of health care. In addition, the multilateral agencies depend heavily on donations from national governments in order to carry out their international obligations. In recent years many governments in both developing and developed regions of the globe have reneged on their financial obligations toward these agencies. The choice of Uganda and Ivory Coast as experimental sites for the WHO/UNAIDS' epidemiologic program was based on four cogent reasons; the willingness of the governments to admit the magnitude of the AIDS epidemic in their countries; the manageable size of each country; and the government's willingness to embark-on aggressive primary prevention health education programs. Of particular significance is their decision to introduce AIDS/HIV education into the curriculum from elementary to university level (Bethel, 1995).

Against this background, Peter Piot, executive director of the Joint United Nations Programme on HIV/ AIDS (UNAIDS), recently suggested that the global AIDS pandemic should be treated as a human rights concern. At the 12th World AIDS Conference held in June 1998, he called for a strategic partnership between religious organizations, human rights groups and the corporate sector alliance for the purpose of mobilizing available resources to effect a global intervention on behalf of AIDS victims in Africa and other poverty stricken parts of the world (Piot, 1998). In a similar effort to find a lasting solution to the global AIDS situation, Jonathan Mann stated the following:

We propose that, as respect for human rights and dignity is a sine qua non for promoting and protecting human well-being, the human rights framework offers public health a more coherent, comprehensive, and practical framework for analysis and action on the societal root causes of vulnerability to HIV/AIDS than any framework inherited from traditional public health or biomedical science. We propose that promoting and protecting human rights is therefore inextricably linked with our ability to promote and protect health ... Clearly, human rights work will obviously not bring to a halt all preventable illnesses or premature deaths. However, the realization of rights and increasing respect for human dignity will reduce or even eliminate the societal contributions, which we know is the major contribution to this burden of disease, disability, and death (Mann et al, 1999).

The above authors evoked established international principles to make their case for a more aggressive global strategy for dealing with the AIDS/HIV crisis. These principles are enshrined in the United Nations Universal Declaration of human rights, which states that every person has the right to a good standard of living, including the right to medical care. Recognizing the unique vulnerability of children and women, the above document specifies that "motherhood and childhood are entitled to special care and assistance" (Donnelly, 1998: 168). Notably, four out of every five women HIV-positive women in the world live in Africa. An even higher proportion of the children living with HIV in the world are in Africa -- an estimated 87%. In addition, of the 8.2 million children orphaned by AIDS worldwide, over 6.5 million are in Africa. This is due partly to the fact that more women of childbearing age are HIV-infected in Africa than elsewhere. Secondly, African women have more children on average than those in other continents. Consequently, one infected woman may pass the virus on to a higher number of children. Thirdly, nearly all children in Africa are breast-fed. Experts believe that breast-feeding accounts for between a third and half of all HIV transmission from mother to child. Finally, new drugs which help reduce transmission from mother to child before and around childbirth are far less readily available in developing countries, including those in Africa, than in the industrialized world (Report on the Global HIV/AIDS epidemic, June 1998).

In spite of its strong emotional appeal, the prospects for convincing the international community to act along the lines suggested by proponents of the human rights framework appear to be slim at the present time. This is because AIDS is a pandemic rather than an endemic disease. It is difficult to make the case for international intervention on behalf of AIDS victims in a particular segment of the globe since each country has its own share of the disease and its socioeconomic implications. Additionally, favorable statistics on the AIDS trends in the industrialized countries act as disincentive for them to come to the aid of Africans and other regions burdened with the HIV/AIDS epidemic. Furthermore, there is still a general reluctance on the part of African governments to admit the magnitude of HIV/AIDS prevalence in their countries. This is due, in part, to the fact that these governments are afraid of the economic ramifications of posting a high HIV/AIDS statistics that could have the negative effect of keeping potential investors and tourists away. In addition, many national leaders see no political benefit in declaring the true estimates of HIV/AIDS cases in their countries, considering the fact that they lack the resources to combat the disease. Finally, as amply demonstrated by recent disasters in Somalia and Rwanda, the international community is usually slow in responding to African problems. It is a fact that the continent has been historically marginalized in the policies of the industrialized countries. Thus, despite the strength of humanitarian appeal on behalf of Africa's HIV/AIDS victims, it is unlikely that there will be an international response to their predicament that will be as massive and swift as they desire.


Unfortunately, the existing body of literature on Africa's AIDS crisis appears to be silent on the relationship between the epidemics and the failure of the state in African countries to cater to the basic needs of the people as a result of greed, corruption, and lack of vision on the part of the ruling classes. Yet, it is a well known fact that economic difficulties and the checkered state of health care delivery systems in African countries are partly a function of social neglect and/or ill-conceived priorities by national elites. Academic discussion on African affairs is replete with references to leaders who stash away billions in public money in foreign banks and engage in wanton brutalization of their people. The AIDS dilemma should serve as an imperative for Africans to insist on governmental accountability; good governments should make good faith efforts to procure existing drugs which are effective for the management of HIV/AIDS, not just for politicians and top government officials, but also for the ordinary citizens infected with the disease. Given the existing body of knowledge relative to transmission and barriers to the treatment of AIDS, it is pertinent that African governments take more responsibility in implementing primary preventive measures against the spread of HIV in their countries. These measures would still be necessary even if Africa's AIDS victims were being provided with more support from the international community.

African governments should and could do more to prevent the spread of HIV among their citizens by declaring war on prostitution, polygamy, concubinage, child marriage, female illiteracy and other cultural practices that adversely affect the status of women. Although there are cultural proscriptions against sexual promiscuity in African marriages, it is evident that the polygamous family system creates conditions that make it practically impossible to confine sexual intercourse within conjugal relationships. In theory cultural proscriptions against marital infidelity are equally applicable to both men and women. However, in reality African societies tend to frown more at women who engage in extramarital affairs. Given the insidious nature of HIV, a single act of sexual infidelity on the part of one partner could potentially jeopardize the well-being of the extended family.

Against this background, the importance of education for African women as an avenue to self-empowerment can not be over emphasized. Unfortunately, in almost every African society traditional role expectations have made their way into the arena of Western education and the post-colonial economy. Consequently, not only are women provided with limited opportunities for self-empowerment, those who are fortunate to acquire higher education are socialized into disciplines that confine them to traditional feminine occupations such as teaching, nursing, office management, counseling, social work and the like. As part of a long-term strategy to eradicate AIDS and other social impediments to sustainable development, women's education must be reoriented toward disciplines hitherto reserved for their male counterparts. Not only will the suggested change increase women's chances of operating as decision makers and advocates for their group, it will empower them to resist social and economic exploitation in their homes and in the public arena. AIDS education should be intensified through parents, the media, schools, government agencies as well as non-governmental organizations. Specifically, every effort must be made to stress the importance of abstinence, safe sex and other primary prevention strategies as the only guaranteed protection against HIV/ AIDS infections. AIDS education and other preventative initiatives are all the more important in view of the limited resources at the disposal of African countries for combating the epidemic.


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Appendix 1

Table 1. Estimated current and Cumulative HIV/AIDS Cases by Region, End of 1997
Region                      Total         Women        Children

North                      860,000       170,000         8,600

Caribbean                  310,000        98,000         9,000

Latin America            1,300,000       240,000        15,000

Western                    480,000       100,000         5,000

N.Africa/                  210,000        40,000         7,000
Middle East

Sub-Saharan             21,000,000     9,900,000       960,000

E.Europe/                  190,000        38,000         4,700
Central Asia

South/                   5,800,000     1,500,000        81,000

East                       420,000        53,000         1,800

Australia/New               12,000           700         < 100

World                   30,300,000    12,200,000     1,100,000

Source: UNAIDS and WHO, Report on the Global HIV/AIDS Epidemic, June 1998.

Appendix 2

Table 2. Cumulative AIDS Deaths as of End of 1997, by Regions.
                                 Adults &     Percentage of
Region                           Children         Total

North America                    420,000           3.7

Western                          190,000           1.6

Latin America 470,000            470,000           4.0

North                             42,000           0.4

Sub-Saharan                    9,600,000          82.1

Eastern                            5,400           0.1
Central Asia

South/                           730,000           6.2
Southeast Asia

East                              11,000           0.1

Total                         11,700,000         100

Source: UNAIDS and WHO, Report on the Global HIV/AIDS Epidemic, June 1998.
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