THE GLOBAL AIDS DISASTER: IMPLICATIONS FOR THE 1990S <SANITIZED>

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• Case Number: F-2015-02015
• Publication Date: July 1, 1991

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Director of
Central
Intelligence
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The Global AIDS Disaster:
Implications for the 1990s
Interagency Intelligence Memorandum
1467
651-651
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NI IIM 91-10005
July 1991
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Director of
Central
Intelligence
NI IIM 91-10005
The Global AIDS Disaster:
Implications for the 1990s
Information available as of 15 July 1991 was used
in the preparation of this Memorandum.
The following intelligence organizations participated
in the preparation of this Memorandum:
The Central Intelligence Agency
The Defense Intelligence Agency
The National Security Agency
The Bureau of Intelligence and Research,
Department of State
also participating:
The Deputy Chief of Staff for Intelligence,
Department of the Army
The Director of Naval Intelligence,
Department of the Navy
The Assistant Chief of Staff, Intelligence,
Department of the Air Force
Director of Intelligence, Headquarters,
Marine Corps
This Memorandum was approved for publication by the
Chairman of the National Intelligence Council.
Se
July 1991
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The Global AIDS Disaster:
Implications for the 1990s
� AIDS cases worldwide will increase rapidly during the 1990s, from
about 1.5 million now to a cumulative total of more than 10 million
by the end of the century.
� Whatever the success of research on vaccines and treatment, the
upward trend in AIDS cases through the mid-1990s will not be
affected.
� Currently, the problem is worst in Africa, but rapidly spreading
infections in India, Brazil, and Thailand will contribute significantly
to an estimated 45 million infections worldwide by 2000.
� By any measure�deaths, number of people infected, economic
cost�the impact of AIDS will be far greater in the 1990s than in
the 1980s.
� The United States will face three basic foreign policy problems:
How to allocate assistance for AIDS prevention, how to manage the
testing and distribution of a vaccine, and how to deal with countries
that are heavily afflicted with AIDS and consequently undergo
substantial economic and political change.
'steer.
NI IM 91-10005
July 1991
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Figure 1
Global Human Immunodeficiency Virus (HIV): Rates of Infection per 100,000 Persons
f-i2EILv 'Rem a MI
g..rga4
avpct
agw
*1,000 to 5,000
Burundi
Cameroon
Congo
French Guiana
Guinea-Bissau
Haiti
Ivory Coast
Nicaragua
Rwanda
Swaziland
1,200
1,975
2,598
4,921 _
2,933
1,941
3,082
1,199
3,796
1.164 -
Tanzania 2,977
Trinidad and Tobago 1,145
Zaire 1,586
00 to 1,000
C pe Verde 6
D rninican Republi 9
Gambi
Gabon
Hondura
Kenya
ozambigue
Namibia
Senegal
Suriname
Thailand
6
756
792
662
9 7
200 to 500
Angola
496
Argentina
276
Bahamas, The
476
Belize
351
Benin
310
Brazil
451
Burkina
214
200 to 500
Ecuador
233
France
441
Ghana
288
Grenada
430
Guinea
241
Guyana
387
Mali
288
Martinique
246
Netherlands
220
Nigeria
408
Panama
202
South Africa
369
Spain
419
Switzerland
262
United States
396
Uruguay
320
Less than 200
All other countries
Boundary representanon Is
not necessanly authoritative.
�er
iv
722488 (301111) 7-91
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Key Judgments
The number of AIDS cases worldwide will increase rapidly during the
1990s, from about 1.5 million as of early 1991 to a cumulative total of
more than 10 million by the end of the century. The great majority of the
new AIDS cases during the 1990s will occur in Sub-Saharan Africa, with
North America a distant second. This increase is inevitable because about
11.5 million people are now infected with the virus that leads to AIDS, a
figure we expect to quadruple by 2000.
Current preventive measures are not being used on a sufficient scale to
reverse the spread of the disease. No "cure" for HIV infection is in
prospect. Even if an effective vaccine is devised within the next few years,
technical and financial obstacles probably will limit its use and, thus, its
impact on the spread of the disease. Whatever the success of any of these
measures, the upward trend in AIDS cases through the mid-1990s will not
be affected.
The AIDS epidemic is at its worst in Sub-Saharan Africa. Some 7 million
Africans are already infected. By the mid-1990s the cumulative total
probably will exceed 20 million, and beyond 2000 infection rates will be up
to 40 percent for typical young-adult populations in urban areas, with life
expectancy at birth reduced by 15 years or more.
This explosion of AIDS cases will substantially weaken the political elites
and damage the economies of affected African countries. A greater portion
of their limited budgets will have to be devoted to prevention and
treatment. At the same time, the dangers posed by AIDS and the AIDS-in-
duced economic decline will discourage foreign investment.
During the 1990s, AIDS in the Caribbean countries will proceed on a scale
comparable to that in Africa, with similar dire results for the affected
societies. In India, AIDS is a major threat on the horizon, but the
government probably will not take adequate steps to counter the disease
during the next five years. This neglect has the potential of allowing
replication of the African experience in 10 or 15 years. Brazil is in a similar
situation, whereas Thailand's early prevention programs may slow the
epidemic.
Using any standard of measure�deaths, number of people infected,
economic cost�the impact of AIDS will be much greater in the 1990s
than it was in the 1980s. The resulting social and economic calamity will
v -StefeL
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Data Deficiences
No country has an accurate count of the number of people infected by
HIV. Much of the testing to date comprises small samples of high-
risk groups, such as prostitutes and drug addicts, and is therefore
unrepresentative of entire populations. Within countries, infection
rates vary widely from region to region, further complicating the
problem of generalizing from a small sample. Counting the number
of AIDS cases and AIDS-related deaths is also difficult, particularly
since health care systems in many countries lack the required
diagnostic ability. Moreover, some governments suppress what infor-
mation they have
The data in figure 1 are Intelligence Community estimates of HIV
prevalence from open-source information in conjunction with intelli-
gence reports. Our aggregate figures are somewhat higher than those
published by the World Health Organization. In some countries�India,
Brazil, and Nigeria for example�the data are particularly weak. Our
world total may well be off by more than a million. We believe that
further improvements in data collection will probably reveal a crisis of
even greater magnitude than is portrayed in this Memorandum. For
instance, recent refinements of information mostly account for larger
figures for several countries than in our previous Estimates.
force the United States to make politically sensitive decisions regarding the
prevention programs that it will encourage and the aid it will dispense.
The three basic foreign policy problems are:
� How to allocate assistance for AIDS prevention. Anti-AIDS programs are
most effective when started early in an epidemic, but most of the money now
goes to countries where the disease is already well entrenched.
� Managing the testing and distribution of a vaccine. Political friction will
arise as countries haggle over the terms for allowing tests to take place
among their people and over access to vaccines.
� Dealing with countries that are heavily afflicted with AIDS. Achieving
US objectives for development in less developed countries will be made
much more difficult in AIDS-stricken countries.
Compared with the situation in the less developed countries, the West is
better equipped to combat AIDS. Nevertheless, AIDS will spread slowly
there, but without reaching the epidemic proportions of Africa or the
Caribbean.
This information is
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Contents
Page
Key Judgments
Discussion
A Time Bomb for the 1990s
AIDS Is Now Global
V
1
1
1
AIDS in the Industrial Countries
AIDS in the Developing Countries
Africa: Getting Worse
The African Response: Too Little, Too Late
Grim Future: A Changed Continent
Will Africa's Experience Be Repeated Elsewhere?
Other AIDS Hotspots Around the Globe
Thailand
3
5
7
7
7
8
8
8
Brazil 8
India 11
The Caribbean
Other Problem Countries
Prevention Strategies
Implications of Research on Treatments and Vaccines
Treatment for HIV Infection
Vaccines
11
11
12
13
13
14
Other Technical Progress
International Transmission
Implications for the United States
What To Spend Where
Vaccine Politics
14
14
15
15
15
Dealing With Decimated Countries 16
Military Basing and Access Issues 16
vii
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Basic Facts About AIDS
Acquired Immune Deficiency Syndrome (AIDS),
first identified in 1981, is the final stage of a viral
infection caused by the Human Immunodeficiency
Virus (HIV). Medical experts recognize two
strains: HIV-1, discovered in 1983, which is gener-
ally accepted as the cause of most AIDS cases
throughout the world; and HIV-2, discovered in
West Africa in 1986 and later found in some
former Portuguese colonies elsewhere and in Eu-
rope. HIV is a retrovirus: a virus that inserts�
probably for life�its genetic material into the
cells of the host at the time of the infection.
Inasmuch as the ability to remove genetic material
from cells is far beyond the capability of current
medical science, the infection may be said to be
incurable.
The Course of HIV Infection
Following infection with HIV, only the most so-
phisticated tests can detect its presence during the
first weeks or months. After this period, the
infected person's system begins producing antibod-
ies to HIV, which blood testing can reveal. Such
tests were first available in 1985 and vary as to
their ability to detect HIV. About half of the
infected people will develop AIDS symptoms in
less than 10 years, and some within five years. The
incubation period can be lengthened with drug
therapy, and it is shorter where health care is
poor. Death from AIDS usually occurs in one to
two years; infants generally die more rapidly.
Everyone infected will acquire AIDS, and AIDS is
always fatal.
Transmission
Three main routes of transmission exist:
� Contact with infected blood or blood products
via transfusions, transplants, or shared needles.
� Sexual contact with an infected person.
� Infection of infants born to an infected mother.
�irt.
Preventive Measures
A contaminated blood supply is often the first sign
of an incipient AIDS epidemic, and it is relatively
easy to control. Donated blood should be tested for
HIV, which is costly but feasible.
The next stage of an epidemic is often the preva-
lence of HIV infection among prostitutes, prison-
ers, or intravenous (1-I drug users. This is far
more difficult to control, and few countries have
taken meaningful steps to do so.
When the virus infects IV drug users, it spreads
rapidly if needles are shared. Distributing needles
free, as in the Netherlands, is one way of combat-
ing this, with differing claims as to success.
The spread of HIV in the general population is
typically very slow, yet potentially it is the source
of far greater numbers of AIDS cases than in the
smaller groups of IV drug users and male homo-
sexuals. Once the infection is established in the
general population, it spreads mainly by sexual
contact and thus may be impossible to eradicate.
Reducing the prevalence of other sexually trans-
mitted diseases can slow the transmission but
would require public health expenditures in LDCs
far greater than any to date.
In addition to all of these steps, behavioral
changes�less promiscuity and more frequent con-
dom use�by large numbers of people are essential
for effective control. The main programs to achieve
this are dissemination of information and distribu-
tion of condoms. Many public health experts are
pessimistic about the prospect that the necessary
behavioral changes will occur. Some decry the
lack of research into prevention measures that
women could use.
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Discussion'
The number of Acquired Immune Deficiency Syn-
drome (AIDS) cases worldwide will increase rapidly
during the 1990s, from about 1.5 million people as of
early 1991 to a cumulative total of more than 10 mil-
lion by the end of the century. Most of those infected
will die within a year or two of developing AIDS
symptoms, whether or not they have access to modern
health care. This increase in AIDS cases is inevitable
because about 11.5 million are now infected, all of
whom are vulnerable to AIDS-related diseases
Past 1995, the number of AIDS cases will continue to
grow. Current prevention programs will begin to pay
off at the margin, but by then AIDS will be deeply
entrenched in many countries. After 2000, the trend
in AIDS deaths will depend crucially on changes in
behavior or whether a scientific breakthrough is made
during the next several years. For the 1990s, however,
the trend is fairly clear and virtually independent of
new scientific progress�barring development of a
drug that disables the virus
However the impact of the disease is reckoned�by
deaths, AIDS cases, or monetary losses�it is just
beginning. The worldwide impact during the 1990s
will be five to 10 times that of the 1980s. As this
process unfolds, the United States will find itself
progressively more involved with prevention programs
and with the political changes that AIDS will bring
about in the hard-hit countries
A Time Bomb for the 1990s
Much of the difficulty in halting the spread of AIDS
stems from the long incubation period of the disease.
Unlike any deadly epidemic of the past, AIDS takes
' This Memorandum was requested by the Assistant Secretary of
State for Oceans and International Environmental and Scientific
Affairs. It focuses on the worldwide scope and impact of the disease
during the 1990s. For a more complete assessment of Africa's
prospects, see SNIE 70-90, Sub-Saharan Africa's Worsening AIDS
Crisis, August 1990
1
years to develop after the initial infection. During this
time, infected people can infect others
This lengthy incubation makes it hard to detect early
signs of an AIDS epidemic. In the absence of an
outbreak of AIDS cases, countries rarely undertake
the rigorous test sampling needed to accurately mea-
sure Human Immunodeficiency Virus (HIV) preva-
lence. More commonly, recognition of the disease is
delayed until the epidemic is well established making
preventive action far more difficult
Indeed, AIDS is unstoppable in the short term.
Because it takes an HIV infection so long to develop
into AIDS, virtually all of the AIDS cases that occur
during the next five years will be the result of existing
infections. Therefore, the epidemic cannot be materi-
ally reduced in this time frame by any reduction in
new HIV cases. Worldwide, millions of HIV infec-
tions are set to explode into AIDS during the 1990s.
The long incubation period probably contributed to
initial overestimates of how fast AIDS would spread
globally. In the early 1980s, many cases of AIDS
went undetected. As AIDS became better understood,
the number of individuals diagnosed increased much
more rapidly than the rise in the actual number of
cases. Some projections of these rising numbers of
cases diagnosed resulted in astronomical forecasts for
the late 1990s. By now, the number of diagnoses
probably has about caught up with the number of
actual cases in the industrial countries but not yet in
the Third World.
AIDS Is Now Global
The great majority of the new AIDS cases during the
1990s will occur in Sub-Saharan Africa, with North
America a distant second. This is simply a projection
Thteret....
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AIDS: The New Plague?
Bubonic plague�the "black death"�is the
best known of the earlier pandemics. It first
appeared in the sixth century, then in the 14th,
when it killed 20 million people in Europe, a
quarter to a third of the population. Its last
major appearance in England was the Great
Plague of 1665, described in Defoe's Journal of
the Plague Year. France underwent its last
epidemic in 1720. Later outbreaks occurred in
Asia, Africa, and, as recently as 1983, in the
United States.
WHO AIDS logo
AIDS differs from the plague in several
important ways:
AIDS
Incubation period lasts up to 10 years or more.
Infection likely to persist in large parts of the
world's population.
Spread primarily by sexual contact or needle
sharing. Prevention efforts aim at public aware-
ness and behavior change. Other measures are of
secondary importance so far.
Natural immunity uncertain, not yet observed.
No vaccine, no cure.
The impact of AIDS may not approach the
historical significance of the black death. By
killing some of the rich and many of the poor,
the plague helped end the feudal system. Serfs
inherited or occupied estates whose owners had
died. Peasant revolts and severe labor shortages
made workers more mobile; many moved to
towns, forming the nucleus of the urban middle
class. Some historians argue that the black
death ended wars everywhere in Europe and, by
weakening Viking settlements in Greenland and
Vinland during one of its early surges, set back
Europe's reach toward the New World.
Bubonic Plague
Illness comes on quickly, spreads rapidly, disap-
pears only to reoccur episodically.
Spread by rodent fleas. Personal measures for
protection were not known, but public health mea-
sures are now effective.
Rodent and human populations build natural im-
munity on exposure.
Vaccine now available, can be cured if treated
quickly.
2
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Figure 2
AIDS Cases and HIV Infections Estimated
Through 2000
Millions of people
0
Through 1991
Through 2000
331529 7-91
of the location of current HIV infections: about two-
thirds in Africa and one-tenth in North America
Elsewhere, the AIDS epidemic generally is in an
earlier stage, though practically every country has
reported the presence of AIDS, and some have several
thousand cases. The Caribbean has some of the
highest infection rates in the world. In some coun-
tries�India, Brazil, and Thailand, for example�the
infection rate is comparatively low overall but quite
high among certain segments of the population and
growing rapidly with little to impede it
We believe that during the 1990s some 35 million
people or more will become infected, these in addition
to the 11.5 million estimated to date. About 85 per-
cent of the new infections will occur in developing
countries, mainly in Africa. The epidemic will spread
fastest in Asia and South America, setting the stage
for a large increase in AIDS cases after 2000.
3
AIDS in the Industrial Countries
Industrial countries have important advantages over
developing countries in combating AIDS:
� Greater literacy. This makes publicity campaigns
more effective, facilitating the spread of knowledge
necessary to avoid infection.
� Money. AIDS prevention campaigns are expensive,
as they require widespread testing of blood, educa-
tional programs, and other costly measures. Well-
developed health care systems aid in tracking the
epidemic and assessing the effectiveness of policies.
� Lower prevalence of sexually transmitted diseases
(STDs). A person already infected with an STD,
such as gonorrhea or syphilis, may be as much as
10 times more likely to contract HIV from a sexual
contact with an infected person than is a person
without an STD.
The situation in the industrial countries, however, is
favorable only in comparison with Africa and some
other places in the developing world. Western Europe
as a whole reports some 50,000 cumulative AIDS
cases; Switzerland, for example, with a population of
6.9 million, has had more than 1,000 AIDS deaths.
The epidemic in Western Europe afflicts mainly
homosexuals as well as a growing number of intrave-
nous (IV) drug users. IV drug users in Eastern
Europe�notably in Poland and Yugoslavia�have
also been infected, although overall rates are much
lower than in the West. The main source of AIDS in
Eastern Europe and the Soviet Union has been the
government health care infrastructure, which has
unwittingly infected patients through the practice of
using needles more than once.
The mid-1990s will see great increases in AIDS cases
in some industrial countries, given the extent of
today's HIV infections. Beyond that, and into the next
century, the outlook is mixed. While some affected
groups have made substantial behavioral changes (US
homosexuals, for example), other groups (IV drug
'Ll'er
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3itrefe&
Figure 3
Estimated HIV Infections and AIDS Cases, 1991 a
Percent
Asia and Oceania 7
Europe 6
South America 11
North America 11
Sub-Saharan Africa 65
I_
a AIDS in the Middle East and North Africa appears to be
negligible as compared to other regions.
Asia and Oceania 1
Europe 6
South America 7
North America 21
Sub-Saharan Africa 65
AIDS Cases
Total: 1.5 million
users and, in some countries, heterosexuals) are at risk
of accelerating infection rates. HIV infection among
these groups is characterized by rapid spread, then
saturation. Among heterosexuals in industrial coun-
tries, there is likely to be a very slow buildup, but
ultimately many more AIDS cases than in the smaller
cohorts of homosexuals and IV drug users. AIDS will
affect people in every demographic group, but it will
remain predominantly a disease of the poor, who are
prone to riskier behavior regarding drugs and sex.
btbc,
331530 7-91
AIDS will be a growing concern in industrial coun-
tries. The major issues will focus on health care cost�
which will grow rapidly in the 1990s�and equity in
benefits and burdens. Should an effective vaccine or
treatment be discovered, questions will arise over how
rapidly and cheaply it will be made available and over
the patent rights and liability of drug manufacturers.
4
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sckt
The Epidemic Has Limits
Epidemics typically reach a point of "satura-
tion" whereby incidence levels off at well under
100 percent of the population. This happens
because some people either are naturally im-
mune or avoid exposure to the disease. Thus,
AIDS will not wipe out entire populations, but
the point of saturation for HIV probably varies
substantially from population to population and
cannot be predicted with any precision.
AIDS in the Developing Countries
Without the industrial countries' advantages, the
LDCs will be far more vulnerable to AIDS. The
disease will bring fundamental changes in the eco-
nomic structure of the developing countries where it is
widespread
Impact on the Work Force. The years of highest
economic productivity coincide with the age groups of
highest infection rates. Workers will begin succumb-
ing to the disease in greatest numbers just as they
finish their education or apprenticeships and enter
their most productive years.
Regional Trade. Governments may come under pres-
sure to "protect" their citizens by restricting the free
flow of labor from countries that have higher rates of
infection than they. Foreign investment will also be
hurt. In Africa, Western investors probably will see
AIDS as just one more reason to put their money
elsewhere. Expatriate workers from industrial coun-
tries may prove increasin 1 reluctant to come to
AIDS-stricken countries
Health Care Expenditures. It is not clear just how
much governments or international organizations will
choose to spend on care for AIDS sufferers. The harsh
reality is that most victims will receive little treatment
beyond home care. Ameliorating drugs like AZT are
beyond the reach of all but the most wealthy. Many in
Africa die of AIDS without even being tested for HIV
5
infection. The ELISA test costs about $5 to admin-
ister. The Western Blot test, which is used to confirm
a positive ELISA test, costs about $35. To put this in
perspective, the entire annual health budget for Ivory
Coast is around $10 per person, high for Africa.
Education and Training. AIDS could ruin a nation's
strategy of higher education. If AIDS reduces school
graduates' worklives by 15 years, then the payoff to
investment in education is greatly reduced. Policy-
makers will face the grim question: Why spend money
training people who are likely to die before the cost of
specialized instruction can be recouped? This consid-
eration applies not only to those who are infected but
also to the entire cohort of young people likely to
become so.
Impact on Elite Groups. Elites in Africa, with greater
access to travel and multiple sex partners, are af-
flicted by AIDS in increasing numbers, with negative
consequences for filling skilled jobs and for national
economic productivity. Whether this trend will con-
tinue or elites will change their high-risk behavior is
unclear. Also unclear is the susceptibility of elites in
other parts of the Third World. The urban base and
risky behavior of most elites, however, leads us to
speculate that the African pattern will be followed
elsewhere.
Impact on Military Personnel. Screening in many
countries of soldiers and recruits for HIV has turned
up a number of high rates of infection. This has
implications for national security and for the ability of
rulers to maintain their hold on power, mainly in
Africa at present, but possibly elsewhere in time.
Revenues From Tourism. Revenues from tourism
comprise 4 to 5 percent of gross national product in
Kenya and Thailand, and more than 20 percent in
some Caribbean countries. In Haiti, tourism was
virtually wiped out when the country became associat-
ed with the disease, though tourists' fear of violence
played a role too. Tourist visits fell from 70,000 to
(b)(3)
(b)(3)
(b)(3)
(b)(3)
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Impact of AIDS on Security Forces
In militaries where AIDS becomes widespread,
readiness and effectiveness will be degraded. This
will become apparent in some armed forces in
Africa within two to three years, particularly from
the loss of technical and specialized personnel.
While the problem is most serious in Africa, some
hard-hit countries elsewhere will steer important
losses of personnel by the end of the decade.
In Haiti, the military is a high-risk group, with an
estimated 15 percent of active-duty personnel in-
fected, compared with 2 percent of the general
population. The infection complicates the search
for healthy recruits-80 percent are turned down
for poor health. Forty percent of beds in the
military hospital in Port-au-Prince are occupied
by AIDS patients, and four of the 49 Army doctors
are infected. The epidemic threatens to overwhelm
the alread inade uate Haitian military medical
system.
AIDS will not degrade the combat capabilities of
other key countries before the end of this decade
but will impose a growing burden. In Brazil, data
on the infection rate in Rio de Janeiro, coupled
with a serious IV drug problem, suggest a growing
epidemic among recruit-aged youths. The Brazil-
ian armed forces are aware of the danger and have
incorporated general information on AIDS into
military training classes. Due to fear of criticism
from the Catholic Church, active measures such as
condom distribution are not being pursued. In
addition, legal challenges led to a cessation of
testing of draftees and active-duty personnel. We
believe health care costs will consume most of the
military's medical budget within 5 to 10 years.
The Indian Army has no screening or education
programs despite a growing AIDS problem in
society at large. Several divisions of the Indian
Army are garrisoned near the Burma border where
widespread infection is related to IV drug use. The
use of prostitutes by troops and unscreened blood
supplies suggest the epidemic will spread rapidly
rough the armed forces.
Screening potential conscripts in Thailand re-
vealed the overall infection rate of 2.1 percent in
1990, but in three major northern cities the rate
ranged from 6 to 14 percent. Recruitment, how-
ever, will not suffer because of the large pool of
conscripts. Confidential screening of active-duty
soldiers suggests the Thai military is nonetheless
concerned about AIDS. The potential for infection
among high-ranking officers could lead to unex-
pected leadership changes. By the end of the
decade, the cost of AIDS-related health care could
consume a third to a half of the military's medical
budget
The Soviet military has not incorporated AIDS
prevention into its health program. When discov-
ered, infected individuals are released from active
duty, relieving the military of health care costs.
Poor medical hygiene combined with a growing
incidence of STDs and a lack of disposable
syringes suggest that the infection will spread
slowly in the security forces along with Soviet
society.
6
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�Te,
10,000 a year. Some of the sizable decline in Kenya's
tourism is ascribable to foreign fears of AIDS. Thai-
land's tourism is also threatened because its sex
industry is a major attraction
For these reasons, AIDS will be a huge drain on the
economies of highly infected countries. Moreover, the
epidemic will not alleviate problems stemming from
rapid population growth. Development policies of the
past several decades will be undercut or reversed, and
aid donors will feel obliged to reexamine their assis-
tance policies to determine whether to redirect their
aid to�or away from�AIDS-ridden countries
Political Instability. AIDS may in time undermine
political stability in some countries as key officials
succumb to the disease. In Uganda, for example, at
least three ministers who were recently dismissed are
reported to be HIV positive, and several other Cabinet
members may be infected. AIDS will generate a
search for scapegoats that will focus on leaders who
fail to stop the epidemic. Leaders who themselves
contract the disease may change their behavior drasti-
cally owing to "AIDS dementia." Corruption may
worsen as elites attempt to accumulate more wealth
for their heirs at public expense in countries where
this is possible. Leaders' illnesses may lead to power
struggles among would-be successors
Africa: Getting Worse
The AIDS epidemic is at its worst in Sub-Saharan
Africa. HIV infection was well established there by
the early 1980s, and, until recently, little was done to
slow its spread. We estimate that 7-8 million of the
560 million Sub-Saharan Africans are already in-
fected with HIV, and by the mid-1990s the cumula-
tive total probably will exceed 20 million. The number
of AIDS cases will grow apace, well into the millions
this decade
The African Response: Too Little, Too Late
In 1990, about $150 million was spent on AIDS
prevention in Africa, nearly all of it coming from the
World Health Organization's Global Program on
AIDS and other foreign donors. However, even this
modest level of effort is very recent and will have only
7
a marginal effect on the spread of HIV infection.
Africans are not changing their sexual behavior fast
enough to affect the course of the disease, even
though the basics of HIV transmission have been
widely publicized.
Few African political leaders now put the full force of
government into the fight, and fewer still share the
medical professionals' sense of urgency. In Zimba-
bwe, for example, despite high and rising infection
rates, the Minister of Health downplayed the threat;
only after his replacement last year�and subsequent
death from AIDS�did the government embark on an
aggressive prevention program. In Uganda, with one
of the world's worst epidemics, President Museveni
has wavered on encouraging condom use despite his
acute awareness of the problem's seriousness
Grim Future: A Changed Continent
Infection rates are rising almost everywhere and are
particularly high in cities and certain countries. Bot-
swana, Central African Republic, Malawi, Uganda,
Zambia, and Zimbabwe all have HIV infection rates
exceeding 5 percent of the population. In a variety of
subgroups in these and other African countries, infec-
tion rates of 40 or 50 percent have been recorded.
Nigeria, the continent's most populous country (120
million), has recently acknowledged that 500,000 are
infected�probably a substantial underestimate.
Without an effective vaccine or widespread behavioral
change, the virus beyond 2000 is likely to infect 10 to
30 percent of the Sub-Saharan population
Infection rates could
reach 40 percent for young-adult age groups in many
urban areas. Life expectancy at birth could be re-
duced by 15 years or more.
Some African economies will be stunted by AIDS, for
reasons discussed above. In particular, foreign invest-
ment in Africa, now only a tiny fraction of world
investment, is likely to dry up almost entirely later
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(b)(3)
(b)(3)
this decade in countries where AIDS is widespread.
Foreign companies probably will substantially reduce
their operations out of fear for the health of their
personnel and in recognition of worsening perfor-
mance of African economies.
Will Africa's Experience Be Repeated Elsewhere?
Conditions in Africa that contributed to the AIDS
disaster included sexual behavior patterns conducive
to the spread of HIV infection, high incidence of
STDs, nonuse of condoms, governmental inattention
to the problem in its early years, and contaminated
blood supplies in some places. Wherever such condi-
tions prevail, the African experience is likely to be
repeated
In certain Latin American and Asian countries condi-
tions resemble those of Africa. There, the future
course of AIDS threatens to follow Africa's path.
Elsewhere, the outlook for the 1990s is better for two
reasons: the slow-moving epidemic is in an earlier
stage and conditions that govern the spread of AIDS
range from somewhat better to much better than in
Africa. However, the potential number of AIDS cases
in newly infected countries is enormous; for example,
Brazil and India together have almost twice the
(b)(3) population of Sub-Saharan Africa
(b)(3)
Other AIDS Hotspots Around the Globe
Thailand
Thailand is the most AIDS-prone country in South-
east Asia, according to the World Health Organiza-
tion, owing mainly to widespread prostitution and IV
drug use. Although Thailand's Minister of Public
Health claimed the number of infected Thai at 27,000
early this year, some outside experts estimate a more
accurate figure as 200,000 to 300,000 in a population
of 57 million. Recent projections indicate that more
than 1 million and up to 3 million could be infected by
2000. A study by the Thai Development Research
Institute puts the potential earnings losses in the
billions of dollars by the mid-1990s.
Infection rates are highest among Thailand's half-
million or more prostitutes (ranging from 10 to
40 percent, depending on the region) and IV drug
users (25 to 30 percent). The rate among military
conscripts is about 2 percent, with much higher rates
(6 to 14 percent) among those from the northern
provinces
The government recognizes the problem and has
launched large-scale programs to counter it, including
systemic surveys for those infected, education efforts,
and promotion of condom use. Critics say the program
is too small and disorganized, but it appears that some
behavioral changes have been made. Debate still
rages over what, if anything, to do about the sex
industry, which is a major foreign exchange earner.
Prime Minister Anan Panyarachun, installed by the
military junta, described prostitution and AIDS as
two of Thailand's greatest problems.
Brazil
Estimates of the number of Brazilians infected with
HIV range from 500,000 to 1.5 million in a popula-
tion of 155 million. The spread of the disease will at
least double the number of infections by the mid-
1990s
Brazilian authorities lack an adequate picture of the
overall problem. Testing for HIV infection is minimal,
and the number of unknown, unregistered AIDS cases
is likely to be many times greater than published
figures. A large proportion of prostitutes in Recife
and Rio de Janeiro is believed to be infected, and IV
drug use is a growing urban problem. The city of
Santos may have a 5-percent overall infection rate.
Rates are reportedly over 50 percent in Brazil's
prisons. Prevalence rates among new military con-
scripts are not well established, since testing is infre-
quent, but the rate is increasing and is apparently
much greater than in the general population.
Brazil's anti-AIDS policies are inadequate. The
awareness program is small, and the program for
distribution of condoms disburses only 6 million per
year. The director of the national AIDS control
division of the Health Ministry has shortsightedly
downplayed the problem; commenting on WHO fig-
ures showing Brazil to have the world's third-highest
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9
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Figure 5
AIDS Cases as Reported to World Health Organization (WHO)
Greater than 5,000
Brazil 17,373
France 'i4,449 _
Germany 6,176
Italy 9,083 -7
Ivory Coast _ 683
Kenya
Malawi
Mexico
Spain
Tanzania-
Uganda
United States
Zaire
Zimbabwe
1,000 to 5,000
Australia
2,494
Burundi
3,305
Canada
4,885
Colombia
1,285
Congo
2,405
Dominican Rep.
1,506
Ghana
1,732
1,000 to 5,000
200 to 500
Haiti
3,086
Cameroon
429
Honduras
1,133
Chile
255
Netherlands
1,68.3
Costa Rica
232
Romania
1,331
El Salvador
357
Rwanda
3,407
French Guiana
232
Switzerland
1,778
Greece
457
United Kingdom
4,454
Jamaica
201
Venezuela
1,061
Japan
374
Zambia
4,036
Mali
338
Namibia
311
New Zealand
229
500 to 1,000
Norway
208
Panama
249
Argentina
920
Peru
398
Austria
557
Senegal
307
Bahamas, The
599
Sudan
265
Belgium
852
Burkina
978
Central Afr. Rep.
662
Denmark
784
Less than 200
Ethiopia
636
Portugal
647
All other countries
South Africa
764
Sweden
557
Trinidad and Tobago
736
Boundary representation ts
not necessanty autnontaove
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722542 (B0111_1) 7.91
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number of AIDS cases, he argued that the figures
overstated the problem since the number was small in
relation to Brazil's population.
India
The WHO estimates 250,000 infections in India,
though reporting from scattered locales suggests a
number several times larger, possibly more than
1 million in a population of 866 million. Conditions in
India point to a rapid spread of the epidemic: sexual
behavior patterns conducive to the spread of HIV
infection, high incidence of STDs and IV drug use,
high rates of infection among prostitutes, and insuffi-
cient safeguards to the blood supply. Moreover, with a
nationwide literacy rate of only 36 percent, no doubt
much lower among prostitutes and drug users, anti-
AIDS publicity campaigns will not be highly effec-
tive.
The Indian Government does not recognize AIDS as a
serious problem. According to press reports, a recent
meeting of experts advised adhering to "Indian cul-
tural values" as the best way of combating the
disease. Foreigners are frequently blamed for trans-
mitting AIDS. According to US public health experts,
the official Indian attitude toward AIDS is consistent
with earlier policies on STDs, which over the years
have resulted in very little preventive action
These attitudes are reflected in India's health care
budget. In 1991, the government announced a three-
year AIDS prevention program costing $1.8 million�
.2 cent per capita. India's slow-moving bureaucracy,
lack of funding, and lack of technical equipment will
keep thegovernment's efforts lagging far behind the
problem.
This neglect probably will continue until AIDS cases
and deaths exceed the hundreds of thousands. As with
other epidemics, a death toll lower than this will not
be clearly evident in a country of India's size and
impoverishment. Therefore, we conclude that the
Indian Government will not take meaningful steps to
counter AIDS during the next five years. The epi-
demic will most likely grow to Africa-like proportions
in 10 to 15 years
11
The Caribbean
AIDS is a major concern in the Caribbean, and the
rate of infection is increasing rapidly. Haiti, the
Dominican Republic, and The Bahamas are particu-
larly hard hit. AIDS initially affected mainly homo-
sexuals, but now it is well established among hetero-
sexual men and women, as well as among children
Caribbean governments are aware of the problem, but
the prevalence of sexual behavior patterns conducive
to the spread of HIV infection, IV drug use, and
inadequate prevention programs point toward a con-
tinued rapid spread of the disease. During the 1990s,
AIDS in much of the Caribbean will proceed on a
scale similar to that in Africa, with similar dire results
for the economies of the affected nations
In Haiti, government officials have not publicly
acknowledged the seriousness of Haiti's epidemic,
even though the country has the highest number of
reported cases in the Caribbean, with infection rates
now at 7 to 10 percent of adults. Until recently,
officials refused to gather data on AIDS. An esti-
mated 15 percent of military personnel tested HIV
positive.
The Dominican Republic has a far more active anti-
AIDS program than Haiti, but infected prostitutes
and contaminated blood supplies are still spreading
the disease. The Bahamas has one of the highest
infection rates, difficult to control for similar reasons.
AIDS is also spreading steadily elsewhere in the
region.
Other Problem Countries
Romania. AIDS is a major health problem in Roma-
nia, particularly among infants. Hundreds of them
received infected blood transfusions in hospitals. This
type of transmission is far easier to prevent than
sexual transmission, as it only requires improving
conditions in the hospitals. Romania with consider-
able international assistance is attempting to correct
this, but the infection has already spread to the adult
population through contaminated blood supplies and
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sexual transmission. The scope of infection is poorly
understood and prevention programs are only just
(b)(3) beginning
(b)(3)
(b)(3)
(b)(3)
(b)(3)
Soviet Union. The AIDS problem in the Soviet Union
is relatively small�around 600 people with AIDS
and about 20,000 infected with HIV, according to
Soviet scientists. Primitive conditions in hospitals
have led to transmission by infected needles, but that
problem is now widely recognized, and limited efforts
are under way to deal with it. Some hospital patients
are now tested for HIV (though they are not always
told the results). The disease will probably continue to
spread slowly.
Cuba. AIDS in Cuba will not approach the infection
rate in Haiti or other Caribbean hotspots, largely
because Cuba's AIDS control program is the most
aggressive in the world. It includes nationwide HIV
screening, lifetime quarantine of those who test posi-
tive, and strict control of blood supplies and products.
According to the Cuban Health Ministry in early
1991, 9.6 million tests had been given since 1986.
(Cuba's population is 10.7 million.) These tests have
identified 609 HIV positives, and of the 73 with AIDS
symptoms 44 have died. However, it appears that
testing for HIV-2 (a strain found in Angola) was not
sufficiently rigorous
Despite draconian measures, HIV prevalence in Cuba
is likely to grow. Conditions are ripe: widespread
promiscuity, high incidence of STDs, and the return
of troops from Angola. Perhaps in recognition of this
likelihood, the network of quarantine facilities is
being expanded, with plans said to call for at least one
facility in each of Cuba's 14 provinces.
Mexico. Mexico is second to Brazil among Latin
American countries in AIDS cases. It has a moderate
but growing rate of HIV infection. The Mexican
Government views AIDS as a serious public health
problem and recognizes the threat it poses. But eight
years of austerity measures have limited the resources
available for combating the disease. The government
has established a national council on AIDS, which
conducts public awareness programs. Military leaders
are wary of the potential for infection among soldiers.
S�et
Prevention Strategies
The effectiveness of AIDS prevention strategies
worldwide is difficult to assess. Worldwide publicity
on AIDS has induced a portion of the world's popula-
tion to protect itself against the disease, particularly
in the industrial countries. In the LDCs, current
programs may well be worthwhile in terms of lives
saved per dollar spent, but they are extremely small in
scale. These programs are very difficult to evaluate,
because of data shortcomings and because their bene-
fits may not be observable for years.
The unanswered question is whether greatly expanded
programs could reverse the long-term trend. Most
likely, the question will remain unanswered, since
anti-AIDS resources will probably grow only moder-
ately during the 1990s. However, it is clear that
foreign assistance without powerful national leader-
ship will have little impact
The developing countries that are taking steps to
contain the infection are mainly those where the
problem is already obvious, grave, and intractable. In
other countries such as India, Brazil, Nigeria, and
Thailand, where infection rates are sure to accelerate,
preventive measures range from "totally lacking" to
"inadequate." This is particularly troubling, since
preventive strategies are far more effective when they
are taken early in the epidemic
The reasons for this nonaction involve medical tech-
nology, politics, and cost:
� In the early years of an epidemic, few infected
people display symptoms. Without appropriate
blood testing, sizable rates of HIV infection can go
unnoticed.
� The design and implementation of anti-AIDS pro-
grams is an evolving field. Preventive measures are
now familiar in basic outline, but none guarantees
success. Indeed, behavioral patterns that cause the
spread of HIV infection are extremely resistant to
change. Another serious deficiency is the lack of
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preventive methods designed for women. Govern-
ments lack clear guidance on the effectiveness of
alternative prevention strategies.
� Even if dangerous rates of infection are detected,
remedial actions are often politically difficult. Pub-
lic awareness programs, for example, require a
country to advertise its problems boldly�never an
easy political course, especially in countries with
sizable tourist industries.
� An effective political constituency for action is often
lacking, particularly in the early stages of an epi-
demic when action is most effective. In the badly
infected African countries, governments tradition-
ally have not been very responsive to public wishes
or needs, and there has been little public outcry to
initiate strong anti-AIDS programs.
� Full-scale prevention programs are costly. Free
distribution of condoms, for example, would require
a government to establish a permanent program
costing upwards of $10 per year for each person in
the targeted population. Even measuring the extent
of the problem is costly: testing and analysis, costing
roughly $5 to $10 per person, represent a major
investment for health systems that are already
meagerly funded. In Africa, even modest prevention
programs can easily double the public health
budget.
A few countries, however, have taken action early in
the epidemic. For example, China adopted an aggres-
sive policy to identify infected individuals and to
educate the population. Beijing recently hosted an
international symposium on hepatitis and AIDS, even
though China has announced less than 500 HIV
infections and hepatitis is a more pressing problem.
Likewise, after the first AIDS case was reported in
Japan in 1985, Tokyo instituted universal screening of
blood products and ended their importation. Japan
estimates less than 1,700 infections, including about
400 AIDS cases, but the disease still poses a risk, and
Tokyo will continue to use education and screening to
control its spread.
In Africa and the Caribbean, resources are lacking,
and behavioral change on the scale that is needed has
not occurred. In South America, political pressures
for governmental action probably will increase during
the 1990s, but dramatic spending increases are not
likely to occur. The WHO now spends about $70
million on 14 countries, but much greater expendi-
tures are required. For example, it would cost $460
million a year to provide condoms to Africa for an
adequate program
In Western countries, by contrast, far more will be
spent. Political pressures are substantial for spending
on research, public awareness, and health care. The
economic situation is far more favorable too: not only
is far more money available, the payoff per dollar
spent may be greater as well. For example, Japanese
researchers estimated that each AIDS case costs more
than $450,000 in treatment costs and lost productivity
and that a prevention program in Japan would there-
fore be worthwhile, even if only a relatively small
number of cases could be prevented.
Implications of Research on Treatments and
Vaccines 3
Even the most optimistic researchers acknowledge
that an immediate breakthrough would not appre-
ciably reduce the number of AIDS cases during the
next five years. An effective treatment for HIV
infection�even if discovered right now�would take
several years to test, manufacture, and implement.
Likewise for a vaccine: by the time everyone at risk
was inoculated, it would take another decade for the
epidemic to wind down.
Treatment for HIV Infection
Medical experts believe that no outright cure for HIV
infection is likely. Viruses in the human body cannot
be killed or removed by drug treatment, but the
disease can be slowed by impeding their ability to
' This Memorandum makes no attempt to predict the success of the
research efforts under way. Rather, it deals with the implications of
ongoing research and what might occur if it were successful
Even though the 1990s will bring an upsurge in AIDS
cases, anti-AIDS expenditures will probably increase
only modestly in developing and midincome countries.
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multiply or incapacitate cells. Much effort is directed
toward drugs, like AZT, that postpone the onset of
AIDS symptoms. Progress along these lines is gener-
ally expected to be incremental, with gradual im-
provements in effectiveness and reductions in cost.
These drugs, however, probably will remain too ex-
pensive for widespread use in any but the richest
countries. By comparison, penicillin at 10 cents a
dose, is too expensive to treat everyone in poorer
countries who needs it
Vaccines
Expert opinion varies on the prospects for a vaccine
against HIV infection. Some think that the technical
barriers may never be fully overcome, in part because
of the high mutability of the virus, while the most
optimistic think that the massive research effort
might produce a useable vaccine within five years or
so. Eleven "candidate" vaccines are in the early stages
of testing on small numbers of people and may be
ready for large-scale testing in two to four years. Once
into a field trial, these experimental vaccines probably
will need at least four to five additional years of
development and testing before they could be proved
safe and effective.
Several problems will hinder progress. For example,
Africa's high rate of infection makes it a good choice
as a test site. But the strains of HIV prevalent in
Africa may differ from those isolated in the United
States. This suggests that a vaccine optimized for the
United States may not be effectively tested in Africa.
Testing in a country where AIDS is less prevalent
than in Africa would require a larger sample and a
longer trial period.
At this early stage, the likely cost of mass-producing a
vaccine is uncertain. If previous patterns hold, it will
probably be priced much higher in the United States
than elsewhere. For example, vaccine for hepatitis B
costs about $100 to $150 in the United States, versus
$3 or less in some Asian countries. The difference in
price stems from the higher quality of vaccines pro-
duced in the United States, plus costs that producers
allocate to research and testing and to provision for
product liability. This could lead to disputes over
patents between US firms and their low-price compet-
itors, an issue that the WHO has begun to address.
A different vaccine may be required for each region of
the world, because the prevalent strain of HIV varies
from country to country. This suggests that pharma-
ceutical companies may concentrate on the strains of
HIV prevalent in the United States and Europe rather
than on African strains that promise far lower profits.
However, medical experts believe that in time all HIV
strains will spread globally
In the long term, an effective vaccine may be the best
hope for a radical reduction in the spread of the
disease. Based on experience, even after effectiveness
is established, it takes many years before vaccines are
used widely, particularly in LDCs. Polio and measles
vaccines�effective and cheat. but still not in univer-
sal use�are examples.
Other Technical Progress
The area of testing shows some promise. Cheaper tests
for HIV infection would help in pinpointing the new
infections, so that preventive measures could be better
targeted. Tests that work in the earliest stages of
infection (conventional tests do not) would permit
more effective blood product screening.
International Transmission
AIDS has crossed virtually every national border in
its global spread, and international transmission re-
mains a significant source of infection and subsequent
growth of the epidemic. For example, emigration from
Haiti is believed responsible for much of the spread of
HIV into the Dominican Republic, The Bahamas, and
Jamaica. Many Cuban troops were infected in
Angola. Thailand's sex industry has the potential to
infect tourists from several countries, Japan for one
example.
To counter the spread of the disease and reduce costs
of caring for infected immigrants, more than 40
countries now restrict the entry of short-term visitors
or immigrants with HIV infection or AIDS. Several
single out black Africans, and some deport infected
foreigners. We expect restrictive measures to increase
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AIDS and Immigration
Laws and policies designed to reduce the foreign
threat to populations from AIDS will remain
controversial in several countries. Restrictions
on immigration are aimed at reducing risks to
residents and costs of caring for infected immi-
grants. For instance, a Canadian study con-
cluded that there would be a net saving in direct
health costs if all potential Canadian immi-
grants were screened and those found to be HIV
positive were excluded. Critics charge, however,
that this unfairly targets HIV-positive individ-
uals and unnecessarily highlights AIDS among
diseases. The Canadian study also determined
that screening immigrants for cardiovascular
disease would be even more cost effective than
screening for HIV. It is likely that the debate
over the laws and policies designed to restrict
immigration on the basis of HIV infection will
become more heated as AIDS cases and associ-
ated costs rise during the decade.
during the next five years, when the numbers of HIV
infections in many countries will be much larger than
they are today. US policies will also receive more
attention as AIDS increases in countries that supply
many of the immigrants to the United States.
Implications for the United States
programs in South America and Asia. Thus, the
money goes where the disease is worst and where the
demand for assistance is the highest
In allocating funds, US policymakers will face the
problem of how to choose between countries where the
disease is already widespread and those where infec-
tion rates are low but threaten to grow rapidly. The
payoff to AIDS prevention assistance might be higher
in countries where the epidemic is in a much earlier
stage�Brazil, India, and Thailand, for example.
These countries, however, have only recently acknowl-
edged their AIDS problem and have not yet developed
effective strategies. Indeed, the US Agency for Inter-
national Development programs in Brazil and India
are directed largely at persuading leaders that AIDS
is, in fact, a major problem.
The United States will face three basic foreign policy
problems associated with the spread of AIDS in the
1990s:
� Allocating assistance for AIDS prevention abroad.
� Managing the testing and distribution of a vaccine
in other countries.
� Dealing with afflicted countries.
What To Spend Where
The United States now spends about $65 million
annually on AIDS programs in foreign countries.
Africa gets most of the resources, but there are small
15
For Africa, AIDS support will be an expanding part
of the aid package during the 1990s. One study
concluded that in five central African countries,
AIDS medical care and screening alone could con-
sume all foreign aid. Caribbean nations will follow
this pattern, and later so will India. The rapidly rising
incidence of AIDS�particularly in Africa�will at-
tract concentrated, graphic media attention during
the 1990s. Whether this will build popular support for
large-scale relief programs�as has often been the
case with natural disasters and refugee problems�
remains to be seen. In a broader context, the experi-
ence with AIDS demonstrates the importance of
quick intervention, which may well be needed to deal
with the other deadly but undetected viruses that now
exist in quiescent forms and may spread in the future.
Vaccine Politics
Working out arrangements for testing and distribu-
tion of a vaccine will pose numerous political hazards.
It is conceivable that US efforts to protect people
from AIDS could be tarnished, as countries haggle
over the terms for allowing tests to take place among
their people and demand more aid than the United
States can offer. Rivalries among producers of vac-
cine and disputes over patent rights might also slow
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the delivery of vaccine. Similar problems over distri-
bution of improved drug treatments probably will also
(b)(3) arise.
(b)(3)
(b)(3)
Testing vaccines could be a political minefield for the
United States. As the WHO supervises foreign test-
ing, conflict may arise as to which vaccines to test�
those developed by and for the United States, or
others aimed at European strains of HIV. Some
African leaders are concerned that their countries will
be used as a testing site and then abandoned once the
results are in. They will probably make demands for
the continued availability of any successful vaccine
that they allow to be tested. Conflict may arise if the
United States refuses to supply a particular vaccine
on grounds that it is not effective. Other friction over
who controls the design and management of testing is
foreseeable. There will also be inevitable ethical issues
on how to integrate prevention programs with testing.
Many public health experts doubt that the capability
exists to dispense AIDS vaccines on a worldwide
scale. Some have suggested establishing an interna-
tional corporation, funded by a consortium of indus-
trial nations, to produce and distribute a vaccine at
cost or below, with clear standards for assigning
priorities for treatment. This approach would have the
advantage of removing the United States from the
focal point of criticism. In addition, companies capa-
ble of developing vaccines would be given clear guide-
lines on their patent rights; otherwise, it is argued,
they may hold back on development efforts out of fear
that these rights would be preempted by an interna-
tional regulatory effort
Anti-US disinformation may flare up in connection
with the testing and distribution of a vaccine, particu-
larly in Africa. Charges of racial discrimination,
shifting unacceptable risks to Africans by testing
vaccines on them, and distortions as yet unimagined
are likely to be publicized. During the 1980s, various
stories blaming the United States for the spread of
AIDS were published, often instigated by the Soviet
'Tie4
Union. Such disinformation still crops up occasional-
ly. Just before the Persian Gulf war, for instance,
Iraqi officials playing to Arab fears asserted that US
troops in the Arabian peninsula included "thousands
of AIDS victims."
Dealing With Decimated Countries
AIDS threatens US objectives of promoting economic
development in LDCs. Though we cannot quantify
the economic impact of AIDS, it is hard to conceive of
a developing country with both a serious AIDS prob-
lem and a thriving economy. The badly infected
countries will be radically transformed, with greatly
reduced chances of developing.
US economic assistance will become less effective in
AIDS-ridden countries. For example, the rate of
return to money spent on education will be less.
Generating private enterprise activity and foreign
investment will be more difficult. The question will
arise whether these diminished prospects for effective-
ness are a reason for more or for less aid. Whatever
the scale of future aid programs, assistance to AIDS-
ridden countries is likely to be spent on basic subsis-
tence rather than on development projects.
Military Basing and Access Issues
These issues have quieted in recent years. Most
governments seem satisfied that US forces in their
countries pose little risk from the standpoint of AIDS.
In early negotiations over basing rights in the Philip-
pines, for example, numerous political and press state-
ments claimed that US servicemen were spreading the
disease. Such claims have largely subsided and are no
longer impediments to an agreement
In most countries, operationally deployed US troops
are no more at risk from HIV than if they were
stationed in the United States. As AIDS spreads,
however, increasing portions of the globe will become
less suitable as peacetime sites for US bases.
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