Almost seven million people are receiving treatment — more than half of them thanks to American taxpayers — and that number has been steadily rising. But it is still not close to catching up to the new infection rate: Last year, 1.35 million got on treatment for the first time, meaning 200 people were newly infected for each 100 newly treated.
That is an improvement over two years ago, when 250 were infected for each 100 treated.
And, in a development that augurs badly for the future, donor funds dropped about 10 percent last year as the worldwide economic crisis made some countries cut their donations.
Whether the world’s generosity is producing a triumph or a failure depends on what yardstick is used. The seven million receiving treatment represent about half the people sick enough to need immediate treatment under World Health Organization guidelines. But the figure falls far short of reaching the ambitious new “test and treat” goal adopted last year by U.N.AIDS and endorsed this month by Secretary of State Hillary Rodham Clinton in her speech calling for an “AIDS-free generation.” To reach that, all 34 million infected people in the world would have to be found — a Sisyphean task in itself — and then put on antiretroviral drugs immediately so they would stop passing the virus on.
(Moreover, they would all need to be on newer drugs like tenofovir, while at present many are still getting the old, cheap ones with harsh side effects.)
U.N.AIDS officials tried to put an optimistic spin on the report.
Dr. Bernhard Schwartländer, the agency’s chief of strategy, said AIDS had seen a “game-changing year in science,” noting especially a study showing that people on drugs lowered by 96 percent their chances of passing on the infection. And he highlighted areas where progress had been made.
Almost half the world’s pregnant women with H.I.V. get at least one drug to help prevent passing the virus to their children.
Eleven poor or middle-income countries now treat more than 80 percent of their infected citizens. That is about as well as the United States does, since the Centers for Disease Control and Prevention assumes that 20 percent of infected Americans do not know they are infected. The 11 countries are: Botswana, Cambodia, Chile, Comoros, Croatia, Cuba, Guyana, Namibia, Nicaragua, Rwanda and Slovakia.
Also, in 22 countries new infections have declined. Epidemiologists credit several factors: Fear of death stems some reckless behavior; safe-sex education is slowly growing; and the surging number of people on AIDS drugs, especially in southern Africa, means more people with lower viral loads who are thus less likely to infect others.
Despite improvement in Africa, new infections remain stuck at 2.7 million a year worldwide because Asia and Eastern Europe are doing so badly. Those epidemics are driven by drug addicts, who are notoriously hard to reach, and also by groups like gay men and prostitutes who in conservative societies lack the political clout that would let them demand drugs and who fear police crackdowns and therefore have furtive, rapid sex — a high-risk behavior.
Studies in Eastern Europe and Central Asia show that many drug users avoid clinics even when they need medical care for fear they will be turned in to the police.
The report drew a contrast between Dhaka, where the Bangladeshi government introduced measures like clean-needle swaps, and St. Petersburg, where the Russian government would not. Infections among drug users dropped 25 percent in Dhaka and doubled in St. Petersburg. Despite its conservative Islamic government, Iran has done particularly well at stopping infections among its addicts by creating a network of 600 clinics that offer clean needles and methadone-type therapy.
The report is unusually blunt for a United Nations agency in that it directly compares countries with one another. Cambodia, for example, has lowered infections far faster than its richer neighbor Vietnam because it targeted its sex tourism industry while Vietnam has shied away from helping the drug users and gay men who drive its epidemic.
Brazil and Russia both have economies of similar size and both spend about $700 million a year on AIDS, but Brazil does far better because it concentrates on high-risk groups like gay prostitutes. Russia made “largely a political decision” not to help its drug injectors, Dr. Schwartländer said. “That’s not cost-efficient.”
Countries where homosexuals face jail or execution will never address their epidemics, he said, because gay men will stay hidden.
Many countries doing poorly have large populations, so even though their infection rates are lower than Africa’s, they have large epidemics. In Egypt, Iran, Pakistan and Ukraine, for example, less than 20 percent of those needing treatment are getting it. In Bangladesh, China, India, Indonesia, Nigeria and Russia, less than 40 percent are.
Up to half the children infected at birth, the report said, get infected because their mothers avoid testing for fear that the nurses or their neighbors will sneer at them. The report endorsed H.I.V. home-testing kits, which use a cheek swab or a finger prick, cost pennies and give results in minutes.
Global AIDS leaders, including Michel Sidibé, the executive director of U.N.AIDS, are urging countries to rely less on donors. He regularly praises South Africa, which pays 80 percent of its own costs.
The medical charity Doctors Without Borders has noticed several countries making plans to start people on drugs earlier in their illnesses; they include Kenya, Lesotho, Malawi, Uganda, South Africa and Zambia.
“They’re signaling they want to move faster,” said Sharonann Lynch, the charity’s AIDS policy adviser. “But none of them can do it without outside support, except for maybe South Africa.”