systems; and improvements in national health care capacities take hold in all but the least developed countries. barring the appearance of a deadly and highly infectious new disease, a catastrophic upward lurch by hiv/aids, or the release of a highly contagious biological agent capable of rapid and widescale secondary spread, these developments produce at least limited gains against the overall infectious disease threat. the remaining virulent diseases, led by hiv/aids and tb, continue to take a significant toll. economic, social, and political impact the persistent infectious disease burden is likely to aggravate and, in some cases, may even provoke economic decay, social fragmentation, and political destabilization in the hardest hit countries in the developing and former communist worlds, especially in the worst-case scenario outlined above: the economic costs of infectious diseases—especially hiv/aids and malaria—are already significant, and their increasingly heavy toll on productivity, profitability, and foreign investment will be reflected in growing gdp losses, as well, that could reduce gdp by as much as 20 percent or more by 2010 in some sub-saharan african countries, according to recent studies. some of the hardest hit countries in sub-saharan africa—and possibly later in south and southeast asia—will face a demographic upheaval as hiv/aids and associated diseases reduce human life expectancy by as much as 30 years and kill as many as a quarter of their populations over a decade or less, producing a huge orphan cohort. nearly 42 million children in 27 countries will lose one or both parents to aids by 2010; 19 of the hardest hit countries will be in sub-saharan africa. the relationship between disease and political instability is indirect but real. a wide-ranging study on the causes of state instability suggests that infant mortality—a good indicator of the overall quality of life—correlates strongly with political instability, particularly in countries that already have achieved a measure of democracy. the severe social and economic impact of infectious diseases is likely to intensify the struggle for political power to control scarce state resources. as a major hub of global travel, immigration, and commerce with wide-ranging interests and a large civilian and military presence overseas, the united states and its equities abroad will remain at risk from infectious diseases. emerging and reemerging infectious diseases, many of which are likely to continue to originate overseas, will continue to kill at least 170,000 americans annually. many more could perish in an epidemic of influenza or yet-unknown disease or if there is a substantial decline in the effectiveness of available hiv/aids drugs. infectious diseases are likely to continue to account for more military hospital admissions than battlefield injuries. u.s. military personnel deployed at nato and u.s. bases overseas, will be at low-to-moderate risk. at highest risk will be u.s. military forces deployed in support of humanitarian and peacekeeping operations in developing countries. the infectious disease burden will weaken the military capabilities of some countries—as well as international peacekeeping efforts—as their armies and recruitment pools experience hiv infection rates ranging from 10 to 60 percent. the cost will be highest among officers and the more modernized militaries in sub-saharan africa and increasingly among fsu states and possibly some rogue states. infectious diseases are likely to slow socioeconomic development in the hardest-hit developing and former communist countries and regions. this will challenge democratic development and transitions and possibly contribute to humanitarian emergencies and civil conflicts. infectious disease-related embargoes and restrictions on travel and immigration will cause frictions among and between developed and developing countries intelligence community assessment on the next wave of hiv/aids in july, 2002, the national intelligence council released the intelligence community assessment on the next wave of hiv/aids. this paper examined hiv epidemics in five countries of strategic importance to the united states that have large populations at risk for hiv infection: nigeria, ethiopia, russia, india, and china. the five countries were selected because they were: among the world’s most populous countries, together representing over 40 percent of the world population. in the early-to-mid-stages of an hiv/aids epidemic at the time of analysis. led by governments that have not yet given the issue the sustained high priority that has been key to stemming the tide of the disease in other countries. the paper concluded that hiv/aids is spreading at different rates in the five countries, with the epidemic the most advanced in nigeria and ethiopia. in all countries, however, risky sexual behaviors are driving infection rates upward at a precipitous rate. adult prevalence rates—the total number of people infected as a percentage of the adult population—are substantially lower in russia, india, and china, where the disease remains concentrated in high-risk groups, such as ivda in russia and people selling blood plasma in china, where some villages have reported 60% infection rates. nevertheless, the disease is spreading to wider circles through heterosexual transmission in india, the movement of infected migrant workers in china, and frequent prison amnesty releases of large numbers of infected prison inmates and rising prostitution in russia. it will be difficult for any of the five countries to check their epidemics by 2010 without dramatic shifts in priorities. the disease has built up significant momentum, health services are inadequate, and the cost of education and treatment programs will be overwhelming. government leaders will have trouble maintaining a priority on hiv/aids—which has been key to stemming the disease in uganda, thailand, and brazil—because of other pressing issues and the lack of aids advocacy groups. the governments of nigeria, india, and china are beginning to focus more attention on the hiv/aids threat. even if the five next-wave countries devote more resources to hiv/aids programs, implementation is likely to miss significant portions of the population, given weak or limited government institutions and uneven coordination between local and national levels. nigeria and ethiopia have very limited public services to mobilize. russia is beset by other major public health problems. china has decentralized most responsibility for health and education issues to local governments that often are corrupt. india has taken some steps to improve its healthcare infrastructure to combat hiv/aids, but the government has few resources to treat existing infections and must cope with other major health problems such as tuberculosis (tb), which has become linked to the spread of hiv/aids. the rise of hiv/aids in the next-wave countries is likely to have significant economic, social, political, and military implications. the impact will vary substantially among the five countries, however, because of differences among them in the development of the disease, likely government responses, available resources, and demographic profiles. nigeria and ethiopia will be the hardest hit, with the social and economic impact similar to that in the hardest hit countries in southern and central africa—decimating key government and business elites, undermining growth, and discouraging foreign investment. both countries are key to regional stability, and the rise in hiv/aids will strain their governments. in russia, the rise in hiv/aids will exacerbate the population decline and severe health problems already plaguing the country, creating even greater difficulty for russia to rebound economically. these trends may spark tensions over spending priorities and sharpen military manpower shortages. hiv/aids will drive up social and healthcare costs in india and china, but the broader economic and political impact is likely to be readily absorbed by the huge populations of these countries. we do not believe the disease will pose a fundamental threat through 2010 to their status as major regional players, but it will add to the complex problems faced by their leaders. the more hiv/aids spreads among young, educated, urban populations, the greater the economic cost of the disease will be for these countries, given the impact on, and the need for, skilled labor. the growing aids problem in the next-wave countries probably will spark calls for more financial and technical support from donor countries. it may lead to growing tensions over how to disburse international funds, such as the global fund for aids, tb and malaria. the cost of antiretroviral drugs—which can prolong the lives of infected people—has plunged in recent years but still may be prohibitively high for low-income countries. more importantly, the drug costs are only a portion of hiv/aids treatment costs. drug-resistant strains are likely to spread because of the inconsistent use of antiretroviral therapies and the manufacture overseas of unregulated, substandard drugs. if an effective vaccine is developed in the coming years, western governments and pharmaceutical companies will come under intense pressure to make it widely available. the next-wave countries are likely to seek greater u.s. technical assistance in tracking and combating the disease. according to unaids, asia alone is likely to outstrip sub-saharan africa in the absolute number of hiv carriers by 2010. governments often do not spend enough money to get quality infection surveillance because they have other budget priorities, do not want to acknowledge the extent of the epidemic, and the drug users and prostitutes at high risk of infection are not key political constituencies. other hidden pockets of infection include tb patients—some of whom have contracted tb because they are hiv positive—and patients with venereal diseases and reproductive tract infections. it is difficult to get data on hiv prevalence rates in foreign military ranks, which harbor significant numbers of infected men. even if testing is available, many people do not get tested because of denial, stigma, discrimination, or resignation. ivda, prostitutes, and homosexuals usually are reluctant to identify themselves for fear of punishment. some avoid testing when healthcare and treatment for the disease is unavailable. nigeria heterosexual transmission of hiv is the primary mode of spread in nigeria, and infections appear to be as numerous in rural areas as in the cities. in other words, hiv is endemic in the general population. the reported rate of infection apparently varies significantly by region, with the lowest reported rate found generally in the predominantly muslim northern parts of the country. infections are most numerous among men ages 20 through 24, but some experts caution that infection rates are rising quickly in young women. nigerian hiv prevalence at prenatal clinics given the already advanced state of the disease and the government's limited capacity to respond, the intelligence community expects hiv/aids to infect as many as 10 to 15 million people by 2010. nigerian prevalence may be 18 to 26 percent of adults—close to the current rates in some of the hardest hit countries in southern africa. this graphic is of a second-wave country; southern africa is already badly affected by the first wave. ethiopia ethiopia is estimated to have the highest adult prevalence rate, between 10 and 18%—was the highest among the five countries. this reflects two social effects: like nigeria, the disease has moved into the general population unlike the other countries, the effects of war have a significant effect on spread another surge of infections may be underway from the 150,000 demobilized soldiers over the last two years as the conflict with eritrea has wound down. more troops will be sent home as the border dispute is settled. as soldiers demobilize, prostitutes—who have even higher rates of infection—disperse around the country as well. the figure to the right shows prevalence at prenatal clinics, which appears to be the best single indicator. hiv seropositivity at ethiopian prenatal clinics expert estimates the actual number of hiv patients may be between 3 and 5 million. adult prevalence is much higher in cities (13–20%) than in rural areas (5%). heterosexual transmission is the primary mode of spread, and people with multiple partners—especially those with sexually transmitted diseases (stds) and prostitutes—have significantly higher infection rates. unlike conditions in other next-wave countries, war has significantly contributed to the spread of the disease in ethiopia. many soldiers contracted hiv/aids during the civil war in the 1980s by having contact with multiple sex partners. when the war ended in 1991, thousands of infected soldiers and prostitutes returned home, spreading hiv/aids in their villages and towns. ethiopians, due to result of drought, malnutrition, limited healthcare, and other infectious diseases, have generally poor health. in the hiv-seropositive group, this has caused hiv to progress rapidly to aids. looking ahead, we expect 7 to 10 million ethiopians probably will be infected by 2010 because of the high current rate of adult prevalence, widespread poverty, low educational levels, and the government's limited capacity to respond more actively. russia each country in the second