The global burden of HIV and prospects for control

HIV/AIDS continues to have devastating health effects globally, with over 39 million HIV/AIDS-related deaths to date and more than 36 million people living with HIV currently.1UNAIDS90-90-90: treatment for all.https://www.unaids.org/en/resources/909090Date accessed: July 19, 2019Google Scholar, 2GBD 2017 HIV CollaboratorsGlobal, regional, and national incidence, prevalence, and mortality of HIV, 1980–2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors 2017 Study.Lancet HIV. 2019; (published online Aug 19.)http://dx.doi.org/10.1016/S2352-3018(19)30196-1Google Scholar Despite great advancements in antiretroviral therapy (ART) and worldwide progress towards implementation of treatment-as-prevention programmes, approximately 2 million people become newly infected with HIV every year.2GBD 2017 HIV CollaboratorsGlobal, regional, and national incidence, prevalence, and mortality of HIV, 1980–2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors 2017 Study.Lancet HIV. 2019; (published online Aug 19.)http://dx.doi.org/10.1016/S2352-3018(19)30196-1Google Scholar, 3GBD 2015 HIV CollaboratorsEstimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: the Global Burden of Disease Study 2015.Lancet HIV. 2016; 3: e361-e387Summary Full Text Full Text PDF PubMed Scopus (437) Google Scholar Retrospectively, evaluations of the HIV burden are integral to the assessment of control approaches. Prospectively, projections of future HIV burdens are instrumental to guide resource allocation and policy optimisation. In The Lancet HIV, the GBD 2017 HIV Collaborators2GBD 2017 HIV CollaboratorsGlobal, regional, and national incidence, prevalence, and mortality of HIV, 1980–2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors 2017 Study.Lancet HIV. 2019; (published online Aug 19.)http://dx.doi.org/10.1016/S2352-3018(19)30196-1Google Scholar assess trends in HIV incidence, prevalence, mortality, and treatment coverage for 195 countries and territories from 1980 to 2017. Furthermore, they use these trends to forecast the course of country-specific HIV trends in the context of achieving UNAIDS goals. The aspirational 90-90-90 goal of UNAIDS aims to globally diagnose 90% of people living with HIV, provide treatment to 90% of people diagnosed, and achieve viral suppression in 90% of people on treatment by 2020. A subsequent 95-95-95 goal is set for 2030. The global HIV care continuum stands today at 75-79-81, corresponding to viral suppression in 48% of people living with HIV.4Global HIV and AIDS statistics: 2017 global HIV statistics. Avert, 2018https://www.avert.org/global-hiv-and-aids-statisticsDate accessed: August 6, 2019Google Scholar The GBD 2017 HIV collaborators found that the scale-up of access to ART from 2·98 million people in 2006 to 21·8 million in 2017 was accompanied by a 51% reduction in HIV mortality, from 1·95 million in 2006 to 0·95 million in 2017. However, annual incidence decreased only by 17% during 2007–17 (from 2·35 million [95% uncertainty interval 2·02–2·76] to 1·94 million [1·63–2·29]). The combination of decreased mortality and only a small decrease in incidence has led to an increase in people living with HIV from 8·74 million in 1990 to 36·82 million in 2017. Young adults remain at the highest risk of acquiring HIV. Despite men aged 25–29 years making up 4·2% and women aged 20–24 years making up 3·8% of the global population,5Population pyramids of the world from 1950 to 2100. PopulationPyramid.net.https://www.populationpyramid.net/world/2017/Date accessed: July 19, 2019Google Scholar they accounted for 9·3% and 10·3% of new infections in 2017.2GBD 2017 HIV CollaboratorsGlobal, regional, and national incidence, prevalence, and mortality of HIV, 1980–2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors 2017 Study.Lancet HIV. 2019; (published online Aug 19.)http://dx.doi.org/10.1016/S2352-3018(19)30196-1Google Scholar Among young adults, increased risk of HIV infection is associated with transactional sex, men who have sex with men (MSM), and injection drug use. Although between 40% and 50% of new infections among adults occur within these key populations, only 2% of HIV funding is spent on interventions aimed at reducing transmission among them.6AVERTFunding for HIV and AIDS. AVERT, March 19, 2019https://www.avert.org/professionals/hiv-around-world/global-response/fundingDate accessed: July 19, 2019Google Scholar This disparity between the burden and resources allocated highlights the persistent need for targeted strategies aimed at increasing awareness about HIV and providing tools to adopt safe behaviours among those at highest risk. Expansion of treatment coverage and preventive measures have reduced HIV burden in many sub-Saharan African countries. Conversely, eastern Europe and central Asia, which are less affected by HIV historically, have begun to see an increasing incidence.2GBD 2017 HIV CollaboratorsGlobal, regional, and national incidence, prevalence, and mortality of HIV, 1980–2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors 2017 Study.Lancet HIV. 2019; (published online Aug 19.)http://dx.doi.org/10.1016/S2352-3018(19)30196-1Google Scholar Particularly, Russia had the highest annualised rate of change in incidence of 13·2% between 2007 and 2017.2GBD 2017 HIV CollaboratorsGlobal, regional, and national incidence, prevalence, and mortality of HIV, 1980–2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors 2017 Study.Lancet HIV. 2019; (published online Aug 19.)http://dx.doi.org/10.1016/S2352-3018(19)30196-1Google Scholar This increase in incidence might be due to limited access to ART, which is exacerbated by an absence of syringe exchange programmes, bans on opiate substitutes, and stigmatisation of high-risk populations.7Cohen J Russia's HIV/AIDS epidemic is getting worse, not better. Science, AAAS.https://www.sciencemag.org/news/2018/06/russia-s-hivaids-epidemic-getting-worse-not-betterDate: June 11, 2018Date accessed: July 19, 2019Google Scholar Similarly, harm reduction services are inadequate in much of eastern Europe and central Asia. Beyond determination of prevailing HIV burdens and treatment coverage, the GBD 2017 HIV collaborators forecast trajectories to 2030. Extrapolations of treatment coverage incorporated forecasts of ART prices, funding trends, and changing incidence. The authors project that treatment coverage will increase on a global scale from the current 59%8WHOAntiretroviral therapy (ART) coverage among all age groups. Geneva: World Health Organization.https://www.who.int/gho/hiv/epidemic_response/ART_text/en/Date accessed: August 6, 2019Google Scholar to 64·8% by 2020 and to 71·9% by 2030. Although these anticipated improvements reflect progress, they fall short of the UNAIDS targets of 81% by 2020 and 90% by 2030. At the country level, 54 countries are on track to meet the 2020 ART coverage goal and only 12 countries to meet the 2030 goal. Most countries projected to achieve these goals are middle-income or high-income countries where risks are relatively low. Donor and domestic investments for HIV response in low-income countries have stagnated over the past 5 years.9UNAIDSPress release. Galvanizing global ambition to end the AIDS epidemic after a decade of progress.https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2019/june/20190603_sg-reportDate accessed: July 19, 2019Google Scholar Furthermore, annual incidence is projected to decrease between 2010 and 2030 in only 45 countries.2GBD 2017 HIV CollaboratorsGlobal, regional, and national incidence, prevalence, and mortality of HIV, 1980–2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors 2017 Study.Lancet HIV. 2019; (published online Aug 19.)http://dx.doi.org/10.1016/S2352-3018(19)30196-1Google Scholar These projections underscore the dangers of decreasing investment10Galvani AP Pandey A Fitzpatrick MC Medlock J Gray GE Defining control of HIV epidemics.Lancet HIV. 2018; 5: e667-e670Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar in the context of an unsustainably widening gap between multigenerational financial commitments and the resources required to address the pandemic.11Fitzpatrick MC Gray GE Galvani AP The challenge of vanquishing HIV for the next generation-facing the future.JAMA Pediatr. 2018; 172: 609-610Crossref PubMed Scopus (1) Google Scholar The accuracy of any forecast depends on the data underlying the modelling assumptions and input parameters. Given the inconsistent reliability of data on viral suppression, the GBD 2017 HIV collaborators assumed that levels of viral suppression are homogeneous throughout the world. However, retention to care varies extensively, with repercussions on transmission rates. Specifically, incidence projections in countries with lower levels of viral suppression than assumed will be underestimated. While data on viral suppression continue to be collected, incorporating country-specific estimates in future studies will improve evaluations of HIV trends. Despite data limitations, the GBD 2017 HIV collaborators provide fundamental insights regarding the evolving HIV pandemic. Although their assessment affirms the headway that has been made towards expanding treatment coverage and reducing HIV-related deaths over the past decade, their projections identify the urgency of curtailing transmission. The timely findings of this study call for a reinvigorated effort to galvanise targeted preventive interventions and turn the tide of the HIV pandemic. We declare no competing interests. Global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017Despite progress in reducing HIV-related mortality over the past decade, slow decreases in incidence, combined with the current context of stagnated funding for related interventions, mean that many countries are not on track to reach the 2020 and 2030 global targets for reduction in incidence and mortality. With a growing population of people living with HIV, it will continue to be a major threat to public health for years to come. The pace of progress needs to be hastened by continuing to expand access to ART and increasing investments in proven HIV prevention initiatives that can be scaled up to have population-level impact. Full-Text PDF Open Access