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AIDS 2016: New HIV Infections Have Stopped Declining Worldwide, Now Rising in Some Regions

After a decade of rapidly declining HIV incidence following the introduction of effective antiretroviral treatment, progress in reducing new infections has stalled worldwide and in some areas incidence has started to increase, according to a new analysis from the Global Burden of Disease Study presented at the 21st International AIDS Conference (AIDS 2016) last month in Durban and published in the August 2016 edition of The Lancet HIV.

The advent of highly active combination antiretroviral therapy (ART) in the mid-1990s led to a dramatic decline in HIV-related morbidity and mortality, first in the U.S. and Europe, and later in low- and middle-income countries as treatment became more widely available.

Current World Health Organization (WHO) guidelines say that all people diagnosed with HIV are eligible for ART regardless of CD4 T-cell count. Earlier this year UNAIDS announced that an estimated 17 million people living with HIV were receiving ART at the end of 2015, but this leaves some 20 million still in need of treatment.

The UNAIDS "90-90-90" targets call for 90% of people with HIV to be tested and diagnosed, 90% of diagnosed people to be on ART, and 90% of treated people to have fully suppressed viral load by 2020. But some advocates and policymakers have begun to question whether this is achievable as funding for the global HIV/AIDS response has begun to decline.

Global Burden of Disease Study

Haidong Wang and a large international team of collaborators with the Global Burden of Disease Study 2015 calculated national estimates of HIV/AIDS incidence (new infections), prevalence (all existing infections), antiretroviral therapy coverage, and mortality for 195 countries and territories from 1980 through 2015.

For countries with high-quality vital registration data, the researchers estimated HIV prevalence, incidence, and mortality largely based on the number of HIV-related deaths recorded in cause-of-death statistics. For countries lacking high-quality epidemiological data, they estimated HIV prevalence and incidence from prenatal care clinics (where care coverage is relatively high) and population-based seroprevalence surveys, taking into account known information about CD4 count progression, mortality among HIV-positive people on and off ART, and deaths due to other causes.

Results

• Global HIV incidence reached of 3.3 million new infections in 1997 (95% uncertainty interval 3.1-3.4 million).
• After a period of rapid decline between 1997 and 2005, worldwide annual HIV incidence has stayed relatively constant at about 2.6 million new infections per year (range 2.5-2.8 million).
• HIV incidence fell by 0.7% per year on average between 2005 and 2015, compared to a 2.7% annual decline between 1997 and 2005.
• Due to a combination of new infections and HIV-positive people surviving longer, the number of people living with HIV/AIDS worldwide has risen steadily, reaching 38.8 million in 2015 (95% UI 37.6-40.4 million).
• At the same time, global HIV/AIDS-related mortality has declined steadily, from a peak of 1.8 million deaths in 2005 (95% UI 1.7-1·9 million) to 1.2 million in 2015 (95% UI 1.1-1.3 million).
• However, there was substantial heterogeneity or variability in HIV/AIDS incidence and prevalence levels and trends across countries.
• Approximately three-quarters of all new HIV infections occurred in sub-Saharan Africa in 2015.
• 74 countries saw increased age-standardized HIV incidence rates between 2005 and 2015, including Cambodia, Egypt, Kenya, Mexico, Pakistan, the Philippines, and Russia.

"Although many countries have experienced decreases in HIV/AIDS mortality and in annual new infections, other countries have had slowdowns or increases in rates of change in annual new infections," the study authors wrote.

"Scale-up of ART and prevention of mother-to-child transmission has been one of the great successes of global health in the past 2 decades," the researchers concluded. "However, in the past decade, progress in reducing new infections has been slow, development assistance for health devoted to HIV has stagnated, and resources for health in low-income countries have grown slowly. Achievement of the new ambitious goals for HIV enshrined in Sustainable Development Goal 3 and the 90-90-90 UNAIDS targets will be challenging, and will need continued efforts from governments and international agencies in the next 15 years to end AIDS by 2030."

"This study shows that the AIDS epidemic is not over by any means and that HIV/AIDS remains one of the biggest public health threats of our time," Peter Piot from the London School of Hygiene and Tropical Medicine said in a press release issued by the Institute for Health Metrics and Evaluation. "The continuing high rate of over 2 million new HIV infections represents a collective failure which must be addressed through intensified prevention efforts and continued investment in HIV vaccine research."

Prevention Gap Report

In advance of AIDS 2016, UNAIDS release its Prevention Gap Report, highlighting areas that reveal "concerning trends" in new HIV infections among adults despite prevention advances such as pre-exposure prophylaxis and antiretroviral treatment-as-prevention.

According to the report, an estimated 1.9 million adults have become HIV-positive every year for at least the past 5 years. For example, Eastern Europe and Central Asia saw a 57% increase in annual new HIV infections between 2010 and 2015, the Caribbean saw an 9% annual increase after years of steady decline, and the Middle East and North Africa saw a 4% annual rise.

No regions saw major declines over the past 5 years, with most areas -- including North America, Western and Central Europe, most of Africa, and the Asian/Pacific region -- experiencing only marginal decreases since 2010, while Latin America saw a small 2% increase.

But HIV incidence is not distributed equally across populations. Key affected groups -- including gay men, transgender people, sex workers, people who inject drugs, and prisoners -- accounted for 35% of new infections worldwide in 2014, according to the report.

"The power of prevention is not being realized," UNAIDS executive director Michel Sidibé warned. "If there is a resurgence in new HIV infections now, the epidemic will become impossible to control. The world needs to take urgent and immediate action to close the prevention gap."

8/24/16

Reference

H Wang, TM Wolock, A Carter, et al. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2015: the Global Burden of Disease Study 2015. The Lancet HIV 3(8):e361-e387. August 2016.

Other Sources

Institute for Health Metrics and Evaluation. Rate of new HIV infections increased in 74 countries over past decade. Press release. July 19, 2016.

UNAIDS. Prevention Gap Report. July 11, 2016.

UNAIDS. UNAIDS warns that after significant reductions, declines in new HIV infections among adults have stalled and are rising in some regions. Press release. July 11, 2016.