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. 2021 Oct;8(10):e633-e651.
doi: 10.1016/S2352-3018(21)00152-1.

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990-2019, for 204 countries and territories: the Global Burden of Diseases Study 2019

GBD 2019 HIV Collaborators
Collaborators

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990-2019, for 204 countries and territories: the Global Burden of Diseases Study 2019

GBD 2019 HIV Collaborators. Lancet HIV. 2021 Oct.

Erratum in

  • Correction to Lancet HIV 2021; 8: e633-51.
    [No authors listed] [No authors listed] Lancet HIV. 2022 Dec;9(12):e822. doi: 10.1016/S2352-3018(22)00042-X. Epub 2022 Feb 21. Lancet HIV. 2022. PMID: 35202594 Free PMC article. No abstract available.

Abstract

Background: The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic.

Methods: To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0).

Findings: In 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1-38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78-0·91) per female living with HIV in 2019, 0·99 male infections (0·91-1·10) for every female infection, and 1·02 male deaths (0·95-1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58-35·43, and a 39·66% decrease in deaths, 36·49-42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05-0·06) and the global incidence-to-mortality ratio was 1·94 (1·76-2·12). No regions met suggested thresholds for progress.

Interpretation: Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics.

Funding: The Bill & Melinda Gates Foundation, the National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

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Conflict of interest statement

Declaration of interests S Afzal reports an unpaid leadership role as General Secretary for the Pakistan Society of Community Medicine and Public Health, working for prevention and advocacy of AIDS in families of HIV patients by providing advocacy and counseling services to the families, children, and partners of patients with AIDS and screening them for HIV in Pakistan, outside the submitted work. T Bärnighausen reports research grants from the European Union (Horizon 2020 and EIT Health), German Research Foundation (also known as DFG), US National Institutes of Health (NIH), German Ministry of Education and Research, Alexander von Humboldt Foundation, Else-Kröner-Fresenius-Foundation, the Wellcome Trust, the Bill & Melinda Gates Foundation, KfW, UNAIDS, and WHO; consulting fees for KfW on the OSCAR initiative in Vietnam; and participation on a Data Safety Monitoring Board or Advisory Board through the NIH-funded study Healthy Options (Principle Investigators Smith Fawzi, Kaaya), Chair, Data Safety and Monitoring Board, German National Committee on the Future of Public Health Research and Education, Chair of the scientific advisory board to the EDCTP Evaluation, Member of the UNAIDS Evaluation Expert Advisory Committee, National Institutes of Health Study Section Member on Population and Public Health Approaches to HIV/AIDS, US National Academies of Sciences, Engineering, and Medicine's Committee for the Evaluation of Human Resources for Health in the Republic of Rwanda under the President's Emergency Plan for AIDS Relief (also known as PEPFAR), University of Pennsylvania Population Aging Research Center External Advisory Board Member; and a leadership or fiduciary role in other board, society, committee, or advocacy group, paid or unpaid as Co-Chair of the Global Health Hub Germany (which was initiated by the German Ministry of Health), all outside the submitted work. J Eaton reports institutional support for the manuscript from the Gates Foundation, UNAIDS, and National Institutes of Health; grants or contracts from WHO, Gates foundation, and UNAIDS; consulting fees from WHO; and support for attending meetings or travel from WHO and UNAIDS, all outside the submitted work. I Filip reports financial support from Avicenna Medical and Clinical Research Institute, outside the submitted work. I Iyamu reports support for attending FHI 360 HIV prevention, care, and treatment training events in Nigeria, outside the submitted work. K Krishan reports non-financial support from UGC Centre of Advanced Study, CAS II, Department of Anthropology, Panjab University, Chandigarh, India, outside the submitted work. K LeGrand reports support for the present manuscript through payment to the institution (Institute for Health Metrics and Evaluation) from the Gates Foundation. M Postma reports a leadership or fiduciary role in other board, society, committee, or advocacy group, unpaid as member of UK's JCVI. O Rezahosseini reports grants or contracts from the Research Foundation of Rigshospitalet and the A P Møller Fonden; and support for attending meetings or travel from EACS 2019 Basel, all outside the submitted work. J Salomon reports support for the present manuscript through a research grant paid to the institution (Institute for Health Metrics and Evaluation) from the Gates Foundation. J Singh reports consulting fees from Crealta/Horizon, Medisys, Fidia, Two labs, Adept Field Solutions, Clinical Care Options, Clearview Health-Care Partners, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, UBM LLC, Trio Health, Medscape, WebMD, and Practice Point Communications, the NIH, and the American College of Rheumatology; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Simply Speaking; support for attending meetings or travel from OMERACT, an international organisation that develops measures for clinical trials and receives arm's-length funding from 12 pharmaceutical companies, when traveling biannually to OMERACT meetings; participation on a Data Safety Monitoring Board or Advisory Board as a member of the FDA Arthritis Advisory Committee; a leadership or fiduciary role in other board, society, committee, or advocacy group, paid or unpaid, with OMERACT as a member of the steering committee, with the Veterans Affairs Rheumatology Field Advisory Committee as a member, and with the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis as a director and editor; and stock or stock options in TPT Global Tech, Vaxart pharmaceuticals, Charlotte's Web Holdings, and previously owned stock options in Amarin, Viking, and Moderna pharmaceuticals, all outside the submitted work. D Stein reports personal fees from Lundbeck, Takeda, Johnson & Johnson and Servier, all outside the submitted work. A Tsai reports stipend for work as Editor-in-Chief of Social Science and Medicine, Mental Health from Elsevier. All other authors declare no competing interests.

Figures

Figure 1
Figure 1
Global HIV burden 1990–2019
Figure 2
Figure 2
Male-to-female sex ratios for 204 countries and territories in 2019 Incident cases (A). Deaths (B) Countries and territories with fewer than 100 incident cases or deaths in 2019 were excluded from this calculation because of small burdens that drove high ratios that could not easily be interpreted.
Figure 3
Figure 3
Change in HIV burden by GBD super-region for both sexes combined, by decade, from 1990 to 2019 (A) Annualised rate of change: derived as the mean yearly percentage change averaged over the given time period. (B) Total percentage change: the labelled numbers are the global percentage change in each measure over the given time period. Each bar shows the proportion and direction of change attributable to each super-region. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study.
Figure 4
Figure 4
Incidence-to-mortality and incidence-to-prevalence ratios for 204 countries and territories in 2010 versus 2019, and direction of change from 2010 to 2019 The blue dotted lines represent UNAIDS thresholds (<1·0 for incidence-to mortality ratio and <0·03 for incidence-to-prevalence ratio). Points to the left of the vertical line met the threshold in 2019, whereas points below the horizontal line met the threshold in 2010. Countries and territories are sorted into a directional change matrix for deaths and incidence on the basis of changes between 2010 and 2019.
See this image and copyright information in PMC

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