November 6, 2018
Global Trends in HIV/AIDS
Global Trends
Positive Developments
According to the Joint U.N. Program on HIV/AIDS
ART Coverage and Prevention. Antiretroviral therapy
(UNAIDS), since 1996, when the pandemic began, more
(ART) prevents the progression of HIV infection. ART also
than 70 million people have been infected with the HIV
often suppresses viral loads to levels that significantly
virus, about half of whom have died. At the end of 2017, 37
reduce the risk of HIV transmission, and it is a key tool for
million people were living with HIV/AIDS, including 2.1
preventing sexual transmission of HIV. Without treatment,
million children younger than 15 years. The same year,
those infected with HIV will die.
940,000 people died of HIV-related illnesses, and 1.8
million people were newly infected with HIV. Globally, an
U.S. and international efforts to expand access to ART have
estimated one out of four people infected with HIV do not
increased coverage rates of those infected with HIV from
know they have it. In 2017, an estimated 75% of people
2% in 2003 to 60% in 2017. Currently, 57% of those in
living with HIV knew their status.
need of treatment, or 22 million people, are receiving ART.
Since 2003, new HIV infections among adults have been
Successive U.S. Administrations and Congresses have
reduced by 39%. Among children, new infections have
supported efforts to combat global HIV/AIDS over the past
dropped by 56%, largely due to increased access to ART
few decades. The United States provides more funding than
for the prevention of mother-to-child transmission.
any other country in the global fight against HIV/AIDS.
Since the launch of the President’s Emergency Plan for
Between 2003 and 2017, annual global HIV incidence (new
AIDS Relief (PEPFAR) from FY2004 through FY2017,
cases) declined by 42%. This decrease has been largely
appropriations for global HIV/AIDS programs have
fueled by access to biomedical interventions such as ART,
averaged $4.6 billion per year and totaled $64 billion in that
though evidence suggests that the scaling up of behavior-
span. This assistance has been provided through PEPFAR,
change strategies, which experts view as a key prevention
bilateral State Department- and USAID-administered
approach, will be critical to achieving further declines. Such
programs, and the United Nations’ (U.N.’s) Global Fund to
strategies include counseling to improve knowledge of the
Fight AIDS, Tuberculosis and Malaria.
disease, and increased risk awareness and communications.
Despite substantial global investments in response to the
Care. Care of people living with HIV refers to nonclinical
HIV/AIDS pandemic—with $21 billion in international
services (e.g., psychosocial, physical, socioeconomic,
funding for HIV/AIDS programs in low- and middle-
nutritional, and legal support) intended to improve quality
income countries in 2017—advocates argue that substantial
of life, minimize suffering and ill health, and enable access
work remains to achieve the UNAIDS “90-90-90” goals.
to treatment. In 2016, there were 13.4 million orphans and
vulnerable children (OVC) living without one or both
What are the 90-90-90 goals? As part of its goal to
parents due to an AIDS-related death. Through PEPFAR,
end the AIDS epidemic, UNAIDS has set a target for
expanded access to care programs helped to support 6.4
90% of all people living with HIV knowing their HIV
million OVC in 2017.
status, 90% of all people diagnosed with HIV receiving
sustained antiretroviral therapy, and 90% of all people
Figure 1. AIDS-Related Deaths and ART Access,
receiving antiretroviral therapy (ART) experiencing
2003-2017
viral suppression. To achieve these goals, UNAIDS is
seeking an additional $5.4 billion from 2016 to 2020.
On average, low- and middle-income HIV/AIDS-affected
countries funded roughly 57% of HIV/AIDS programs in
2016, though the amount they provided varies. Wealthier
countries, like South Africa and India, self-finance around
80% of their national HIV programs, whereas many low-
income states—including several PEPFAR priority
countries—rely on donors for 75% or more of their funding
needs. PEPFAR funding has remained flat for the past

seven years, and global HIV/AIDS aid declined by 7%
Source: CRS graphic created from UNAIDS data, 2018.
between 2015 and 2016. (Data used in this In Focus derive

primarily from UNAIDS and PEPFAR.)
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link to page 1 Global Trends in HIV/AIDS
AIDS Deaths. Expanded access to prevention
Financing. Some health experts are concerned that gains
programming and higher ART coverage rates have driven
recorded to date are threatened by declining global financial
declines in AIDS deaths. Between 2003 and 2017, AIDS-
support. While low- and middle-income countries have
related deaths declined by 51% (Figure 1).
deepened their financial commitments, stagnating funding
Challenges
from donor countries has reduced overall funding for the
HIV/AIDS response. A new prospective challenge will be
Some experts now believe it is possible to see an AIDS-free
to establish sustainable financing mechanisms in middle-
generation, though significant challenges remain.
income countries, where 70% of people living with HIV
will reside by 2020. Globally, assistance for HIV dropped
HIV/TB Co-infection. The growing global tuberculosis
by $3 billion between 2012 and 2017.
(TB) burden complicates efforts to reduce HIV/AIDS-
related deaths; co-infection increases the progress of both
Stigma. Advocates at the conference contended that the
diseases and renders treatment more difficult. Those with
stigmatization and criminalization of homosexuality,
HIV are 20 times more likely to develop TB, the leading
injection drug use, and sex work across several regions
cause of death for those with HIV. TB accounted for
present continuing challenges to HIV prevention efforts.
300,000 deaths in 2017.
Low use of HIV services (e.g., HIV testing and treatment)
among stigmatized groups—notably injecting drug users,
HIV Treatment and Testing Coverage. While ART
men who have sex with men, transgender persons, sex
treatment rates are climbing, ART coverage is not
workers, and prisoners—has been identified as a key
expanding fast enough to meet UNAIDS targets. At the end
challenge to meeting the 90-90-90 goals. Conference
of 2017, 43% of those in need of treatment lacked access to
participants called for a greater focus on these groups, who
ART. Inadequate access to HIV/AIDS testing services is an
accounted for 47% of new HIV infections globally in 2017.
impediment to increasing ART coverage rates. Roughly 11
million people in 2017 lacked access to HIV testing
Gender. Conference participants also focused on bolstering
services.
efforts to improve women’s knowledge of their status while
Regional Challenges
simultaneously prioritizing community awareness. HIV
self-testing kits, for example, have shown promise in both
Africa. The HIV/AIDS pandemic is concentrated in sub-
supplementing incomes of women who distribute the kits
Saharan Africa. In 2017, two-thirds of all people living with
and increasing HIV/AIDS awareness of their sexual
HIV/AIDS resided in the region, as did 66% of all HIV-
partners and communities.
positive children. The region also accounted for 57% of
new infections in 2017. Addressing low testing coverage
Outlook and U.S. Engagement
within this population remains an impediment to further
In 2017, the United States supported 14 million people with
reducing HIV transmission rates, where heterosexual sex is
ART through PEPFAR, which is the main channel through
the primary mode of HIV transmission. HIV/AIDS testing
which the United States supports efforts to more rapidly
rates are particularly low among African men aged 25-34.
achieve the 90-90-90 goals. Known as PEPFAR 3.0, it
Central Asia and Eastern Europe. Experts are concerned
seeks to focus investments in geographic areas and
about a rise in HIV/AIDS infections in Central Asia and
populations with the highest HIV/AIDS burden, to
Eastern Europe, where infection rates grew by 57% from
maximize the cost-effectiveness of PEPFAR funding.
2010 to 2015, mainly due to increased injection drug use.
The Trump Administration has proposed reductions in
ART coverage rates are also relatively low in the region:
PEPFAR funding, requesting $7 billion for global health
36% of people living with HIV receive ART, indicating a
assistance in FY2019, 24% less than FY2018-enacted
relatively large unmet need for scaling up treatment and
prevention programs.
levels. The Administration has recommended cuts of 11%
and 31% to funding for PEPFAR programs managed by the
Middle East and North Africa. Low ART coverage in the
State Department and the Global Fund, respectively.
Middle East and North Africa also concerns observers. At
Some Members of Congress and HIV/AIDS advocates have
the end of 2017, less than 39% of infected adults were
expressed concern regarding the Administration’s
receiving ART—the lowest coverage rate in the world. In
willingness to devote resources to combating the global
this region, conservative cultural practices, inadequate
AIDS epidemic and the prospect that people on ART might
HIV/AIDS policies, and stigma are key barriers to
lose coverage due to spending cuts. PEPFAR continues to
improving ART coverage.
receive bipartisan support in Congress, which has
Issues at the 2018 UNAIDS Conference
appropriated global health and HIV/AIDS funding over the
past two years at levels consistent with funding during the
At the July 2018 UNAIDS Conference, 16,000 stakeholders
last Administration.
gathered in the Netherlands to discuss science, advocacy,
and human rights issues related to the HIV/AIDS epidemic.
Sara M. Tharakan, Analyst in Global Health and
Key issues discussed included the following:
International Development
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Global Trends in HIV/AIDS


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