Updated October 10, 2019
Global Trends in HIV/AIDS
Progress in Addressing HIV/AIDS
According to the Joint U.N. Program on HIV/AIDS
(UNAIDS), more than 75 million people have been infected
with the HIV virus since 1996, when the pandemic began.
At the end of 2018, 38 million people were living with
HIV/AIDS, including 2.1 million children younger than 15
years. The same year, 770,000 people died of HIV-related
illnesses, and 1.7 million people were newly infected with
HIV. Globally, an estimated one out of four people infected
with HIV do not know they have it. In 2018, an estimated
79% of people living with HIV knew their status.
ART Coverage and Prevention. Antiretroviral therapy
(ART) prevents the progression of HIV infection. ART also
often suppresses viral loads to levels that significantly
reduce the risk of HIV transmission, and it is a key tool for
preventing sexual transmission of HIV. Without treatment,
those infected with HIV will die.
Successive U.S. Administrations and Congresses have
supported efforts to combat global HIV/AIDS over the past
few decades. The United States provides more funding than
any other country in the global fight against HIV/AIDS.
Since the launch of the President’s Emergency Plan for
AIDS Relief (PEPFAR) in FY2004, the United States has
provided a total of about $68 billion for global HIV/AIDS
programs through FY2018 (averaging about $4.6 billion per
year). This assistance has been provided through PEPFAR,
bilateral State Department- and USAID-administered
programs, and the Global Fund to Fight AIDS, Tuberculosis
and Malaria (the Global Fund).
Despite substantial global investments in response to the
HIV/AIDS pandemic—with $19 billion in international
funding for HIV/AIDS programs in low- and middleincome countries in 2018—advocates argue that substantial
work remains to achieve the UNAIDS “90-90-90” goals.
What are the 90-90-90 goals? As part of its goal to
end the AIDS epidemic, UNAIDS has set a target for
90% of all people living with HIV knowing their HIV
status, 90% of all people diagnosed with HIV receiving
sustained antiretroviral therapy, and 90% of all people
receiving antiretroviral therapy (ART) experiencing
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 56% of HIV/AIDS programs in
2018, though the amount they provided varies. Wealthier
countries, like South Africa and India, self-finance around
80% of their national HIV programs, whereas many lowincome 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%
between 2017 and 2018. (Data used in this In Focus derive
primarily from UNAIDS and PEPFAR.)
U.S. and international efforts to expand access to ART have
increased coverage rates of those infected with HIV from
2% in 2003 to 62% in 2018. Currently, 61% of those in
need of treatment, or 23 million people, are receiving ART.
Since 2003, new HIV infections among adults have been
reduced by 39%. Among children, new infections have
dropped by 56%, largely due to increased access to ART
for the prevention of mother-to-child transmission.
Between 2003 and 2018, annual global HIV incidence (new
cases) declined by 32%. This decrease has been largely
fueled by access to biomedical interventions such as ART,
though evidence suggests that the scaling up of behaviorchange strategies, which experts view as a key prevention
approach, will be critical to achieving further declines. Such
strategies include counseling to improve knowledge of the
disease, and increased risk awareness and communications.
Care. Care of people living with HIV refers to nonclinical
services (e.g., psychosocial, physical, socioeconomic,
nutritional, and legal support) intended to improve quality
of life, minimize suffering and ill health, and enable access
to treatment. In 2016, there were 13.4 million orphans and
vulnerable children (OVC) living without one or both
parents due to an AIDS-related death. Through PEPFAR,
expanded access to care programs helped to support 6.8
million OVC in 2018.
Figure 1. AIDS-Related Deaths and ART Access,
Source: CRS graphic created from UNAIDS data, 2019.
Global Trends in HIV/AIDS
AIDS Deaths. Expanded access to prevention
programming and higher ART coverage rates have driven
declines in AIDS deaths. Between 2003 and 2018, AIDSrelated deaths declined by 59% (Figure 1).
Some experts believe it is possible to see an AIDS-free
generation, though significant challenges remain.
HIV/TB Co-infection. The growing global tuberculosis
(TB) burden complicates efforts to reduce HIV/AIDSrelated deaths; co-infection increases the progress of both
diseases and renders treatment more difficult. Those with
HIV are 20 times more likely to develop TB, the leading
cause of death for those with HIV. TB accounted for
256,000 deaths in 2018.
HIV Treatment and Testing Coverage. While ART
treatment rates are climbing, ART coverage is not
expanding fast enough to meet UNAIDS targets. At the end
of 2018, 39% of those in need of treatment lacked access to
ART. Inadequate access to HIV/AIDS testing services is an
impediment to increasing ART coverage rates. In 2018, 8
million people lacked access to HIV testing services.
Africa. The HIV/AIDS pandemic is concentrated in subSaharan Africa. In 2018, two-thirds of all people living with
HIV/AIDS resided in the region, as did 66% of all HIVpositive children. The region also accounted for over half of
new infections in 2018. Addressing low testing coverage
within this population remains an impediment to further
reducing HIV transmission rates, where heterosexual sex is
the primary mode of HIV transmission. HIV/AIDS testing
rates are particularly low among African men aged 25-34.
Central Asia and Eastern Europe. Experts are concerned
about a rise in HIV/AIDS infections in Central Asia and
Eastern Europe, where infection rates grew by 57% from
2010 to 2015, mainly due to increased injection drug use.
ART coverage rates are also relatively low in the region:
36% of people living with HIV receive ART, indicating a
relatively large unmet need for scaling up treatment and
Middle East and North Africa. Low ART coverage in the
Middle East and North Africa also concerns observers. At
the end of 2018, 32% of infected adults were receiving
ART—the lowest coverage rate in the world. Here,
conservative cultural practices, inadequate HIV/AIDS
policies, and stigma are key barriers to improving ART
Issues at the 2019 IAS Conference on
The follow-on to the UNAIDS 2018 Conference, the
International AIDS Society Conference on HIV Science,
was held in Mexico City in July 2019. Stakeholders
gathered to discuss the state of the science related to the
HIV/AIDS epidemic. Key issues discussed included the
Preventing Mother-to-Child Transmission (MTCT) and
Treatment Access for Children. Some health experts are
concerned that gains recorded in improving prevention and
access to treatment differ across age groups. Conference
participants noted that the global health community is not
meeting its commitment to end the AIDS epidemic amongst
children and adolescents. Scientists discussed how, for
example, gaps in treatment of pregnant women in eastern
Africa, have led to high rates of MTCT.
Stigma and Key Populations. Some civil society members
and advocates discussed the global stigmatization and
criminalization of homosexuality, injection drug use, and
sex work noting that these issues present challenges to HIV
prevention efforts. Some experts noted that low use of HIV
services (e.g., HIV testing and treatment) among
stigmatized groups could be improved by uptake of
prevention drugs, such as PreP, but reiterated that
decreasing stigma and improving overall service access is
still necessary to meet the 90-90-90 goals. Conference
participants called for a greater focus on these groups, and
for further integration of HIV treatment and prevention
services into existing sexual and reproductive health
Gender. Scientific experts presented on interventions to
improve prevention efforts among young women and
adolescent girls, as well as improving women’s knowledge
of their status and uptake of treatment regimens. Experts
believe this is a key area in reducing transmission, as
infection rates among women continue to outpace
infections in men.
Outlook and U.S. Engagement
In 2018, the United States supported 14 million people with
ART through PEPFAR, the main channel through which
the United States supports efforts to more rapidly achieve
the 90-90-90 goals. Known as PEPFAR 3.0, it seeks to
focus investments in geographic areas and populations with
the highest HIV/AIDS burden, to maximize the costeffectiveness of PEPFAR funding.
The Trump Administration has proposed reductions in
PEPFAR funding as well as the U.S. contribution to the
Global Fund. It requested $3.4 billion for PEPFAR in
FY2020, a 29% cut from FY2019-enacted levels, including
cuts to funding for PEPFAR programs managed by the
State Department and the Global Fund.
Some Members of Congress and HIV/AIDS advocates have
expressed concern regarding the Administration’s
willingness to devote resources to combating the global
AIDS epidemic and the prospect that people on ART might
lose coverage due to spending cuts. PEPFAR continues to
receive bipartisan support in Congress, which has
appropriated global health and HIV/AIDS funding over the
past three years at levels consistent with funding during the
Sara M. Tharakan, Analyst in Global Health and
Global Trends in HIV/AIDS
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