Global Trends in HIV/AIDS

Updated October 10, 2019 Global Trends in HIV/AIDS Global Trends 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, 2003-2017 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). Challenges 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. Regional Challenges 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 prevention programs. 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 coverage. Issues at the 2019 IAS Conference on HIV Science 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 following: 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 programs. 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 last Administration. Sara M. Tharakan, Analyst in Global Health and International Development Global Trends in HIV/AIDS IF11018 Disclaimer This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress. 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