The Global HIV/AIDS Epidemic
HIV, the virus that causes AIDS, “acquired immunodeficiency syndrome”1, 2, 3 has become one of the world’s most serious health and development challenges. The first cases were reported in 1981 and today, more than 30 years later:
- There are approximately 35 million people currently living with HIV and tens of millions of people have died of AIDS-related causes since the beginning of the epidemic.1, 3, 4
- While new cases have been reported in all regions of the world, 95% of new infections occur in individuals that reside in low- and middle-income countries, particularly in sub-Saharan Africa.5
- Most people living with HIV or at risk for HIV do not have access to prevention, care, and treatment, and there is still no cure.6
- HIV primarily affects those in their most productive years; about half of new infections are among those under age 25.5
- HIV not only affects the health of individuals, it impacts households, communities, and the development and economic growth of nations. Many of the countries hardest hit by HIV also suffer from other infectious diseases, food insecurity, and other serious problems.
- Despite these challenges, new global efforts have been mounted to address the epidemic, particularly in the last decade, and there are signs that the epidemic may be changing course. The number of people newly infected with HIV and the number of AIDS-related deaths have declined, contributing to the stabilization of the epidemic. In addition, the number of people with HIV receiving treatment in resource poor countries has increased from 400,000 in 2003 to 9.7 million in 2012.1, 2, 3, 6
Current Global Snapshot
- There were 35.3 million people living with HIV in 2012, up from 29.4 million in 2001, the result of continuing new infections, people living longer with HIV, and general population growth.
- The global prevalence rate (the percent of people ages 15-49 who are infected) has leveled since 2001 and was 0.8% in 2012.
- 1.6 million people died of AIDS in 2012, a 30% decrease since 2005. Deaths have declined due in part to antiretroviral treatment (ART) scale-up. HIV is a leading cause of death worldwide and the number one cause of death in Africa.
- New HIV infections overall have declined by 33% since 2001 and, in 26 low- and middle-income countries, new infections have declined by 50% or more. Still, there were about 2.3 million new infections in 2012 or more than 6,300 new HIV infections per day.
- Most new infections are transmitted heterosexually, although risk factors vary. In some countries, men who have sex with men, injecting drug users, and sex workers are at significant risk.
- Although HIV testing capacity has increased over time, enabling more people to learn their HIV status, the majority of people with HIV are still unaware they are infected.6
- HIV has led to a resurgence of tuberculosis (TB), particularly in Africa, and TB is a leading cause of death for people with HIV worldwide.7, 8 In 2012, approximately 13% of new TB cases occurred in people living with HIV. However, between 2004 and 2012 TB deaths in people living with HIV declined by 36%, largely due to the scale up of joint HIV/TB services.
- Women represent about half (52%) of all people living with HIV worldwide. HIV is the leading cause of death among women of reproductive age. Gender inequalities, differential access to services, and sexual violence increase women’s vulnerability to HIV, and women, especially younger women, are biologically more susceptible to HIV.
- Young people, ages 15–24, account for approximately 39% of new HIV infections (among those 15 and over).5 Globally, young women twice as likely to become infected with HIV than their male counterparts. In some areas, young women are more heavily impacted than young men.
- Globally, there were 3.3 million children living with HIV in 2012, 260,000 new infections among children, 210,000 AIDS deaths, and in 2011, approximately 17.3 million AIDS orphans (children who have lost one or both parents to HIV), most of whom live in sub-Saharan Africa (88%).
|Figure 2: HIV Prevalence & Incidence by Region 1, 5|
|Region||Total No. (% Living with HIV), 2012||Newly Infected, 2012||Adult Prevalence Rate, 2012|
|Global Total||35.3 million (100%)||2.3 million||0.8%|
|Sub-Saharan Africa||25.0 million (71%)||1.6 million||4.7%|
|South/South-East Asia||4.0 million (11%)||270,000||0.3%|
|Latin America||1.5 million (4%)||86,000||0.4%|
|Eastern Europe/Central Asia||1.3 million (4%)||130,000||0.7%|
|North America||1.3 million (4%)||48,000||0.5%|
|Western/Central Europe||860,000 (2%)||29,000||0.2%|
|East Asia||880,000 (2%)||81,000||<0.1%|
|Middle East/North Africa||260,000 (0.7%)||32,000||0.1%|
- Sub-Saharan Africa. Sub-Saharan Africa, the hardest hit region, is home to 71% of people living with HIV but only about 12% of the world’s population.1, 9 Most children with HIV live in this region (88%).5 Almost all of the region’s nations have generalized HIV epidemics—that is, their national HIV prevalence rate is greater than 1%. In 8 countries, 10% or more of adults are estimated to be HIV-positive. South Africa has the highest number of people living with HIV in the world (4.3 million). Swaziland has the highest prevalence rate in the world (24.8%). Recent data offer promising signs, with national HIV prevalence and/or incidence stabilizing or even declining in many countries in the region.1
- Latin America & The Caribbean. About 1.6 million people are estimated to be living with HIV in Latin America and the Caribbean combined, including 98,000 newly infected in 2012. The Caribbean itself, with an adult HIV prevalence rate of 1%, is the second hardest hit region in the world after sub-Saharan Africa. Seven countries in Latin America and the Caribbean have generalized epidemics, with the Bahamas having the region’s highest prevalence rate (3.4-3.5%), and Brazil the greatest number of people living with the disease.1
- Eastern Europe & Central Asia. An estimated 1.3 million people are living with HIV in this region, including 130,000 newly infected in 2012. The epidemic is driven primarily by injecting drug use, although heterosexual transmission also plays an important role. The Russian Federation and Ukraine have the highest prevalence rates in the region, and Russia has the region’s highest number of people living with HIV.1
- Asia. An estimated 4.8 million people are living with HIV across South/South-East Asia and East Asia. The region is also home to the two most populous nations in the world – China and India – and even relatively low prevalence rates translate into large numbers of people.1
Prevention and Treatment
- Effective prevention strategies include behavior change programs, condoms, HIV testing, blood supply safety, harm reduction efforts for injecting drug users, and male circumcision. Additionally, recent research has shown that providing HIV treatment to people with HIV significantly reduces the risk of transmission to their negative partners and the use of antiretroviral-based microbicide gel has been found to reduce the risk of HIV infection in women. Pre-exposure antiretroviral prophylaxis (PrEP) has also been shown to be an effective HIV prevention strategy in individuals at high risk for HIV infection.
- Experts recommend that prevention be based on “knowing your epidemic,” that is, tailoring prevention to the local context and epidemiology, and using a combination of prevention strategies, bringing programs to scale, and sustaining efforts over time.
- Access to prevention, however, remains limited.
HIV treatment includes the use of combination antiretroviral therapy to attack the virus itself, and medications to prevent and treat the many opportunistic infections that can occur when the immune system is compromised by HIV.1, 2, 3, 6
- Combination ART, first introduced in 1996, has led to dramatic reductions in morbidity and mortality, and access has increased in recent years, rising from less than half a million people on treatment in 2003 to 9.7 million people in 2012, a 1.6 million increase in the number of people on treatment since 2011.
- In Sub-Saharan Africa alone, the number of people receiving ART increased significantly from 50,000 in 2002 to 7.5 million in 2012.
- The number of pregnant women receiving ART for the prevention of mother-to-child transmission of HIV increased by one third from 2009 to 2012, reaching 900,000 in 2012. Access to ART among children has also risen significantly, although they have less access than adults.
- 9.7 million people received treatment in 2012, covering 61% of individuals who were eligible for treatment in 2012, and representing 65% of the 2011 UNGASS target of treating 15 million by 2015. New WHO guidelines recommend starting treatment of HIV earlier in the course of illness. Given these new recommendations, 25.9 million people are now eligible for treatment.
The U.S. Government Response
The U.S. first provided funding to address the global HIV epidemic in 1986. U.S. efforts and funding increased slowly over time, intensifying relatively recently. Key initiatives include:
- In 1999, President Clinton announced the Leadership and Investment in Fighting an Epidemic (LIFE) Initiative to address HIV in 14 African countries and in India.
- In 2002, President Bush announced the International Mother and Child HIV Prevention Initiative focused on 12 African and 2 Caribbean countries.
- The creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 brought significant new attention and funding to address the global epidemic, as well as TB and malaria.11 PEPFAR authorized up to $15 billion over 5 years, primarily for bilateral programs and multilateral contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) as well as UNAIDS. In 2008, PEPFAR was reauthorized for an additional 5 years at up to $48 billion. In FY 2012, Congress appropriated $5.1 billion for bilateral HIV and $1.3 billion for the Global Fund, totaling $6.4 billion. The President’s FY 2014 budget request for bilateral HIV programs is $4.9 billion, which would represent a decrease of more than 200 million (5%) below FY 2012 levels. The Global Fund request is for $1.65 billion, a 27% increase.12
- Today, there are multiple federal departments, agencies, and programs that address the global epidemic, and the U.S. government is the single largest donor to international HIV efforts in the world, including the largest donor to the Global Fund.12, 13
The Global Response to HIV/AIDS
International efforts to combat HIV began in the first decade of the epidemic with the creation of the WHO’s Global Programme on AIDS in 1987. UNAIDS was formed in 1996 to serve as the UN system’s coordinating body and to help galvanize worldwide attention to AIDS. The role of affected country governments and civil society also has been critical to the response. Over time, funding by donors and others has increased and several key initiatives have been launched:
- In 2000, all nations agreed to global HIV targets to halt and begin to reverse the spread of HIV by 2015, as part of the UN Millennium Development Goals (MDGs), and the World Bank launched its Multi-Country AIDS Program (MAP).
- In 2001, a United Nations General Assembly Special Session on HIV/AIDS (UNGASS) was convened and the Global Fund was created. More recently, at the June 2011 UNGASS meeting, world leaders adopted a new Declaration that reaffirmed commitments and called for an intensification of efforts to combat the epidemic through new commitments and targets.14
- Most funding has come from international donor governments who disbursed $7.9 billion in 2012, up from $1.2 billion in 2002, to address HIV in low- and middle-income countries.13 Hard hit countries have also provided significant resources to address their epidemics. The Global Fund has approved more than $14 billion for HIV efforts in more than 100 countries to date,15 and the private sector, including foundations and corporations, also plays a major role, particularly the Bill & Melinda Gates Foundation which has committed more than $2.5 billion for HIV, with additional funding provided to the Global Fund.16
- UNAIDS estimates global HIV funding totaled $18.9 billion in 2012, however, this total is below the UNAIDS estimate of $22 to $24 billion needed to address the impacts of HIV.13
UNAIDS. Report on the Global AIDS Epidemic; 2013.
UNAIDS. Together We Will End AIDS; 2012.
UNAIDS. World AIDS Day Report: Results; 2012.
UNAIDS. AIDS at 30: Nations at the crossroads; 2011.
UNAIDS. Core Slides: Global Summary of the AIDS Epidemic; 2013.
WHO/UNAIDS/UNICEF. Global update on HIV treatment 2013; June 2013.
WHO. Tuberculosis: http://www.who.int/mediacentre/factsheets/fs104/en/index.html.
WHO. Tuberculosis and HIV: http://www.who.int/hiv/topics/tb/en/index.html.
Population Reference Bureau. 2012 World Population Data Sheet; 2012.
Global HIV Prevention Working Group. Behavior Change for HIV Prevention: (Re) Considerations for the 21st Century; August 2008.
U.S. Congress. P.L. 108-25; May 27, 2003.
Kaiser Family Foundation analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, and Congressional Appropriations Bills. Totals include funding for HIV and the Global Fund. FY 2014 is President’s Budget Request to Congress.
KFF/UNAIDS. Financing the Response to AIDS in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2012; September 2013.
UNAIDS. 2011 Political Declaration on HIV/AIDS; 2011, available at: http://www.unaids.org/en/aboutunaids/unitednationsdeclarationsandgoals/2011highlevelmeetingonaids/.
Global Fund. Grants Portfolio; accessed October 2013, available at: http://portfolio.theglobalfund.org/en/Home/Index.
Bill & Melinda Gates Foundation, HIV Strategy Overview; July 2012.