The Global HIV/AIDS Epidemic
HIV, the virus that causes AIDS, “acquired immunodeficiency syndrome”1 has become one of the world’s most serious health and development challenges. The first cases were reported in 1981 and today:
- There are approximately 36.9 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
- While new cases have been reported in all regions of the world, approximately 70% are in sub-Saharan Africa.2
- 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.3
- HIV primarily affects those in their most productive years; about 38% of new infections are among those under age 25.2
- 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 has increased to 15.8 million as of June 2015, a 2.2 million increase since June 2014.4
Current Global Snapshot
- There were 36.9 million people living with HIV in 2014, up from 29.8 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 2014.
- 1.2 million people died of AIDS in 2014, a 42% decrease since 2004. 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 globally have declined by 35% since 2000. In 61 countries, new HIV infections have decreased by more than 20%. Still, there were about 2.0 million new infections in 2015 or about 5,600 new 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 disproportionally affected by HIV.
- Although HIV testing capacity has increased over time, enabling more people to learn their HIV status, nearly half of all people with HIV are still unaware they are infected.3
- 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.5, 6 In 2014, approximately 12% of new TB cases occurred in people living with HIV.7 However, between 2004 and 2014 TB deaths in people living with HIV declined by 33%, largely due to the scale up of joint HIV/TB services.
- Women represent approximately half (51%) of all adults living with HIV worldwide. HIV is the leading cause of death among women of reproductive age. Gender inequalities, differential access to service, 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 30% of new HIV infections (among those 15 and over).2 In sub-Saharan Africa, young women account for 63% of young people living with HIV.
- Globally, there were 2.6 million children living with HIV in 2014, 220,000 new infections among children, and 150,000 AIDS deaths.
|Table 1: HIV Prevalence & Incidence by Region, 2013 1, 2|
|Region||Total No. (% Living with HIV)||Newly Infected||Adult Prevalence Rate|
|Global Total||36.9 million (100%)||2.0 million||0.8%|
|Sub-Saharan Africa||25.8 million (70%)||1.4 million||4.8%|
|Asia and the Pacific||5.0 million (14%)||340,000||0.2%|
|Western and Central Europe and North America||2.4 million (7%)||85,000||0.3%|
|Latin America||1.7 million (5%)||87,000||0.4%|
|Eastern Europe and Central Asia||1.5 million (4%)||140,000||0.9%|
|Middle East and North Africa||240,000 (<1%)||22,000||0.1%|
- Sub-Saharan Africa. Sub-Saharan Africa, the hardest hit region, is home to 70% of people living with HIV but only about 13% of the world’s population.1, 8 Most children with HIV live in this region (88%).2 Almost all of the region’s nations have generalized HIV epidemics—that is, their national HIV prevalence rate is greater than 1%. In 9 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 (6.8 million). Swaziland has the highest prevalence rate in the world (27.7%). 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 2.0 million people are estimated to be living with HIV in Latin America and the Caribbean combined, including 100,000 newly infected in 2014. The Caribbean itself, with an adult HIV prevalence rate of 1.1%, is the second hardest hit region in the world after sub-Saharan Africa. Six countries in Latin America and the Caribbean have generalized epidemics. Of the countries with available data, Haiti has the region’s highest prevalence rate (1.9%), and Brazil the greatest number of people living with the disease (approximately 610,000 to 1,000,000).1
- Eastern Europe & Central Asia. An estimated 1.5 million people are living with HIV in this region, including 140,000 newly infected in 2014. The epidemic is driven primarily by injecting drug use, although heterosexual transmission also plays an important role. The Russian Federation and Ukraine account for 85% of people living with HIV in the region.1
- Asia and the Pacific. An estimated 5.0 million people are living with HIV in Asia and the Pacific. 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. Pre-exposure antiretroviral prophylaxis (PrEP) has also been shown to be an effective HIV prevention strategy in individuals at high risk for HIV infection. In 2015, WHO released a guideline which recommends daily oral PrEP as a form of prevention for high-risk individuals in combination with other prevention methods.10
- 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. In light of recent research findings, WHO released a guideline in 2015 recommending starting HIV treatment earlier in the course of illness.1, 3, 10, 11, 12
- Combination ART, first introduced in 1996, has led to dramatic reductions in morbidity and mortality, and access has increased in recent years, rising to 15.8 million people as of June 2015,4 achieving a goal set by world leaders in 2011 to have 15 million people on treatment by 2015.
- Globally, 40% of people living with HIV are receiving treatment, which includes 41% of adults and 32% of children living with HIV.
- Approximately 76% of all people receiving antiretroviral therapy in sub-Saharan Africa are virally suppressed, which means they are likely healthier and less likely to transmit the virus.
- The percentage of pregnant women receiving ART for the prevention of mother-to-child transmission of HIV increased to 73% in 2014, up from 36% in 2009. Access to ART among children has also risen significantly, although they have less access than adults.
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.13 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 and, in 2013, the PEPFAR Stewardship and Oversight Act of 2013 extended a number of existing authorities and strengthened the oversight of the program through updated reporting requirements, among other things.14 In FY 2015, Congress appropriated a total of $5.2 billion for bilateral HIV and $1.35 billion for the Global Fund, totaling $6.6 billion. The President’s FY 2016 budget request for bilateral HIV programs is $5.2 billion. The Global Fund request is for $1.1 billion, which would represent a decrease of $244 million below FY 2015 levels.15
- 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.15, 16
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). As of 2015, the AIDS-related targets of MDGs were met.1 In 2015, the international community agreed upon new Sustainable Development Goals (SDGs), which included a target to end the AIDS epidemic by 2030.17
- 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.18
- On World AIDS Day 2014, UNAIDS set targets for 2020 aimed at ending the epidemic by 2030. The targets include achieving “90% of people living with HIV knowing their HIV status; 90% of people who know their HIV-positive status on treatment; and 90% of people on treatment with suppressed viral loads.”19
- Most funding has come from international donor governments who disbursed $8.6 billion in 2014, up from $1.2 billion in 2002, to address HIV in low- and middle-income countries.16 Hard hit countries have also provided significant resources to address their epidemics. The Global Fund has committed approximately $17 billion for HIV efforts in more than 100 countries to date,20 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.21
- UNAIDS estimates global HIV funding totaled $20.2 billion in 2014, however, this total is below the UNAIDS estimate of $22 to $24 billion needed to address the impacts of HIV.16
- UNAIDS. How AIDS Changed Everything; 2015.
- UNAIDS. 2015 Epidemiological slides – How AIDS Changed Everything report; 2015.
- WHO/UNAIDS/UNICEF. Global update on HIV treatment 2013; June 2013.
- UNAIDS. Focus on location and population; November 2015.
- 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.
- WHO. Global tuberculosis report; 2015.
- Population Reference Bureau. 2014 World Population Data Sheet; 2014.
- Global HIV Prevention Working Group. Behavior Change for HIV Prevention: (Re) Considerations for the 21st Century; August 2008.
- WHO. Guideline on When to Start antiretroviral Therapy and on Pre-Exposure Prophylaxis for HIV; September 2015.
- WHO. Press Release: NIAID START Trial confirms that immediate treatment of HIV with antiretroviral drugs (ARVs) protects the health of people living with HIV; May 28, 2015.
- NIAID. Starting Antiretroviral Treatment Early Improves Outcomes for HIV-Infected Individuals; May 27, 2015.
U.S. Congress. P.L. 108-25; May 27, 2003.
- U.S. Congress. Public Law No: 113-56; December 2, 2013.
- 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 2015 is President’s Budget Request to Congress.
KFF/UNAIDS. Financing the Response to HIV in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2014; July 2015.
- United Nations. Transforming our world: the 2030 Agenda for Sustainable Development; 2015.
UNAIDS. 2011 Political Declaration on HIV/AIDS; 2011, available at: http://www.unaids.org/en/aboutunaids/unitednationsdeclarationsandgoals/2011highlevelmeetingonaids/.
- UNAIDS. Fast-Track: ending the AIDS epidemic by 2030; 2014.
Global Fund. Grants Portfolio; accessed November 2015, available at: http://www.theglobalfund.org/en/portfolio/.
Bill & Melinda Gates Foundation, HIV Strategy Overview; accessed November 2015, available at: http://www.gatesfoundation.org/What-We-Do/Global-Health/HIV#OurStrategy.