Global, Regional, and National Sex-Specific Burden and Control of the HIV Epidemic, 1990–2019, for 204 Countries and Territories: The Global Burden of Diseases Study 2019

Background The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic. Methods To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold \u3e75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio thresholdFindingsIn 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1–38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78–0·91) per female living with HIV in 2019, 0·99 male infections (0·91–1·10) for every female infection, and 1·02 male deaths (0·95–1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58–35·43, and a 39·66% decrease in deaths, 36·49–42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05–0·06) and the global incidence-to-mortality ratio was 1·94 (1·76–2·12). No regions met suggested thresholds for progress. Interpretation Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990–2019, for 204 countries and territories : the Global Burden of Diseases Study 2019

Funding Information: L Abu-Raddad acknowledges the support of Qatar National Research Fund (NPRP 9-040-3-008) who provided the main funding for generating the data provided to the GBD-IHME effort. T Bärnighausen was supported by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the German Federal Ministry of Education and Research. S Bazargan-Hejazi was partly supported by the National Institute of Health (NIH) National Center for Advancing Translational Science UCLA CTSI (grant number UL1TR001881). L Degenhardt is supported by an NHMRC Senior Principal Research Fellowship (1135991) and a US NIH National Institute on Drug Abuse (NIDA) grant (R01DA1104470). NDARC, UNSW Sydney, is supported by funding from the Australian Government Department of Health under the Drug and Alcohol Programme. J Eaton was supported by the Bill & Melinda Gates Foundation (OPP1190661), UNAIDS, the National Institute of Allergy and Infectious Disease of the NIH under award numbers R01AI136664, and the MRC Centre for Global Infectious Disease Analysis (reference MR/R015600/1), jointly funded by the UK Medical Research Council (MRC) and the UK Foreign, Commonwealth, and Development Office (FCDO), under the MRC/FCDO Concordat agreement and is also part of the EDCTP2 programme supported by the European Union. V B Gupta acknowledges funding support from National Health and Medical Research Council (NHMRC), Australia. V K Gupta acknowledges support from NHMRC, Australia. S Haque is grateful to the DSR, Jazan University, Saudi Arabia for providing the access of the Saudi Digital Library for this study. P Hoogar would like to acknowledge the Centre for Bio Cultural Studies Directorate of Research, Manipal Academy of Higher Education, Manipal-Karnataka, India. Y J Kim's portion of this work was supported by the Research Management Centre, Xiamen University Malaysia (Np:XMUMRF-C6/ITCM/0004). S L Koulmane Laxminarayana acknolwedges institutional support by Manipal Academy of Higher Education. K Krishan is supported by the UGC Centre of Advanced Study (phase 2), awarded to the Department of Anthropology, Panjab University, Chandigarh, India. M Kumar acknowledges grant FIC/NIH K43 TW010716-04. I Landires is member of the Sistema Nacional de Investigación, supported by the Secretaría Nacional de Ciencia, Tecnología e Innovación, Panama. J Lazarus acknowledges support to ISGlobal from the Spanish Ministry of Science, Innovation, and Universities through the Centro de Excelencia Severo Ochoa 2019–23 programme (CEX2018-000806-S), and from the Government of Catalonia, Spain, through the CERCA programme. P Mahasha acknowledges grants, innovation, and product development from the South African Medical Research Council. P Meylahk's portion of this research was supported by the Russian Science Foundation (under grant project number 20-18-00307; the health of nation: the multidimensional analysis of health, health inequality, and health-related quality of life). M Molokhia is supported by the National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas’ National Health Service Foundation Trust and King's College London. J Nachega is an infectious disease internist and epidemiologist and Principal Investigator of NIH/Fogarty International Center (grant numbers 1R25TW011217-01, 1R21TW011706-01, and 1D43TW010937-01A1). A Samy acknowledges support from a fellowship of the Egyptian Fulbright Mission programme. A Shetty acknowledges the support given by Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal. N Taveira's work is partially funded by Fundação para a Ciência e Tecnologia, Portugal, and Aga Khan Development Network, Portugal Collaborative Research Network in Portuguese speaking countries in Africa (project 332821690), and by the LIFE project (RIA2016MC-1615), and European and Developing Countries Clinical Trials Partnership. G Tessema was funded by the Australian National Health and Medical Research Council Investigator (grant number 1195716). B Unnikrishnan acknowledges Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal. A Zumla acknowledges support from the European and Developing Countries Clinical Trials Partnership programme, Horizon 2020, and the European Union's Framework Programme for Research and Innovation (grants PANDORA-ID-NET, TESA-2, and CANTAM-2). Funding Information: S Afzal reports an unpaid leadership role as General Secretary for the Pakistan Society of Community Medicine and Public Health, working for prevention and advocacy of AIDS in families of HIV patients by providing advocacy and counseling services to the families, children, and partners of patients with AIDS and screening them for HIV in Pakistan, outside the submitted work. T Bärnighausen reports research grants from the European Union (Horizon 2020 and EIT Health), German Research Foundation (also known as DFG), US National Institutes of Health (NIH), German Ministry of Education and Research, Alexander von Humboldt Foundation, Else-Kröner-Fresenius-Foundation, the Wellcome Trust, the Bill & Melinda Gates Foundation, KfW, UNAIDS, and WHO; consulting fees for KfW on the OSCAR initiative in Vietnam; and participation on a Data Safety Monitoring Board or Advisory Board through the NIH-funded study Healthy Options (Principle Investigators Smith Fawzi, Kaaya), Chair, Data Safety and Monitoring Board, German National Committee on the Future of Public Health Research and Education, Chair of the scientific advisory board to the EDCTP Evaluation, Member of the UNAIDS Evaluation Expert Advisory Committee, National Institutes of Health Study Section Member on Population and Public Health Approaches to HIV/AIDS, US National Academies of Sciences, Engineering, and Medicine's Committee for the Evaluation of Human Resources for Health in the Republic of Rwanda under the President's Emergency Plan for AIDS Relief (also known as PEPFAR), University of Pennsylvania Population Aging Research Center External Advisory Board Member; and a leadership or fiduciary role in other board, society, committee, or advocacy group, paid or unpaid as Co-Chair of the Global Health Hub Germany (which was initiated by the German Ministry of Health), all outside the submitted work. J Eaton reports institutional support for the manuscript from the Gates Foundation, UNAIDS, and National Institutes of Health; grants or contracts from WHO, Gates foundation, and UNAIDS; consulting fees from WHO; and support for attending meetings or travel from WHO and UNAIDS, all outside the submitted work. I Filip reports financial support from Avicenna Medical and Clinical Research Institute, outside the submitted work. I Iyamu reports support for attending FHI 360 HIV prevention, care, and treatment training events in Nigeria, outside the submitted work. K Krishan reports non-financial support from UGC Centre of Advanced Study, CAS II, Department of Anthropology, Panjab University, Chandigarh, India, outside the submitted work. K LeGrand reports support for the present manuscript through payment to the institution (Institute for Health Metrics and Evaluation) from the Gates Foundation. M Postma reports a leadership or fiduciary role in other board, society, committee, or advocacy group, unpaid as member of UK's JCVI. O Rezahosseini reports grants or contracts from the Research Foundation of Rigshospitalet and the A P Møller Fonden; and support for attending meetings or travel from EACS 2019 Basel, all outside the submitted work. J Salomon reports support for the present manuscript through a research grant paid to the institution (Institute for Health Metrics and Evaluation) from the Gates Foundation. J Singh reports consulting fees from Crealta/Horizon, Medisys, Fidia, Two labs, Adept Field Solutions, Clinical Care Options, Clearview Health-Care Partners, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, UBM LLC, Trio Health, Medscape, WebMD, and Practice Point Communications, the NIH, and the American College of Rheumatology; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Simply Speaking; support for attending meetings or travel from OMERACT, an international organisation that develops measures for clinical trials and receives arm's-length funding from 12 pharmaceutical companies, when traveling biannually to OMERACT meetings; participation on a Data Safety Monitoring Board or Advisory Board as a member of the FDA Arthritis Advisory Committee; a leadership or fiduciary role in other board, society, committee, or advocacy group, paid or unpaid, with OMERACT as a member of the steering committee, with the Veterans Affairs Rheumatology Field Advisory Committee as a member, and with the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis as a director and editor; and stock or stock options in TPT Global Tech, Vaxart pharmaceuticals, Charlotte's Web Holdings, and previously owned stock options in Amarin, Viking, and Moderna pharmaceuticals, all outside the submitted work. D Stein reports personal fees from Lundbeck, Takeda, Johnson & Johnson and Servier, all outside the submitted work. A Tsai reports stipend for work as Editor-in-Chief of Social Science and Medicine, Mental Health from Elsevier. All other authors declare no competing interests. Funding Information: L Abu-Raddad acknowledges the support of Qatar National Research Fund (NPRP 9-040-3-008) who provided the main funding for generating the data provided to the GBD-IHME effort. T Bärnighausen was supported by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the German Federal Ministry of Education and Research. S Bazargan-Hejazi was partly supported by the National Institute of Health (NIH) National Center for Advancing Translational Science UCLA CTSI (grant number UL1TR001881). L Degenhardt is supported by an NHMRC Senior Principal Research Fellowship (1135991) and a US NIH National Institute on Drug Abuse (NIDA) grant (R01DA1104470). NDARC, UNSW Sydney, is supported by funding from the Australian Government Department of Health under the Drug and Alcohol Programme. J Eaton was supported by the Bill & Melinda Gates Foundation (OPP1190661), UNAIDS, the National Institute of Allergy and Infectious Disease of the NIH under award numbers R01AI136664, and the MRC Centre for Global Infectious Disease Analysis (reference MR/R015600/1), jointly funded by the UK Medical Research Council (MRC) and the UK Foreign, Commonwealth, and Development Office (FCDO), under the MRC/FCDO Concordat agreement and is also part of the EDCTP2 programme supported by the European Union. V B Gupta acknowledges funding support from National Health and Medical Research Council (NHMRC), Australia. V K Gupta acknowledges support from NHMRC, Australia. S Haque is grateful to the DSR, Jazan University, Saudi Arabia for providing the access of the Saudi Digital Library for this study. P Hoogar would like to acknowledge the Centre for Bio Cultural Studies Directorate of Research, Manipal Academy of Higher Education, Manipal-Karnataka, India. Y J Kim's portion of this work was supported by the Research Management Centre, Xiamen University Malaysia (Np:XMUMRF-C6/ITCM/0004). S L Koulmane Laxminarayana acknolwedges institutional support by Manipal Academy of Higher Education. K Krishan is supported by the UGC Centre of Advanced Study (phase 2), awarded to the Department of Anthropology, Panjab University, Chandigarh, India. M Kumar acknowledges grant FIC/NIH K43 TW010716-04. I Landires is member of the Sistema Nacional de Investigación, supported by the Secretaría Nacional de Ciencia, Tecnología e Innovación, Panama. J Lazarus acknowledges support to ISGlobal from the Spanish Ministry of Science, Innovation, and Universities through the Centro de Excelencia Severo Ochoa 2019–23 programme (CEX2018-000806-S), and from the Government of Catalonia, Spain, through the CERCA programme. P Mahasha acknowledges grants, innovation, and product development from the South African Medical Research Council. P Meylahk's portion of this research was supported by the Russian Science Foundation (under grant project number 20-18-00307; the health of nation: the multidimensional analysis of health, health inequality, and health-related quality of life). M Molokhia is supported by the National Institute for Health Research Biomedical Research Centre at Guy's and St Thomas’ National Health Service Foundation Trust and King's College London. J Nachega is an infectious disease internist and epidemiologist and Principal Investigator of NIH/Fogarty International Center (grant numbers 1R25TW011217-01, 1R21TW011706-01, and 1D43TW010937-01A1). A Samy acknowledges support from a fellowship of the Egyptian Fulbright Mission programme. A Shetty acknowledges the support given by Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Manipal. N Taveira's work is partially funded by Fundação para a Ciência e Tecnologia, Portugal, and Aga Khan Development Network, Portugal Collaborative Research Network in Portuguese speaking countries in Africa (project 332821690), and by the LIFE project (RIA2016MC-1615), and European and Developing Countries Clinical Trials Partnership. G Tessema was funded by the Australian National Health and Medical Research Council Investigator (grant number 1195716). B Unnikrishnan acknowledges Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal. A Zumla acknowledges support from the European and Developing Countries Clinical Trials Partnership programme, Horizon 2020, and the European Union's Framework Programme for Research and Innovation (grants PANDORA-ID-NET, TESA-2, and CANTAM-2).Peer reviewedPublisher PD

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990–2019, for 204 countries and territories: the Global Burden of Diseases Study 2019

Background: The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic. Methods: To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0). Findings: In 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1–38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78–0·91) per female living with HIV in 2019, 0·99 male infections (0·91–1·10) for every female infection, and 1·02 male deaths (0·95–1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58–35·43, and a 39·66% decrease in deaths, 36·49–42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05–0·06) and the global incidence-to-mortality ratio was 1·94 (1·76–2·12). No regions met suggested thresholds for progress. Interpretation: Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990–2019, for 204 countries and territories: the Global Burden of Diseases Study 2019

Background The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic. Methods To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0). Findings In 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1–38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78–0·91) per female living with HIV in 2019, 0·99 male infections (0·91–1·10) for every female infection, and 1·02 male deaths (0·95–1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58–35·43, and a 39·66% decrease in deaths, 36·49–42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05–0·06) and the global incidence-to-mortality ratio was 1·94 (1·76–2·12). No regions met suggested thresholds for progress. Interpretation Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics