Video: HIV rates have declined, but not for all populations

Declines in HIV incidence among men and women in a South African population-based cohort

Video: HIV rates have declined, but not for all populations

  • Epidemiology
  • HIV infections

Over the past decade, there has been a massive scale-up of primary and secondary prevention services to reduce the population-wide incidence of HIV.

However, the impact of these services on HIV incidence has not been demonstrated using a prospectively followed, population-based cohort from South Africa—the country with the world’s highest rate of new infections.

To quantify HIV incidence trends in a hyperendemic population, we tested a cohort of 22,239 uninfected participants over 92,877 person-years of observation. We report a 43% decline in the overall incidence rate between 2012 and 2017, from 4.0 to 2.3 seroconversion events per 100 person-years.

Men experienced an earlier and larger incidence decline than women (59% vs. 37% reduction), which is consistent with male circumcision scale-up and higher levels of female antiretroviral therapy coverage. Additional efforts are needed to get more men onto consistent, suppressive treatment so that new HIV infections can be reduced among women.

Over the past decade, there has been a massive scale-up of treatment and prevention services to bring the HIV epidemic under control1. These efforts have led to an estimated 50% reduction in the number of AIDS-related deaths over the last 6 years2.

However, progress to reduce the HIV incidence rate (IR) by 75% is off track3, with 1.8 million new infections occurring in 20174.

The Joint United Nations Programme on HIV and AIDS (UNAIDS) has recently described the limited success in reducing new HIV infections, which is unmatched by the success in reducing AIDS-related deaths, as a “prevention crisis”5.

There is an urgent need to measure the impact of primary and secondary prevention services on long-term HIV incidence trends in southern Africa—the region accounting for one-third of all new infections4,6.

In eastern Africa, estimates of HIV incidence declines have varied between 40–50% following increased antiretroviral therapy (ART) and voluntary medical male circumcision (VMMC) coverage7,8.

Nevertheless, reductions in incidence have not been rigorously demonstrated using a prospectively followed, population-based cohort from southern Africa, which has a much higher rate of new HIV infections and has received substantial domestic and international investment to achieve epidemic control1,4. Attention is focused on the country with the world’s largest treatment and prevention program: South Africa9.

One major challenge in reliably measuring HIV incidence trends in southern Africa (as well as the broader African region) has been the limited number of population-based cohort studies. Previous estimates of incidence declines in the region have been derived from mathematical models or cross-sectional assay-based studies5,10,11.

However, mathematical models rely on strong assumptions and non-representative data (e.g., women attending antenatal clinics), while cross-sectional studies do not track the same participants over time12,13.

The repeated testing of a complete population of participants until HIV seroconversion is generally recognized as the gold-standard approach for measuring trends in the incidence of infection14.

In our previous work, we demonstrated a clear relationship between ART coverage in the surrounding local community and individual risk of HIV acquisition in a hyperendemic South African setting15. However, we have yet to report on long-term, population-wide HIV incidence trends and their relation to the scale-up of primary and secondary prevention services.

Specifically, we use one of the world’s largest population-based HIV cohorts, with over 90,000 person-years of observation, to quantify sex-specific trends in HIV incidence following changes in ART coverage, prevalence of detectable viremia, condom use, and male circumcision.

We leverage several differing methodologies to validate our estimates and ensure the robustness of our findings.

We report that the overall incidence of HIV infection between 2012 and 2017 declined by 43%. Our key finding is that men experienced earlier and larger declines than women, plausibly due to a sex differential in the uptake of primary and secondary prevention services.

Specifically, we show that male incidence declined by 59%, from 2.5 to 1.0 seroconversion events per 100 person-years, which is consistent with VMMC scale-up in 2009 and female ART coverage surpassing 35% in 2012. We also report a 37% reduction in the female incidence between 2014 and 2017, from 4.

9 to 3.1 seroconversion events per 100 person-years, which occurred after male ART coverage reached 35%.

Thus, although HIV prevention efforts should continue to focus on both men and women, there is an urgent need to get more men onto consistent, suppressive ART so that new HIV infections can be further reduced among women.

The Africa Health Research Institute (AHRI) runs a population-based HIV testing platform in the Hlabisa sub-district of KwaZulu-Natal16.

Approximately 90,000 persons reside in 11,000 households, which are mostly scattered across the 438 km2 study area.

As is typical for a rural South African setting, there are several informal peri-urban settlements and a single urban township. The majority of the residents are Zulu-speaking (black) Africans.

Two to three times yearly, trained field workers visit all households in the study area to interview a key resident informant. The key informant is often the household head or the most senior household member; if not available, other suitable household members are selected.

The key informant provides information on the physical attributes of the household; the resident members and their relationship to one another; members who join, leave, or die; and the migration patterns of members, including place of origin and destination.

For each death in the household, the key informant completes a detailed verbal autopsy questionnaire administered by the field-worker. To undertake annual HIV testing, field workers obtain written consent from eligible participants who are present, mentally able, and older than 15 years of age.

Participants first answer questions about their sexual health, relationship history, use of condoms with a sexual partner, and circumcision status (men only between 2009 and 2016). The field workers then extract dried blood spot (DBS) samples for HIV and viral load testing17,18.

Prevention services at the 17 public healthcare clinics in or adjacent to the study area have included HIV testing and counseling, condom distribution, ART availability, and voluntary medical circumcision for men.

The local VMMC program was started in 2009 and the national HIV testing and counseling services were expanded in 2010.

ART became freely available nationwide in 2004, with a CD4+ T-cell count eligibility criteria of


Understanding the reasons for decline of HIV prevalence in Haiti

Video: HIV rates have declined, but not for all populations

1. UNAIDS/WHO AIDS Epidemic Update December 2004. Geneva: UNAIDS/WHO, 2004

2. Gaillard E M, Cayemittes M, Boulos L ‐ alLe VIH/SIDA en Haiti: une raison d'espérer. Haiti: The POLICY Project, 2004

3. Gaillard E M, Boulos L ‐ M, Cayemittes alAnalyse secondaire des études de sero surveillance par méthode sentinelle de la prévalence du VIH chez les femmes enceintes en Haiti entre 1993 et 2004. Haiti: The POLICY Project, 2005

4. Institut Haitien de l'Enfance, Centres Gheskio Résultat d'une étude de surveillance serosentinelle: Prévalence du VIH, du VHB et de la Syphilis chez les femmes enceintes dans cinq (5) sites de surveillance serosentinelle en Haiti. Haiti: Organisation Panaméricaine de la Santé/Organisation Mondiale de la Santé, 1994

5. Institut Haitien de l'Enfance, Les Centre Gheskio Evolution Globale des prévalence de l'infection au VIH, de la syphilis et de l'hépatite B chez les femmes Haitiennes enceintes. Haiti: Organisation Panaméricaine de la Santé/Organisation Mondiale de la Santé (OPS/OMS), 1996

6. Institut Haitien de l'enfance C G. Etude de séro surveillance par méthode sentinelles de la prévalence du VIH, de la syphilis et de l'hépatite B chez les femmes enceintes en Haiti. 1999–2000. Haiti: Ministère de la Santé Publique et de la Population; Organisation Pan Américaine de la Santé/Organisation Mondiale de la Santé, 2000

7. Ministère de la Santé Publique et de la Population; Institut Haitien de l‘Enfance; Centres GHESKI0; and Centers for Disease Control and Prevention Etude de Sero Surveillance par Methode Sentinelle de la Prevalence du VIH, de la Syphilis, de l‘ Hépatite C chez les femmes encaintes en Haiti 2003/2004. Haiti 2004

8. Theodore H, Jean‐Baptiste F, Nerette alHigh‐risk behavior among female commercial sex workers coming to a VCT center in Haiti. Port‐au‐Prince: Les Centres GHESKIO 2004

9. Family Health International (FHI), Centre d'Évaluation et de Recherche Appliquée (CERA) Premier tour d'enquete de surveillance comportementale a Port‐au‐Prince et au Cap Haitien ESC I. Haiti 1999. Haiti: Ministere de la Santé Publique, 1999

10. Cayemittes M, Placide M F, Barrère alEnquête Mortalité, Morbidité et Utilisation des Services – EMMUS III – Haiti 2000. Haiti: Ministère de la Santé Publique et de la Population; Institut Haitien de l'Enfance; ORC Macro, 2001

11. Family Health International (FHI), Centre d'Évaluation et de Recherche Appliquée (CERA) Deuxieme tour d'enquete de surveillance comportementale en Haiti ESC II. Haiti 2003. Haiti: Ministere de la Santé Publique, 2003

12. Ghys P D, Brown T, Grassly N al The UNAIDS Estimation and Projection Package: a software package to estimate and project national HIV epidemics. Sex Transm Infect 200480(suppl 1)i5–i9. [PMC free article] [PubMed] [Google Scholar]

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14. Stover J.AIM Version 4: A computer program for making HIV/AIDS projections and examining the social and economic impacts of AIDS–Spectrum systems of Policy models. Washington DC: The POLICY Project 2003

15. Theodore H, Jean‐Baptiste F, Nerette alPrevalence of HIV infection and serologic syphilis among Haitian and Dominican female commercial sex workers in Port‐au‐Prince, Haiti (1985–2003). Les Centres GHESKIO 2004

16. Croix‐Rouge Haitiennne (Section de Transfusion Sanguine), Organisation Panaméricaine de la Santé/Organisation Mondiale de la Santé Analyse Epidemiologique des donnees du Centre de Transfusion de la Croix‐Rouge Haitienne de Port‐au‐Prince. 1970–1990. Haiti: Pan American Health Organization 1992

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23. Cayemites M, Chahnazarian A, Augustin alSurvie et Sante de l'Enfant en Haiti. Résultats de l'Enquête Mortalité, Morbidité et Utilisation des Services—1987. Port‐au‐Prince: Institut Haitien de l'Enfance; Ministère de la Santé Publique et de la Population; Johns Hopkins University, 1989

24. Augustin A. Abstinence, fidelity, condom use and the stabilization of the AIDS Epidemic in Haiti. 2004.


The Status of the HIV/AIDS Epidemic in Sub-Saharan Africa

Video: HIV rates have declined, but not for all populations
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The Status of the HIV/AIDS Epidemic in Sub-Saharan Africa

Despite the fact that sub-Saharan Africa contains only about 11 percent of the Earth’s population, the region is the world’s epicenter of HIV/AIDS. The numbers are daunting. Adult HIV prevalence is 1.2 percent worldwide (0.6 percent in North America), but it is 9.0 percent in sub-Saharan Africa.

UNAIDS estimates that at the end of 2001, there were 40 million people living with HIV/AIDS, 28.5 million of them from sub-Saharan African. Five million adults and children became newly infected with HIV in 2001, 3.5 million of them from sub-Saharan Africa. Three million people died from AIDS-related causes in 2001, and 2.

2 million of these deaths were among sub-Saharan Africans.2

AIDS is now the leading cause of death in sub-Saharan Africa. (Worldwide, AIDS is the fourth leading cause of death.) Life expectancy at birth has plummeted in many African countries, wiping out the gains made since independence.

The combination of high birth rates and high AIDS mortality among adults, including many parents, has meant that more than 90 percent of children who have been orphaned as a consequence of the HIV/AIDS epidemic are in this region.


These statistics disguise an important part of the story, however. Most of the worst affected countries form an “AIDS belt” in eastern and southern Africa.

This belt consists of about 16 countries3 and stretches from Djibouti and Ethiopia down the east side of the continent through South Africa.

These countries constitute only a little more than 4 percent of the world’s population but account for more than 50 percent of HIV infections worldwide.

According to UNAIDS, all the worst affected countries (with prevalence rates over 20 percent) are contiguous to one another in the lower part of the continent. These include South Africa, Lesotho, Swaziland, Botswana, Namibia, Zambia, and Zimbabwe. Botswana, Lesotho, Swaziland, and Zimbabwe have prevalence rates above 30 percent.4

Further north in the AIDS belt, Mozambique, Malawi, Burundi, Rwanda, Kenya, Tanzania, and Ethiopia all have adult prevalence rates in the 6-15 percent range. Adult prevalence in Uganda is estimated to be around 5 percent.

Uganda is the one country in the region that has probably achieved a longstanding decline in HIV prevalence. Prevalence in Uganda may have peaked in the 12-13 percent range in the early 1990s before the onset of this decline.

Elsewhere, Somalia, Eritrea, Djibouti, and Sudan have little or no data, and Madagascar remains an interesting case. Despite tourism, an active commercial sex trade, and high rates of other sexually transmitted infections (STIs), and despite being separated from the African mainland by only 60 kms of water, adult HIV prevalence remains below 1 percent.5

Though having overall adult prevalence rates lower than in the eastern and southern parts of the continent, the middle part of Africa6 is undergoing a serious and generalized7 HIV/AIDS epidemic.

Among the countries in the region, the Democratic Republic of Congo, Chad, and Equatorial Guinea show adult HIV prevalence rates under 5 percent.

Angola has been war-torn and chaotic for so long that it is difficult to know exactly what is transpiring with the epidemic there. However, UNAIDS places the adult prevalence rate at 5.5 percent. Elsewhere in the region, UNAIDS reports prevalence rates of 7.

2 percent in the Congo, 11.8 percent in Cameroon, and 12.9 percent in the Central African Republic.8 Many of the worst affected countries in middle Africa have the highest rates of other STIs on the continent.

Among the 15 countries of West Africa,9 only a few countries have prevalence rates over 5 percent. These include Burkina Faso (6.5 percent), Côte d’Ivoire (9.7 percent), Nigeria (5.8 percent), and Togo (6.0 percent). With an estimated population of 127 million, Nigeria is the demographic giant of sub-Saharan Africa.

After South Africa, Nigeria has more people living with HIV/AIDS (3.5 million in 2001) than any other place on the continent. Côte d’Ivoire receives a large number of male migrants from neighboring countries who are temporary workers.

Along with a vibrant commercial sex industry, especially in the capital city of Abidjan, this helps explain why Côte d’Ivoire has emerged as the epicenter of the epidemic in West Africa.

Table 1
Estimated Number of People in the African “AIDS Belt” Living with HIV/AIDS, end of 2001

 Total Adults and Children Total Women (15-49) Adults (15-49) rate (%)
Global Total 40 million 18.5 million 1.2
Sub-Saharan Africa 28.5 million 15 million 9.0
Ethiopia 2.1 million 1.1 million 6.4
Uganda 600,000 280,000 5.0
Kenya 2.5 million 1.4 million 15.0
Tanzania 1.5 million 750,000 7.8
Rwanda 500,000 250,000 8.9
Burundi 390,000 190,000 8.3
Mozambique 1.1 million 630,000 13.0
Malawi 850,000 440,000 15.0
Zambia 1.2 million 590,000 21.5
Zimbabwe 2.3 million 1.2 million 33.7
Namibia 230,000 110,000 22.5
Botswana 330,000 170,000 38.8
Swaziland 170,000 89,000 33.4
Lesotho 360,000 180,000 31.0
South Africa 5.0 million 2.7 million 20.1

Source: UNAIDS, Report on the Global HIV/AIDS Epidemic: July 2002.

Why have rates in West Africa not soared to the levels found in the AIDS belt countries of eastern and southern Africa? If the African epidemic has its roots in the Great Lakes region, the epicenter could well have moved westward into middle and western Africa. Instead, it moved primarily southward.

The question is an intriguing one and no consensus has emerged in response. Cultural and social norms may have played a role.

10 For example, in countries with conservative Islamic traditions and a large proportion of Muslims in the population, sexual networking may be more circumscribed than in other countries.

Demographers John and Pat Caldwell suggest at least two additional factors. They point out that the presence of other STIs is probably the single most important factor contributing to the rapid spread of HIV.

However, it is not all STIs, but especially those that cause genital ulcers that serve as an effective conduit of HIV. In West Africa, gonorrhea is the most common STI, but this is a non-ulcerative STI and an ineffective transmitter of HIV.

By contrast, syphilis and chancroid are the dominant STIs in eastern and southern Africa. Both are ulcerative STIs that greatly increase the probability of HIV transmission.

Also, in most societies in West Africa, male circumcision is almost always practiced, while it is uncommon in a very large swathe of the AIDS-belt countries.

11 Several studies conducted over the last decade and a half point to an association between male circumcision in some areas of sub-Saharan Africa and a reduced risk of HIV infection.

However, it is still not clear whether circumcision’s apparent protective effect is due to culturally or religiously dictated behaviors — such as limiting the number of sex partners — or what the foreskin’s biological role is in male infection with HIV and other STIs.

Is the epidemic still worsening or is the situation improving? Uganda is still the only country in the region that has achieved a sustained decline in HIV prevalence. In some places — parts of Zambia, for example — prevalence appears to be dropping among the younger age groups, a possible prelude to an overall prevalence decline.

UNAIDS indicates that in 2000 the number of annual new infections went down for the first time relative to the previous year.12 While this is an encouraging trend, a drop in the annual number of new infections over a short period does not mean very much by itself.

Some eventual downturn in incidence (annual new infections) would eventually occur even in the absence of any successful prevention efforts. The high levels of incidence that drove expansion of the epidemic during the 1990s could not be sustained indefinitely.

This happens, in part, because prevalence levels become so high in certain high-risk groups that there is little room for expansion. A drop in incidence over a number of years is needed before it signifies a change in the overall course of the epidemic.

Also, a rise in a few key but large countries — Congo and Nigeria, for example — could see incidence climbing again.

The best assessment is that, while there are some hopeful signs, overall the epidemic continues to rage throughout the Africa region.

Even if prevention efforts become radically more successful in the near future than they have been, the impacts of the HIV/AIDS epidemic are going to echo for generations.

If prevention, treatment, and care programs evolve at a more modest pace, it is certain that HIV/AIDS will have a profound impact on African development well into the 21st century.


  1. The Joint United Nations Programme on HIV/AIDS (UNAIDS), Report on the Global HIV/AIDS Epidemic: July 2002 (Geneva: UNAIDS, 2002).
  2. USAID, Leading the Way: USAID Responds to HIV/AIDS (Washington, DC: The Synergy Project, 2001).
  3. The definition of the AIDS belt can vary.

    In this case, it includes 16 contiguous countries in eastern and southern Africa with serious HIV/AIDS epidemics. The countries are Djibouti, Ethiopia, Uganda, Kenya, Tanzania, Rwanda, Burundi, Mozambique, Malawi, Zambia, Zimbabwe, Namibia, Botswana, Swaziland, Lesotho, and South Africa.

  4. UNAIDS, Report on the Global HIV/AIDS Epidemic: July 2002.

  5. UNAIDS, Report on the Global HIV/AIDS Epidemic: July 2002.
  6. Middle Africa countries include Angola, Cameroon, the Central African Republic, Chad, Democratic Republic of Congo, Congo, Equatorial Guinea, and Gabon.
  7. One definition of a generalized HIV/AIDS epidemic is that HIV has spread beyond initial subpopulations engaged in high-risk sexual behavior to the general population, as evidenced by prevalence rates of 5 percent or more in urban areas.

    See, for example, Confronting AIDS: Public Priorities in a Global Epidemic, A World Bank Policy Research Report (New York: Oxford University Press, 1997): 87.

  8. UNAIDS, Report on the Global HIV/AIDS Epidemic: July 2002.

  9. West African countries include Benin, Burkina Faso, Cote d’Ivoire, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, and Togo.
  10. Leading the Way: USAID Responds to HIV/AIDS.
  11. John C. Caldwell and Pat Caldwell, “Toward an Epidemiological Model of AIDS in Sub-Saharan Africa,” Social Science History 4 (Winter 1996): 567, 576, 578-585, 592.
  12. UNAIDS, AIDS Epidemic Update: December 2000 (Geneva: UNAIDS, 2000).


New HIV Infections Drop 18 Percent in Six Years

Video: HIV rates have declined, but not for all populations

Decline signals HIV prevention and treatment efforts in the U.S. are paying off, but not all communities are seeing the same progress.

The number of annual HIV infections in the United States fell 18 percent between 2008 and 2014 — from an estimated 45,700 to 37,600 — according to new estimates from the Centers for Disease Control and Prevention (CDC) presented today at the Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle. Progress, however, was not the same among all populations or areas of the country.

“The nation’s new high-impact approach to HIV prevention is working. We have the tools, and we are using them to bring us closer to a future free of HIV,” said Jonathan Mermin, M.D., director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “These data reflect the success of collective prevention and treatment efforts at national, state and local levels. We must ensure the interventions that work reach those who need them most.”

The most recent analysis of the number of new HIV infections estimated to occur each year in the U.S. provides a sign of progress in HIV prevention. In addition to the national decline, a new CDC analysis also examined trends by transmission route from 2008 to 2014 and found annual HIV infections dropped:

  • 56 percent among people who inject drugs (from 3,900 to 1,700);
  • 36 percent among heterosexuals (from 13,400 to 8,600);
  • 18 percent among young gay and bisexual males ages 13 to 24 (from 9,400 to 7,700);
  • 18 percent among white gay and bisexual males (from 9,000 to 7,400);
  • And substantially in some states and Washington, D.C. — Washington, D.C. (dropping 10 percent each year over the six-year period); Maryland (down about 8 percent annually); Pennsylvania (down about 7 percent annually); Georgia (down about 6 percent annually); New York and North Carolina (both down about 5 percent annually); Illinois (down about 4 percent annually); and Texas (down about 2 percent annually).

Furthermore, CDC researchers did not find any increases in annual HIV infections in the 35 states and Washington, D.C., where annual HIV infections could be estimated — they decreased or remained stable in all of those areas.

CDC researchers believe the declines in annual HIV infections are due, in large part, to efforts to increase the number of people living with HIV who know their HIV status and are virally suppressed — meaning their HIV infection is under control through effective treatment. This is a top public health priority.

Studies have shown that, in addition to improving the health of people living with HIV, early treatment with antiretroviral medications dramatically reduces a person’s risk of transmitting the virus to others.Increases in the use of pre-exposure prophylaxis, or PrEP, may also have played a role in preventing new infections in recent years.

CDC issued interim clinical guidelines in 2012 for PrEP, a pill that people who do not have HIV can take daily to reduce their risk of infection from sex by more than 90 percent. The FDA approved PrEP for HIV prevention in 2012.

“Maximizing the power of these new prevention tools in conjunction with testing and education efforts, offers the hope of ending the HIV epidemic in this nation,” said Eugene McCray, M.D., director of CDC’s Division of HIV/AIDS Prevention. “Science has shown us the power of HIV treatment medicines in benefitting people with and without HIV.”

Progress must accelerate for people at greatest risk

Gay and bisexual men were the only group that did not experience an overall decline in annual HIV infections from 2008 to 2014. This is because reduced infections among whites and the youngest gay and bisexual men were offset by increases in other groups.

Annual infections remained stable at about 26,000 per year among gay and bisexual men overall and about 10,000 infections per year among black gay and bisexual men — a hopeful sign after more than a decade of increases in these populations.

However, concerning trends emerged among gay and bisexual males of certain ages and ethnicities, with annual infections increasing:

  • 35 percent among 25- to 34-year-old gay and bisexual males (from 7,200 to 9,700);
  • 20 percent among Latino gay and bisexual males (from 6,100 to 7,300);

These data also show regional disparities in southern states, which are home to 37 percent of the U.S. population but accounted for 50 percent of estimated infections in 2014. Future analyses will examine racial and ethnic disparities of annual HIV infections.“Unfortunately, progress remains uneven across communities and populations,” said Dr. McCray.

“High-impact prevention strategies must continue to be developed and implemented at the state and local levels to accelerate progress. That means more testing to diagnose infections, increasing the proportion of people with HIV who are taking HIV treatment effectively and maximizing the impact of all available prevention tools.

”While HIV infections fell from 2008 to 2014 among people who inject drugs, this progress may be threatened by the nation’s opioid epidemic.

“The opioid epidemic in our country is jeopardizing the dramatic progress we’ve made in reducing HIV among people who inject drugs,” said Dr. Mermin.

“We need to expand the reach of comprehensive syringe services programs, which reduce the risk of HIV infection without increasing drug use, and can link people to vital services to help them stop using drugs.”

CDC focuses on high-impact, cost-effective solutions

CDC is working to accelerate prevention progress by implementing its High-Impact Prevention (HIP) approach. HIP involves delivering scientifically proven, cost-effective, and scalable interventions, with particular attention to the most heavily affected populations and geographic areas.

As part of HIP, CDC is taking action with national, state and local partners to help ensure:

  • HIV testing is simple, available and routine;
  • People living with HIV get care and treatment, starting the day they are diagnosed;
  • And that people who are not infected with HIV have prevention information and tools, such as comprehensive syringe services programs and PrEP, as indicated.

The bulk of CDC’s HIV prevention funding is provided to state and local health departments who tailor their programming to address the most urgent local needs.



UNAIDS warns that after significant reductions, declines in new HIV infections among adults have stalled and are rising in some regions

Video: HIV rates have declined, but not for all populations

Globally, new HIV infections among adults and children were reduced by 40% since the peak in 1997. However, new analysis from UNAIDS shows that new HIV infections among adults have stalled, failing to decline for at least five years. The report outlines what is needed to step up prevention efforts

GENEVA, 12 July 2016—A new report by UNAIDS reveals concerning trends in new HIV infections among adults.

The Prevention gap report shows that while significant progress is being made in stopping new HIV infections among children (new HIV infections have declined by more than 70% among children since 2001 and are continuing to decline), the decline in new HIV infections among adults has stalled. The report shows that HIV prevention urgently needs to be scaled up among this age group.

HIV prevention gap among adults  

The Prevention gap report shows that an estimated 1.9 million adults have become infected with HIV every year for at least the past five years and that new HIV infections among adults are rising in some regions. The Prevention gap report gives the clear message that HIV prevention efforts need to be increased in order to stay on the Fast-Track to ending AIDS by 2030.

  • Eastern Europe and central Asia saw a 57% increase in annual new HIV infections between 2010 and 2015.
  • After years of steady decline, the Caribbean saw an 9% rise in annual new HIV infections among adults between 2010 and 2015.
  • In the Middle East and North Africa, annual new HIV infections increased by 4% between 2010 and 2015. 
  • There have been no significant declines in any other regions of the world.
    • In Latin America the annual number of new adult HIV infections increased by 2% since 2010; New HIV infections declined marginally in western and central Europe and North America and in western and central Africa since 2010; New HIV infections among adults declined by 4% in eastern and southern Africa since 2010, and by 3% in Asia and the Pacific since 2010.

“We are sounding the alarm,” said Michel Sidibé, Executive Director of UNAIDS. “The power of prevention is not being realized. If there is a resurgence in new HIV infections now, the epidemic will become impossible to control. The world needs to take urgent and immediate action to close the prevention gap.”

The AIDS epidemic has had a huge impact over the past 35 years. Since the start of the epidemic, 35 million people have died from AIDS-related illnesses and an estimated 78 million people have become infected with HIV.

Equity and access for key populations

In 2014, key populations, including gay men and other men who have sex with men, sex workers and their clients, transgender people, people who inject drugs and prisoners, accounted for 35% of new HIV infections globally.

It is estimated that men who have sex with men are 24 times more ly to become infected with HIV than the general population, while sex workers are 10 times more ly and people who inject drugs are 24 times more ly to become infected than the general population.

In addition, transgender people are 49 times more ly to be living with HIV and prisoners are five times more ly to be living with HIV than adults in the general population

It is essential for key populations to have access to the full range of HIV prevention options in order to protect themselves and their sexual partners from HIV. “Today, we have multiple prevention options,” said Mr Sidibé. “The issue is access—if people do not feel safe or have the means to access combination HIV prevention services we will not end this epidemic.”

Prevention dividend from HIV treatment still to be realized

The report highlights that the major hopes for antiretroviral therapy to have an impact on preventing new HIV infections are starting to be realized, although the full benefits may not be seen for some years.

The Prevention gap report estimates that over half of all people living with HIV, 57%, now know their HIV status, that 46% of all people living with HIV have access to antiretroviral treatment and that 38% of all people living with HIV have viral suppression, keeping them healthy and preventing onward transmission of the virus.

This underscores the urgent need for the UNAIDS 90–90–90 targets to be met to realize the full potential of antiretroviral therapy. The 90–90–90 targets are 90% of people knowing their HIV status, 90% of people who know their status accessing antiretroviral treatment and 90% of people on treatment having suppressed viral loads.


HIV prevention funding gap

The reports of rising numbers of new HIV infections are coming as data reveal donor funding has declined to its lowest levels since 2010. International donor contributions dropped from a peak of US$ 9.

7 billion in 2013 to US$ 8.1 billion in 2015. Low- and middle-income countries are stepping up to fill the gap, with domestic resources accounting for 57% of the US$ 19.2 billion total funding in 2015.

The report notes that although international funding, the main source of funding for HIV prevention for people at higher risk of HIV, has reduced, some major donors are making bold commitments to ensure that funding reaches the people most affected by HIV. In June 2016, the United States of America announced the launch of a new US$ 100 million Key Populations Investment Fund to increase access to HIV services for key populations.

The current allocation of resources for HIV prevention is falling far short of what is needed. Currently, 20% of global resources for HIV are being spent on HIV prevention. The report indicates that to have maximum impact funding should focus on the location and population approach in order to reach people at higher risk with combination prevention options where they live and work.

Regional HIV prevention gaps

The report details the trajectory of new HIV infections and looks at which populations and which locations are most affected. It also outlines where countries need to make more tailored HIV prevention investments.

In eastern and southern Africa, for example, three quarters of all new HIV infections among adolescents aged 10–19 years are among adolescent girls. Adolescent girls are often prevented from accessing HIV services owing to gender inequality, a lack of age-appropriate HIV services, stigma, a lack of decision-making power and gender-based violence.

In 2014, only 57% of countries globally (of 104 countries reporting) had an HIV strategy that included a specific budget for women. It is estimated that worldwide only three in 10 adolescent girls and young women between the ages of 15 and 24 years have comprehensive and correct knowledge about HIV.

Reaching adolescent girls and young women, especially in sub-Saharan Africa, will be a key factor in ending the AIDS epidemic.

In eastern Europe and central Asia, 51% of new HIV infections occur among people who inject drugs. More than 80% of the region’s new HIV infections in 2015 were in the Russian Federation.

The epidemic is concentrated predominantly among key populations and their sexual partners, in particular people who inject drugs, who accounted for more than half of new HIV infections in 2015.

However there is very low coverage of prevention programmes, in particular harm-reduction interventions among people who inject drugs.

In the Middle East and North Africa, 96% of new HIV infections occur among key populations, predominantly among people who inject drugs, men who have sex with men and female sex workers and their sexual partners. However, prevention programmes for men who have sex with men and sex workers rarely receive support from domestic resources or through public services.

In western and central Europe and North America, around half of all new HIV infections occur among gay men and other men who have sex with men and while a significant proportion of resources are being invested for this key population group, prevention efforts are failing to have an impact. Between 2010 and 2014, new HIV diagnoses among men who have sex with men increased by 17% in western and central Europe, and by 8% in North America.

The report shows the complexity of the AIDS epidemic and how the populations and locations most affected change dramatically across each country and region. It also shows that investments need to be made in effective HIV programmes that are proven to make a significant difference in reducing the number of new HIV infections.

Combination HIV prevention, gaps and opportunities

Compared to 20 years ago when HIV prevention options were limited, there is now a range of options available to suit people’s needs throughout their lives to ensure that they can protect themselves from HIV.

UNAIDS urges countries to take a location and population approach to HIV programming efforts following five prevention pillars, to be delivered comprehensively and in combination:

  • Programmes for young women and adolescent girls and their male partners in high-prevalence locations.
  • Key population services in all countries.
  • Strengthened national condom programmes.
  • Voluntary medical male circumcision in priority countries.
  • PrEP for population groups at higher risk of HIV infection.

Closing the HIV prevention gap

“Science, innovation and research have provided new and effective HIV prevention options, rapid diagnostics and improved treatment for HIV,” said Mr Sidibé. “Investing in innovation is the only way to secure the next big breakthrough—a cure or a vaccine.”   

The data in the report, collected from more than 160 countries, demonstrate that enormous gains can be achieved when concerted efforts are made. It outlines that by 2015 some 17 million people had access to antiretroviral therapy, double the number in 2010 and 22 times the number in 2000.

UNAIDS will be calling on implementers, innovators, communities, scientists, donors and others at the 2016 International AIDS Conference, taking place from 18 to 22 July, in Durban, South Africa, to close the prevention gap. 

Global summary of the AIDS epidemic in 2015 
Number of people living with HIV Total 36.7 million [34.0 million–39.8 million]
Adults 34.9 million [32.4 million–37.9 million]
Women 17.8 million [16.4 million–19.4 million]
Children (


Global HIV and AIDS statistics

Video: HIV rates have declined, but not for all populations

HIV continues to be a major global public health issue. In 2018 an estimated 37.9 million people were living with HIV (including 1.7 million children), with a global HIV prevalence of 0.8% among adults. Around 21% of these same people do not know that they have the virus.1

Since the start of the epidemic, an estimated 74.9 million people have become infected with HIV and 32 million people have died of AIDS-related illnesses. In 2018, 770,000 people died of AIDS-related illnesses. This number has reduced by more than 55%  since the peak of 1.7 million in 2004 and 1.4 million in 2010.2

The vast majority of people living with HIV are located in low- and middle- income countries, with an estimated 68% living in sub-Saharan Africa. Among this group 20.6 million are living in East and Southern Africa which saw 800,000 new HIV infections in 2018.3

While there has been progress towards UNAIDS’ 90-90-90 targets for prevention and treatment, year-on-year reductions this appears to be stalling and at current rates the targets will not be achieved by the 2020 deadline.

The first 90
In 2018, nearly four five people living with HIV (79%) knew their status.

The second 90
Among people who knew their status, four five (78%) were accessing treatment.

The third 90
And among people accessing treatment, four five (86%) were virally suppressed. West and Central Africa, Eastern Europe and Central Asia regions need urgent action if they are to reach the targets.

There is renewed concern that the annual number of new infections among adults has remained static in recent years. In 2018, there were roughly 1.7 million new HIV infections – an insignificant improvement on 2017 (1.8 million).4

In the past eight years, global new HIV infections have declined by just 16%, from 2.1million in 2010. Although this is nearly half the number of new infections compared to the peak in 1997 (2.9 million), the decline is not quick enough to reach the target of fewer than 500,000 by 2020.

While new HIV infections among children globally have also declined, from 280,000 in 2010 to 160,000 in 2018 – a 41% reduction – reports indicate that this is far less progress being made than previously thought and there is much more that needs to be done to improve knowledge of HIV and HIV testing among adolescents and young adults.

In 2018, more than half of new HIV infections globally were among key affected populations and their partners.

Moreover, they accounted for more than 95% of new HIV infections in Eastern Europe and Central Asia; 95% of new HIV infections in Middle East and North Africa; 88% of new HIV infections in Western and central Europe and North America; 78% of new HIV infections in Asia and the Pacific; 65% of new HIV infections in Latin America; 64% of new HIV infections in Western and central Africa; 47% of new HIV infections in the Caribbean and 25% of new HIV infections in eastern and southern Africa.5

Young women are especially at risk, with around 6,200 new infections each week among young people aged 15-24 occurring among this group.6 In sub-Saharan Africa, four in five new infections are among girls aged 15–19 years and young women aged 15–24 years are twice as ly to be living with HIV as men.

More than one third (35%) of women around the world have experienced physical and/or sexual violence at some time in their lives. In some regions, women who experience violence are one and a half times more ly to become infected with HIV. 7

Yet the tide may be slowly changing for women, as new global HIV infections among young women aged 15–24 years were reduced by 25% between 2010 and 2018.8

The reduction in new HIV infections has been strongest in the region most affected by HIV, East and Southern Africa, where new HIV infections have been reduced by 28% since 2010.

However, in 2017 new HIV infections rose in around 50 countries.

In Eastern Europe and Central Asia the annual number of new HIV infections has doubled, and new HIV infections have increased by more than a quarter in the Middle East and North Africa over the past 20 years.9

We are sounding the alarm. Entire regions are falling behind, the huge gains we made for children are not being sustained, women are still most affected and key populations continue to be ignored. All these elements are halting progress and urgently need to be addressed head on.

– Michel Sidibé, Executive Director of UNAIDS

Despite challenges, new global efforts have meant that the number of people receiving HIV treatment has increased dramatically in recent years, particularly in resource-poor countries. In 2018, 62% of all people living with HIV were accessing treatment. Of those, 53% were virally suppressed.

This equates to 23.3 million people living with HIV receiving antiretroviral treatment (ART) in 2018 – up from 7.7 million in 2010. However, this level of treatment scale up is still not enough for the world to meet its global target of 30 million people on treatment by 2020.10

Significant progress has been made in the prevention of mother-to-child transmission of HIV (PMTCT). In 2018, 82% of all pregnant women living with HIV had access to treatment to prevent HIV transmission to their babies – an increase of more than 90% from 2010.11 12

HIV and tuberculosis (TB)

Tuberculosis (TB) remains the leading cause of death among people living with HIV, accounting for around one in three AIDS-related deaths. In 2016, 10.4 million people developed TB; of those 1.2 million were living with HIV.


At the end of 2018, US$ 19billion was available for the AIDS response. This was the first year global resources made available for the AIDS response declined – dropping from 19.9 billion in 2017.

Around 56% of the total resources for HIV in low- and middle-income countries in 2018 were drawn from domestic sources.

UNAIDS estimates that US$ 26.2 billion will be required for the AIDS response in 2020.

While considerable progress has been made, there is a risk that we will lose momentum. If the world is to be on track to end AIDS by 2030, there must be adequate and predictable financing for development. But, for the first time since 2000, the resources available for the AIDS response globally have declined. Ending AIDS is a life-saving investment that pays for itself many times over.

– Gunilla Carlson, Former UNAIDS Interim Executive Director (July, 2019)