Global HIV Goals Suffer Major Setbacks During COVID-19

Although we have seen a lot of progress in HIV/AIDS over the past two decades, this year's update from the Joint United Nations Programme on HIV/AIDS (UNAIDS) struck a dismal tone. The update, released on July 27, 2022, was appropriately titled "In Danger" because of the setbacks in the HIV response that occurred during COVID-19.

The major data in this report are summarized below.

Overall, the number of people living with HIV in the world has increased to 38.4 million (range, 33.9-43.8 million), which is the highest number of people ever living with HIV recorded. Of those 38.4 million, 36.7 million are adults and 1.7 million are children (0-14 years); 54% are women and girls; and 85% know their HIV status. One of the most striking statistics is that approximately 1.5 million (1.1 million–2.0 million) new HIV infections occurred last year in 2021 — more than 1 million more than previously established UNAIDS global targets.

In terms of treatment and mortality, 650,000 (510,000-860,000) people died from AIDS-related illnesses in 2021. And only 28.7 million people out of the 38.4 million infected (75%) were accessing antiretroviral therapy (ART) in 2021, leaving 25% tragically without access. Moreover, there were disparities in that access: 76% of adults aged 15 years or older living with HIV had access to treatment, while only 52% of children aged 0-14 years had access. In terms of the sex breakdown, 80% of female adults aged 15 years or older had access to treatment (a percentage that is usually higher than for men because women access perinatal care). Among pregnant women with HIV, 81% (63%-97%) had access to ART to prevent transmission of HIV to their child in 2021. And finally, just 70% of male adults aged 15 years or older had access to life-saving ART.

In terms of the overall impact of HIV/AIDS, 84.2 million (64.0 million-113.0 million) people have become infected with HIV since the start of the epidemic and 40.1 million (33.6 million-48.6 million) people have died from AIDS-related illnesses. This has a staggering impact on the planet, and we have to work harder.

In terms of key populations, defined as sex workers and their clients, gay men and other men who have sex with men, people who inject drugs, and transgender people and their sexual partners, 70% of new HIV infections occur in these populations globally (94% of new infections outside of sub-Saharan Africa compared with 51% of new HIV infections inside sub-Saharan Africa).

The risk of acquiring HIV is:

35 times higher among people who inject drugs than among adults who do not inject drugs
30 times higher for female sex workers than for adult women
28 times higher among gay men and other men who have sex with men than among adult men
14 times higher for transgender women than for adult women

The statistics are very dramatic for young women. Every week in 2021, around 4900 young women aged 15-24 years became infected with HIV (that is a new infection every 2 minutes). In fact, in sub-Saharan Africa, 6 in 7 new HIV infections among adolescents aged 15-19 years are among girls. Girls and young women aged 15-24 years are twice as likely to be living with HIV than are young men.

The setbacks to the HIV response during the COVID-19 pandemic have been enormous, with the pandemic leading to disruptions to key HIV treatment and prevention services, millions of girls out of school, and spikes in teenage pregnancies and gender-based violence. Low- and middle-income countries became more economically distressed during the COVID-19 pandemic, with 60% of the world's poorest countries being either in debt or in high risk of it; an estimated 75-95 million people have been pushed into poverty, an increase during COVID without precedent. While new HIV infections did fall globally last year, the drop was only 3.6% compared with in 2020 — the smallest annual reduction since 2016.

Eastern Europe, central Asia, the Middle East, North Africa, and Latin America have all seen increases in annual HIV infections over the past decade. In Asia and the Pacific, the world's most populous region, UNAIDS data now show that new HIV infections are rising where they had been falling over the past 10 years. Malaysia and the Philippines are among the countries with rising epidemics among key populations, particularly in key locations.

There have been declines in annual HIV infections in the Caribbean and western and central Africa, the latter driven largely by improvements in Nigeria. These decreases in infections represent accelerating progress. In global figures, however, this progress is being drowned out by a lack of progress in other regions: HIV infections have now increased since 2015 in 38 countries globally.

Over the past 2 years, the AIDS response has faced serious pressure while communities that were already at greater risk for HIV are now even more vulnerable. The AIDS pandemic took a life every minute in 2021, with 650,000 AIDS-related deaths despite effective HIV treatment and the tools to prevent. The number of people on HIV treatment grew more slowly in 2021 than it has in over a decade, with the gap in HIV treatment coverage between children and adults increasing rather than narrowing.

So, not to leave you on such a depressing note, the executive summary of the UNAIDS reports ends with these powerful words:

What we need to do is not a mystery. We know it from what we've repeatedly seen succeed across different contexts: shared science, strong services and social solidarity. We can... end the AIDS pandemic by ending the inequalities that perpetuate it. We can end AIDS by 2030. But the curve will not bend itself. We have to pull it down.

Let's apply ourselves to reversing these setbacks suffered during the pandemic to the goals of ending the HIV epidemic.

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About Dr Monica Gandhi

Monica Gandhi, MD, MPH, is an infectious diseases doctor, professor of medicine, and associate chief in the Division of HIV, Infectious Diseases, and Global Medicine at the University of California, San Francisco (UCSF). She is also director of the UCSF Center for AIDS Research (CFAR) and medical director of the HIV Clinic ("Ward 86") at San Francisco General Hospital. Her research focuses on HIV and women; adherence measurement in HIV treatment and prevention; and, most recently, on how to mitigate the COVID-19 pandemic.

Connect with her on Twitter: @MonicaGandhi9

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