Global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017

Abstract

Background: Understanding the patterns of HIV/AIDS epidemics is crucial to tracking and monitoring the progress of prevention and control efforts in countries. We provide a comprehensive assessment of the levels and trends of HIV/AIDS incidence, prevalence, mortality, and coverage of antiretroviral therapy (ART) for 1980-2017 and forecast these estimates to 2030 for 195 countries and territories.

Methods: We determined a modelling strategy for each country on the basis of the availability and quality of data. For countries and territories with data from population-based seroprevalence surveys or antenatal care clinics, we estimated prevalence and incidence using an open-source version of the Estimation and Projection Package-a natural history model originally developed by the UNAIDS Reference Group on Estimates, Modelling, and Projections. For countries with cause-specific vital registration data, we corrected data for garbage coding (ie, deaths coded to an intermediate, immediate, or poorly defined cause) and HIV misclassification. We developed a process of cohort incidence bias adjustment to use information on survival and deaths recorded in vital registration to back-calculate HIV incidence. For countries without any representative data on HIV, we produced incidence estimates by pulling information from observed bias in the geographical region. We used a re-coded version of the Spectrum model (a cohort component model that uses rates of disease progression and HIV mortality on and off ART) to produce age-sex-specific incidence, prevalence, and mortality, and treatment coverage results for all countries, and forecast these measures to 2030 using Spectrum with inputs that were extended on the basis of past trends in treatment scale-up and new infections.

Findings: Global HIV mortality peaked in 2006 with 1·95 million deaths (95% uncertainty interval 1·87-2·04) and has since decreased to 0·95 million deaths (0·91-1·01) in 2017. New cases of HIV globally peaked in 1999 (3·16 million, 2·79-3·67) and since then have gradually decreased to 1·94 million (1·63-2·29) in 2017. These trends, along with ART scale-up, have globally resulted in increased prevalence, with 36·8 million (34·8-39·2) people living with HIV in 2017. Prevalence of HIV was highest in southern sub-Saharan Africa in 2017, and countries in the region had ART coverage ranging from 65·7% in Lesotho to 85·7% in eSwatini. Our forecasts showed that 54 countries will meet the UNAIDS target of 81% ART coverage by 2020 and 12 countries are on track to meet 90% ART coverage by 2030. Forecasted results estimate that few countries will meet the UNAIDS 2020 and 2030 mortality and incidence targets.

Interpretation: Despite progress in reducing HIV-related mortality over the past decade, slow decreases in incidence, combined with the current context of stagnated funding for related interventions, mean that many countries are not on track to reach the 2020 and 2030 global targets for reduction in incidence and mortality. With a growing population of people living with HIV, it will continue to be a major threat to public health for years to come. The pace of progress needs to be hastened by continuing to expand access to ART and increasing investments in proven HIV prevention initiatives that can be scaled up to have population-level impact.

Funding: Bill & Melinda Gates Foundation, National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

Figure 1

Global HIV incidence, prevalence, mortality, and people on ART, by sex, for all ages, 1980–2017 Shaded areas are 95% uncertainty intervals. ART=antiretroviral therapy.

Figure 2

Percentage of deaths and new cases of HIV occurring in each age group, by sex, 2007 and 2017

Figure 3

Proportion of people living with HIV who are on and off ART in sub-Saharan Africa, 2017, by country and sex Countries are subdivided by total HIV prevalences of 27 to 213 per 1000 population (A), 9 to <27 per 1000 population (B), and 0 to <9 per 1000 population (C). Proportions given in bar charts are for those on ART. ART=antiretroviral therapy.

Figure 4

Age-standardised HIV incidence (A), prevalence (B), and mortality (C) for both sexes, 2017 ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines. Isl=islands. FSM=Federated States of Micronesia. LCA=Saint Lucia. TTO=Trinidad and Tobago. TLS=Timor-Leste.

Figure 4

Age-standardised HIV incidence (A), prevalence (B), and mortality (C) for both sexes, 2017 ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines. Isl=islands. FSM=Federated States of Micronesia. LCA=Saint Lucia. TTO=Trinidad and Tobago. TLS=Timor-Leste.

Figure 5

All-age annualised rate of change of ART coverage between 2007 and 2017, both sexes ART=antiretroviral therapy. ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines. Isl=islands. FSM=Federated States of Micronesia. LCA=Saint Lucia. TTO=Trinidad and Tobago. TLS=Timor-Leste.

Figure 6

Forecast of percentage ART coverage in 2020 and 2030, by country Each datapoint is a country. ART=antiretroviral therapy.

Figure 7

Forecast percentage decrease in HIV mortality (A) and incidence (B) from 2010 to 2020 and 2030, by country Each datapoint is a country. The plots are truncated at 100% increase, so in (A) 47 countries have been excluded and in (B) 35 countries have been excluded.