On the eve of 30 years of the HIV epidemic, UNAIDS has released a report entitled ‘AIDS at 30: Nations at the crossroads’.
This report provides evidence of how much we have achieved and weighs that against the vision of zero new HIV infections, zero discrimination and zero AIDS‑related deaths. It includes scientific analysis, personal insights and the results of extensive national and regional consultations at the front lines of the AIDS response.
Key Global Findings (pdf)
AIDS: The first two decades (1981 – 2000)
- In the first two decades of the AIDS epidemic, the global community failed—as a whole—to act. From 1981-2000 the number of people living with HIV increased from 1 million to 27.5 million [25.9 million–29.1 million].
- Results of governmental inaction became most visible in southern Africa:
- In 1990, less than 1% of adults in South Africa were living with HIV. A decade later, adult HIV prevalence was 16.1%.
- Between 1990 and 2000, adult HIV prevalence rose from 1% to 24.5% in Lesotho and from 3.5% to 26% in Botswana.
- From the epidemic’s earliest years, people living with and affected by HIV responded where governments failed.
- The Denver Principles, drafted in 1983 by people living with AIDS, insisted on respect for the rights of people living with HIV to self-determination, freedom from discrimination and active participation in decision-making.
- At the Paris AIDS Summit in 1994, 42 nations formally recognized the principle of Greater Involvement of People living with HIV.
- Several governments took early action, such as Uganda, Brazil, Thailand and Senegal, implementing AIDS policies and programmes that collectively averted millions of new HIV infections.
- Scientific knowledge expanded steadily, from the discovery of HIV in 1983 to the first serologic test in 1985 and proof in the 1990s that vertical transmission could be prevented.
- In 1996, a new class of antiretroviral drugs—protease inhibitors—gained regulatory approval. Combination antiretroviral therapy proved powerfully effective, lowering rates of AIDS deaths by two-thirds or more in many high-income countries.
- Between 1996 and 2000, combination antiretroviral therapy was largely unavailable in low- and middle-income countries due to its high cost. One notable exception was Brazil, which in 1996 became the first middle-income country to adopt a national policy of free antiretroviral therapy through its public sector.
- During the first two decades of AIDS, the condom—the most basic HIV prevention tool—was largely unavailable in countries where the epidemic was expanding most rapidly.
- Since the early years of the epidemic, stigma and discrimination against people living with HIV have blocked effective HIV responses by countries and communities. In many countries, laws and policies institutionalize discriminatory attitudes and practices.
- In 1996, UNAIDS was established through a pioneering collaboration within the UN system, helping galvanize global action among governments, donors, multilateral institutions and civil society.
AIDS: The third decade (2000 – 2010)
Global milestones and commitments
- In January 2000, the UN Security Council broke new ground when it held a special session on HIV—the first for any health issue—and recognized AIDS as a threat to global security.
- At the 2000 International AIDS Conference in Durban, delegates called for concerted global action to bring HIV treatment and prevention tools to resource-limited settings.
- At a 2001 UN General Assembly Special Session on HIV/AIDS, Member States established global goals for the HIV response. The goals were unanimously endorsed by 189 countries.
- At the 2006 High Level Meeting on HIV/AIDS, UN Member States embraced the goal of universal access to HIV prevention, treatment, care and support. Global leaders agreed that no one would be left behind in the response to HIV.
- Between 2006 and 2010, the percentage of countries submitting progress reports on global HIV commitments increased from 64% to 94%.
- In 2010, 94% of countries (162 of 172 countries reporting) had national HIV strategic plans, up from 87% in 2006.
Investment and accountability
- Between 2001 and 2009, investments in the HIV response in low- and middle-income countries rose nearly 10-fold, from US $1.6 billion to US $ 15.9 billion.
- In 2010, international AIDS resources declined for the first time in a decade. Financial challenges in many countries have put downward pressure on funding sources.
- A 2011 investment framework proposed by UNAIDS and partners found that a more focused annual investment of at least US$ 22 billion is needed by the year 2015, US$ 6 billion more than is available today.
- The estimated return on this investment: 12 million more HIV infections averted and 7.4 million more deaths averted by the year 2020.
- Many low-income countries remain heavily dependant on external financing: In 56 countries, international donors supply at least 70% of HIV resources.
- According to the UNAIDS Domestic Investment Priority Index, a formula that accounts for total HIV burden and government resources, eight of 14 countries in West and Central Africa, six of 16 countries in Eastern and Southern Africa and all but four countries in Asia allocated inadequate resources to HIV in 2009.
- The ‘3 by 5’ campaign, launched by UNAIDS and WHO in 2003, accelerated global momentum for expanded treatment access. The campaign aimed to deliver antiretroviral therapy to 3 million people by the year 2005.
- Seven countries had reached at least 80% of treatment-eligible people with antiretroviral therapy as of December 2009: Botswana, Cambodia, Cuba, Guyana, Oman, Romania and Rwanda. Eighteen countries reported treatment coverage of at least 60%.
- As of December 2010, an estimated 6.6 million people in low- and middle-income countries were receiving antiretroviral therapy, an increase of 1.4 million from the previous year and a nearly 22-fold increase since 2001.
- Despite dramatic gains in treatment access, nine million people who were eligible for treatment were not receiving it as of December 2010.
- An estimated 420 000 – 460 000 children were receiving antiretroviral therapy at the end of 2010. Treatment coverage for children (28%) was lower than for people of all ages (36%) in 2009.
- Treatment adherence remains a challenge: In 2009, nearly one in five people (18%) who started antiretroviral therapy in low- and middle-income countries were no longer on treatment 12 months later.
- More than 95% of patients on treatment are taking first-generation antiretroviral medicines. As drug resistance increases over time, more patients will require second- and third-line medicines, which may have major cost implications.
HIV prevention and safer sex
- Between 2001 and 2009, global HIV incidence steadily declined, with the annual rate of new HIV infections falling by nearly 25%. HIV incidence varied widely between regions.
- According to the most recent population-based surveys in low- and middle-income countries, only 24% of young women and 36% of young men responded correctly when asked five questions on HIV prevention and misconceptions around HIV transmission.
- HIV testing rates vary widely between countries. According to recent demographic and health surveys, the percentage of adults tested for HIV within the last 12 months ranged from less than 5% of women and men in Bolivia and the Philippines to more than 42% of women in Lesotho.
- According to recent demographic and health surveys, an estimated 74% of young men know that condoms help prevent HIV infection, compared to 49% of young women.
- Globally, rates of condom use remain low. In 14 countries with high HIV prevalence, more than 70% of men and women practicing high-risk sex (defined as sexual intercourse with more than one partner over a 12-month period) reported that they did not use a condom the last time they had sex.
Preventing new HIV infections among children
- The results of two studies, released in 1999, showed that the risk of HIV transmission from mother to child could be significantly reduced by providing pregnant women with zidovudine or a single dose of nevirapine.
- By 2005, only 15% of HIV-positive pregnant women in low- and middle-income countries were receiving antiretroviral prophylaxis to prevent new HIV infections in their children.
- Since 2005, there has been rapid progress in the scale-up of services to prevent new HIV infections among children: global coverage reached 53% in 2009.
- Over time, as scientific knowledge expanded, drug regimens prescribed for HIV-positive pregnant women have changed. While a single dose of nevirapine reduces the risk of HIV transmission by 50%, combination regimens are capable of reducing transmission by more than 90%. Consequently, single-dose nevirapine is no longer recommended as the main option to prevent new HIV infections among children.
- Gains in reducing new HIV infections among children have helped reduce the rate of childhood mortality: The number of children newly infected with HIV in 2009 was 26% lower than in 2001.
- Beginning in 2005, a series of randomized controlled trials in sub-Saharan Africa found that circumcising adult men reduced the risk female-to-male sexual transmission of HIV by about 60%.
- Following the 2007 release of WHO and UNAIDS guidelines, 13 countries in Africa planned strategies to introduce medical male circumcision.
- In 2009, just over 100 000 men were circumcised in eight priority countries; more than 350 000 men in these same countries were circumcised in 2010.
Women and girls
- HIV is leading cause of death among women of reproductive age.
- The number of girls aged 10-14 living with HIV grew from about 50 000 in 1999 to more than 300 000 in 2010.
- Young women aged 15-24 account for 26% of all new HIV infections globally.
- In Southern Africa, young women are up to five times more likely to become infected with HIV than young men.
- More than 60 countries have started implementing the UNAIDS Agenda for Women and Girls, engaging over 400 civil society organizations.
Men who have sex with men
- In 2009, 63 out of 67 countries reported a higher HIV prevalence among men who sex with men compared to the general population.
- Despite high HIV prevalence among men who have sex with men, most countries lack data on basic HIV prevention services for this population.
People who inject drugs
- An estimated 20% of the estimated 15.9 million injecting drug users worldwide are living with HIV.
- In at least 69 countries where injecting drug use has been documented, there are no programmes in place to provide even sterile needles and syringes.
- In 77 countries where injecting drug use has been documented, opioid substitution therapy is illegal or not available.
- Although sex workers have been at higher risk of HIV infection since the early stages of the epidemic, the reach of HIV prevention programmes for this population remains inadequate.
- Where programmes are implemented with appropriate quality and scale, they appear to be having an impact: Among 56 countries reporting in 2008 and 2010, median condom use among sex workers with the most recent client reached 84%.
Punitive laws and practices
- In many parts of the world, discrimination against people living with HIV is institutionalized in national legal or policy frameworks:
- More than 56 countries have laws that specifically criminalize HIV transmission or exposure.
- 47 countries, territories or areas impose some form of restriction on the entry, stay and residence of people living with HIV.
- 116 countries, territories and areas criminalize some aspect of sex work.
- 79 countries, territories and areas criminalize consensual same-sex relations
- 32 countries have laws that allow for the death penalty for drug-related offences.
- Between 2006 and 2010, the proportion of countries reporting programmes to address stigma and discrimination increased from 39% to 92%. However, less than half of these countries had allocated a budget for these programmes.
AIDS plus MDGs
The HIV response is intimately linked with progress towards all Millennium Development Goals, especially goals 4, 5 and 6. Service integration is vital to progress in HIV, maternal and child mortality and tuberculosis.
Maternal and child mortality
- HIV is a leading cause of pregnancy-related death, accounting for an estimated 11% of maternal deaths in 2008.
- Without treatment, HIV-positive newborns have about a 50% risk of death before the age of two.
- Recent gains in the HIV response are contributing to global efforts to reduce mortality in children under five: In 2009, HIV accounted for 2.1% of under-five deaths in low-and middle-income countries, a decline from 2.6% in the year 2000.
- Tuberculosis (TB) is the most common cause of death among people living with HIV.
- Globally, an estimated 28% of TB patients knew their HIV status in 2009, and just 5% of people living with HIV were screened for TB.
- Though early initiation of antiretroviral treatment significantly reduces the risk death among HIV-positive people living with TB, only 37% of people co-infected with HIV and TB received HIV treatment in 2009.
- Better results were reported for cotrimoxazole prophlyaxis: 75% of HIV-positive people with TB received this drug regimen that reduces the risk of death by 40%.
- Universal access to effective prevention, diagnosis and treatment for HIV-related tuberculosis could prevent up to one million TB deaths in people living with HIV between now and 2015. However, the world is falling far short of this target.