The global reduction in HIV transmissions has slowed over the past two years due to crises like the COVID-19 pandemic, economic crunches and the war in Ukraine, according to a new UNAIDS report entitled “In Danger.”

“These data show the global AIDS response in severe danger,” said UNAIDS executive director Winnie Byanyima. “If we are not making rapid progress then we are losing ground, as the pandemic thrives amidst COVID-19, mass displacement, and other crises. Let us remember the millions of preventable deaths we are trying to stop.”

Approximately 1.5 million new cases of occurred last year, over a million beyond UNAIDS targets. Of these, 70% were in key populations like young women and adolescent girls, men who have sex with men, trans women and people who inject drugs. Progress on treatment also lagged: In 2021, fewer people started antiretroviral therapy than any year since 2016.

If these trends continue, the global health community will drastically miss UNAIDS reduction goals. At current rates, UNAIDS estimates 1.2 million new cases annually, more than triple the number that had been anticipated.

This stagnation will continue to result in lost lives. AIDS took a life every minute in 2021, adding up to 650,000 AIDS-related deaths, according to the report. With effective treatment available, these deaths were the preventable result of inaction and lack of access to resources.

But with major changes, global health leaders can still catch up on HIV reduction and treatment goals. The response will require increased access to health services and treatment, community-led programs, fighting stigma, empowering women and girls, education and social protection for people living with HIV, the report says.

Actions taken now to address AIDS will also help with future pandemic preparedness, Byanyima emphasized during a July 27 press conference. COVID-19 and now monkeypox have shown the importance of this.

“We can end AIDS by 2030 as promised,” she said. “But what it takes is courage.”

 

HIV Disparities 

The report reveals major disparities in diagnosis and treatment according to gender, race/ethnicity, region, and economic and education status. And key populations face the brunt of the impact of the inadequate HIV response.

Young women and adolescent girls face a disproportionately burden of HIV: One acquires HIV every two minutes. In sub-Saharan Africa, adolescent girls and young women are three times as likely to acquire HIV as their male peers.

But the news is not all bad. HIV diagnosis and treatment rates were higher for women than for men. While 89% of women living with HIV know their status, this falls to 82% of men. Similarly, 80% of women with HIV are on treatment, compared with 70% of men. And 74% had viral suppression, compared to 65% for men.

Gay men and other men who have sex with men have 28 times the risk of contracting HIV in their lifetimes. For transgender women, the likelihood is 14 times that of the population at large. People who inject drugs face the most heightened risk: 35 times the general population rate. And sex workers are 30 times more likely to acquire HIV in their lifetime. Adequate responses to curb the spread of HIV must especially consider these groups.

While some regions have seen great progress curbing the spread of HIV, others have faltered, and some have even reversed past progress.

HIV transmission rates are increasing in Eastern Europe, Central Asia, Latin America, the Middle East and North Africa. In Asia and the Pacific, with more people than any other region, HIV rates are rising in some places where they have been falling. In contrast, there have been notable declines in new HIV infections in western and central Africa and the Caribbean.

Some countries have done better than others, pointing to differences in public health responses. The spread of HIV has substantially decreased in South Africa, Nigeria, India and Tanzania, while increasing in countries such as the Philippines, Madagascar, Congo and South Sudan.

And even within countries, HIV care and treatment can greatly vary based on economic status. In many countries, the poorest quintile of people living with HIV are the least likely to have reached an undetectable viral load. Two countries in Africa where HIV is endemic, Côte d’Ivoire and Cameroon, have the lowest rates of viral suppression levels among people living with HIV.

Prevention and Treatment 

HIV testing had slowed in some regions, such as eastern and southern Africa, with 2021 test counts falling below those of 2019.

Treatment rollout is also slowing down. The number of individuals who started treatment in 2021 was just 1.47 million more than previous years, compared to increases of over 2 million people in previous years. The report also says that just over half of children living with HIV (52%) had access to treatment.

Globally, the use of pre-exposure prophylaxis (PrEP) remains far below UNAIDS goals. Only eastern and southern Africa, where almost a million people used PrEP at least once in 2021, has made notable progress towards the goals. This region is over halfway to targeted PrEP prescriptions.

For people who inject drugs, methadone and other opioid substitution therapies can lower HIV risk, but only five countries have met goals of providing this treatment: Malaysia, Ireland, Mauritius, Malta and the Seychelles. But besides Malaysia, these countries are relatively small.

Beefing up needle exchange programs and other safe injection practices will also reduce HIV transmission. Right now, 54 countries have these programs, but only 18 have reported coverage that hits safe injecting targets.

Getting Back on Track
Disruptions from crises like the COVID-19 pandemic and, now, the war in Ukraine have sidetracked initiatives against the spread of HIV/AIDS in recent years, reported UNAIDS.

At the same time, international aid for fighting HIV in low- and middle-income countries is less than half of what it was ten years ago. As domestic outlays have declined, the United States and other funders have made up for some of the losses, funding still falls short of projected need.

In 2021, international resources available for HIV were 6% less than in 2010. In low- and middle- income countries, budgets for HIV response are $8 billion short of what’s necessary to reach 2025 reduction targets.

“When international support has been most needed, global solidarity has stalled, said Byanyima. “Leaders must not mistake the huge red warning light for a stop sign. This must become a moment for a surge of international support.”

But not all is lost. It could be possible to reverse trends and even end AIDS by 2030 with a concerted global effort, UNAIDS asserts. Though it will be costly, ending AIDS will be much cheaper in the long run than letting the pandemic continue.

“We cannot afford to lose more ground in the global response to HIV,” said International AIDS Society president Adeeba Kamarulzaman, MBBS. “We urgently need to make more resources available, close research gaps and eliminate the stigma that still pervades thinking. Most crucially, we need to ensure that scientists, policy makers and activists come together to achieve progress. It’s time to re-engage and follow the science.”

Click here to read the full UNAIDS report.