A new report by UNAIDS shows that 19 million of the 35 million people living with HIV globally do not know their HIV-positive status.
"Whether you live or die should not depend on access to an HIV test," said Michel Sidibé, Executive Director of UNAIDS. "Smarter scale-up is needed to close the gap between people who know their HIV status and people who don't, people who can get services and people who can't and people who are protected and people who are punished."
The UNAIDS Gap report shows that as people find out their HIV-positive status they will seek life-saving treatment. In sub-Saharan Africa, almost 90% of people who tested positive for HIV went on to access antiretroviral therapy (ART). Research shows that in sub-Saharan Africa, 76% of people on ART have achieved viral suppression, whereby they are unlikely to transmit the virus to their sexual partners New data analysis demonstrates that for every 10% increase in treatment coverage there is a 1% decline in the percentage of new infections among people living with HIV.
The report highlights that efforts to increase access to ART are working. In 2013, an additional 2.3 million people gained access to the life-saving medicines. This brings the global number of people accessing ART to nearly 13 million by the end of 2013. Based on past scale-up, UNAIDS projects that as of July 2014 as many as 13 950 296 people were accessing ART.
"If we accelerate all HIV scale-up by 2020, we will be on track to end the epidemic by 2030," said Mr Sidibé. "If not, we risk significantly increasing the time it would take - adding a decade, if not more."
By ending the epidemic by 2030, the world would avert 18 million new HIV infections and 11.2 million AIDS-related deaths between 2013 and 2030.
Ending the AIDS epidemic
The report reveals that just 15 countries* account for more than 75% of the 2.1 million new HIV infections that occurred in 2013. In every region of the world the report finds that there are three or four countries that bear the burden of the epidemic. In sub-Saharan Africa, just three countries - Nigeria, South Africa and Uganda - account for 48% of all new HIV infections.
However, the report also shows that entire countries are being left behind - for example, six nations - Central African Republic, Democratic Republic of the Congo, Indonesia, Nigeria, Russian Federation and South Sudan - are facing the triple threat of high HIV burden, low treatment coverage and no or little decline in new HIV infections.
In the first report of its kind, the UNAIDS Gap report emphasizes the importance of location and population through an in-depth regional analysis of HIV epidemics and through analysis of 12 populations at higher risk of HIV. It analyses the reasons for the widening gap between people gaining access to HIV prevention, treatment, care and support, and people being left behind. It shows how focusing on populations that are underserved and at higher risk of HIV will be key to ending the AIDS epidemic.
HIV prevalence is estimated to be 28 times higher among people who inject drugs, 12 times higher among sex workers and up to 49 times higher among transgender women than among the rest of the adult population. In sub-Saharan Africa, adolescent girls and young women account for one in four new HIV infections. The report looks at why certain populations are not accessing HIV services and outlines the urgent need to address their specific needs.
"There will be no ending AIDS without putting people first, without ensuring that people living with and affected by the epidemic are part of a new movement," said Mr Sidibé. "Without a people-centred approach, we will not go far in the post-2015 era."
The report shows that it is both essential and possible to go deeper than a country-wide approach. Because countries and regions have multiple and varying epidemics, the report outlines that having country targets and sound policies in place creates space to address complex micro-epidemics with tailored, bite-sized solutions that will help reach people faster with better HIV services. It notes that cities and communities will play an increasingly major role in effective scale-up.
However, the report also shows that a lack of data on people most affected by HIV, coupled with widespread stigma and discrimination, punitive legal environments, barriers to civil society engagement and lack of investment in tailored programmes are holding back results. It confirms that countries that ignore discrimination and condone inequalities will not reach their full potential, and face serious public health and financial consequences of inaction. The report emphasizes the need for equal access to quality HIV services as both a human rights and public health imperative.
Hope and gaps
UNAIDS is reporting the lowest levels of new HIV infections this century, at 2.1 million [1.9 million-2.4 million]. In the last three years alone new HIV infections have fallen by 13%.
It is estimated that 35 million people were living with HIV in the world at the end of 2013. AIDS-related deaths are at their lowest since the peak in 2005, having declined by 35%. Tuberculosis continues to be the leading cause of death among people living with HIV.
New HIV infections among children have fallen by 58% since 2001 and dropped below 200 000 for the first time in the 21 most affected countries in Africa.
The highest number of people living with HIV was in sub-Saharan Africa - 24.7 million [23.5 million - 26.1 million] people. Asia and the Pacific had the next largest population of people living with HIV, at an estimated 4.8 million [4.1 million-5.5 million] people.
The percentage of people living with HIV who were receiving treatment was found to be highest in western Europe and North America, at 51% [39-60%], and in Latin America, at 45% [33-51%]. However, coverage was lowest in the Middle East and North Africa, at just 11% [8-16%].
New HIV infections declined most in the Caribbean - by 40% since 2005; however, new HIV infections have risen by 8% in western Europe and North America, by 7% in the Middle East and North Africa and by 5% in eastern Europe and central Asia since 2005.
AIDS-related deaths were seen to be rising steeply in the Middle East and North Africa, by 66%. The only other region where AIDS-related deaths are increasing is eastern Europe and central Asia, where AIDS-related deaths rose by 5% between 2005 and 2013.
The report outlines that to close the gap between people who are reached with HIV services and people who are not will require research and innovation combined with protective laws that promote freedom and equality for all people. It will also require increased commitment from the global community and countries most affected to the remarkable returns on investment that have been witnessed over the last 10 years to continue so that the end of the AIDS epidemic can be achieved by 2030.
In 2013, an estimated:
- 35 million [33.2 million-37.2 million] people globally were living with HIV
- 2.1 million [1.9 million-2.4 million] people became newly infected with HIV
- 1.5 million [1.4 million-1.7 million] people died from AIDS-related illnesses