September 24, 2013

The Burden of HIV

AIDS

Insights From the Global Burden of Disease Study 2010

Katrina F. Ortblad, Rafael Lozano, Christopher J.L. Murray

AIDS. 2013;27(13):2003-2017.

Abstract and Introduction

Abstract

Objectives: To evaluate the global and country-level burden of HIV/AIDS relative to 291 other causes of disease burden from 1980 to 2010 using the Global Burden of Disease Study 2010 (GBD 2010) as the vehicle for exploration.

Methods: HIV/AIDS burden estimates were derived elsewhere as a part of GBD 2010, a comprehensive assessment of the magnitude of 291 diseases and injuries from 1990 to 2010 for 187 countries. In GBD 2010, disability-adjusted life years (DALYs) are used as the measurement of disease burden. DALY estimates for HIV/AIDS come from UNAIDS' 2012 prevalence and mortality estimates, GBD 2010 disability weights and mortality estimates derived from quality vital registration data.

Results: Despite recent declines in global HIV/AIDS mortality, HIV/AIDS was still the fifth leading cause of global DALYs in 2010. The distribution of HIV/AIDS burden is not equal across demographics and regions. In 2010, HIV/AIDS was ranked as the leading DALY cause for ages 30–44 years in both sexes and for 21 countries that fall into four distinctive blocks: Eastern and Southern Africa, Central Africa, the Caribbean and Thailand. Although a majority of the DALYs caused by HIV/AIDS are in high-burden countries, 20% of the global HIV/AIDS burden in 2010 was in countries where HIV/AIDS did not make the top 10 leading causes of burden.

Conclusion: In the midst of a global economic recession, tracking the magnitude of the HIV/AIDS epidemic and its importance relative to other diseases and injuries is critical to effectively allocating limited resources and maintaining funding for effective HIV/AIDS interventions and treatments.

Introduction

In the last 30 years, the HIV/AIDS epidemic has emerged as one of the major challenges for the world, going from a relatively small problem in the 1980s to one of the leading causes of mortality and burden over the last decade.[1–3] The global trend is towards a larger and larger share of disease burden coming from noncommunicable diseases and injuries; however, HIV/AIDS is a dramatic exception.[2–4] Mortality and burden from HIV/AIDS increased steadily until around 2004, against the general trend of declining infectious disease burden. The HIV/AIDS epidemic has been truly global with 186 countries reporting HIV cases or deaths in 2012.[5,6]

Substantial concerted global action has emerged around the HIV/AIDS epidemic. New institutions have been formed: UNAIDS in 1996[7] and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) as well as the US President's Emergency Plan for AIDS Relief (PEPFAR) in 2002.[8,9] These new global actors with substantial commitments to HIV/AIDS have been, along with many other nongovernmental programmes, key in raising national policy awareness in many affected countries and in scaling up access to antiretroviral therapies (ARTs).[10,11] In 2011, eight million HIV-positive people received ARTs (a 20-fold increase since 2003), translating into 54% of all eligible people in low and middle-income countries.[5] Expansion of ART coverage is likely to have contributed to the reversal of the global trend in HIV/AIDS mortality. Successful scale-up of ARTs and the progress in reducing HIV/AIDS mortality have sparked excitement in the global community, and ambitious goals have followed.[12] In 2011, UNAIDS released its 'Getting to Zero' campaign with a vision that entails a future generation with 'zero new HIV infections, zero discrimination and zero AIDS-related deaths'.[13,14]

Many factors have contributed to the achievements of the global response to the epidemic; new financial resources are likely to have been critical. Between 2002 and 2010, development assistance for health (DAH) targeted for HIV/AIDS increased from US$1.4 billion to US$6.8 billion (385.7%);[15] and this does not include the substantial funds spent by low- and middle-income countries themselves.[13] Since 2010, however, levels of DAH have stagnated, as the long-run effects of the global financial crisis become apparent in the budgets of high-income countries. Because of the success of ART programmes and the continued evolution of the epidemic, the numbers of individuals who need ARTs will continue to rise steadily.[5] Increasing need for resources for HIV/AIDS programmes in the context of flat-line budgets is also happening in parallel with renewed attention to other health problems such as child mortality, maternal mortality and more recently noncommunicable diseases.[15]

Maintaining and expanding the response to the HIV/AIDS epidemic will require continued emphasis on quantifying the magnitude of the impact of the epidemic in each country. UNAIDS and the WHO provide bi-annual assessments of the epidemic in terms of incidence of new infections, the prevalence of people living with HIV and deaths from HIV/AIDS for the vast majority of countries.[5,16–18] These analyses have been invaluable in garnering policy attention and response. The financial needs of HIV/AIDS programmes during a period of stagnant DAH levels highlight the importance of tracking the HIV/AIDS epidemic in the context of other health problems. At the national level, understanding the importance of the HIV/AIDS epidemic and its trends is facilitated by measuring the burden of disease in units that allow comparison with other major conditions. Comparable metrics of disease burden provide much-needed information on where the epidemic remains one of the dominant causes of health loss and where the burden is still rising despite progress in many countries.[19]

The Global Burden of Disease Study 2010 (GBD 2010)[1–3,20–25] provides a comprehensive coherent view of the magnitude of 291 diseases and injuries from 1990 to 2010 for 187 countries. GBD 2010 uses a consistent set of definitions, approaches to data and methods to quantify health loss from all these diseases and injuries.[21] Multiple metrics are used to compare conditions, including death numbers, age-specific mortality rates, years of life lost due to premature mortality (YLLs), years lived with disability (YLDs) and disability-adjusted life years (DALYs). DALYs are a summation of YLLs and YLDs and serve as an overall metric of disease burden. In this study, we use GBD 2010 to understand the magnitude of the HIV/AIDS epidemic at the national level, in the context of all other major health problems, and how it has been changing over the last two decades.

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