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More Than 60% of New HIV and HIV Deaths Now in "Low-Prevalence" Countries
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CROI 2024 (Conference on Retroviruses and Opportunistic Infections), March 3-6, 2024, Denver
Mark Mascolini
More than 60% of new HIV infections and HIV-related deaths now occur in low-prevalence countries outside Southern and East Africa, according to a global analysis by Toby Pepperrell (University of Edinburgh) and colleagues [1]. Antiretroviral use proved lower in lower- than higher-prevalence countries, and PrEP uptake everywhere greatly lags the level needed to stem the epidemic.
The 1.3 million new HIV infections reported worldwide in 2022 dim hopes of reaching the UNAIDS target of 370,000 new infections by 2025, Pepperrell and coworkers observed. They pointed out that the lion's share of international funding for HIV prevention and treatment goes to countries in Southern and East Africa, yet countries in West Africa, South America, and Asia clearly have daunting HIV epidemics.
To get an idea of where the HIV epidemic is growing fastest-and how many at-risk people use PrEP to avoid HIV infection-these investigators scoured data in the UNAIDS AIDSINFO 2022 database, which analyzes country-level HIV data, supplemented by PUBMED and EMBASE searches and national reports. They divided countries with more than 40,000 HIV cases into higher-prevalence (above 3.5%) and lower-prevalence (under 3.5%) countries.
In 2022 the 14 higher-prevalence countries counted 19,462,000 people with HIV, compared with 17,459,000 in 54 lower-prevalence countries (53% vs 47% of the epidemic). But new HIV infections numbered 468,400 in higher-prevalence countries and 770,703 in lower-prevalence countries (higher-to-lower ratio 0.61), and mortality proved lower in higher-prevalence countries (225,100 vs 383,190, ratio 0.59). The researchers figured annual epidemic growth (new HIV infections/total epidemic size) at 2.4% in higher-prevalence countries and 4.4% in the lower-prevalence set.
Three antiretroviral factors that could contribute to these differences are 1.21-fold higher antiretroviral therapy (ART) coverage in higher-prevalence countries (82% vs 67%), 1.13-fold more PrEP starts in higher-prevalence countries (1,323,493 vs 1,174,539), and lower vertical transmission rates in the higher-prevalence group (9% vs 16%, higher-to-lower ratio 0.56). Pepperrell and colleagues pointed out that total PrEP use greatly lags the 74 million persons cited as the target to optimize HIV prevention.
Despite higher HIV prevalence in high-prevalence countries concentrated in Southern and Eastern Africa, coauthor Andrew Hill (University of Liverpool) told NATAP that most new HIV infections and deaths now occur in South America, Southeast Asia, and Central Europe, where proportionately fewer people have access to ART and PrEP. Antiretroviral prices remain high, he added, in several middle-income countries with still-burgeoning epidemics. "Brazil is a key example," Hill said, with "the same GDP as South Africa but no access to key drugs at low cost through voluntary licenses." Pepperrell and colleagues stressed that ART and PrEP-including long-acting lenacapavir and cabotegravir plus rilpivirine-must be affordable everywhere.
Reference
1. Pepperrell T, Cross S, Hill A. 62% of new HIV infections and 63% of deaths now reported in countries outside Southern/East Africa. CROI 2024 (Conference on Retroviruses and Opportunistic Infections), March 3-6, 2024, Denver. Abstract 1033.
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