Background The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic.Methods To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0•03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1•0). FindingsIn 2019, there were 36•8 million (95% uncertainty interval [UI] 35•1-38•9) people living with HIV worldwide. There were 0•84 males (95% UI 0•78-0•91) per female living with HIV in 2019, 0•99 male infections (0•91-1•10) for every female infection, and 1•02 male deaths (0•95-1•10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28•52% decrease in incident cases, 95% UI 19•58-35•43, and a 39•66% decrease in deaths, 36•49-42•36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0•05 (95% UI 0•05-0•06) and the global incidence-to-mortality ratio was 1•94 (1•76-2•12). No regions met suggested thresholds for progress.Interpretation Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics.
Study Aims. Evaluate the quality and effectiveness of the medication-assisted therapy (MAT) pilot in Kazakhstan and review implementation context and related challenges. Methods. We performed a desk review of MAT policy and program documents and reviewed medical records at three MAT sites in Kazakhstan. MAT patients (n = 93) were interviewed to assess their perceptions of the program and its impact on their health, criminal, drug use, and HIV risk related behaviors as well as expenditures on nonprescribed psychoactive drugs. Persons injecting drugs who are not in treatment, MAT program staff, and other stakeholders were interviewed to obtain their perspectives on MAT. Results. Legislation supports introducing MAT as a standard of care for treatment of opioid dependence; however, its progress has been hampered by active opposition. Inadequate access and coverage, insufficient supply management, scarce infrastructure of narcological facilities, limited opportunities for staff development, and restrictive methadone dispensing policies compromise the quality of the intervention and limit its potential benefits. There were significant reductions in criminal, drug use, and HIV risk related behaviors in patients receiving MAT. Conclusions. The MAT pilot in Kazakhstan demonstrated its feasibility and effectiveness in the local context and is recommended for scaleup throughout the country.
Objective Disparities in HIV infection, with females having higher rates of HIV infection than males, have been noted among persons who inject drugs (PWID) in many countries. We examined male/female HIV disparities among PWID in Central Asia and compared these disparities with patterns worldwide. Methods A systematic review and meta-analyses were conducted for studies reporting HIV prevalence by gender among PWID. To be included in the analyses, reports had to contain 1) samples of PWID from Central Asian, 2) HIV data based on laboratory testing, 3) HIV prevalence reported for males and females, and 4) samples that were not recruited on the basis of HIV status. Results Data were abstracted from 11 studies in 5 countries in Central Asia: China, Kazakhstan, Russia, Tajikistan, and Uzbekistan; the total sample size was 12,225. The mean weighted OR for HIV prevalence among females to males was 0.913 (95% CI 0.07, 1.26), with high heterogeneity among studies (I2 = 70.0%) and a possible publication bias among studies with small sample sizes (Eggers test = -1.81, 95% CI -5.18, 0.54). Conclusions The non-significant higher HIV prevalence among male PWID in Central Asia contrasts with the worldwide findings which show slightly higher HIV prevalence among female PWID. This may reflect the relative recency of the HIV epidemics in Central Asia. The findings also suggest that there may be factors that protect female PWID from HIV in some settings. Further examination of transmission dynamics in Central Asia is necessary to better understand the HIV epidemic among PWID.
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