Introduction
The Joint United Nations Programme on human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) (UNAIDS) “90–90–90” strategy has called for 90% of HIV-infected individuals knowing their HIV status, 90% of diagnosed people living with HIV receiving antiretroviral therapy (ART), and 90% of individuals on treatment being virally suppressed by 2020.[1] [2] [2]
Since the Chinese National Free Antiretroviral Therapy Program and other comprehensive HIV response efforts by the Chinese Government have been scaled up in China, the national prevalence of HIV/AIDS in China has stabilized, and the incidence has declined.[3,4] [5,6] prevalence , and mortality trends of HIV nationally need to be described, over an extended period. Previously, several studies have described elemental characteristics of the HIV epidemic in China over the long term.[7–9] [4] [10]
A more comprehensive understanding of the trends of incidence, prevalence , and mortality, and their complex interrelationships, may provide policymakers, sponsors, and medical practitioners with important evidence for decision-making related to HIV prevention and control. To comprehensively assess the burden of disease in populations with different characteristics, the mortality-to-prevalence ratio (MPR) could be an alternative index to utilize for statistical purposes, as it presents mortality data after accounting for prevalence . Moreover, MPR reflects deaths resulting from diseases that the health system ought to cure or prevent.[11] [12] et al [13] prevalence for coronavirus disease 2019 (COVID-19), and have presented these data as MPR figures to accurately assess the proportion of individuals with undocumented severe acute respiratory syndrome coronavirus 2 infection. Herein, we attempt to use the MPR index as a useful indicator to reflect the changes in HIV/AIDS burden associated with the scale-up of HIV screening, the expansion of ART, and the upgrade to modern antiretroviral drugs in recent decades. In the present study, we describe the trends of HIV/AIDS incidence, prevalence , mortality, and MPR over the past three decades globally and in China. Furthermore, we have analyzed the differences in these indices in the context of different gender and age groups in order to extricate and decipher the varying patterns of the HIV/AIDS pandemic in specific populations.
Methods
Data source
A secondary analysis of existing data was conducted using data extracted from the Global Burden of Disease (GBD) study of 2019, which was conducted by the Institute for Health Metrics and Evaluation (IHME). GBD 2019 systematically, scientifically, and comprehensively estimated 286 causes of death, 369 diseases and injuries, and 87 risk factors in 204 countries and regions based on age, sex, and geography over time.[14] prevalence data obtained from antenatal care clinics or serum antibody surveys of representative populations (ie, 48 countries in total, including several in sub-Saharan Africa, and the Dominican Republic, Haiti, India, Papua New Guinea, and Sudan). Group 2 includes the remaining 156 countries, with HIV mortality data gradually becoming available for most countries except 33 that do not have it. These groups are further divided according to the peak prevalence with or without registered data integrity.[14] [14] http://www.healthdata.org/gbd/2019
In the present work, the burden of disease indices extracted from the GBD statistics comprised HIV/AIDS incidence, prevalence , and mortality rates in groups stratified by different genders and ages (0–14, 15–49, 50–69, and ≥70 years). A further outcome, that is, MPR, was calculated by dividing the HIV/AIDS mortality (estimated number of deaths) by the corresponding prevalence (estimated number of infections) during the same period.
Data analysis
HIV/AIDS incidence, prevalence , and AIDS-related mortality globally and in China are presented per 100,000 persons and 95% confidence intervals (CIs). MPR are presented as a number and 95% CIs. All of the above rates or ratio are described by gender and age group.
Next, joinpoint regression was used to visualize the change points of indices of HIV burden and to evaluate whether there were significant changes in the observed trend at particular points. HIV/AIDS incidence, AIDS-related mortality, and MPR for annual percentage change (APC), average annual percentage change (AAPC), and corresponding 95% CIs were calculated. All analyses were conducted using the Joinpoint Regression Program (v.4.9.0.1, National Cancer Institute, Bethesda, MD, USA; surveillance.cancer.gov/joinpoint/). Within Joinpoint regression software, we used the Grid Search Method, and selected a model where errors are assumed to have constant variance (homoscedasticity). Joinpoint regression utilized several permutation tests to perform joinpoint regression, and the Monte Carlo permutation method was used for tests of significance.[15] P values <0.05 were considered statistically significant.
Results
Incidence, prevalence , mortality rate, and MPR comparison with respect to HIV/AIDS globally and in China, 1990–2019
Globally, the temporal trend was an initial increase, and then a subsequent decline of incidence and mortality rates of HIV/AIDS from 1990 to 2019; the peak of the incidence rate and mortality rate was 56.0 (95% CI: 67.2, 47.5) in 1996 and 28.5 (95% CI: 22.3, 35.2) in 2004 per 100,000, respectively. The global AAPC of HIV/AIDS incidence and AIDS-related mortality rates were –1.4 (95% CI: –1.6, –1.2) and 2.0 (95% CI: 1.7, 2.3) between 1990 and 2019, respectively [Figure 1 A]. The global HIV/AIDS prevalence rate increased between 1990 and 2019, and the peak value was observed to be 476.2 (95% CI: 454.3, 502.2) per 100,000 in 2019. Accordingly, the global MPR also rose and subsequently declined, and the peak value was observed to be 0.07 in 2004 [Figure 1 C]. In addition, the global AAPC of prevalence rate was 4.1 (95% CI: 4.0, 4.3) and the global AAPC of MPR was –2.1 (95% CI: –2.3, –1.8).
Figure 1: Temporal trends in HIV/AIDS incidence, prevalence , and mortality rate per 100,000 persons (A) globally and (B) in China, 1990 to 2019. (C) MPR was calculated both globally and in China. AIDS: acquired immune deficiency syndrome; HIV: Human immunodeficiency virus; MPR: Mortality-to-prevalence ratio.
The incidence rate of HIV/AIDS in China initially rose and then subsequently decreased, and the peak value was seen to be 4.8 (95% CI: 3.2, 6.9) per 100,000 in 2005 [Figure 1 B]. In contrast to the global trend, the mortality rate in China can be seen to plot an increasing trend as a whole, and the peak value was 2.2 (95% CI: 1.9, 2.5) per 100,000 persons in 2018 [Figure 1 B]. Additionally, the AAPC of incidence rate was 3.5 (95% CI: 2.2, 4.8) and the AAPC of mortality rate was 8.1 (95% CI: 7.1, 9.1) in China. The prevalence rate in China initially increased; however, a slight decreasing trend of prevalence rate was observed from its peak (41.9 per 100,000 persons) in 2014. The HIV/AIDS MPR for China initially increased, subsequently decreased, and then has risen again in the three decades between 1990 and 2019; the peak value of the MPR index in China was 0.06 in 2019 [Figure 1 C]. Thus, the AAPC of prevalence rate was 6.9 (95% CI: 6.8, 7.0) and the AAPC of MPR was 1.2 (95% CI: 0.1, 2.3) in China. Detailed HIV/AIDS incidence, prevalence , and AIDS-related mortality rates in China and globally from 1990 to 2019 are listed in Table 1 .
Table 1 -
HIV/AIDS incidence,
prevalence , and AIDS-related mortality rate in China and globally, 1990 to 2019.
Prevalence rate per 100,000 (95% CI)Incidence rate per 100,000 (95% CI)
Mortality rate per 100,000 (95% CI)
Year
China
Globally
China
Globally
China
Globally
1990
5.6 (4.2, 7.3)
146.3 (128.5, 165.4)
0.8 (0.5, 1.5)
38.5 (31.9, 45.4)
0.2 (0.1, 0.3)
6.3 (4.8, 8.5)
1991
6.2 (4.9, 8.0)
177.9 (156.6, 198.7)
1.0 (0.7, 1.6)
43.6 (36.0, 51.5)
0.3 (0.1, 0.4)
7.9 (6.0, 10.7)
1992
6.9 (5.5, 9.0)
210.6 (185.8, 233.6)
1.1 (0.8, 1.8)
47.6 (39.2, 56.8)
0.3 (0.2, 0.4)
9.8 (7.3, 13.2)
1993
7.6 (6.0, 10.2)
243.3 (215.1, 268.5)
1.2 (0.8, 1.8)
50.7 (41.8, 61.0)
0.4 (0.3, 0.4)
11.9 (8.9, 16.0)
1994
8.4 (6.4, 11.6)
275.3 (245.3, 302.0)
1.5 (1.0, 2.4)
53.0 (44.1, 63.7)
0.4 (0.3, 0.5)
14.1 (10.5, 19.0)
1995
9.3 (6.9, 13.2)
306.1 (275.4, 334.0)
1.5 (1.0, 2.4)
54.8 (46.0, 65.8)
0.5 (0.4, 0.5)
16.3 (12.0, 21.9)
1996
10.0 (7.3, 14.4)
335.5 (304.6, 364.3)
1.5 (0.9, 2.4)
56.0 (47.5, 67.2)
0.5 (0.5, 0.6)
18.2 (13.3, 24.4)
1997
10.8 (7.8, 16.2)
362.6 (331.6, 390.4)
1.7 (1.0, 2.9)
56.0 (47.4, 67.5)
0.6 (0.5, 0.6)
19.9 (14.4, 26.6)
1998
11.9 (8.2, 18.2)
385.8 (355.4, 412.4)
2.0 (1.2, 3.4)
54.5 (46.2, 66.0)
0.6 (0.6, 0.7)
21.8 (15.9, 28.9)
1999
13.1 (8.8, 20.5)
404.3 (376.4, 429.5)
2.4 (1.4, 4.0)
52.5 (44.7, 63.6)
0.7 (0.6, 0.8)
23.7 (17.4, 31.2)
2000
14.8 (9.5, 23.4)
418.2 (394.2, 442.0)
2.9 (1.7, 4.8)
50.0 (42.7, 60.6)
0.8 (0.7, 0.8)
25.4 (18.8, 32.8)
2001
16.9 (10.4, 27.1)
427.5 (405.9, 449.3)
3.5 (2.0, 5.5)
47.3 (40.4, 57.2)
0.8 (0.8, 0.9)
26.7 (20.0, 34.2)
2002
19.3 (11.6, 31.3)
432.8 (414.0, 452.2)
4.0 (2.4, 6.2)
44.9 (38.6, 53.9)
0.9 (0.8, 1.0)
27.7 (21.0, 35.1)
2003
21.9 (13.1, 36.2)
434.5 (417.6, 451.4)
4.5 (2.8, 6.6)
42.7 (37.0, 51.0)
0.9 (0.8, 1.0)
28.3 (21.7, 35.5)
2004
25.0 (14.7, 40.9)
433.6 (417.3, 450.2)
4.7 (3.1, 6.8)
40.8 (35.7, 48.2)
1.0 (0.9, 1.1)
28.5 (22.3, 35.2)
2005
28.0 (16.3, 46.0)
430.9 (414.5, 447.9)
4.8 (3.2, 6.9)
39.3 (34.5, 46.0)
1.1 (1.1, 1.2)
27.9 (22.4, 34.2)
2006
30.8 (17.4, 50.4)
427.7 (410.2, 446.8)
4.6 (3.2, 6.6)
38.0 (33.6, 44.1)
1.1 (1.0, 1.2)
26.6 (21.9, 32.2)
2007
33.5 (18.5, 54.9)
425.0 (406.4, 446.8)
4.4 (3.2, 6.2)
36.8 (32.7, 42.5)
1.1 (1.0, 1.2)
24.8 (20.9, 29.7)
2008
35.8 (19.6, 59.1)
424.1 (404.8, 447.8)
4.1 (3.0, 5.8)
35.7 (31.9, 41.1)
1.2 (1.1, 1.3)
22.9 (19.7, 27.3)
2009
37.8 (20.8, 62.7)
425.1 (405.8, 449.6)
3.8 (2.8, 5.5)
34.8 (31.5, 39.9)
1.2 (1.1, 1.3)
21.1 (18.4, 25.0)
2010
39.4 (21.8, 65.6)
427.8 (408.5, 452.9)
3.5 (2.6, 5.2)
33.9 (30.9, 38.7)
1.2 (1.1, 1.4)
19.5 (17.2, 23.3)
2011
40.6 (22.6, 67.8)
431.7 (411.8, 456.6)
3.1 (2.3, 4.8)
33.1 (30.2, 37.6)
1.2 (1.2, 1.4)
18.2 (16.0, 21.7)
2012
41.4 (22.9, 69.3)
436.4 (416.6, 461.4)
2.8 (1.9, 4.4)
32.3 (29.4, 36.7)
1.2 (1.1, 1.3)
16.8 (14.8, 20.0)
2013
41.8 (23.1, 70.5)
441.8 (421.9, 467.0)
2.6 (1.6, 4.0)
31.6 (28.6, 35.8)
1.3 (1.2, 1.4)
15.6 (13.8, 18.6)
2014
41.9 (23.1, 71.6)
447.7 (427.9, 473.2)
2.4 (1.3, 3.8)
30.9 (28.0, 35.0)
1.6 (1.4, 1.7)
14.7 (13.0, 17.5)
2015
41.5 (22.6, 72.4)
453.8 (433.7, 479.6)
2.3 (1.0, 3.6)
30.3 (27.3, 34.2)
1.9 (1.7, 2.0)
13.9 (12.3, 16.5)
2016
40.9 (21.9, 72.8)
459.8 (439.0, 485.5)
2.3 (1.1, 3.7)
29.3 (26.3, 33.0)
2.1 (1.9, 2.2)
13.3 (11.8, 15.7)
2017
40.2 (21.1, 72.5)
465.6 (444.5, 491.2)
2.3 (1.1, 3.7)
28.1 (25.1, 31.8)
2.2 (1.9, 2.4)
12.5 (11.2, 14.6)
2018
39.5 (20.5, 72.4)
471.2 (449.8, 497.0)
2.3 (1.1, 3.7)
26.7 (23.7, 30.2)
2.2 (1.9, 2.5)
11.7 (10.6, 13.5)
2019
38.8 (20.1, 72.2)
476.2 (454.3, 502.2)
2.2 (1.1, 3.6)
25.7 (22.8, 29.2)
2.2 (1.8, 2.6)
11.2 (10.2, 12.9)
AIDS: acquired immune deficiency syndrome; CI: Confidence interval; HIV: Human immunodeficiency virus.
Different gender and age trends globally and in China between 1990 and 2019
In terms of differences in the aforementioned indicators by gender, we observed a similar pattern of trends in incidence, prevalence , mortality and MRP for male and female people living with HIV/AIDS (PLWH) globally and in China during the entire study period [Figure 2 ]. Nonetheless, the global incidence, prevalence , and mortality rates of female PLWH were higher than male PLWH from 1990 to 2019, while the preceding observations for China were higher in male PLWH than in female PLWH. Interestingly, the global incidence and mortality rate gaps for HIV/AIDS between men and women have narrowed from the peak. Nevertheless, the gaps for these indices have not narrowed for HIV/AIDS between men and women in China. The MPR trends were observed to be very similar between male and female PLWH, both globally and in China.
Figure 2: Temporal trends in HIV/AIDS incidence, prevalence , mortality rate, and MPR per 100,000 persons according to gender globally (A, upper four graphs) and in China (B, lower four graphs), 1990–2019. AIDS: acquired immune deficiency syndrome; HIV: Human immunodeficiency virus; MPR: Mortality-to-prevalence ratio.
The data presented in Figure 3 show that both globally and in China, each age stratum of PLWH has its own unique trend in terms of incidence, prevalence , mortality rate, and MPR. Overall, the main trend seen globally is that incidence, prevalence , and mortality rate in the 15 to 49-year group have always been notably higher than any other age group between 1990 and 2019 [Figure 3 A]. In China, these indices in the 0 to 14-year group are appreciably lower and remain relatively stable compared with other age groups. In contrast to the global trend, persons of the older age group (aged >50 years) had a higher incidence rate between 2001 and 2012 and a higher prevalence rate between 2005 and 2019. Moreover, the mortality rate of older age persons was higher in 1990 to 2019 compared to that of individuals aged ≤50, with the difference having become more noticeable since 2014. The MPR seen in the 0 to 14-year group continued to decline both in China and globally from 1990 to 2019 [Figures 3 A and 3B].
Figure 3: Temporal trends in HIV/AIDS incidence, prevalence , mortality rate, and MPR per 100,000 persons, by age, globally (A, upper four graphs) and in China (B, lower four graphs), 1990 to 2019. Age was stratified into four groups (0–14, 15–49, 50–69, and ≥70 years). AIDS: acquired immune deficiency syndrome; HIV: Human immunodeficiency virus; MPR: Mortality-to-prevalence ratio.
Joinpoint analysis indicated that persons in the age-range of 0 to 14 years had a significant upward trend of incidence rate among females (2.1, 95% CI: 0.8, 3.4) and males (1.3, 95% CI: 0.1, 2.6) between 1990 and 2019; however, a sharp decline was found from the peak in 2016, where the APC values were observed to be –16.9 (95% CI: –20.8, –12.8) and –16.3 (95% CI: –19.9, –12.5) for females and males, respectively [Figure 4 and Table 2 ]. Also, the incidence rate in the 15 to 49, 50 to 69, and ≥70 years groups had a significant upward trend, except for the ≥70 years male group between 1990 and 2019 [Table 2 ]. With respect to the prevalence rate, all age groups were seen to have a significant upward trend [Table 2 ]. In relation to mortality rate, the 0–14-year group had an almost identical significant upward trend both in male and female PLWH. Additionally, the 15 to 49, 50 to 69, and ≥70 year groups also had significant upward trends for both male and female PLWH, although men had a higher AAPC than women. Figure 4 D and Table 2 summarize the results of joinpoint regression analyses of the age and gender-stratified burden of HIV/AIDS in China. The AAPC of calculated MPR indices demonstrated a significant declining trend in all age groups in both genders in the period between 1990 and 2019 [Table 2 ].
Figure 4: Joinpoint regression analyses of trends in HIV/AIDS incidence rate (A, four graphs in the first row), prevalence rate (B, four graphs in the second row), mortality rate (C, four graphs in the third row), and MPR per 100,000 persons in China (D, four graphs in the fourth row), while considering gender differences in each age group, 1990 to 2019. AIDS: acquired immune deficiency syndrome; APC: Annual percentage change; HIV: Human immunodeficiency virus; MPR: Mortality-to-prevalence ratio.
Table 2 -
Joinpoint trend analysis of HIV/AIDS incidence,
prevalence , mortality rate, and MPR per 100,000 in China, 1990 to 2019.
0–14 years
15–49 years
50–69 years
≥70 years
Measure
Gender
Trend
Year
APC (95% CI)
Year
APC (95% CI)
Year
APC (95% CI)
Year
APC (95% CI)
Incidence
Female
Trend1
1990–1994
13.6∗ (10.2, 17.1)
1990–1994
16.1∗ (14.0,18.3)
1990–1997
13.4∗ (11.0, 15.9)
1990–1996
–7.4∗ (–11.1, –3.5)
Trend2
1994–2001
0.4 (–1.3, 2.0)
1994–1997
4.2 (–1.8, 10.6)
1997–2002
24.1∗ (17.9, 30.7)
1996–2004
28.1∗ (24.0, 32.3)
Trend3
2001–2007
9.0∗ (6.7, 11.3)
1997–2001
17.5∗ (14.0, 21.0)
2002–2005
3.63 (–12.0, 22.0)
2004–2009
–0.7 (–7.9, 7.2)
Trend4
2007–2013
–1.5 (–3.6,0.6)
2001–2004
1.6 (–4.3, 7.8)
2005–2015
–13.3∗ (–14.6, –12.0)
2009–2015
–28.9∗ (–32.6, –25.0)
Trend5
2013–2016
6.6 (–3.2, 17.4)
2004–2012
–10.3 (–11.0, –9.6)
2015–2019
0.4 (–4.7, 5.7)
2015–2019
–7.0 (–13.8, 0.3)
Trend6
2016–2019
–16.9∗ (–20.8, –12.8)
2012–2019
1.0∗ (0.2, 1.9)
AAPC
1990–2019
2.1∗ (0.8, 3.4)
1990–2019
2.2∗ (1.2, 3.1)
1990–2019
2.3∗ (0.3, 4.4)
1990–2019
–2.9∗ (–5.0, –0.7)
Male
Trend1
1990–1994
14.5∗ (11.3, 17.7)
1990–1992
21.0∗ (11.7, 31.2)
1990–1997
8.7∗ (7.1, 10.4)
1990–1997
–3.0∗ (–6.0, 0)
Trend2
1994–1998
–4.6∗ (–8.7, –0.3)
1992–1996
7.7∗ (3.5, 12.2)
1997–2003
27.3∗ (24.1, 30.5)
1997–2005
31.1∗ (27.2, 35.2)
Trend3
1998–2007
6.6∗ (5.6, 7.6)
1996–2003
16.3∗ (14.7, 17.9)
2003–2007
1.7 (–3.9, 7.5)
2005–2010
–1.6 (–8.4, 5.8)
Trend4
2007–2013
–2.8∗ (–4.7, –0.8)
2003–2012
–5.7∗ (–6.5, –4.9)
2007–2015
–13.6∗ (–14.8, –12.3)
2010–2015
–29.8∗ (–34.7, –24.6)
Trend5
2013–2016
5.0 (–3.9, 14.8)
2012–2019
0 (–1.1, 1.1)
2015–2019
0.5 (–3.0, 4.1)
2015–2019
–7.5∗ (–14.0, –0.6)
Trend6
2016–2019
–16.3∗ (–19.9, –12.5)
AAPC
1990–2019
1.3∗ (0.1, 2.6)
1990–2019
4.2∗ (3.4, 5.1)
1990–2019
3.3∗ (2.2, 4.5)
1990–2019
–0.72 (–2.8, 1.4)
Prevalence Female
Trend1
1990–1992
23.2∗ (20.5, 26.0)
1990–1995
11.2 (10.9, 11.6)
1990–1998
8.8∗ (8.5, 9.1)
1990–1993
–5.3∗ (–6.1, –4.5)
Trend2
1992–1995
13.5∗ (11.0, 16.1)
1995–1998
8.2 (6.9, 9.6)
1998–2005
16.9∗ (16.4, 17.4)
1993–1997
1.6∗ (0.7, 2.5)
Trend3
1995–2000
7.8∗ (7.1, 8.6)
1998–2004
9.5 (9.2, 9.8)
2005–2008
8.4∗ (5.9, 11.0)
1997–2000
11.2∗ (9.3, 13.1)
Trend4
2000–2007
9.7∗ (9.3, 10.1)
2004–2008
4.2 (3.5, 4.8)
2008–2011
3.5∗ (1.1, 6.0)
2000–2006
21.3∗ (20.9, 21.8)
Trend5
2007–2012
4.6∗ (3.9, 5.4)
2008–2013
1.1 (0.7, 1.5)
2011–2015
0.2 (–1.0, 1.4)
2006–2010
8.7∗ (7.8, 9.7)
Trend6
2012–2019
–0.5∗ (–0.8, –0.2)
2013–2019
–1.4 (–1.6, –1.2)
2015–2019
–3.4∗ (–4.1, –2.6)
2010–2019
–0.9∗ (–1.1, –0.8)
AAPC
1990–2019
7.2∗ (6.8, 7.5)
1990–2019
5.1∗ (4.9, 5.3)
1990–2019
7.1∗ (6.7, 7.5)
1990–2019
5.8∗ (5.5, 6.0)
Male
Trend1
1990–1992
23.0∗ (20.3, 25.7)
1990–1994
11.5∗ (11.2, 11.9)
1990–1999
6.7∗ (6.5, 6.9)
1990–1994
–2.5∗ (–3.4, –1.6)
Trend2
1992–1995
13.6∗ (11.1, 16.1)
1994–1998
9.1∗ (8.5, 9.7)
1999–2006
19.4∗ (19.0, 19.8)
1994–1998
2.5∗ (1.0, 3.9)
Trend3
1995–2000
8.0∗ (7.3, 8.8)
1998–2005
11.5∗ (11.3, 11.7)
2006–2010
8.2∗ (7.1, 9.3)
1998–2001
14.0∗ (10.8, 17.3)
Trend4
2000–2007
9.8∗ (9.4, 10.2)
2005–2009
5.4∗ (4.8, 5.9)
2010–2014
1.5∗ (0.5, 2.6)
2001–2007
25.2∗ (24.4, 26.0)
Trend5
2007–2012
4.8∗ (4.0, 5.5)
2009–2013
2.6∗ (2.1, 3.2)
2014–2019
–3.0∗ (–3.4, –2.5)
2007–2011
7.4∗ (5.8, 8.9)
Trend6
2012–2019
–0.2 (–0.5, 0.1)
2013–2019
–0.3∗ (–0.5, –0.1)
2011–2019
–5.4∗ (–5.7, –5.1)
AAPC
1990–2019
7.3∗ (7.0, 7.7)
1990–2019
6.6∗ (6.4, 6.7)
1990–2019
7.3∗ (7.1, 7.5)
1990–2019
5.6∗ (5.2, 6.0)
Mortality
Female
Trend1
1990–1995
10.7∗ (9.4, 12.1)
1990–1994
18.7∗ (14.8, 22.8)
1990–1992
24.9∗ (11.1, 40.5)
1990–1994
22.4∗ (17.3, 27.8)
Trend2
1995–2002
–2.7 (–3.6, –1.7)
1994–2001
10.9∗ (8.9, 12.9)
1992–2004
9.7∗ (8.9, 10.6)
1994–2004
7.0∗ (5.7, 8.3)
Trend3
2002–2009
7.3∗ (6.3, 8.3)
2001–2005
4.1 (–1.3, 9.8)
2004–2013
–3.4∗ (–4.6, –2.1)
2004–2013
–2.7∗ (–4.2, –1.3)
Trend4
2009–2012
–1.6 (–6.8, 4.0)
2005–2013
–1.0 (–2.4, 0.4)
2013–2016
26.7∗ (12.7, 42.6
2013–2016
31.7∗ (14.9, 50.9)
Trend5
2012–2017
2.7∗ (0.9, 4.5)
2013–2016
15.8∗ (4.1, 28.9)
2016–2019
0.3 (–5.4, 6.4)
2016–2019
4.2 (–2.6, 11.6)
Trend6
2017–2019
–5.9∗ (–10.9, –0.6)
2016–2019
1.6 (–3.6, 7.2)
AAPC
1990–2019
2.7∗ (1.9, 3.5)
1990–2019
7.1∗ (5.5, 8.7)
1990–2019
7.0∗ (5.4, 8.7)
1990–2019
7.8∗ (6.0, 9.6)
Male
Trend1
1990–1995
11.6∗ (10.3, 12.9)
1990–1993
22.2∗ (18.2, 26.3)
1990–1993
21.3∗ (16.7, 26.0)
1990–1993
21.3∗ (14.9, 28.1)
Trend2
1995–2002
–2.7∗ (–3.6, –1.9)
1993–2000
11.0∗ (9.8, 12.3)
1993–2005
6.8∗ (6.3, 74)
1993–2001
7.1∗ (5.5, 8.6)
Trend3
2002–2009
7.5∗ (6.5, 8.4)
2000–2005
7.2∗ (4.9, 9.4)
2005–2013
2.3∗ (1.3, 3.4)
2001–2013
3.6∗ (2.8, 4.3)
Trend4
2009–2012
–2.3 (–7.3, 2.9)
2005–2013
3.0∗ (2.1, 3.9)
2013–2016
25.0∗ (15.7, 35.0)
2013–2016
24.9∗ (12.0, 39.2)
Trend5
2012–2017
2.9∗ (1.2, 4.6)
2013–2016
15.8∗ (8.3, 23.7)
2016–2019
0.1 (–3.7, 4.0)
2016–2019
–0.2 (–5.4, 5.4)
Trend6
2017–2019
–5.8∗ (–10.6, –0.8)
2016–2019
1.5 (–1.9, 4.9)
AAPC
1990–2019
2.8∗ (2.1, 3.6)
1990–2019
8.6∗ (7.7, 9.6)
1990–2019
8.0∗ (6.9, 9.0)
1990–2019
7.91∗ (6.5, 9.4)
MPR
Female
Trend1
1990–1992
–18.8∗ (–20.7, –17.0)
1990–1995
–10.1∗ (–10.4, –9.9)
1990–1998
–8.1∗ (–8.3, –7.9)
1990–1993
5.6∗ (4.7, 6.5)
Trend2
1992–1995
–11.9∗ (–13.9, –9.9)
1995–1998
–7.6∗ (–8.7, –6.5)
1998–2005
–14.5∗ (–14.8, –14.1)
1993–1997
–1.5∗ (–2.4, –0.7)
Trend3
1995–2000
–7.3∗ (–7.9, –6.6)
1998–2004
–8.7 (–8.9, –8.4)
2005–2008
–7.8∗ (–9.9, –5.5)
1997–2000
–10.1∗ (–11.6, –8.5)
Trend4
2000–2007
–8.8∗ (–9.2, –8.5)
2004–2008
–4.0∗ (–4.6, –3.4)
2008–2011
–3.4∗ (–5.7, –1.0)
2000–2006
–17.6∗ (–17.9, –17.3)
Trend5
2007–2012
–4.4∗ (–5.1, –3.7)
2008–2013
–1.0∗ (–1.4, –0.7)
2011–2015
–0.2 (–1.3, 1.0)
2006–2010
–8.0∗ (–8.8, –7.2)
Trend6
2012–2019
0.5∗ (0.2, 0.8)
2013–2019
1.4∗ (1.2, 1.6)
2015–2019
3.5∗ (2.7, 4.3)
2010–2019
0.9∗ (0.8, 1.1)
AAPC
1990–2019
–6.7∗ (–7.0, –6.4)
1990–2019
–4.9∗ (–5.0, –4.7)
1990–2019
–6.6∗ (–7.0, –6.3)
1990–2019
–5.5∗ (–5.7, –5.2)
Male
Trend1
1990–1992
–18.7∗ (–20.4, –16.9)
1990–1994
–10.3∗ (–10.6, –10.0)
1990–1999
–6.2∗ (–6.4, –6.1)
1990–1994
2.5∗ (1.6, 3.5)
Trend2
1992–1995
–11.9∗ (–13.8, –10.0)
1994–1998
–8.3∗ (–8.8, –7.8)
1999–2006
–16.3∗ (–16.5, –16.0)
1994–1998
–2.4∗ (–3.8, –1.0)
Trend3
1995–2000
–7.4∗ (–8.0, –6.8)
1998–2005
–10.3∗ (–10.5, –10.2)
2006–2010
–7.6∗ (–8.5, –6.7)
1998–2001
–12.3∗ (–14.8, –9.7)
Trend4
2000–2007
–8.9∗ (–9.2, –8.6)
2005–2009
–5.1∗ (–5.6, –4.6)
2010–2014
–1.5∗ (–2.5, –0.5)
2001–2007
–20.1∗ (–20.6, –19.6)
Trend5
2007–2012
–4.5∗ (–5.2, –3.9)
2009–2013
–2.6∗ (–3.1, –2.0)
2014–2019
3.1∗ (2.6, 3.6)
2007–2011
–6.8∗ (–8.2, –5.5)
Trend6
2012–2019
0.2 (–0.1, 0.5)
2013–2019
0.3∗ (0.1, 0.5)
2011–2019
5.7∗ (5.4, 6.0)
AAPC
1990–2019
–6.8∗ (–7.1, –6.5)
1990–2019
–6.2∗ (–6.3, –6.0)
1990–2019
–6.8∗ (–7.0, –6.6)
1990–2019
–5.3∗ (–5.7, –4.9)
AAPC: Average annual percent change; AIDS: acquired immune deficiency syndrome; APC: Annual percent change; CI: Confidence interval; HIV: Human immunodeficiency virus; MPR: Mortality-to-prevalence ratio.
∗ Statistically significant at alpha = 0.05 (P < 0.05).
Discussion
According to the data from the GBD, the global incidence of HIV has decreased since 1996, and the AIDS-related mortality rate has decreased since 2004. Global HIV incidence, prevalence , and mortality rates are dissimilar to prevailing trends in China. The HIV epidemic began relatively late in China, initially spreading among people who injected drugs (PWID), then breaking out in the general population in the mid-1990 s due to contamination of community plasma collections, and subsequently evolving into a sexually transmitted epidemic over recent years.[6] [16] et al [4] [17] [17]
Global HIV incidence and mortality in females have been observed to be higher than those in males; however, these gender gaps have reduced in the past 20 years.[14] [18] [19] [14] prevalence , and mortality gaps for HIV/AIDS between men and women have widened over the past three decades. This tendency might well be inseparable from the increase in numbers of men who have sex with men (MSM) in China. The proportion of newly diagnosed HIV-infected MSM cases has increased exponentially, peaking at 28.2% in 2015, and subsequently falling to 23.3% in 2018.[6]
The young and middle-aged group (15–49-year-olds) has the highest HIV incidence, prevalence , and mortality rates globally, while the MPR in this population is lower than that in other age groups. Conversely, we found that HIV incidence in China in the older age group (aged >50 years) surged in the 2000 s, and subsequently decreased. The increased HIV incidence in the elderly population in China is likely to be attributable to a variety of factors. Lack of awareness of HIV risk and the low exposure and coverage of HIV prevention campaigns, may be some of the reasons for the high incidence of HIV in this population. Low-cost commercial sex establishments are the primary sites for HIV acquisition in the elderly, and the risk of HIV infection in males aged >50 years who have commercial sex significantly increased due to a certain preference for aphrodisiac use by older men, and the presumed consequent increased bodily fluid exchange with commercial sex workers.[20] [21,22] [23] [23,24] [25] [26] [27] [28–30]
Over the past 30 years, the Chinese government has made continuous and sustained efforts to prevent and control HIV/AIDS in China. Between 1995 and 2015, fiscal spending allocated to HIV prevention and treatment in China increased by 10.1% annually, which equates to thrice the global financial commitment to HIV/AIDS-related causes.[31] prevalence of HIV in China has decreased, and that the mortality rate has increased significantly since the 2010 s. Correspondingly, the MPR began to increase sharply from approximately this time. The possible reason for this phenomenon is likely to be related to the fact that the CRF01_AE sub-type has now become the most prevalent strain in China among individuals infected with HIV through sexual transmission, especially among MSM, since 2006.[32] vs . 8–10 years, respectively).[33] et al [34] prevalence is declining, and a longer duration of HIV infection is associated with increasing mortality in HIV-infected individuals.[35–37]
Several limitations exist in the present study. This is an ecological study based on aggregate data extracted from a large cohort; hence the ecological fallacy should not be ignored when making inferences at the individual level. A male–female gender binary was used in this work due to insufficiency in availability of data pertaining to special gender populations, such as transgender individuals. Sexual orientation was not analyzed in this work; thus, we could not accurately estimate the impact of homosexuality and bisexuality on the HIV/AIDS burden. Sexual transmission has now become the major mode of HIV transmission in China, and therefore the detailed epidemiology of gender characteristics and sexual behaviors relating to HIV/AIDS warrants further investigation.
In conclusion, the prevalence and mortality rate for HIV globally and in China increased during 1990 to 2019. The incidence rate and MPR globally have declined over the past three decades, while those in China present a rising trend. In terms of HIV burden in different genders, the HIV burden in females globally is higher than that in males; however, this gap has reduced over the past 20 years. While there has been a male-dominated HIV burden pattern in China, the gender gap has not narrowed between males and females. In contrast to the high HIV burden among young and middle-aged adults globally, the elderly are much more at risk in China. HIV screening in older age groups should be scaled up, and patients with advanced HIV disease should be provided with early additional care and health resources.
Funding
This work was supported by grants from the Joint Medical Research Projects of Chongqing Municipal Health Committee and Chongqing Municipal Science and Technology Bureau (Nos.2022QNXM032, 2020FYYX066, 2020MSXM097, and 2020FYYX118), Chongqing Science and Technology Bureau (No.cstc2020jscx-cylhX0001), and Chongqing Talent Cultivation Program (No.cstc2021ycjh-bgzxm0275).
Conflicts of interest
None.
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