HIV / AIDS in transition: Global disparities, Africa's uneven progress and struggles, and the emerging threat of funding cuts (global burden of disease study, 1990–2021)

Abstract

BACKGROUND: HIV/AIDS remains a global health crisis marked by profound regional disparities. Sub-Saharan Africa (SSA) bears the greatest burden but has achieved partial progress in reducing its impact. Within the region, however, heterogeneous patterns of progress and setbacks persist, underscoring ongoing challenges in epidemic control and suggesting potential misalignment in the focus of current interventions. METHODS: We analysed HIV/AIDS disability-adjusted life years (DALYs) from 2016 to 2021, disaggregated at subregional and local levels across continents using Global Burden of Disease (GBD) estimates. This high-resolution analytical approach enabled the identification of nuanced temporal trends and geographic hotspots requiring urgent intervention, with particular emphasis on SSA. FINDINGS: Southern SSA recorded a 20.8% decline in DALY rates, from 18 280 to 14 470 per 100 000 population, while eastern, western and central SSA each achieved reductions exceeding 27%. Despite these gains, some areas maintained alarmingly high burdens, including Lesotho (26 516), eastern Cape, South Africa (25 004), Eswatini (22 944) and Homa Bay, Kenya (21 747). Outside Africa, the Caribbean achieved a 29% decline, whereas North America and Europe registered more modest improvements. In Asia, several Indian states recorded up to 27% reductions, contrasted by increases in parts of Pakistan, Mongolia, China and Yemen. INTERPRETATION: Marked regional contrasts highlight the need to reframe HIV/AIDS control strategies at the subregional level. Despite setbacks linked to the COVID-19 pandemic, targeted, data-driven interventions in persistent high-burden areas remain essential to sustain progress and accelerate the global HIV/AIDS response. Yet, just as encouraging transitions are beginning to take hold across several parts of SSA, the continent is now confronted-suddenly and unprepared-for a renewed challenge: a decline in HIV/AIDS funding.