Global AIDS mortality fell by over 20% in the last five years

the overall death rate from aids-related complications has fallen by 21% since 2006, the most recent study in the global burden of disease (gbd) series shows. however, while a number of countries with large hiv burdens have significantly reduced the pandemic's death and disability toll, there is huge disparity in progress between different regions and neighboring nations.

the report also finds in 22% of the 182 countries with documented cases of aids, aids-related mortality and hiv-related disability is still rising. in most cases this is because the countries still have very low prevalence, or in some cases, hiv has arrived very late.

yet there are several counties, most notably the democratic republic of congo (drc), ukraine and russia who have high aids mortality and large numbers of cases where there is little sign of mortality falling. similarly, there are still eight countries in the world - small, mainly pacific nations - who have never had a single recorded case of aids.

the gbd study compiles causes of death and disparity. it computes the number and proportion of disability-adjusted life years (dalys) lost to individual conditions, the proportion of dalys lost, the percentage of deaths attributable to the condition and the proportion of global death and disability due to the condition occurring in each country. from these statistics, it computes a ranking for each condition, globally and per country, in terms of the proportion of death and disability it causes.

the 2010 study found ischaemic heart disease is the number one killer worldwide, and strokes are at number three, meaning cardiovascular diseases in general cause 9.3% of all dalys lost worldwide. while overall mortality and disability rates have fallen, the proportion due to heart disease has risen by 29% and strokes by 19% since 1990.

lower respiratory infections (pneumonia) and diarrhoeal diseases are at number two and four respectively: in 1990 they were numbers one and two, and their death and disability ranking has fallen by 44% and 51% respectively.

hiv and aids are the number five condition. death and disability due to hiv increased by 354% during that time. since 1990, no other condition's disease burden increased more than the 69% rise in diabetes. the disease burden of malaria and tuberculosis, which are at number seven and 13 respectively, fell by 20% since 1990.

furthermore, hiv is responsible for 3.3% of all dalys lost worldwide, though in high-prevalence countries such as south africa it is responsible for up to 40% of dalys lost. hiv and aids are exceptional for its age profile. whereas most other conditions disproportionately affect the old and the very young, hiv is the number one cause of dalys lost for women aged 25-45 and men aged 30-45.

the gbd study revealed which countries are most affected by hiv. as such, hiv is the number one cause of death and disability in a swathe of eastern and southern african countries stretching from somalia to south africa. its also the worst health problem in the west african countries of equatorial guinea and gabon, and number two in the populous countries of cameroon, ghana and nigeria.

hiv is the number one cause of dalys lost in a cluster of caribbean countries, including the bahamas, belize, jamaica and suriname. hiv is number two in nearby guyana and panama, and in the top five in colombia and venezuela. in south-east asia, hiv is most notably the biggest cause of death and disability in thailand, but its also in the top five in nearby malaysia, myanmar and vietnam. in eastern europe, its the third and fourth most significant cause of death and disability in ukraine and russia, respectively.

india and russia, because of their size, contribute more to the global burden of disease in absolute numbers than in prevalence - they are the only two countries in the top ten in terms of numbers of dalys lost not in africa. india is number two after south africa, even though hiv is only the 15th most significant cause of death and disability there. similarly, china, where hiv is the 38th most significant cause of illness, loses as many dalys to hiv than zambia.

the proportion of dalys lost to hiv-related illnesses is generally correlated with how far up the list hiv is in terms of the country's ranking of diseases, but not entirely: it depends how the country's disease burden is distributed. thus, hiv is the number one cause of death and disability in kenya, south africa and thailand, but the proportion of total dalys lost attributable to hiv is 40% in south africa, 15% in kenya and 5.6% in thailand.

among the study's most interesting findings are how each country's hiv burden correlates with the reduction in dalys lost to hiv since aids deaths were at their peak. this peak could have happened anywhere between 1996 - when antiretroviral therapy (art) started becoming available in developing countries - and last year. 

countries who demonstrated progress in lifting their aids burden fell into two types: they were either high-income countries who controlled their hiv burden early, or low-income countries with good art programs instituted more recently. eight countries where dalys lost due to hiv fell by more than 80% from their peak are cambodia, france, haiti, japan, netherlands, new zealand, rwanda and spain.  

the united kingdom had a 63.5% fall in dalys lost to hiv. botswana, germany and the u.s. had a 75% fall in dalys lost to hiv. by contrast, ethiopia showed a 68% fall in dalys lost to hiv, compared with the countries on either side, somalia and sudan, which have seen no fall. in india, dalys have fallen by 8.6% but in south Africa, 11 billion dalys were lost to hiv (500 times as many as the uk), which is remarkable considering the daunting pandemic they face.

in vietnam, dalys lost to hiv have yet to fall, yet hiv is the sixth most significant cause of death and disability there. vietnam may be an example of a country where hiv arrived quite late and is only now going through its phase of expansion. other examples include afghanistan, china, pakistan and the philippines. most of these countries are currently seeing rapid hiv prevalence increases in gay men, men who have sex with men or in people who inject drugs.

unfortunately, some countries where there has been a significant hiv presence for some time have not succeeded in bringing down aids deaths and hiv disability. these countries include the drc with a 2.7% fall in dalys, Ukraine with a 2% fall, Russia with a 0.5% fall, and Indonesia, where there has been no fall at all.  

some countries miserably fail to address their hiv crises. publicly, they blame many reasons why, but two factors have emerged: hiv treatment unsurprisingly lags behind in countries recently torn apart by war (Liberia and sierra leone are prime examples); others where treatment does not get to high-prevalence is largely because of their highly stigmatized populations.

corruption and gross economic inequality are other factors contributing to human misery. hiv death and disability has fallen disproportionately little in the oil-rich but extremely unequal states of angola and equatorial guinea - the latter is the only country in the world where hiv is the number one cause of death and disability but which has seen no fall in dalys lost to hiv.

in Europe, economic decline may be a factor, with Greece and Portugal only seeing relatively poor 29% and 33% declines in dalys lost respectively, compared to at least twice those numbers with their european neighbors. papua new guinea, which a few years ago saw alarming rises in hiv prevalence, was being talked about as the possible site of the first hyperepidemic outside Africa. in the last few years, it has seen a 51% fall in hiv-related death and disability.