Global Health Action

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Demographic change and HIV epidemic

projections to 2050 for adolescents and young
people aged 15-24

Aleya Khalifa, John Stover, Mary Mahy, Priscilla Idele, Tyler Porth & Chibwe
Lwamba

To cite this article: Aleya Khalifa, John Stover, Mary Mahy, Priscilla Idele, Tyler Porth &
Chibwe Lwamba (2019) Demographic change and HIV epidemic projections to 2050 for
adolescents and young people aged 15-24, Global Health Action, 12:1, 1662685, DOI:
10.1080/16549716.2019.1662685

To link to this article: https://doi.org/10.1080/16549716.2019.1662685

© 2019 The Author(s). Published by Informa Published online: 12 Sep 2019.

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 GLOBAL HEALTH ACTION
2019, VOL. 12, 1662685
https://doi.org/10.1080/16549716.2019.1662685

ORIGINAL ARTICLE

Demographic change and HIV epidemic projections to 2050 for adolescents

and young people aged 15-24
a b c
Aleya Khalifa , John Stover , Mary Mahy , Priscilla Idelea, Tyler Portha and Chibwe Lwambaa
a
Division of Data, Research and Policy, United Nations Children’s Fund, New York, NY, USA; bCenter for Modeling, Planning and Policy
Analysis, Avenir Health, Avenir Health, Glastonbury, CT, USA; cDepartment of Strategic Information and Evaluation, Joint United Nations
Programme for HIV/AIDS, Geneva, Switzerland

ABSTRACT ARTICLE HISTORY

Background: Ending AIDS as a public health threat by 2030 is a significant challenge, as new Received 25 March 2019
HIV infections among adolescents and young people have not decreased fast enough to curb Accepted 23 August 2019
the epidemic. The combination of slow HIV response and increasing youth populations 15–24
RESPONSIBLE EDITOR
could affect progress towards 2030 goals.
Peter Byass, Umeå
Objective: This analysis aimed to describe global and regional trends from 2010–2050 in the University, Sweden
HIV epidemic among adolescents and young people by accounting for demographic projec-
tions and recent trends in HIV interventions. KEYWORDS
Methods: 148 national HIV estimates files were used to project the HIV epidemic to 2050. HIV; HIV/AIDS;
Numbers of people living with HIV and new HIV infections were projected by sex and five-year epidemiology; demography;
age group. Along with demographic data, projections were based on three key assumptions: epidemic modelling
future trends in HIV incidence, antiretroviral treatment coverage, and coverage of antiretrovirals
for prevention of mother-to-child transmission. Results represent nine geographic regions.
Results: While the number of adolescents and young people is projected to increase by 10%
from 2010–2050, those living with HIV is projected to decrease by 61%. In Eastern and Southern
Africa, which hosts the largest HIV epidemic, new HIV infections among adolescents and young
people are projected to decline by 84% from 2010–2050. In West and Central Africa, which hosts
the second-largest HIV epidemic, new infections are projected to decline by 35%.
Conclusions: While adolescents and young people living with HIV are living longer and
ageing into adulthood, if current trends continue, the number of new HIV infections is not
projected to decline fast enough to end AIDS as a health threat in this age group. Regional
variations suggest that while progress in Eastern and Southern Africa could reduce the size of
the epidemic by 2050, other regions exhibit slower rates of decline among adolescents and
young people.

Background To end AIDS by 2030, the United Nations Joint

Programme on HIV/AIDS (UNAIDS) developed the
The global community has committed to ending
Fast-Track agenda. Under this agenda, the 95 – 95 –
AIDS as a public health threat by 2030. This means
95 goals for 2030 specify that 95 per cent of people
the number of new HIV infections and AIDS-related
living with HIV should know their HIV status,
deaths must decrease by 90 per cent between 2010
95 per cent of those who know their status should
and 2030 [1]. However, this goal will not be achieved
be on antiretroviral treatment, and 95 per cent of
unless greater attention is dedicated to preventing
those on treatment should be virally suppressed and
HIV infection among adolescents and young people.
sustained. The strategy also calls for a reduction of
In 2017, an estimated 3.9 million [2.1–5.7 million]
the current 1.6 million [1.3–2.1 million] annual num-
adolescents and young people aged 15–24 were living
ber of new HIV infections among adults to 200,000
with HIV. About 61 per cent of adolescents and
new HIV infections among adults by 2030 [1,2]. The
young people living with HIV are adolescent girls
Super – Fast Track agenda was set for 2020 to accel-
and young women (AGYW), and about 78 per cent
erate progress towards these 2030 goals for child,
live in sub-Saharan Africa. While new HIV infections
adolescent and young populations. Specifically, it
decreased by 20 per cent among adolescents and
calls for a reduction in the annual number of new
young people between 2010 and 2017, today they
HIV infections among adolescent girls and young
account for 36 per cent of new HIV infections
women to 100,000 in 2020 [3]. However, in 2017
among adults aged 15 and above. About 1,600 ado-
alone there were 340,000 [200,000–490,000] new
lescents and young people become infected with HIV
HIV infections among adolescent girls and young
every day [2].

CONTACT Aleya Khalifa [email protected] Division of Data, Research and Policy, United Nations Children’s Fund, 3 UN Plaza, New York, NY
10017, USA
© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2 A. KHALIFA ET AL.

women [2]. This means that new HIV infections change may also affect the absolute number of new HIV
among this population have been decreasing at an infections and total number of people living with HIV in
average annual rate of 3 per cent between 2010 and parts of the world where HIV incidence has increased or
2017, while a 13 per cent average annual rate of remained the same since 2010, namely Latin America
decrease has been required to achieve less than and the Caribbean, East Asia and the Pacific and Eastern
100,000 new infections by 2020. It is clear from Europe and Central Asia.
current estimates that the HIV response is off track By 2050, the population aged 15–24 is expected to
for this 2020 goal. increase by 10 per cent globally. This is mostly driven
HIV prevention has been particularly challenging by sub-Saharan Africa, where the population aged
in this population due to issues with social norms, 15–24 is projected to more than double [12]. Sub –
social vulnerability, high-risk sexual behaviour, policy Saharan Africa is also home to 72 per cent of new
barriers, poor care-seeking behaviours and access to HIV infections among adolescents and young people,
services [4–7]. HIV testing coverage remains low in and the number of new HIV infections among ado-
this age group for these same reasons. In South lescents and young people in the region has only
Africa, the country with the highest burden of HIV decreased by 22 per cent since 2010.
in the world, only 38 per cent of adolescent girls and The combination of a growing population of
29 per cent of adolescent boys in the general popula- young people, high fertility rates and persistent HIV
tion report testing for HIV in the last 12 months and incidence could impact the rate of reduction of new
receiving the results of the test [8]. Even among those HIV infections in various geographies. This paper
living with HIV in the United States, only an esti- uses an HIV epidemic model to assess the influence
mated 41 per cent of HIV-positive young people aged of HIV programme response and demographic fac-
13–29 know their HIV status [9]. Adolescents and tors such as trends in population size of adolescents
young people living with HIV also exhibit low adher- and youth, fertility rate, and HIV incidence on the
ence to antiretroviral therapy (ART). For example, future of the HIV epidemic for adolescents and
a meta-analysis from 53 countries found that 62 young people from 2010 to 2050. The ultimate objec-
[57–68] per cent of adolescents and young people tive of this analysis is to evaluate whether the HIV
living with HIV aged 12–24 adhered to therapy response is on track for global goals to end AIDS
[10]. This is of concern because 90 – 90 – 90 goals among adolescents and young people by 2030.
for 2020 call for 73 per cent prevalence viral load
suppression among people living with HIV, which
cannot be achieved without adequate adherence to
Methods
ART. The Namibia Population-based HIV Impact
Assessment (PHIA) found that 82 per cent and HIV projections were generated for 148 countries from
70 per cent of adult women and men living with the most recent country-produced HIV estimates using
HIV, respectively, were virally suppressed, but only the AIDS Impact Model (AIM) in Spectrum software
65 per cent of adolescent girls and young women and (Avenir Health, Glastonbury, CT, USA). 21 countries
61 per cent of adolescent boys and young men were with a 2018 Spectrum file and no historical HIV inci-
virally suppressed [11]. Evidence shows that the HIV dence data available (mostly in the Middle East, North
response is off-track for global targets among adoles- Africa and Western Europe) were excluded from the
cents and young people. To address this problem, analysis. Countries may not have historical HIV inci-
more evidence is needed to monitor progress towards dence data if no population-based survey has been
global HIV goals, understand barriers in HIV preven- conducted, or no data are available from routine sur-
tion, care and treatment, and improve interventions veillance or HIV programme data. The remaining
for this age group. countries have no Spectrum file at all. The Spectrum
Demographic shifts could impact the HIV response model utilizes both historical and latest demographic,
and pose an additional complication in preventing HIV epidemiologic and HIV programme data to inform
infection and improving treatment among adolescents HIV estimates and measure progress in the epidemic
and young people in countries experiencing population response [13,14]. Demographic data are gathered from
growth in this age group. Age structures have changed the United Nations Population Division’s World
over time and are projected to continue changing as Population Prospects or national census data belonging
countries undergo demographic transition. The recent to that country [12]. Epidemiologic data include scien-
2017 Revision of World Population Prospects shows that tifically-informed parameters and prevalence, inci-
while fertility rates are on the decline globally, some parts dence, or mortality data from surveillance, surveys
of the world are still projected to face population growth and special studies [15–18]. Finally, HIV programme
in adolescent and youth age groups between now and data are imported from national health information
2050 [12]. This projected growth is largest in the region systems. Methods are documented in the UNAIDS
most affected by HIV: sub – Saharan Africa. Population Annex on Methods [19].
 GLOBAL HEALTH ACTION 3

In the country-produced files, HIV incidence and Results

prevalence estimates are projected five years into the
The 148 countries included in this analysis repre-
future. However, for this analysis the timeframe in
sented about 95 per cent of adults aged 15 and
the model was extended to 2050 in order to assess
above and nearly 100 per cent of adults aged 15 and
possible demographic trends, which cannot be ade-
above living with HIV in 2017. For adolescents and
quately assessed using five years of projected esti-
young people aged 15–24, the countries included in
mates. This required various assumptions about
this analysis represented 97 per cent and 100 per cent,
how to project HIV incidence, and coverage of anti-
respectively, of the absolute population size and those
retroviral therapy (ART) and prevention of mother-
living with HIV. The following results are organized
to-child transmission (PMTCT) services past 2017
by the two output indicators: number of people living
(the last year in the model with observed data).
with HIV and number of new HIV infections.
Trends from 2013–2017 of ART and PMTCT cover-
age were extrapolated into the future using a log-linear
curve to reflect typical coverage trajectories in these key
HIV interventions. Coverage rates were held constant Projected number of people living with HIV
once they reached 95 per cent. For most countries, HIV
The proportion of the population that is in the 15–24
incidence trends from 2017–2022 were projected until
age group is projected to decline from 18 per cent in
2050 using a log-linear curve. A linear projection was
2010 to 14 per cent in 2050 (Figure 1). However,
applied for all countries where incidence was increasing
a more rapid pattern is projected for the population
from 2017–2022.
living with HIV from 2010 to 2050, as less adolescents
Two outputs were extracted from the Spectrum
living with HIV are projected to join that age group
AIDS impact model (AIM) to assess the trajectory
over time (Figure 2). In 2010, the majority of the
of the HIV epidemic over time and by five-year age
global population living with HIV was under the age
group and sex for each country by number of new
of 35, while in 2050 the majority of the population
HIV infections and people living with HIV. Although
living with HIV is projected to be under age 55.
the assumptions and projections were calculated at
Projections show a more dramatic ageing of the popu-
the national level, these were aggregated from the
lation living with HIV compared to the general popu-
regional and global level for this analysis, with speci-
lation. By 2050, the majority of the general population
fic focus on the 15–24 age group. All projections were
is projected to be under age 40; suggesting that in 2050
compared to 2010, which was the base year for the
the population living with HIV will be on average
Political Declaration on HIV and AIDS: On the Fast
older than the general population. In 2010, there
Track to Accelerating the Fight against HIV and to
were about 3.9 million adolescents and young people
Ending the AIDS Epidemic by 2030 [20]. Decade-long
aged 15–24 living with HIV (12 per cent of all people
increments are used to compare HIV projections over
living with HIV). This number is projected to decline
time: 2010, 2020, 2030, 2040 and 2050. All results
to 1.5 million (5 per cent of all people living with HIV)
were rounded to the nearest thousand to avoid false
in 2050. Between 2010 and 2050, the number of ado-
precision.
lescents and young people living with HIV is projected
Nine geographic regions based on UNICEF classi-
to decline by 61 per cent, compared to a 10 per cent
fication were used in this analysis: East Asia and the
decline in the general adolescent and youth popula-
Pacific, Eastern and Southern Africa, Eastern Europe
tion. By sex, the number of AGYW living with HIV
and Central Asia, Latin America and the Caribbean,
are projected to decline by 65 per cent while the
the Middle East and North Africa, North America,
number of adolescent boys and young men (ABYM)
South Asia, West and Central Africa, and Western
living with HIV are projected to decline by 55 per cent.
Europe.

2010 2030 2050

Male Female Male Female Male Female

80+ 80+ 80+

70-74 70-74 70-74

60-64 60-64 60-64

Five-year age group
Five-year age group

Five-year age group

50-54 50-54 50-54

40-44 40-44 40-44

30-34 30-34 30-34

20-24 20-24 20-24

10-14 10-14 10-14

00-04 00-04 00-04

400,000 200,000 0,000 200,000 400,000 400,000 200,000 0,000 200,000 400,000 400,000 200,000 0,000 200,000 400,000
Population size (thousands) Population size (thousands) Population size (thousands)

Figure 1. Population size (thousands) by age and sex, 2010, 2030 and 2050, UNAIDS 2018 estimates.
4 A. KHALIFA ET AL.

2010 2030 2050

Male Female Male Female Male Female

80+ 80+ 80+

70-74 70-74 70-74

60-64 60-64 60-64

Five-year age group

Five-year age group

Five-year age group

50-54 50-54 50-54

40-44 40-44 40-44

30-34 30-34 30-34

20-24 20-24 20-24

10-14 10-14 10-14

00-04 00-04 00-04

3,500,000 1,500,000 500,000 2,500,000 3,500,000 1,500,000 500,000 2,500,000 4,500,000 3,500,000 1,500,000 500,000 2,500,000
Number of people living with HIV Number of people living with HIV Number of people living with HIV

Figure 2. Number of people living with HIV by age and sex, 2010, 2030 and 2050, UNAIDS 2018 estimates.

The projected population living with HIV differs average annual rate of reduction) compared to 2030
by region (Table 1). The total adult population aged to 2050 (2.4 average annual rate of reduction).
15–49 living with HIV is projected to decline by at By region, the largest reduction in new HIV infec-
least 50 per cent in Eastern and Southern Africa, East tions among adolescents and young people from 2010
Asia and the Pacific and South Asia between 2010 to 2050 is projected for Eastern and Southern Africa
and 2050. In these same regions, the population aged (84 per cent) (Table 2). In East Asia and the Pacific,
15–24 living with HIV is projected to decline by at North America, and South Asia, the number of new
least 60 per cent. HIV infections among adolescents and young people
In West and Central Africa, the number of all is projected to decline by at least 57 per cent from
adults living with HIV is projected to decrease by 2010 to 2050. In Eastern Europe and Central Asia,
9 per cent between 2010 and 2050, while the number new HIV infections among those aged 15–24 are
of adolescents and young people living with HIV is projected to increase until 2040 and will decrease
projected to decrease by 33 per cent. thereafter. In West and Central Africa, the region
Further, the adult population aged 15–49 living with the second – highest burden, the number of
with HIV is projected to increase in Eastern Europe new HIV infections among adolescents and young
and Central Asia and Middle East and North Africa people is projected to decrease by 35 per cent
between 2010 and 2050. between 2010 and 2050 assuming incidence patterns
In Eastern Europe and Central Asia, the popula- follow current trends.
tion aged 15–24 living with HIV is projected to These regional projections result in sex-specific
increase by 28 per cent by 2030, but then growth is changes in the percent distribution of new HIV
expected to taper and then decline so that the overall infections among adolescents and young people by
increase between 2010 and 2050 will only be region (Figure 4). Among AGYW aged 15–24,
4 per cent. This is the only region with a projected 64 per cent of new HIV infections occurred in
increase in adolescent and youth populations living Eastern and Southern Africa in 2010. By 2050,
with HIV from 2010 to 2050. only 32 per cent of new HIV infections among
AGYW are projected to occur in Eastern and
Southern Africa – or a decrease from 270,000 in
Projected number of new HIV infections 2010 to 41,000 in 2050 in absolute numbers. By
2050, 40 per cent of new HIV infections among
Projected numbers of new HIV infections also differ AGYW are projected to occur in West and
by age, sex and region. Globally, new HIV infections Central Africa (compared to 18 per cent in 2010).
are projected to decline between 2010 and 2050, the Other regions that are projected to contribute more
most for adolescent girls aged 15–19 (70 per cent to the global total of new HIV infections among
decline) and young women aged 20–24 (70 per cent AGYW include Eastern Europe and Central Asia
decline) (Figure 3). The number of new HIV infec- (2 per cent in 2010 to 6 per cent in 2050) and
tions among ABYM is projected to decline by Latin America and the Caribbean (4 per cent in
59 per cent and 65 per cent, respectively. While 2010 to 8 per cent in 2050).
adolescent boys only accounted for 14 per cent of Among ABYM aged 15–24, 31 per cent of new
new HIV infections among adolescents and young HIV infections occurred in Eastern and Southern
people in 2010, this is projected to account for Africa in 2010, and this is projected to decline to
18 per cent in 2050. For all age groups, steeper 17 per cent of new HIV infections by 2050, while
reductions in the number of new HIV infections are 25 per cent is projected to occur in West and Central
projected to occur between 2010 and 2030 (3.1
Table 1. Number of people living with HIV by decade, region, age and sex, 2010–2050, UNAIDS 2018 estimates.
2010 2020 2030 2040 2050
% of adults % of adults % Change % of adults % Change % of adults % Change % of adults % Change
Region Estimate aged 15–49 Estimate aged 15–49 since 2010 Estimate aged 15–49 since 2010 Estimate aged 15–49 since 2010 Estimate aged 15–49 since 2010
Eastern and Southern Africa
Adults aged 15–49 14,476,000 15,841,000 9.4 12,284,000 −15.1 8,027,000 −44.6 5,218,000 −64.0
Adults aged 15–24 2,157,000 14.9 1,982,000 12.5 −8.1 1,459,000 11.9 −32.4 885,000 11.0 −59.0 548,000 10.5 −74.6
Girls and women aged 15–24 1,483,000 10.2 1,290,000 8.1 −13.0 913,000 7.4 −38.4 548,000 6.8 −63.0 336,000 6.4 −77.4
Boys and men aged 15–24 675,000 4.7 692,000 4.4 2.6 546,000 4.4 −19.0 337,000 4.2 −50.0 212,000 4.1 −68.5
East Asia and the Pacific
Adults aged 15–49 2,129,000 2,099,000 −1.4 1,693,000 −20.5 1,279,000 −40.0 1,062,000 −50.1
Adults aged 15–24 300,000 14.1 205,000 9.8 −31.7 167,000 9.9 −44.3 135,000 10.5 −55.1 110,000 10.3 −63.4
Girls and women aged 15–24 123,000 5.8 76,000 3.6 −38.7 57,000 3.4 −54.0 44,000 3.5 −64.1 34,000 3.2 −72.3
Boys and men aged 15–24 177,000 8.3 129,000 6.2 −26.8 110,000 6.5 −37.6 91,000 7.1 −48.8 76,000 7.1 −57.3
Eastern Europe and Central Asia
Adults aged 15–49 680,000 1,158,000 70.3 1,263,000 85.8 1,178,000 73.3 1,171,000 72.3
Adults aged 15–24 69,000 10.1 68,000 5.9 −1.5 88,000 7.0 27.5 92,000 7.8 33.2 72,000 6.1 4.2
Girls and women aged 15–24 33,000 4.8 34,000 2.9 2.5 44,000 3.5 34.9 45,000 3.8 35.9 35,000 3.0 7.4
Boys and men aged 15–24 36,000 5.3 34,000 3.0 −5.2 44,000 3.5 20.7 47,000 4.0 30.7 37,000 3.1 1.4
Latin America and the Caribbean
Adults aged 15–49 1,386,000 1,662,000 20.0 1,633,000 17.8 1,386,000 0.1 1,168,000 −15.7
Adults aged 15–24 224,000 16.2 214,000 12.9 −4.5 187,000 11.4 −16.8 167,000 12.1 −25.4 142,000 12.2 −36.6
Girls and women aged 15–24 92,000 6.7 86,000 5.2 −6.6 76,000 4.7 −17.3 69,000 5.0 −25.6 58,000 5.0 −36.8
Boys and men aged 15–24 132,000 9.5 128,000 7.7 −3.0 110,000 6.8 −16.4 99,000 7.1 −25.3 84,000 7.2 −36.5
Middle East and North Africa
Adults aged 15–49 119,000 150,000 26.3 156,000 31.1 145,000 21.5 141,000 18.8
Adults aged 15–24 16,000 13.7 14,000 9.1 −16.3 16,000 10.1 −4.0 16,000 11.0 −2.4 14,000 10.1 −13.1
Girls and women aged 15–24 7,000 5.6 6,000 4.1 −6.0 7,000 4.7 11.1 7,000 5.1 12.5 7,000 4.7 1.6
Boys and men aged 15–24 10,000 8.2 7,000 5.0 −23.3 8,000 5.4 −14.2 9,000 5.9 −12.5 8,000 5.3 −23.0
North America
Adults aged 15–49 567,000 628,000 10.9 624,000 10.2 529,000 −6.7 432,000 −23.7
Adults aged 15–24 74,000 13.0 58,000 9.2 −21.4 48,000 7.7 −34.4 40,000 7.6 −45.3 33,000 7.7 −55.0
Girls and women aged 15–24 20,000 3.6 16,000 2.6 −19.7 14,000 2.2 −32.1 12,000 2.2 −43.5 10,000 2.2 −53.4
Boys and men aged 15–24 53,000 9.4 42,000 6.6 −22.1 35,000 5.5 −35.2 29,000 5.4 −46.0 24,000 5.5 −55.5
South Asia
Adults aged 15–49 2,282,000 2,307,000 1.1 1,795,000 −21.3 1,363,000 −40.3 1,013,000 −55.6
Adults aged 15–24 260,000 11.4 231,000 10.0 −11.0 161,000 9.0 −38.0 103,000 7.6 −60.2 71,000 7.0 −72.8
Girls and women aged 15–24 121,000 5.3 108,000 4.7 −10.8 76,000 4.2 −37.6 48,000 3.6 −60.0 33,000 3.3 −72.6
Boys and men aged 15–24 139,000 6.1 123,000 5.3 −11.2 86,000 4.8 −38.4 55,000 4.0 −60.5 38,000 3.7 −73.0
West and Central Africa
Adults aged 15–49 4,485,000 4,480,000 −0.1 4,389,000 −2.1 4,229,000 −5.7 4,094,000 −8.7
Adults aged 15–24 787,000 17.6 788,000 17.6 0.1 733,000 16.7 −6.9 620,000 14.7 −21.3 529,000 12.9 −32.9
Girls and women aged 15–24 488,000 10.9 474,000 10.6 −2.9 443,000 10.1 −9.2 375,000 8.9 −23.2 323,000 7.9 −33.9
Boys and men aged 15–24 299,000 6.7 314,000 7.0 5.0 290,000 6.6 −3.0 245,000 5.8 −18.1 206,000 5.0 −31.1
Western Europe
Adults aged 15–49 313,000 311,000 −0.8 293,000 −6.6 268,000 −14.4 255,000 −18.6
Adults aged 15–24 37,000 11.7 31,000 10.1 −14.2 30,000 10.3 −17.3 28,000 10.4 −23.3 27,000 10.5 −26.7
Girls and women aged 15–24 13,000 4.3 11,000 3.7 −14.8 11,000 3.8 −17.6 10,000 3.8 −23.9 10,000 3.8 −26.9
Boys and men aged 15–24 23,000 7.4 20,000 6.4 −13.9 19,000 6.6 −17.2 18,000 6.7 −22.9 17,000 6.7 −26.5
Global
GLOBAL HEALTH ACTION

Adults aged 15–49 26,437,000 28,635,000 8.3 24,130,000 −8.7 18,404,000 −30.4 14,555,000 −44.9
Adults aged 15–24 3,925,000 14.8 3,592,000 12.5 −8.5 2,890,000 12.0 −26.4 2,087,000 11.3 −46.8 1,545,000 10.6 −60.6
Girls and women aged 15–24 2,381,000 9.0 2,102,000 7.3 −11.7 1,641,000 6.8 −31.1 1,158,000 6.3 −51.4 845,000 5.8 −64.5
5

Boys and men aged 15–24 1,544,000 5.8 1,491,000 5.2 −3.5 1,249,000 5.2 −19.1 929,000 5.0 −39.8 700,000 4.8 −54.6
6 A. KHALIFA ET AL.

Girls 15-19 Women 20-24 Boys 15-19 Men 20-24

250,000
231,723

195,263
200,000

187,602
154,823
150,000 137,532

137,039 114,998

106,080
100,000 87,662
103,031 100,111
69,755
80,966 84,912
71,620 68,559
50,000 63,663 56,304
50,068
42,219

Figure 3. Number of new HIV infections among adolescent and young people, by sex and five-year age group, 2010–2050,
UNAIDS 2018 estimates.

Africa (compared to 12 per cent in 2010). Other adolescent girls and young women in 2020 compared
regions that are projected to contribute more to the to the Super – Fast Track targets of less than 100,000
global total of new HIV infections among ABYM new HIV infections. Current trends in HIV incidence
include East Asia and the Pacific (9 per cent in 2010 and intervention coverage must change if an AIDS Free
to 13 per cent in 2050), Eastern Europe and Central Generation is to be achieved by 2030.While new HIV
Asia (3 per cent in 2010 to 7 per cent in 2050) and infections among adolescent girls and young women
Latin America and the Caribbean (6 per cent in 2010 are projected to decrease at an average annual rate of
to 13 per cent in 2050). −2 per cent between 2017 and 2030, the necessary rate
of reduction should be −14 per cent for infections to
decrease in this population in order to contribute to the
Discussion global 2030 goal of under 200,000 new HIV infections
These findings show that the total number of young among all people age 15 and above.
people newly infected with HIV will not surge over Finally, projections show that recent trends in the
time, given trends in population size, HIV incidence, HIV response, independent of demographic change,
and key HIV interventions. However, the pattern in may have a lasting effect on the future of the epidemic.
HIV infections and age and sex structure of people The number of people living with HIV would be
living with HIV will differ by region given region- expected to change in the same proportion to the total
specific population dynamics and epidemic trends. population if population change were the only factor.
After 2010, the global youth bulge population from Since projected numbers of people living with HIV are
previous decades will finally age out of the 20–24 age different from projected numbers of the general popu-
group. However, the number of adolescents and young lation, it is evident that demographic changes are not
people aged 15–24 is projected to grow at a slow and the only factor in HIV projections. Thus, this analysis
steady rate until 2050. Unlike the general population, the suggests that improvements in the HIV response could
age structure of the population living with HIV is pro- change the trajectory of the HIV epidemic for the better,
jected to change dramatically over the next 30+ years. despite demographic factors. However, it would be
The proportion of all people living with HIV in the helpful to quantify the contribution of demographic
15–24 age group is projected to decline as adolescents factors alone on HIV epidemic projections. For exam-
and young people age into adulthood. Since these projec- ple, a recent UNAIDS analysis showed that if popula-
tions do not mimic the general population age structure tion growth had been stable, the number of new HIV
these global HIV projections are more a function of infections among people in sub-Saharan Africa would
trends in the HIV response than of population change. have decreased by 19 per cent instead of 16 per cent
Findings on HIV projections differ by region. As pro- between 2010 and 2016 [21].
gress is made in Eastern and Southern Africa, the relative
burden of new HIV infections in adolescent and youth
Limitations
age groups is projected to tilt to other world regions.
The projections suggest that, with current trends, the This analysis includes some key limitations. First,
2020 Super – Fast Track targets are not likely to be some countries were excluded from the analysis. In
achieved in any region. For example, this analysis pro- 2018, 169 countries created a Spectrum file available
jected about 292,000 new HIV infections among through UNAIDS (representing 99 per cent of the
Table 2. Number of new HIV infections by decade, region, age and sex, 2010–2050, UNAIDS 2018 estimates.
2010 2020 2030 2040 2050
% of adults % of adults % Change % of adults % Change % of adults % Change % of adults % Change
Region Estimate aged 15–49 Estimate aged 15–49 since 2010 Estimate aged 15–49 since 2010 Estimate aged 15–49 since 2010 Estimate aged 15–49 since 2010
Eastern and Southern Africa
Adults aged 15–49 951,000 612,000 −35.7 400,000 −58.0 264,000 −72.2 181,000 −81.0
Adults aged 15–24 398,000 41.9 247,000 40.4 −37.9 154,000 38.6 −61.2 96,000 36.2 −76.0 62,000 34.5 −84.3
Girls and women aged 15–24 266,000 28.0 166,000 27.2 −37.5 104,000 26.0 −61.0 64,000 24.2 −76.0 41,000 22.6 −84.6
Boys and men aged 15–24 132,000 13.9 81,000 13.2 −38.7 50,000 12.6 −61.8 32,000 12.1 −75.8 22,000 11.9 −83.7
East Asia and the Pacific
Adults aged 15–49 165,000 133,000 −19.4 105,000 −36.1 90,000 −45.3 82,000 −50.4
Adults aged 15–24 64,000 38.5 43,000 32.4 −32.2 32,000 30.6 −49.2 27,000 29.4 −58.3 23,000 27.8 −64.2
Girls and women aged 15–24 25,000 15.2 15,000 11.0 −41.9 10,000 9.5 −60.2 8,000 8.7 −68.7 7,000 8.0 −73.8
Boys and men aged 15–24 38,000 23.3 28,000 21.4 −25.9 22,000 21.1 −42.1 19,000 20.7 −51.5 16,000 19.8 −57.9
Eastern Europe and Central Asia
Adults aged 15–49 97,000 123,000 27.0 118,000 20.9 106,000 9.4 102,000 5.4
Adults aged 15–24 19,000 19.9 17,000 13.6 −12.9 22,000 18.6 13.5 21,000 20.2 11.2 17,000 16.5 −12.2
Girls and women aged 15–24 8,000 8.6 8,000 6.2 −8.3 10,000 8.5 19.5 9,000 8.8 11.2 8,000 7.4 −9.8
Boys and men aged 15–24 11,000 11.2 9,000 7.4 −16.4 12,000 10.1 8.9 12,000 11.4 11.2 9,000 9.2 −14.0
Latin America and the Caribbean
Adults aged 15–49 105,000 104,000 −0.5 97,000 −7.3 88,000 −16.3 78,000 −25.6
Adults aged 15–24 41,000 38.8 38,000 35.9 −7.7 33,000 33.8 −19.0 30,000 33.7 −27.3 26,000 33.1 −36.4
Girls and women aged 15–24 15,000 14.7 14,000 13.6 −7.8 13,000 13.0 −18.3 11,000 13.0 −26.3 10,000 12.8 −35.2
Boys and men aged 15–24 25,000 24.1 23,000 22.3 −7.7 20,000 20.9 −19.5 18,000 20.7 −27.9 16,000 20.3 −37.2
Middle East and North Africa
Adults aged 15–49 12,000 11,000 −3.4 11,000 −8.6 10,000 −15.7 9,000 −20.0
Adults aged 15–24 3,000 29.7 3,000 24.6 −19.9 3,000 29.0 −10.8 3,000 30.3 −13.9 3,000 29.2 −21.4
Girls and women aged 15–24 1,000 11.3 1,000 10.4 −11.3 1,000 12.5 1.3 1,000 13.1 −2.1 1,000 12.9 −8.7
Boys and men aged 15–24 2,000 18.4 2,000 14.2 −25.1 2,000 16.4 −18.2 2,000 17.1 −21.2 1,000 16.2 −29.2
North America
Adults aged 15–49 43,000 34,000 −21.3 28,000 −34.4 23,000 −46.0 19,000 −55.5
Adults aged 15–24 14,000 33.0 11,000 31.3 −25.3 9,000 31.4 −37.6 7,000 31.9 −47.8 6,000 31.7 −57.3
Girls and women aged 15–24 4,000 8.5 3,000 8.3 −23.6 2,000 8.3 −35.8 2,000 8.5 −46.3 2,000 8.5 −55.9
Boys and men aged 15–24 11,000 24.5 8,000 23.0 −25.9 7,000 23.0 −38.2 5,000 23.5 −48.3 4,000 23.3 −57.7
South Asia
Adults aged 15–49 111,000 87,000 −21.4 68,000 −38.5 56,000 −49.6 50,000 −55.4
Adults aged 15–24 44,000 39.8 31,000 35.0 −30.8 21,000 31.0 −52.1 15,000 27.3 −65.4 12,000 24.4 −72.6
Girls and women aged 15–24 20,000 17.6 13,000 15.2 −31.7 9,000 13.5 −52.7 7,000 11.8 −66.1 5,000 10.6 −73.2
Boys and men aged 15–24 25,000 22.2 17,000 19.8 −30.1 12,000 17.5 −51.6 9,000 15.5 −64.8 7,000 13.9 −72.2
West and Central Africa
Adults aged 15–49 271,000 249,000 −8.0 233,000 −14.0 218,000 −19.4 210,000 −22.3
Adults aged 15–24 127,000 46.8 115,000 46.3 −9.1 104,000 44.7 −17.9 90,000 41.0 −29.4 82,000 39.1 −35.0
Girls and women aged 15–24 77,000 28.4 69,000 27.9 −9.8 64,000 27.3 −17.5 55,000 25.2 −28.4 51,000 24.2 −33.7
Boys and men aged 15–24 50,000 18.4 46,000 18.4 −8.0 41,000 17.4 −18.5 34,000 15.8 −30.8 31,000 14.9 −37.1
Western Europe
Adults aged 15–49 22,000 20,000 −10.4 18,000 −19.0 17,000 −23.7 16,000 −26.3
Adults aged 15–24 7,000 32.3 6,000 32.7 −9.3 6,000 34.3 −13.9 6,000 34.2 −19.1 6,000 34.3 −21.8
Girls and women aged 15–24 2,000 11.0 2,000 11.1 −9.4 2,000 11.6 −14.4 2,000 11.6 −19.8 2,000 11.6 −22.1
Boys and men aged 15–24 5,000 21.3 4,000 21.6 −9.2 4,000 22.7 −13.7 4,000 22.7 −18.8 4,000 22.6 −21.7
Global
GLOBAL HEALTH ACTION

Adults aged 15–49 1,777,000 1,374,000 −22.7 1,078,000 −39.3 872,000 −50.9 748,000 −57.9
Adults aged 15–24 718,000 40.4 510,000 37.1 −28.9 385,000 35.7 −46.4 294,000 33.7 −59.0 237,000 31.7 −67.0
Girls and women aged 15–24 419,000 23.6 292,000 21.2 −30.4 215,000 20.0 −48.7 159,000 18.3 −62.0 126,000 16.9 −69.9
7

Boys and men aged 15–24 298,000 16.8 218,000 15.9 −26.8 170,000 15.7 −43.1 135,000 15.5 −54.7 111,000 14.8 −62.9
8 A. KHALIFA ET AL.

Adolescent girls and young women Adolescent boys and young men
aged 15-24 aged 15-24 Western Europe
100% 100% North America
90% 90% Middle East and North Africa
Eastern Europe and Central Asia
80% 80%
Latin America and the Caribbean
70% 70%
South Asia
60% 60%
East Asia and the Pacific
50% 50% West and Central Africa

40% 40% Eastern and Southern Africa

30% 30%

20% 20%

10% 10%

0% 0%
2010
2012
2014
2016
2018
2020
2022
2024
2026
2028
2030
2032
2034
2036
2038
2040
2042
2044
2046
2048
2050

2010
2012
2014
2016
2018
2020
2022
2024
2026
2028
2030
2032
2034
2036
2038
2040
2042
2044
2046
2048
2050
Figure 4. Percent distribution of new HIV infections among adolescents and young people by region, 2010–2050, UNAIDS 2018
estimates.

global population). While some country models were age group and sex as the unit for analysis, which could
excluded from this analysis due to a lack of historical mask sub-population HIV incidence trends. For exam-
HIV incidence data, the final set of 148 countries ple, a study of HIV case reports in South-eastern China
represent 97 per cent of the global adolescent and found that the percent of new reported HIV cases in the
youth population and almost 100 per cent of the all 15–18 age group has decreased while the percent of new
adolescents and young people living with reported HIV cases in the 19–22 age group has
HIV. Second, projections are only as strong as the increased from 2000 to 2015 [33]. Local trends and
input data. Model inputs include population statis- finer age groups may elucidate further contextual fac-
tics, survey data and HIV programme data. The qual- tors that play a role in the projected number of new HIV
ity of HIV estimates depends on the robustness of infections among adolescents and young people.
input data, especially programme statistics. While the
issue of data quality cannot be completely addressed,
UNAIDS, WHO, UNICEF and other partners under- Conclusion
take a rigorous review of PMTCT and ART data to
minimize some errors. The quality of HIV estimates The numbers of young people living with HIV are
also depends on the accuracy of inherent assumptions projected to decline globally if current trends in HIV
and algorithms in the model, of which scientific lit- infection rates, programmatic response, and popula-
erature is reviewed biennially to implement any tion changes continue. However, HIV will remain
methodological changes. Knowledge of epidemic pat- a serious problem in regions where HIV testing, treat-
terns and programme effects is constantly improving ment and retention coverage remains low for this
which can cause modelled estimates to change from population group and where the adolescent and
one year to the next. The UNAIDS Reference Group young adult population is expected to increase in the
recommends changes based on the latest scientific coming decades. Strong efforts are needed to ensure
evidence but some gaps may remain [14,22–30]. For that the numbers continue to decline and to speed that
example, while the results suggest that HIV epidemic decline to achieve global targets. Regions of the world
projections differ by sex in each region, information with increasing HIV incidence like Eastern Europe and
about incidence rate ratios outside of sub-Saharan Central Asia must be targeted with locally appropriate
Africa is relatively weak due to sparse surveillance interventions. HIV prevention must continue to be
and survey data, in addition to small sample sizes in prioritized among adolescents and young people living
both data types [31,32]. Thus, there is limited cer- in high – prevalent areas. In these areas, the contextual
tainty around sex-specific projection patterns outside challenges to HIV prevention must be addressed [4].
of sub-Saharan Africa. Pre-exposure prophylaxis for adolescents at higher risk
Projections to 2050 assume that external factors will of HIV infection is one tool that can still be improved
remain the same as they were in 2018. This model does and brought to scale in high-prevalent areas, but more
not account for unforeseen changes in HIV treatment research is needed to inform effective implementation
availability, HIV-related policies, or funding contexts. of this interventions in adolescent populations [34–
Furthermore, this analysis aggregated country esti- 36]. These HIV prevention challenges are often gen-
mates to a regional level, thus masking country varia- dered. Adolescent boys and young men face different
tions. It also used national HIV estimates by five-year barriers to HIV prevention services compared to ado-
lescent girls and young women [5,37]. These findings
 GLOBAL HEALTH ACTION 9

demonstrate that the end of the HIV epidemic is not Data availability statement
close for adolescents and young people. By utilizing The data that support the findings of this study are openly
current trends in the HIV response in the epidemic available in national HIV estimates files published through
model, these results illustrate which populations and UNAIDS at http://www.unaids.org/en/dataanalysis/data
regions may need more attention to end AIDS as tools/spectrum-epp.
a public health threat by 2030. While reducing HIV
incidence in adolescence and young adulthood is cri-
ORCID
tical to ending the epidemic, it will also be important
to plan sustainable and integrated testing, care and Aleya Khalifa http://orcid.org/0000-0001-8234-1295
John Stover http://orcid.org/0000-0001-7236-1989
treatment programmes for this age group- and as
Mary Mahy http://orcid.org/0000-0001-6023-3023
they age.

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