Fewer people in India are dying from HIV/AIDS, tuberculosis, and malaria than a decade ago, but Indians still face enormous health threats from the three diseases, according to a new, first-of-its-kind analysis of trend data. The pace of decline in deaths and infections has accelerated since 2000, when the Millennium Development Goals (MDGs) were established worldwide to stop the spread of these diseases by 2015.
Of the three diseases, India has made the most progress against HIV/AIDS. The Indian annual rate of decline in new infections since 2000 was more than four times that of the worldwide rate, a decrease of 16.3% per year compared to the global drop of 3.9%. Gains during the same time period for TB and malaria were only slightly higher than the worldwide average.
Published in The Lancet on July 22, the study, “Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013,” was conducted by an international consortium of more than 1,000 researchers from 106 countries, and was led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. The research consortium included nearly 20 experts in India.
The GBD 2013 study provides a consistent and comprehensive approach to estimating the impact in India and around the world of HIV, TB, and malaria from 1990 to 2013. In a novel approach, IHME analyzed and triangulated incidence, prevalence, and deaths over time. Special emphasis was also given to incorporating new data, more rigorously identifying sources of uncertainty, and accounting for biases that may be present in various data sources.
“This massive new study, on the eve of the end of the MDG era, documents impressive recent progress against HIV and malaria, in particular, but it also shows that much more needs to be done,” said Dr. Alan Lopez, Melbourne Laureate Professor at the University of Melbourne and co-founder of the GBD study. “All three are major causes of health loss in poor countries, and all three should be a key focus of concerted global health action and support. Without it, we risk stagnation, or even worse, unconscionable reversal of recent gains.”
Due in large part to India’s success, age-standardized rates of incidence, prevalence, and mortality for HIV/AIDS in 2013 were far lower for South Asia than other parts of the world. Despite these gains, more than 78,600 Indians – nearly 50,000 of them males – died last year from HIV/AIDS, and 31,057 new cases were recorded.
Researchers found that the expansion of interventions for HIV/AIDS—including antiretroviral therapy (ART), programmes to prevent mother-to-child transmission (PMTCT), and the promotion of condom use—have helped drive reductions in years of life lost to the disease, particularly in more recent years. HIV is increasingly a condition people live with rather than die from, and the world has added nearly 20 million life years as a result of these programmes.
“The global investment in HIV treatment is saving lives at a rapid clip,” said Dr. Christopher Murray, IHME Director and a co-founder of the GBD study with Dr. Lopez. “But the quality of antiretroviral programs varies widely. In order to reduce HIV-related deaths even further, we need to learn from the best programs and do away with the worst ones.”
Researchers found that greater access to treatment is needed as well. Globally, in 2013, there were nearly 30 million people living with HIV/AIDS, 1.8 million new cases, and 1.3 million deaths from the disease. At the peak of the epidemic in 2005, HIV/AIDS caused 1.7 million deaths. Global HIV/AIDS incidence peaked in 1997 with 2.8 million new infections and has declined since the peak at 2.7% per year. The epidemic remains concentrated in sub-Saharan Africa.
The study reveals substantial changes to previous understanding of HIV epidemics. Improvements in IHME’s methodology revealed that cumulatively, countries identified as having concentrated epidemics had 39 per cent fewer deaths and 53 per cent fewer people living with HIV. In contrast, deaths in countries with generalized epidemics increased by 23 per cent, and the HIV-infected populations were slightly higher by 3 per cent.
On TB, the study says in India, success at reducing the prevalence of TB has fallen behind global progress, despite more significant gains against HIV/AIDS. Around the world, prevalence of TB in people without HIV/AIDS infection in 2013 was 160.2 (out of 100,000 people) but India’s prevalence was 275.3. Last year, more than 545,500 Indians who did not suffer from HIV died from TB; males were almost twice as likely to be victims of the deadly disease.
These grim statistics mask the beginnings of progress. TB mortality rates globally have declined between 2000 and 2013, due largely to progress in South and East Asia. South Asia, a region where the population is dominated by India, accounts for almost half of TB deaths. TB mortality rates in the region declined annually over the course of the past decade by 4.2 per cent, compared to the global decline of 3.7 per cent. In East Asia, TB death rates fell annually by 7.5 per cent.
Earlier and more effective treatment has helped shorten the duration of TB infections, but the authors note that as the world ages, higher numbers of cases and deaths will occur. When looking at death rates that are age-standardized, meaning they were adjusted for differences in population size and ages over time and across countries, the highest rates for TB were in sub-Saharan Africa (Lesotho, Somalia, and Burundi all had over 150 deaths per 100,000 in 2013).
“As the world’s population grows older, tuberculosis will remain a major health threat,” said Dr. Nobhojit Roy of the BARC Hospital in India and a co-author of the study. “TB presents unique challenges across different countries and regions, and better data will help drive the most effective strategies to address it.”
In 2013, there were 7.1 million new TB cases in people without HIV/AIDS, and the disease caused 1.3 million deaths worldwide.
Similar to HIV and TB, researchers found that an increased focus due to the Millennium Development Goals has helped drive down malaria infections and deaths in India and worldwide.
India has seen a considerable decrease in mortality due to malaria, halving the number of deaths per 100,000 between 1990 and 2013. But malaria remains a tremendous health burden for Indians, killing more than 116,000 people last year; 60.7 million cases of the disease were recorded in 2013. The global malaria epidemic peaked in the early 2000s, at 232 million cases in 2003 and 1.2 million deaths in 2004. Worldwide, there were 164.9 million malaria cases and 854,568 deaths due to malaria in 2013.
As with HIV/AIDS, the burden of malaria is concentrated in sub-Saharan Africa; however, India was one of three countries, along with Nigeria and the Democratic Republic of the Congo (DRC), where roughly half of all malaria deaths occurred in 2013. Only a few countries outside of sub-Saharan Africa recorded higher malaria mortality rates than India’s 11 deaths per 100,000 (Papua New Guinea, Myanmar, and Yemen), whereas many of India’s neighbors had malaria mortality rates between 1 to 2 deaths per 100,000.
The Institute for Health Metrics and Evaluation (IHME) is an independent global health research organization at the University of Washington that provides rigorous and comparable measurement of the world’s most important health problems and evaluates the strategies used to address them.