AIDS is not over.

2058 www.thelancet.com Vol 380 December 15/22/29, 2012 Optimism and momentum has been building around the real possibility that an AIDS-free generation is imminent. Public enthusiasm is fuelled by news about the rapid scale-up of antiretroviral therapy, evidence that HIV treatment can prevent new infections, and expanded cover age of programmes to prevent mother-to-child transmission of HIV. Yet, the most recent estimates of HIV prevalence and incidence and of AIDS-related mortality released by UNAIDS, together with data from the Global Burden of Disease Study 2010 in The Lancet, make it clear that AIDS is not over. The estimates from the Global Burden of Disease Study 2010 confi rm that HIV/AIDS remained a leading cause of disease burden and death in 2010. It was ranked 33rd in 1990, but its burden had moved up to fi fth by 2004 and remained there in 2010, despite major declines in AIDS-related mortality as a result of fewer new infections and the increased availability of antiretroviral therapy, care, and support. Looking at the most common causes of death globally, HIV/AIDS ranked sixth in 2004 and held the same position in 2010. The Global Burden of Disease Study 2010 estimates 1·5 million AIDS-related deaths in 2010, whereas UNAIDS data show 1·8 (range 1·6–2·0) million AIDS-related deaths. Both estimates highlight a persistent, signifi cant, and egregious burden of avoidable death. Worldwide AIDS-related deaths increased dramatically during the late 1980s and peaked in 2005–06, followed by a steep decline to 2010–11. Yet, despite substantial reductions in AIDS mortality rates in many countries, AIDS remains the leading cause of death in southern and eastern Africa, and ranks number three in eastern Europe. Furthermore, AIDS continues to aff ect young people disproportionately. In 2010, AIDS was the leading cause of death in women aged 15–49 years (14·4%) and the second most common cause of death for men aged 15–49 years (10·7%). UNAIDS estimated that 34 (range 31·4–35·9) million people lived with HIV in 2011, with substan tial geographical variations. Adult prevalence remains highest in sub-Saharan Africa at 4·9% (range 4·6–5·1%). The good news is that since 2001, annual HIV incidence has fallen in 38 countries, most of them in sub-Saharan Africa. However, new infections are on the rise in some countries in eastern Europe, central Asia, the Middle East, and north Africa. It is a cause for concern that 2·5 (range 2·2-2·8) million people were newly infected with HIV in 2011. One of the great global health achievements of the past decade has been the scale-up of HIV treatment. In 2011, more than 8 million people living with HIV in low-income and middle-income countries received antiretroviral treatment. Largely because of this unprecedented scale-up, supplemented by expanded HIV prevention services, the numbers of AIDS-related deaths and incidence rates worldwide have steadily decreased. To consolidate and intensify the accomplishments of the past decade, and to save millions of lives now in jeopardy, we must confront four realities. First, it will be impossible to sustain current eff orts to tackle HIV and AIDS with current levels of funding. In 2015, when resource needs are expected to peak, an estimated US$22–24 billion per year will be needed, but international AIDS funding has been stagnant since 2009 at about $8·2 billion per year. Many countries have increased their domestic funding for HIV, notably Benin, China, and South Africa, and they are to be supported and further encouraged. 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