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. 2025 Dec 3;138(24):3434–3442. doi: 10.1097/CM9.0000000000003867

Global, regional, and national burden of HIV and other sexually transmitted infections, 1990–2021, and forecasts to 2030: A population-based analysis based on the Global Burden of Disease Study 2021

Zhenhao Wu 1,2,3,4, Lanfeng Yue 1,2,3,4, Zhenxing Chu 1,2,3,4, Yongjun Jiang 1,2,3,4,✉, Qinghai Hu 1,2,3,4,✉
Editor: Yanjie Yin
PMCID: PMC12721775  PMID: 41342243

Abstract

Background:

Monitoring the progression of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) is crucial for evidence-based decision-making in prevention and control strategies. This study aimed to delineate the global, regional, and national burden of these infections from 1990 to 2021 and forecast trends to 2030.

Methods:

We retrieved data from the Global Burden of Disease (GBD) study 2021, including incidence and disability-adjusted life-years (DALYs) of HIV and other STIs from 1990 to 2021. Trends were quantified using estimated annual percentage changes (EAPCs) in age-standardized incidence and DALY rates. The Bayesian age-period-cohort (BAPC) model was used to forecast the future burden from 2022 to 2030.

Results:

In 2021, global epidemiological surveillance documented 1,645,333 incident cases of HIV and 722,752,642 incident cases of other STIs. Concurrently, the burden of disease analysis revealed 40,266,792 DALYs attributable to HIV and 7,953,311 DALYs linked to STIs worldwide. The global age-standardized incidence rate (ASIR) of HIV declined from 36.7 (95% uncertainty interval [UI]: 33.0–40.6) per 100,000 population in 1990 to 20.7 (95% UI: 17.7–24.4) in 2021 per 100,000 population, with an EAPC of −2.58% (95% confidence interval [CI]: −2.95% to −2.20%). In contrast, the ASIR of other STIs remained relatively stable, changing from 8692.6 (95% UI: 6256.5–11,811.2) per 100,000 in 1990 to 8871.7 (95% UI: 6388.4–12,055.1) per 100,000 in 2021, with an EAPC of −0.02% (95% CI: –0.07% to 0.03%). The BAPC model predicts a decline in the ASIR of HIV to 12.9 (95% UI: 4.3–21.5) per 100,000 by 2030, whereas the ASIR of other STIs is expected to increase to 9150.0 (95% UI: 7913.6–10,386.3) per 100,000. Regionally, Sub-Saharan Africa is projected to have the highest ASIRs of HIV and other STIs in 2030, with estimates of 38.4 (95% UI: 11.7–65.2) and 13,865.8 (95% UI: 11,915.6–15,816.0) per 100,000 population, respectively.

Conclusions:

Despite declining HIV ASIRs, DALY burdens remain high, with significant regional disparities. HIV and other STIs continue to pose major public health challenges, necessitating targeted interventions, early sexual health education, enhanced screening, and cost-effective policies informed by GBD 2021 data.

Keywords: Human immunodeficiency virus, HIV, Sexually transmitted infections, Disease burden, Bayesian projections, Bayesian age-period-cohort

Introduction

Human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) remain a persistent global public health challenge, with significant epidemiological disparities in transmission dynamics and intervention efficacy across sexually active populations.[1,2] Despite a decline in HIV-related mortality, approximately 39 million individuals still live with HIV, with nearly 630 thousand annual deaths, predominantly in Sub-Saharan Africa.[3] The global STI burden in 2020 was substantial, with 374 million cases, including 7.1 million syphilis, 82 million gonorrhea, 129 million chlamydia, and 156 million trichomonas infections.[4] Renewed interest in HIV prevention has driven increased research investment and the development of promising new prevention strategies.[5] However, gaps in standardized surveillance systems and inconsistent reporting, particularly in low-resource settings, hinder precise estimation of concentrated HIV/STI epidemics among high-risk groups.[6] The persistent HIV burden, with no significant decline,[1] is largely attributed to inequitable healthcare resource distribution across regions. Meanwhile, the rising global STI incidence reflects shifting social norms toward greater sexual liberation, facilitated in part by the availability of oral contraceptives since the 1960s.[7] In addition, although pre-exposure prophylaxis (PrEP)[8] has shown efficacy in reducing HIV transmission, its widespread use may inadvertently promote unprotected sexual encounters, potentially accelerating STI spread.

In response to the ongoing HIV and STI crisis, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) have established ambitious targets for 2030[9,10] aimed at eliminating these epidemics. UNAIDS seeks to reduce global HIV incidence and mortality by 75% from 2010 to 2020 and by 90% by 2030 globally,[11] while WHO aims for a 90% reduction in syphilis and gonorrhea incidence.[10] Zheng et al[7] and Lu et al[12] using data from the Global Burden of Disease (GBD) 2019, comprehensively assessed the global HIV and STI burden. However, these diseases exhibit temporal and spatial variability, necessitating continuous updates. The impact of the coronavirus disease 2019 (COVID-19) pandemic on the global HIV/STI landscape also warrants scrutiny, and GBD 2021 incorporates these critical data, offering a timely assessment. This study aims to evaluate the current and projected burden of HIV and STIs while monitoring progress toward global targets.

Methods

Study population

We retrieved cross-sectional data on HIV and other STIs from the GBD 2021 study through the Global Health Data Exchange (GHDx) tool. This study provides comprehensive estimates for 369 diseases and injuries across 204 countries and territories from 1990 to 2021. Our analysis focused on HIV, syphilis, chlamydia, gonorrhea, trichomoniasis, and genital herpes, based on the availability of burden estimates in the GBD 2021 dataset.

Data collection

Using GBD 2021 data (https://ghdx.healthdata.org/gbd-results/), we extracted key metrics, including incidence, prevalence, mortality, and disability-adjusted life years (DALYs)—stratified across six 5-year age groups. The methodology and data sources for STI burden estimation are detailed in the GBD 2021 appendix,[1] grounded in previous research.[1,3]

GBD 2021 also introduced the sociodemographic index (SDI), an integrated measure of socioeconomic determinants of health. The SDI is derived from the geometric mean of three normalized indicators (ranging from 0 to 1): fertility rate under 25 years, mean years of education for individuals aged 15 years and above, and lag-distributed per capita income.[13] Countries are categorized into five SDI tiers: low, low-middle, middle, high-middle, and high.

Statistical analysis

Age-standardized rates per 100,000 population, obtained from the GBD database, were used to analyze temporal, gender, and regional disparities in STI burden while controlling for population age structure. Uncertainty intervals (UIs) at the 95% level were calculated from the 2.5th and 97.5th percentiles of 1000 ordered draws.

To project HIV/STI cases and age-standardized rates from 2022 to 2030, we applied a Bayesian age-period-cohort (BAPC) model, which accounts for age-related risk factors as well as period- and cohort-specific influences. This model, structured as a log-linear Poisson framework, assumes multiplicative effects among age, period, and cohort variables. Implementation was performed using the R-BAPC and R-INLA packages.[14] The 95% confidence interval (CI) for the estimated EAPC is obtained from the regression model.

Smoothing spline models were used to evaluate the relationship between the burden of STIs and the SDI across 21 regions and 204 countries/territories. By incorporating both SDI and disease rates, these models enabled the derivation of expected values. We applied the Locally Weighted Scatterplot Smoothing (LOWESS) technique to fit smooth splines, with spline degrees, knot numbers, and positions determined in a data-driven manner based on the span parameter. In addition, Spearman correlation analysis quantified the strength (r indices) and statistical significance (P <0.05) of the association with SDI.

All data analysis and mapping were conducted using R software (version 4.4.0, R Foundation, Vienna, Austria).

Results

Global trends from 1990 to 2021, forecasting to 2030

In 2021, global epidemiological surveillance documented 1,645,333 incident cases of HIV and 722,752,642 incident cases of STIs. Concurrently, the burden of disease analysis revealed 40,266,792 DALYs attributable to HIV and 7,953,311 DALYs linked to STIs worldwide. The global age-standardized incidence rate (ASIR) of HIV declined from 36.7 (95% uncertainty interval [UI]: 33.0–40.6) per 100,000 population in 1990 to 20.7 (95% UI: 17.7–24.4) per 100,000 in 2021, with an EAPC of −2.58% (95% CI: −2.95% to −2.20%). The BAPC model projects a further decline to 12.9 (95% UI: 4.3–21.5) per 100,000 by 2030 [Table 1]. From 2021 to 2030, the global ASIR of HIV continued to decline, whereas the age-standardized DALYs (ASDR) rate initially increased before stabilizing [Figure 1A]. The ASDR of HIV rose from 347.0 (95% UI: 257.3–466.0) per 100,000 in 1990 to 496.3 (95% UI: 417.4–603.9) per 100,000 in 2021, with an EAPC of −0.54% (95% CI: −1.98% to 0.92%) [Table 2].

Table 1.

Number and incidence rate of HIV and other STIs by sex and age at 1990, 2021 and projected 2030.

Category Number of cases (95% UI) Age-standardized incidence rate per 100,000 population (95% UI) EAPC (95% CI), % (1990–2021)
1990 2021 2030 1990 2021 2030
HIV
Global 2,008,916 (1,809,497 to 2,220,628) 1,645,333 (1,408,052 to 1,936,178) 1,108,751 (370,935 to 1,846,566) 36.7 (33.0 to 40.6) 20.7 (17.7 to 24.4) 12.9 (4.3 to 21.5) −2.58 (−2.95 to −2.20)†
Sex
Male 916,531 (852,687 to 990,409) 851,686 (766,117 to 944,187) 635,580 (248,294 to 1,022,867) 33.8 (30.0 to 38.0) 21.1 (17.3 to 25.8) 13.9 (6.1 to 21.7) −2.27 (−2.62 to −1.92)†
Female 1,092,385 (977,941 to 1,208,438) 793,647 (703,406 to 901,252) 473,171 (122,642 to 823,699) 39.6 (34.9 to 44.8) 20.4 (17.5 to 23.9) 10.5 (3.3 to 17.7) −2.86 (−3.25 to −2.46)†
7 GBD super-regions
Central Europe, Eastern Europe, and Central Asia 15,288 (10,530 to 20,980) 170,006 (102,713 to 281,661) 233,838 (0 to 1,290,218) 3.5 (2.4 to 4.9) 39.8 (24.4 to 66.3) 29.8 (−34.4 to 94.0) 8.53 (7.77 to 9.29)†
High-income 125,244 (94,369 to 156,405) 110,021 (63,656 to 16,4123) 94,418 (0 to 189,206) 13.1 (9.8 to 16.4) 10.4 (6.1 to 15.5) 7.7 (1.0 to 14.4) 0.08 (−0.23 to 0.40)
Latin America and Caribbean 91,118 (75,595 to 11,0336) 121,335 (76,763 to 186,280) 92,951 (12,817 to 173,496) 23.6 (19.6 to 28.6) 19.3 (12.2 to 29.6) 12.4 (2.6 to 22.2) 0.00 (−0.37 to 0.38)
North Africa and Middle East 3498 (1492 to 9481) 26,786 (10,813 to 70,188) 46,035 (21,495 to 70,575) 1.1 (0.5 to 3.1) 4.1 (1.7 to 10.7) 5.6 (2.8 to 8.4) 3.07 (2.63 to 3.51)†
South Asia 20,066 (11,348 to 33,222) 98,389 (56,382 to 19,1852) 123,673 (0 to 601,045) 2.0 (1.1 to 3.4) 5.1 (2.9 to 9.9) 2.7 (−3.4 to 8.8) −2.10 (−4.11 to −0.06)†
Southeast Asia, East Asia, and Oceania 83,076 (55,169 to 117,817) 141,042 (93,688 to 213,119) 167,658 (0 to 375,585) 4.5 (3.0 to 6.5) 6.8 (4.4 to 10.4) 7.2 (0.0 to 14.3) 0.50 (0.12 to 0.89)†
Sub-Saharan Africa 1,670,626 (1,456,222 to 1,892,642) 977,754 (804,091 to 1,183,329) 551,605 (140,754 to 962,456) 377.8 (327.9 to 430.4) 95.8 (78.9 to 115.4) 38.4 (11.7 to 65.2) −4.90 (−5.25 to −4.54)†
Other STIs*
Global 455,951,390 (329,195,941 to 615,997,008) 722,752,642 (519,916,135 to 983,945,513) 810,673,563 (701,188,358 to 920,158,769) 8692.6 (6256.5 to 11,811.2) 8871.7 (6388.4 to 12,055.1) 9150.0 (7913.6 to 10,386.3) −0.02 (−0.07 to 0.03)
Sex
Male 251,395,034 (211,058,830 to 303,382,974) 395,707,155 (333,181,719 to 478,335,321) 442,874,741 (384,818,176 to 500,931,306) 9548.1 (6825.6 to 13,100.0) 9619.5 (6888.9 to 13,170.6) 9856.0 (8612.4 to 11,099.6) −0.03 (−0.07 to 0.02)
Female 204,556,356 (173,081,775 to 244,693,272) 327,045,487 (275,523,643 to 398,027,388) 367,798,822 (316,370,182 to 419,227,463) 7822.8 (5610.6 to 10,615.0) 8121.7 (5803.6 to 11,052.4) 8400.9 (7268.5 to 9533.3) 0.00 (−0.07 to 0.07)
7 GBD super-regions
Central Europe, Eastern Europe, and Central Asia 41,020,985 (29,455,778 to 55,906,561) 40,731,083 (29,232,707 to 55,830,622) 38,404,571 (34,587,354 to 42,221,789) 9503.5 (6816.2 to 12,950.7) 9599.6 (6900.6 to 13,084.4) 9532.3 (8597.8 to 10,466.8) 0.01 (−0.01 to 0.02)
High-income 45,777,080 (3,158,0283 to 65,197,505) 52,117,408 (35,776,824 to 74,833,024) 51,123,960 (45,416,028 to 56,831,893) 4651.1 (3213.7 to 6612.9) 4651.5 (3194.3 to 6633.4) 4566.4 (4069.7 to 5063.0) −0.04 (−0.07 to −0.02)†
Latin America and Caribbean 42,290,589 (30,260,746 to 57,096,402) 73,289,767 (51,920,437 to 100,681,033) 79,110,273 (68,124,277 to 90,096,268) 11,587.9 (8236.7 to 15,806.7) 11,455.0 (8123.7 to 15,712.2) 11,378.6 (9883.3 to 12,873.8) −0.03 (−0.05 to −0.01)†
North Africa and Middle East 26,663,129 (19,137,620 to 36,228,305) 55,794,563 (39,445,275 to 77,154,804) 63,808,922 (56,283,950 to 71,333,894) 8873.5 (6338.5 to 12,150.1) 8393.9 (5943.8 to 11,597.5) 8319.9 (7355.1 to 9284.7) −0.20 (−0.22 to −0.18)†
South Asia 61,711,326 (44,115,003 to 84,770,282) 11,9667,712 (85,643,800 to 165,429,068) 142,627,619 (117,496,292 to 167,758,946) 6208.1 (4447.6 to 8525.6) 6065.8 (4342.3 to 8389.9) 6301.7 (5301.9 to 7301.5) −0.10 (−0.12 to −0.09)†
Southeast Asia, East Asia, and Oceania 178,357,485 (126,562,762 to 245,802,815) 237,867,193 (168,502,297 to 330,567,171) 248,028,345 (211,491,586 to 284,565,103) 10,160.2 (7200.8 to 14,054.4) 10,089.3 (7154.4 to 13,958.7) 10,704.2 (9187.9 to 12,220.5) −0.17 (−0.28 to −0.07)†
Sub-Saharan Africa 60,130,796 (43,918,264 to 80,330,314) 143,284,916 (103,239,003 to 193,751,938) 183,625,233 (155,869,048 to 211,381,418) 14,994.0 (10,809.2 to 20,392.0) 14,423.3 (10,288.6 to 19,790.3) 13,865.8 (11,915.6 to 15,816.0) −0.22 (−0.25 to −0.18)†
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Data in parentheses are 95% UIs for cases and incidence rate, and 95% CIs for EAPCs. *Other STIs comprised syphilis, chlamydia, gonorrhea, trichomoniasis, and genital herpes. †EAPC is statistically significant at the 5% α level. CI: Confidence interval; EAPC: Estimated annual percentage change; HIV: Human immunodeficiency virus; STI: Sexually transmitted infection; UI: Uncertainty interval.

Figure 1.

Figure 1

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Global age-standardized incidence and DALY rates of HIV (A) and other STIs (B) from 1990 to 2021, forecasting to 2030, by sex. Other STIs comprised syphilis, chlamydia, gonorrhoea, trichomoniasis, and genital herpes. DALYs: Disability-adjusted life-years; HIV: Human immunodeficiency virus; STI: Sexually transmitted infection.

Table 2.

Number and DALYs rate of HIV and other STIs by sex and age at 1990, 2021 and projected 2030.

Category Number of cases (95% UI) Age-standardized DALY rate per 100,000 population (95% UI) EAPC (95% CI), % (1990–2021)
1990 2021 2030 1990 2021 2030
HIV
Global 18,673,403 (13,921,454 to 25,033,333) 40,266,792 (33,931,094 to 48,906,119) 50,044,236 (0 to 108,122,359) 347.0 (257.3 to 466.0) 496.3 (417.4 to 603.9) 574.4 (0 to 1242.7) −0.54 (−1.98 to 0.92)
Sex
Male 9,308,640 (7,281,981 to 1,1945,246) 1,9157,019 (15,963,604 to 23,523,143) 22,864,841 (0 to 46,467,317) 348.2 (270.9 to 448.4) 466.4 (388.0 to 573.5) 457.9 (50.4 to 865.4) −0.54 (−1.82 to 0.76)
Female 9,364,763 (6,566,792 to 13,110,725) 21,109,773 (16,789,316 to 27,028,502) 27,179,395 (0 to 61,655,042) 345.6 (240.5 to 485.2) 528.0 (419.7 to 676.0) 538.5 (−27.5 to 1104.6) −0.53 (−2.11 to 1.07)
7 GBD super-regions
Central Europe, Eastern Europe, and Central Asia 323,400 (317,696 to 333,457) 1,565,042 (1,504,830 to 1,653,894) 1,740,967 (442,855 to 3,042,006) 75.2 (73.9 to 77.5) 338.1 (325.1 to 357.6) 359.1 (120.6 to 597.7) 5.04 (4.37 to 5.71)†
High-income 2,178,880 (2,122,093 to 2,252,148) 741,086 (633,747 to 877,409) 944,284 (0 to 3,393,862) 222.9 (217.2 to 230.3) 57.7 (50.0 to 67.7) 46.4 (−39.2 to 131.9) −5.91 (−6.57 to −5.25)†
Latin America and Caribbean 1,187,542 (1,021,590 to 1,432,349) 1,982,272 (1,851,627 to 2,145,965) 1,789,434 (509,465 to 3,069,403) 319.9 (274.8 to 387.2) 312.0 (290.6 to 338.7) 241.1 (79.9 to 402.2) −1.40 (−2.06 to −0.73)†
North Africa and Middle East 40,783 (28,099 to 76,188) 563,053 (344,001 to 1,131,452) 776,495 (221,578 to 1,331,412) 13.2 (9.0 to 24.6) 87.4 (52.3 to 179.2) 91.5 (34.9 to 148.2) 5.21 (4.12 to 6.31)†
South Asia 18,632 (9174 to 34,935) 2,457,111 (1,465,872 to 4,428,636) 5,582,225 (0 to 43,921,160) 1.9 (0.9 to 3.5) 129.9 (77.6 to 234.8) 84.7 (−140.5 to 309.8) 8.93 (4.12 to 13.96)†
Southeast Asia, East Asia, and Oceania 723,859 (648,374 to 795,022) 3,261,429 (2,703,643 to 4,085,021) 2,559,340 (0 to 5,918,185) 40.5 (35.8 to 45.0) 133.6 (111.5 to 166.5) 91.2 (−9.9 to 192.3) 2.75 (1.51 to 4.00)†
Sub-Saharan Africa 14,200,306 (9,625,729 to 20,327,943) 29,696,799 (24,027,307 to 37,249,752) 43,750,674 (0 to 104,684,896) 3163.8 (2033.3 to 4665.9) 3247.6 (2646.1 to 4053.0) 2811.6 (−320.3 to 5943.5) −1.90 (−3.49 to −0.29)†
Other STIs*
Global 8,789,664 (3,503,296 to 16,602,714) 7,953,311 (3,371,682 to 15,337,092) 8,008,305 (6,233,771 to 9,782,838) 146.0 (59.2 to 274.6) 116.9 (48.6 to 226.8) 116.1 (90.0 to 142.3) −1.24 (−1.42 to −1.05)†
Sex
Male 4,662,174 (1,794,997 to 9,111,680) 4,087,927 (1,654,344 to 8,006,270) 3,952,470 (3,032,578 to 4,872,362) 149.7 (58.5 to 291.4) 118.1 (47.2 to 232.3) 112.8 (87.2 to 138.4) −1.27 (−1.46 to −1.09)†
Female 4,127,490 (1,689,384 to 7,776,339) 3,865,384 (1,674,110 to 7,521,597) 4,055,835 (3,201,193 to 4,910,476) 141.9 (59.0 to 266.4) 115.3 (48.8 to 226.2) 117.7 (93.7 to 141.8) −1.21 (−1.39 to −1.02)†
7 GBD super-regions
Central Europe, Eastern Europe, and Central Asia 79,654 (53,967 to 121,386) 70,543 (43,160 to 11,5848) 64,520 (45,008 to 84,031) 18.5 (12.5 to 28.3) 16.2 (9.6 to 27.0) 15.3 (11.1 to 19.6) −0.64 (−0.84 to −0.43)†
High-income 128,047 (75,156 to 218,673) 129,508 (71,981 to 227,988) 129,679 (109,615 to 149,744) 13.9 (8.1 to 23.9) 11.4 (6.3 to 20.4) 10.9 (9.4 to 12.5) −0.56 (−0.64 to −0.48)†
Latin America and Caribbean 288,043 (149,861 to 518,683) 294,649 (156,088 to 532,877) 317,345 (256,842 to 377,849) 65.7 (34.9 to 117.5) 54.3 (28.1 to 99.2) 55.0 (45.2 to 64.7) −0.80 (−0.96 to −0.65)†
North Africa and Middle East 412,021 (151,706 to 844,426) 330,051 (138,505 to 665,864) 380,830 (262,848 to 498,812) 86.5 (33.1 to 175.3) 53.6 (22.4 to 108.2) 33.4 (24.4 to 42.3) −1.35 (−1.80 to −0.89)†
South Asia 2,468,667 (962,036 to 4,896,978) 1,892,629 (798,737 to 3,835,754) 3,521,754 (1,753,136 to 5,290,373) 168.9 (68.8 to 329.2) 116.5 (48.3 to 238.0) 126.9 (67.8 to 186.0) −2.68 (−3.21 to −2.15)†
Southeast Asia, East Asia, and Oceania 1,159,469 (473,111 to 2,308,323) 987,515 (434,319 to 1,879,876) 765,457 (596,796 to 934,117) 67.4 (27.7 to 133.9) 60.7 (25.0 to 118.1) 50.4 (39.4 to 61.3) −0.01 (−0.26 to 0.23)
Sub-Saharan Africa 4,253,763 (1,626,995 to 7,977,994) 4,248,416 (1,709,489 to 8,406,067) 4,536,742 (3,598,786 to 5,474,699) 507.1 (200.5 to 946.7) 263.9 (109.7 to 517.3) 237.2 (190.3 to 284.1) −2.42 (−2.58 to −2.26)†
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Data in parentheses are 95% uncertainty intervals for DALYs and DALY rate, and 95% CIs for EAPCs. *Other STIs comprised syphilis, chlamydia, gonorrhea, trichomoniasis, and genital herpes. †EAPC is statistically significant at the 5% α level. CI: Confidence interval; DALYs: Disability-adjusted life-years; EAPC: Estimated annual percentage change; HIV: Human immunodeficiency virus; STI: Sexually transmitted infection; UI: Uncertainty interval.

Globally, the ASIR of other STIs remained relatively stable, increasing slightly from 8692.6 (95% UI: 6256.5–11,811.2) per 100,000 in 1990 to 8871.7 (95% UI: 6388.4–12,055.1) per 100,000 in 2021, with an EAPC of −0.02% (95% CI: −0.07% to 0.03%). The BAPC model predicts an increase in ASDR for other STIs to 9150.0 (95% UI: 7913.6–10,386.3) per 100,000 by 2030 [Table 1]. The ASDR of other STIs declined from 146.0 (95% UI: 59.2–274.6) per 100,000 in 1990 to 116.9 (95% UI: 48.6–226.8) per 100,000 in 2021, with an EAPC of −1.24% (95% CI: −1.42% to −1.05%) [Table 2]. Between 2021 and 2030, the ASIR of other STIs is projected to rise, while the ASDR of HIV initially declines before increasing again [Figure 1B].

Global trends by sex and age group

Gender-based analyses revealed that women had lower HIV ASIR rates than men, with a slightly faster rate of decline [Table 1]. The ASDR of HIV remained stable for both genders from 1990 to 2021 [Table 2]. In 2021, the highest incidence of HIV was observed in the 25 to 29 year-old population in low-SDI regions. The highest prevalence, mortality, and DALY burden of HIV in 2021 were concentrated in the 30 to 34 year-old population in low-SDI regions [Figure 2A].

Figure 2.

Figure 2

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Number of age-specific incidence, prevalence, deaths, and DALYs of HIV (A) and other STIs (B) in 5 SDI regions. Other STIs comprised syphilis, chlamydia, gonorrhea, trichomoniasis, and genital herpes. DALYs: Disability-adjusted life-years; SDI: Sociodemographic index; STI: Sexually transmitted infection.

Similarly, the ASIR of other STIs remained stable for both genders from 1990 to 2021 [Table 1], and ASDR for other STIs exhibited no significant change over time [Table 2]. In 2021, the highest incidence of other STIs occurred in the 20 to 24 year-old population in low-SDI regions. The highest prevalence was reported in the 25 to 29 year-old population, whereas the highest mortality and DALY burden were observed in children under 5 years old in low-SDI regions [Figure 2B].

Regional trends and association between regional burden and SDI

Regionally, Sub-Saharan Africa is projected to have the highest HIV ASIR by 2030, reaching 38.4 (95% UI: 11.7–65.2) per 100,000 [Table 1]. The region is also expected to have the highest DALY burden for HIV, with a predicted 43,750,674 (95% UI: 0–104,684,896) per 100,000 [Table 2]. Nationally, Gambia is projected to have the highest HIV ASIR, estimated at 99.5 (95% UI: −13.1 to 212.1) per 100,000 by 2030 [Supplementary Table 1, http://links.lww.com/CM9/C654]. Notably, regions such as Southern Sub-Saharan Africa, High-income Asia Pacific, and Western Europe exhibited higher-than-expected HIV ASDR from 1990 to 2021, surpassing SDI-based projections. Across regions, HIV ASDR was negatively correlated with SDI (r = −0.56, P <0.001) [Figure 3A], with the highest burden in low- and low-middle SDI regions.

Figure 3.

Figure 3

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Age-standardized DALY rates for HIV (A) and other STIs (B) across 21 GBD regions by the sociodemographic index, 1990–2021. Expected values, calculated based on SDI and disease rates across all locations, are represented by a solid line; expected values based on a calculation accounting for the SDI and disease rates across all locations. For each region, 32 points are plotted, representing the observed age-standardized DALY rates for each year from 1990 to 2021. Points plotted above the solid line signify a higher-than-expected burden, while those below the line indicate a lower-than-expected burden. Other STIs comprised syphilis, chlamydia, gonorrhea, trichomoniasis, and genital herpes. DALYs: Disability-adjusted life-years; GBD: Global Burden of Diseases, Injuries, and Risk Factors Study; HIV: Human immunodeficiency virus; SDI: Sociodemographic index; STI: Sexually transmitted infection.

For other STIs, Sub-Saharan Africa is also expected to have the highest ASIR by 2030, reaching 13,865.8 (95% UI: 11,915.6–15,816.0) per 100,000 [Table 1]. The region is projected to bear the highest DALY burden of other STIs, estimated at 4,536,742 (95% UI: 3,598,786–5,474,699) per 100,000 [Table 2]. Unexpectedly high ASDR levels were observed in Southern and Central Sub-Saharan Africa, Oceania, and other regions from 1990 to 2021, exceeding SDI-based projections. ASDR for other STIs was strongly negatively correlated with SDI (r = −0.84, P <0.001; [Figure 3B]), with low- and low-middle SDI regions facing the highest burden.

Global burden ranking of HIV and other STIs

In both males and females, trichomoniasis had the highest incidence in 1990 and 2021, rising from 4265.2 (2467.4–6776.1) to 4353.4 (2514.7–6903.6) per 100,000 population in males and from 3635.1 (2041.1–5951.8) to 3921.3 (2195.6–6431.6) per 100,000 in females [Supplementary Table 2, http://links.lww.com/CM9/C654]. Genital herpes remained the most prevalent STI in both years, increasing from 8407.9 (6756.8–10,236.4) to 8697.6 (6952.2–10,634.0) per 100,000 in males and from 14,348.4 (11,882.1–17,028.5) to 14,859.5 (12,090.5–17,856.3) per 100,000 in females [Supplementary Table 3, http://links.lww.com/CM9/C654]. HIV accounted for the highest DALYs in both years [Supplementary Table 4, http://links.lww.com/CM9/C654]. Among STIs excluding HIV, syphilis had the greatest DALY burden in 1990 and 2021 [Supplementary Table 4, http://links.lww.com/CM9/C654].

Discussion

Although global efforts have led to a steady annual decline in HIV ASIR since 1997, substantial reductions in HIV-related DALYs remain elusive. Concurrently, the ASIR and the burden of other STIs have increased. By 2030, Sub-Saharan Africa is projected to be the regional epicenter of HIV and STIs, with Gambia expected to have the highest national HIV ASIR. Notably, ASIR and ASDR for HIV and STIs are inversely correlated with the SDI, disproportionately affecting low and lower-middle-SDI regions. The 20–29 years age cohort bears the highest ASIR, underscoring the urgency for targeted interventions to reduce global disparities in HIV and STI outcomes.

During 1990–2021, the burden of HIV and other STIs evolved in response to various interventions. Following a peak in HIV incidence in 1997, a gradual decline ensued, coinciding with the introduction of antiretroviral therapy (ART) that same year.[15] This decline likely reflects the global expansion of ART over two decades, reinforced by its widespread adoption, intensified HIV prevention efforts, and increased global funding for HIV control.[16] In addition, the downward trend may be attributed to the promotion of PrEP since 2012.[8] In contrast, STI incidence has surged, mirroring findings by Zheng et al[7], potentially driven by the increased popularity of PrEP,[8] rising rates of unprotected sex, insufficient early screening and treatment, and inadequate sexual health education.[17] Recent evidence suggests that doxycycline postexposure prophylaxis reduces STI infection rates by 66%.[18] However, concerns over potential drug resistance hinder its widespread adoption, with only a few guidelines, most notably from New York and San Francisco, supporting its use.[19] Consequently, high-quality evidence is urgently needed to inform future research and guideline development. Overall, our GBD 2021 study highlights critical insights for policymakers on optimizing HIV and STI intervention strategies.

Our findings indicate a declining ASIR of HIV from 1990 to 2030. However, DALYs have not declined significantly, with pronounced disparities across regions, genders, and age groups. Low- and lower-middle-SDI regions bear the highest HIV burden, emphasizing the potential impact of targeted prevention efforts in these areas. Alarmingly, HIV-related DALYs in 2021 nearly doubled compared to 1990, aligning with findings by Liang et al.[20] Although HIV incidence has declined slightly more steeply, consistent with global trends[21]—women continue to face disproportionately higher infection risks and associated morbidities due to social discrimination, inadequate support, and comorbidities.[22] Sustained prevention and control measures with a gender-specific focus are therefore crucial. The highest HIV incidence was reported in the 25–29 years age group, consistent with GBD 2019 data.[23] Priority should be placed on controlling HIV among young women aged 25–29 years, particularly in Sub-Saharan Africa,[24] where they remain at the epicenter of the epidemic and key drivers of its persistence. Our GBD 2021 analysis further identifies SDI regions with higher disease burdens, offering critical guidance for policymakers in designing cost-effective interventions.

The ASIR of STIs is rising, with significant geographical disparities in health outcomes. Sub-Saharan Africa, Latin America, and the Caribbean report the highest ASIR of STIs (excluding HIV), whereas North America, Western Europe, and Australasia report the lowest. This pattern aligns with WHO findings from 1999[25] and remains consistent with the epidemiology of syphilis, gonorrhea, chlamydia, and trichomoniasis reported in 2016.[26] These trends broadly correspond with the findings of Zhang et al[27] and Fu et al[28] with minor discrepancies likely attributable to differences in the age groups analyzed. The high burden of STIs in Sub-Saharan Africa and Latin America is likely driven by persistent poverty, limited healthcare access, low sexual health awareness, inadequate screening, and lower treatment rates—factors that render low-income countries disproportionately vulnerable compared to high-income regions.[29] Therefore, intensified public health efforts and resource allocation are essential for advancing STI elimination campaigns, particularly in low-income countries.

The disparities in four key epidemiological indicators across age groups and SDI regions are noteworthy. Figure 2 demonstrates that high ART coverage in high- and high-middle-SDI regions significantly reduces these metrics compared with lower-SDI regions.[30] Middle-SDI regions bear the highest burden of other STI cases, largely due to their larger populations.[1] HIV incidence is predominantly concentrated among young adults (20–29 years), while prevalence is highest among middle-aged individuals (30–49 years), reflecting the chronic nature of HIV and the efficacy of evolving prevention and treatment strategies.[29] The substantial burden of STI-related deaths and DALYs in infants under five underscores the urgency of early screening, health education, and mother-to-child transmission prevention.[31] Moreover, rising sexual health concerns among infants, low-income populations, and other vulnerable groups necessitate urgent, in-depth research and sustained intervention efforts.

In this study, we forecasted the ASIR of HIV and other STIs from 2022 to 2030 using the BAPC model. Our projections are primarily based on observed gender disparities in 2021 and align with WHO’s anticipated global population trends, corroborating findings from the GBD 2019 study.[20] If global health indicators and economic conditions improve significantly, our SDI-based analysis suggests that the actual ASIR of non-HIV STIs could fall well below our projections. In addition, increased global investments in STI prevention and treatment, along with greater sexual health awareness, could further accelerate this decline.[32,33] These findings highlight the critical role of strategic investment and public health interventions in combating HIV and other STIs.[34] The GBD 2021 report, for the first time, integrates global HIV and STI data amid the ongoing COVID-19 pandemic. Pandemic control measures implemented during COVID-19[35] led to a temporary decline in STI incidence in multiple regions. Although social distancing restricted sexual interactions and reduced transmission, the reallocation of healthcare resources to COVID-19 management inadvertently disrupted access to STI screening, treatment, and sexual health services.[36–38] COVID-19 has had a complex impact on STI transmission and management, warranting further investigation into its long-term effects on STI prevalence and control.

A key strength of this study lies in its analysis of GBD 2021 data, underscoring the substantial global burden of HIV and other STIs, particularly in low-income countries with poor sanitation and limited access to treatment. Reducing this burden is crucial for global health efforts, necessitating a deeper understanding of STI impacts to inform targeted interventions and optimize public health strategies. However, this study has certain limitations. First, the STI burden in low- and low-middle-SDI regions may be underestimated due to inadequate screening, potentially introducing bias. Second, the absence of gender minority data in GBD 2021 limits the representativeness of our findings. Last, while the GBD database provides valuable insights, our reliance on it is constrained by variations in data quality and occasional data omissions.

In conclusion, addressing disparities in healthcare resource allocation across SDI regions is essential, given their strong correlation with the burden of HIV and other STIs. Policymakers could refer to leverage GBD 2021 data to design cost-effective interventions that mitigate STI impact and improve global health outcomes.

Funding

The study was supported by grants from the National Natural Science Foundation of China (Nos. 82473696, 82073620), Department of Science and Technology of Liaoning Province Project for the High-Quality Scientific and Technological Development of China Medical University (No. 2025JH2/102800057), and the Non-profit Central Research Institute Fund of Chinese Academy of Medical Sciences (No. 2023-PT320-01).

Conflicts of interest

None.

Supplementary Material

cm9-138-3434-s001.pdf (1.2MB, pdf)
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Footnotes

Zhenhao Wu and Lanfeng Yue contributed equally to this work.

How to cite this article: Wu ZH, Yue LF, Chu ZX, Jiang YJ, Hu QH. Global, regional, and national burden of HIV and other sexually transmitted infections, 1990–2021, and forecasts to 2030: A population-based analysis based on the Global Burden of Disease Study 2021. Chin Med J 2025;138:3434–3442. doi: 10.1097/CM9.0000000000003867

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