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Chris Collins is Chief of the Community Mobilization Division at UNAIDS. Thoughts expressed are his own.
All the recent scientific advances in the response to AIDS present the world with a stark choice: accelerate delivery of HIV treatment and prevention and drive down HIV infection and mortality, or settle for the status quo and accept a grave, avoidable AIDS epidemic for decades to come.
New targets from UNAIDS make this clear. They are based on a modeling exercise that asked where HIV service levels need to be in six years (by 2020) if we want to be on a path so that by 2030 HIV infection and death are down to a tenth of where they were in 2010, and HIV-related discrimination is also dramatically reduced.
We can debate the details of any analysis, but the bottom line is inescapable. Without ramped up delivery of lifesaving treatment and targeted prevention in the next five years, along with advances in non-discrimination and human rights that make these services possible, the AIDS epidemic will remain a serious global health threat as far as we can see. We have the chance to change that outcome—but will we seize it?
Ambitious targets are critical now because the health of the global AIDS response is in question. Funding has slowed; stigma and discrimination continue to magnify vulnerability and have worsened in some places. The world needs ambitious targets that will drive new resources based on the evidence and human rights.
Today’s targets need to be different than those of the past. The “3 by 5 Initiative” and “15 by 15” set our sights on reaching millions with lifesaving HIV treatment. As powerful as these initiatives were, it is time for bold targets that do not close coverage gaps alone—new targets should address the interconnection of treatment, prevention and human rights, as well as the quality of service delivery, in making accelerated progress.
In July UNAIDS announced a new HIV treatment target, “90 90 90,” that calls for, by 2020, 90% of people living with HIV to know their HIV status, 90% of them to be receiving sustained antiretroviral therapy, and 90% of them to have achieved viral suppression. Taken together, the three 90s would mean that 73% of people living with HIV have achieved viral suppression by 2020, a threefold increase from current estimates. (In September President Zuma of South Africa, U.S. Secretary of State Kerry, and others endorsed 90 90 90.)
UNAIDS is now consulting with partners to develop prevention and non-discrimination targets that will promote action alongside the new treatment targets. In September, UNAIDS announced one aspect of the prevention target: to reduce annual new HIV infections to 500,000 or lower by 2020, a 75% decrease from 2010 levels.
The targets represent a new phase in goal setting for the global AIDS response. The viral suppression treatment target puts a premium on quality healthcare outcomes for people living with HIV, in addition to the total number of people reached. In July, over 40 AIDS advocacy groups called for the opportunity for viral suppression for all treatment eligible people by 2020 (here). As they emphasized, respect for human rights must underpin this effort, with respect for personal choice and vigilance against coercion in health services.
The new targets also emphasize equity. The treatment target report (here) points out that key population groups need to realize the same levels of coverage and quality treatment outcomes as everyone else. The prevention target will also highlight the need for major reductions in HIV incidence among key populations, including people who inject drugs, sex workers, gay men and other men who have sex with men, transgender people, and young women and girls.
There is no doubt the new targets are very ambitious. They assert that countries and populations all over the world should be able, in the next six years, to achieve what model programs have achieved - or are near achieving - today. For example, it is estimated that in Latin America 70% of people living with HIV know their status; in Botswana 69% of people living with HIV (PLWH) are receiving lifesaving treatment; in Chile and Venezuela retention rates in treatment are at 90% or above; in Rwanda 83% of PLWH on ART have achieved viral suppression.
Targets are about making change: pushing for new money, strategic investments, and advances in human rights. The targets need to be used as a tool for confronting barriers like drug pricing, discrimination, failing health systems, and underfinancing. They need to be a means for dramatically advancing the response among key population groups and promoting the critical enablers that make services possible, including much greater emphasis on community-provided services and treatment and rights literacy.
The next step is to put the targets to work in financing and national planning. UNAIDS is now working on a Fast Track initiative that will analyze where countries stand in implementing bold targets and help advocates and policy makers fill the gaps.
The next five years are crucial in the trajectory of the AIDS epidemic. A decade ago the “3 by 5” target galvanized advocates, funders and policy makers and changed our conception of what was possible. Today we need that kind of ambition for dramatic advances in HIV treatment reach and quality, prevention and human rights.