90-90-90 treatment target

The challenges for the AIDS response in small island developing states are unique. Increasingly, they face natural disasters, community displacement and migration. On these small islands, HIV is most prevalent among key populations—sex workers, gay men and other men who have sex with men and people who inject drugs—and most HIV infections are among young people.

In a recent visit to Seychelles, Michel Sidibé, the UNAIDS Executive Director, addressed a meeting on laws, policies and strategies to meet the 90–90–90 targets—whereby, by 2020, 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads—in small island developing states.

Mr Sidibé highlighted the need for small island developing states to protect the human rights of key populations and to invest in HIV prevention and treatment services for adolescents and young people. He also stressed the importance of improving economic opportunities for communities.

During his visit, Mr Sidibé also addressed the Seychelles National Assembly to stress the importance of ensuring that Seychelles is on the Fast-Track towards ending AIDS. Despite Seychelles’ efforts towards meeting the 90–90–90 targets, new HIV infections among key populations are continuing to grow, highlighting the need to reach populations at higher risk of HIV with effective HIV services.

Mr Sidibé commended the President of Seychelles, Danny Faure, for his bold leadership of the national AIDS response and his commitment to build a generation without AIDS. 

GENEVA/NEW YORK, 20 September 2017—UNAIDS congratulates Lesotho and Uganda on the progress made towards ending AIDS shown in their respective Population-Based HIV Impact Assessments (PHIAs).

According to the new Lesotho PHIA results, HIV viral load suppression—a key marker indicating that the body is successfully suppressing the virus—has reached 68% among all adults living with HIV between the ages of 15 and 59 years. People living with HIV with suppressed viral loads live longer, have fewer complications due to HIV and are less likely to transmit the virus. The findings suggest that Lesotho is on track to achieve the 90–90–90 targets by 2020, whereby 90% of people living with HIV know their status, 90% of people who know their status are accessing treatment and 90% of people on treatment are virally suppressed.  

The Uganda PHIA results indicate that 60% of adults living with HIV between the ages of 15 and 64 years are virally suppressed. The results demonstrate that Uganda is making steady progress towards its national goal of reaching 73% viral load suppression among adults living with HIV between the ages of 15 and 49 years by 2020. Uganda’s epidemic has stabilized in part due to increases in the coverage of voluntary medical male circumcision for HIV prevention and the expansion of HIV treatment, including for pregnant women living with HIV.

“The Population-Based HIV Impact Assessment studies demonstrate that by committing to the 90–90–90 targets countries are making progress faster,” said UNAIDS Executive Director Michel Sidibé. “Working together with the United States President’s Emergency Plan for AIDS Relief and partners, Lesotho and Uganda are saving lives and getting on track to ending AIDS.”

In addition to the Lesotho and Uganda surveys, similar data from Malawi, Swaziland, Zambia and Zimbabwe were gathered through nationally representative household surveys, in collaboration with local governmental and nongovernmental partners, in 2016. The surveys for Lesotho and Uganda were conducted with funding from the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and assistance from the United States Centers for Disease Control and Prevention and ICAP at Columbia University’s Mailman School of Public Health.

UNAIDS thanks the United States of America for its commitment to the global AIDS response. On 19 September 2017, PEPFAR released its new Strategy for Accelerating HIV/AIDS Epidemic Control (2017–2020). The strategy reaffirms the United States Government’s leadership and commitment to support the response to HIV in more than 50 countries and is in line with the Fast-Track Targets.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

Zambia has launched its AIDS Response Fast-Track Strategy 2017–2021, which provides a road map to achieve the global Fast-Track prevention and 90–90–90 targets whereby 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads.

Building on the results achieved so far, the strategy has three main objectives: establish clear approaches to accelerate the HIV response for everyone, including key populations; set yearly targets at the national and provincial levels; and estimate costs and the resources gap.

So far, the government’s commitment has had significant impact: new HIV infections have decreased from 69 000 in 2005 to 59 000 in 2016 and coverage of pregnant women receiving antiretroviral medicines to prevent mother-to-child transmission of HIV has increased to 87%. Efforts to reach the most vulnerable people are being made, and new national policies outline targets and strategies to intensify prevention services in all the 10 provinces of the country.

The strategy provides for specific facility-based and community-led programmes, such as accelerating HIV testing and counselling in districts with high HIV prevalence, targeting key populations and integrating testing with other health-care services. 

The strategy will guarantee access to HIV treatment and care services and improve HIV testing services. One of the treatment goals emphasized in the strategy is the total elimination of new HIV infections among children.

The strategy was developed by a technical task team led by the National HIV/AIDS/STI/TB Council and UNAIDS.

Health department representatives from Amsterdam, Nairobi, Paris, San Francisco and São Paulo gathered during a Fast-Track Cities Symposium at the 2017 International AIDS Conference on HIV Science in Paris. They shared their lessons learned and challenges in preventing new HIV infections and addressing barriers to health.

Amsterdam is among the first cities to have reached the 90-90-90 targets whereby 90% of people living with HIV know their HIV status, 90% of people diagnosed are on treatment, and 90% of people on treatment are virally suppressed.

Many other cities like Paris are on the right track and have mobilized political commitment for the Fast-Track Cities agenda.  With support from the core partners of the Fast-Track Cities network, including UNAIDS, International Association of Providers of AIDS Care, the City of Paris and UN Habitat, cities are adopting innovative approaches to reach affected populations, to optimize linkages to HIV treatment and care, and to address different gaps according to the cities.

Early HIV diagnosis has boosted early treatment uptake as has using strategic data to improve various HIV programmes.  The cities of Bangkok, Nairobi and New Orleans launched city dashboards at the conference, illustrating significant progress.  Baseline 90-90-90 data published include 79-57-79 for Bangkok, 77-96-86 for Nairobi, and 87-69-91 for New Orleans.  Additional data presented at the afternoon session showed 87-65-91 for São Paulo, 93-79-91 for San Francisco and 94-90-94 for Amsterdam.

Since the 2014 launch of the Paris Declaration—Fast-Track Cities: Ending the AIDS Epidemic—more than 200 cities and municipalities around the world have committed to the achieving the 90-90-90 targets by 2020. Almaty in Kazakhstan was the latest city to sign the declaration on 20 July 2017.

Hundreds of the world’s leading HIV researchers, programme planners and implementers and civil society advocates gathered prior to the 2017 IAS Conference on HIV Science to assess progress towards the 90-90-90 targets. The workshop, sponsored by the International Association of Providers of AIDS Care (IAPAC) and UNAIDS, in partnership with the Global Network of People Living with HIV, focused on the latest data on progress and on new opportunities to continue to speed gains towards the 90-90-90 milestones.

The targets were launched by UNAIDS in 2014 to accelerate progress so that, by 2020, 90% of all people living with HIV know their HIV status, 90% of all people with diagnosed HIV are accessing sustained antiretroviral therapy and 90% of all people accessing antiretroviral therapy are virally suppressed. In 2016, for the first time, more than two-thirds of people living with HIV knew their HIV status and more than half of all people living with HIV had access to antiretroviral therapy.

Celebrating the marked advances made towards each of the three 90s, attendees agreed that attainment of 90-90-90 and ultimate control of the epidemic are achievable. New evidence of sharp declines in HIV incidence in numerous countries in eastern and southern Africa demonstrates that HIV treatment scale-up is not only reducing AIDS-related deaths but also contributing to epidemic control.

Following a keynote address by UNAIDS Executive Director Michel Sidibé, the workshop began with a dialogue between health ministers and senior ministerial officials from Botswana, Cambodia, Lesotho and Panama and global health leaders. This political session highlighted examples of how numerous countries are translating strong political commitment on AIDS into achievement of the 90-90-90 target.

Workshop sessions focused on areas where the push for 90-90-90 is falling short, on populations that are being left behind, and on potentially transformative opportunities to close these gaps. With the greatest gap across the HIV treatment cascade occurring at the first 90, participants called for an HIV testing revolution, including initiatives to nest HIV testing with screening programmes for other health conditions. Workshop presentations also underscored the importance of rapid roll-out of HIV self-testing.

To attain 90-90-90, it is clear that services must be expanded beyond health facilities and brought closer to the communities that need them. This conclusion was buttressed by findings from the SEARCH and PopART trials, which employed community-centred approaches to generate rapid progress towards the 90-90-90 targets. To enable the rapid scale-up of community-based services, African Union Heads of State this month enthusiastically endorsed a new regional initiative to recruit, train and deploy 2 million community health workers.

Multiple workshop sessions focused on challenges in reaching populations that are being left behind, including men, adolescent girls and young women, and such key populations as gay men and other men who have sex with men, people who inject drugs, sex workers and transgender people. Data presentations on diverse national and local experiences highlighted various strategies to close testing and treatment gaps among these groups, including service delivery strategies tailored to these groups, investment in communities, and strategies to minimize stigma and discrimination, including law and policy reform.

New resources will be needed to Fast-Track the global AIDS response, as amounts available for HIV programmes are roughly 25% short of the resource target for the Fast-Track response. According to modelling data presented at the workshop, South Africa could save US$3 billion and avert 1 million AIDS-related deaths by front-loading investments to reach 90-90-90, compared to continuation of the current pace of scale-up. 

The 90–90–90 targets are galvanizing global action and saving lives. Eastern and southern Africa leading the way in reducing new HIV infections by nearly 30% since 2010—Malawi, Mozambique, Uganda and Zimbabwe have reduced new HIV infection by nearly 40% or more since 2010. Concerted efforts still needed for children, adolescents, men and key populations, and in certain regions.

GENEVA/PARIS, 20 July 2017—UNAIDS has released a new report showing that for the first time the scales have tipped: more than half of all people living with HIV (53%) now have access to HIV treatment and AIDS-related deaths have almost halved since 2005. In 2016, 19.5 million of the 36.7 million people living with HIV had access to treatment, and AIDS-related deaths have fallen from 1.9 million in 2005 to 1 million in 2016. Provided that scale-up continues, this progress puts the world on track to reach the global target of 30 million people on treatment by 2020.

“We met the 2015 target of 15 million people on treatment and we are on track to double that number to 30 million and meet the 2020 target,” said Michel Sidibé, Executive Director of UNAIDS. “We will continue to scale up to reach everyone in need and honour our commitment of leaving no one behind.”

The region showing the most progress is eastern and southern Africa, which has been most affected by HIV and which accounts for more than half of all people living with HIV. Since 2010, AIDS-related deaths have declined by 42%. New HIV infections have declined by 29%, including a 56% drop in new HIV infections among children over the same period, a remarkable achievement resulting from HIV treatment and prevention efforts that is putting eastern and southern Africa on track towards ending its AIDS epidemic.

WHAT’S ON TRACK

90–90–90 progress

The report, Ending AIDS: progress towards the 90–90–90 targets, gives a detailed analysis of progress and challenges towards achieving the 90–90–90 targets. The targets were launched in 2014 to accelerate progress so that, by 2020, 90% of all people living with HIV know their HIV status, 90% of all people with diagnosed HIV are accessing sustained antiretroviral therapy and 90% of all people accessing antiretroviral therapy are virally suppressed.

The report shows that in 2016 more than two thirds (70%) of people living with HIV now know their HIV status. Of the people who know their status, 77% were accessing treatment, and of the people accessing treatment, 82% were virally supressed, protecting their health and helping to prevent transmission of the virus.

Eastern and southern Africa, western and central Europe and North America and Latin America are on track to reach the 90–90–90 targets by 2020. In eastern and southern Africa, 76% of people living with HIV know their HIV status, 79% of people who know their HIV-positive status have access to antiretroviral therapy and 83% of people who are on treatment have undetectable levels of HIV—this equates to 50% of all people living with HIV in eastern and southern Africa with viral suppression. The Caribbean and Asia and the Pacific can also reach the 90–90–90 targets if programmes are further accelerated.

Seven countries have already achieved the 90–90–90 targets—Botswana, Cambodia, Denmark, Iceland, Singapore, Sweden and the United Kingdom of Great Britain and Northern Ireland—and many more are close to achieving it.

“Ending AIDS is possible - it is a shared engagement and aspiration. One that cities can lead while promoting inclusive societies for all,” said Anne Hidalgo, Mayor of Paris.

The most significant impact of 90–90–90 scale-up has been in reducing AIDS-related deaths, which have been reduced by almost half in the past 10 years. As a result, life expectancy has increased significantly in the most affected countries. In eastern and southern Africa, life expectancy increased by nearly 10 years from 2006 to 2016.

“Communities and families are thriving as AIDS is being pushed back,” said Mr Sidibé. “As we bring the epidemic under control, health outcomes are improving and nations are becoming stronger.”

90-90-90: more work to do

Progress against the 90–90–90 targets has, however, been poor in the Middle East and North Africa and in eastern Europe and central Asia, where AIDS-related deaths have risen by 48% and 38%, respectively. There are exceptions within these regions showing that when concerted efforts are made, results happen. For example, Algeria has increased HIV treatment access from 24% in 2010 to 76% in 2016, Morocco from 16% in 2010 to 48% in 2016 and Belarus from 29% in 2010 to 45% in 2016.

Globally, progress has been significant, but there is still more work to do. Around 30% of people living with HIV still do not know their HIV status, 17.1 million people living with HIV do not have access to antiretroviral therapy and more than half of all people living with HIV are not virally suppressed.

Eliminating new HIV infections among children

Global solidarity to stop new HIV infections among children has produced results. Around 76% of pregnant women living with HIV had access to antiretroviral medicines in 2016, up from 47% in 2010. New HIV infections among children globally have halved, from 300 000 [230 000–370 000] in 2010 to 160 000 [100 000–220 000] in 2016. Five-high burden countries—Botswana, Namibia, South Africa, Swaziland and Uganda—have already met the milestone of diagnosing and providing lifelong antiretroviral therapy to 95% of pregnant and breastfeeding women living with HIV.

New HIV infections are declining, but not fast enough

The report also shows that, globally, new HIV infections are declining, but not at the pace needed to meet global targets. Globally, new HIV infections declined by 16% from 2010 to 2016, to 1.8 million [1.6 million–2.1 million]. Declines were estimated in 69 countries, in the majority of which treatment scale-up has been implemented alongside an increase in the availability of combination HIV prevention services and in some countries condom use. However, alarming increases have been seen in new HIV infections in eastern Europe and central Asia.

Tuberculosis

Major gains in the global response to tuberculosis and HIV led to a 33% decline in tuberculosis deaths among people living with HIV. As of 2015, only 11% of the 10.4 million cases of tuberculosis globally were among people living with HIV. However, nearly 60% of tuberculosis cases among people living with HIV were not diagnosed or treated.

Community health workers needed

Ending AIDS shows that providing services closer to where people live and work will be a key factor in ending the AIDS epidemic. UNAIDS is championing an initiative recently backed by the African Union to recruit and train 2 million community health workers in Africa to further bolster the capacity of health systems to deliver health-care services across the region.

“When health services reach the doorsteps, the health of families and communities is transformed,” said Mr Sidibé. “Community health workers will become the backbone of strong and resilient health systems across Africa.”

"I am not alone living with HIV, there are millions of us and we are determined to put an end to AIDS," said Christine Kafando, community health worker and founder of Association Espoir pour Demain. "We have the will to do it and must continue our concerted efforts."

WHAT’S OFF TRACK?

Treatment for children living with HIV

Only 43% of children living with HIV have access to antiretroviral therapy, compared to 54% of adults. Ending AIDS also reveals that as many as two thirds of children under two years old are diagnosed late and start treatment with advanced immunodeficiency, resulting in a high mortality rate for children of this age group. More action is needed to diagnose and treat children living with HIV.

Young people are lagging behind

Young people (15–24 years) are lagging behind on multiple fronts—knowledge of HIV, HIV testing, treatment and prevention. Young people continue to be at great risk of HIV infection, especially young women in sub-Saharan Africa. New HIV infections among young women in sub-Saharan Africa are 44% higher than among young men of their age in the region. Around 610 000 new HIV infections occurred among young people aged 15–24 years; 59% of those new infections occurred among young women age 15–24 years.

In Malawi, Zambia and Zimbabwe, half of young people do not know their status and more than half do not have access to HIV treatment. Only 36% of young men and 30% of young women in sub-Saharan Africa had a basic knowledge of how to protect themselves from HIV. Population-based HIV Impact Assessments (PHIAs) conducted in Malawi, Zambia and Zimbabwe, and supported by the United States President’s Emergency Plan for AIDS Relief, found that less than 50% of young people living with HIV were aware of their HIV status, compared to 78% of adults aged 35–59 years.

Men not being reached

The report reveals that less than 50% of young men know how to protect themselves from HIV infection, that men are much less likely to know their HIV status or start treatment than women and that less than 50% of men living with HIV are accessing antiretroviral therapy. Many men who are diagnosed with HIV are diagnosed late and start treatment only when they fall ill, making them much more likely to die of AIDS-related illnesses than women. Deaths from AIDS-related illnesses were 27% lower among women than among men.

Key populations

Outside of sub-Saharan Africa, key populations and their sexual partners accounted for 80% of new HIV infections in 2015 and even in sub-Saharan Africa key populations account for 25% of new HIV infections. The report outlines that efforts to reach key populations with integrated HIV services are essential and that a combination approach is needed that includes harm reduction services.

Regions off track

Eastern Europe and central Asia is the only region in the world where new HIV infections and AIDS-related deaths are both rising. New HIV infections increased from 120 000 [100 000–130 000] in 2010 to 190 000 [160 000–220 000] in 2016. People who inject drugs accounted for 42% of new HIV infections in the region. In the Russian Federation, newly reported cases of HIV increased by 75% from 2010 to 2016. Several other countries in the region—including Albania, Armenia and Kazakhstan—also have rapidly growing epidemics.

Even though access to HIV treatment in eastern Europe and central Asia has more than doubled in the past six years, still only 28% of people living with HIV have access to antiretroviral therapy, despite two out of three people living with HIV knowing their HIV status. AIDS-related deaths have increased by 38%.

In the Middle East and North Africa, just over half of people living with HIV knew their HIV status, with less than half of those on HIV treatment. Only one out of five people living with HIV was virally suppressed.

UNAIDS has been working with Doctors Without Borders and the African Union on a catch-up plan for western and central Africa, which is lagging far behind the rest of the continent. Only 42% of the 6.1 million people living with HIV in the region knew their HIV status, just 35% were accessing HIV treatment and only one in four people living with HIV were virally suppressed in 2016.

“I would like to reiterate our support for the catch-up plan for western and central Africa, launched by UNAIDS and now joined by partners. The adoption of this plan by the heads of state of the African Union is an essential step for mobilization and the efficient implementation of this plan by the countries in the region.” said Michèle Boccoz, French AIDS Ambassador.

Resources for the AIDS response continue to flatline

Resources for the AIDS response remain flat. At the end of 2016, around US$ 19 billion was available in low- and middle-income countries, with domestic resources accounting for 57% of the global total. An estimated US$ 26 billion will be needed for the global response to HIV by 2020.

“We are maximizing the use of every dollar available, but we are still US$ 7 billion short,” said Mr Sidibé. “With more international assistance, increased domestic funding, innovative financing and effective programming can end the AIDS epidemic by 2030.”

Ending AIDS: progress towards the 90–90–90 targets can be downloaded from unaids.org. UNAIDS is the global leader and repository of AIDS-related programme data. The full data set can be accessed at http://aidsinfo.unaids.org/

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.