90-90-90 treatment target

The mayors of the Portuguese cities of Cascais, Lisbon and Porto have signed the Paris Declaration on ending the AIDS epidemic in cities—the first time that three cities in the same country have signed the declaration together.

In signing the Paris Declaration, mayors commit to putting their cities on the Fast-Track to ending the AIDS epidemic. The three mayors committed to achieving the 90–90–90 targets by 2020, 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. They also committed to eliminating all forms of discrimination and developing a people-centred approach to the AIDS response, leaving no one behind.

During the signing ceremony, which took place on 29 May in Lisbon, Portugal, the Minister of Health of Portugal, Adalberto Campos Fernandes, reaffirmed the political commitment at the highest level to the response to HIV and highlighted that the 90–90–90 targets have a new impetus in the country.

The three cities will establish local strategies to remove barriers to accessing HIV services, eliminate discrimination and close the gaps to reaching the targets in the Paris Declaration. To that end, the Government of Portugal has put together a group of experts from government bodies, civil society and academia, who will identify and recommend concrete actions in the next 90 to 120 days.

During the event, the Director of the national AIDS programme, Isabel Aldir, presented the results of the national programme for HIV and tuberculosis for 2017. Ms Aldir said that in 2016, there were 841 new HIV infections in the country, the lowest for 15 years. Nonetheless, the plan for 2017 will focus on increasing the number of rapid tests by 15% and developing clinical guidance standards for the effective provision of pre- and post-exposure prophylaxis. The plan will also include preparing an evaluation report on a pilot project for dispensing HIV treatment in community pharmacies and promoting the implementation of the Fast-Track cities commitments.

The Democratic Republic of the Congo’s HIV catch-up plan shows that impressive results in the response to HIV can be made when partners work together.

Launched in December 2016, the western and central Africa catch-up plan aims to ensure that 4.5 million people living with HIV in the region will have access to HIV treatment by 2020. In support of the regional plan, the Democratic Republic of the Congo’s country plan—developed and implemented by the Ministry of Health and the National AIDS Commission—aims to increase the number of people on antiretroviral therapy in the country by 80 000 people, to more than 200 000 people by June 2018.

An intensive HIV testing campaign in the country has enabled 2 million people to know their status—essential to enabling people to access HIV treatment.

Coverage of antiretroviral therapy in the country stood at just 33% of people living with HIV in 2015, higher than the region’s coverage (28%), but much lower than the coverage in eastern and southern Africa (54%). According to government estimates, by April 2017, 34 000 more people were on treatment. The increase puts the country on track to reach the June 2018 target, which would see 73% of people living with HIV on treatment.

The encouraging increase in treatment coverage resulted from a range of partners—the Ministry of Health and the National AIDS Commission, United Nations agencies, the Global Fund to Fight AIDS, Tuberculosis and Malaria and the United States President’s Emergency Plan for AIDS Relief, among others—working together to finance and give technical support to the scale-up. By focusing on the three most affected provinces in the country, resources have been maximized where they are most needed.

Community-based antiretroviral medicine distribution points and community-based early warning systems have helped to reduce drug stock-out and improve the quality of HIV services. These community health services are among the best practices that have been scaled up to increase treatment coverage.

UNAIDS is working with countries to ensure that 30 million people living with HIV have access to treatment through meeting the 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—by 2020.

The Ministry of Health and Sports of Myanmar launched the country’s latest five-year HIV plan on 17 May. The plan provides a road map on how to Fast-Track the national HIV response and end the AIDS epidemic as a public health threat by 2030.

Myanmar is one of the 35 countries accounting for 90% of new HIV infections globally. The new plan adapts global Fast-Track Targets to the local context to ensure an effective, cost-effective and high-impact HIV response. Locations are prioritized based on their HIV epidemic and risk of new HIV infections and service delivery approaches are tailored to reach priority populations and speed up access to services.

The ambitious plan aims to ensure the 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—are met by 2020. The plan also aims to ensure that 90% of key populations access HIV prevention services and that 90% of people living with and affected by HIV report zero discrimination, especially in health, education and workplace settings.

During the launch, the Union Minister of the Ministry of Health and Sports, Myint Htwe, stressed the importance of translating the plan’s strategies into action. 

There are around 1.5 million people living with HIV in Kenya, around 400 000 of whom are unaware that they have the virus. If people do not know their status, it is impossible for them to access life-saving treatment.

There are also high numbers of new HIV infections, particularly among young people and among key populations. In 2015, there were an estimated 78 000 new HIV infections in Kenya. And testing rates are low, especially among men, meaning they are not able to benefit from treatment.  

In response, the Government of Kenya has launched two innovative technologies that it hopes will bring ending the AIDS epidemic one step closer: self-testing for HIV and pre-exposure prophylaxis (PrEP) to prevent HIV infection.

The Kenyan Ministry of Health has launched the Be Self Sure campaign to encourage people to get tested for HIV. As part of the campaign, the government is making HIV self-test kits available through public and private health facilities and selected pharmacies for around US$ 8 each, a low price which was negotiated in a partnership between government of Kenya and the private sector. From July 2017 the government hopes to make the test kits available for free in public health facilities.

PrEP is pre-exposure prophylaxis—the use of antiretroviral medicines to prevent HIV among people who are HIV-negative. 

The campaign website includes an interactive map to let people know where to get the testing kits from and plays videos demonstrating how to use the kits and tells people what to do if they are HIV-positive or if they are HIV-negative. A helpline, open for 12 hours a day, is also available.

For people testing negative for HIV, the site urges people to talk to their health providers about HIV prevention options, including PrEP, a medicine that people at higher risk of HIV infection can take to prevent becoming infected with the virus. PrEP is being rolled out as part of the campaign, with the Government of Kenya offering it free of charge in selected public health facilities as part of a combination HIV prevention programme for people most at risk of HIV infection, including young people, serodiscordant couples, people who inject drugs and sex workers. The medicine will also be available for around US$ 36 dollars a month at private hospitals and pharmacies for anyone wishing to use it.

Around 10 countries and the European Medicines Agency have now approved the use of antiretroviral medicines for HIV prevention, with more set to follow. The implementation of PrEP strategies follows the guidelines established by the World Health Organization in 2015, which recommend the use of PrEP by members of key populations. The number of people using PrEP to prevent HIV is now thought to have risen to around 120 000 people, the majority in the United States of America. The roll out of PrEP in Kenya is a major advance in efforts to stop new HIV infections in the countries most affected by HIV.

By launching this new initiative, Kenya is continuing to affirm its position as a leader and innovator in efforts to end the AIDS epidemic by 2030.

UNAIDS is working closely with Kenya to prevent new HIV infections and to ensure that, 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. By achieving these targets, Kenya will be able to end its AIDS epidemic by 2030.

Ahead of the mid-term review of the 90–90–90 treatment targets in 2017, Marc Angel, Chair of Foreign Affairs and Development Committee of the Luxembourg Parliament and UNAIDS Champion for the 90-90-90 targets, undertook a multicountry fact-finding visit to Botswana, South Africa and Lesotho from 17 to 21 April. The visit provided Mr Angel with the opportunity to conduct high-level political advocacy to continue and accelerate momentum towards achieving 90–90–90 by 2020.

The fact-finding visits to southern Africa confirmed the importance of intensifying efforts to increase the proportion of people living with HIV who know their HIV status. In addition, the visits highlighted the central importance of community health workers, both to achieve the 90–90–90 targets and to ensure national preparedness to identify and address emerging health challenges.

What are the 90–90–90 targets?

• By 2020, 90% of all people living with HIV will know their HIV status.
• By 2020, 90% of people who know their HIV-positive status are accessing treatment.
• By 2020, 90% of all people on treatment have suppressed viral loads .

Modelling suggests that achieving these targets by 2020 will enable the world to end the AIDS epidemic as a public health threat by 2030, which in turn will generate profound health and economic benefits

Find out more here

In each country he visited, Mr Angel met with leaders from government and civil society to witness how 90–90–90 is being adopted in high-burden countries. He also visited numerous health facilities and community-based projects to experience first-hand how 90–90–90 is being implemented on the ground. All three countries have adopted and implemented the World Health Organization guidelines for universal HIV testing and treatment for all people living with HIV and have strong political commitment to reaching 90–90–90. The three ministers of health from each country agreed that community health workers must be the central mode of delivery for 90–90–90.

Representatives of the ministries of health of the Commonwealth of Independent States (CIS) have reconfirmed their commitment to end AIDS by 2030. The ministers made the commitment at a meeting at the Health Council of the CIS, held in Bishkek, Kyrgyzstan, on 28 April.

Since 1997, the CIS has consistently highlighted the importance of the AIDS response. However, since 2010 the HIV epidemic in the CIS countries has continued to get worse. At the end of 2015, UNAIDS estimates that 1.5 million people were living with HIV in eastern Europe and central Asia, of which more than 90% are in the CIS countries.

The Director of the UNAIDS Regional Support Team for Eastern Europe and Central Asia, Vinay Saldanha, was invited to the meeting to present how the CIS countries can reach the ambitious targets of the Political Declaration on Ending AIDS by taking a Fast-Track approach. He made a special call for reaching the 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—zero discrimination and a 75% reduction in new HIV infections by 2020 by rapidly scaling up the quality and coverage of HIV prevention services.

Mr Saldanha also highlighted the recent developments in the Russian Federation, where the Duma is considering a draft law that proposes removing restrictions on the travel and residence of foreigners living with HIV and other infectious diseases.

During the meeting, the ministers also discussed ways for better information exchange between CIS countries on epidemiological emergencies and outlined a plan for the implementation of the CIS health strategy.

It was also decided to further strengthen efforts to promote joint health-care programmes among the CIS countries, in close cooperation with the World Health Organization and UNAIDS.

Veena has been living with HIV for more than 15 years. The community educator, who lives in Bangalore, India, has been on HIV treatment for more than a decade and says antiretroviral medicine has given her back her health and happiness.

“This medicine is very good. I am very happy,” said Veena. “My life has changed. I am learning three languages and working.”

There are 2.1 million people living with HIV in India, which has the third largest HIV epidemic in the world. On 28 April, during an event in New Delhi, Jagat Prakash Nadda, the Minister of Health and Family Welfare, announced a new test-and-treat policy that commits to providing access to HIV treatment for everyone living with HIV in the country. Prior to the change in policy, people living with HIV could only access antiretroviral medicine for free if their CD4 cells had decreased to less than 500 cells/mm³.

Mr Nadda also said that the ministry’s 90–90–90 strategy will identify 90% of people living with HIV, place 90% of people identified as living with HIV on treatment and ensure that 90% of people on treatment have sustained viral load suppression. “This strategy will offer us an opportunity to work towards our commitment made during the United Nations High-Level Meeting on Ending AIDS.”

People living with HIV in India often access treatment late. This was the case for Veena when she began taking medicine.

“I had lost a lot of weight and I had a high fever. I was tired and I couldn’t work,” said Veena. Initially she did not respond well to treatment, but slowly her weight started to increase and her immune system became better.

UNAIDS has called on all countries to provide HIV treatment to anyone who tests positive for HIV, because treatment keeps a person living with HIV healthy and has the double benefit of stopping the transmission of the virus to other people.

“The Government of India is showing bold leadership and commitment to people living with HIV,” said Steve Kraus, Director of the UNAIDS Regional Support Team for Asia and the Pacific. “This new policy will bring life-saving treatment within reach of more than one million people living with HIV. It will keep individuals, families and communities healthy and productive and ensure that India ends its AIDS epidemic by 2030.”

To rapidly scale-up treatment, India will rely on its network of facilities spread across the country providing HIV services. Rolling out the new policy will also entail strengthening the procurement and supply chain management system as well as sustained community participation.

According to the country’s national AIDS programme, annual AIDS-related deaths declined by 54% between 2007 and 2015, while new HIV infections dropped by 32%. As more people living with HIV follow Veena onto treatment, the double benefits of antiretroviral medicines are expected to lead to a further decline in deaths and new HIV infections.

Veena has managed what she never thought possible: watch her daughter grow into a young adult.

“My life has a future. I don’t have a proper education, but my daughter has completed her degree. She is working. She is an empowered woman,” said Veena.

UNAIDS is working with countries to ensure that 30 million people living with HIV have access to HIV treatment by 2020.

The participants of a meeting of the UNAIDS Scientific and Technical Advisory Committee (STAC) have called on UNAIDS to lead global efforts to galvanize an HIV testing revolution. The target is to achieve 90% of people living with HIV knowing their HIV status by 2020. In 2015, only 60% of people living with HIV knew their HIV status.

In a mid-term review of progress towards the 90–90–90 targets, held on 9 and 10 April in Geneva, Switzerland, the participants heard that late HIV diagnosis represents the single greatest barrier to increasing rates of HIV viral suppression globally. New testing technologies have emerged, but programmes must reach the people who need HIV testing services.

Key barriers to HIV testing uptake include lack of individual awareness of risk, stigma, legal and structural barriers, associated costs such as travel to facilities and the perception that there is little benefit from diagnosing HIV infection if no symptoms are present. The participants heard that many people avoid seeking HIV testing services at health facilities, since both travel and waiting times can often be long. Barriers to testing are often experienced by young people, men and members of key populations.

The participants agreed that political and financial support for HIV testing must be significantly increased and that the central focus of HIV testing services should be moved from the health facility to the community. Community workers have a critical role in scaling up these community-centred strategies. The STAC recommended that UNAIDS develop a road map for the HIV testing revolution, for review and comment by the STAC at its next meeting in July.

The STAC recommended that UNAIDS emphasize leveraging the 90–90–90 targets to better link the HIV response to the broader agenda for sustainable health. It was noted that HIV testing services provide a platform for screening for other health problems. Likewise, momentum towards the 90–90–90 targets also offers opportunities to address health workforce shortages.

The global response to HIV has averted almost 9 million deaths since 2000, when the Millennium Development Goals (MDG) were set. Despite such progress, AIDS is the leading cause of death among women aged 15–49, the sixth leading cause of death among adolescents and a leading cause of death among children worldwide.

Recognizing the impact of HIV on health and development, in 2016 United Nations Member States adopted a Political Declaration on Ending AIDS to advance progress towards ending AIDS by 2030.

Essential to these efforts will be achieving 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 October 2016, Sweden announced that it was the first country to reach the 90–90–90 targets, having reached them in 2015. Today, Sweden estimates that 90% of people living with HIV in Sweden know their HIV status, 97% of people who know their HIV-positive status are accessing treatment and 95% of people living with HIV who are accessing treatment have viral suppression.

Sweden remains a political champion and supporter of HIV efforts globally. Sweden is also a key donor to UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria. From 26 to 28 March, UNAIDS Executive Director Michel Sidibé visited Sweden, at the invitation of State Secretary Ulrika Modéer, to discuss how the response to HIV can be a catalyst for accelerating progress towards achieving the Sustainable Development Goals.

In meetings with a series of key political and technical stakeholders, as well as civil society organizations working on HIV, the participants stressed that HIV prevention must be expanded to end AIDS. They also stressed that HIV programmes must be integrated, brought to scale and implemented to maximum effect, ensuring they reach the people most affected by HIV.

There was consensus that a single disease approach to HIV is inadequate to reach the Sustainable Development Goals and that there is a need for an approach that looks on health not as an outcome but as a prerequisite for development and sustainability.