90-90-90 treatment target

A number of important updates were announced at the annual Conference on Retroviruses and Opportunistic Infections (CROI) that have shown the importance of, and ways to achieve, 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.

Held in Seattle, United States of America, from 13 to 16 February, CROI, the foremost annual scientific research conference on HIV, brought together around 4000 scientists, researchers, clinicians, students and others working in the response to HIV and related diseases.

A way of helping to meet the first 90—90% of people living with HIV knowing their HIV status—is the scale-up of self-testing. The STAR project, a four-year programme to build up HIV self-testing, has now distributed around 200 000 self-testing kits in Malawi, Zambia and Zimbabwe and is showing promising results. The project found that self-testing is a good way of reaching people who had previously not been reached before. Research is ongoing into the different ways the kits could be distributed—community-based distribution, pharmacy support, etc. With around 19 million people living with HIV not knowing that they have the virus, HIV self-testing could be a vital step towards ensuring that all who need HIV treatment have access to it.

The announcement of several promising new medicines in the pipeline may help to meet the second 90—90% of people who know their HIV-positive status are accessing treatment. A range of new single-dose, effective medicines, including new classes of medicine, new examples of existing classes and long-acting preparations that are produced by different manufacturers, will help to increase competition and hence access. Having new medicines will also be good news in the event of the development of resistance to current medicines in the future.

The importance of the third 90, viral suppression, and of a combination prevention approach to HIV was shown in a study in Rakai, Uganda. Studies of more than 33 000 people from 1999 to 2016 showed that an increase in antiretroviral therapy and hence viral suppression, scale-up of voluntary medical male circumcision and delayed sexual debut contributed to a 42% reduction in HIV incidence.

Also important for viral suppression is keeping people on treatment. The SWORD-1 and SWORD-2 studies show that a two-medicine regimen is as good as the current three-medicine approach. By reducing the amount of medicines that people living with HIV need to take, side-effects are reduced and adherence improves. Since antiretroviral therapy is taken for life, a simplification in treatment could benefit millions of people. 

Economic experts and representatives of national AIDS programmes, health ministries and health professional organizations endorsed the creation of a global coalition of community health workers in UNAIDS-convened consultations in New York, United States of America, on 9 and 10 February.

Community health workers bring cost-effective services to communities and increase service access for marginalized people, who often struggle to access essential health services. More than 6 million community health workers are already in place across the world. However, many are unpaid and are typically not fully integrated into health systems.

The participants called for an urgent initiative to recruit, train and deploy at least 2 million community health workers over the next two years to drive progress towards 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—and to lay the foundation for sustainable health for all.

The consultations generated strong support for UNAIDS to establish a new international coalition of community health workers by mid-2017. This coalition will help to galvanize the creation of national associations of community health workers, support their harmonization and formalization, advocate for actions that support them and provide a unifying platform.

As a next step, it was agreed that UNAIDS will seek input from country-level community health workers on the vision, mission and structure of the coalition. UNAIDS will lead a global effort to mobilize resources for an emergency fund to support national initiatives for community health workers and to incorporate them as formalized, integral members of the health system.

Funding from Luxembourg supported the consultations. The Earth Institute of Columbia University and the International Association of Providers of AIDS Care were co-hosts.

Michel Sidibé, UNAIDS Executive Director, delivered the keynote address to the opening plenary of the International Association of Providers of AIDS Care (IAPAC) summit on 13 October in Geneva, Switzerland. Speakers at the summit, entitled Controlling the HIV Epidemic with Antiretrovirals: Leveraging Progress, Seizing Opportunities, discussed the implications of new research confirming the benefits of early antiretroviral therapy for all people living with HIV in order to save lives, reduce coinfections such as tuberculosis and prevent HIV transmission.

Mr Sidibé highlighted the strategies, emerging opportunities and political processes needed to achieve the 90–90–90 targets by 2020, which call for 90% of people living with HIV knowing their HIV status, 90% of people who know their HIV-positive status accessing treatment and 90% of people on treatment having suppressed viral loads. These are central to the Fast-Track response to ending AIDS by 2030.

During the summit, the Director of the Swedish National Institute of Public Health, Johan Carlson, presented the findings of a scientific publication that announced that Sweden was the first country to declare that it had reached the 90–90–90 targets, in 2015. Mr Carlson highlighted the factors that contributed to the success, including free access to quality HIV education, testing, treatment, care and support, overcoming stigma and discrimination against people at higher risk of HIV, including gay men and other men who have sex with men, sex workers and migrants, the protection of human rights and programme monitoring and evaluation.  

Mr Sidibé congratulated Sweden for its impressive progress on the 90–90–90 targets and noted that other high-income countries, as well as many low- and middle-income countries, including Botswana, Brazil, Cambodia, Kenya, Malawi, Rwanda, Swaziland and Thailand, are also on track to achieve them.

Leading stakeholders involved in paediatric HIV treatment joined together in a special session on 19 July at the 21st International AIDS Conference, being held in Durban, South Africa, to launch an urgent global push to end paediatric AIDS by 2020. In particular, the session focused on reaching the global target of at least 1.6 million children accessing antiretroviral therapy by 2018.

Sustained gains in preventing new HIV infections among children have laid the groundwork to end paediatric AIDS at least a decade sooner than the global target for the epidemic as a whole. However, to end paediatric AIDS, prevention efforts will need to be matched by an equally robust effort to address the treatment needs of children living with HIV.

While children (aged 0–14 years) accounted for 5% of people living with HIV in 2015, they represented 10% of all AIDS-related deaths. Half of all children who acquire HIV perinatally die by their second birthday unless they receive antiretroviral therapy, with peak mortality occurring at 6–8 weeks of life.

Participants in the session included Raymonde Goudou-Coffie, Minister of Health and Public Hygiene of Côte d’Ivoire, Molotsi Monyamane, Minister of Health of Lesotho, David Parirenyatwa, Minister of Health and Child Welfare of Zimbabwe, and high-level representatives of the United Nations Children’s Fund, the World Health Organization, the Elizabeth Glaser Pediatric AIDS Foundation, ELMA Philanthropies and Caritas Internationalis.

The session resulted in an urgent call to increase political commitment for paediatric HIV treatment, rapid scale-up of point-of-care diagnostic tools for children, intensifying testing efforts for older children, strengthening service delivery and patient monitoring for mothers and their infants and expanding the array of child-appropriate antiretroviral medicines. The renewed global push to close paediatric treatment gaps support the AIDS-free component of the Start Free, Stay Free, AIDS Free framework launched by UNAIDS and partners.

Fast-Track cities are making tangible progress towards the 90–90–90 targets of 90% of people living with HIV knowing their HIV status, 90% of people who know their HIV-positive status accessing treatment and 90% of people on treatment having suppressed viral loads.

Four signatories to the Paris Declaration on Fast-Track Cities released data today demonstrating significant progress towards achieving the 90–90–90 targets and confirming their commitment to ending AIDS in their cities. The announcement was made at a satellite meeting cohosted by the International Association of Providers of AIDS Care (IAPAC) and UNAIDS at the 21st International AIDS Conference, taking place in Durban, South Africa.

Amsterdam, Denver, Paris and Kyiv announced their 90–90–90 data as part of the Fast-Track approach by cities around the world to reach ambitious goals by 2020 in order to end the AIDS epidemic by 2030. Achieving these goals requires accelerated and focused action, innovation in service delivery and working in partnership with key stakeholders and affected populations.

IAPAC has launched a Fast-Track cities web portal with dashboards for five cities: Amsterdam, Netherlands; Denver, United States of America; Kyiv, Ukraine; Paris, France; and San Francisco, United States. The dashboards include data on cities’ progress in reaching the 90–90–90 targets for 2020 and their broader response to HIV. The dashboards can be seen at www.Fast-TrackCities.org.

Countries are making rapid progress in scaling up HIV testing and treatment across several regions, participants at an event entitled “90–90–90 target workshop: a vehicle for knowledge translation of treatment as prevention” heard.

Taking place at the 21st International AIDS Conference in Durban, South Africa, the event saw the launch of advance draft copies of a new UNAIDS report, 90–90–90: on the right track towards the treatment target. The report highlights best practices and provides examples of countries that are already coming close to achieving the 90–90–90 targets, which are that 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. 

The meeting heard that in at least 10 countries from diverse regions, HIV treatment coverage either doubled or almost doubled from 2012 to 2015, reinforcing the feasibility of rapid scale-up. Especially encouraging is the rapid expansion of treatment services in certain fragile settings, such as the Democratic Republic of the Congo, where the proportion of people living with HIV receiving HIV treatment also doubled, from 16% to 33% between 2012 and 2015. These encouraging results from diverse countries provide credibility to the attainment of the 90-90-90 targets. However, challenges remain and many countries are struggling to achieve the third 90 target.

The report outlines steps that are needed to expedite gains towards each of the three 90s. Technological and service delivery innovations rapidly need to be brought to scale, communities must be empowered to lead the push to end the epidemic, new resources must be mobilized to reach the final mile of the response to HIV and steps must urgently be taken to eliminate social and structural barriers to service access.

The 90–90–90 treatment target cannot be reached without a substantially greater involvement of a well-resourced and well-trained community health workforce, experts told a side event at the United Nations General Assembly High-Level Meeting on Ending AIDS, taking place in New York, United States of America, from 8 to 10 June.

Speakers at the side event, held on 9 June and entitled “90–90–90 and human resources for health,” emphasized that the 90–90–90 treatment target offers a road map towards the ultimate goal of ending the AIDS epidemic by 2030. However, shortages in human resources for health pose a grave threat to hopes for ending the epidemic as a public health threat.

Community health workers represent a potentially transformative mechanism for closing health workforce gaps and accelerating progress in scaling up HIV treatment and improving treatment outcomes. Kesetebirhan Admasu, Minister of Health of Ethiopia, described how the country’s health extension worker programme has substantially improved health-care access and helped make health services more sensitive to the needs of communities.

Community health systems are especially critical for ensuring access to essential health services among people who face challenges in accessing mainstream services, including members of key populations. Surang Janyam, of the Service Workers In Group in Thailand, explained how trained community health workers have expanded access to HIV services among sex workers, men who have sex with men and transgender people in Thailand and increased community ownership of the AIDS response.

Sigrun Mogedal, of the Global Health Workforce Alliance, said that the AIDS response should partner and coordinate closely with the many efforts already being undertaken to strengthen the health workforce. In 2016, the World Health Assembly approved a new global strategy for the health workforce, prioritizing the strengthening of community health systems. The Earth Institute of Columbia University is spearheading a global partnership to mobilize 1 million community health workers in Africa, and countries such as Ghana have taken important steps to train and deploy new cadres of community health workers.

However, the lack of growth in international HIV assistance potentially jeopardizes the world’s capacity to build a strong and durable health workforce to achieve the 90–90–90 treatment target, speakers in the session emphasized. Jeffrey Sachs, Director of the Earth Institute, and Stephen Lewis, Co-Founder of AIDS-Free World, called for urgent action to mobilize new resources for AIDS and to ensure that sufficient new funding is channelled to community systems.

African health ministers, leaders of paediatric HIV treatment programme implementers, philanthropic foundations, civil society and private sector partners convened in New York, United States of America, on 6 June to celebrate successes in closing HIV treatment gaps for children and to call for an expanded global partnership to build on this momentum to end paediatric AIDS.

Many countries have made important strides towards ending paediatric AIDS, but major challenges persist. Even as the number of children newly infected with HIV continues to decline, only about half of HIV-exposed children are tested for HIV within the first two months of life and only 30% of children living with HIV are linked to HIV treatment in a timely manner. Because far too many children living with HIV begin treatment too late, children are far more likely than adults living with HIV to die of AIDS-related illnesses.

At a major global ministerial meeting in Abidjan, Côte d’Ivoire, in May, health ministers from Africa endorsed a Fast-Track approach for children. This approach calls for reaching a 95% coverage of antiretroviral therapy for both pregnant women and children living with HIV by 2018. By reaching this target, the world could effectively end paediatric AIDS by 2020—one decade earlier than the elimination goal for the epidemic as a whole.

To reach these ambitious targets, attendees at this week’s meeting in New York emphasized the importance of a renewed, expanded, inclusive global partnership to close the paediatric HIV treatment gap. During an interactive conversation among the meeting participants, speakers emphasized the importance of involving families, communities and civil society organizations. There was also agreement regarding the need to engage the private sector in efforts to develop new paediatric treatment tools and fund programmes to close gaps across the continuum of care for children. The Medicines Patent Pool, which has prioritized paediatric HIV treatment in its negotiations of licences for the generic manufacture of priority antiretroviral medicines, is an example of how innovative approaches to private sector involvement can contribute to improved access to essential treatments.

Meeting attendees stressed the need for improved coordination of the many efforts being undertaken to address various aspects of paediatric HIV treatment. At the Abidjan meeting, health ministers endorsed efforts to maximize coordination in the paediatric AIDS arena.

To achieve the Fast-Track Targets for children—and to sustain these gains over time—new resources will be needed. Several countries are taking steps to increase domestic allocations for paediatric HIV treatment. Namibia, for example, covers 60% of its national AIDS response with domestic resources, and Felix Kabange Numbi, Minister of Public Health for the Democratic Republic of the Congo, reported that his country is pledging to increase domestic resources for AIDS.

It was agreed that philanthropy offers a potentially important avenue to generate new resources for paediatric HIV treatment. ELMA Philanthropies, for example, is allocating US$ 12.5–15 million per year for at least the next three years to support HIV treatment programmes for children, with a comparable amount to be invested in supportive programmes for childhood development.

African ministers of health called on the international community to make ending the paediatric AIDS epidemic a global political priority. Meeting in Abidjan, Côte d’Ivoire, on 10 May, dignitaries called for the Political Declaration on Ending AIDS, to be agreed upon at the upcoming United Nations General Assembly High-Level Meeting on Ending AIDS, to include targets to scale up prevention of mother-to-child transmission of HIV services and paediatric HIV testing and treatment.

Participants included 11 national ministers, as well as deputy ministers and senior HIV programme officials from across Africa, which is home to nearly 90% of all children living with HIV.

In 2014, 2.6 million children were living with HIV and 32% had access to antiretroviral therapy. Without treatment, half of all children living with HIV will die before they are two years old.

“Ending paediatric AIDS requires action at two levels,” said the First Lady of Côte d’Ivoire, Dominique Ouattara, UNAIDS Special Ambassador for the Elimination of Mother-to-Child Transmission and the Promotion of Paediatric Treatment for HIV. “On the one hand, we must prevent new HIV infections among children, and, on the other hand, we must provide treatment and care to all children who are living with HIV.”

Continued progress in preventing new HIV infections among children has been made by ensuring all pregnant women are tested for HIV and women living with HIV receive treatment. This has established a strong foundation for ending paediatric AIDS. But to make it a thing of the past, substantially better results are needed across the HIV treatment cascade for children.

UNAIDS projects that it is possible to end the epidemic of paediatric AIDS by 2020 if prevention and treatment targets are met by 2018. These include reaching 95% treatment coverage for both pregnant women and children living with HIV.

Recent trends point towards the feasibility of achieving these targets. Major gains have been made in providing antiretroviral medicines to pregnant women living with HIV to prevent transmission of HIV to their babies. From 2010 to 2014, new HIV infections among children dropped by 58%. In the same period, HIV treatment coverage among children living with HIV more than doubled.

However, more needs to be done to ensure that no child is left behind. “Today we have effective treatment regimens, yet how many children are still dying in the age of antiretroviral therapy?,” asked Jeanne Gapiya Niyonzima, president of the Burundi Association Nationale de Soutien aux Séropositifs et aux Malades du SIDA and mother of a child who died of AIDS-related causes at 18 months of age.

“This is a question of social justice, a question of equality,” said UNAIDS Executive Director Michel Sidibé. “We have the opportunity to have a Political Declaration on Ending AIDS from the United Nations General Assembly High-Level Meeting on Ending AIDS to help us set concrete objectives so that treatment becomes universal for everyone, wherever they find themselves.”

The African ministers attending the Abidjan meeting called for the Political Declaration on Ending AIDS to include clear targets to scale up prevention and treatment services in order to end paediatric AIDS. To achieve these targets, the ministers endorsed the immediate front-loading of resources for paediatric HIV treatment and the elimination of mother-to-child transmission of HIV.

Scientific developments have the potential to dramatically improve treatment outcomes for children. Ministers noted the importance of fully leveraging and scaling up innovative tools, including point-of-care technologies for early infant diagnosis, paediatric treatment regimens recommended by the World Health Organization and family-centred service delivery approaches that improve retention in care and treatment adherence.

Ministers called for UNAIDS to coordinate initiatives on paediatric HIV treatment across all sectors. “We need to strengthen cooperation among stakeholders to get better results for children,” said Juliet Kavetuna, Deputy Minister of Health and Social Services of Namibia. “If we work in silos, we will never achieve our goal.”

The meeting generated considerable optimism regarding the potential to meet the 2018 targets for children. “We know what we have to do,” said David Parirenyatwa, Zimbabwe’s Minister of Health and Child Care. “The key is to do it in a systematic way and ensure that it is well-funded.”

Uganda’s Minister of State for Primary Health Care, Sarah Opendi, said, “Working together, we can end the AIDS epidemic among children, and also among adults.”

Prior to the closing remarks by the First Lady of Côte d’Ivoire, Mr Sidibé was presented with the Grand Officier de l'Ordre National de la République de Côte d'Ivoire, in recognition of his global leadership on behalf of children affected by HIV. In accepting the award, Mr Sidibé encouraged all participants to work towards the goal of ending paediatric AIDS.

Leading donors, programme implementers and civil society involved in paediatric HIV treatment, as well as private industry, also attended the ministerial meeting. The event was convened by UNAIDS, the Government of Côte d’Ivoire, ELMA Philanthropies, Funders Concerned About AIDS, the Children’s Investment Fund Foundation, Johnson & Johnson and Luxembourg. More than 150 people from 34 countries participated.