90-90-90 treatment target

In 2016, the United Nations General Assembly’s Political Declaration on Ending AIDS committed countries to the 90–90–90 targets, which aim to bring HIV testing and treatment to the vast majority of people living with HIV by the end of 2020 and to reduce the amount of HIV in their bodies to undetectable levels, so they keep healthy and to prevent the further spread of the virus.

Globally, there have been remarkable gains across the HIV testing and treatment cascade. At the end of 2019, 81% of people living with HIV knew their HIV status, and more than two thirds (67%) were on antiretroviral therapy, equal to an estimated 25.4 million of the 38.0 million people living with HIV—a number that has more than tripled since 2010.

Gains in treatment effectiveness, as well as increases in the number of people who know their status and are on treatment, are reflected in the fact that viral load suppression levels among all people living with HIV increased by 18 percentage points between 2015 and 2019. Almost 59% of people living with HIV globally had suppressed viral loads in 2019. However, achieving the 90–90–90 targets results in a minimum of 73% of people living with HIV having suppressed viral loads, so the global target for the end of 2020 is unlikely to be met.

The COVID-19 pandemic also could have an impact on viral load. Early modelling showed that a severe disruption in HIV treatment could result in additional AIDS-related deaths in sub-Saharan Africa. Some countries have reported reductions in medicine collections of up to 20% in some areas and there have been multiple reports of people living with HIV not having enough antiretroviral medicine for a lockdown of more than 60 days, as well as reports of people having abandoned their HIV treatment due to a lack of food. However, monthly data from January to June 2020 reported by countries to UNAIDS have not shown substantial declines in the numbers of people currently on treatment over the six-month period.

UNAIDS International Goodwill Ambassador urges people to test for HIV and to seek treatment if necessary  

GENEVA, 23 November 2018—A little over one week before World AIDS Day, UNAIDS International Goodwill Ambassador Victoria Beckham has visited the organization’s Geneva, Switzerland, headquarters to support calls for people to know their HIV status and to seek treatment for HIV if necessary.

“I am really happy to be in Geneva to support UNAIDS in the run-up to World AIDS Day,” said Ms Beckham during her visit. “We need to make sure that people feel supported to take an HIV test by ending the stigma and discrimination still too often associated with the virus. Today, we have the medicines to keep people healthy and to stop the virus being transmitted. AIDS isn’t over yet, but it can be.”

UNAIDS estimates that there were around 36.9 million people living with HIV worldwide in 2017, with around 21.7 million people accessing life-saving medicines that keep people alive and well and stop the transmission of the virus. However, UNAIDS also estimates that around one in four people worldwide continue to be unaware that they are living with HIV.

During the visit, the UNAIDS Executive Director, Michel Sidibé, met with Ms Beckham to thank her for her support and to discuss the latest developments in the AIDS response.

“We have made a lot of progress in expanding access to treatment, but the number of people who don’t know their HIV status is still far too high,” said Mr Sidibé. “We have to make sure that people have access to testing services and are provided with treatment immediately if they need it. We also have to make sure that people have access to the full range of HIV prevention options to bring down the number of new HIV infections.”

Thanks to antiretroviral therapy, AIDS-related deaths have been reduced by more than 51% since the peak in 2004. In 2017, 940 000 people died from an AIDS-related illness worldwide, compared to 1.9 million in 2004. In 2017, however, there were 1.8 million new HIV infections.

In many regions of the world, women continue to be the worst affected by the epidemic and every week 6600 young women aged 15–24 years become infected with HIV. In sub-Saharan Africa, three in four new infections among adolescents aged 15–19 years are among girls, and young women aged 15–24 years are twice as likely to be living with HIV than men.

In other regions, the epidemic is concentrated among key populations, such as gay men and other men who have sex with men, sex workers, transgender people, people who inject drugs, prisoners and other incarcerated people and migrants.

It is estimated that around 35.4 million people worldwide have died from an AID-related illness since the start of the epidemic.

The Russian Minister of Health, Veronika Skvortsova, has reiterated the commitment to reach the targets agreed at the 2016 United Nations General Assembly High-Level Meeting on Ending AIDS.

“We have to provide every person living with HIV with quick access to the correct treatment. The Ministry of Health plans to increase the coverage of people living with HIV who know their status on antiretroviral therapy to 75% by 2019, and by 2020 the figure should reach 90%,” said Ms Skvortsova at the 28th meeting of the Health Council of the Commonwealth of Independent States, held in Saransk, Russian Federation, on 4 September 2018.

In 2018, the Russian Federation reported for the first time on national progress towards the 90–90–90 targets—in 2017, 81% of people living with HIV in the Russian Federation knew their status, 45% who knew their status were on treatment and 75% who were on treatment were virally suppressed.

In order to improve strategic information and build evidence for decision-making at the local level, the Russian Ministry of Health recently conducted a workshop on HIV estimates for representatives of 10 Russian regions. Regional experts were trained on modelling HIV estimates, which will help to ensure a more complete picture of the number of people living with HIV and of the 90–90–90 targets at the subnational level.

Eastern Europe and central Asia is the only region in which the numbers of new HIV infections and AIDS-related death are still on the rise. At the end of 2017, the number of new HIV infections in the region reached 130 000. At the end of 2017, it was estimated that the 90–90–90 cascade in the region was 73%, 50% and 72%.

“The Russian Minister of Health’s statement is another important step in a series of consistent actions undertaken by the Government of the Russian Federation to accelerate the country’s Fast-Track approach to reach 90–90–90 by 2020,” said Vinay P. Saldanha, Director of the Regional Support Team for Eastern Europe and Central Asia.

Health situation rooms—software platforms designed to support decision-making on countries’ health responses—are opening up across Africa, bridging data and decision-making in order to improve the health and lives of tens of millions of the world’s most vulnerable people.

Data integration, data warehousing and data visualization are the core of the situation room concept, providing transparent and improved information on a range of diseases. While situation rooms are virtual working space, some countries also use physical rooms in which the analytics can be discussed and acted upon.

The idea of a health situation room is that data—whether on the availability of HIV medicines, the effects of a strike by health-care workers or diagnoses of cervical cancer—are centralized, yet accessible to everyone. Whereas in the past health data on different diseases would be spread around several databases in assorted government ministries, disease-specific organizations, etc., situation rooms collect the data in one place, on one system, in a form that is easily shared. The information held by the situation room can be utilized on tablets or computers throughout the country.

“We must continue to innovate in our response to HIV,” said Michel Sidibé, the UNAIDS Executive Director. “Having reliable and up-to-date information is vital if the world is to meet its commitment to end AIDS and reach the Sustainable Development Goals.”

By pooling the health data in the virtual situation room, better and more focused health services can be made available to the people who need them. For example, having data on specific parts of a city helps to drive a location–population approach to HIV prevention services, ensuring that the right people are reached in the right place with the right services.

Through combining data on, for example, HIV, tuberculosis and cervical cancer, interlinkages between the diseases can be seen and responded to. Data can be viewed in real time, so, for example, levels of HIV medicines can be monitored in order to anticipate and respond to medicine stock-outs. Studying the effects of HIV test and treat campaigns in Uganda, the effectiveness of cervical cancer screening in Côte d’Ivoire and malaria testing and new diagnoses in Zambia are other examples how health situation rooms are benefiting health responses.

Five countries—Côte d’Ivoire, Kenya, Lesotho, Zambia and Uganda—have launched situation rooms. Data on indicators, including on HIV, tuberculosis, malaria, noncommunicable diseases and reproductive, maternal, newborn and child health are gathered, with different countries collecting different information depending on the local situation. Namibia, Mozambique and Zimbabwe are preparing to launch situation rooms, and several other countries are in the planning stage.

As part of its work, UNAIDS has been helping countries to set up their situation rooms, with UNAIDS working with countries to select the specific indicators and connecting data in the country to their situation room. Countries with existing data collection systems, that collect data separated by age and sex and at the local level, that have good Internet connectivity and that have qualified local staff are best placed to establish their own situation rooms.

The situation room programme has resulted in UNAIDS’ support to countries being enhanced, with UNAIDS able to support health information systems in a way unique in the United Nations system. UNAIDS is therefore supporting country and programmatic monitoring in a more meaningful way in those countries that have invested in situation rooms.

“For us, its strength is in bringing multiple data sets together, and sharing powerful analytics in a visual and understandable way,” said Andrew Kashoka, Deputy Director of Information Technology, Zambia Ministry of Health.

For the future, UNAIDS plans to ensure that countries have technical support so that they can continue to operate their situation rooms without support from UNAIDS. UNAIDS will also work with partners, including the Africa Centres for Disease Control and Prevention, the private sector and others, to reduce the dependency of countries on UNAIDS’ support in setting up and running the platforms.

Such investments in technology and collaboration between UNAIDS, governments and partners are driving innovative approaches to responding to AIDS and to ultimately ending the AIDS epidemic as a public health threat by 2030.

Seventy-seven per cent of all adults living with HIV are virally supressed in Namibia

AMSTERDAM/GENEVA, 26 July 2018—UNAIDS welcomes new survey data showing that 77% of all adults living with HIV in Namibia are virally suppressed. The Namibia Population-Based HIV Impact Assessment (NAMPHIA) survey included 24 000 people from 0–64 years old. Participants were offered HIV counselling and testing as well as linkage to care and treatment for people who tested positive for HIV.

“Namibia’s concerted efforts to reach people with HIV testing and treatment are producing extraordinary results,” said Michel Sidibé, Executive Director of UNAIDS. “UNAIDS will continue to support Namibia in reaching all people living with HIV with testing and treatment and in boosting Namibia’s HIV prevention efforts to further bring down new HIV infections.”

NAMPHIA was a widespread household HIV survey funded by the Government of the United States of America and conducted by the Centres for Disease Control and Prevention, Columbia University and local government and nongovernmental partners from June to December 2017.

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.

New HIV infections are rising in around 50 countries, AIDS-related deaths are not falling fast enough and flat resources are threatening success. Half of all new HIV infections are among key populations and their partners, who are still not getting the services they need

PARIS/GENEVA, 18 July 2018—UNAIDS is issuing countries with a stark wake-up call. In a new report, launched today in Paris, France, at an event co-hosted with Coalition PLUS, UNAIDS warns that the global response to HIV is at a precarious point. At the halfway point to the 2020 targets, the report, Miles to go—closing gaps, breaking barriers, righting injustices, warns that the pace of progress is not matching global ambition. It calls for immediate action to put the world on course to reach critical 2020 targets.

“We are sounding the alarm,” said Michel Sidibé, Executive Director of UNAIDS. “Entire regions are falling behind, the huge gains we made for children are not being sustained, women are still most affected, resources are still not matching political commitments and key populations continue to be ignored. All these elements are halting progress and urgently need to be addressed head-on.”

HIV prevention crisis

Global new HIV infections have declined by just 18% in the past seven years, from 2.2 million in 2010 to 1.8 million in 2017. Although this is nearly half the number of new infections compared to the peak in 1996 (3.4 million), the decline is not quick enough to reach the target of fewer than 500 000 by 2020.

The reduction in new HIV infections has been strongest in the region most affected by HIV, eastern and southern Africa, where new HIV infections have been reduced by 30% since 2010. However, new HIV infections are rising in around 50 countries. In eastern Europe and central Asia the annual number of new HIV infections has doubled, and new HIV infections have increased by more than a quarter in the Middle East and North Africa over the past 20 years.

Treatment scale-up should not be taken for granted

Due to the impact of antiretroviral therapy roll-out, the number of AIDS-related deaths is the lowest this century (940 000), having dropped below 1 million for the first time in 2016. Yet, the current pace of decline is not fast enough to reach the 2020 target of fewer than 500 000 AIDS-related deaths.

In just one year, an additional 2.3 million people were newly accessing treatment. This is the largest annual increase to date, bringing the total number of people on treatment to 21.7 million. Almost 60% of the 36.9 million people living with HIV were on treatment in 2017, an important achievement, but to reach the 30 million target there needs to be an annual increase of 2.8 million people, and there are indications that the rate of scale-up is slowing down.

West and central Africa lagging behind

Just 26% of children and 41% of adults living with HIV had access to treatment in western and central Africa in 2017, compared to 59% of children and 66% of adults in eastern and southern Africa. Since 2010, AIDS-related deaths have fallen by 24% in western and central Africa, compared to a 42% decline in eastern and southern Africa.

Nigeria has more than half (51%) of the HIV burden in the region and there has been little progress in reducing new HIV infections in recent years. New HIV infections declined by only 5% (9000) in seven years (from 179 000 to 170 000) and only one in three people living with HIV is on treatment (33%), although HIV treatment coverage has increased from just 24% two years ago.

Progress for children has slowed

The report shows that the gains made for children are not being sustained. New HIV infections among children have declined by only 8% in the past two years, only half (52%) of all children living with HIV are getting treatment and 110 000 children died of AIDS-related illnesses in 2017. Although 80% of pregnant women living with HIV had access to antiretroviral medicines to prevent transmission of HIV to their child in 2017, an unacceptable 180 000 children acquired HIV during birth or breastfeeding—far away from the target of fewer than 40 000 by the end of 2018.

“One child becoming infected with HIV or one child dying of AIDS is one too many,” said Mr Sidibé. “Ending the AIDS epidemic is not a foregone conclusion and the world needs to heed this wake-up call and kick-start an acceleration plan to reach the targets.”

Key populations account for almost half of all new HIV infections worldwide

The report also shows that key populations are not being considered enough in HIV programming. Key populations and their sexual partners account for 47% of new HIV infections worldwide and 97% of new HIV infections in eastern Europe and central Asia, where one third of new HIV infections are among people who inject drugs.

“The right to health for all is non-negotiable,” said Mr Sidibé. “Sex workers, gay men and other men who have sex with men, prisoners, migrants, refugees and transgender people are more affected by HIV but are still being left out from HIV programmes. More investments are needed in reaching these key populations.”

Half of all sex workers in Eswatini, Lesotho, Malawi, South Africa and Zimbabwe are living with HIV. The risk of acquiring HIV is 13 times higher for female sex workers, 27 times higher among men who have sex with men, 23 times higher among people who inject drugs and 12 times higher for transgender women.

“Communities are echoing UNAIDS’ call,” said Vincent Pelletier, positive leader and Executive Director of Coalition PLUS. “We need universal access to adapted prevention services, and protection from discrimination. We call upon world leaders to match commitments with funding, in both donor and implementing countries.”

Stigma and discrimination persists

Discrimination by health-care workers, law enforcement, teachers, employers, parents, religious leaders and community members is preventing young people, people living with HIV and key populations from accessing HIV prevention, treatment and other sexual and reproductive health services.

Across 19 countries, one in five people living with HIV responding to surveys reported being denied health care and one in five people living with HIV avoided visiting a health facility for fear of stigma or discrimination related to their HIV status. In five of 13 countries with available data, more than 40% of people said they think that children living with HIV should not be able to attend school with children who are HIV-negative.

New agenda needed to stop violence against women

In 2017, around 58% of all new HIV infections among adults more than 15 years old were among women and 6600 young women between the ages of 15 and 24 years became infected with HIV every week. Increased vulnerability to HIV has been linked to violence. More than one in three women worldwide have experienced physical or sexual violence, often at the hands of their intimate partners.

“Inequality, a lack of empowerment and violence against women are human rights violations and are continuing to fuel new HIV infections,” said Mr Sidibé. “We must not let up in our efforts to address and root out harassment, abuse and violence, whether at home, in the community or in the workplace.”

90–90–90 can and must be achieved

There has been progress towards the 90–90–90 targets. Three quarters (75%) of all people living with HIV now know their HIV status; of the people who know their status, 79% were accessing treatment in 2017, and of the people accessing treatment, 81% had supressed viral loads.

Six countries, Botswana, Cambodia, Denmark, Eswatini, Namibia and the Netherlands, have already reached the 90–90–90 targets and seven more countries are on track. The largest gap is in the first 90; in western and central Africa, for example, only 48% of people living with HIV know their status.

A big year for the response to tuberculosis

There have been gains in treating and diagnosing HIV among people with tuberculosis (TB)—around nine out of 10 people with TB who are diagnosed with HIV are on treatment. However, TB is still the biggest killer of people living with HIV and three out of five people starting HIV treatment are not screened, tested or treated for TB. The United Nations High-Level Meeting on Tuberculosis in September 2018 is an opportunity to bolster momentum around reaching the TB/HIV targets.

The cost of inaction

Around US$ 20.6 billion was available for the AIDS response in 2017—a rise of 8% since 2016 and 80% of the 2020 target set by the United Nations General Assembly. However, there were no significant new commitments and as a result the one-year rise in resources is unlikely to continue. Achieving the 2020 targets will only be possible if investments from both donor and domestic sources increase.

Ways forward

From townships in southern Africa to remote villages in the Amazon to mega-cities in Asia, the dozens of innovations contained within the pages of the report show that collaboration between health systems and individual communities can successfully reduce stigma and discrimination and deliver services to the vast majority of the people who need them the most.

These innovative approaches continue to drive the solutions needed to achieve the 2020 targets. When combination HIV prevention—including condoms and voluntary medical male circumcision—is pursued at scale, population-level declines in new HIV infections are achieved. Oral pre-exposure prophylaxis (PrEP) is having an impact, particularly among key populations. Offering HIV testing and counselling to family members and the sexual partners of people diagnosed with HIV has significantly improved testing access.

Eastern and southern Africa has seen significant domestic and international investments coupled with strong political commitment and community engagement and is showing significant progress in achieving the 2020 targets.

“For every challenge there is a solution,” said Mr Sidibé. “It is the responsibility of political leaders, national governments and the international community to make sufficient financial investments and establish the legal and policy environments needed to bring the work of innovators to the global scale. Doing so will create the momentum needed to reach the targets by 2020.”

In 2017, an estimated:

36.9 million [31.1 million–43.9 million] people globally were living with HIV

21.7 million [19.1 million–22.6 million] people were accessing treatment

1.8 million [1.4 million–2.4 million] people became newly infected with HIV

940 000 [670 000–1.3 million] people died from AIDS-related illnesses

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.

There has been global progress in accelerating towards the 90–90–90 targets—whereby, by 2020, 90% of people living with HIV will know their HIV status, 90% of people who know their HIV-positive status will be accessing treatment and 90% of people on treatment will have suppressed viral loads—since their launch at the International AIDS Conference in 2014 in Melbourne, Australia.

Four years later, global leaders from civil society, governments, the private sector and academia came together for a two-day workshop, on 21 and 22 July in Amsterdam, Netherlands, to highlight the successes, identify gaps and share best practices in order to reach 90–90–90.

By the end of 2017, the world had achieved 75–79–81. Globally, 75% of people living with HIV know their status, 79% of people living with HIV who know their status are accessing antiretroviral therapy and 81% of people accessing treatment had suppressed viral loads.

The participants at the workshop reviewed the progress made with the rapid adoption of global policies, political commitment, the engagement of civil society and regular evaluation of progress and gaps.

Despite the global successes, evidence presented at the workshop showed that entire regions and populations are still being left behind. Progress in eastern Europe and central Asia, western and central Africa and the Middle East and North Africa is falling behind. Key populations, adolescents and men are not being reached by traditional health facility-based HIV testing services. Lack of political commitment, user fees and stigma and discrimination are some of the barriers to progress.

During the session, the participants discussed ways to identify and correct gaps and direct resources to where they are most needed, including by investing in data collection, reducing the turnaround time from testing to treatment initiation, prioritizing adherence and retention in care, increasing access to affordable viral load testing and the meaningful engagement of civil society in order to reach the people currently being left behind.

The participants also called for the political commitment and financial resources needed to make 90–90–90 a reality everywhere.