Leading HIV researchers describing results from multiple clinical trials in sub-Saharan Africa report that innovative service delivery models are achieving results across the HIV treatment cascade that approach or exceed the 90–90–90 target.

Study results were presented at an all-day workshop hosted by the British Columbia Centre for Excellence in HIV/AIDS and the Division of AIDS at the University of British Columbia, prior to the opening of the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Vancouver, Canada. The studies are being undertaken in a number of high-burden countries in sub-Saharan Africa, including Botswana, Kenya, Malawi, South Africa, Swaziland, Uganda and Zambia.

“These exceptional clinical trial results show yet again how innovation is driving progress in the AIDS response,” said UNAIDS Executive Director Michel Sidibé. “The results demonstrate that the 90–90–90 target is more than a dream. It is entirely feasible.”

Diane Havlir, of the University of California, San Francisco, presented interim results from the Sustainable East Africa Research for Community Health (SEARCH) trial in more than 30 rural communities in Kenya and Uganda. Having enrolled more than 334 000 people, the SEARCH trial is evaluating a multicomponent programme, including use of community-centred, multidisease campaigns to provide HIV testing and link HIV-positive individuals to immediate initiation of antiretroviral therapy.

At a population level, the SEARCH programme has achieved 90% knowledge of HIV status. Among participants living with HIV, more than 90% of people in Uganda and 83% in Kenya are receiving antiretroviral therapy. At 24 weeks, 92% of trial participants who have initiated antiretroviral therapy have achieved viral suppression.

Similarly encouraging, although preliminary, results were reported from the PopART trial by Richard Hayes of the London School of Hygiene and Tropical Medicine. Working in 21 communities, the trial is evaluating a combination HIV prevention package that includes repeated rounds of community-level HIV testing and immediate initiation of antiretroviral therapy for all people who are diagnosed HIV-positive. Among more than 115 000 community members enumerated in the trial, 90% of all men living with HIV and 92% of all women living with HIV were aware of their HIV status following the PopART programme. Among people with an HIV diagnosis, 62% of men and 65% of women were receiving antiretroviral therapy, highlighting the need to further strengthen linkage to care for people living with HIV. Data on rates of viral suppression among PopART participations will be available next year.

Max Essex, of the Harvard University School of Public Health, presented baseline findings for the Botswana Combination Prevention Protocol. Mr Essex and his colleagues have found that 79% of all people living with HIV in Botswana knew their HIV status as of mid-2015, 86% of adults who have been diagnosed with HIV were receiving antiretroviral therapy and 96% of people receiving antiretroviral therapy had achieved viral suppression.

Comparably impressive results have been achieved by a Médicins Sans Frontières (MSF) programme in the District of Chiradzulu in Malawi, according to David Maman of MSF. In Chiradzulu, 77% of all people living with HIV know their HIV status, 84% of people with an HIV diagnosis are receiving antiretroviral therapy and 91% of people receiving antiretroviral therapy have achieved viral suppression.

François Dabis, of the Bordeaux School of Public Health, described preliminary results from a separate trial in the Hlabisa district in KwaZulu-Natal, South Africa, of a test-and-treat initiative that includes six-month rounds of community-level testing and establishment of antiretroviral treatment sites in all communities in the study. Among more than 26 000 people in the study communities, 85% know their HIV status. Among HIV-diagnosed people reached by the programme, 86% are receiving antiretroviral therapy. Study results indicate that linkage to care remains suboptimal and an important focus of further work and innovation.

Several important themes emerged from these study findings. Researchers emphasized the importance and value of engaging and collaborating with local communities in developing programme approaches tailored to local needs and circumstances. Most of the studies have also taken multidisciplinary approaches to the development, monitoring and evaluation of programmes, involving social scientists, economists and community representatives as well as clinicians and biostatisticians.

Innovation in HIV diagnostics is urgently needed if the world hopes to achieve the 90–90–90 target for access to antiretroviral therapy, leading scientific experts advised this week. The call for intensified effort and innovation on HIV diagnostics occurred during two sessions at the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, held in Vancouver, Canada.

“It is clear that we can’t accept business as usual when it comes to HIV diagnostics,” said UNAIDS Deputy Executive Director Luiz Loures, who moderated a special satellite session on enhancing diagnostic access. “We must do things differently if we are to reach the 90–90–90 target.”

Global experts focused on three key diagnostic challenges: ensuring timely diagnosis of HIV among children, rapidly increasing knowledge of HIV status among adults living with HIV and scaling up essential viral load testing. These three focus areas are key priorities for the Diagnostics Access Initiative, a multi-stakeholder global initiative that aims to fully leverage the potential of laboratory medicine to lay the groundwork to end the AIDS epidemic as a public health threat.

Diagnosing children living with HIV

Unlike adults, who can be diagnosed with HIV through a simple antibody test, very young children require more expensive molecular tests, which use centralized laboratories that are remote from clinical sites. This creates substantial delays in diagnosing HIV-exposed children and also increases both costs and the risks that specimens or results will be lost. Even when early infant diagnostic services are available, many HIV-exposed children only receive their HIV test results after the time when peak mortality occurs, at six to eight weeks old, according to Trevor Peter, of the Clinton Health Access Initiative (CHAI).

Relatively simple, point-of-care diagnostic tests for early infant diagnosis are now emerging, Mr Peter reported, and these will need to be rapidly scaled up. In addition, mobile health technologies have the potential to reduce delays in the communication of test results and help ensure that test results for HIV-exposed children are actually received at the clinical site. At the Vancouver conference, UNAIDS and its partners in the Diagnostics Access Initiative announced with Roche Diagnostics a 35% decline in the global price for early infant diagnostic testing.

Ensuring 90% knowledge of HIV status among adolescents and adults living with HIV

UNAIDS sponsored a separate session at the conference on democratizing HIV testing to reach the 90–90–90 target. Joseph Amon of Human Rights Watch advised that all people should feel empowered to choose where, when and how they want to be tested for HIV. Consistent with this human rights approach, there is growing interest in HIV self-testing tools.

New international guidelines on HIV testing services, launched by the World Health Organization (WHO) in Vancouver this week, indicate that WHO envisages widespread access to self-testing as an important component of a comprehensive HIV testing effort. Several countries in different regions currently allow HIV self-testing, but most countries have yet to adapt their laws and regulatory frameworks to permit it.

The new WHO guidelines on HIV self-testing emphasize the importance of moving testing access closer to communities. In particular, the new guidelines recommend steps to enable lay workers to administer HIV tests. Results from the Sustainable East Africa Research for Community Health (SEARCH) trial in more than 30 rural communities in Kenya and Uganda indicate that population-level knowledge of HIV status approaching or exceeding 90% can be achieved through community-owned, multidisease testing campaigns.

Presenting modelling work, John Stover of Avenir Health said that 90% knowledge of HIV status is achievable more broadly through a strategic combination of testing strategies, such as provider-initiated testing in diverse health settings, outreach to key populations, fixed centres for HIV testing and counselling, and various community-based approaches, such as HIV self-testing, mobile testing and door-to-door, home-based efforts.

Ensuring universal access to viral load testing

Conference participants also heard urgent calls to expand access to viral load testing. Not only is access to viral load testing essential for monitoring the 90-90-90 target, but viral load testing is an essential clinical tool to detect early treatment failure and permit intervention to improve treatment adherence. However, projections by CHAI indicate that current trends in the uptake of viral load testing are insufficient to ensure achievement of the 90–90–90 target.

During the diagnostics-focused sessions, several ways forward were suggested to close the viral load testing gap. Partners in the Diagnostics Access Initiative, along with the Government of South Africa, last year concluded an agreement with Roche Diagnostics to reduce the price of viral load testing by 40% worldwide. In addition, steps need to be taken to maximize the effective use of the viral load platforms that presently exist, as many viral load technologies are severely under-utilized at present.

AIDS strategies and efforts must give greater priority to humanitarian emergencies and the millions of people affected by them, members of the UNAIDS governing body agreed at the thematic segment of the 36th meeting of the UNAIDS Programme Coordinating Board (PCB), which took place in Geneva, Switzerland, on 2 July.

New data presented at the thematic session by the Office of the United Nations High Commissioner for Refugees (UNHCR), the World Food Programme (WFP) and UNAIDS Secretariat estimate that of the 314 million people affected by humanitarian emergencies in 2013, 1.6 million people--or 1 in 22-- are living with HIV, and many thousands more are at risk.

“We are talking about incredible numbers of people and multiple layers of vulnerability. This is too big a scale and impact to ignore. We have to ensure that HIV prevention and treatment services are systematically integrated into emergency responses,” said Mr Michel Sidibé, Executive Director of UNAIDS.

The thematic session contemplated the vast and complex issue of HIV in emergency contexts, including the delivery of health and HIV services in the context of conflict situations, natural disasters, public health emergencies, displacement and migration. On protection issues, vulnerability to HIV due to sexual violence, human rights violations, restrictions, punitive laws and policies were topics of discussion. On resilience, participants talked about the need for community building and preparedness.

Panelists from a wide range of countries including Burundi, Central African Republic, Djibouti, Haiti, Lebanon, Liberia, Nepal, Nigeria, Sierra Leone and Ukraine told of the realities on the ground. They spoke of barriers and opportunities and gave examples of successful government and civil society efforts to address HIV in the wide variety of humanitarian emergency contexts.

In his keynote speech, former refugee Mr Noé Seisaba from Burundi, who founded the Stop SIDA organization that brings key HIV initiatives to refugee camps and settings, called for the community of people living with HIV to be involved in all aspects of planning and implementation. “I faced a lot of discrimination, but I broke my silence on HIV to try to make working on HIV a community issue and to show that we can intervene as refugees because we have a true understanding of the challenges and realities,” he said. “I am happy to see we are all talking about this issue, but I want to see concrete action.”

Many participants echoed that community involvement and empowerment of people living with and most affected by HIV are critical to achieve results for people in such difficult contexts. “If we are going to end the AIDS epidemic by 2030, we have to shine light on root causes of vulnerability in humanitarian settings and increase action to promote respect for rights and basic humanitarian dignity,” said Mr George Okoth-Obbo, Assistant High Commissioner for Operations at UNHCR.

Cross-regional strategies were encouraged to enable maximum impact and coverage of people. The challenge of sexual violence in emergency settings and gender inequalities was highlighted as a fundamental issue to be given greater focus, action and investment. 

The use of illicit drugs needs to be understood as a social and health condition requiring sustained prevention, treatment and care. This is one of the major conclusions emerging from the 2015 World Drug Report, published on 26 June by the United Nations Office on Drugs and Crime (UNODC).

Launched to coincide with the International Day against Drug Abuse and Illicit Trafficking, the report gives a detailed snapshot of the latest developments in drug use, production, trafficking and consequences for health. It finds that some 27 million people are dependent on drugs, half of whom inject; that an estimated 1.65 million people who inject were living with HIV in 2013 (around 13.5%) and that women who inject drugs, though fewer in number, are often much more likely to become infected than men.

In a specific chapter on HIV, it is also noted that there is a major issue in access to antiretroviral therapy and harm reduction programmes among people who inject drugs and that only one in six of all users suffering from drug use disorders or drug dependence benefit from such programmes, which include needle and syringe programmes and opioid substitution therapy. The report acknowledges that some progress has been made in lowering HIV transmission among people who inject drugs: newly diagnosed cases of HIV in this group fell by roughly 10% between 2010 and 2013. However, the international community is far off the global target of reducing transmission by 50% by 2015, set in the 2011 United Nations Political Declaration on HIV and AIDS.

The public health implications of illicit drug use highlighted in the report were explored at length during a special briefing in Geneva hosted by UNODC, UNAIDS and World Health Organization (WHO). During the event, UNODC Deputy Executive Director Aldo Lale-Demoz stressed the need for a multipronged approach which goes beyond disrupting criminal networks. “More also needs to be done in promoting the importance of understanding and addressing drug use as a social and health condition requiring sustained prevention, treatment and care,” he said.

Luiz Loures, UNAIDS Deputy Executive Director, stressed that a people-centred approach was required to reach people who use drugs. "We have the knowlege and technology to end the AIDS epidemic but access has been selective. The difference is determined by good or bad policy. Human rights should be guaranteed and health be at the centre of the response."

According to Shekhar Saxena, Director of WHO’s Department of Mental Health and Substance Abuse, national health care systems often lack the capacity to provide effective treatment and care to drug users. He added that WHO would continue to offer guidance and assistance to countries, “to strengthen health-care systems to reach the ultimate goal of the UN Drug Conventions – to protect the health and welfare of humankind.”

People who inject drugs account for some 30% of new HIV infections outside sub-Saharan Africa and two subregions have notably high rates of HIV infection among people who inject drugs: an estimated 29% in south-west Asia and around 23% in eastern and south-eastern Europe—a region with approximately 40% of the global number of such users living with HIV, mainly residing in the Russian Federation and Ukraine.

Despite significant achievements, too many of the world’s poorest children face inequalities that are having a dramatic impact on their health, education and future prospects, warns UNICEF in a report published on 23 June.

In Progress for children: beyond averages, the final report on child-related Millennium Development Goals (MDGs), UNICEF highlights that millions of children and young people are still dying early, missing out on school, living in poverty and being disproportionately affected by the AIDS epidemic.

“The MDGs helped the world realize tremendous progress for children – but they also showed us how many children we are leaving behind,” said UNICEF Executive Director Anthony Lake. “The lives and futures of the most disadvantaged children matter – not only for their own sake, but for the sake of their families, their communities and their societies,” he added.

The report acknowledges that huge strides have been made in attaining MDG 6–combatting HIV/AIDS, malaria and other diseses.  For instance, between 2001 and 2013 new HIV infections have declined by 58% in children under 15, mainly due to progress in the prevention of mother-to-child transmission of HIV. The Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive has helped achieve a rapid expansion in the availability of antiretroviral medicines to pregnant women found to be living with HIV.

However, only 23% of HIV-positive children received such life-saving medicines in 2013 (compared to 37% of adults) and, in addition, adolescents aged 10-19 are the only group that has not seen a decrease in AIDS-related deaths in recent years.

The report also notes that about 35% of the 1.9 million people newly infected with HIV were young people aged 15-24. Adolescent girls are still most affected by HIV and in some countries are two to three times more likely to be infected than their male counterparts.

Progress for Children highlights a number of other such disparities and areas of deep concern across the spheres of health, education and income. It contends that as the era of the MDGs draws to a close, making way for preparations among world leaders to adopt new Sustainable Development Goals, disadvantaged children must be at the heart of these goals and targets.

The report also argues that better data collection, that tells a more rounded story and is not simply reliant on averages such as those used to measure the MDGs, will help identify the most vulnerable children and encourage tailor-made health and education solutions that help them to live longer, happier and healthier lives.

The number of people and families forced to flee their homes has reached an all-time high, with nearly 60 million people worldwide now displaced by conflict and persecution, says a new report published by the Office of the United Nations High Commissioner for Refugees (UNHCR) for World Refugee Day on 20 June. 

According to UNHCR Global trends 2014, this number is accelerating rapidly. At the end of 2014, some 59.5 million were forcibly displaced, compared to 51.2 million in 2013. Every day last year, an average of 42 500 people became refugees, asylum seekers or internally displaced. This fourfold increase in four years has largely been driven by the war in the Syrian Arab Republic, though numbers are rising across the globe as new conflicts break out or reignite.

In highlighting the unprecedented level of forced displacement and people crossing borders, UNHCR acknowledges that anxiety and intolerance towards them is also growing.  

To address this, the theme of World Refugee Day 2015 is to give a human face to the crisis and show who refugees are and why they need help. By reinforcing the fact that they are ordinary people in extraordinary circumstances, UNHCR hopes to galvanize governments and the public into doing more to improve conditions, empathy and opportunities for people who are forced to move.

United Nations High Commissioner for Refugees António Guterres stressed, "With huge shortages of funding and wide gaps in the global regime for protecting victims of war, people in need of compassion, aid and refuge are being abandoned.” He added, “For an age of unprecedented mass displacement, we need an unprecedented humanitarian response and a renewed global commitment to tolerance and protection for people fleeing conflict and persecution."

A critical part of the UNHCR campaign is to tell the stories of a range of refugees and internally displaced people who are attempting to forge new lives. Several such stories revolve around people living with, or affected by HIV. People who are forcibly displaced may become more vulnerable to HIV as health services become harder to access. They might be more likely to engage in transactional sex if basic needs are not met, and rape is also often used as a weapon of war.

This was the case for Maria Kamwendo, featured by UNHCR, who was raped by rebels in the Democratic Republic of the Congo. She managed to escape and found her way to South Africa. After the shock of being diagnosed as HIV-positive, she has built a new life there and is now an HIV counsellor. “I enjoy what I do,” she says. “HIV is not a death sentence but one can be instrumental in empowering people about the disease.”

By encouraging people to get to know the stories of individual refugees, UNHCR aims to make a link between people lucky enough to have living settled lives and those who are struggling to cope with the trauma of having, through no fault of their own, to flee from their homes.

Zimbabwe has one of the largest HIV epidemics in the world, with an estimated adult HIV prevalence of 15% and 1.4 million people living with HIV. However, the country is accelerating action and increasing investment in its HIV prevention and treatment programmes.

As part of a three-day visit to Zimbabwe, UNAIDS Executive Director Michel Sidibé met with the Vice-President of Zimbabwe, Emmerson Mnangagwa, to discuss the country’s role in the AIDS response. 

During the meeting, Mr Sidibé congratulated the government on progress made in treatment scale-up and prevention, and pointed to the need to Fast-Track the AIDS response to end the epidemic in Zimbabwe by 2030. They talked about securing medicines to keep people living with HIV healthy, as well as the challenges in making sure that adolescent girls are not left behind.

Mr Sidibé also joined the Ministers of Health and Child Care and Finance and Economic Development to discuss with business leaders, civil society and diplomatic missions how to Fast-Track the AIDS response in Zimbabwe.

“The price of medicines has fallen from US$ 10 000 per person per year to under US$ 100,” said Mr Sidibé. “But, to ensure that Africa can deliver a fully sustainable response to HIV, Africa has to start producing its own generic medicines rather than import them from abroad.”

The business leaders present affirmed their commitment to keep investing in the AIDS response even as the country faces severe economic challenges. Pharmaceutical manufacturers pledged to continue looking for ways to be competitive so that the country can play a greater part in the production of antiretroviral and other medicines to lessen its dependence on imports.

The Health Minister, David Parirenyatwa recognized that the AIDS response is a national responsibility. In 2014, Zimbabwe only paid 15% of the response from domestic sources, relying heavily on donor funding to make up the gap. The minister acknowledged that Zimbabwe must do more against stigma and discrimination. Mr Parirenyatwa reaffirmed the government’s commitment to build a concerted strategy to Fast-Track programmes to end the AIDS epidemic by 2030.

To support its response to HIV, in 2000 Zimbabwe introduced an innovative 3% AIDS levy on taxable income. Largely through this levy, domestic financing has increased by 40% in the past three years. To ensure that domestic contributions to Zimbabwe’s response continue to rise, the Minister of Finance, Patrick Chinamasa, said, “Zimbabwe will keep its AIDS levy for the foreseeable future.”

Mr Parirenyatwa said that it is important for Zimbabwe, despite its limited resources, to share a portion of its national trust fund to further the global AIDS response. The government of Zimbabwe presented Mr Sidibé with a cheque for US$ 100 000 to contribute to the UNAIDS core budget for 2015. 

UNAIDS Executive Director Michel Sidibé visited the Mbare City Health Clinic in Harare, Zimbabwe, on 11 June. The public clinic runs an antiretroviral treatment programme that also provides services for victims of rape.

During the visit to the clinic, which is supported by the City of Harare and Médecins sans Frontières, he met people living with HIV, including 19-year-old Thandiwe. Mr Sidibé heard the harrowing story of how she contracted HIV through rape and described her tears as, “A sign of our collective failures. We must do better for her and all women and girls.”

Speaking at the clinic, traditional leader Chief Chiveso denounced violence against women and called on men to be activists against gender-based violence. Mr Sidibé hailed the Chief as a champion for gender equality and for ending gender-based violence and the AIDS epidemic.

Earlier, Mr Sidibé engaged in a dialogue with community leaders, who told him of the challenges that marginalization and unemployment bring. Mr Sidibé said that adolescent girls are affected by the poor economic situation, which has resulted in more girls being infected with HIV compared to their male peers.

Two thirds of the population in Zimbabwe is under 25 years and HIV prevalence is almost two times higher among women aged 15–24 than among men of the same age. Zimbabwe has the sixth highest number of annual adolescent AIDS-related deaths in the world.

Mr Sidibé lauded the combined efforts of Zimbabwe’s civil society and government, which have resulted in a drop in HIV prevalence and the number of AIDS deaths, but warned that the country needs to do more to Fast-Track the response to HIV in order to end the AIDS epidemic in Zimbabwe by 2030. “If we are not careful, after 2015 people will forget about AIDS, complacency will creep in and people will look at other crisis,” he said.