HIV/AIDS and the Millennium Development Goals

Man with AIDS awareness ribbon wrapped around his finger
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The Millennium Development Goals (MDGs) are eight strategic objectives established by the United Nations (UN) in 2000, which aim to improve the global quality of life, health, education, economic development, and the environment by 2015. Among the listed goals is a call to "halt and reverse" the spread of HIV, tuberculosis, and malaria—particularly in areas of high prevalence such as Sub-Saharan Africa.

In order to achieve these goal, a number of organizations, including the Joint United Nations Programme on HIV/AIDS (UNAIDS), have set measurable targets by which to reduce not only the global prevalence and incidence of HIV, but many of the social barriers that continue to confound public health efforts (including HIV stigma, gender violence, and the criminalization of HIV).

Since the initiation of the MDGs, there have been both criticisms and concerns regarding the sustainability of the UN-led initiative, given the inconsistency of funding in the wake of the global recession and an increasing—rather than decreasing—numbers of new infections in a number of key priority states, including South Africa and Uganda.

Goal #1: Reduce Sexual Transmissions of HIV by 50%

From 2001 to 2011, the incidence of new HIV infections dropped by approximately 21% world. While much media coverage has been given to a UNAIDS report in September 2013 citing a 33% drop in new infections, that number included both adults and children.

From the perspective of sexual transmissions alone—particularly among individuals aged 15-24—the decreases are only half of what had been envisioned by UNAIDS, with most data suggesting a 25% drop in Sub-Saharan Africa and other high-prevalence regions.

More concerning still is the escalating number of new infections reported in Eastern Europe and Central Asia, which have literally doubled since 2001 (driven mainly by injection drug use).

Similarly, the failure to stave HIV infections among men who have sex with men (MSM) will likely contribute to an upward or stagnating trend in many developed and non-developed countries.

By contrast, impressive gains have been achieved in the Caribbean, where the new infection rate has plummeted by some 43% during the same period.

Goal #2: Place 15 Million HIV-Positive People on Antiretroviral Therapy

As of January 2014, nearly 3 million people in developing countries had been placed on antiretroviral therapy (ART). Expanded treatment guidelines issued by the World Health Organization (WHO) in 2013—wherein therapy can now be initiated at CD4 counts of 500 cells/mL or less—will only increase the potential for ART access.

Despite these advances, the MDG target was missed in 2010, with only 55% of the 14.4 million people in need of ART actually receiving it. More concerningly, only 28% of eligible children had access to ART, less than half that of women on ART (63%).

As of June 2013, the highest ART coverage has been achieved in Latin America and the Caribbean (68%), with Eastern Europe and Central Asia demonstrating the weakest coverage (19%).

Based on current trends, it is possible to approach the target of 15 million on ART by the end of 2015, particularly as the procurement of generics has cut the cost of some drug regimens to as little as $8 per month.

However, unless new infection rates can be brought down by some 50% by 2020, as many are hoping, the economic strain of providing ART to an ever-increasing HIV population will be great.

Goal #3: Eliminate Mother-to-Child Transmission of HIV and Reduce AIDS-Related Maternal Deaths by 50%

In June 2013, UNAIDS reported that seven African countries achieved a 50% reduction in new HIV infections among children since 2009. Much of the success is due to antiretroviral programs design to prevent mother-to-child transmission (MTCT), with 75% program coverage in many key priority states. In South Africa alone, MTCT rates have dropped to an astounding 5%, down from a high of 37% in 2000.

Similarly, MTCT interventions in Botswana and Namibia are now well in excess of 90%, nearing what would be considered universal coverage in this key population.

In terms of child mortality, the MDGs called for a reduction in HIV-related maternal deaths to 38 deaths per 100,000 births. Most data suggests that these goals are attainable, with countries like South Africa reporting as few as 60 HIV-related deaths per 100,000 births as of 2014.

Still, there remain concerns as to the number of children receiving ART. While coverage increased by some 15% from 2009 to 2011, those numbers still lag behind those of adult men and women (21%).

Goal #4: Halve the Number of Tuberculosis Deaths in People Living With HIV

The MDGs have called for a reduction in tuberculosis (TB)-related deaths among people living with HIV to less than 250,000 by 2015. While TB remains the most common cause of death for this coinfected population, steady progress has been seen in a number of priority states, with 17 of 44 reporting greater than 50% reductions in death as of 2013.

Overall, there has been a 38% reduction in TB-related deaths, bolstered by intensified TB identification, greater infection control, and widespread use of prophylactic medications to prevent infection in vulnerable populations.

Increased access of ART has also contributed to the diminishing rate, particularly with the implementation of "directly observed therapy" (DOT) in many high-prevalence countries. The strategy, by which TB drugs are given daily by trained adherence monitors, has resulted in an impressive 85% cure rate in some of the hardest hit regions.

Despite this, there are a number of challenges that hinder progress. Today, more than a third of TB treatment centers do not offer DOT, while most cases of multi-drug resistant TB are neither diagnosed nor treated in accordance with prescribed WHO guidelines. Far more concerning is the fact that, of the countries with high HIV/TB prevalence, only Kenya and Malawi are delivering ART to more than 50% of cases. Further progress needs to be made to ensure reduced TB-related mortality within these regions.

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