Can the UN Strategy to End HIV Epidemic Work?

Policymakers call for an end to the epidemic by 2030

AIDS March
United States Agency for International Development (USAID)

The Joint United Nations Programme on HIV/AIDS (UNAIDS) announced bold, new targets aimed at ending the global AIDS epidemic back in 2014. The initiative, known as the 90-90-90 strategy, outlines the means by which to achieve three preliminary goals by 2020: 

  1. To identify 90% of people living with HIV through expanded testing.
  2. To place 90% of positively identified individuals on antiretroviral therapy (ART).
  3. To ensure that 90% of those on therapy are able to achieve undetectable viral loads indicative of treatment success.

It is known that by achieving this level of viral suppression, people with HIV are far less likely to pass the virus to others. By doing so on a global scale, UNAIDS officials strongly believe that the epidemic can effectively be ended by as early as 2030.

But is it really as easy as all that?

Even the most ardent supporters of the strategy acknowledge that such targets have never before been achieved in the history of public health. In the same breath, however, most will also agree that without the aggressive expansion of existing national HIV programs, the window of opportunity to stave that global crisis could be all but lost.

It was this latter reality that eventually led to the endorsement of the 90-90-90 strategy at a United Nations High-Level Meeting on Ending AIDS, held in New York City in June 2016.

Where We Are Today

According to a 2020 UNAIDS report, while there have been impressive gains made over the last several years, the progress has been by no means uniform and many countries will not meet the 2020 targets by year end. 

On the plus side, 82% of those who know their HIV status are accessing treatment, and 81% of people living with HIV know their status. Of those who are being treated, 88% were virally suppressed. These figures hit close to the 90-90-90 target by the end of 2020.

Unfortunately, one crucial part of this data is the number of people who know their HIV status. There is still a significant number of people who don't know they have HIV. Although an estimated 25.4 million people, as of 2019, have been receiving HIV treatment, that number only reflects 67% of all those who need it. Almost a third of all individuals with HIV don't know they have it, which means these individuals aren't accessing treatment they may very much need.

Still, the 2019 figures show vast improvement from 2010 numbers, when only 47% of those in need of treatment were receiving ART.

With underfunding and a lack of donor commitment set to impede the expansion of global programs, the ability to improve upon these figures could likely be dramatically undercut.

Even in the U.S., national figures are falling well below the benchmarks set by the UN, with the Centers for Disease Control and Prevention reporting that, of the 1.2 million Americans living with HIV in 2017, 86% have been diagnosed, 49% are on treatment, and 63% on treatment are virally suppressed.

From a global perspective, the 2020 UNAIDS report highlighted both bright spots and areas of concern in reaching the 90-90-90 goals:

  • As a whole, Central Europe, Western Europe, and North America are faring best, with nearly 90% of the HIV population positively identified and on treatment, and over 80% achieving an undetectable viral load.
  • In sub-Saharan Africa, a region which accounts for two-thirds of all global infections, progress has been impressive in many of the hardest-hit countries, with Botswana, Rwanda, Malawi, and Kenya at 85% or above with regard to 2020 targets.
  • Eswatini in Southern Africa has already reached the 2030 target of 95%.
  • Similarly, Singapore, Vietnam, Thailand, and Cambodia are well ahead of their 2020 targets.
  • In terms of treatment delivery, western and central Europe and North America have the highest coverage, at approximately 81%.
  • By contrast, regions in Eastern Europe, central Asia, the Middle East, and North Africa have the lowest treatment coverage. Access to care and supply chain failures continue to hamper progress within these regions. Injecting drug use continues to drive infection rates. Barrier to care within these regions (including homophobia and criminalization) have led to dramatic increases in the annual infection rate.

The Cost of Hitting the 90-90-90 Targets

According to UNAIDS officials, the plan to reach the 90-90-90 targets by 2030 required international funding to reach an estimated $26.2 billion in 2020. But with a funding shortfall of about 30%, financial commitments will have to increase between 2020 and 2030.

Should the program goals be reached, the benefits could be enormous, as evidenced by a 2016 study published in the Annals of Internal Medicine. According to the study, the implementation of the strategy in South Africa—the country with the world’s largest HIV burden—could avert as many as 873,000 infections and 1.2 million deaths over five years, and 2 million infections and 2.5 million deaths over 10 years.

While the cost of implementation was pegged at a staggering $15.9 billion in South Africa alone, the cost-effectiveness of the plan (in terms of fewer hospitalizations, deaths, and maternal orphans) was deemed to justify the high expense.

While the funding goals like these may seem reasonable, given the long-term benefits to national health systems, the simple truth is that global contributions have continued to decline year on year. From 2014 to 2015 alone, international donations fell by more than a billion dollars, from $8.62 billion to $7.53 billion.

Even the U.S, who remains the single largest contributor to the global HIV initiative, contributions under the Obama administration have flat-lined since 2011. Most pundits suggest that the trend will continue, with many in Congress calling for the "re-purposing" of funds rather than an increase in overall AIDS spending.

As it currently stands, the U.S. has agreed to match one dollar for every two contributed by other countries, up to a hard ceiling of $4.3 billion (or one-third of the Global Fund’s $13 billion goal). This actually translates to a reduction in the ceiling from the previous $5 billion, with only a marginal 7% increase from the previous $4 billion U.S. contribution.

By contrast, many countries with deeper economic woes have increased their commitments, with the European Commission, Canada, and Italy each upping their pledge by 20%, while Germany has increased theirs by 33%. Even Kenya, whose per capita GDP is 1/50th that of the U.S., has committed $5 million to HIV programs outside of its national borders.

But even beyond the issue of dollars and cents, the impact of the 90-90-90 strategy will put added strain on many national health systems that have neither the means to absorb the funding nor the infrastructure or supply chain mechanisms to effectively deliver care. Medication stock-outs are already regular occurrences in many parts of Africa, while the failure to retain patients in care is reversing any gains made by placing individuals on therapy in the first place.

Can We Treat Our Way Out of the Epidemic?

While remarkable progress has been in curbing the global HIV epidemic, investigators at the London School of Hygiene and Tropical Medicine suggest that the 90-90-90 targets have little chance of ending the crisis by 2030. The strategy, they assert, is based on evidence that expanded treatment can reverse infection rates by lowering the so-called "community viral load"—a strategy known popularly as Treatment as Prevention (or TasP).

According to the research, there remain serious gaps in the strategy. From a historic standpoint, the greatest decline in HIV infections occurred between 1997 and 2005, the years of which were marked by three major events:

  1. The introduction of highly potent combination therapies, known at the time as HAART (or highly active antiretroviral therapy).
  2. The advent of generic antiretrovirals, which made the drugs affordable for the developing countries.
  3. The introduction of more effective HIV drugs, such as tenofovir, as well as simpler, single-pill combination therapies.

However, since that time, there have been only modest decreases in the global infection rate. In fact, of the 195 countries included in the study, 102 experienced annual increases from 2005 to 2015. Among those, South Africa reported increases of over 100,000 new infections from 2014 to 2015, adding to the 1.8 million infections in Africa and the 2.6 million reported globally each year.

HIV prevalence (i.e., the proportion of a population living the disease) has reached an estimated 38 million in 2019. And while mortality rates have decreased from 1.7 million deaths in 2004 to 690,000 in 2019, HIV-associated illnesses have increased dramatically in many countries. Tuberculosis (TB) is a case in point, accounting for nearly 20% of deaths among people living with HIV (predominantly in developing countries). Yet despite the fact that HIV co-infection rates run high in people with TB, HIV is frequently omitted as the cause of death (or even the contributing cause of death) in national statistics. 

The researchers further noted that rising infection rates paired with longer life spans (a result of expanded treatment coverage) will require governments to manage an ever-increasing population of HIV-infected individuals. And without the means to sustain viral suppression within that population—and not just for a few years, but for a lifetime—it is all but likely that infection rates will rebound, possibly dramatically.

While there is compelling evidence that TasP can reverse HIV rates in high-prevalence populations, researchers argue that we cannot rely on treatment alone to end the epidemic. They instead advise dramatic changes in the way that programs are both financed and delivered. These include an increase in domestic funding, allowing for the free flow of even cheaper HIV generic drugs, and investing in the improvement of national health delivery systems.

It would also demand more effective preventive interventions, including an investment in harm reduction strategy for injecting drugs users, the strategic use of HIV pre-exposure prophylaxis (PrEP) in appropriate populations, and a reinforcement of condom programs at a time when usage among the young is on the wane.

Without these foundational changes, the researchers argue, the 90-90-90 strategy will likely have more impact on mortality rates and less on achieving a durable reversal of HIV infections.

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