HIV epidemic will spring back without near-universal diagnosis and treatment, says UNAIDS

“Without scale-up, the AIDS epidemic will continue to outrun the response, increasing the long-term need for HIV treatment and increasing future costs.” These are among the opening words of the 2014 “Fast Track” report issued by UNAIDS, the Joint UN Programme on HIV and AIDS, explaining the thinking behind their campaign for an ambitious ‘90-90-90’ target, previewed at the International AIDS Conference in Melbourne this July.

This target means that 90% of people with HIV should be diagnosed, 90% of those on treatment and 90% of those virally suppressed (having an undetectable viral load) – implying that 72.9% of all the people with HIV in the world would be on treatment with an undetectable viral load, a feat never achieved for any infectious disease.

Why 90/90/90?

In the last decade, the world has achieved significant reductions in HIV and in AIDS, the report notes. By the end of 2013, an estimated 35 million people were living with HIV worldwide. New HIV infections in 2013 were estimated at 2.1 million, which was 38% lower than in 2001. The number of AIDS-related deaths also continues to decline, with 1.5 million people dying of AIDS-related causes in 2013, down 35% from the peak in 2005.

Largely because people with HIV are living longer, however, UNAIDS projects that under current treatment rates, HIV incidence and prevalence will start to increase again from 2015. The annual number of new infections, its modelling predicts, will rise to 2.5 million by 2030 and the number of people living with HIV to 41.5 million.

UNAIDS says that if the 90/90/90 target was achieved, it could slash the annual number of HIV infections fourfold to 500,000 by 2020. From then on, the world would have to adopt an even tougher 95/95/95 target, i.e. 86% of everyone with HIV in the world on treatment and virally suppressed, if they are to achieve the desired target of a 90% cut in infections to 200,000 a year by 2030.

Achieving these targets, UNAIDS says, would avert 28 million HIV infections between 2015 and 2030. The economic return on fast-tracked investment is expected to be 15 times the investment, as an annual cost of US$24 billion for HIV treatment (in addition to what is already being invested) would be averted. To do this would cost a steady $22-24 billion a year from 2015 onwards, and more from 2020, but, says UNAIDS, “With the dramatic increase in HIV resources over the past decade, the world is closing in on the target”, with $19.3 billion invested in HIV in 2013. This is now largely being driven by increases in domestic spending on HIV by affected countries,

The 90/90/90 target implies that 81% of people with HIV in the world should be on antiretroviral therapy (ART) by 2020. At present only 39% are (13.6 million people) and only 24% of children, one of a number of under-served groups. UNAIDS maintains, however, that doubling the proportion of people on ART by 2020 is not an impossible target, and that some African countries, such as Uganda, have national plans to achieve that. A few, such as Rwanda, are close to achieving it. Here in the UK, Public Health England recently announced that, for gay men at least, the equivalent figures had reached 84/90/90.

Better prevention needed too

UNAIDS admits that achieving a 90% cut in infections will not be achieved by viral suppression alone, however. Some way through the document, they write: “Antiretroviral therapy is projected to account for 60% of infections prevented through scale-up of these priority strategies.”

In other words, the targets for annual incidence by 2020 and 2030 will only be achieved if the 90/90/90 treatment target is also accompanied by scale-ups in HIV prevention.

“There are…many proven opportunities for HIV prevention beyond medicines,” says UNAIDS, “Including condom programming, behaviour change, voluntary medical male circumcision and programmes with key populations. These have clearly demonstrated their capacity to sharply lower rates of new HIV infections.”

Regarding circumcision, in 2013, around a million men in priority countries in sub-Saharan Africa were newly circumcised, bringing to six million the number of men circumcised since 2007, when UNAIDS and the World Health Organization (WHO) first recommended rolling out voluntary male medical circumcision as a prevention tool. To achieve UNAIDS’ targets, 80% of men in target countries would need to be circumcised by 2020.

UNAIDS acknowledges, however, that the biggest barrier to achieving these targets, both in terms of testing and prevention, is the fact that almost everywhere, “key populations at higher risk of acquiring HIV are not benefiting equally from these gains, underscoring the need to strengthen HIV prevention and treatment efforts with these groups”.

In this respect they agree with the WHO, whose July 2014 Guidelines emphasised the crucial role that mobilising services for men who have sex with men (MSM), people who inject drugs, female sex workers and other key affected populations would play in any global push to end the HIV epidemic. At the time, WHO said: “Without addressing the needs of Key Populations, a sustainable response to HIV will not be achieved” – a statement UNAIDS comes close to echoing.

UNAIDS also aligns itself with WHO in recommending pre-exposure prophylaxis (PrEP) and goes further in not just recommending it for men who have sex with men (MSM), but also for sex workers, couples of differing HIV status, and “adolescents in settings where HIV prevalence is extremely high.”

Condom distribution and use will also remain crucial to ending the epidemic, they add: “Very high levels of coverage for programmes that promote correct and consistent condom use will be needed in all types of epidemics.”

Recognising, however, that some vulnerable populations find it hard to maintain condom use at high enough levels to avoid HIV, they also recommend not only PrEP but financial incentives: “In settings with very high HIV prevalence, new evidence suggests that programming cash transfers for girls will need to be introduced and substantially scaled up.” (A recent US study found that cash transfers could also improve viral suppression and retention in care.)

“Many members of key populations report having no contact with HIV prevention programmes in the past twelve months,” UNAIDS says. “Therefore, much higher coverage – close to saturation – will be required for outreach programmes with sex workers, men who have sex with men, transgender people and people who inject drugs.”

Are the targets achievable?

How realistic are UNAIDS’ aims? Even they admit that “To end the AIDS epidemic by 2030, the global community will need again to defy expectations.”

However, they add that to not pursue the targets will mean an inexorable growth in the HIV-positive population, and continued spending on ART anyway. And, they add, not only is urgent action necessary because the prevalence curve is due to creep up again, but that “Time-bound targets drive progress, promote accountability and unite diverse stakeholders in pushing towards common goals.”

With, for instance, a 5.2% annual increase in GDP forecast for Africa as a whole over the next decade, they say that, financially, a response is within the reach of most countries, leaving the big donors such as the Global Fund to concentrate on the poorest ones.

“The cost of inaction will be huge,” they add. “If countries do not scale up HIV prevention and treatment services rapidly by 2020, but instead continue with the existing coverage levels of services, they will lose the opportunity to save 21 million lives, and an additional 28 million people would be living with HIV by 2030…Continuation of current coverage levels will mean that the world will have to pay an additional $24 billion every year for antiretroviral therapy by 2030.”

What’s missing?

The UNAIDS report, as with the WHO guidelines published earlier this year, is a departure from their previous reports issued before World AIDS Day, which have been often lengthy summaries of the latest statistics on the world epidemic. This replaces most data with the making of a case. As such, much is missing, and UNAIDS omits several conditions that may be necessary to achieve such targets.

AVAC comments on the UNAIDS document that “In broad strokes, it’s the right message, with the right vision, at the right time.”

But, they add, much of the details of strategy, resources and milestones needed are missing – especially as both the 90/90/90 target itself and the gains from it and from improved prevention depend on some countries fundamentally changing the discriminatory way they treat minority populations – a big ask. How UNAIDS thinks this could happen awaits the publication of their prevention and non-discrimination targets.

“The details of what goes where, – which packages, in which places, and what specific terms mean – are missing,” comments AVAC, instancing that 'cash transfers' can be delivered in a large number of ways ranging from grants to lottery tickets to payment in kind, and have different targets ranging from incidence of sexually transmitted infections, level of viral load, to school attendance.

AVAC also adds that the UNAIDS report does not cover innovations that may come online in the next few years (other than PrEP, which is already there in embryo form). UNAIDS does mention that “Innovation is required to produce more potent and long-lasting formulations of antiretroviral medicines for treatment and prophylaxis, a prophylactic or curative vaccine, and a cure”, but does not forecast when any of these may come online or how they may alter their projections.

In addition, they do not mention one piece of crucial missing technology that may need to be present for the 90/90/90 target to be fully realised – a portable and affordable way of performing viral load tests in the field.

Another thing conspicuous by its absence from the UNAIDS targets is any mention of the high-income countries, which may contain low-income affected populations such as migrants within them; the admission on 25 November by the US Centers for Disease Control and Prevention (CDC) that even now only 30% of Americans with HIV are on treatment and virally suppressed – a lower proportion than some African countries – underlines the fact that it is not only poorer countries that will need to address discrimination and inequalities to combat HIV.

Another thing not mentioned by UNAIDS in the main document – though divinable from the Country Scorecards they issue at the end – is the importance of improved surveillance in many countries, as targets that cannot be measured cannot be enforced. This is an issue not only in some of the lowest-income, most chaotic countries such as Somalia and South Sudan, but also on some countries in western Europe such as Spain that do not collect systematic centralised HIV statistics.

AVAC emphasises that some of the responsibility in ending the HIV epidemic belongs to the activists: “We as advocates and activists…must ensure that clear targets, resources and messages are developed with the same strategy, rigour and urgency as 90/90/90.”

“As UNAIDS stress,” they add, “we must all ‘Hold one another accountable and make sure no one is left behind’.”