"This report clearly demonstrates the power of the 90-90-90 targets....It shows that innovations are possible at every level - from communities to research laboratories, from villages to cities. It illustrates the power of political leadership..." - Michel Sidibé, UNAIDS Executive Director
Since they were launched at the 20th International AIDS Conference in Melbourne, Australia, in 2014, the 90-90-90 targets - 90% of people living with HIV know their status, 90% of people living with HIV who know their status are on treatment, and 90% of people on treatment are virally suppressed - have become a central pillar of the global quest to end the AIDS epidemic. The targets reflect a fundamental shift in the world's approach to HIV treatment, moving it away from a focus on the number of people accessing antiretroviral therapy (ART) and towards the importance of maximising viral suppression among people living with HIV. As the world approaches the midway point between the 2014 launch of the 90-90-90 targets and their December 2020 deadline, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has reviewed the progress made. To that end, the first half of this report looks at: the 90-90-90 vision, the state of the epidemic, efforts to close the gaps, and 90-90-90 within a comprehensive approach. The second half includes data from each of the world's regions (see also Related Summaries, below).
In short, the data show that substantial progress has been made towards the 90-90-90 targets. More than two thirds of all people living with HIV globally knew their HIV status in 2016. Among those who knew their HIV status, 77% [57- >89%] were accessing ART, and 82% [60- >89%] of people on treatment had suppressed viral loads. In 2016, for the first time, more than half of all people living with HIV (53% [39-65%]) were accessing ART. This acceleration of HIV testing and treatment - within a comprehensive approach that includes condoms, voluntary medical male circumcision, pre-exposure prophylaxis (PrEP), and efforts to protect human rights and establish an enabling environment for service delivery - contributed to a 32% global decline in AIDS-related deaths and a 16% global decline in new HIV infections between 2010 and 2016.
Some communication-related observations:
- UNAIDS notes that, globally, progress made in improving knowledge of HIV status in 2016 was lower than progress in other areas of the cascade, with gaps in knowledge of HIV status often largest among young people and men. Closing those gaps calls for approaches such as the UNITAID-supported HIV Self-Testing Africa (STAR) project, which is demonstrating that self-testing can reach many people who do not seek HIV tests in health facilities.
- For the second 90, lessons from the results achieved by the Sustainable East Africa Research in Community Health (SEARCH) and HPTN071 (PopART) studies are worth exploring, including the strategic use of trained community health workers and adoption of a holistic approach that treats not only HIV but the entire health needs of the client.
- With regard to the third 90, UNAIDS holds that it is critical for treatment programmes to establish community-centred strategies and systems that support patient adherence to treatment and reduce the number of patients lost to follow-up. The use of peer support groups, well-trained and supportive health workers, short message service (SMS) reminders, and reduced waiting times at clinics have proven successful for increasing retention among adolescents and young people living with HIV.
As UNAIDS reports, "[d]ata from a variety of sources show that that gaps in the 90-90-90 continuum are greater for men, young people, and key populations. Harmful masculine gender norms contribute to greater risk-taking and poorer uptake of health services among men. Consent laws and insufficient access to comprehensive sexuality education deny young people the services and knowledge they need. Key populations often face criminalization and high levels of stigma and discrimination. Closing gaps in service coverage requires intensified efforts to convince men to reject harmful versions of masculinity, and to reach and empower women and girls, young people and key populations, to enhance their agency and to ensure their human rights are respected and protected. Addressing stigma, discrimination and human rights violations at all levels through the creation of a protective and empowering legal environment and strong rule of law is an imperative for both the AIDS response and the wider 2030 Agenda for Sustainable Development."
In addition to its focus on regional data, the report emphases the role of the world's cities, which are home to more than half of the world's population and a large and growing proportion of people living with diseases like HIV and tuberculosis (TB). However, cities can serve as hubs of innovation, community involvement, and strong local leadership - all of which are advantages in accelerating health responses. For example, at least two cities - Amsterdam, Netherlands, and Melbourne, Australia - attaining the 90-90-90 targets, and others closing in. Mayors such as Anne Hidalgo of Paris, France, are playing key leadership roles. The engagement of communities - including people living with HIV and their clinical and service providers - in decision-making processes is described here as being critical to refocusing city AIDS plans. Strategic use of data has reportedly improved prioritisation of resources and programmes to address gaps across the HIV care continuum. While progress has been achieved in many cities, UNAIDS stresses that much more remains to be done. Stigma and discrimination, including in health-care settings, need to be addressed to break down barriers to accessing and utilizing HIV services, especially among key and vulnerable populations. Case studies in this report highlight progress achieved in cities worldwide. "Best practices and lessons learned by Fast-Track cities must be leveraged to inspire and encourage the many other cities facing similar challenges in their local AIDS responses."
Email from Shona Wynd to The Communication Initiative on October 16 2017; and UNAIDS website, October 16 2017. Image credit: UNAIDS