. “90–90–90 is not just a numeric target. It is a moral and economic imperative. It will keep people living with HIV alive and healthy, protect future generations from infection, provide economic value over the long term and drive the AIDS epidemic into history.”
Michel Sidibé, Executive Director of UNAIDS
Ending AIDS is more than a historic obligation to the 39 million people who have died of AIDS-related illnesses. It also represents a momentous opportunity to lay the foundation for a healthier, more just and equitable world. Ending AIDS will inspire broader global health and development efforts, demonstrating what can be achieved through global solidarity, evidence-based action and multisectoral partnerships.
Although many strategies will be needed to close the book on the AIDS epidemic, it will be impossible to end the AIDS epidemic without bringing HIV treatment to all who need it.
As we contemplate the way forward following the 2015 deadline for the targets and commitments in the 2011 Political Declaration on HIV and AIDS, a final set of targets is needed to drive progress towards the concluding chapter of the AIDS epidemic, promote accountability and unite diverse stakeholders in a common effort. Whereas previous AIDS targets sought to achieve incremental progress in the response, our aim in the post-2015 era is nothing less than the end of the AIDS epidemic by 2030.
In December 2013, the UNAIDS Programme Coordinating Board called on UNAIDS to support country- and region-led efforts to establish new targets for HIV treatment scale-up beyond 2015. In response, countries across the world have launched national processes to develop new treatment targets for 2020. Stakeholder consultations on new targets have been held in all regions of the world. At the global level, stakeholders assembled in a variety of thematic consultations focused on civil society, laboratory medicine, paediatric HIV treatment, adolescents and other key issues.
These diverse consultative processes have generated powerful momentum towards a new narrative on HIV treatment and a set of ambitious, but achievable targets:
. By 2020, 90% of all people living with HIV will know their HIV status.
. By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
. By 2020, 90% of all people receiving antiretroviral therapy will have durable viral suppression.
When these targets are achieved, at least 73% of all people living with HIV worldwide will be virally suppressed—a three-fold increase over current estimates of viral suppression. Modelling demonstrates that achieving these targets by 2020 will enable us to end the AIDS epidemic by 2030.
Overcoming the epidemic is a generations-long struggle that will require uninterrupted access to lifelong treatment for tens of millions of people,necessitating strong, flexible health and community systems and self-replenishing financing mechanisms capable of supporting treatment programmes across the lifespan of people living with HIV. As new technologies arise—including simpler, cheaper diagnostics and longer-lasting antiretrovirals that obviate the need for daily dosing—political will, system preparedness and timely normative guidance will be needed to bring these new tools to scale.
Just as prophylaxis for pneumocystis carinii pneumonia served in the early years of AIDS as a life-saving bridge to the antiretroviral treatment era for millions of people living with HIV, we need to maximize the effectiveness of existing tools in order to extend lives towards the era when a cure or substantially more patient-friendly treatment approaches will be available.
HIV treatment: critical to ending AIDS and making HIV transmission rare
HIV treatment is a unique tool in the AIDS response, preventing illness and death, averting new infections and saving money. As hopes for ending AIDS depend in large measure on our ability to provide HIV treatment to all who need, it, final targets for universal treatment access are critical.
HIV treatment prevents HIV-related illness and disability
In 2013, in recommending an increase in the CD4 count threshold for initiation of HIV treatment from 350 to 500 cells/mm3, WHO cited growing evidence of the clinical benefits of earlier treatment initiation. Since the launch of the guidelines, additional analysis of the HPTN 052 results found that trial participants randomized to early treatment arm had higher median CD4 counts during the trial, were 27% less likely to experience a primary clinical event, 36% less likely to experience an AIDS-defining clinical event and 51% less likely to be diagnosed with tuberculosis.
HIV treatment averts AIDS-related deaths
Whereas someone who acquired HIV in the pre-treatment era could expect to live only 12.5 years, a young person in industrialized countries who becomes infected today can expect to live a near normal lifespan (or an additional five decades) with the use of lifelong HIV treatment.
Low- and middle-income countries have also seen AIDS-related deaths plummet upon introduction of widespread HIV treatment. As treatment access expanded over the last decade in high-prevalence countries, the devastating health effects of the epidemic were reversed, with life expectancy rising markedly in countries where HIV treatment was brought to scale.
HIV treatment prevents new HIV infections
Among prevention interventions evaluated to date in randomized, controlled trials, HIV treatment has demonstrated by far the most substantial effect on HIV incidence. Interim findings from the PARTNER study indicate that among 767 serodiscordant couples, no case of HIV transmission occurred when the person living with HIV had suppressed virus—after an estimated 40,000 instances of sexual intercourse.
For the complete text of the discussion paper go here.