Among all the messages out there in this time of great optimism around the fight against HIV in the world, none may be as snappy and as attached to the “treatment cascade” as the 90-90-90 goal by 2020 enunciated by UNAIDS and embraced by many, including our own federal government. There is a lot to like about it, but I think it still bears a little dissecting to understand its strengths and weaknesses.
Just a reminder for those who might be less familiar with the 90-90-90 goals: 90% of people living with HIV will be aware of their status; of that 90%, 90% will be on treatment; of the 90% on treatment, 90% will have an undetectable viral load.
Let’s have a look at the first 90: testing. Isn’t there a 90 that should come before that? Like prevention? Or do we give up on prevention and take the purely medical road and content ourselves with finding the infected rather than working on preventing those infections? Definitely a 90 to add in there, like 90% of people have access to the full range of prevention services and materials, or 90% of people have access to the means to benefit from the social determinants of health.
But let’s go back to testing. This year, the estimates issued by the Public Health Agency of Canada put the percentage of people living with HIV who are unaware of their status at 21% overall, lower for some populations and higher for others. There’s a bit of distance to cover to get this down to 10% within the next four years, and we in Canada might have to look at some successes elsewhere in the world to get there.
"If you don’t know your status, you aren’t criminally responsible for not disclosing it…and you’re probably a lot more likely to transmit HIV."
We also need to start looking at some of the disincentives for testing that we seem to accept as given. If a sexually active gay man follows the public health suggestions and gets tested every 3 months, he will find himself having some trouble getting life insurance, even though all his tests come back negative. If you don’t know your status, you aren’t criminally responsible for not disclosing it…and you’re probably a lot more likely to transmit HIV. Those are just two things that we could fix to make testing more interesting to the people we are trying to reach.
The second 90: treatment. I used to resist the message that everyone should be on treatment right away, and I do still insist that the person need to give informed consent for that treatment. But the proof is in with respect to the benefit for the person taking the treatment (and not just as prevention for the rest of the community), so I have changed my tune. Always consent, but informed by the knowledge we now have of the benefits of treatment.
What are the barriers to this? Try moving between provinces. We have ten different systems of distribution of medications, more if you count the territories and the multiple formularies managed by the federal government. The answer surely lies in those governments working out a better system for mobility, but not necessarily a single system for the country. We also need to pay attention to the costs for the patients, not only of their HIV meds, but also of the other range of meds that almost everyone I know with HIV is also taking. As an employed person, I am fine with contributing, but the graduation of the contributions expected has to be much more realistic about people’s means.
The third 90: undetectable. With the meds we now have available to us, there is no reason an attentive doctor and an active patient can’t identify a combination that works for the individual with minimal side effects and a schedule that fits in the person’s life. But there’s more to this, and it’s about really getting the benefit of doing the work to get and stay undetectable. We know that undetectable people don’t transmit HIV, yet the Supreme Court is telling us that it takes more than that to not have to disclose. We also get discriminated against and stigmatized in our communities by those who don’t know and haven’t bothered to learn what undetectable means. That needs to change.
My title asks if we are headed toward failure. I think that bears explaining. We are at a turning point where we really could eliminate first AIDS (being advanced HIV disease with the associated health consequences) and then eventually HIV. But what are we doing to take advantage of this opportunity? Not much. Few new investments. An international conference to reconstitute the Global Fund that set its objectives by what it could achieve rather than by what is actually needed to step up the global response to meet those 90-90-90 goals and the next ones: 95-95-95 by 2030.
And a word about the “zero discrimination” added as an afterthought. Yes, it’s important and I agree that we won’t get anywhere until we do something about it. But it has become a vague apple-pie type statement: everyone is against it, no one is doing anything proactive to eliminate it.
As a whole, I’m on board with the 90-90-90 strategy, with the addition of a 90 (and then a 95) about prevention and some real action to get to zero discrimination. We won’t get there if we don’t put enough resources into it. We also won’t get there if we are unwilling to work on bringing down the other barriers that are keeping us from success.