90-90-90: An Ambitious Treatment Target to Help End the AIDS Epidemic

Released by the Joint United Nations Programme on HIV/AIDS (UNAIDS) as part of the global push to end the AIDS epidemic by 2030, this report seeks to contribute to the momentum building towards a new narrative on HIV treatment and the following target: By 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART), and 90% of all people receiving ART will have viral suppression. As UNAIDS stresses, the only way to achieve this ambitious target is through approaches grounded in principles of human rights, mutual respect, and inclusion. For example, to put in place a comprehensive response to end the epidemic, concerted efforts will be needed to eliminate stigma, discrimination, and social exclusion.

The report explains that, as hopes for ending the AIDS epidemic depend in large measure on the world's ability to provide HIV treatment to all who need it, in a rights-based approach, final targets for universal treatment access are critical. Explored here are the reasons why HIV treatment is a critical (though not the only) tool in ending the AIDS epidemic. For instance, efforts will be needed to explain to individuals, communities, decision-makers, and society at large that ART not only keeps people alive but also prevents further transmission of the virus. However, substantial coverage gaps exist within and among regions; this is where equity considerations come into play in the approach to treatment scale-up. This is one of the reasons why, for UNAIDS, this newly articulated 90-90-90 goal is needed: A new target, based on new scientific knowledge and implementation evidence, will help drive progress in addressing still-persistent challenges, including access gaps still experienced by children, key populations, and other groups.

The report examines some of the challenges associated with making 90-90-90 a reality for all populations. For instance, surveys through the People Living with HIV Stigma Index indicate that members of key populations commonly experience disapproval, rejection, and sub-optimal services in health care settings. Transgender individuals commonly confront hostile, judgmental, and/or dismissive attitudes when they attempt to access health services. Young people often have no access to sexuality education and limited information regarding sexual and reproductive health and rights. Many adolescents living with HIV struggle with disclosure of their HIV status, in part because they are frequently left on their own to navigate the complexities of living with HIV as a young person. And there is insufficient attention to children's HIV treatment needs, UNAIDS finds, although the World Health Organization (WHO) is leading global efforts in this area.

Despite these challenges, according to UNAIDS, at a national level, several countries are either on track to achieve the 90-90-90 target or have approached, met, or exceeded one or more of the elements of the target. What is needed now, the organisation stresses, is to link lessons learned across each and every stage of the treatment cascade, and to transfer best practices in high-achieving countries and programmes to those that lag behind. The report thus shares several examples. To illustrate, in terms of target 1: Sharply increasing the proportion of people living with HIV who know their HIV status will require moving beyond a passive approach to testing, which relies on individuals to recognise their own risk and come forward on their own to learn their status, often without meaningful education or support. More proactive, rights-based testing initiatives will be needed, including focused testing promotion for key geographic and population hotspots, investments in strategies to increase demand for testing services, and utilisation of a broader array of HIV testing and counselling approaches, including self-testing, provider-initiated counselling and testing, and community-based approaches.

The countries in which progress towards the 90-90-90 target has been most pronounced have found ways to overcome challenges such as those related to stigma and discrimination. For example, UNAIDS claims that punitive frameworks must be repealed and replaced with national responses that recognise people living with HIV and members of key populations as essential partners in the development and implementation of rights-based programmes and policies. In addition, because knowledge of HIV status has often yet to be established as a fundamental social norm, specific efforts are needed to educate communities regarding the HIV testing imperative. This should be done while working to leverage strategies such as community-centred testing campaigns, full implementation of provider-initiated HIV counseling and testing, social marketing, self-testing, and the like.

To mobilise the resources needed to finance and sustain the push to achieve the 90-90-90 target, UNAIDS urges that principles of global solidarity and shared responsibility will need to prevail. One concrete suggestion is that brokering of South-South information-sharing, pooled procurement, and focused technical support could help settings with higher facility costs bring expenses down.

Along the lines of collaboration, the report concludes: "Only a partnership approach will enable the world to the AIDS epidemic. The world will need to combine political will, evidence-based normative guidance, continued generation of critical evidence for action, and sufficient financial resources....UNAIDS is committed to working in partnership with the full array of essential stakeholders...to make the 90-90-90 target a reality."