Featured Journal Content
Jul 22, 2017 Volume 390 Number 10092 p333-428
The global HIV/AIDS epidemic—progress and challenges
On July 20, UNAIDS released their annual report on the status of the global HIV/AIDS epidemic, which also includes a comprehensive analysis of progress towards ending AIDS as a public health threat. The latest epidemiological estimates and programmatic data from 168 countries in all regions were reviewed. Worldwide, AIDS-related deaths have declined from a peak of about 1·9 million in 2005 to around 1·0 million in 2016, largely due to treatment scale-up—for the first time more than half of people with HIV are estimated to be on treatment. Since 2010, the annual number of new infections in all age groups has decreased by 16% to around 1·8 million in 2016. However, progress is variable, and despite a global downward trend in the epidemic, several regions are experiencing sharp increases in new infections and struggling to expand treatment.
In 2014, to accelerate progress towards ending AIDS as a public health threat by 2030, UNAIDS launched the 90-90-90 goals. The goals are that 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 people receiving ART will achieve viral suppression. The report states that considerable progress has been made towards the 90-90-90 targets, but there are gaps along the continuum that vary across regions. Globally, more than two-thirds of people living with HIV knew their status in 2016. Around 77% of them were on treatment, and 82% of those on treatment had suppressed viral loads. In 2016, around 19·5 million people with HIV (53%) were on treatment, up from 17·1 million in 2015.
If reached, the 90-90-90 targets translate into 73% of all people living with HIV being virally suppressed. Botswana, Cambodia, Denmark, Iceland, Singapore, Sweden, and the UK already achieve or exceed this target, and 11 other countries are moving closer. However, the report notes that globally when the gaps along the cascade are combined, only 43% of all people living with HIV were virally suppressed in 2016, which is far lower than the final target, which means many regions are not on track to meet the 2020 target.
Progress in the world’s most affected areas, eastern and southern Africa, has been striking. With rapid scaling up of treatment in combination with existing prevention interventions, AIDS-related deaths have nearly halved in the past 6 years. New infections have declined from around 1·1 million to about 790 000, a 29% reduction. The region’s progress across the three 90s is comparable with that in Latin America, and if progress is sustained both are likely to achieve the targets alongside western and central Europe and North America, which have already met the 2020 goal.
Progress is less positive elsewhere. In the Middle East and north Africa, trends vary, and although numbers of new infections seem stable since 2010, AIDS-related mortality has increased in the past decade. In the same period in eastern Europe and central Asia, the number of new infections has risen to 190 000 in 2016, a 60% increase. The region’s HIV epidemic is mainly within two countries: Russia and Ukraine. People who inject drugs accounted for 42% of new HIV infections in the region in 2015. In both countries, there are large gaps across the 90-90-90 continuum. HIV testing and treatment coverage are low. Key populations in these regions are unable to access services and linkage to care is weak. These regions are unlikely to meet the 90-90-90 target.
The report points out challenges across all regions. Late diagnosis in key populations counteracts the potential effects of treatment as prevention in the general population. Gaps in the 90–90–90 continuum are greater for men, young people, and key populations. Women continue to be disproportionately affected by the epidemic. Criminalisation, stigma, and discrimination act as barriers to key populations entering care programmes. Funding too is a concern with resources falling short of global commitments.
The report emphasises that there is no room for complacency. Indeed, 53% of all people living with HIV being on ART means that another 17 million people with HIV are not. Indeed, in a letter in this week’s Lancet, Brian Williams and Reuben Granich call for an urgent review of the assumptions used to calculate the effect of ART on rates of new infections and AIDS-related mortality. Current approaches need to be more efficient, and innovations around diagnosis, treatment, service delivery, and surveillance and monitoring need to be brought to bear.
The UNAIDS annual report is a vital benchmark for identifying progress, successes, shortfalls, and gaps in tackling the global HIV epidemic. The use of the 90-90-90 goals provides a useful framework that can help countries prioritise their paths and actions toward an AIDS-free world. But what actions will now follow?