Global HIV efforts have long relied on target setting to drive innovation, create a sense of urgency and encourage collective action. But with the dawn of a new decade, it is time to evaluate targets. By the end of this year, 2020, the 90-90-90 Fast-Track targets are due to be reached. These targets are that 90% of all people living with HIV know their HIV status, 90% of all people diagnosed with HIV are receiving sustained antiretroviral therapy (ART) and 90% of all people receiving ART have viral suppression . As the deadline approaches, only six countries have reached the 90-90-90 targets and seven others are on track to reach them by the end of the year .
Targets, by their very nature, are ambitious. It is this ambition that has driven the HIV response to achieve remarkable progress, which some never thought possible in the early 1980s when the first AIDS diagnoses were made. While it is difficult to assess where the HIV epidemic would be without aspirational goals, the role of targets cannot be underplayed: from the “3 by 5” initiative, launched in 2003 to reach 3 million people with ART by 2005, which was widely credited with kick-starting the global effort to increase treatment access, to momentum built by 90-90-90.
Despite global targets driving urgent action and aiding accountability, advances in prevention, testing and treatment for the people who need them most have been unequal. Behind the slogans that unite communities and clinicians, behind the statistics that inspire new scientific research, behind the aspirations that drive political commitment, lies an uncomfortable truth: the most marginalized people – socially and geographically – remain incredibly vulnerable to HIV acquisition, have poorer access to testing and treatment, are more likely to present with advanced HIV disease and are all too often missed. It will take more than targets to ensure that all people receive the quality health and other services they need and are entitled to.
In 2018, key populations and their sexual partners accounted for more than half (54%) of new HIV infections globally. Of the 1.7 million children living with HIV, only 54% were on ART. In West and Central Africa in particular, ART coverage for children has been defined as a crisis, with only 28% on treatment . In the Middle East, North Africa, Eastern Europe and Central Asia, nearly three-quarters of people living with HIV were not virally suppressed .
This is unacceptable. Even where the 90-90-90 targets have been met, there are enduring inequalities for populations within these countries that are obfuscated by averages – reaching the targets are nowhere near reality within some communities. Vulnerable populations make up a small percentage of the total population and are often masked by averages as countries focus solely on overall progress towards global targets.