TARGETS:

TRUTH OR TYRANNY?

ANNUAL LETTER 2020

TARGETS: THE CLARITY OF 20/20 VISION

While targets in the HIV response have galvanized global and national efforts, progress is uneven and may mask a sobering reality for many vulnerable people who are hidden by averages. People are more than a number; reaching targets cannot be valued over ensuring that people are at the centre of the HIV response.

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 [1]. 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 [2].

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 [3]. In the Middle East, North Africa, Eastern Europe and Central Asia, nearly three-quarters of people living with HIV were not virally suppressed [4].

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.

Reporting on progress towards the 90-90-90 targets importantly holds governments accountable, highlights a lack of coverage and draws attention to regions, countries and cities that are making headway or falling behind.
However, the HIV response needs to better understand who is not being reached and why the targets are not being met, and fund interventions and responses that are community led to reach the populations for whom the system is not working. But improvements to programming must be done without inadvertently fuelling further stigma for vulnerable populations by implementing population-specific targets.

The ambition of global targets is also felt at a national, city and even facility level. Countries translate global targets into national targets and annually report on results for greater transparency and accountability. The United States was the first country to boldly commit to a national target of ending the HIV epidemic within 10 years [5]. Similarly, the goal of ending the AIDS epidemic in our lifetime is shared by more than 300 cities and municipalities that have committed to doing so by 2030 [6]. At the facility level, enormous pressure is placed on implementers to reach targets and, while this may be in response to data-driven gaps, it is important to be cognizant of how reaching targets is sometimes prioritized over meeting the needs of people and respecting human rights.

Globally, nationally and locally, the HIV response owes much of its successes to the powerful narrative that targets help create. But results in 2019 showed a global HIV response that is stalling in some aspects. It is clear that the Fast-Track targets, which were put in place to accelerate progress towards ending the epidemic, will not be reached in 2020.

However, sometimes missing the targets can be the most important wake-up call the global community needs to hone its skills, improve focus and try even harder; failure can be the catalyst for change.

Although the 2020 Fast-Track targets are not the first that will be missed, they underscore the urgency to revitalize all levels of the HIV response. Is reaching targets being valued over providing a person-centred approach to treatment and care? How can future targets be set to better account for the everyday barriers in accessing services for vulnerable populations? Could targets be more nuanced without losing their universal appeal? How can lessons learned from missed targets improve the HIV response in the future?

HIV targets from 2000 to today

Although the HIV response has not always met the targets it has made, each set of targets and each year of reporting on results has highlighted the importance of robust measurement and an evidence-informed response.

The first time-bound targets for HIV were agreed on in 2000 when the world committed to the Millennium Development Goals (MDGs) [7]. MDG 6 set out to reverse the epidemic – a target that was met with declining new HIV infections by its 2015 deadline – and achieve universal access to HIV treatment [8]. Although treatment coverage expanded quickly, it did not meet the 2010 target [9].

In 2001, the African Union countries committed to the Abuja Declaration on domestic funding for health. In it, they pledged to set a target of allocating at least 15% of their annual budgets to improving the health sector and urged donor countries to scale up support. Yet by 2011, only one African country had reached this target. Twenty-six countries had increased the proportion of government expenditures allocated to health and 11 had reduced it [10].

In 2003, the “3 by 5” target was set to provide 3 million people with ART by 2005. Although not achieved by the deadline, working towards the target galvanized an unprecedented global commitment to bring HIV treatment to all resource-limited settings [11].

Similarly, in 2006 at a Special Session of the United Nations General Assembly, African heads of state endorsed a commitment towards universal access to HIV prevention, treatment, care and support by 2010 [12]. The commitments made were monitored regularly both by countries and civil society to track progress and ensure accountability. Even though commitments remain unrealized, they helped catalyse a further expansion of the reach and coverage of HIV health and other services, with especially encouraging gains in countries in eastern and southern Africa where the burden of HIV is greatest.

A Political Declaration on HIV and AIDS was made at the 2011 United Nations High-Level Meeting on AIDS [13]. The world committed to providing HIV treatment to 15 million people by December 2015 (a target that was achieved ahead of the deadline), eliminating new HIV infections among children and cutting by half sexual HIV transmission and transmission through injection drug use. The latter two targets remain unmet [14].

Launched in 2014, the UNAIDS Fast-Track strategy outlined prevention and treatment targets, particularly accelerating the HIV response in low- and middle-income countries [1]. The Fast-Track strategy included reducing new annual HIV infections to fewer than 500,000 by 2020 and fewer than 200,000 by 2030 [1], as well as achieving the 90-90-90 targets by 2020 and the 95-95-95 targets by 2030. In reality, a stocktake is needed to assess what will be required to reach 95-95-95 by 2030 when globally the 90-90-90 targets remain out of reach for most countries in 2020. The 95-95-95 targets are that 95% of people living with HIV know their HIV status, 95% of people who know their status are on treatment and 95% of people on treatment have suppressed viral loads.

The year, 2015, saw the eight MDGs replaced with the 17 Sustainable Development Goals (SDGs) [15]. SDG 3 aspires to “ensure healthy lives and promote well-being for all at all ages” and includes a specific indicator in relation to HIV, tracking estimates of new HIV infections [16].

Transformative lessons can be learned from both the failures of not meeting targets and the successes of achieving targets in the HIV response as the global health community works towards achieving the target of universal health coverage (UHC) for all by 2030. In an era of the SDGs and momentum towards stronger health systems, there are a number of other related health targets that will support achieving and sustaining progress in the HIV response.

These include: reducing new hepatitis infections by 90% and deaths by 65% from 2016 to 2030 [1, 17]; reducing TB deaths by 90% and TB incidence by 80% by 2030 compared with 2015 [18]; and ensuring universal access to sexual and reproductive healthcare services by 2030 [19]. While meeting other targets will be key to improving health services and quality of life for people living with and most vulnerable to HIV, it is important that due attention is given to HIV targets to ensure that the gains made are not lost.

Other innovative approaches to target setting and holding stakeholders accountable in the HIV response have seen success with, for example, the Rome Action Plan where a diverse group of stakeholders accelerated research, development, registration, introduction and uptake of HIV diagnostics and optimal antiretroviral (ARV) drugs for children living with HIV [20].

What is essential to consider with the 90-90-90 and subsequent 95-95-95 targets is whether those who are “missing” from each 90 or 95 are, in fact, the most marginalized populations in society and the hardest to reach. The balance between scaling up coverage of prevention and treatment programmes while ensuring that adequate resources are devoted to targeted interventions for the most vulnerable populations can be precarious. Nevertheless, tracking progress has highlighted where momentum is building in an effective HIV response and also provided important early warning signs of where a change, more attention, course correction or more nuanced targets are needed.

Prevention

Fast-Track Prevention Targets for 2020

Where we are missing the mark

The number of new HIV infections has increased in approximately 50 countries since 2010 despite effective prevention measures [2].

It is estimated that in 2018, 1.7 million people acquired HIV, which is more than three times higher than the global Fast-Track prevention target to reduce new HIV infections to 500,000 by 2020 [21, 25].

The number of estimated new HIV infections among adolescent girls and young women was more than three times higher than the target for reducing new HIV infections among this group [26, 27]. In the Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial, an estimated new HIV infection rate of 3.8% among the young women in the study demonstrated that HIV prevention needs of young women are unmet. Among ECHO trial participants younger than 25, the estimated rate of new HIV infections was even higher, at 4.3% per year [28].

We are also not on track to achieve the target of eliminating new HIV infections among children, with an estimated 160,000 children aged 0-9 years newly infected with HIV worldwide in 2018 [26, 29]. This is partly due to the fact that ART coverage for pregnant women has stalled and is falling in West and Central Africa. In Nigeria, only 44,000 (44%) pregnant women living with HIV were reported as having been provided with antiretroviral medicines in 2018 to prevent vertical transmission, a notable decline from previous records, which reported that almost 60,000 women were reached [27].

Despite the proven effectiveness of pre-exposure prophylaxis (PrEP) as an HIV prevention method, the number of people receiving PrEP as of October 2019 (380,000-385,000) is only about one-eighth of the way towards the 2020 target (3 million) [2, 26, 30].

Success stories

Cambodia has reduced the number of incident/new HIV infections by more than 40% since 2010 [31]. More than 300 cities and municipalities have now committed to the Fast-Track Cities initiative, launched in 2014, working to achieve 90-90-90. A growing number of Fast-Track Cities have achieved the 90-90-90 targets, in part due to improved prevention services, such as increased access to PrEP; these include Amsterdam, Brighton and Hove, London, Melbourne and Nairobi [6].

San Francisco was one of the first places to implement PrEP, rolling out the service in 2012 [32]. A 43% decline in new diagnoses in just three years has been attributed to PrEP scale up and quicker achievement of viral suppression among people living with HIV. (from 2013 to the end of 2016) [33]. In 2017, PrEP was included in the city’s HIV programme and around half of men who have sex with men who are vulnerable to HIV acquisition were estimated to be on PrEP that year – an important step in HIV prevention as San Francisco gets closer to achieving the Fast-Track Cities targets [33, 34]. To further support PrEP access, the state of California has passed legislation to allow access to PrEP without a prescription [35].

Treatment

Fast-Track Treatment Targets for 2020

Where we are missing the mark

In 2018, 53% of people living with HIV achieved viral suppression – far short of the global target of 73% for 2020 [2, 21].

While AIDS-related deaths continue to decline, the pace of this decline has slowed, with the number of AIDS-related deaths in 2018 (770 000) again falling far short of the global target for 2020 (500,000 AIDS-related deaths) [21, 36]. In 2020, with access to timely testing, treatment, care and support, no one should die due to AIDS.

Success stories

From 2010 to 2018, ART coverage rose more than six-fold in the Democratic Republic of Congo (from 9% to 57%) and by more than five-fold in Myanmar (from 13% to 70%) [4].

South Africa has the largest ART programme in the world and it funds over 70% of the HIV expenditure from its own domestic resources [37]. The total government budget for 2020/21 was $2.1 billion, a considerable increase from $1.7 billion in 2018/19 [38]. Treatment and care accounts for the largest part of these costs and political commitment to domestic funding has resulted in great gains for treatment coverage, with 68% of all people living with HIV now on treatment [31, 37].

Social & Structural Barriers

Effectively setting appropriate targets and measuring progress on social and structural issues can be challenging, particularly when compared with prevention and treatment where progress can be easier to count.

Where we are missing the mark

In 26 countries with recent data from household surveys, more than half of people surveyed expressed discriminatory attitudes towards people living with HIV [2]. In eight countries where recent surveys have been conducted, at least one in four people living with HIV reported avoiding healthcare services due to the fear of discrimination [39].

Fuelled by gender inequalities, adolescent girls and young women face heightened vulnerabilities to HIV. Violence against women persists, with roughly one in three women globally having experienced physical and/or sexual violence [2]. In addition to gender-based violence, factors that place women and adolescent girls at increased vulnerability of HIV acquisition include early and forced marriage, limited access to information around sexual choice and health and a lack of negotiating power and economic autonomy, such as inheritance rights. Changing systemic attitudes, valuing women and girls, and breaking the vicious cycle of gender inequities, gender-based violence and HIV acquisition will require more than just targets.

Gender inequality is also magnified among women who inject drugs. Women who inject drugs are uniquely vulnerable to medical, legal, economic and social consequences, gender-based violence and loss of custody of their children; they also experience high levels of stigma, both within general society and among the community of people who use drugs [40].

More broadly, discriminatory policies and punitive laws related to HIV transmission, exposure and non-disclosure, same-sex relationships, drug use or the selling or soliciting of sex create formidable barriers in access to health services. Social stigmatization and prejudicial attitudes held by healthcare workers and law enforcement personnel often compound the barriers these laws and policies create in denying access to health services and the realization of human rights.

Sex workers are at heightened risk of sex- and gender-based violence. Discrimination has been documented specifically in relation to support and recourse measures for sex workers whose rights have been violated, as well as in relation to HIV prevention services for sex workers [33]. In some countries, sex workers have no access to condoms, or police may identify sex workers through possession of condoms. These social and structural barriers render conservative countries in the Middle East and North Africa and Southeast Asia as generally having inadequate condom use to prevent HIV transmission to and from sex workers. In 2017, only 13.9% of sex workers in Egypt, for example, reported using a condom [41].

Despite the scientific evidence that proves that criminalization of HIV is a direct threat to the HIV response, 75 countries (including sub-national jurisdictions within these countries) still criminalize HIV exposure, non-disclosure or transmission [42]. And while the criminalization of consensual same-sex sexual relations has been decreasing overall, a concerning resurgence in conservative populism has also given rise to anti-LGBT+ sentiments across regions from Africa, Asia, the Caribbean and Europe, threatening to create further barriers to LGBT+ communities accessing HIV and other health services.

Issues of social justice, including race and ethnicity, also heavily influence increased vulnerability to HIV, access to HIV services and health equity. In the US, in particular, black people/African Americans and Hispanics/Latinx are disproportionately affected by HIV compared with the proportionality of the total population [43]. HIV also has an adverse impact on indigenous peoples; in 2016, indigenous peoples made up 4.9% of the Canadian population and yet accounted for 11% of new HIV infections and an estimated 10% of all Canadians living with HIV [44].

Zero discrimination is a rallying call to the world to examine discriminatory laws and policies and an attempt to create a target to address complicated social and structural barriers in the HIV response. To pave the way towards achieving zero discrimination and more effectively tackle the structural and social determinants of health to enable – and not jeopardize – health and well-being, measurable targets must be coupled with a sustained intervention that can respond to the nuanced and diverse needs of key and vulnerable populations.

These include targets that encompass a range of issues, from enabling rights-based approaches to inclusive workplace policies that focus on the principles of meaningful and greater involvement of people living with HIV (GIPA/MIPA), and targets that address social justice issues through, for example, leveraging national health insurance systems to ensure access to HIV services.

Success stories

In 2019, the Supreme Court of Colombia struck down a section of the national penal code that criminalized HIV transmission – a year after a judicial invalidation of a similar legal provision in the Veracruz state of Mexico [2]. In the same year, courts in Botswana and India overturned decades-old sodomy laws [2]. And a growing number of countries are taking steps towards drug decriminalization [45].

Other examples show where a change in the law can address a structural barrier to HIV prevention services. In 2019, the United Republic of Tanzania approved a change to the law that lowered the age of consent for HIV testing from 18 to 15 years. The amendment to legislation also made self-testing for HIV legal from 15 years old. The changes to the law will contribute to improved access to HIV testing for adults aged 15 years and older. At the end of 2018, progress on the 90-90-90 targets in the United Republic of Tanzania was 78-92-87. In 2018, there were 72,000 estimated new HIV infections in the country. While this is a 13% reduction from 2010, it is less than the 28% reduction across eastern and southern Africa [46].

LEARNING FOR SUCCESS

There have been many achievements in the HIV response – from increases in access to testing services to the rapid scale up of treatment coverage. However, reflecting on targets set and met to date serves as a stark reminder of persistent gaps and the need for nuanced targets in the response. It is essential that these lessons learned are assessed to help identify approaches and strategies to improve future programming.

The world is not making the most effective use of the biomedical and programmatic tools that are available. Coverage of services to prevent vertical HIV transmission has stalled [21]. The number of condoms distributed was less than half of the target. And coverage for combination prevention is only about a third of the way towards the 90% coverage promised for adolescent girls and young women, men who have sex with men and people who inject drugs [47].

Despite increased rhetoric around key and vulnerable populations, programmes are leaving far too many people behind. Across regions, young people are less likely than adults and men are less likely than women to know their HIV status, to receive ART and to achieve viral suppression [48]. And in every part of the world, men who have sex with men, people who inject drugs, sex workers and transgender people are denied not only basic human rights, but also meaningful access to essential health and other services.

A growing funding gap is contributing to slowing progress towards targets. China and South Africa markedly increased their domestic HIV investments over the past decade [2], while in October 2019, donors pledged an unprecedented US$14 billion over the next three years to the Global Fund [49]. Yet the Fast-Track targets call for at least US$26 billion annually in funding for HIV programmes [2, 25]. In 2018, only US$19 billion was mobilized – roughly US$1 billion less than in 2017 [2]. Despite repeated proposals to dramatically cut funding to PEPFAR in recent years, PEPFAR funding has remained flat for the past decade. PEPFAR has emphasized programming that is efficient and effective to expand its HIV prevention and treatment efforts.

Social and structural drivers increase vulnerability to HIV and reduce service uptake. Of the countries reporting data to UNAIDS in 2018, three-quarters had laws requiring parental consent for adolescents to receive HIV testing services [50]. These and other legal and policy barriers slow progress towards HIV targets by making services more difficult to access or by discouraging people from using available services.

Learning for success

Be more inclusive

Include the engagement of civil society in any target setting or progress review process, as has been largely commonplace in the global HIV response. People living with HIV, key populations and young women and girls have critical insights into the nuances needed to connect global targets with local realities.

Principles of inclusion should also be applied to research and development, for example, through the enrolment of women, including those of childbearing potential, and people living with HIV and other health conditions in clinical trials, so that new treatment options can reflect and meet the diverse needs of the people who need them. Data disaggregation in research will provide important information for analysis to track progress (or lack of) and tailor future target setting appropriately. Without better addressing the needs of vulnerable populations, targets will remain unmet and will continue to obscure priorities of communities.

Targets must also be accompanied by effective and empowering social and structural interventions, including law reform and progressive law enforcement. Without real progress on addressing social and structural barriers, bold targets around ending national HIV epidemics by 2030 – such as the target set by the US – will remain elusive. Measuring and documenting progress of such interventions will be essential to ensure that advances towards addressing stigma, discrimination and other social and structural issues can be appropriately reported on.

Be more innovative

Targets of the future should consider that finding those who have yet to be reached with HIV services is likely to be the greatest challenge and that some communities will be the hardest to engage. Because of this, it is essential that efforts towards finding an HIV vaccine and cure are bolstered to reach those who remain underserved in the response. Additionally, there must be better use of technology for HIV prevention and care to reach vulnerable populations and communities [51]. As the time to achieve the 2020 Fast-Track targets will soon have elapsed, UNAIDS is working on transition guidance and interim targets for 2025 to help chart the way towards achieving the 2030 goal of ending the AIDS epidemic. To support further progress, HIV vaccine and cure research will need to be adequately resourced.

Given the urgent need to expand the funding base for HIV services, targets should assess progress towards engaging new partners, such as the private sector, better integrating HIV with other health services and leveraging national health insurance systems to increase access to HIV services. The Business Alliance to End AIDS by 2030, launched in Davos by UNAIDS and GBCHealth, could be one such model; it aims to support industry in new and creative ways, providing businesses with the necessary tools needed from public sector partners to help realize the target of ending the AIDS epidemic by 2030.

Be more inspirational

Targets are meaningless without regular and timely analysis of progress. The HIV response must continue to enhance its use of robust, disaggregated and routinely collected data, which will be essential to chronicle nuances, respect diversity and identify and overcome implementation hurdles to reach marginalized and vulnerable communities. Resources around targets should increasingly be focused on testing and linkage to appropriate treatment, care and support services, such as through differentiated service delivery models.

HIV has demonstrated that effective prevention and treatment, while essential, will not conquer an epidemic without a robust community response, resource mobilization and political will [52]. As the global health community works towards achieving the target of universal health coverage for all by 2030, working collaboratively in the SDG and UHC era will be essential to ensure that related targets help the HIV response achieve its goals and that people living with and most affected by HIV benefit from access to quality and affordable health services for all.

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TARGETS:

TRUTH OR TYRANNY?

ANNUAL LETTER 2020

TARGETS: THE CLARITY OF 20/20 VISION

HIV targets from 2000 to today

Prevention

Fast-Track Prevention Targets for 2020

Where we are missing the mark

Success stories

Treatment

Fast-Track Treatment Targets for 2020

Where we are missing the mark

Success stories

Social & Structural Barriers

Where we are missing the mark

Success stories

LEARNING FOR SUCCESS

Learning for success

Be more inclusive

Be more innovative

Be more inspirational

References