The participants of a meeting of the UNAIDS Scientific and Technical Advisory Committee (STAC) have called on UNAIDS to lead global efforts to galvanize an HIV testing revolution. The target is to achieve 90% of people living with HIV knowing their HIV status by 2020. In 2015, only 60% of people living with HIV knew their HIV status.

In a mid-term review of progress towards the 90–90–90 targets, held on 9 and 10 April in Geneva, Switzerland, the participants heard that late HIV diagnosis represents the single greatest barrier to increasing rates of HIV viral suppression globally. New testing technologies have emerged, but programmes must reach the people who need HIV testing services.

Key barriers to HIV testing uptake include lack of individual awareness of risk, stigma, legal and structural barriers, associated costs such as travel to facilities and the perception that there is little benefit from diagnosing HIV infection if no symptoms are present. The participants heard that many people avoid seeking HIV testing services at health facilities, since both travel and waiting times can often be long. Barriers to testing are often experienced by young people, men and members of key populations.

The participants agreed that political and financial support for HIV testing must be significantly increased and that the central focus of HIV testing services should be moved from the health facility to the community. Community workers have a critical role in scaling up these community-centred strategies. The STAC recommended that UNAIDS develop a road map for the HIV testing revolution, for review and comment by the STAC at its next meeting in July.

The STAC recommended that UNAIDS emphasize leveraging the 90–90–90 targets to better link the HIV response to the broader agenda for sustainable health. It was noted that HIV testing services provide a platform for screening for other health problems. Likewise, momentum towards the 90–90–90 targets also offers opportunities to address health workforce shortages.

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The global response to HIV has averted almost 9 million deaths since 2000, when the Millennium Development Goals (MDG) were set. Despite such progress, AIDS is the leading cause of death among women aged 15–49, the sixth leading cause of death among adolescents and a leading cause of death among children worldwide.

Recognizing the impact of HIV on health and development, in 2016 United Nations Member States adopted a Political Declaration on Ending AIDS to advance progress towards ending AIDS by 2030.

Essential to these efforts will be achieving the 90–90–90 targets, whereby, by 2020, 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads.

In October 2016, Sweden announced that it was the first country to reach the 90–90–90 targets, having reached them in 2015. Today, Sweden estimates that 90% of people living with HIV in Sweden know their HIV status, 97% of people who know their HIV-positive status are accessing treatment and 95% of people living with HIV who are accessing treatment have viral suppression.

Sweden remains a political champion and supporter of HIV efforts globally. Sweden is also a key donor to UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria. From 26 to 28 March, UNAIDS Executive Director Michel Sidibé visited Sweden, at the invitation of State Secretary Ulrika Modéer, to discuss how the response to HIV can be a catalyst for accelerating progress towards achieving the Sustainable Development Goals.

In meetings with a series of key political and technical stakeholders, as well as civil society organizations working on HIV, the participants stressed that HIV prevention must be expanded to end AIDS. They also stressed that HIV programmes must be integrated, brought to scale and implemented to maximum effect, ensuring they reach the people most affected by HIV.

There was consensus that a single disease approach to HIV is inadequate to reach the Sustainable Development Goals and that there is a need for an approach that looks on health not as an outcome but as a prerequisite for development and sustainability.

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A number of important updates were announced at the annual Conference on Retroviruses and Opportunistic Infections (CROI) that have shown the importance of, and ways to achieve, the 90–90–90 targets, whereby, by 2020, 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads.

Held in Seattle, United States of America, from 13 to 16 February, CROI, the foremost annual scientific research conference on HIV, brought together around 4000 scientists, researchers, clinicians, students and others working in the response to HIV and related diseases.

A way of helping to meet the first 90—90% of people living with HIV knowing their HIV status—is the scale-up of self-testing. The STAR project, a four-year programme to build up HIV self-testing, has now distributed around 200 000 self-testing kits in Malawi, Zambia and Zimbabwe and is showing promising results. The project found that self-testing is a good way of reaching people who had previously not been reached before. Research is ongoing into the different ways the kits could be distributed—community-based distribution, pharmacy support, etc. With around 19 million people living with HIV not knowing that they have the virus, HIV self-testing could be a vital step towards ensuring that all who need HIV treatment have access to it.

The announcement of several promising new medicines in the pipeline may help to meet the second 90—90% of people who know their HIV-positive status are accessing treatment. A range of new single-dose, effective medicines, including new classes of medicine, new examples of existing classes and long-acting preparations that are produced by different manufacturers, will help to increase competition and hence access. Having new medicines will also be good news in the event of the development of resistance to current medicines in the future.

The importance of the third 90, viral suppression, and of a combination prevention approach to HIV was shown in a study in Rakai, Uganda. Studies of more than 33 000 people from 1999 to 2016 showed that an increase in antiretroviral therapy and hence viral suppression, scale-up of voluntary medical male circumcision and delayed sexual debut contributed to a 42% reduction in HIV incidence.

Also important for viral suppression is keeping people on treatment. The SWORD-1 and SWORD-2 studies show that a two-medicine regimen is as good as the current three-medicine approach. By reducing the amount of medicines that people living with HIV need to take, side-effects are reduced and adherence improves. Since antiretroviral therapy is taken for life, a simplification in treatment could benefit millions of people. 

Economic experts and representatives of national AIDS programmes, health ministries and health professional organizations endorsed the creation of a global coalition of community health workers in UNAIDS-convened consultations in New York, United States of America, on 9 and 10 February.

Community health workers bring cost-effective services to communities and increase service access for marginalized people, who often struggle to access essential health services. More than 6 million community health workers are already in place across the world. However, many are unpaid and are typically not fully integrated into health systems.

The participants called for an urgent initiative to recruit, train and deploy at least 2 million community health workers over the next two years to drive progress towards the 90–90–90 targets—whereby 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads—and to lay the foundation for sustainable health for all.

The consultations generated strong support for UNAIDS to establish a new international coalition of community health workers by mid-2017. This coalition will help to galvanize the creation of national associations of community health workers, support their harmonization and formalization, advocate for actions that support them and provide a unifying platform.

As a next step, it was agreed that UNAIDS will seek input from country-level community health workers on the vision, mission and structure of the coalition. UNAIDS will lead a global effort to mobilize resources for an emergency fund to support national initiatives for community health workers and to incorporate them as formalized, integral members of the health system.

Funding from Luxembourg supported the consultations. The Earth Institute of Columbia University and the International Association of Providers of AIDS Care were co-hosts.

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Michel Sidibé, UNAIDS Executive Director, delivered the keynote address to the opening plenary of the International Association of Providers of AIDS Care (IAPAC) summit on 13 October in Geneva, Switzerland. Speakers at the summit, entitled Controlling the HIV Epidemic with Antiretrovirals: Leveraging Progress, Seizing Opportunities, discussed the implications of new research confirming the benefits of early antiretroviral therapy for all people living with HIV in order to save lives, reduce coinfections such as tuberculosis and prevent HIV transmission.

Mr Sidibé highlighted the strategies, emerging opportunities and political processes needed to achieve the 90–90–90 targets by 2020, which call for 90% of people living with HIV knowing their HIV status, 90% of people who know their HIV-positive status accessing treatment and 90% of people on treatment having suppressed viral loads. These are central to the Fast-Track response to ending AIDS by 2030.

During the summit, the Director of the Swedish National Institute of Public Health, Johan Carlson, presented the findings of a scientific publication that announced that Sweden was the first country to declare that it had reached the 90–90–90 targets, in 2015. Mr Carlson highlighted the factors that contributed to the success, including free access to quality HIV education, testing, treatment, care and support, overcoming stigma and discrimination against people at higher risk of HIV, including gay men and other men who have sex with men, sex workers and migrants, the protection of human rights and programme monitoring and evaluation.  

Mr Sidibé congratulated Sweden for its impressive progress on the 90–90–90 targets and noted that other high-income countries, as well as many low- and middle-income countries, including Botswana, Brazil, Cambodia, Kenya, Malawi, Rwanda, Swaziland and Thailand, are also on track to achieve them.

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Leading stakeholders involved in paediatric HIV treatment joined together in a special session on 19 July at the 21st International AIDS Conference, being held in Durban, South Africa, to launch an urgent global push to end paediatric AIDS by 2020. In particular, the session focused on reaching the global target of at least 1.6 million children accessing antiretroviral therapy by 2018.

Sustained gains in preventing new HIV infections among children have laid the groundwork to end paediatric AIDS at least a decade sooner than the global target for the epidemic as a whole. However, to end paediatric AIDS, prevention efforts will need to be matched by an equally robust effort to address the treatment needs of children living with HIV.

While children (aged 0–14 years) accounted for 5% of people living with HIV in 2015, they represented 10% of all AIDS-related deaths. Half of all children who acquire HIV perinatally die by their second birthday unless they receive antiretroviral therapy, with peak mortality occurring at 6–8 weeks of life.

Participants in the session included Raymonde Goudou-Coffie, Minister of Health and Public Hygiene of Côte d’Ivoire, Molotsi Monyamane, Minister of Health of Lesotho, David Parirenyatwa, Minister of Health and Child Welfare of Zimbabwe, and high-level representatives of the United Nations Children’s Fund, the World Health Organization, the Elizabeth Glaser Pediatric AIDS Foundation, ELMA Philanthropies and Caritas Internationalis.

The session resulted in an urgent call to increase political commitment for paediatric HIV treatment, rapid scale-up of point-of-care diagnostic tools for children, intensifying testing efforts for older children, strengthening service delivery and patient monitoring for mothers and their infants and expanding the array of child-appropriate antiretroviral medicines. The renewed global push to close paediatric treatment gaps support the AIDS-free component of the Start Free, Stay Free, AIDS Free framework launched by UNAIDS and partners.

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