Missing the Mark Hitting HIV 2020 Targets

Marcia Frellick

November 25, 2019

BASEL, Switzerland — To be on track to meet the UNAIDS goal of eliminating AIDS by 2030, which was set 5 years ago, 90% of people with HIV have to be diagnosed, 90% of those have to be on treatment, and 90% of those have to achieve viral suppression by 2020.

With 2020 fast approaching, the numbers are not that promising. HIV-related infections dropped worldwide by 47% from 1996 to 2017, but Eastern Europe and Central Asia continue to see annual rates of new infection 29% higher than they were in 2010, according to the European AIDS Clinical Society.

Were the targets too high? This was addressed by clinicians, researchers, and people living with HIV during a roundtable panel on what the next benchmarks should be at the European AIDS Conference 2019.

"The targets were ambitious but, with the tools we have, they were not targets that could not be achieved," said Nikos Dedes, president of Positive Voice, an association of people living with HIV in Greece.

Failure to reach the targets falls on the prevention side, and that is likely related stigma and discrimination, he explained.

"It's time we moved beyond the numerical targets of 90-90-90 and address the long-term concerns of quality of life and comorbidities. This is true for the West and the East," he said.

For me, the most important next phase is to make absolutely clear who we have not reached.

"For me, the most important next phase is to make absolutely clear who we have not reached," Dedes added. "There have to be cascades that are key-population-specific. More important, we need to personalize. So many people have not been diagnosed. I would like to see them in colors. I would like to see them in genders. I would like to see faces. That should be the next analysis. And then we can judge how countries have performed."

Although in some ways the goals were aspirational, having benchmarked numbers opened up a way to see where the problem areas are and at what point they are seen in the care cascade, said Peter Ghys, MD, director of strategic information and evaluation for UNAIDS.

When a country has trouble reaching the first 90% in the cascade because people are not getting tested and diagnosed, it shows that there is much work to be done around stigma and discrimination, he explained.

Benchmarks mean that numbers can be tracked, which demonstrates that a failure to meet the goals has a direct cost in human lives, Ghys said.

The 90-90-90 messaging helped give an easily understandable way of looking at the problem, said Teymur Noori, MSc, a psychologist at the European Centre for Disease Prevention and Control.

"That's probably the biggest benefits of these targets," he said. "I was extremely critical of these targets when they came out, but very quickly I turned. It makes it comprehensible to everyone in the community, and physicians and those in public health get it. Before these targets, the HIV response had not been very focused. You can see the inequalities that exist in a way that wouldn't have been feasible without these targets."

Important Targets

What has become clear from these targets is each country's level of connection with policymakers. In London, which was the first city to achieve the targets, Noori pointed out, you see a great response to the results, and governments have joined the celebration of success.

"But I don't see that sense of urgency in countries that are not achieving them," he said. "There's quietness there on the policy level because either they don't care or they're ashamed."

Although many countries have achieved the 90-90-90 targets, "many countries in Europe still have 50% late diagnosis, and that's not going down," Noori pointed out. "As you know, there's a tenfold increase in morbidity if you diagnose late. It looks like we've been doing well in some places, but we still have major challenges."

Comments from audience members inspired a discussion on stigma — what it means and how to measure it.

Because stigma means different things to different people, it is difficult to measure, said Ghys.

UNAIDS is currently looking into surveys that ask whether people have had negative experiences at a health service and whether they have not gone to a health service because they are not sure how they will be received, he reported.

Measuring Stigma, Helping People

"We started measuring stigma in New York and we got very effective at it because we did something that others didn't — we put money into it," said audience member and AIDS activist David Miller from Rochester, New York. "When you put money into something, you can measure it. When you put money into something and measure it, you can start making changes."

One measure of stigma is where HIV/AIDS organizations put their conferences, Miller suggested.

"We're putting the next world AIDS conference (AIDS 2020) in San Francisco — one of the most expensive cities in the world," he said. "That's a form of stigma. If you haven't noticed, most people with AIDS are impoverished. We can start by measuring stigma just by looking at the decision-making progress we're making ourselves."

Another audience member, Ben Collins, founder and director of International HIV Partnerships, said that people seem "almost hypnotized" by the notion of stigma.

"There are very concrete things that people can do," he said. "People concerned about stigma should start antistigma campaigns in their hospitals. It's very simple training. And if people do stigmatize, they should be dealt with."

"I don't see much demonstration of antistigma activities," Collins said. "In some countries, it's about the corruption of officials. And those officials don't just make bad decisions about how money is being spent, they also make bad decisions about who's being treated in their health systems."

European AIDS Conference (EACS) 2019. November 9, 2019.

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