UNAIDS
The Joint United Nations Program on HIV/AIDS (UNAIDS) is a United Nations (UN) program that was launched in 1994 with the primary mission of eradicating Acquired immunodeficiency syndrome (AIDS). The program is a joint effort of eleven UN agencies namely; UNHCR1, UNICEF 2, WFP3, UNDP4, UNFPA5, UNODC6, UN Women, ILO7, UNESCO8, WHO9 and the World Bank. These agencies collaborate with partners like U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) to achieve the goal of eliminating AIDS epidemic1.
In 2014, UNAIDS unveiled ambitious targets encapsulated in the 90-90-90 and the 95-95-95 targets, which aimed at accelerating the fight against HIV/AIDS by optimizing prevention, testing, treatment, and care initiatives. These targets were known as 90-90-90 target for 2020 and 95-95-95 target for 20252.
90-90-90 targets
The 90-90-90 targets envisioned that by 2020;
- 90% of people living with HIV (PLWH) knew their HIV status
- 90% of PLWH and knew their status were on antiretroviral therapy (ART10 )
- 90% of PLWH on ART had viral suppression 11
Reaching the 90-90-90 target would have meant that the 34.4 million people living with HIV in 2014, would be healthy and alive with 30 million of them on ART and 27 million of them virally suppressed. This would have resulted in reducing new HIV infections to less than 500 000 people per year and reducing AIDS related deaths by less than 500 000 from 20206.
95-95-95 targets
The 95-95-95 targets envisioned that by 2025:
- 95% of people living with HIV will know their HIV status
- 95% of people who know their status will be on ART
- 95% of people on ART will be virally suppression
Achieving 95-95-95 targets will reduce new HIV infections by less than 200 000 per year. This would fulfil the UN Sustainable Development Goal for ending the AIDS epidemic as a public health threat by 20307.
Global view of targets
The percentage of people living with HIV (PLWH) and on ART was lagging behind (67%) in 2015. This was a year after 90-90-90 targets were announced. However, in 2017, there was an increase in the percentage of people living with HIV and on ART. This was likely due to countries implementing the 2016 World Health Organization (WHO) recommendation that all PLWH should start antiretroviral therapy as soon as they are diagnosed with HIV and are ready to start treatment. The use of oral pre-exposure prophylaxis and was also recommended by WHO in the same year8. The 2022 data shows that an estimated 83% of PLWH know their HIV status, 89% of them are on ART and 93% are virally suppressed. The global picture shows an upward trend though a nuanced picture can be seen when looking at geographical regions and countries.
Regional view of targets
There was a 34% increase from 2012 to 2022 in the percentage of PLWH who knew their status in Western and Central Africa while Eastern and Southern Africa had a 33% increase. Though, Middle East and North Africa is lagging behind with 67% of PLWH who knew their HIV status in 2022. Eastern Europe and Central Asia had a slight decline from 2019 (64%) to 2021 (61%). The disruptions in healthcare systems due to COVID-2019 pandemic likely led to diversion of resources which negatively impacted routine HIV testing. The Ukraine war could have also played a role9. None of the regions reached the 95% target for PLWH knowing their HIV status by 2022.
From 2012 to 2022, there was a 41% increase in percentage of PLWH on ART in Western and central Africa and 35% increase for Eastern and Southern Africa. Western and central Africa was the only region to reached the 95% target for PLWH on ART. Asia and the Pacific reached the 95% target for viral suppression with Eastern Europe and central Asia edging close (94%).
So far, there is no region that has reached the 95-95-95 targets for all three metrics. These regional estimates are arrived upon with data from some but not all countries. In addition, there are variations in the percentages between countries. So just because a region reached the 95% target, it does not mean that all countries within the region reached the target.
Countries that reached 90-90-90 targets and 95-95-95 targets
Countries that reached 90-90-90 targets by 2020
Country-level achievements illuminate both progress and gaps. By 2020, 12 countries reached the 90-90-90 targets with six12 of them from Eastern and Southern Africa (Table 1). This region is comprised of 20 countries known to have the highest number of people living with HIV-1 globally.
In 2020, these six countries had 16.5% (3.4 million of 20.6 million) of all PLWH within Eastern and Southern Africa with an estimated 49 000 of the total 280 000 AIDS-related deaths and 84 900 of the total 600 000 new HIV infections within the region.
The global targets in 2020 stood at 82% of people who PLWH who knew their status, 85% of PLWH were on ART and 90% of them were virally suppressed in 2020.
Countries that reached 90-90-90 targets by 2022
Twenty-three countries reached the 90-90-90 target in 2022 with 1113 of them from Eastern and Southern Africa (Table 2). These 11 countries had a total of 45.7% (9.5 million of 20.8 million) of PLWH within the region and had 124 300 of the total 260 000 AIDS related death and 193 700 of the total 500 000 new HIV infections within the region in 2022.
Countries that reached/within reach of 95-95-95 targets by 2022
So far, there are five countries, all within Eastern and Southern Africa Table 3, that have reached the 95-95-95 targets with five other countries within reach of the targets Table 4. These five Eastern and Southern African countries had a total of 2.1 million PLWH, 29 200 AIDS related deaths and 28 300 new HIV infections in 2022.
The 2022 globally targets stood at 86% of people who PLWH who knew their status, 89% of PLWH who were on ART and 93% of them were virally suppressed.
The data used for these estimates are produced by countries and submitted to UNAIDS at the end of March every year. This data is then modelled to produce the estimates published. Therefore, the unavailability of data for some countries could be due to countries not having the data, not submitting data on time for yearly estimates or differences in reporting practice. An example of different reporting practice can be seen, in Western European and North American countries, where the number of people on ART are only collected once every few years.
In addition, estimates can only be produced for countries with populations above 250 000 people. Furthermore, for some of the statistics, complete historical data for a specified period is required. Therefore, incomplete historical data means estimates cannot be obtained. Last but not least, some of the estimates may require more data inorder to produce a valid/confident estimate. In this case, the invalid estimate is not published.12
Data was obtained from the Global HIV & AIDS statistics
Progress Assessment
Evaluation of UNAIDS’ targets showcases a journey marked by incremental achievements and persistent challenges. Globally, the progress from 2015 to 2022 reflects a promising trajectory, with increased awareness, treatment, and viral suppression rates among PLWH. However, regional disparities underscore the complexity of the epidemic and the diverse contexts within which interventions must operate.
In Western and Central Africa, notable advancements in PLWH awareness and ART use have propelled the region closer to the 95-95-95 targets. Conversely, Eastern Europe and Central Asia face lingering hurdles, including healthcare system disruptions and socioeconomic upheavals, hindering progress towards optimal HIV care.
The attainment of targets at the country level offers insights into localized successes and areas requiring intensified efforts. Countries within Eastern and Southern Africa have demonstrated remarkable progress, exemplified by the achievement of 95-95-95 targets in select nations. Meanwhile, disparities persist in regions such as the Middle East and North Africa, where low awareness and limited access to ART remain formidable challenges.
Addressing the complexities of the AIDS epidemic necessitates tailored interventions that align with regional contexts and societal realities. Sustainable progress hinges on collaborative partnerships, robust healthcare infrastructure, and inclusive strategies that prioritize marginalized populations.
Challenges and Opportunities in the Journey Towards Eradication
Despite significant strides, persistent challenges impede the realization of UNAIDS’ ambitious targets. Stigma 14, socioeconomic disparities 15, healthcare access 16 and limited training and knowledge by health care providers continue to undermine efforts to combat HIV/AIDS effectively. Furthermore, the emergence of new challenges, such as the COVID-19 pandemic, underscores the dynamic nature of public health crises and the need for adaptive responses16,19.
There has been a notable improvement towards reaching the UNAIDS targets, from 71-67-83 achievements in 2015 to 86-89-93 in 2022. Moreover, new HIV infections have been gradually declined from 1.8 million in 2015 to 1.3 million in 2022. This positive trend partly reflects efforts to dismantle barriers, reduce stigma and discriminatory laws, integrate community-led interventions, and enhance healthcare provider attitudes, as well as scale up ART services for all PLWH16.
While increasing viral suppression has shown some reduction in new HIV infections, the impact falls short of expectations, especially in regions with high HIV prevalence. Late HIV diagnosis poses a significant challenge, compounded by limited access to affordable and reliable diagnostic technologies for detection of eclipse and acute HIV infection 17. Additionally, gaps in healthcare service engagement and external introduction of new HIV infections into local populations contribute to the persistence of new HIV infections21–23.
Pre-exposure prophylaxis (PreP) holds significant promise in reducing new HIV infections, particularly among high HIV risk individuals who infrequently test. However, adherence barriers persist due to concerns about adverse effects, daily pill burden, stigma, and lack of social support. Integrating PreP services into existing ART care programs presents logistical challenges, including strained healthcare resources and stigma perpetuation. Overcoming these hurdles requires enhanced healthcare provider awareness, streamlined PreP service delivery models, and increased access to long-acting injectable PreP24,25.
In summary, while progress has been made in reducing HIV infections and enhancing treatment access, concerted efforts are needed to address persistent challenges and optimize preventive strategies to achieve lasting impact in the fight against HIV/AIDS.
Towards a Future Without AIDS
The journey towards eradicating AIDS is marked by progress, challenges, and unwavering determination. UNAIDS’ targets serve as a beacon of hope, guiding efforts to mitigate the impact of HIV/AIDS and build resilient health systems worldwide.
Ending the AIDS epidemic demands a multifaceted approach where ART serves as a pivotal component but not the sole solution. Essential elements include stigma reduction, expanded access to ART care and HIV prevention for marginalized populations. Increased availability and utilization of pre-exposure prophylaxis (PreP) and the development of an effective HIV vaccine are vital in reducing new HIV infections. Moreover, gene editing technologies such as CRISPR offers promise in the quest for HIV cure. By integrating these tools and strategies, we can advance towards the goal of ending the AIDS epidemic.16,26.
Tools for ending AIDS epidemic by Bixa Ogola
Last but not least, my deepest gratitude to healthcare professionals, researchers, advocates, and individuals living with HIV/AIDS whose tireless efforts and unwavering commitment continue to drive progress in the fight against the epidemic. Their resilience, compassion, and advocacy inspire us to redouble our efforts and remain steadfast in our pursuit of an AIDS-free world.
| Year | Country | Know HIV status | PLWH on ART | On ART and Virally suppressed |
|---|---|---|---|---|
| 2016 | Australia | 91 | 90 | 97 |
| 2017 | Spain | 91 | 93 | 90 |
| 2018 | Botswana | 94 | 94 | 97 |
| 2018 | Netherlands | 90 | 93 | 98 |
| 2019 | Malawi | 90 | 91 | 92 |
| 2019 | Namibia | 92 | 90 | 92 |
| 2019 | Rwanda | 93 | 90 | 91 |
| 2019 | Saudi Arabia | 90 | 98 | 98 |
| 2019 | Germany | 90 | 94 | 98 |
| 2019 | Italy | 94 | 93 | 98 |
| 2020 | Eswatini | 97 | 94 | 95 |
| 2020 | Zambia | 91 | 93 | 93 |
| Year | Country | Know HIV status | PLWH on ART | On ART and Virally suppressed |
|---|---|---|---|---|
| 2016 | Australia | 91 | 90 | 97 |
| 2017 | Spain | 91 | 93 | 90 |
| 2018 | Botswana | 94 | 94 | 97 |
| 2018 | Netherlands | 90 | 93 | 98 |
| 2019 | Malawi | 90 | 91 | 92 |
| 2019 | Namibia | 92 | 90 | 92 |
| 2019 | Rwanda | 93 | 90 | 91 |
| 2019 | Saudi Arabia | 90 | 98 | 98 |
| 2019 | Germany | 90 | 94 | 98 |
| 2019 | Italy | 94 | 93 | 98 |
| 2020 | Eswatini | 97 | 94 | 95 |
| 2020 | Zambia | 91 | 93 | 93 |
| 2021 | Uganda | 90 | 92 | 95 |
| 2021 | United Republic of Tanzania | 91 | 97 | 98 |
| 2021 | Zimbabwe | 94 | 96 | 93 |
| 2021 | Cyprus | 91 | 94 | 97 |
| 2021 | Denmark | 92 | 92 | 98 |
| 2021 | Luxembourg | 90 | 90 | 97 |
| 2022 | Thailand | 90 | 90 | 97 |
| 2022 | Kenya | 94 | 98 | 95 |
| 2022 | Lesotho | 94 | 91 | 98 |
| 2022 | Kuwait | 94 | 98 | 98 |
| 2022 | Slovenia | 90 | 93 | 98 |
| Year | Country | Know HIV status | PLWH on ART | On ART and Virally suppressed |
|---|---|---|---|---|
| 2019 | Botswana | 95 | 95 | 96 |
| 2022 | Eswatini | 97 | 97 | 98 |
| 2022 | Rwanda | 95 | 97 | 98 |
| 2022 | United Republic of Tanzania | 95 | 98 | 98 |
| 2022 | Zimbabwe | 95 | 98 | 95 |
| Year | Country | Know HIV status | PLWH on ART | On ART and Virally suppressed |
|---|---|---|---|---|
| 2021 | Netherlands | 94 | 94 | 98 |
| 2022 | Kenya | 94 | 98 | 95 |
| 2022 | Malawi | 94 | 98 | 94 |
| 2022 | Namibia | 95 | 97 | 94 |
| 2022 | Kuwait | 94 | 98 | 98 |
References
Footnotes
UNHCR is abbreviation for United Nations High Commissioner for Refugees↩︎
UNICEF is abbreviation for United Nations Children’s Fund↩︎
WFP is abbreviation for World Food Programme↩︎
UNDP is abbreviation for United Nations Development Programme↩︎
UNFPA is abbreviation for United Nations Fund for Population↩︎
UNODC is abbreviation for United Nations Office on Drugs and Crime↩︎
ILO is abbreviation for International Labour Organization↩︎
UNESCO is abbreviation for United Nations Educational, Scientific and Cultural Organization↩︎
WHO is abbreviation for World Health Organization↩︎
Antiretroviral therapy (ART) comprises a treatment regimen combining three or more antiretroviral drugs from at least two different drug classes to manage and treat HIV. While not curative, ART enables individuals with HIV to lead longer, healthier lives and reduces the risk of transmission. Successful ART entails treatment support, including monitoring and providing interventions as needed to sustain treatment efficacy3.↩︎
Viral suppression, achieved through ART, entails low viral load resulting from suppressed viral replication. The United States Centers for Disease Control and Prevention (CDC) defines viral suppression as having fewer than 200 copies of HIV per milliliter of blood, while the World Health Organization (WHO) defines it as fewer than 1000 copies per milliliter. This benchmark signifies effective treatment in controlling HIV replication and reducing the risk of transmission.4,5.↩︎
The six countries are Botswana, Malawi, Namibia, Rwanda, Eswatini and Zambia↩︎
The 11 countries are Botswana, Malawi, Namibia, Rwanda, Eswatini, Zambia, Uganda, United Republic of Tanzania, Zimbabwe, Kenya and Lesotho↩︎
The belief that HIV testing is for people who acted immorally creates negative attitudes towards testing. Unfortunately, HIV is unfairly associated with specific groups such as men who have sex with men or drug users. Such stigma can lead to discriminatory practices at work, health centers and within communities that PLWH resides. Some countries criminalize HIV transmission and HIV exposure which may discourage people from testing or seeking treatment.13.↩︎
Socioeconomic disparities impact HIV testing and access to ART for PLWH from low-income backgrounds. Low-income jobs often necessitate daily wages for subsistence, making it difficult to take time off for treatment. Additionally, distant treatment centers incur travel expenses, further straining tight budgets. These challenges hinder PLWH from low-income households from initiating or maintaining ART care. This phenomenon may contribute to men’s lower engagement with ART due to financial responsibilities. However, studies suggest minimal differences in HIV testing and ART use between low and high-income PLWH. High-income individuals may avoid testing and treatment due to fear of stigma, discrimination and losing social status, while low-income individuals face financial barriers to ART care acquisition.14,15.↩︎
HIV testing and viral suppression rates are lower among males, while youth, particularly young women, exhibit reduced likelihood of testing and linking to ART care. Stigma surrounding sexuality, legal constraints, and societal barriers contribute to this trend among young women. Additionally, the transient living arrangements of youth and male demographics, often driven by employment mobility, further hinders linkage and sustained ART care. Children and adolescents also demonstrate low rates of testing, ART coverage, and viral suppression, highlighting challenges in reaching these populations with effective HIV services14,16.
Access to ART remains challenging, especially in high HIV burden regions, where countries often rely on foreign companies for antiretroviral drugs. However, inefficient drug supply chains contribute to deficient distribution and stock-outs, potentially allowing counterfeit drugs to infiltrate the supply chain. Weak regulatory policies and corruption further complicate efforts to eliminate counterfeit drugs, leading to lapses in adherence among PLWH on ART. Consequently, this impacts the percentages of individuals on ART and achieving viral suppression17,18.
Access to ART care is hindered by a shortage of skilled healthcare providers, particularly in low and middle-income countries. The talent drain to high-income countries exacerbates this challenge, leaving the available healthcare workforce overworked. Consequently, patients face limited access to treatment centers, often necessitating travel to overcrowded facilities, further straining the healthcare system17.↩︎Eclipse phase is a period that occurs within the first days to weeks after HIV acquisition. During this phase, HIV is not detectable in plasma. Acute HIV is the phase of infection that occurs shortly after eclipse phase when HIV-1 is detectable but antibody respose is not present. These two phases are characterized by exponential viral growth and elevated viral loads. Initiating ART during these phases is crucial to not only prevents further immune system deterioration but also curtail the likelihood of onward HIV transmission20.↩︎