90-90-90, or how we can end AIDS

The AIDS pandemic claimed around 36 million lives between 1981 and 2016, and a similar number around the world currently live with the HIV virus. Some 1.2 million people died of AIDS last year, and another 1.8 million were infected. Those statistics are daunting, but the startling news is that the goal of an “AIDS-Free Generation” is realistically within reach. The required policy steps should be agreed in the early days of US President-elect Donald Trump’s administration.

The key reason that the epidemic can be ended is a scientific finding back in 2011 that showed that HIV-positive individuals receiving antiretroviral (ARV) treatment suppress the HIV virus in their bloodstreams so dramatically that they are very unlikely to transmit the virus to others through sex or shared needles. This finding confirmed the concept of “treatment as prevention.” If a high enough proportion of HIV-positive individuals receive ARV treatment, it is possible not only to save their lives, but also to break the transmission of the virus itself, thereby ending the epidemic.

Building on this idea, AIDS specialists developed two crucial ideas: “90-90-90” and the “cascade of AIDS care.” The 90-90-90 program aims to ensure that by the year 2020, 90% of all HIV-infected individuals know that they are infected (the first 90); 90% of all those who know they are infected are receiving ARV treatment (the second 90); and 90% of all those receiving ARV treatment successfully suppress the HIV virus in the blood. The idea of the cascade is that if each of the three “90s” is achieved, the proportion of all HIV-infected individuals with viral suppression would be 90% x 90% x 90%, which is equal to 72%.

If 72% of those infected today can no longer infect others, the HIV/AIDS epidemic will be curtailed. Indeed, if 90-90-90 in 2020 becomes 95-95-95 by the year 2030, the proportion of HIV-positive individuals that cannot infect others would rise to 86%. The ongoing epidemic would grind to a halt, just as a measles epidemic among children in a metropolitan area ends when 80% percent of the children are vaccinated, even if the other 20% percent of children remain unvaccinated. Some cases would remain, but the AIDS catastrophe would be over.

The goal of reaching 90-90-90 by the year 2020 and 95-95-95 by 2030 is realistic, if countries strive for success. Sweden recently announced that it has reached the 90-90-90 targets. Many other high-income countries are close. With international help and national efforts, 90-90-90 could be achieved not only in high-income countries but in developing countries as well.

For most of the world, the biggest challenge is ensuring that by 2020 at least 90% of HIV-positive individuals are tested and learn that they are infected – the first of the three 90s. To reach this goal, people who are symptomatic or at high risk need to be connected to the health system for testing.

Once an HIV-infected individual tests positive, achieving the second 90% (AVR treatment) depends mainly on funding and staffing; with a sufficient health budget, medicines can be made available for all infected individuals.

Achieving the third 90% (suppression of the viral load) depends mainly on whether AVR-treated individuals take the medications on schedule. That may require social support to encourage the patients to continue the medications even when they feel healthy, and to help ensure the timely and affordable supply of medications.

The 90-90-90 targets can be reached even among impoverished and hard-to-reach populations, thanks to a new and powerful public-health solution: community health workers (CHWs) supported by smartphones. CHWs are local community residents with at least a high-school education, who are trained for a few months in the management of specific health challenges, such as identifying potentially HIV-infected individuals, bringing them to the clinic for testing, and helping them to adhere to their medical protocols. New smartphone apps help them to do their job.

In rural Africa, where doctors are typically very scarce and AIDS prevalence is often high, the high life-saving potential of CHWs has been very well demonstrated and documented. Moreover, being a CHW offers a good way for young people to start their careers. Though initial compensation is very modest (perhaps $100 per month), the experience and training can put these young workers on a path toward further education (such as nursing), rising skills, and higher incomes.

Yet, despite the potential to bring the AIDS epidemic to an end, the world is currently stuck in limbo. Sadly, our governments operate not on the basis of bold goals and the means to achieve them, but on “business as usual.” Sixteen years ago, business as usual meant almost no treatment of poor people with AIDS, because financing was not available. At that time, I recommended a new “Global Fund” to finance AIDS treatment, an idea that was adopted and then helped to start an era of AIDS control in Africa.

US President George W. Bush’s administration made a major US financial commitment to AIDS, and the Global Fund and US programs together helped millions of people gain access to treatment. Yet, after the 2008 financial crisis erupted, President Barack Obama leveled off the US financing, and the global AIDS control effort got caught in a “half-way” mode. As of 2016, roughly half of all HIV-positive individuals are on ARV treatment, far short of the 90% target.

The incoming Trump administration should grasp the historic opportunity to help bring AIDS to an end through a modest financial commitment by governments and other funders. An extra $10 billion per year from all sources would likely be sufficient to get the job done, with just $3-4 billion annually from the US.

Skeptics will scoff that Trump is an unlikely champion of such an effort; but, frankly, who would have guessed 15 years ago that Bush would be the key mover of the financial scale-up of the fight against AIDS? History is full of positive as well as negative surprises; the end of AIDS can be a historic achievement of our generation, if we reach for it.