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The world is on track to reach global targets for reducing AIDS deaths and HIV treatment access by 2020, but some regions of the world risk falling further behind due to lack of political commitment, UNAIDS announced in the run-up to the 9th International AIDS Society Conference on HIV Science (IAS 2017), which opened today in Paris.

More than half of all people living with HIV (53%) now have access to HIV treatment and AIDS-related deaths have almost halved since 2005, UNAIDS reports in Ending AIDS: progress towards the 90-90-90 targets.

The 90-90-90 targets endorsed by governments in 2014 call for 90% of people to know their HIV status, 90% of people with diagnosed HIV infection on treatment, and 90% of people on treatment to be virally suppressed. If all these targets can be met, AIDS deaths can be cut dramatically and new infections will begin to fall.

Past the tipping point

The world has passed a tipping point in progress towards the 90-90-90 targets, UNAIDS Executive Director Michel Sidibé said.

The report shows that in 2016, 70% of people living with HIV knew their HIV status. Of the people who know their status, 77% were accessing treatment, and of the people on treatment, 82% were virally suppressed. In lower- and middle-income countries, progress towards achieving the targets has been especially strong in Cambodia and Botswana, which have already reached the 90-90-90 goals.

“There is no level of funding that compensates for the lack of political commitment. In the two regions that have made the least progress, lack of political commitment and poor policy decisions are more important than the lack of funding.” Marijke Wijnrocks, Global Fund
Eastern and southern Africa has also made good progress and the region is on course to reach the 90-90-90 targets. Seventy-six per cent of people living with HIV know their HIV status, 79% of people who know their HIV-positive status have access to antiretroviral therapy and 83% of people who are on treatment have undetectable levels of HIV – this equates to 50% of all people living with HIV in Eastern and Southern Africa with viral suppression.

Denmark, Iceland, Singapore, Sweden and the United Kingdom have also reached the 90-90-90 target. Australia, Belgium, France, Germany, Italy, Kuwait, Luxembourg, Netherlands, Spain, Swaziland and Switzerland are close to reaching the target, and four ‘fast-track’ cities – Amsterdam, Melbourne, New York City and Paris – have either reached the target or are very close.

AIDS deaths and new infections continue to fall

The sharpest reduction in deaths has been seen in Eastern and Southern Africa – a 62% fall since 2004. Deaths have fallen by 52% in the Caribbean and 39% in the Asia-Pacific region but risen by 48% in the Middle East and North Africa and by 38% in Eastern Europe and Central Asia.

Deaths were 27% lower among women and girls than among men and boys due to better rates of diagnosis and earlier treatment.

AIDS deaths have almost halved among children from 210,000 to 120,000 a year since 2010.

Since 2010, the annual number of new HIV infections has declined by 16% to 1.8 million, but progress is still far short of the 2020 target of fewer than 500,000 infections per year.

UNAIDS says that the new estimates for 2016 should be more accurate because more countries are producing better-quality data, especially in Eastern and Southern Africa. Independent door-to-door surveys in several countries in the region, Population Health Impact Assessments, have fed into these estimates, giving confidence that the changes seen in the region are real.

National progress towards 90-90-90 shows level of political commitment

The countries that have made the best progress all show strong political commitment to achieving the 90-90-90 targets, speakers at the 90-90-90 Targets Workshop agreed. The workshop, sponsored by UNAIDS and the International Association of Providers in AIDS Care (IAPAC), took place immediately prior to the opening of IAS 2017.

“There is no level of funding that compensates for lack of political commitment. In the two regions that have made the least progress, lack of political commitment and poor policy decisions are more important than lack of funding, I’m convinced,” said Marijke Wijnrocks, Interim Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Least progress towards the targets has been made in Eastern Europe and Central Asia where 63% of people living with HIV know their HIV status but only 43% of those diagnosed are on treatment. Seventy-seven per cent of people on treatment are virally suppressed in this region. Furthermore, new infections have continued to rise in the region even as new infections continue to decline by 29% in Eastern and Southern Africa between 2010 and 2016.

Even fewer people living with HIV know their status in Western and Central Africa: just 42% of people have been diagnosed in this region according to UNAIDS, and of these 83% are on treatment and 73% are virally suppressed.

Dr Debbie Birx, US Global AIDS Coordinator, said that Western and Central Africa had received the highest rate of investment but showed the least success in diagnosing and bringing people onto treatment. She blamed the persistence of formal and informal fees – effectively, tips or gratuities to salaried individuals to obtain medical attention – for the low rates of diagnosis and treatment.

“I think that policy is key. Our money can’t work if we don’t have the policies to make it work. We need to eliminate all clinical and informal fees. I’ve seen fees charged for what we provide for free,” she said.

Community health workers

Another factor determining regional success is the way that services are delivered, argued Dr Badara Samb of UNAIDS. “What is characteristic of health service delivery in eastern and southern Africa? It relies heavily on good community health systems and community health workers,” he told the 90-90-90 Targets Workshop.

UNAIDS won the endorsement of African heads of government at a recent African Union summit for an ambitious plan to recruit, train and put to work 2 million extra community health care workers at a cost of $4-$6 billion a year. UNAIDS calculates that this expenditure will result in a return on investment of $21.75 billion a year from health care savings, disease reduction and expanded employment.

Read the entire UNAIDS Report here.

A study of 343 gay couples, where one partner had HIV and the other did not, has not found a single case of HIV transmission in 16,889 acts of condomless anal sex, the 9th International AIDS Society Conference on HIV Science (IAS 2017) in Paris, France, was told today.

The Opposites Attract study looked at whether HIV is transmitted between gay male couples of different HIV status when the HIV-positive partner is on treatment that fully suppresses HIV. The HIV-positive partners in Opposites Attract had a so-called ‘undetectable viral load’ 98% of the time.

The study recruited and followed-up gay couples at clinics in Australia, in Bangkok and in Rio de Janeiro.

The evidence from Opposites Attract adds to the evidence from the PARTNER study that HIV-positive people on effective HIV treatment that fully suppresses their virus cannot transmit their infection through sex. Taken together, the two studies have not found a single case of HIV transmission in nearly 40,000 acts of condomless anal sex between gay men.

This adds further strength to the “U=U” (Undetectable equals Untransmittable) tagline of the Prevention Access Campaign, whose consensus statement has been signed by NAM and also by the International AIDS Society (IAS), organisers of this week’s Conference on HIV Science in Paris.

The studies also found that if the positive partner is on successful treatment, even having another sexually transmitted infection (STI) does not increase the risk of HIV being transmitted. In Opposites Attract, participants had an STI during 6% of anal sex acts and in PARTNER, 17.5% of participants had an STI at some point in the study.

Sexual position also made no difference even though when viral load is not suppressed, transmission is 10-20 times more likely if the HIV-positive partner is the insertive one; in Opposites Attract, the HIV-positive partner was ‘top’ over a third of the time.

During the Opposites Attract study, three men became infected with HIV, but genetic analysis showed that these infections came from a partner outside the main relationship who was not virally suppressed.

Only 0.9% of the total proportion of condomless anal sex acts happened where the HIV-positive partner had a detectable viral load and only 1.7% during their first six months on antiretroviral therapy. There were no transmissions from men in these groups either. Presenter Andrew Grulich commented: “In our Thai site, 40% of the men who entered the study were not on antiretroviral therapy when they entered the study, but immediately started it and were rapidly virally suppressed. They were really good at using condoms and other strategies to avoid transmission while they were still detectable, so the number of condomless anal sex acts with a detectable partner was very small.”

In PARTNER, despite not many more episodes of condomless sex, there were ten such ‘unlinked’ infections in gay men. The difference may be due to 24% of the HIV-negative partners in Opposites Attract taking pre-exposure prophylaxis (PrEP). Researcher Benjamin Bavinton told aidsmap.com there was evidence that PrEP-takers in Opposites Attract were indeed mostly taking it to protect themselves from HIV infection from partners outside the main relationship.

At a press conference the previous day on viral load and infectiousness, Dr Anthony Fauci, director of the US National Institute for Allergies and Infectious Diseases, said: “Scientists never like to use the word “Never” of a possible risk.

“But I think in this case we can say that the risk of transmission from an HIV-positive person who takes treatment and has an undetectable viral load may be so low as to be unmeasurable, and that’s equivalent to saying they are uninfectious. It’s an unusual situation when the overwhelming evidence base in science allows us to be confident that what we are saying is fact.”

Dr Luiz Loures, Deputy Executive Director of UNAIDS, said that in terms of the public impact of treatment as prevention, the agency was seeing more and more cities where HIV incidence was falling as they reached a tipping point in terms of the number of people who are on therapy and non-infectious: he quoted San Francisco, Sāo Paulo and Nairobi as examples.

Bruce Richman, a Harvard-trained lawyer, is the prime mover behind the “U=U” campaign.

He said: “In 2006 when I was diagnosed, I was terrified of infecting someone I loved and was terrified of taking a pill that reminded me every day I was infectious. But in 2012 when I finally started therapy, my doctor told me that if I suppressed my viral load, I would become non-infectious.

“Terror turned to outrage because every website I found was saying I was still a risk. The breakthrough science was not breaking through to communities that needed to know it. Doctors would tell people on a one-to-one basis while withholding the info from those they deemed irresponsible.

“So we collaborated with doctors to endorse the U=U consensus statement. This is demolishing HIV stigma and encouraging people to start treatment and bring an end to the epidemic. We need people like UNAIDS, as they did today, to confirm it’s true.”

Reference:

Bavinton B et al. (presenter Grulich A) HIV treatment prevents HIV transmission in male serodiscordant couples in Australia, Thailand and Brazil. 9th International AIDS Society Conference on HIV Science, Paris, abstract no TUAC0506LB, July 2017.

Parliamentarians for Global Action (PGA) LGBTI Inclusion Site (available in English and Spanish) provides user-friendly tools designed to help parliamentarians, and other relevant stakeholders, better understand their role in ensuring equality and non-discrimination of all individuals, regardless of who they are or whom they love. The Site describes relevant human rights frameworks and highlights the role of parliamentarians, civil society and other stakeholders in implementing Agenda 2030 (the Sustainable Development Goals adopted by world leaders in 2015), to ensure no one, including Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) persons, is left behind. It offers practical tips, tools and resources designed to support parliamentarians to undertake legislative, representational and oversight activities that advance the rights and inclusion of LGBTI people.

The LGBTI Handbook for Parliamentarians produced with UNDP is available for download in PDF form (in English and Spanish) on the Site.

Access the website here.

On a separate note, here you can find more information about PGA’s Parliamentary Delegation to Belize on Human Rights, Equality and Non-Discrimination.

To mark the 9th IAS Conference on HIV Science, the Lancet journals have made a selection of content free that reflects some of the breadth and diversity of clinical, epidemiological, and operational HIV research produced by the tireless global HIV community. The content includes research published across the Lancet titles—taken from six of their journals, well established and recently launched. The growing family of journals offers an increasing number of outlets for HIV research that build on and expand The Lancet’s longstanding engagement with and commitment to the work of the global HIV community.

View now by clicking here.