90 – 90 – 90: Chris Collins of UNAIDS breaks down the math, and the meaning

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909090Remember “3 by 5,” the World Health Organization articulated goal of getting life-saving antiretroviral treatment to three million people in low-and-middle income countries by 2005? It became “3 by 7” — 2007 before treatment available in wealthy countries since the mid-1990s fell within the reach of those three million less fortunate people. But the goal, even if it was missed by two years, went beyond numbers, Chris Collins of UNAIDS said today.

“It radically changed people’s understanding of what the issue was,” he said.

Collins, formerly of amfAR and AVAC, and now chief of the Community Mobilization Division at UNAIDS, was participating in AVAC’s “Research and Reality” webinar series about the impact of continuing biomedical HIV prevention breakthroughs on the ground. Specifically he was talking about a new goal, launched at AIDS 2014, for 90 percent of people living with HIV to know they have the virus, 90 percent of those who know they are infected to be receiving sustainable antiretroviral treatment, and 90 percent of those people on treatment to have sustainable suppression of their virus — 90-90-90 — by 2020. With that, UNAIDS says, the goal of ending AIDS as a global pandemic can be reached by 2030. The targets, incorporating the evidence that treatment prevents transmission as well as illness, and that viral load is the most effective way to measure the success of treatment, embody the application of research to reality. In addition, the targets address what has so far been elusive: an impetus embedded in the goal to strive beyond those easiest to reach, to overcome discrimination, to reach those whose marginalized status — as sex workers, men who have sex with men, people who inject drugs, young women and girls, transgender women — has made testing, treatment, and durable health benefits difficult to access. Still questions since the announcement of the targets have included:

  • That they are unrealistically ambitious — considering existing laws and policies standing between people and treatment, and costs of medicine and diagnostics turning a continuum of care for HIV patients into an obstacle course;
  • That they are not ambitious enough — what, after all, happened to Zero new HIV infections, Zero discrimination, Zero AIDS-related deaths;
  • What happened to numbers, and can countries be held accountable without numerical targets?

All of that is where “3 by 5” comes in; targets are meant to drive as well as measure progress. And what is being driven by these percentages is equity, an effort to reach all countries and all populations, a prioritization of quality, equity of access, and through all of that a human rights approach to service delivery, Collins said. How realistic? He pointed to progress made — in places that include Rwanda, Botswana, Uruguay, and yes, the United States — where majorities of people have been tested at least once, know their status, are accessing treatment, or are virally suppressed. Doing the math, when just 90 percent of people who are infected know it, 90 percent of those are on sustainable antiretroviral treatment, and 90 percent of those have suppressed viral loads, it comes to 73 percent of the people with HIV accessing effective care, which while sounding considerably less ambitious, adds up to a controllable epidemic.

“It’s definitely not going to be easy,” he acknowledged, pointing to structural barriers, costs, gaps in treatment cascades, delivery challenges, continuing lags in getting testing and treatment to children and adolescents, and financing, with a flat-lined U.S. President’s Emergency Plan for AIDS Relief. But targets are useful in addressing all of those, offering a standard of measurement. And more targets for nondiscrimination, Collins promises, are forthcoming.

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