Something to cheer about!
In 2014, UNAIDS launched the 90-90-90 initiative to end AIDS: 90% of people with HIV know they are infected, 90% who know are on antiretroviral therapy (ART), and 90% on ART have suppressed viral loads. In 2016, the United Nations General Assembly endorsed 90-90-90, committing member countries to aim for the three targets.
90-90-90 saves lives, preserves families
By 2017, 15.3 million (60%) of 25.7 million HIV-positive people in Africa were on ART. Only 11 years earlier, in 2006, only 1.34 million (8.5%) of 15.7 million HIV-positive people in Africa were on ART.[p 15 in 4] With ART: HIV-positive people are living longer; HIV-discordant couples are having children without one partner infecting the other; and infected mothers are delivering and breastfeeding babies who remain HIV-negative.
90-90-90 reduces HIV sexual transmission
One of the expectations motivating the 90-90-90 program is that reducing HIV viral load in a large percentage of people living with HIV will reduce sexual transmission. In communities that achieve the 90-90-90 targets, 73% (~90%x90%x90%) of HIV-positive adults will be virally suppressed, almost eliminating their risk to transmit through sex. In addition, with more testing, including self-testing, people will be more aware if one or another partner is HIV-positive, and will be able to avoid transmission with condoms and other options.
But will 90-90-90 be enough to stop HIV transmission?
If sex did it all, as WHO and UNAIDS have preached for decades, 90-90-90 would stop most HIV transmission. But this ignores the contribution of blood-borne transmission through unsafe healthcare. Investigations in countries outside Africa find that HIV can go very fast from one infection to hundreds through a clinic that reuses instruments. That has very likely been happening in Africa all along, but ignored. It is also likely to continue as long as governments are not investigating unexpected infections.
Will 90-90-90 educate and motivate people to demand outbreak investigations?
Through the early 2000s, less than 10% of Africans with HIV knew they were infected. With prevention messages focusing on sex and with limited testing, HIV-positive people with only blood-borne risks didn’t worry about HIV, didn’t get tested, and so didn’t know. In consequence, few people knew about their own non-sexual HIV infections.
This has changed! More testing is the first of the three 90-90-90 targets. In 2015, WHO revised recommendations to promote partner tracing and even self-testing. By 2017, 75% of HIV-positive Africans knew they were infected.
With more testing, many more HIV-positive people who know they have no sex risks — eg, a negative spouse and no other lifetime partner — are learning they are infected. More people are finding a child to be HIV-positive even though the mother is not. This can be expected to feed public and private discussions.
Increasing public awareness of blood-borne risks can have a big impact on Africa’s HIV epidemics. In countries where more people are aware of blood-borne risks, fewer adults are infected. [see also references 6 and 7].
What will happen as countries reach the first 90 – with 90% of HIV-positive people knowing they are infected? Will people talk, become more aware, and avoid risks? Will people push governments to investigate unexpected infections to find outbreaks from healthcare? Will people push doctors and nurses to improve sterile practices?
1. UNAIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. 2014. Available at: http://www.unaids.org/sites/default/files/media_asset/90-90-90_en.pdf (accessed 19 October 2018).
2. United Nations. Political Declaration on HIV and AIDS: On the Fast Track to Accelerating the Fight against HIV and to Ending the AIDS Epidemic by 2030. General Assembly resolution 70/266, adopted 8 June 2016. Available at: http://www.unaids.org/sites/default/files/media_asset/2016-political-declaration-HIV-AIDS_en.pdf (accessed 19 October 2018).
3. UNAIDS. HIV estimates with uncertainty bounds 1990-2017. Available at: http://www.unaids.org/en/resources/documents/2018/HIV_estimates_with_uncertainty_bounds_1990-present (accessed 19 October 2018).
4. WHO, UNAIDS, UNICEF. Towards Universal Access: scaling up priority HIV/AIDS interventions in the health sector: progress report, April 2007. Available at: https://www.who.int/hiv/mediacentre/universal_access_progress_report_en.pdf (accessed 19 October 2018).
5. Baggaley R, Henson B, Ajose O, et al. From caution to urgency: the evolution of HIV testing and counselling in Africa. Bull WHO 2012; 90: 652-658B. Available at: http://www.who.int/bulletin/volumes/90/9/11-100818.pdf?ua=1 (accessed 19 October 2018).
6. Gisselquist. Break the silence: stop HIV through health care and cosmetic procedures. Available at: https://dontgetstuck.org/2012/10/15/3-in-african-countries-where-more-people-are-aware-of-blood-borne-risks-fewer-people-have-hiv-part-2-of-3/
7. Brewer DD. Knowledge of blood-borne transmission risk is inversely associated with HIV infection in sub-Saharan Africa. J Infect Dev Ctries 2011; 5: 182-198. Available at: http://jidc.org/index.php/journal/article/view/1308/518 (accessed 7 July 2011).