Can We Treat Our Way Out of the AIDS Epidemic?

Harsh Realities, Challenges Yet To Be Faced Before An "End" Is Possible

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Since as far back at 2011, a growing number of global health experts have stated  that, with increased testing and treatment, the end of the global HIV epidemic could effectively be over by as early as 2030. In the face of such assertions—which reflect, in part, the genuine successes seen in reducing AIDS-related deaths and infections in many high prevalence countries—some have begun to question whether they lay the groundwork for a sustainable global policy or, perhaps, oversimplify the very real challenges we have yet to face.

On December 1, 2014, the United Nations Joint Programme on HIV/AIDS (UNAIDS) placed the issue front and center in their annual World AIDS Day report, warning that "(without) scale-up, the AIDS epidemic will continue to outrun the response, increasing the long-term need for HIV treatment and increasing future costs." 

The report was designed to fast track the agency's 90-90-90 campaign, the initiative of which aims to

By achieving these goals, it is suggested that the epidemic will largely burn itself out by reducing the so-called "community viral load" to such levels as to effectively stamp out the spread of the virus within target populations.

This would require that roughly three out of four people currently living with HIV today (72.9%) be placed on ART—and adhere to ART, without interruption—in order to achieve sustainable viral suppression.

It is an ambitious goal, one that has never been achieved in the history of infectious diseases, leading some to argue that a true "end" can only be reached, not with treatment but with the development of a fully neutralizing HIV vaccine.

Moreover, the campaign would require that those on therapy remain on therapy for a lifetime, demanding not only a rapid scale-up but sustained global and national investment to subsidize the massive cost of ongoing care and treatment.

Despite these challenges, UNAIDS officials believe that the campaign presents a "winnable fight," citing advances made in their "15 by 15" campaign (placing 15 million people on ART by 2015), as well as the reductions in new infections seen in sub-Saharan Africa and other hyper-prevalent populations.

If realized, the 90-90-90 campaign would effectively cut the annual infection rate by 75% to 500,000 by 2020, after which the goals would become stricter, requiring that 86% of the HIV population be on fully suppressive ART, roughly at a cost of $27 billion per year. In doing so, say UNAIDS authorities, the new infection rate could be slashed to as little as 200,000 infections by the target date of 2030.

Challenges to Achieving 90-90-90 Targets

Today, only around 40% of adults and 24% of children with HIV receive ART, with rates of viral suppression varying significantly from country to country (ranging from as high as 83% in Rwanda to less than 60% in most of Western Europe).  Much of the current data suggests that suppression rates—particularly in Eastern Europe and parts of Latin America—fall well below these standards.

Even in the U.S., only around 25% of those qualified for ART are able to achieve undetectable viral loads, according to research presented at the 2014 International Congress on Drug Therapy in HIV Infection in Glasgow. In order to improve upon these figures, an increased effort has been made to expand HIV testing to all Americans; improve patient surveillance and retention in care; increase preventive strategies, including HIV pre-exposure prophylaxis (PrEP); and overcome the numerous socio-economic barriers that prevent as many as one-in-four Americans with HIV from being tested.  

Meanwhile, in countries with some of the highest HIV prevalence—and far lower economic growth and resources—doubts remain high as to whether the 90-90-90 goals can be realistically achieved, despite policy recommendations issued by the World Health Organization in September 2015 calling for the initiation of ART in all people with HIV, irrespective of CD4 count, geographic region or income.

At a debate at the Southern African HIV Clinicians Society Conference in September 2014, clinicians argued that the campaign had almost insurmountable challenges to overcome, citing the flattening of funding in the current donor climate, as well as an insufficient healthcare infrastructure to support the proposed scale-up. With few systems in place to ensure patient retention, monitor adherence, or prevent drug pipeline interruptions, an informal vote overwhelmingly suggested that 90-90-90 goals were not only unattainable but could negatively impact the individual patient's care and needs.

For its part, even the UNAIDS concedes that the challenges for implementation are vast, and that, in order to achieve the saturation envisioned in the 90-90-90 manifesto, the global community would have to "defy expectations." A 2016 study from researchers at the Yale School of Public Health concluded that the 90-90-90 initiative would end up costing $54 billion, an increase of 42 percent over current funding reserves.

Still, the same researchers insist that it would be money well spent and that, without it, the consequences of inaction could very well reverse many of the gains made in global fight, allowing the epidemic to spring back with the kinds of increases seen in Eastern Europe and Central Asia, where infection rates have literally doubled since 2004.


Agence France Press (AFP). "AIDS epidemic's end by 2030 seen: UN official." Panama City, Panama. Newswire September 20, 2013.

United Nations Joint Programme on HIV/AIDS (UNAIDS). "Fast-Track: Ending the AIDS Epidemic by 2030. " Geneva, Switzerland; issued December 1, 2014.

UNAIDS. "2013 Progress Report on the Global Plan." Geneva, Switzerland; published June 2013.

Raymond, A.; Hill, A.; and Pozniak, A. "Large disparities in HIV treatment cascades between eight European and high-income countries – analysis of break points." International Congress on Drug Therapy in HIV Infection; Glasgow, Scotland; November 2-6, 2014; abstract O237.

Southern African HIV Clinicians Society (SAHIVCS). "Debate: Can we treat our way out of the epidemic?" ;SAHIVCS Conference 2014; September 24-27, 2014; Cape Town, South Africa.

Elul, B.; Basinga, P.; Nuwagaba-Biribonwoha, H.; et al. "High Levels of Adherence and Viral Suppression in a Nationally Representative Sample of HIV-Infected Adults on Antiretroviral Therapy for 6, 12 and 18 Months in Rwanda." PLoS|ONE. January 9, 2013; published online: DOI: 10.1371/journal.pone.0053586.

DeHovitz, J.; Uuskula, A.; and El-Bassel, N. "The HIV Epidemic in Eastern Europe and Central Asia." Current HIV/AIDS Reports. June 2014; 11(2):168-176.

Science Daily. "New UN treatment targets for HIV/AIDS would be 'expensive but worth every penny.'" Published online May 30, 2015.

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