Prevention must be at the forefront to meet global HIV goals

Audacious goals have powered some of humanity’s biggest achievements — the race to the moon, the eradication of smallpox, and, since the early 2000s, our response to the global HIV crisis.

When the World Health Organization called for expanding HIV treatment to 3 million people by 2005, many thought the goal was absurdly ambitious. Yet the world mobilized, met that goal, and then went much further. Ten years later, some 17 million people were receiving lifesaving HIV treatments despite massive financial and logistical hurdles. AIDS deaths have fallen around the world.

Today’s HIV goals are even more ambitious, and rightly so. Thanks to a spate of scientific advances, this decade could be the beginning of the end of the HIV/AIDS epidemic. But it won’t be if the focus stays only on scaling up treatment.

It is undeniably good that more people will be treated for HIV, live longer and better lives, and fewer will die of AIDS. But as long as we regard essential components of HIV prevention as secondary, millions of people will continue to be infected with HIV. That means the epidemic will rage on, and the costs of treatment will continue to escalate.

Sixteen years ago, the AIDS 2000 conference in South Africa proved to be a watershed moment for treatment. As individuals who have devoted our professional lives to halting the transmission of HIV, we believe this week’s International AIDS Conference in Durban can be a similar moment for prevention.

In the lingo of the HIV/AIDS community, today’s primary global goal is known simply as “90-90-90.” The idea is that, by 2020, 90 percent of all people infected with HIV be diagnosed with the disease; 90 percent of those who are diagnosed be treated for it; and 90 percent of people on treatment have the virus under control.

These targets are critically important. When antiviral therapy suppresses HIV, it not only keeps individuals healthy but can also keep them from transmitting HIV to others. In other words, scaling up treatment is a powerful prevention strategy.

Yet simple arithmetic dictates that treatment is not enough. Even if all three targets are met, more than a quarter of people with HIV would not have their virus suppressed.

The latest data from the Joint United Nations Programme on HIV/AIDS (UNAIDS) show that despite expanded treatment and declining deaths worldwide, the number of new infections has remained stable at about 2 million per year for almost a decade. Botswana is within reach of meeting the 90-90-90 treatment targets, yet the number of people acquiring HIV in Botswana remains unchanged.

Proven prevention strategies exist. These include condoms, voluntary medical male circumcision, the daily prevention pill known as PrEP, and clean injecting equipment for people who use drugs. But there is a massive failure to deliver effective prevention, especially among young women in Southern Africa; people who use drugs, especially in the former Soviet republics; and in all regions gay men and other men who have sex with men.

The “prevention gap” isn’t just mathematical — it has a human face. In sub-Saharan Africa, that face often belongs to a young woman. In KwaZulu-Natal, the South African province where next week’s AIDS conference is taking place, a staggering 3 percent to 9 percent of young women become infected with HIV each year. These women, and millions of other people at risk, cannot wait for the ancillary benefits of treatment programs to trickle down to them. They desperately need prevention methods they can use today, as well as new ones still to be developed.

UNAIDS has, in fact, established specific prevention targets to be met by 2020. These targets are even more ambitious than the 90-90-90 treatment goals, yet they’ve been relegated to the background, as though it’s safe to assume they will take care of themselves. One goal is to provide 27 million voluntary medical male circumcisions in sub-Saharan Africa over and above the procedures completed to date. That represents a massive scale-up of circumcision programs even as funding remains stagnant. Another is placing 3 million people on PrEP, even though current and planned PrEP programs in Sub-Saharan Africa will reach only a few thousand people in the next four years.

Clearly, we need a huge shift in both mentality and approach. In at least one African country, that is already happening. Kenya’s leaders realized that the country’s epidemic isn’t the same everywhere, and that a range of options is needed. Since 2014, Kenya has grouped its 47 counties into high-, medium-, and low-impact clusters, then created tailored comprehensive HIV prevention and care programs accordingly.

We all need to follow Kenya’s lead. That means using every tool and every bit of useful data, while tackling stigma, drug abuse, gender violence, and other factors that put some people at much higher risk than others. Meanwhile, researchers need to keep up the search for new tools, including vaccines and cures. Today’s prevention methods can go a long way if we use them well, but they’re still not enough to close the door on the epidemic.

Big endeavors need ambitious goals. The 90-90-90 strategy has prompted a huge and welcome outpouring of energy, enthusiasm, and investment into treating HIV/AIDS. It’s now time to commit to bringing the rest of HIV prevention into the foreground.

Peter Piot, MD, is director and professor of global health at the London School of Hygiene & Tropical Medicine and founding executive director of UNAIDS. Mitchell Warren is executive director of AVAC (formerly the AIDS Vaccine Advocacy Coalition) in New York City.