90-90-90, epidemic control, and ending AIDS: review of global situation and recommendations

Background: Over 35 years after its discovery, human immuodeficiency virus (HIV) is still a major public health threat. More than 30 million people have already died and HIV/AIDS is ranked the third largest pandemic after the 14th century Black Death and the 1918 influenza pandemic. HIV continues to spread and 37 million people are living with HIV (PLHIV) globally. Ending the HIV pandemic is necessary and feasible but poses a number of important challenges. Findings: The HIV response can be characterized by three overlapping phases: 1) Devastation 2) Discovery and 3) Ending AIDS. After coming to our attention in 1981, the HIV pandemic has infected over 70 million people, caused over 39 million deaths, and has had a devastating impact. The Discovery Phase resulted from community, scientific, and political response that unraveled the secrets of HIV more rapidly than any other pathogen in history. The End of AIDS phase represents the shift from a chronic struggle with hopes pinned on a future vaccine or cure to a winnable public health battle. Scientific evidence demonstrates that increasing HIV testing and treatment prevents illness including AIDS, deaths and HIV transmission. To End AIDS, the Joint United Nations Programme on HIV/AIDS (UNAIDS), Presidents Emergency Plan for AIDS Relief (PEPFAR), national governments and cities adopted the 90-90-90 targets: by 2020, 90% of people living with HIV diagnosed, 90% of people diagnosed on sustained ART, and of those, 90% virally suppressed. Ending AIDS includes the epidemiological target of reducing AIDS cases and HIV incidence to less than 1 per 1000 population per annum. As part of Ending AIDS, 35 million people living with HIV will require treatment until a cure or vaccine can be developed and made widely available. Five major innovations will accelerate progress of 90-90-90 and the end of AIDS: 1) reliable, easy-to-use, HIV self-tests 2) same-day integrase inhibitor based treatment regimens 3) expanded access to integrated multi-disease community-based HIV services 4) improved monitoring and evaluation using national cohorts and unique identifiers and 5) global leadership around HIV epidemic control objectives and priority interventions Interpretation: Global public health security and human rights demand that we focus on ending AIDS for the millions of people living with HIV and impacted by the pandemic. Ending AIDS is feasible and will require expanded access to HIV testing, life-long treatment, community delivery of HIV services, increased efficient use of scarce resources, and meaningful community engagement.