Is UNAIDS being optimistic when it says we can end AIDS by 2030?
Article Number: 8
The 2023 Global AIDS Report does not show that as a world we are already on the path, but it does show that we can be
The Joint United Nations Programme on HIVAIDS, UNAIDS, has just launched its 2023 Global AIDS Update, in which it not only argues that AIDS can be ended by 2030 but it outlines the path to get there. Wishful thinking? Or a blueprint for success?
On 13 July The Joint United Nations Programme on HIVAIDS (UNAIDS) launched its 2-23 Global AIDS Update. This new report, ‘The Path that Ends AIDS’, shows that there is a clear path to ending AIDS. It contains data and case studies which highlight that ending AIDS is a political and financial choice, and that the countries and leaders who are already following the path are achieving extraordinary results.
In her Foreword to the report, UNAIDS’ Executive Director Winnie Byanyima says that this path will also help prepare for and tackle future pandemics and advance progress towards achieving the Sustainable Development Goals.
Two decades ago, the global AIDS pandemic seemed unstoppable. More than 2.5 million people were acquiring HIV each year, and AIDS was claiming two million lives a year. In parts of southern Africa, AIDS was reversing decades of gains in life expectancy. Effective treatments had been developed but were available only at prohibitively expensive prices, limiting their use to a privileged few people.
Treatment and prevention are saving millions of lives
UNAIDS data show that today, 29.8 million of the 39 million [33.1 million–45.7 million] people living with HIV (PLHIV) globally are receiving life-saving antiretroviral treatment (ART). Access to ART has expanded massively in sub-Saharan Africa and Asia and the Pacific, which together account for about 82% of all PLHIV. An additional 1.6 million people received ART in each of 2020, 2021 and 2022. If this annual increase can be maintained, the global target of 35 million people on HIV treatment by 2025 will be within reach.
Globally, almost three-quarters (71%) of PLHIV in 2022 (76% of women and 67% of men living with HIV) had suppressed viral loads. Viral suppression enables PLHIV to live long, healthy lives and to have zero risk of transmitting HIV sexually. Viral load suppression in children, however, was only 46%.
Improved access to HIV treatment has averted almost 20.8 million AIDS-related deaths in the past three decades (Figure 1).
Figure 1 Number of AIDS-related deaths: current situation versus scenario without available ART, 1990–2022
Sub-Saharan Africa leads the way in declines in numbers of new HIV infections
Overall, numbers of AIDS-related deaths have been reduced by 69% since the peak in 2004. Five countries in sub-Saharan Africa (Botswana, Eswatini, Rwanda, Tanzania, and Zimbabwe), the region which accounts for 65% of all PLHIV, have already achieved the “95-95-95” targets. That means 95% of PLHIV know their HIV status, 95% of PLHIV who know their status are on ART, and 95% of PLHIV on treatment are virally suppressed. A further 16 other countries, eight of them in sub-Saharan Africa, are also close to doing so.
Figure 2. Change in number of new HIV infections, 2010–2022, and number of new HIV infections, 2022, global and by region
Factors contributing to success
Building on public health priorities
HIV programmes succeed when public health priorities prevail, as experiences in multiple countries attest. In Botswana and Cambodia, evidence-based polices and scaled up responses have paid off in reducing new HIV infections and AIDS-related deaths. Cameroon, Nepal and Zimbabwe have achieved major reductions in new HIV infections due to focused prevention programmes. The number of people on pre-exposure prophylaxis (PrEP) in Latin America has increased by over 55% since 2021, with 10 countries providing PrEP to people from key populations in 2022. Thailand is well on its way to achieving the 95– 95–95 targets and has successfully integrated a response to addressing stigma and discrimination into its national HIV response.
The report highlights that HIV responses succeed when they are anchored in strong political leadership. This means following the data, science, and evidence; tackling the inequalities holding back progress; enabling communities and civil society organizations in their vital role in the response; and ensuring sufficient and sustainable funding.
Putting communities and people first, supported by an enabling legal and human rights environment
The biggest breakthroughs are occurring in countries that have forged and maintained strong political commitment to put people first and invest sufficiently in proven strategies. They have prioritized inclusive approaches that respect people’s human rights, and they have engaged affected communities across the HIV response. They have acted to remove or defuse the societal and structural factors that put people in harm’s way and prevent them from protecting their health and well-being—including criminalizing laws and policies, gender and other inequalities, stigma and discrimination, and human rights violations.
Progress in the HIV response has been strengthened by ensuring that legal and policy frameworks do not undermine human rights but enable and protect them. Several countries removed harmful laws in 2022 and 2023, including five (Antigua and Barbuda, the Cook Islands, Barbados, Saint Kitts and Nevis, and Singapore) that have decriminalized same-sex sexual relations.
Providing strong national financial commitment
Progress has been strongest in the countries and regions that have the most financial investments, such as in eastern and southern Africa where new HIV infections have been reduced by 57% since 2010.
Thanks to support for and investment in ending AIDS among children, 82% of pregnant and breastfeeding women living with HIV globally were accessing antiretroviral treatment in 2022, up from 46% in 2010. This has led to a 58% reduction in new HIV infections among children from 2010 to 2022, the lowest number since the 1980’s.
The number of people on ART worldwide rose almost fourfold, from 7.7 million in 2010 to 29.8 million in 2022.
It’s not all a success story…
The gains made against AIDS are a major public health achievement, particularly in the absence of a vaccine capable of protecting against infection or a cure. But in a world marked by intersecting inequalities, not everyone is benefiting yet.
Ending AIDS will not come automatically. AIDS claimed a life every minute in 2022. Around 9.2 million people still miss out on treatment, including 660,000 children living with HIV.
Women and girls are still disproportionately affected, particularly in sub-Saharan Africa. Globally, 4,000 young women and girls became infected with HIV every week in 2022. Only 42% of districts with HIV incidence over 0.3% in sub-Saharan Africa are currently covered with dedicated HIV prevention programmes for adolescent girls and young women.
Almost one quarter (23%) of new HIV infections were in Asia and the Pacific where new infections are rising alarmingly in some countries. Steep increases in new infections are continuing in eastern Europe and central Asia (a rise of 49% since 2010) and in the Middle East and North Africa (a rise of 61% since 2010). These trends are due primarily to a lack of HIV prevention services for marginalized and key populations and the barriers posed by punitive laws and social discrimination.
Barriers to progress include a widening funding gap
A backdrop to many of the remaining challenges is the widening funding gap for the global HIV response. A total of $20.8 billion (constant 2019 US$) was available for HIV programmes in low- and middle-income countries in 2022—2.6% less than in 2021 and well short of the $29.3 billion needed by 2025 (Figure 3). Having increased substantially in the early 2010s, HIV funding has fallen back to the same level as in 2013.
Figure 3. Resource availability for HIV in low- and middle-income countries by source, 2010–2022 and 2025 target
UNAIDS analysis shows that where HIV prevention funding has increased, HIV incidence has declined. Currently, the regions with the biggest funding gaps—eastern Europe and central Asia and the Middle East and North Africa—are making the least headway against their HIV epidemics. Some countries where HIV incidence is declining, including the Dominican Republic, India, Kyrgyzstan and Togo, are putting between 3% and 16% of HIV spending towards prevention programmes for people from key populations (KPs). More funding for prevention programmes, especially among KPs , is badly needed—as is smarter, more cost-effective use of those funds.
Partnership and leadership are critical
The path to ending AIDS is clear, says UNAIDS. We have a solution if we follow the leadership of countries that have forged strong political commitment to put people first and invest in evidence-based HIV prevention and treatment programmes. The building blocks of a successful AIDS response come together through partnerships between countries, communities, donors including the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund and the private sector.
There is an opportunity now to end AIDS by increasing political will by investing in a sustainable response to HIV through financing what matters most: evidence-based HIV prevention and treatment, health systems integration, non- discriminatory laws, gender equality, and empowered community networks.
“We are hopeful, but it is not the relaxed optimism that might come if all was heading as it should be. It is, instead, a hope rooted in seeing the opportunity for success, an opportunity that is dependent on action,” said Winnie Byanyima, Executive Director of UNAIDS. “The facts and figures shared in this report do not show that as a world we are already on the path, they show that we can be. The way is clear.
“The end of AIDS is an opportunity for a uniquely powerful legacy for today’s leaders. They could be remembered by future generations as those who put a stop to the world’s deadliest pandemic. They could save millions of lives and protect the health of everyone. They could show what leadership can do.”