Co-authored by Todd Schafer
“90-90-90 to break the AIDS epidemic by 2020.”
It’s a brilliant public health strategy developed by UNAIDS that holds “treatment as prevention” at its core. The success of the strategy lies in getting people tested and on treatment so they are virally suppressed and no longer infectious. 90-90-90 is working and we are on the precipice of ending the deadliest pandemic in human history. News that the current administration is proposing significant cuts to AIDS funding globally is tragic, however, for the people around the world who will die, and for the incredible progress made. Specifically, the current budget proposes to reduce U.S. spending on AIDS relief by about $1.1 billion out of a $6 billion budget, which comes primarily through PEPFAR, the President’s Emergency Program for AIDS Relief started by former President George W. Bush and largely credited with 15 years of steady global progress against the disease.
The State Department says that all people currently on treatment will be able to continue (how that’s possible given roughly 20% cuts was not made clear). But say that is possible, the bigger problem is that in much of the developing world, and in sub-Saharan Africa that carries two-thirds of the world’s HIV/AIDS burden, roughly half of the population is under age 15 and most new infections are occurring in youth ages 15-24. That means the fire – now nearly under control ― will coming roaring back if the supply of medication for new infections runs dry. So, in other words, these cuts would not just stall progress, they would actually spark an inferno, a massive increase in HIV incidence and continued death and devastation around the world.
The great challenge for public health officials with regard to epidemics is that once they get rolling, they fuel themselves. Much like a raging forest fire, the first challenge is not to extinguish the fire, but rather to “get it under control.” Epidemics are like this too. The ultimate public health challenge with regard to HIV, beyond treating the afflicted, is forestalling its future spread. And that takes tools. We now have highly effective antiretroviral Therapy (ART) that cannot only save the life of the person on treatment but also suppress the virus in the infected person.
However, tools alone can’t stop a raging fire. You need a strategy, like firebreaks, to weaken it to the point where it can no longer fuel itself. In the case of the HIV epidemic, that firebreak strategy is 90-90-90. A couple years ago, the epidemiologists at UNAIDS determined that if we can achieve viral suppression in three-quarters of all people living with HIV, we can achieve that tipping point, leading to the end of the epidemic. And with proper adherence to ART, we have the tools to achieve viral suppression.
So, how do we get three-quarters of the world’s HIV-infected to be virally suppressed? First, we need to find them. Second, we need to move them onto treatment. And third, we need to monitor and support their adherence until they achieve viral suppression. A tall order, but we don’t need 100 percent success to achieve this. We need 90-90-90. We need to find 90 percent of the HIV cases, move 90 percent of those cases onto treatment, and then we need 90 percent to achieve viral suppression. Ninety times 90 times 90 roughly equals the three-fourths reduction required to reach the tipping point.
But just last month, a team of researchers at UCLA published an article on the likelihood of 90-90-90 being achieved in the region with the world’s highest HIV burden, sub-Saharan Africa. Their conclusion? NO. Why? Because the vast majority of people living with HIV are in remote, rural areas, far from care. As two organizations dedicated to achieving 90-90-90 in southern rural Malawi, an AIDS hotspot and one of the poorest countries in the world, we respectfully disagree. We are seeing firsthand that these targets can, in fact, be achieved at the far end of the road and the numbers back that up. Today, at 73-89-91, Malawi is well on its way to the tipping point.
As the UCLA study argues convincingly, remote areas hold the key to ending the epidemic. Success there is irrefutable evidence that success is achievable on a global scale.
But just how do we impact 90-90-90 in remote and rural settings? First: We extend the healthcare grid. GAIA and The Elizabeth Taylor AIDS Foundation (ETAF) have partnered for years, using mobile health clinics to deliver clinical personnel and medical supplies to remote locations to provide primary healthcare, including HIV testing and care. Second: We staff the healthcare grid In response to the extraordinary shortage of health professionals – 65% of public sector nursing jobs are vacant in Malawi – GAIA implements a nursing scholarship and training program that is also supported by ETAF. Third: We work to prevent new HIV infections – keeping girls in school, for example, which is a proven protective factor against HIV ― as well as implement testing programs to find new cases, rapidly link them to treatment and provide follow-care to ensure adherence. While the majority of people living with HIV in Africa are women, we have special programs for men who are far more likely to remain undiagnosed, transmit the infection, and die of the disease quite simply because they are further from each of the three 90s.
Since its launch in 2003, PEPFAR has saved millions of lives. In 2016, almost 12 million people (of the 18.2 million people on treatment) had access to ART through PEPFAR-funded programs, nearly two million babies were born HIV-free to infected mothers, and more than six million orphans and vulnerable children received care and support.
PEPFAR funding has been the steady firehose and a key to world progress. Our work has confirmed that achieving 90-90-90 is possible in even the most challenging settings… but this window of opportunity will not remain open indefinitely. The key is to get the firebreaks built before the wind shifts, which is why you’ve heard bipartisan calls for maintenance and expansion of PEPFAR funding in the Trump administration budget. ETAF and PEPFAR recently announced a $4 million partnership to support programs in Mulanje. PEPFAR’s commitment in the region is critical to its progress.
The time to put this fire out is now. If we lose momentum, the fire rages on.
Todd Schafer is the Chief Executive Officer of GAIA, the Global AIDS Interfaith Alliance. The Elizabeth Taylor AIDS Foundation has partnered with GAIA to bring quality village-based healthcare to Malawi’s Mulanje District, working together toward achieving UNAIDS 90-90-90 target in this HIV/AIDS hotspot. Ingrained and well-trusted in the community that consists of 577 villages, the GAIA Elizabeth Taylor mobile health clinics have provided over 1 million patient care visits free of charge since 2008.