Background:
If we are to end the AIDS epidemic by 2030, new adult infections[1] need to decline dramatically. Between 2010 and 2013, the number of new adult infections declined from 2.1 million to 1.9 million (including about 100,.000 new infections through needle-sharing), significant but insufficient. Unless prevention is intensified among those most at risk, both the existing 50% reduction of sexual transmission and 50% transmission due to injecting drug use targets will be missed. In this context, new 2020 prevention targets and sub-targets are being discussed. In order to catalyze and accelerate policy and programmatic action, they will need to be owned and adopted by countries and communities.
Rationale:
An ambitious 2020 prevention target is needed to catalyze action towards ending the AIDS epidemic by 2030.
The new global prevention target proposed is:
- Highly ambitious, but not impossible to reach, if all elements of combination prevention are vigorously supported, resourced and implemented (see below country examples)
- Very close to 2020 reductions in modelled scenarios for ending the AIDS epidemic by 2030 - the idea of ending the AIDS epidemic could be a good motivating factor
- Easy to convey and remember
- Not a separate target from treatment, e.g. only focusing on those HIV negative. It reflects the sum of all combination prevention and treatment efforts, including treatment as prevention (TasP)
- Not an appeal only to individuals to protect themselves but a call to governments and international partners, including donors, to provide access to services and empower those “at risk” to use them.
Sub-targets:
Two global sub-targets are being proposed:
- By 2020, new infections in key populations[2] will be reduced by 75%
- By 2020, new infections in young women and girls[3] will be reduced by 75%
These sub-targets address concerns that progress could be uneven and those most vulnerable might be left behind. Theyshould be further disaggregated, e.g. by age, specific key populations, and population subgroups.
Critically important, each country would determine and plan how to reach these targets, e.g. determine what a 75% reduction would imply for them. This should imply [EB1]considering a mix of old existing/established and new prevention interventions, such as: tailored programs to reach and empower key populations, including expanded and strengthened community strengthening and access to male and female condoms, oral Pre-exposure Prophylaxis (PrEeP), harm reduction (including needle exchange programs) and Treatment as Prevention (TasP), Voluntary Medical Male Circumcision (VMMC), intensified condom programming and cash transfers for young women and girls [EB2]in high-prevalence areas, among others. It also recognizes that the environment in which interventions are delivered has a great impact on uptake and long term effectiveness; programmatic action is therefore needed to transform social norms and reach gender equality. [EB3]Along with addressing punitive laws that affect key populations,these interventions will have a positive impact on reducing new infections in the future[MW4][MW5]. [EB6]
Country examples
Examples of potential indicators[4] for key effective interventions are included in the table below and need further refinement. Other interventions that may not have a proven or direct impact may be included as critical enablers or synergies with other health and development sectors.
Potential global indicators and targets for prevention interventions
Aspirefor 2020 / Ending AIDS by 2030
Treatment
- Viral load suppression among people on antiretroviral therapy
- Other targets related to the 90:90:90 for treatment roll-out
Key populations [MW7]
- Female sex workers, transgenders, men who have sex with men reached with basic services including male and female condoms and condom compatible lubricants.
its impact)
- Gay men and other Men who have Sex with Men, Sex Workers, and Transgender people reached with PrEeP
- Opiate-dependent People who use drugs (PWIDs)reached with OST
- PWID reached with Needle Syringe Programs
10%
40%
85% / 90%
30%
40%
90%
Young women and girls in high-prevalence settings
- Young women and girls access cash or other economic support [EB8]
- Sexually active young women and girls in hyper-endemic countries settings have access to PrEP[EB9]
- Young women and girls access integrated, comprehensive, and youth-friendly HIV, Sexual and Reproductive Health and Intimate Partner Violence/Gender Based Violence services [EB10]
10%
? / 50%
30%
?
Men in selected high-prevalence countries[5]
- Voluntary medical male circumcision (for specific countries) uptake among males 15-29 years
- (or among 15-49)
- [MW11]Condoms and lubricants distributed and sold per male adult (15–64 years old)
30 / 80%
40
General population and young people in (high-prevalence countries)
- Access to mass media including digital media communication onHIV prevention and demand generation for population (15-49 years) [MW13]
- Young people attending schools benefiting from comprehensive quality
? / 80%
?
Potential impact to be expected / 2020 / 2030
Reduction in new HIV infections (baseline 2010) / 75% / 90%
Draft Prevention Target as of 24 October 2014
[1] There is an existing target for elimination of child infections (< 40,000 by 2015). Countdown to zero: Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. 2011–2015. Geneva: UNAIDS.
[2]Key populations, or populations at higher risk, are groups of people who are more likely to be exposed to HIV or transmit it and whose engagement is critical to successful response. In most settings, men who have sex with men, transgender people, people who inject drugs and sex workers and their clients are at higher risk of exposure than other groups. However, each country should define the specific populations that are “key” to their epidemic. (Getting to Zero: UNAIDS Strategy 2011-2015)
[3]The definition of young women and girls used here includes age groups 10-24 and comprises diverse sub-groups, for which specific targets in line with an overall target of 75% reduction of new infections could be agreed. A prevention focus on young women and girls is particularly important in sub-Saharan Africa where the vast majority of infections occur.
[4]Those highlighted in red were included as proven core prevention activities in a UNAIDS modelling exercise to determine the financial resources needed to reach a 90% reduction in new infections by 2030, in line with the proposed definition of ”Ending AIDS” by 2030.
[5]An alternative or additional condom indicator would be global condom supply in all countries, e.g. 20 billion by 2020
[EB1]These sentences don’t track – what a 75% reduction would mean to them has to start not with the method mix but with adequately measuring the incidence and populations in need – this is jumping the gun to go to method mix without talking about knowing one’s epidemic.
[EB2]The literature on cash transfers is mixed – there’s a whole bunch of different approaches, from block grants that pay school fees to everyone (not just at risk girls) in a community, versus individual support – I am not sure what this is referring to, what evidence base we’re relying on, why we are not talking about domestic violence mitigation, school fees (explicity) and so on … this just really needs substantiation to stand on its own.
[EB3]Throwaway sentence, feels like box-ticking. What is the programmatic action? How does it relate to cash transfers? How does it get measured and resources. How do you program to reach gender equality? Take the time to give some examples.
[MW4]Given that results for both1% tenofovir gel and dapivirine vaginal ring microbicides are due to be released in 2015, it seems especially important to create a target – pending positive results – that would have the world act swiftly to make accessible, given the immediate benefit these products could have for young women.
[MW5]Also important to highlight the importance of R&D for other interventions as well – the target may not include specific coverage rates, but it could include targets for large-scale efficacy trials and/or demonstration projects that might reflect the long-term approach to target-setting and implementation across the research-to-rollout continuum.
[EB6]What about laws criminalizing HIV transmission that affect all populations? I think that the use of the term “key population” is problematic, perhaps even a little messy/sloppy – are you going to mention women repeatedly as well? Most people think of key pops being gay men and other msm, IDUs and SWs. The point is, as Chris Beyrer says, underserved and overimpacted.
[MW7]There is no mention of sero-discordant couples. While it will vary by country, the evidence is incredibly strong for both ARVs for tx (HPTN 052) and px (Partners PrEP) and would seem like this would be a critical population to create a target for testing, tx and px in couples.
[EB8]See previous comment. Where is the literature on this? What do we mean? “other economic support? Sounds really vague…
[EB9]Is this really the right PrEP target – how did it come to be?
[EB10]This just feels like a pie in the sky goal – hard to define, measure and so on. How about an increase in health facilities measuring IPV/GBV, a decrease in reports, ditto for SRHR and HIV integration.
[MW11]There is a robust debate within the VMMC community about age ranges – some countries are looking at 10-14 as well as 15+. Not sure how this aligns with the models being supported by PEPFAR and Gates.
[MW12]Both male and female condoms are important commodities to provide both men and women. By placing the condom target under “men in selected countries” this seems to be a missed opportunity.
[MW13]Not at all sure how this target is actually measured, and I suspect that 50% media access has been achieved already in most places. Also not at all clear how this coverage translates to reduced incidence.
[EB14]Why is this evidence-based? What is this here for except to make people with behavior change funding happy? What is “demand generation for population”? wouldn’t you want to measure this in terms of demand – uptake of services – not just whether someone sees a billboard?