Political will and targeted funding are key to ending AIDS by 2030: UNAIDS

A new report from UNAIDS says the path to ending the global AIDS epidemic by 2030 may not be easy, but it's clear: collect and act on good data, boost health system integration, empower community networks, and strengthen equality and human rights protections. And key to all of these is political will and sustainable, targeted funding.

Today, there are 39 million people living with HIV around the world. The development of antiretroviral drugs means that, in many countries, most people with HIV-positive status never develop AIDS, the potentially deadly final stage of HIV infection. First recognized in 1981, AIDS hit its peak in 2004 when there were two million AIDS-related deaths globally.

That figure has dropped by 69% as the number of people on life-saving antiretroviral therapy (ARV) worldwide has almost quadrupled, from 7.7 million in 2010 to nearly 30 million in 2022. Treatment allows people living with HIV to live as long as their peers without HIV and can eliminate the risk of transmitting the virus sexually.

But in 2022, more than one million people globally became newly infected with HIV and there were still around 9.2 million people who were not getting ARV. That year, AIDS killed one person every minute.

For lessons on how to bring that number down to zero, the UNAIDS report looked at a group of countries that have managed to reach the United Nations' 95-95-95 targets: 95% of people living with HIV know their HIV status, 95% of those people are receiving ARV, and 95% of those people have achieved viral load suppression.

Botswana, Eswatini, Rwanda, Tanzania and Zimbabwe have already hit all three targets, and at least 16 other countries are close. Sub-Saharan Africa and Asia and the Pacific are home to more than 80% of all people living with HIV, and it's those regions that have seen the most progress in expanding access to ARV over the past two decades.

Many of them are low- and middle-income countries, but all share a commitment to investing in HIV prevention and treatment, with most focusing programs and interventions on young people and women, which also helps prevent vertical transmissions to children. In 2022, the number of new infections among children globally had dropped to its lowest point since the 1980s.

Integrating HIV testing and treatment with other health services, including maternal and child health, sexual and reproductive health, primary care, and tuberculosis services, is vital to efforts to end AIDS by 2030, the report said. That strategy goes hand-in-hand with the "treat all" policy that has been instrumental in driving down HIV rates in countries where it is implemented, offering free ARV to anyone living with HIV to reduce the spread of the virus.

Botswana, for example, adopted its "treat all" policy for citizens in 2016, then three years later expanded it to all migrants living with HIV. Recently the country went a step further and began offering pre-exposure prophylaxis (PrEP) to women who are HIV negative but at high risk of contracting the virus. As a result, Botswana cut its rate of mother-to-child transmission from 40% in 1999 to under 2% in 2020.

The UNAIDS report points to the essential role that community healthcare systems and community-led organizations play in reaching, treating, and providing consistent support to people living with HIV. Community networks boost awareness and HIV literacy, they make HIV services more accessible and convenient, and they ensure that stigma doesn't keep marginalized populations – such as sex workers and men who have sex with other men – from getting the treatment they need.

Research shows that gay men and other men who have sex with men – whose risk of acquiring HIV is 26 times higher than for other adult men – are more likely to report using HIV services if they experience higher community engagement and the support of LGBTQ-led community groups.

Empowered community organizations and well-funded community health systems also give voice to people living with HIV and those who are at high risk, which helps push policies to combat the inequalities and rights violations that can stop people from seeking and getting HIV treatment. Countries can remove major obstacles for effective HIV response if they create interventions and change laws to tackle issues such as gender inequality, the criminalization of sex work and consensual same-sex intercourse, violence against women and transgender people, and discrimination against high-risk groups, the report said.

Getting more girls and young women into school, for example, allows them to learn how to gain more control over their sexual and reproductive health, which leads to them being more likely to get tested for HIV and less likely to be HIV positive. And a recent study showed that scaling up programs globally to prevent intimate partner violence could avert about 5% of new HIV infections by 2030.

But research by the World Health Organization found that less than half of the countries surveyed had a budget specifically for implementing policies to combat violence against women. If the world has any chance of ending AIDS, governments must devote sufficient funding not just to direct HIV response but also to addressing the underlying societal and structural issues that are holding back progress in many countries, the UNAIDS report said.

Globally, US$20.8 billion was dedicated to HIV programs in low- and middle-income countries in 2022. That's a 2.6% drop from the year before, bringing the funding level back to where it was in 2013 and well short of the US$29.3 billion needed by 2025. Ramping up and then maintaining funding for HIV response is essential – and it could prove one of the biggest challenges. UNAIDS analysis shows the regions with the biggest HIV funding gaps – eastern Europe, central Asia, and the Middle East and North Africa – are making the least progress in tackling the spread of the virus.

On the other hand, countries that have kept stable or increased their funding for HIV response and prevention, many of them with help from the United States President’s Emergency Plan for AIDS Relief (PEPFAR), are seeing HIV incidence decline. Numbers of AIDS-related deaths between 2010 and 2022 fell by 59% in PEPFAR-supported countries, compared with 51% globally.

The solution to ending AIDS "is not a mystery. It is a choice," UNAIDS Executive Director Winnie Byanyima said in the report's foreword. "Countries that put people and communities first in their policies and programs are already leading the world on the journey to end AIDS by 2030. We need all leaders to get on that path."