For the first time since the HIV epidemic began a little over three decades ago, we finally have the tools that could allow us to achieve an AIDS-free generation within the next 15 years. More than any other epidemic in recent memory, HIV/AIDS has exacted a terrible toll on humankind. Since 1981, more than 75 million people have been infected with HIV with more than half of these are already dead from AIDS-related complications.
Despite these grim statistics, the new millennium has witnessed rapid advances in HIV prevention, care and treatment along several fronts, and real progress in reversing the trend of the epidemic in many of the worst affected countries has been realized. Prevention efforts have been buttressed with evidence-based interventions, such as elimination of mother-to-child transmission of HIV (eMTCT), voluntary medical male circumcision (VMMC), proper and regular condom utilization and, more recently, new interventions, such as treatment as prevention (TasP) as well as pre-exposure prophylaxis (PrEP). On the antiretroviral therapy (ART) side, regimens have become greatly simplified, much less expensive, remarkably less toxic and more effective at achieving virological suppression, thus greatly extending life spans of people living with HIV (PLHIV).
Despite the fact that a definitive cure and a potent vaccine still elude us, the current tools, if used to scale and in combination, have the ability to make a great dent in HIV epidemiology and offer us the tantalizing possibility of achieving the AIDS-free generation by 2030; a goal towards which UNAIDS and the wider international community has set a path.
Throughout the history of the HIV epidemic, the global burden of the disease has been skewed in distribution with countries, mainly in sub-Saharan Africa, that have huge generalized epidemics, while the rest of the world experiences concentrated epidemics mainly within key populations. Currently only 15 countries account for 73% of the estimated 37 million PLHIV worldwide and the same countries (with the exception of Ethiopia and Malawi, which are substituted for Indonesia and Cameroon) account for 76% of new HIV infections globally. Therefore, the success of intervention efforts in these countries is imperative to defeating HIV.
What is at stake? At current treatment rates, only a little over 15 million PLHIV are receiving life-saving antiretroviral therapy (globally just 41% of adults and 32% of children who need it with the majority of PLHIV not on treatment residing in some of the worst HIV-affected countries). With the new WHO 2015 HIV testing services and treatment guidelines that advocate for “testing and offering treatment”, we will have to rapidly find more innovative ways of service delivery in order to achieve the 90-90-90 UNAIDS targets in the 5-year window of opportunity that we have before 2020.
Knowing one’s HIV status is a prerequisite to accessing ART and currently only about 46% of PLHIV know their status. A lot more testing (including community and self HIV testing) needs to be done in order to identify positive individuals to be put into care and treatment.
In a paradigm shift from previous efforts, PEPFAR 3.0 advocates for targeted HIV testing after sub-national hotspot mapping (rather than simply just testing the general population) in order to achieve the highest yield of HIV positives. To achieve this requires utilizing available data and modeling to know where the virus is in order to implement appropriate, context-specific responses. Access to site-level real time data will be crucial to a targeted response. Even after hotspots are identified, PLHIV treatment seeking behaviors need to be better understood and patient monitoring protocols simplified so that the already fragile health systems in many of the target countries don’t buckle under the additional burden of caring for a greatly increased number of patients.
In the short term, a lot more resources– from domestic, bilateral, philanthropic, out-of-pocket and multi-lateral sources – will be needed in order to cater to the increased need and scale up of the appropriate interventions. More importantly, we need to think out of the box and craft more innovative and practical approaches to identify, initiate and successfully keep on treatment so many additional PLHIV. These are challenging yet exciting times; what we learn and do over the next crucial 5 years will determine whether one of the greatest calamities that mankind has faced can be consigned to the dustbin of history within our lifetime.
 These 15 countries include: South Africa, Nigeria, India, Kenya, Mozambique, Uganda, Tanzania, Zimbabwe, Zambia, Malawi, China, Ethiopia, Russia, Brazil and the United States.