ASFAW IPH-HIV MP PAGE 1

MAJOR PAPER
LAST NAME: ASFAW
FIRST NAME: BISRAT
PROGRAM CODE: DIPH
COURSE CODE: IPH-HIV
INSTRUCTOR: Dr. ADAMU
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GLOBAL HEALTH POLICY: DO 90 90 90 TARGET

ADDRESS THE BURDEN OF HIV/AIDS

1) INTRODUCTION
HIV, the virus that causes AIDS, is one of the world's most pressing public health

challenges. Nevertheless, there is a global commitment to stopping new HIV infections,

ensuring that everyone with HIV can access HIV treatment, and end the pandemics. The

global incidence: The prevalence ratio was 4.4% in 2019, lower than the 7.0% in 2010;

this reflects the vital progress against the epidemic in the past decade. Indeed, the global

health policy of the HIV Strategic Plan for the period 2016-2021 developed as a set of

evidence-informed strategies focused on building one consolidated, unified, rights-based,

and decentralized HIV program with integrated services the general health services of the

countries.1

1
PEPFAR & Global AIDS, “Global HIV/AIDS Overview,” HIV.gov, 2019.
ASFAW IPH-HIV MP PAGE 2

Above all, to mount the efforts of ending the HIV crisis, UNAIDS's 90-90-90

goals were set as targets by the year 2020, with the aim of 90% of all people with HIV

will know their HIV status, 90% of all people who know their status will be on ART, and

90% of all people receiving ART will have viral suppression 2. In doing so, meantime

monitoring of the progress toward those goals indicated by UNAIDS reports in 2018;

there was promising progress to meet the targets. Hence, of all people with HIV

worldwide: 79% knew their HIV status, 78% of all people who knew their status were

accessing ART, 86% of all people receiving ART had viral suppression. This has

witnessed the scale-up of treatment has decline HIV disease—from a peak of 1.7 million

in 2004 to 770,000 in 2018.3

On the other side, the new figures from the World Health Organization (WHO)

and UNAIDS estimated that if the efforts were disrupted to mitigate and overcome

interruptions in health services and supplies during the COVID-19 pandemic. Notably, a

six-month pause in treatments could result in an additional 500,000 deaths from AIDS

and related diseases in sub-Saharan Africa in 2021. Strikingly, the consequence will bring

the region back to 2008 AIDS mortality levels. Even a 20% disruption could cause an

additional 110 000 deaths.4

Therefore, this major paper assesses the global health policy's opportunities and

challenges in the HIV/AIDS response and its impacts on addressing the burden.

2) THE GLOBAL BURDEN OF HIV/AIDS PANDEMIC

2
UNAIDS, “90-90-90: An Ambitious Treatment Target to Help End the AIDS Epidemic,” 2014, 4.

3
PEPFAR & Global AIDS, “Global HIV/AIDS Overview.”

4
UNAIDS, “SEIZING THE MOMENTS: Tackling Entrenched Inequalities to End Epidemics,” 2020.
ASFAW IPH-HIV MP PAGE 3

The Joint United Nations Program on HIV/AIDS reports that in 2018, the number

of people with HIV was approximately 37.9 million people worldwide. Of these, 36.2

million were adults, and 1.7 million were children (<15 years old).5 However, in 2018

alone, the incidence of HIV infections—estimated 1.7 million individuals worldwide

became newly infected with HIV. Of these new infections: 1.6 million infections were

among people ages 15 and older, and 160,000 infections were among children ages 0-14.6

Later, the 2020 UNAIDS report also revealed the burden of HIV globally were

1.7 million people acquired HIV in 2019, more than three times the 2020 target.

Moreover, 690 000 lives were lost to AIDS-related illnesses in 2019, despite the

availability of effective treatments. Furthermore, the data shows 62% of new adult HIV

infections globally are among key populations and their sexual partners. Again,

adolescent girls and young women account for 1 in 4 infections in Sub-Saharan Africa.

Sadly, in 25 countries, more than 50% of adults have discriminatory attitudes toward

people living with HIV.7

a) Global Health Policy to Respond to the HIV/AIDS

Epidemic
In 2016, the United Nations (UN) General Assembly agreed that ending the AIDS

epidemic by 2030 required an accelerated expansion of HIV services alongside rights

affirming and enabling environments for those services. In parallel, interim targets were

set to be achieved by the end of 2020.8 For this reason, as a response to the pandemic of
5
PEPFAR & Global AIDS, “Global HIV/AIDS Overview.”

6
PEPFAR & Global AIDS.

7
UNAIDS, “UNAIDS Data 2020: REFERENCE,” 2020, 10–20.

8
UNAIDS, 2020 Global AIDS Update — Seizing the Moment — Tackling Entrenched Inequalities to End
Epidemics, 2020, 12.
ASFAW IPH-HIV MP PAGE 4

HIV, numerous international and regional response policies being developed and

implemented. Without a doubt, the WHO developed a health sector strategy policy to end

HIV epidemics called "2016-2021 HIV strategic plan," were comprehensive and

established including five strategic directions: strengthening and focusing national HIV

programs and plans through vital sound information and good governance; defining a

package of essential HIV services and high-impact interventions along the HIV services

continuum; adapting and delivering the HIV services continuum for different populations

and locations to maximize quality and achieve equitable coverage; implementing systems

to fund the continuum of HIV services fully and to minimize the risk of financial

hardship for those requiring the services, and embracing innovation to drive rapid

progress.9

Secondly, the United Nations (UN) General Assembly later articulated interim 2020

milestones in the 2016 Political Declaration on Ending AIDS with the global health

actors. They set a policy known as "The Fast Track Target 90–90–90" to accelerate the

HIV response towards ending the AIDS epidemic by 2030. The Fast-Track targets

include the 90–90–90 target: 90% of the people living with HIV know their HIV status,

90% of the people who know their HIV-positive status are accessing treatment, and 90%

of the people receiving treatment have suppressed viral loads.10

Ultimately, the Fast-Track targets apply to everyone: children, adolescents, and

adults; rich and poor; women and men; and all key populations (including sex workers,

people who inject drugs, men who have sex with men, transgender people, and

prisoners). Hence, to take this HIV program to a new level, the plan recommends for the

9
WHO, Global Health Sector Strategy on HIV 2016-2021, 2016, 8.

10
UNAIDS, UNAIDS Data 2020: REFERENCE, 6.
ASFAW IPH-HIV MP PAGE 5

member's countries to follow critical points: i) Use focused, high-impact prevention

interventions and services, ii) Innovate with HIV testing, iii) Treat all in need and start

treatment earlier, iv) Devote more attention to quality & v) Reduce disparities. 11

Consequently, the global response to HIV/AIDS policy can mobilize the international

community's financial commitment and reach significant results.12

b) HIV TREATMENT: GATEWAY TO PREVENT ILLNESS

AND MAKING TRANSMISSION RARE
Antiretroviral medicines have been instrumental in saving millions of lives from

AIDS-related illnesses. Many scholars proved that HIV treatment is a unique tool in the

AIDS response, preventing disease and death, averting new infections, and saving

money. Despite this, the world faced different choices in the post-2015 era on deciding

on HIV treatment availability. The options were either to maintain the status quo or to

rapidly scale-up HIV treatment for all people living with HIV, regardless of CD4 count.

Finally, the later adapted and this scenario calls for countries to use the total population

of people living with HIV as the denominator for treatment coverage. To this end,

presently, of the 38 million people living with HIV, 25.4 million people are now on

treatment. In fact, 12.6 million people are still waiting.13

Likewise, the study conducted on the effects of early treatment by the WHO

presented considerable evidence of earlier treatment initiation's clinical benefits. And

recommending an increase in the CD4 count threshold for initiation of HIV treatment

11
World Health Organization, Progress Report WHO: Prevent HIV, Test And Treat All: WHO Support
For Country Impact, 2016, 7–8

12
World Health Organization, 11.

13
UNAIDS, 2020 Global AIDS Update — Seizing the Moment — Tackling Entrenched Inequalities to End
Epidemics, 8.
ASFAW IPH-HIV MP PAGE 6

from 350 to 500 cells/mm3. Additionally, the randomized trial conducted on early

treatment revealed that there were 27% less likely to experience a primary clinical event,

36% less likely to experience an AIDS-defining clinical manifestation, and 51% less

likely to be diagnosed with tuberculosis.14 Similarly, the national institute of health study

cited early antiretroviral treatment lowered the risk of serious AIDS-related events by

72%. Moreover, it can minimize the risk of serious non-AIDS events by 39%.15

Furthermore, the consolidated guideline on HIV prevention and treatments

recommends Anti-Retroviral Therapy (ART) should be initiated in all adults living

with HIV, regardless of WHO clinical stage and at any CD4 cell count. Also, retesting all

people living with HIV before starting ART is recommended to ensure a correct

diagnosis of HIV infection. Besides, it underscored that ART initiation must seen as a

non-emergency intervention, and various approaches are used to help prepare people to

begin treatment.16

c) The impact of global health policy

Health policy refers to decisions, plans, and actions undertaken to achieve

specific health care goals within a society. Therefore, the HIV response policy

application has saved millions of lives and reduces new infections, especially the scale-up

of antiretroviral therapy and the 2020 Fast Track Strategy. For instance, at the end of

2019, fourteen countries have achieved the 90–90–90 HIV treatment targets (90% of

people living with HIV know their HIV status, of whom 90% are on antiretroviral
14
UNAIDS, 90-90-90: An Ambitious Treatment Target to Help End the AIDS Epidemic, 6.

15
National Institutes of Health, Benefits of Early Antiretroviral Therapy in HIV Infection, accessed July 7,
2020, https://www.nih.gov/news-events/nih-research-matters.

16
WHO, WHO Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing
HIV Infection: Recommended for Public Health Approach: Second Edition, 2016, 121.
ASFAW IPH-HIV MP PAGE 7

treatment and of whom 90% are virally suppressed). Similarly, Eswatini, which has one

of the highest HIV prevalence rates globally, at 27% in 2019, and has now surpassed the

targets to achieve 95–95–95.17

Even though the 2020 UNAIDS report revealed significant progress obtained,

only a few countries have taken sufficient action from a diverse range of geographic,

economic, and epidemic settings to reach the interim milestones, proving that bold targets

can be met with adequate political will, financial resources, and community engagement.

However, the global aggregate data towards ending AIDS by 2030 was already off track

to achieve the three zeros. Because of limited resources allocation in many countries,

funding gap, discrimination, entrenched inequalities, and failed to bend the curves of new

HIV infections and AIDS-related deaths as significantly as was envisioned in the

UNAIDS 90-90-90 Fast Track Strategy.18

i) COVID-19 Pandemic on HIV/AIDS Response and Next Plan

COVID-19 is exacerbating the risks of stock-outs of antiretroviral (ARV)

medicines. The lockdowns have also closed state borders in numerous countries,

including a shut-down of land and air transport services. Thus an unprecedented global

health crisis, according to the recent WHO report affecting critically in low stock of

ARVs and disruptions in the supply of these life-saving medicines. 19 Therefore, to

minimize the adverse effects of the COVID-19 on HIV response, countries are

mitigating the impact of the disruptions by maintaining flights and supply chains,

17
UNAIDS, SEIZING THE MOMENTS: Tackling Entrenched Inequalities to End Epidemics.

18
UNAIDS, 2020 Global AIDS Update — Seizing the Moment — Tackling Entrenched Inequalities to End
Epidemics, 15–20.

19
WHO, WHO: Access to HIV Medicines Severely Impacted by COVID-19 as AIDS Response Stalls,
accessed July 19, 2020, https://www.who.int/news-room/.
ASFAW IPH-HIV MP PAGE 8

engaging communities in the delivery of HIV medicines, and working with

manufacturers to overcome logistics challenges.

At the same time, WHO developed guidance for countries on how to safely

maintain access to essential health services during the pandemic, including all people

living with or affected by HIV.20 Besides, partners, including PEPFAR and the Global

Fund, are actively working to mitigate this impact and analyze information on promoting

continuity of HIV care and service. Meanwhile, consult and discuss with manufacturers

of antiretroviral medicines for emergency supply and with countries to switch to available

quality alternative products and possible mitigation measures.21

Similarly, as the spread of the coronavirus threatens, the health system capacities

multiple concerted efforts to maximizing the impact of HIV responses and tackling

COVID-19 underway. Along with the accelerated movement towards universal health

coverage that can help the health systems achieve the highest possible standards of health

and wellbeing for all people.22 Although, the global health actors call on comprehensive

approaches for women and girls: All women require access to a complete package of

quality sexual and reproductive health and rights services that are: (a) accessible and

gender-responsive; (b) free from coercion and stigma and discrimination; (c) grounded in

a human-rights based approach, and (d) linked to other relevant services.23

ii) Challenges and Progress of HIV Response

20
WHO.

21
UNAIDS, The Impact of the COVID-19 Response on the Supply Chain, Availability and Cost of Generic
Antiretroviral Medicines for HIV in Low- and Middle-Income Countries, 2020, 2.

22
UNAIDS, 4.

23
UNAIDS, SEIZING THE MOMENTS: Tackling Entrenched Inequalities to End Epidemics, 60.
ASFAW IPH-HIV MP PAGE 9

The 2020 joint UN reports underscored the global health community was already

off track to meet HIV targets for 2020. Despite advances in the HIV prevention and

treatment knowledge and years of significant effort by the global health community,

organization, and government, too many people with HIV or at risk for HIV still do not

have access to prevention, care, and treatment. Many of the countries hardest hit by HIV

also suffer from other infectious diseases, food insecurity, and other serious problems.24

Moreover, the UNAIDS report highlighted, the world is far behind in preventing

new HIV infections. Nearly 1.7 million people were newly infected with the virus, more

than three times the global target. Even though there has been progressing in eastern and

southern Africa, where new HIV infections have reduced by 38% since 2010. The report

added that new HIV infections have also risen in the Middle East and North Africa, by

22% and 21% in Latin America. 25 More importantly, stigma and discrimination, together

with other social inequalities and exclusion, prove critical HIV prevention barriers.

Stigma against people living with HIV is still commonplace in at least 82 countries.

Women and girls in sub-Saharan Africa continue to be the most affected and accounted

for 59% of all new HIV infections in the region in 2019.26

Despite these challenges, there have been successes and promising signs. New

global efforts have increased to address the epidemic, particularly in the last decade. The

number of people newly infected with HIV has declined over the years. In addition, the

number of people with HIV receiving treatment in resource-poor countries has

24
UNAIDS, 17.

25
UNAIDS, 2020 Global AIDS Update — Seizing the Moment — Tackling Entrenched Inequalities to End
Epidemics, 294.

26
UNAIDS, Rights in the Time of COVID-19: Lessons from HIV for an Effective, Community-Led
Response, 2020, 11.
ASFAW IPH-HIV MP PAGE 10

dramatically increased in the past decade, and dramatic progress has made in preventing

mother-to-child transmission of HIV and keeping mothers alive.27

3) CONCLUSION
This major paper reviewed and analyzed the scientific documents, guidelines,

strategic plan, and annual report and summarized the commitments of global health

actors and policy application to end the HIV/AIDS pandemic burden. UNAIDS and

WHO noted that sustained progress was made in HIV testing and antiretroviral therapy

coverage in different countries, leading to a reduction in HIV transmission rates. Also,

new HIV infections fell by 39% between 2000 and 2019. HIV-related deaths fell by 51%

over the same period, and 15 million lives were saved using appropriate policy

implementation.

Moreover, the UN General Assembly's 2016 Political Declaration on Ending

AIDS "the 90–90–90 targets" were the prominent global health policy with core

commitments contributing gains in treatment effectiveness, as well as increases in the

number of people who know their status and are on treatment. Despite the tremendous

achievement, significant gaps remained, and some critical aspects of HIV prevention may

be sliding backward, according to the latest data. For now, the occurrences of COVID-19

disrupting the entire efforts; thus, globally, there is an urgent need to scale up HIV

prevention services, especially in the countries facing a critical shortage of HIV medicine

and a weak health system.

In summary, I conclude that the global HIV response policy has played a

significant role in testing, treating, and preventing HIV/AIDS transmission. Even if

27
PEPFAR & Global AIDS, Global HIV/AIDS Overview.
ASFAW IPH-HIV MP PAGE 11

progress towards global targets is stalling, enhanced targeting of proven prevention and

testing services and minimizing the inequalities will be critical to heighten the global

response to ending HIV.

4) REFERENCE
National Institutes of Health. Benefits of Early Antiretroviral Therapy in HIV
Infection. Accessed July 7, 2020. https://www.nih.gov/news-events/nih-research-
matters/benefits-early-antiretroviral-therapy-hiv-infection.
PEPFAR & Global AIDS. Global HIV/AIDS Overview. HIV.gov, 2019.
UNAIDS. 90-90-90: An Ambitious Treatment Target to Help End the AIDS
Epidemic, 2014, 40.
UNAIDS. 2020 Global AIDS Update — Seizing the Moment — Tackling Entrenched
Inequalities to End Epidemics, 2020, 384.
UNAIDS. Rights in the Time of COVID-19: Lessons from HIV for an Effective,
Community-Led Response, 2020.
UNAIDS. SEIZING THE MOMENTS: Tackling Entrenched Inequalities to End
Epidemics, 2020.
UNAIDS. The Impact of the COVID-19 Response on the Supply Chain, Availability,
and Cost of Generic Antiretroviral Medicines for HIV in Low- and Middle-Income
Countries, 2020.
UNAIDS. UNAIDS Data 2020: REFERENCE, 2020.
WHO. Global Health Sector Strategy on HIV 2016-2021, 2016.
World Health Organization. WHO: Access to HIV Medicines Severely Impacted by
COVID-19 as AIDS Response Stalls. Accessed July 19, 2020. https://www.who.int/news-
room.
World Health Organization. Consolidated Guidelines on the Use of Antiretroviral
Drugs for Treating and Preventing HIV Infection: Recommended for Public Health
Approach: Second Edition 2016.
World Health Organization. Progress Report WHO: Prevent HIV, Test, And Treat
All: WHO Support For Country Impact, 2016.