Almost 37 million people around the world are now infected with human immunodeficiency virus (HIV), the virus that causes AIDS . But many don’t know they are infected or lack access to medical care. Even though major strides have been made in treating the infection, less than half receive antiretroviral therapy (ART) that could prevent full-blown AIDS and reduce the likelihood of the virus being transmitted to other people. Now, a new report restores hope that an end to this very serious public health challenge could be within reach—but that will require a major boost in commitment and resources.
The study conducted by an NIH-funded research team evaluated the costs and expected life-saving returns associated with ambitious goals for HIV testing and treatment, the so-called 90-90-90 program, issued by the Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2014 . The new analysis, based on HIV disease progression and treatment data in South Africa, finds that those goals, though expensive to implement, can be achieved cost-effectively, potentially containing the AIDS epidemic and saving many millions of lives around the globe.
The 90-90-90 program pursues three main objectives: diagnose 90 percent of HIV-infected people worldwide, link 90 percent of them to treatment, and suppress the virus in 90 percent of those receiving ART. By meeting these objectives, the program aims to reduce HIV to undetectable levels in 73 percent (.9 x .9 x .9 =.73) of people infected with the virus by 2020. Current estimates suggest that the virus is suppressed to undetectable levels in just 29 percent of HIV-infected individuals globally .
While it’s recognized that the 90-90-90 program would require a major funding increase from global donor organizations, the possible outcomes of such an investment have not been entirely clear. In the new study, Rochelle Walensky of Massachusetts General Hospital, Boston, and her American colleagues teamed with researchers at the South African Desmond Tutu HIV Center, Cape Town, to estimate the 5-and-10-year health impact and costs of a fully-implemented 90-90-90 program in a nation that is believed to have the world’s highest rate of HIV infection.
To perform their analyses, Walensky and colleagues used a well-validated cost-effectiveness model designed specifically for the delivery of HIV care. They included South African population data and the results from national HIV screening and treatment programs. The researchers also compared their results to those expected if the efforts in South Africa to combat HIV/AIDS were continued at the current pace.
The findings, reported recently in Annals of Internal Medicine, showed that compared to the current slower pace of scale up, the 90-90-90 program could prevent more than 870,000 people in South Africa from becoming infected with HIV by the time of its full implementation in 2020. It would also prevent more than a million deaths and reduce the number of orphaned children by more than 700,000. Over the course of a decade, the program could prevent more than 2 million South Africans from contracting HIV through viral suppression in the population and save almost 2.5 million lives.
To attain these results, the program would need a 42 percent increase in funding, or a total of $54 billion, over the next decade. As the researchers note, this investment would be well worth it. They estimate the cost per year of life saved at $1,260 by 2025, making it about as cost effective as HIV treatment itself.
Those gains in HIV diagnosis, treatment, and suppression will not come easily. The researchers found that achieving 90 percent diagnosis and treatment will require HIV screening of the entire South African population as often as every two years. It also assumes that most people with HIV will respond well to ART and adherence programs will be funded, ensuring that most patients will remain in treatment.
This may sound like a very bold task. But there are indications that it can be done in countries with limited resources and a high burden of HIV. For example, a recent study found a rate of viral suppression in Botswana of 70 percent, remarkably close to the UNAIDS goal of 73 percent .
Based on the evidence, the researchers concluded that global health policymakers should mobilize the political and economic support to realize the 90-90-90 targets. And, in fact, this very week world leaders, HIV program implementers, government representatives and other key stakeholders will convene in New York City at a United Nations meeting to solidify a plan to put an end to the global AIDS epidemic by 2030. Walensky will be in attendance and has been asked to speak about her team’s work.
This encouraging news also happens to coincide with June 5, which this year marks the 35th anniversary of the first AIDS diagnoses and the first published scientific account of the virus we’ve come to know as HIV . As the science and targeted public health efforts continue to progress, evidence is growing to support the bold possibility, perhaps even in the not too-distant future, of an AIDS-free generation.
 HIV/AIDS Fact Sheet (UNAIDS)
 The Anticipated Clinical and Economic Effects of 90-90-90 in South Africa.Walensky RP, Borre ED, Bekker LG, Resch SC, Hyle EP, Wood R, Weinstein MC, Ciaranello AL, Freedberg KA, Paltiel AD. Ann Intern Med. 2016 May 31.[Epub ahead of print]
 90-90-90: an ambitious treatment target to help end the AIDS epidemic [PDF 960 KB] . Joint United Nations Programme on HI/AIDS (UNAIDS) 2014 October.
 Botswana’s progress toward achieving the 2020 UNAIDS 90-90-90 antiretroviral therapy and virological suppression goals: a population-based survey. Gaolathe T, Wirth KE, Holme MP, Makhema J, Moyo S, Chakalisa U, Yankinda EK, Lei Q, Mmalane M, Novitsky V, Okui L, van Widenfelt E, Powis KM, Khan N, Bennett K, Bussmann H, Dryden-Peterson S, Lebelonyane R, El-Halabi S, Mills LA, Marukutira T, Wang R, Tchetgen EJ, DeGruttola V, Essex M, Lockman S; Botswana Combination Prevention Project study team. Lancet HIV. 2016 May;3(5):e221-30.
 Pneumocystis Pneumonia—Los Angeles. Centers for Disease Control and Prevention (CDC). MMWR Surveill Summ. 1981 Jun 5;30(21);1-3.
AIDS Info (NIH)
HIV/AIDS (National Institute of Allergy and Infectious Diseases/NIH)
UNAIDS (The Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland)
Rochelle Walensky (Massachusetts General Hospital, Boston)
NIH Support: National Institute of Allergy and Infectious Diseases; Eunice Kennedy Shriver National Institute of Child Health and Human Development; National Heart, Lung, and Blood Institute; National Institute of Mental Health; National Institute on Drug Abuse