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Mind the Gap

AIDS activism achieved extraordinary victories for health equity by demanding that global and national leaders and funders set and strive for ambitious targets. The “3 by 5” target for expansion of antiretroviral treatment (ART) access engendered a more robust response than would have happened otherwise.

But another lesson from the history of AIDS is that it is essential to match the tactics to the time. When there is too much of a gap between the targets and the reality, or between the people setting the targets and the people on the front lines, then the audacious runs the risk of becoming the absurd. That’s the direction the HIV/AIDS response is heading in today.

The most clearly defined campaign is centered on “90-90-90”. This is a critical goal and laudable in its emphasis on outcomes that reflect quality of care. But the push towards 90-90-90 has come at the cost of advancing a more complex, accurate and less pithy framework that encompasses all of the elements needed for an effective end to new HIV acquisitions and deaths from AIDS. This includes newer strategies like PrEP as well as VMMC, male and female condoms and comprehensive harm reduction—which is in crisis in many settings.

It is a fiction that ART for HIV-positive people will, on its own, end the epidemic. Yes, the models suggest that it is possible. And, yes, there are examples of different countries that are close to meeting some of the 90-90-90 coverage goals. And by all means, it is critical to strive for this level of coverage and this type of quality outcome. But comprehensive prevention is also essential. The story that HIV/AIDS can be conquered by ART alone has to change. Programmatic targets for key prevention options must be set by UNAIDS, PEPFAR and national governments.

Effective images can oversimplify. The pieces of the puzzle above only fit together into an effective response in the context of behavioral and structural strategies that support individual rights, autonomy and dignity.