Although unprecedented progress has been made in the fight to contain AIDS globally, formidable challenges remain. According to a recent study by the AIDS Society of India, 92 percent of those newly infected with HIV now on antiretroviral therapy in Mumbai contracted the virus from unsafe sex. Of all new HIV infections in 2017-2018 in Mumbai, 3.7 percent were in children. Countries such as Thailand have eliminated transmission of HIV from parents to children. India and other nations need to progress faster to eliminate transmission of HIV from parents to children.

Every new case of HIV transmission to an adult or a child is an opportunity to do a reality check on how it could have been averted. Every case of late or missed HIV diagnosis; delay in putting people living with HIV on treatment; stigma and discrimination blocking access to care; or people living with HIV not being virally suppressed, are among reality checks we cannot fail to miss, if we are to end AIDS. Most importantly, game-changing insights of finding solutions that will work in local contexts of communities and regions, come from people who are most affected.

"Despite decades of safe sex campaigns to prevent HIV (and other sexually transmitted infections and unintended pregnancy), recent data show that unsafe sex is a major driver of new HIV infections as reported in the news,” said Ishawar Gilada, president of the AIDS Society of India. “We have to ensure that HIV prevention campaigns are effective and translate into steep decline in new HIV infection rates. Every person, especially those among key affected populations, must have access to the full range of scientific evidence-based HIV prevention options," said Gilada, who was elected to the Governing Council of International AIDS Society this year.

Dr Gilada, among the first doctors to begin HIV care in India, added: “193 governments have committed to end AIDS by 2030, which aspires to eliminate transmission of HIV and ensure healthy and productive normal lifespans for all people living with HIV. We must ensure that all PLHIVs know their status, all of them receive antiretroviral therapy and remain virally suppressed, irrespective of where they reside, and no further transmission of HIV takes place, thereby making Undetectable = Untransmissible (U=U) a reality.”

So-called 90-90-90 targets include: 90 percent of all people living with HIV will know their HIV status, 90 percent of those living with the virus will receive antiretroviral therapy and 90 percent of all people receiving ART will have suppressed the viral load to minimize HIV transmission.

UNAIDS targets achieving 90-90-90 as not only critical but central. But no less emphasis should be given to ensure that while the world progresses towards and beyond 90-90-90, it will be necessary to use every scientific, evidence-based prevention option, so that new HIV infection rates decline steeply to hit zero as soon as possible.

“One of the challenges we have is that the idea of 90-90-90 is often reduced to treatment side of the HIV response,” said Mitchell Warren, executive director of the AIDS Vaccination Advocacy Coalition. “It is obviously an essential component but the whole concept of epidemic control lies not only in reaching the treatment targets of diagnosis, treatment and viral suppression, but also it has to include essential needs of primary prevention, stigma reduction (ideally elimination) and human rights approaches.”

“From my perspective, it is really coming down to deliver with what we have today, which means comprehensive prevention (such as condoms, oral pre-exposure prophylaxis (PrEP), and other evidence-based tools to prevent HIV transmission), human-rights based approaches, along with scaling up treatment,” Warren continued.

The medical community, he said, has to demonstrate the added value of more interventions. Oral prophylaxis was approved by the US FDA in 2012 but still is unavailable in several countries. Of 350,000 people on oral prophylaxis, two-thirds are in the United States, with another large proportion in Europe, Kenya and South Africa, underlining the gap in roll-out globally.

“We have to maintain the thrust on research and development of next generation products, such as vaccines or a possible cure of HIV in the long run,” Warren said.

The clock is ticking to ensure safe sex campaigns (among all other evidence-based prevention approaches) are effective in reducing new HIV cases without any delay. Also, are people, especially key affected populations, able to perceive risk? And do they have all the choices of HIV prevention options within their reach to protect themselves from HIV acquisition? We need to find answers to resolve these real barriers that are impeding progress towards ending AIDS.

Male condom use, for instance, among other evidence-based HIV prevention options, is also far lower than optimum. Although female condoms were approved by the FDA in 1993, countries such as India are yet to fully utilize these female-initiated methods to prevent unintended pregnancy, STIs and HIV. 25 years of long delay is not acceptable if we are to end AIDS and deliver on other related SDGs.

Pre-Exposure Prophylaxis (PrEP) is yet to be optimally used in countries like India where it is not even licensed, although it was approved by the FDA in July 2012, Gilada said. Why are we failing to convert scientific research outcomes into public health gains?

Sowmya Gupta, president of the Transgender Welfare Equity and Empowerment Trust (TWEET) Foundation, and a noted hijra trans activist who is also with the Humsafar Trust, said that “we need to work more rigorously towards providing livelihood to transgender people. Approximately 70 percent of transgender women are engaged in sex work in India. We know the risk factors of HIV and violence associated with sex work. By providing employment we can prevent HIV too. Also, we have to engage the transgender community at every level of program design and implementation, as it will go a long way to eliminate stigma and discrimination, as well as improve access to HIV prevention and ART services, and help in improving adherence to therapy".

How can a preventable, curable disease be a lead cause of death?

Tuberculosis is the leading cause of death for people living with HIV even in 2017 although TB is preventable, treatable and curable. Despite efforts to scale TB and HIV collaborative activities, in 2017 about 300,000 people died of HIV-associated TB, with 900,000 new cases of TB among people who were living with HIV, 72 percent of whom were living in Africa.

If TB is preventable, then we have to demonstrate that by preventing its transmission especially in communities at heightened risk. Same benchmark has to be used for demonstrating that TB is treatable and curable by ensuring no one dies prematurely because of TB.

India’s National Health Policy promises Universal Health Coverage, which is essential to not only ending AIDS but also providing health security for all citizens Gilada said. He advocates a sustainable and holistic approach to universal health coverage.

Shobha Shukla is the Managing Editor of Citizen News Service. Follow her on Twitter @Shobha1Shukla, @CNS_Health or visit www.citizen-news.org.