By 2020, UNAIDS had hoped to meet the 90-90-90 goal it originally set in 2014: to have 90% of people living with HIV know their status, 90% be on antiretroviral therapy (ART), and 90% have achieved viral suppression. The world fell short of meeting that goal, with just 81% knowing their positive status, two-thirds on ART, and 59% being virally suppressed.
The challenge with 90-90-90 was a failure to recognize how complex human beings are, and unless we deal with inherent structural inequities—stigma, discrimination, inequality—the disease will perpetuate, asserted Perry N. Halkitis, PhD, MS, MPH, dean, professor, and the director of the Center for Health, Identity Behavior & Prevention Studies at the Rutgers School of Public Health.
What issues prevented UNAIDS’ 90-90-90 goal from being met?
90-90-90, also known as flattening the curve, also known as ending the epidemic, when we talk about ending the epidemic, what we're really talking about is identifying people, testing them, putting them on treatment, and keeping them suppressed. In the United States right now, about 50% of those who are living with HIV have viral suppression; we're not anywhere near it. It's better in states like New York and New Jersey, but in other parts of other parts of the country, it's extremely bad.
The challenge with 90-90-90, or with ending the epidemic, is the overreliance on biomedical interventions with a failed recognition that human beings are human beings and that they have social, emotional, complex lives, and that without access to care, with ongoing stigma, with ongoing discrimination, you're not going to take your pills every day, you're not going to test for HIV. There's a lot of stigma.
If we think about in the country right now, where the epidemic is manifesting, it's in young Black gay men. Young Black gay men are feeling discrimination because they're gay, often from their families; because they're Black, from society; often because they have less economic means than White men. And you put those 3 stressors together, whenever you put those stressors together, they exacerbate risk. And when you exacerbate risk, you increase HIV transmission.
So, unless you deal with the structural inequities that continue to exist in our society—the stigma, the discrimination, the inequality that continues to exist—then the disease is going to perpetuate because it's not just about a virus. It's about a human being with emotions, and feelings, and reactions responding to the virus.
Very much like COVID-19, right? People did not react rationally to COVID-19. You would think they would, but they didn't. Because human beings are not rational operators. We make the mistake time and again to assume that people are that, and it’s our pitfall in public health. It's our pitfall a lot in the medical profession, which has failed to recognize the complexity of people's lives.