Keeping a tenuous grasp on HIV gains.

2020 should be a landmark year for the global fight against HIV, a key stop on the journey to eliminate HIV epidemics around the world with countries hitting the UNAIDS 90-90-90 targets: 90% of people with HIV aware of their status, 90% of those people on treatment, and 90% of people on treatment with viral suppression. With the ultimate aim of interrupting transmission in multiple countries, communities, and key populations around the world, the 2020 targets would have set the world on track for 95-95-95 by 2030, with some countries eliminating transmission. However, the latest UNAIDS report, Seizing the Moment, shows that few countries are set to hit the 2020 targets, many will miss them by a long mark, and the COVID-19 pandemic threatens to derail HIV programmes as resources and attention are diverted.

Although the final reckoning of the 2020 milestone cannot be made until next year, 2019 figures reveal that key targets are a long way from being met. Worldwide, 81% of people living with HIV are diagnosed, 82% of people diagnosed are on treatment, and 88% of people on treatment have viral suppression. This means that globally 59% of people with HIV are virally suppressed, a substantial shortfall from the 73% expected under 90-90-90. Figures reveal great disparities. Successes include eSwatini and Switzerland, which have achieved 85% viral suppression among people living with HIV, the target under the 95-95-95 goals for 2030. 12 other countries have met the 90-90-90 goals: Australia, Botswana, Cambodia, Ireland, Namibia, the Netherlands, Rwanda, Spain, Thailand, Uganda, Zambia, and Zimbabwe. Although some countries are making great strides for people at risk of and living with HIV, many are not. Indeed, whole regions are seeing worsening HIV epidemics, growing inequalities, and increasing stigma affecting those most at risk.

Substantial gains in women and girls in eastern and southern Africa are offset by a growing gap in care provision between men and women in west Africa and worsening epidemics among drug users in eastern Europe and central Asia. Although HIV epidemics in the Middle East and north Africa account for a small proportion of the global HIV pandemic, if unchecked, this may not remain the case. Those countries and regions where stigma and discrimination remain worst are not coincidentally those with the worst records in the HIV response.

2019 saw 1·7 million new infections, 23% down on the number a decade earlier in 2010, a decline largely driven by reductions in infections in girls and young women in eastern and southern Africa. Boys and men now account for most new infections (52% of infections worldwide). Outside of western Europe and North America, men and boys are much less likely to be on virally suppressive antiretroviral therapy than are women and girls; this disparity is greatest in west Africa where just 49% of men with HIV have viral suppression compared with 67% of women. Worldwide, 62% of new infections were among key populations, which include sex workers, people who inject drugs, prisoners, transgender people, and men who have sex with men. Failure to achieve targets of treatment and prevention mean that since 2015 there have been an excess of 3·5 million new infections and 820 000 deaths.

Against this backdrop of an HIV response struggling to stay on track, the COVID-19 pandemic threatens to derail many HIV programmes completely and in a worst-case scenario could set many HIV programmes back by years if prolonged treatment interruptions occur. In The Lancet Global Health, Alexandra Hogan and colleagues model the impacts of disruptions to prevention and treatment for HIV, tuberculosis, and malaria in low-income and middle-income settings. The researchers predict that over 5 years, HIV deaths could increase by 10% compared with a situation in which there was no COVID-19 pandemic.

Given advances in prevention, testing, and treatment, every HIV infection and death in 2020 is preventable. Nonetheless, we find ourselves falling far short of global targets for treatment and prevention, and in very real jeopardy of backsliding years because of the effects of COVID-19. If countries as disparate as Switzerland and eSwatini can succeed, then targets can be met elsewhere. Local and national governments worldwide must not lose sight of the ultimate goal of ending HIV transmission and AIDS-related deaths. Seizing the moment is an optimistic take as we risk watching successes slip through our fingers.