In the past few years, UNAIDS, the United States President’s Emergency Plan for AIDS Relief (PEPFAR), and The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) have promoted a goal of HIV epidemic transition and an “end of AIDS.” The belief in this goal stems from the significant advances, nearly four decades since the first report of AIDS, in treatment for HIV infection, community mobilization, and political will. Reflecting this optimism, in October 2017 UNAIDS sponsored a meeting of global experts to find a consensus around a single indicator that could define, at national scale, “epidemic control,” generally understood as a shift from high HIV incidence and mortality to low levels of transmission and effectively managed care.
Progress on HIV and AIDS to date is markedly uneven, with 1.8 million new HIV infections in 2017 and stark disparities in incidence and mortality among different populations and locations within countries. Whereas the importance of measuring our success in controlling the HIV epidemic is uncontestable, discussion around the end point and possible indicators at the UNAIDS meeting was hotly contested. Our approach in this article, reflecting the social, political, and structural factors that shape risk and influence access to prevention and care, calls for the use of a collection of indicators that incorporate principles of human rights, gender equality, and participation, recognizing that without equity, epidemic transition cannot truly be achieved or sustained.
- Stark differences in HIV incidence and mortality across locations and populations demonstrate the challenge of identifying a single indicator, at national scale, of progress toward the control of HIV epidemics.
- Even in countries that report decreases in HIV incidence, incidence may be increasing among groups that are particularly vulnerable and face political and social exclusion, especially sex workers, people who inject drugs, transgender persons, men who have sex with men, and prisoners.
- To comprehensively evaluate national progress on HIV, five categories of indicators should be examined that address: levels of coverage of key evidence-based prevention and treatment interventions; incidence and prevalence of HIV infection; AIDS-related or all-cause mortality among people living with HIV; stigma and discrimination; and the legal and policy environment.
- Indicators should be disaggregated, whenever feasible, to fully reflect progress and challenges relating to all populations and locations in the national response.
- The process of evaluating indicators of national progress should meaningfully involve people living with HIV and from key populations as an important part of data validation.