How is HIV not over yet? We have drugs that treat it and prevent transmission to others. We have a whole suite of prevention methods that work, ranging from condoms to clean needles. But despite it all, HIV just won’t go away. There were approximately two million new HIV infections last year, and a million people died from AIDS-related deaths. It’s incredibly frustrating.

The 2015 UNAIDS global AIDS update, just released, offers us some of the reasons why HIV is still around. Really it boils down to two reasons: inequity and discrimination.

First the Good News

We are making real progress against HIV, some of it faster than expected.

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In the last two years the number of people living with HIV on antiretroviral therapy has increased by about a third, reaching 17.0 million people. This is actually two million more than the 15 million by 2015 target set in 2011. The annual total of AIDS-related deaths has gone down by 43% since 2003. Global coverage of antiretroviral therapy hit its highest coverage ever – 46% – at the end of 2015. In Southern and Eastern Africa, the region hit hardest by AIDS, coverage increased from 24% in 2010 to 54% in 2015.

But the progress is not universal, and that’s what is holding us back.

If you look at the data in detail, you can find the places where the anti-AIDS effort is failing. We are failing in both prevention and treatment among young women and girls, and among key populations that include drug users, sex workers, transgender people, and men who have sex with men.

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Adolescent girls and young women were 20% of new HIV infections globally in 2015, although they make up only 11% of the population. In sub-Saharan Africa it’s worse; adolescent girls and young women accounted for 25% of new HIV infections among adults. In some regions, the number of new infections among adolescent girls and young women is actually increasing.

With regard to key populations, the report states that, “Analysis of data available to UNAIDS suggests that more than 90% of new HIV infections in central Asia, Europe, North America, the Middle East and North Africa in 2014 were among people from key populations and their sexual partners.” Data from other regions is less shocking, but still very high. The report attributes this to marginalization. Stigma against sex work, same sex relationships, and drug users  – as well as the stigma against people living with HIV – keeps people at risk for HIV from being about access the services they need. The impact of stigma is made even worse by laws and policies that actively discriminate. In 2016, 72 countries had laws allowing specifically for HIV criminalization. Four of those countries had passed the laws in the last few years.

These failures add up to bad news. Approximately 54% of people living with HIV are in need of treatment. More than half the people who need treatment don’t get it. Many of these people don’t even know they are HIV positive.

Familiar recommendations

HIV is a complex and frustrating problem, but it is a health issue we understand. Our global investment in AIDS has brought us to a place where we know what to do to treat and prevent it. In this document UNAIDS calls for global commitment to bold HIV targets for 2020. They call for countries to adopt the 90-90-90 target for 2020: by 2020 90% of all people living with HIV will know their HIV status. By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy. By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.

A few countries have adopted these targets already; UNAIDs describes them them a coalition of the brave, and calls for more countries to commit. In order to achieve this target, UNAIDS recommends using proven approaches to preventing and treating HIV. It states that, “An array of effective HIV prevention tools is available, including condoms, harm reduction, voluntary medical male circumcision, pre-exposure prophylaxis, cash transfers for girls and structural approaches that promote gender equality and access to secondary education,”

These proven approaches should be used together, according to UNAID, “The key is to combine these tools into combination HIV prevention packages that address the specific needs of populations that are being left behind, and to establish enabling environments that allow these populations to access HIV, health and social services without fear of violence, arrest or persecution.”

What the report doesn’t say

The report never mentions health systems. Adequate human resources, a steady supply of drugs, safe facilities to visit care, and health services that can be trusted are essential to delivering the combination HIV prevention packages they call for. Interventions that reduced HIV rates can support health in other ways, and health system strengthening activities help to fight HIV. None of that is in this document.

One sentence takeaway

We have the skills and knowledge to end HIV, but we need to see a financial and political commitment to make it happen.

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