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Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-901 targets aim to ensure that 90% of people are tested for HIV, and that 90% of those testing positive for HIV receive antiretroviral therapy (ART) and achieve viral suppression by 2020. Those targets are being raised to 95-95-95 by 2030.1 Family Planning 2020 (FP2020) aims to reduce unwanted fertility by providing contraception to 120 million additional women by 2020, significantly increasing modern contraceptive prevalence rates (mCPRs).2 These global goals are grounded in a similar concept: through increased service uptake, significant gains can be made in sexual (HIV) and reproductive health (unwanted fertility). Integrating HIV and family planning (FP) services has broad support from international stakeholders3 4 to reduce unmet need for contraception, unintended pregnancy, and as a cost-effective HIV prevention strategy.5 Results from the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial, a randomised trial measuring HIV risk among African women seeking contraceptive options, found a high level of HIV incidence in this well-counselled study population of women desiring pregnancy prevention, further emphasising the need for service integration.6 Despite both UNAIDS and FP2020 goals focusing on sexual behaviour outcomes, there has been a curious lack of attention to synergy in the processes employed to reach these goals. Arriving at 2020, identifying success stories and critical gaps for country-level progress towards the UNAIDS and FP2020 benchmarks is vital information for donors, policymakers and the research community. We compare for the first time the progress countries have made towards UNAIDS and FP2020 goals.
Our assessment centres on the 69 FP2020 focus countries. We eliminated those that did not report a specific commitment to mCPR (n=24) or lacked UNAIDS target data (n=8). mCPR indicates the proportion of women aged 15–49 years currently using a modern method of contraception and is estimated annually by FP2020 using nationally representative surveys. We derived a measure of projected progress to FP2020 goals as: . UNAIDS provides annual model-based estimates for the target indicators using epidemiological and programmatic data.7 For countries declaring multiple commitments to FP2020, the selected mCPR corresponds with the UNAIDS indicators (2017 or 2018). Projected mCPRs for 2020 are reported by FP2020. We plot progress toward FP2020 goals by each target separately to visualise country-level progress toward each target (figure 1). UNAIDS 90-90-90 and 95-95-95 target cutoffs are represented by orange and red vertical lines, respectively. Median UNAIDS target progress is represented by a blue vertical line.
None of the 37 countries have reached both FP2020 and UNAIDS targets, and vast disparities exist across countries in their progress towards each of the goals. Proportions of people with an HIV test across countries ranges from 7% in Madagascar to 90% in Malawi (median 63%) (figure 1A). Proportions of diagnosed individuals on ART ranges from 5% in Madagascar to 90% in Rwanda (median 47%) (figure 1B). Finally, proportions of ART users with viral suppression ranges from 3% in Madagascar to 63% in Kenya (median 34%), and no countries have reached viral suppression targets (figure 1C). Only three countries reached or surpassed their FP2020 goals (Liberia at 179% of their target, Somalia at 154% and Burkina Faso at 108%). Comparatively, projected progress to FP2020 targets is only 30% in South Sudan, 34% in Niger and 36% in Burundi. Median progress toward FP2020 targets is 70%.
Overall, there was no statistical evidence of linear relationship between countries that are more successful in reaching UNAIDS and FP2020 goals. For example, while Rwanda is a leader in achieving UNAIDS targets, they rank among the bottom in progress toward FP2020 goals. While Madagascar lags behind reaching UNAIDS targets, their projected FP2020 progress is 74%. However, countries such as Pakistan and Afghanistan are consistently far from reaching both UNAIDS and FP2020 targets, while countries such as Zimbabwe and Malawi perform above the median for all targets.
This serves as a call to action, as no country has reached both their UNAIDS and FP2020 goals. Funding for HIV prevention has flatlined and is not projected to reach levels needed to achieve UNAIDS targets,1 global progress toward reducing HIV incidence is at risk of stalling,8 funding for FP is limited,2 and global population growth is unprecedented. We cannot treat our way out of the HIV epidemic,9 nor can we afford to. Innovative, high-impact strategies must address, simultaneously and cost-effectively, the synergistic issues of HIV and unwanted fertility.
Integration of HIV and FP services is one promising solution. Nations with high HIV burden also have considerable unmet need for FP, both of which are grounded in stigma, gender inequity, poverty, and access to quality healthcare. Integrating FP with HIV services is not only feasible but is effective for achieving multiple outcomes and affordable.10 The USAID-funded MEASURE Evaluation programme has published a set of key indicators countries can use to monitor progress toward HIV and FP service integration.11 Importantly, common integration challenges must be considered. For example, inadequate training of health providers (due to staff turnover, limited funds and/or limited organisational capacity to hold trainings) is a major challenge. Successful strategies will need dedicated funding and prioritisation of integrated services at the national level. Additionally, low service demand limits staff ability to gain practical experience (notably for long-acting reversible contraception (LARC) provision). ‘Hub’ training facilities where demand for services (including LARC) is high may be needed to ensure supervised, practical training opportunities along with increase community awareness of integrated services.10
Our data underscore the need to strengthen linkages between FP and HIV prevention. Despite the 2004 Glion Call to Action12 and recent guidance from the World Health Organization,13 these efforts are not taking place rapidly enough. We must scale-up FP programmes within HIV/sexually transmitted infection interventions to reduce morbidity and mortality associated with unintended pregnancy and leverage prevention of HIV; train healthcare workers to understand the sexual and reproductive health needs of people living with or at risk of HIV; and ensure human rights in provision of all contraceptive choices and options, including for people living with HIV.
Contributors KMW and RS conceived the idea for the article. ER gathered and analysed the data. KMW designed the figure. KMW wrote the manuscript, in consultation with ER and RS.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.