Missing the Mark: Why Global AIDS Slogans Flop
The global AIDS response has made enormous progress in delivering lifesaving antiretroviral treatment to millions of people living with HIV worldwide.
Ironically, the expansion of global treatment availability and health equity in the Global South is littered with failed slogans. Bureaucrats often devise these catchphrases in the North to rally the rest of the world to ascribe to their vision of the end of AIDS, while ignoring complex realities on the ground. Despite this, the world has come a long way, but regrettably, AIDS is still far from over.
History will judge whether taglines like AIDS-free Generation, Getting to Zero, or 90–90–90, among many others, helped or distracted the world from achieving Universal Access to HIV treatment. Clearly, more slogans have been created over the past 20 years than targets have been achieved.
Popular slogans often launch to much fanfare from Geneva or New York. But as deadlines are set and milestones remain unfulfilled, goalposts are quietly moved into the future. The unmet UN Millennium Goal 6 — to achieve Universal Access to HIV treatment by 2010 — is one such example. According to UNAIDS numbers, 10 million people are still not getting treatment, and the real-world number is likely higher.
Over roughly 20 years, nascent treatment programs serving a few hundred patients at great expense have evolved into enormous national programs like South Africa’s, which currently provides treatment to an impressive 5.5 million patients.
In the annals of public health, the scale-up of HIV treatment in the developing world has become one of the most successful population-level interventions, which has borne enormous societal and economic benefits in hard-hit regions of Africa, Asia, Latin America, and beyond. So why the poor track record of global AIDS slogans?
Over the past two decades, the most buzzworthy slogans have included: 3 by 5, Getting to Zero, AIDS-free Generation, 90–90–90, and its latest iteration, 95–95–95. All have failed in one way or another to achieve their stated goals and share an apparent commonality — a decidedly top-down approach to goal-setting and success metrics. They fail to consider the needs and capacities of organizations, public health institutions, and communities upon whom the responsibility for implementation ultimately rests.
In practical terms, these are everyday problems, such as: Did anyone budget for fuel to drive from national drug stores to a rural clinic to deliver ARVs? Is the vehicle even operational? Countless stepping stones determine whether a person living with HIV will get their drugs on time. Some clients live in such remote areas, the teams and consultants cooking up the themes and slogans can’t even imagine the challenges involved in executing these plans on the ground.
The WHO introduced 3 by 5 in 2003 to provide treatment to 3 million people by 2005. The campaign fell 1 million short because it failed to account for funding availability and donors’ willingness to contribute when treatment was still prohibitively expensive. Some global health officials quite openly bandied about the pejorative “treatment mortgage” term while sulking about the high cost of saving lives in the developing world.
UNAIDS introduced Getting to Zero in 2011 to drive the global AIDS response toward zero new HIV infections, zero discrimination, and zero AIDS-related deaths by 2015. It should have been apparent from the outset that, like ending world hunger or ushering in global peace, this goal was unattainable within the assigned timeframe.
Some critics might say that these goals were always intended to be aspirational, to encourage countries to strive toward improvement, even if the timeframes and metrics were unattainable. But the initial enthusiasm, buoyed by flashy marketing and bold proclamations, quickly gives way to apathy and the realization that such an undertaking will be, in fact, difficult, expensive, and time-consuming.
In 2011, then-Secretary of State Hillary Clinton unveiled the AIDS-free Generation, a US-led initiative to create a “generation in which all children are born free of HIV.” The aspirations were sincere and well-intentioned; at the time, children made up a staggering 330,000 new annual HIV infections, and only 28% of children living with HIV had access to treatment.
The new tagline neglected to explain what would happen to the AIDS-free Generation once it grew up and started having sex in a world with a stubbornly high rate of 1.5 million new infections per year and far from universal access to treatment. Predictably, as reality set in and Secretary Clinton moved on from her post, the AIDS-free Generation campaign quietly withered away.
Today, tragically, only 52% of children under 14 receive treatment, and 160,000 children acquire HIV annually. While tremendous progress has been made in protecting children from HIV, it is evident just how difficult it is to achieve results at scale globally, even when the group is as politically uncontroversial as children. There is near universal consensus that they must be a priority for the global AIDS response.
After missing the targets of the 2011 UN Political Declaration on AIDS by the 2015 deadline, UNAIDS decided that launching even more ambitious targets in 2016, dubbed 90–90–90, was preferable to taking a long, hard look at what had gone wrong with the prior goals. 90–90–90 targets sought to ensure that 90% of people worldwide were aware of their HIV status, 90% of those people were on treatment, and 90% of those on treatment were virally suppressed by 2020.
Lured by Geneva’s latest and greatest AIDS response pitch, many countries rushed to endorse 90–90–90, even though, in mathematical terms, percentages of percentages make little sense as an epidemiological metric. The second 90 is necessarily dependent on the value of the first 90, and the third 90 is, in turn, dependent on the second. So, if expressed in more comprehensible terms as a percentage of all people living with HIV, 90–90–90 is really 90–81–73.
Setting aside the adage that 80% of all statistics are made up, one can’t help but wonder why UNAIDS thought this convoluted formula would prove successful when verifiable data is difficult to obtain. This is particularly true for countries such as China, India, Russia, and others, which do not report relevant AIDS statistics to UNAIDS. Access to viral load surveillance also remains woefully inadequate in many parts of the world, making it difficult to gauge the attainment of the last 90.
As 2020 approached and it became apparent that most countries would not meet the 90–90–90 targets, UNAIDS raised the bar again. References to 95–95–95 began appearing more frequently at various AIDS conferences and in reports. Two years after the 90–90–90 targets deadline passed, only 11 developing countries have met the first 90, and only nine reached the second and third 90. Like 90–90–90, 95–95–95 seeks to achieve even higher percentages in HIV status awareness, treatment coverage, and viral suppression by 2030.
What lessons can we draw from a string of high-profile slogans that have sought but failed to decisively put the world on a path to ending AIDS? To achieve complex goals on a global scale, aspiration and ambition must be rooted in understanding the mundane realities that create inevitable drag at every step of the implementation ladder.
There are too many implementation roadblocks to enumerate here, but obstacles include: Resistance to change among bureaucrats, poor infrastructure, corruption, apathy, administrative red tape, a lack of human resources, insufficient funding, supply shortages, natural disasters, bad weather, armed conflicts, and an incalculable set of other factors that implementers will encounter and must address to achieve the goals.
Flashy slogans and marketing campaigns are good at selling an idea, which is an important first step in creating momentum for any public health campaign. But from inception, planners must consider whether the idea is implementable and not just aspirational. They must shun the top-down approach and involve communities from the beginning to inform their planning process instead of imposing a ready-made plan with unrealizable goals upon them.
There is no shame in taking a more realistic and somewhat less ambitious approach to goal-setting to set a baseline and then scale up from there. Far too many policy proposals in the global public health space fail because they devote most of the attention to what should be done without doing the hard work of offering ideas on how it should be done, including by whom and from where the money will come. Predictably, without these critical elements, most proposals get repeatedly rehashed, as we have seen with the various AIDS slogans, which fall far short of the goals.
The world has made tremendous strides in ending AIDS. Millions of people are alive today because of the tireless work of advocates, medical providers, decision-makers, and everyday people who care deeply for the pain and suffering this scourge has exacted upon the world. Governments and donors have generously committed billions of dollars to our collective effort to defeat AIDS, making lifesaving treatment more available than ever.
We can be rightfully proud of these accomplishments, but we must remain clear-eyed about how much work remains. We’re here not because of, but despite, a succession of failed catchphrases from the Global North.
At least 10 million people and nearly half of all children living with HIV are not on treatment. Annually, over 1.5 million people are newly infected with HIV, and a staggering 650,000 die of AIDS-related causes.
We cannot wish these tragic statistics away with lofty slogans. We need realistic plans based on accurate data to keep moving forward because AIDS is not over yet.
