UNAIDS 90-90-90 Campaign to End the AIDS Epidemic in Historic Perspective

Original Investigation

Policy Points:

  • Examining the reasons for the failure of 20th-century syphilis eradication programs (difficulties in finding cases, tracing contacts, procuring consistent funding, overcoming moral framing, and rectifying social problems that create vulnerable environments) provides insight into the possibility that today’s UNAIDS campaign may not achieve its goal.
  • Disease eradication, although applicable to smallpox, may not be a realistic goal for public health officials who are designing programs to control sexually transmitted diseases (STDs) like AIDS. STDs such as AIDS have a distinctive array of socioeconomic, behavioral, biologic, and epidemiologic features that may not make these diseases amenable to eradication.

Context: Throughout its course, there has been talk of ending the AIDS epidemic. Initially aspirational in nature, this discourse has now taken the form of an explicit UNAIDS proposal to maximize the number of infected people who are tested and receive antiretroviral treatment (ART). If the milestones are met by 2020, the proposal states, an end to the AIDS pandemic could be achieved by 2030. This article uses a historical approach to explore whether this strategy to end the epidemic is feasible.

Methods: In this article, I identify historical analogues of today’s UNAIDS plan for STDs. I then examine features of today’s HIV campaign and compare them with elements of syphilis eradication campaigns that carried out widespread testing and treatment between the 1930s and 1960s.

Findings: Twentieth-century syphilis campaigns failed because they did not issue specific proposals that would enable them to achieve their eradication goal. They could not change the features of the disease that impeded their test-and-treat strategy: the moral framing (stigma deters people from testing), biologic factors (asymptomatic periods of contagiousness), and epidemiologic issues (difficulty tracking contacts occurring in private settings). Furthermore, they could not ensure sustainable funding, rectify social problems that create vulnerable environments, or issue educational messages to curb unsafe behaviors. Today’s UNAIDS campaign offers no new provisions to address those factors that led to the failure of earlier syphilis campaigns.

Conclusions: The distinctive array of socioeconomic, biologic, and epidemiologic factors that characterize STDs like syphilis also apply to AIDS and weaken the assumption that the AIDS epidemic can be ended by implementing today’s UNAIDS plan. The discourse of ending the AIDS epidemic may be a carryover from the successful elimination, before the appearance of AIDS, of smallpox—a disease that is not comparable to AIDS owing to different biologic qualities, social concerns, epidemiologic behaviors, and the possession of an effective vaccine. Future AIDS control campaigns should therefore concentrate on maximizing ART distribution and not targeting the end of the epidemic.

Keywords: syphilis, venereal, AIDS, eradication.

Read on Wiley Online Library

Volume 95, Issue 2 (pages 408–439)
DOI: 10.1111/1468-0009.12265
Published in 2017