As the global health sector strategies for HIV, viral hepatitis and sexually transmitted infections (STIs) 2016–2021 near the end of their implementation period, this report provides accountability for the main achievements and gaps to date and highlights actions to take forward towards eliminating these diseases as public health threats by 2030. The report publishes new estimates for viral hepatitis with a threefold improvement in the completeness of reporting. It also publishes new estimates for the main STIs, providing a more accurate baseline to guide priorities in the forthcoming decade.
1. HIV, viral hepatitis and sexually transmitted infections (STIs) are major public health threats worldwide. They account for more than 2.3 million people dying per year, which represents 14% of all deaths from infectious and parasitic diseases, digestive diseases and cancer. They also result in more than 1 million people newly infected each day and 1.2 million people developing cancer each year. If we lose focus now, the progress achieved so far will plateau with the risk of resurgence. Time is running short. To reach the 2030 targets, we need to accelerate progress, address specific gaps in implementation, and bring innovation to scale across the three diseases.
2. The epidemics and responses are at different stages. This strategy implementation period has seen tremendous progress, including achievement of the Sustainable Development Goals target to reduce the incidence of hepatitis B virus.
The global target of the Sustainable Development Goals and the global health sector strategy to reduce the incidence of hepatitis B has been met, as measured by the prevalence of hepatitis B surface antigen to less than 1% by 2020 among children younger than five years. Supported by childhood immunization and prevention, the reduction in the incidence of hepatitis B infection is one of the few Sustainable Development Goals health targets that is on track to be achieved. Sustained and regionally focused scale-up of the birth dose of hepatitis B vaccine and of treatment of the mother to prevent further hepatitis B transmission are required to achieve impact by 2030. In addition, there are massive gaps in hepatitis B diagnosis and treatment, including among the populations most severely affected and at higher risk.
New data show that 9.4 million people are receiving treatment to cure chronic hepatitis C virus infection, an almost 10-fold increase from the baseline of 1 million at the end of 2015. This scale-up of treatment has been sufficient to reverse the trend of increasing mortality from hepatitis C for the first time. In Egypt, universal access to treatment has resulted in declining mortality and incidence. However, improved data show that the number of people dying from hepatitis B and C worldwide still remains daunting at 1.1 million per year.
Two thirds of all living with HIV and 85% of pregnant women people living with HIV are receiving antiretroviral therapy, supporting a substantial decline in mortality related to HIV and AIDS. Treatment coverage in sub-Saharan Africa is uniquely higher than global coverage because of sustained partner and country financing.
The global response to STIs is gathering momentum after years of neglect. More countries have national strategic plans and updated guidelines to address STIs, and coverage of interventions such as syphilis screening of pregnant women in antenatal care and human papillomavirus vaccination, are increasing.
3. Yet many gaps remain. Most global 2020 targets have been missed, and accelerated action is needed to reach the Sustainable Development Goals in the next decade.
With an estimated 1.7 million people acquiring HIV in 2019, the number has fallen by 23% to the lowest since 2010. However, this remains far below the global target of less than 500 000 people newly infected by 2020. Ending the global HIV epidemic will require stronger commitment to address the inequalities, stigma and discrimination that continue to drive the epidemic and prevent many people from accessing the services they need. This is the focus of the United Nations High Level meeting on HIV in June 2021.
New data show that hepatitis B and C cause 1.1 million deaths and 3.0 million new infections per year. Only 10% of people who have chronic infection with hepatitis B virus are diagnosed, and 22% of which receive treatment. For hepatitis C infection, 21% of people are diagnosed and 62% of those diagnosed receive treatment. Price reductions have made hepatitis C treatment an affordable high-impact intervention, but coverage needs to increase nearly sixfold in the next decade to reach the 2030 targets for elimination.
New data on STIs show 374 million new cases per year. Other than slow declines in congenital syphilis, the incidence of most other STIs is plateauing despite ambitious targets. There is a major need to boost synergistic efforts to prevent and treat STIs, including HIV, among adolescent girls and young women and key populations. Global commitment, funding and an integrated public health approach are essential to bend the curve for these infections.
Although an increasing number of countries are organizing strategies and planning frameworks across HIV, viral hepatitis and STIs, most are missing important opportunities to integrate and link services and responses to provide people-centred services that also leverage efficiency at the primary health care and health system levels.
4. Stigma and inequalities facing the populations most vulnerable and at risk have to be addressed across all diseases to reach the Sustainable Development Goals. Key populations (including gay men and other men who have sex with men, people who inject drugs, sex workers, transgender people and prisoners) and their partners account for 62% of the people acquiring HIV. Viral hepatitis disproportionately affects those who are economically disadvantaged, displaced people and migrants and rural populations. Further, injecting drug use is a major contributor to the number of people newly infected with hepatitis C globally. Many of these population groups overlap with groups recognized as especially vulnerable to STIs. Access to prevention, harm reduction and health-care services for these populations is largely insufficient, and persistent stigma, inequalities, criminalization and other sociostructural barriers are preventing response efforts from reaching the people who need them most.
5. New WHO data show that HIV testing and prevention, as well as hepatitis B and C services, are among the most frequently disrupted services caused by COVID-19. HIV treatment, as well as STI services have also experienced disruption. The COVID-19 pandemic has forced all three disease programmes to innovate to deliver and maintain essential health services safely within community-led, community-based and differentiated models of care. Making full use of such people-centred and community-led innovations can further enable countries to fully leverage the capacity of health and community systems and respond to the needs of the most vulnerable people in an equitable and sustainable manner.
6. Regional differentiation in implementing the strategies has amplified progress. In the next stages, further granular and differentiated approaches should be developed by region, epidemic status and population to ensure that targets are reached in all settings and that no one is left behind. Chapter 4 of this report present dedicated regional messages.
7. Better data, greater focus on solutions to address gaps in prevention, treatment and delivery and renewed advocacy and demand creation will be needed to reach the 2030 Sustainable Development Goal targets. This report identifies 10 cross-cutting priority areas that must be strengthened across HIV, viral hepatitis and STIs to accelerate impact by 2030. They cover actions updated since 2018 based on successes and gaps for each of the five strategic directions. They also include new actions that align with the WHO Triple Billion targets to address social and structural determinants of these infections, promote joint management across diseases and draws on lessons from the COVID-19 pandemic to strengthen community engagement and service delivery.
Leverage common people-centred and disaggregated data platforms, including strengthening digital health data and building capacity to analyse and use data for improving programmes.
Scale up point-of-care diagnostics, self-testing and self-collection to reach everyone who is vulnerable, at higher risk and hard to reach, including key populations, infants and children and men who are not engaged in care; continue to simplify testing and treatment and improve links so that those already diagnosed can receive care rapidly.
Achieve triple elimination of mother-to-child transmission of HIV, hepatitis B virus and syphilis and explore the expansion of the elimination focus to eliminating infection among children for the next phase of the global health sector strategies.
Improve access to drugs and diagnostics by further reducing prices, including integrating costs in national health and domestic financing.
Innovate to maximize the use of differentiated and people-centred service delivery options across HIV, viral hepatitis and STIs to tailor and deliver services according to people’s needs and preferences and train and empower more health-care workers to provide treatment where the availability of specialists is limited.
Innovate to strengthen community engagement, community-based service delivery and community-led monitoring in the context of primary health care.
Protect against the threat of antimicrobial resistance and other risks, including disruption of services because of COVID-19 and other global health emergencies.
Strengthen joint responses for HIV, viral hepatitis and STIs with TB and other key comorbidities by further aligning programme management, service delivery and monitoring to support universal health coverage.
Integrate sexual and reproductive health and rights into existing programmes, raise the profile of STIs and reinvigorate the emphasis on primary prevention.
Address social and structural determinants that impact vulnerability and access to services and tackle the stigma, discrimination, criminalization and inequalities that undermine the response.
The lessons from the COVID-19 response provide a historical opportunity to foster greater solidarity and innovation in the response to communicable diseases over the next decade. Disease-specific responses and the goals of universal health coverage and global health security are mutually reinforcing and need to be advanced together. By taking decisive action now, we can prevent 2 million people from losing their lives each year and emerge stronger from the challenge of COVID-19 to reach the Sustainable Development Goals by 2030.
The HIV responses of the health sector must be strongly aligned with the Global AIDS Strategy 2021–2026, developed by UNAIDS with support from WHO. It also provides clear opportunities for synergy for the responses focused on viral hepatitis and STIs. The focus of the Global AIDS Strategy on addressing inequalities to end AIDS as a public health threat provides an important framework for all communicable diseases alongside the Strategy’s three interlinked priorities: maximizing equitable and equal access to HIV services and solutions; breaking down barriers to achieving HIV outcomes; and fully resourcing and sustaining efficient HIV responses and integrating them into systems for health, social protection, humanitarian settings and pandemic responses.
Regional differentiation, progress and gaps
The African Region leads the way in HIV testing and treatment and has the opportunity over the next decade to extend this to addressing hepatitis B and C virus and to syphilis transmission from mother to child in order to dramatically reduce the high burden of communicable diseases in the Region.
The Region of the Americas has led approaches to advance the triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis and to deliver services along the cascade for key populations. Over the next decade, they need to systematically fill gaps in the HIV, viral hepatitis and STI service cascades to leave no one behind.
The South-East Asia Region has some of the world’s leading programmes for key populations and community-based responses. Three countries in the Region have been validated for EMTCT of HIV and syphilis and four countries have been certified to have achieved hepatitis B control through immunization. Progress in the response to HIV and STIs has nevertheless plateaued. Financing for HIV, viral hepatitis and STIs needs to be sustained and expanded towards universal health coverage.
In the European Region, gaps in testing and treatment for HIV, viral hepatitis and STIs need to be filled rapidly. There have been major advances in hepatitis programme planning, but the estimated number of people acquiring HIV has been increasing.
The Eastern Mediterranean Region leads the way in scaling up testing and treatment for hepatitis C virus, accounting for 37% of the global total number diagnosed and 52% of the global number of people treated in 2019. Some countries have an opportunity to move towards elimination. The impact of these population-based approaches needs to be expanded and transferred to ensure that nobody is left behind in access to hepatitis B, STIs and HIV services.
The Western Pacific Region has made major progress in expanding access to services for hepatitis B and C virus, largely because of domestic funding and substantial drug price reductions. There is an opportunity to include viral hepatitis, HIV and STIs in national health financing.