- UNAIDS and a broad range of partners have collaborated to establish a new set of HIV prevention targets to be achieved by 2025 as an intermediate step towards the sustainable development target for 2030.
- The number of new HIV infections in the world continues to decline, in part due to the extraordinary expansion of effective HIV treatment. However, the decline is geographically heterogeneous, with some regions reporting a rise in incidence. The incidence target that was agreed for 2020 has been missed.
- A range of exciting new HIV prevention technologies have become available or are in the pipeline but will only have an impact if they are accessible and affordable and delivered within systems that take full account of the social and political context in which most infections occur. Most new infections occur in populations that are marginalised or discriminated against due to structural, legal, and cultural barriers.
- The new targets imply a new approach to HIV prevention that emphasises appropriate, person-centred, prioritised, effective, combination HIV prevention within a framework that reduces existing barriers to services and acknowledges heterogeneity, autonomy, and choice.
- These targets have consequences for people working in HIV programmes both for delivery and for monitoring and evaluation, for health planners setting local and national priorities, and for funders both domestic and global. Most importantly, they have consequences for people who are at risk of HIV exposure and infection.
- Achieving these targets will have a huge impact on the future of the HIV epidemic and put us back on track towards ending AIDS as a public health threat by 2030.
The world (through the United Nations General Assembly) has committed to ending AIDS as a public health threat by 2030. However, progress has not been sufficient and in 2020 there were over 1.5 million new HIV infections, compared to the target of 500,000 that had been adopted. The United Nations Joint Programme on AIDS therefore convened a broad range of partners to develop new targets for 2025 that will put us back on track to meet the 2030 goal. These targets are at the heart of the global HIV strategy for 2021 to 2025 and include targets to maximise HIV services, to minimise societal barriers, and to integrate HIV services within the wider health system.
This paper forms part of a larger PLoS Collection that describes the overall 2025 Targets process and lays out the exciting developments and prospects for HIV prevention and explains the rationale and the details of the new prevention targets.
The specific prevention targets signal a shift in the global HIV prevention strategy to maximise agency, equity, and efficiency. They aim to achieve a world where 95% of people who are exposed to HIV use “Appropriate, Person-centred, Prioritised, Effective, Combination Prevention”.
Citation: Godfrey-Faussett P, Frescura L, Abdool Karim Q, Clayton M, Ghys PD, (on behalf of the 2025 prevention targets working group) (2022) HIV prevention for the next decade: Appropriate, person-centred, prioritised, effective, combination prevention. PLoS Med 19(9): e1004102. https://doi.org/10.1371/journal.pmed.1004102
Published: September 26, 2022
Copyright: © 2022 Godfrey-Faussett et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Course correction needed to reach the 2030 target for the sustainable development goal for HIV
A major course correction is needed to maximise the chance of reaching the targets already established for 2030 in the Sustainable Development Goals (SDGs), which include “Ending the epidemic of AIDS by 2030” . UNAIDS and partners from a diverse range of stakeholders have worked to elaborate a new set of guiding principles and to establish a new set of intermediate targets for 2025 taking into account recent advances in biomedical, social, and epidemiological sciences . These deliberations and the targets that emerged from them are described in more detail in several papers in this Collection and are central to the current UNAIDS Global strategy .
This policy forum lays out the overarching prevention target, the principles for guiding prevention programmes, and highlights the ways in which these principles are incorporated into the mathematical models of the potential impact of implementing the 2025 global targets for the HIV response.
Accomplishments of HIV prevention to date and remaining challenges
Milestones for 2020 were missed
Global progress in controlling the HIV epidemic has been too slow. The target for 2020 included in the SDGs of 500,000 new infections has been missed . There were 1.5 million new HIV infections in 2020 . Although there is good evidence that people on effective treatment do not transmit HIV [6,7], scaling up treatment has not been sufficient to reduce the number of new HIV infections to the levels called for in successive political declarations. Primary prevention of new adult infections remains critical.
HIV prevention has changed
The opportunities for more effective prevention of new HIV infections have expanded over the past decade. Oral pre-exposure prophylaxis (PrEP) has been demonstrated to be highly efficacious and often effective in public health practice [8–10]. Two monthly injections of a long-acting formulation of cabotegravir have been demonstrated in clinical trials to be more effective than oral PrEP [11,12]. Intra-vaginal silicone rings delivering dapivirine topically have also been shown to be moderately effective [13,14] and are included in the WHO HIV prevention guidelines as an additional prevention technology.
While new technologies are needed, their impact will be limited if real challenges in delivery such as barriers to access to services, cost, supply chain and logistics, monitoring, and evaluation are not addressed.
Developments in phylogenetics, mathematical modelling, and enhanced epidemiological surveillance are providing insights into the dynamics of transmission and acquisition of HIV infection related to age and gender ; increasing the geographic resolution ; and predicting current and future contributions to new infections of people with acute and early infection, those PLHIV who have not been previously diagnosed, those PLHIV who are not on treatment, those PLHIV whose virus is resistant to treatment, and those PLHIV who are no longer taking effective treatment .
New HIV targets adopted for 2025
The UNAIDS 2020 “90-90-90” target has been a driving force behind the scale-up of effective HIV treatment, thus reducing onward transmission of HIV . The implementation of HIV treatment services needs to address all the complexity of the diversity of the 37.7 million people estimated to be living with HIV in 2020 . However, the success of the 90-90-90 treatment target arises both from the immediacy of saving lives by treating people living with HIV but also from the conceptual simplicity that every one of the 37.7 million people living with HIV needs to be diagnosed and linked to highly effective treatment. In contrast, HIV prevention is much more complex and the billions of people who are sexually active, use intravenous drugs or are born to mothers living with HIV require a mosaic of interventions and approaches . This leads to a segmentation of the population into multiple overlapping groups according to age, gender, behaviour, sexual orientation and gender identity, geography, and social circumstance. Given the increasing number of prevention technologies and options alongside the many intersections with societal and legal barriers, the number of potential targets expands dramatically, and it is not possible to define a simple target with the specificity of 90-90-90.
The 2025 Targets approach, shown diagrammatically in Fig 1, aims to reduce the separation between treatment and prevention and therefore has a set of 6 overarching targets for HIV services that are all set to an ambitious 95% [2,3].
The new target and approaches for HIV prevention
95% of people at risk of HIV infection use appropriate, person-centred, prioritised, and effective, combination prevention options
The new overarching 95% prevention target is framed to maximise equity and impact. Sufficient access to prevention technologies and services is currently often inadequate even for established modalities such as condom provision or circumcision services  and does not meet the demands of populations to be served . Increasing demand for services is most likely to arise from community-led approaches to planning, delivery, and monitoring in partnership with traditional health service providers .
The overarching target for prevention therefore refers to a proportion of all people at any risk of HIV being reached by effective, evidence-based services, rather than by utilisation of a specific tool.
For large populations in much of the world, the background rates of HIV and the behavioural choices of individuals means that the risk of acquiring HIV is minimal. For such people, the target can be met simply by ensuring a comprehensive understanding of sexual and reproductive health. However, as risks of HIV acquisition increase, a wider range of more HIV-specific tools will be needed and human and financial resources will need to be increased to meet the target.
However, overall resources for HIV have not increased in past years . Increasing the total budget needs to be matched by ensuring fairness through innovative approaches to reduce costs of commodities and their delivery and through appropriate cost sharing internationally and locally . Many sexual and reproductive health services and approaches that reduce HIV acquisition have important wider benefits. For example, needle and syringe programmes are effective at preventing HIV, but also prevent hepatitis C infections, and reduce the risks of bacterial abscesses and endocarditis. For another example, provision of school-based comprehensive sexuality education in regions with low HIV prevalence will lead to many substantive benefits for both girls and boys and will also reduce the chances of HIV acquisition still further. Costs of such services need to be appropriately attributed in developing economic arguments for HIV prevention.
Choice of HIV prevention methods
The range of prevention options means that individuals now have more ability to exercise their autonomy and agency. Individuals need an accurate perception of their risk of exposure as well as agency to adopt the best available solutions for themselves and their partners.
The wide range of options for how to avoid infection with HIV includes behavioural as well as biomedical approaches. Choosing partners, including by HIV status and viral suppression status, choosing how and when sex happens, choosing condoms and lube, choosing PrEP, choosing to access sexual and reproductive health services (including antenatal care for pregnant women), choosing clean needles and syringes for injection, and choosing PEP. Individuals’ choices will vary over time and with different partners. It is appropriate that some approaches will be used on some occasions and not others.
For example, the gay men’s health surveys in Australia demonstrate increasing levels of overall protection, while rates of condom use decline and uptake of other prevention options (notably PrEP) increase .
HIV prevention that is appropriate to individuals’ circumstances
Available prevention approaches should be appropriate to each individual’s circumstances and vulnerability to HIV. Specifics prevention approaches are developed with different populations in mind. Examples include services for prevention of mother to child transmission, harm reduction approaches for people who inject drugs, and topical PrEP products adapted for rectal or vaginal sex. Appropriate advertising, packaging, and presentation of products for different population segments using human-centred design and other techniques are being learned from private sector marketing methods .
An important element of appropriateness is the timing and frequency of use. Event-driven PrEP, where 2 pills are taken before sex and 2 further pills taken 24 and 48 hours later has been shown to be highly effective at preventing HIV acquisition through anal sex . It is therefore particularly appropriate for those men who have sex with men less frequently and that is not protected either by a condom or by accurate knowledge of a partner’s serostatus or viral load status. Similar considerations may also be important for PrEP for vaginal sex. Many people who start oral PrEP do not remain on it after several months . In some, the reason for stopping PrEP may be related to a reduction in risk of HIV acquisition for behavioural or partnership-related reasons . Some people can predict periods when they will be at more exposed to HIV and so choose to start and subsequently stop PrEP . Such individuals may or may not want a product that lasts many months at a time, such as an implant or a long-acting injection. Periods of exposure also relate to the cost of the approach. For those who know that they remain exposed, a model of widely available but intermittent PrEP usage might expand the cost-efficacy envelope considerably .
Prioritised approaches to HIV prevention
As new tools become available, it will be important to ensure that those who need them most are effectively using them. Low coverage of HIV services among key populations often stems from societal and legal barriers that create environments where people living with HIV and people who are exposed to HIV infection may not feel safe to utilise health services. In settings where there is less homophobia and men who have sex with men can access sexual health services including HIV and sexually transmitted infection testing and treatment and PrEP, the number of new infections has fallen substantially [31,32]. Yet, in those areas of the US with the highest incidence of HIV among MSM, the uptake of PrEP has been lower .
One of the most striking features of the epidemiology of HIV is the heterogeneous distribution across geographies . More sophisticated mathematical models are providing better estimates of incidence at subnational levels and highlighting the huge variation in incidence within countries and across different ages and genders [16,35]. The wide range of incidence in different districts in countries in east, central, and southern Africa is demonstrated in the S1 Text.
A consequence of this skewed distribution of HIV incidence, is that the costs of commodities needed to prevent each new HIV infection with any biomedical approach rises steeply if prevention is not prioritised towards those most likely to benefit . A major challenge remains how to achieve these cost efficiencies. In settings where background HIV incidence is already high, simple self-selection may be sufficient , although the evidence is mixed , but in settings where the burden of HIV is lower, some preliminary focusing of efforts is likely to be needed. Geography, age, and gender allow a crude stratification, which can be enhanced, e.g., by self-reports of number of sexual partners or history of sexually transmitted infections. Such screening approaches may be counter-productive if not delivered in a socially acceptable way. Nonetheless, even with inevitable under-reporting, data from recent surveys do show much higher measured HIV incidence in those who do report multiple partners or recent sexually transmitted infections .
HIV acquisition within key populations also varies greatly depending on individual behaviours and the spatial variation in epidemiology. Again, self-selection may be sufficient, but is likely to miss many who might benefit, and conversely to provide services to some who probably have a lower chance of acquiring infection . For example, sex workers in urban areas in eastern and southern Africa are at higher risk than those working in low prevalence areas, including those working in rural areas . For another example, the incidence of HIV among men having sex with men who attended sexual health services in Barcelona more than once (which allowed measurement of HIV incidence) showed large variation among those who reported different behaviours .
To maximise the utility and impact of new prevention technologies, their costs will need to fall substantially in low- and middle-income countries. If such technologies (including long-acting ARV products, topical rings, and eventually broadly neutralising antibody combinations and vaccines) are to be offered to people whose chance of acquiring HIV is less than 1% per year (which is already a considerable risk, see S1 Text), then more than 100 people will have to receive the product for a year to prevent each new HIV infection directly. The cost of commodities for such approaches may therefore be very large to have an important impact on the burden of new infections in “generalised” epidemics . For vaccines, the durability of protection will be a key economic consideration.
In many key populations, incidence rates are higher, and the new technologies may therefore have a greater impact at more affordable costs. More intermittent use of PrEP, focused on shorter periods of known or anticipated risk, would improve efficiency but will be harder to implement for long-acting PrEP options . Post exposure prophylaxis for HIV could be more widely used, in an approach analogous to emergency contraception, for those people who are not regularly exposed to HIV. This could also cut the costs of ARV-based HIV prevention for some populations. New single dose post-exposure prophylaxis could therefore be a significant advance for many people .
Prioritisation does not preclude choice and appropriateness of HIV prevention nor is it a rigid process, but rather a means to allow programme staff and policy makers to maximise the equity, utility, and impact of prevention services. Furthermore, as HIV incidence continues to decline, the importance of prioritisation will increase .
The importance of centering prevention on the person includes the elements of choice and appropriateness above. However, individuals are often not the architect of their own destiny, and those left behind are often from the most marginalised and discriminated communities.
Repeated social science studies demonstrate that for many people at risk of HIV, particularly young people and those from marginalised or criminalised key populations, existing health services that purport to offer HIV treatment and prevention services are not places that welcome the very people who need those services most . Person-centred prevention links to the broader discussions of societal and legal barriers  and ensuring that services are community led  as well as improving the delivery of services.
Combination HIV prevention
The 2025 targets on HIV prevention allow for a combination of effective prevention options for people at risk of HIV. The framework acknowledges that a different combination of interventions may be needed for a particular individual sex or injection act. Combination prevention emphasises the need for behavioural and structural intervention alongside the biomedical approaches (which themselves require behavioural intervention to maximise adherence and thus efficacy).
Combined services also include the provision of integrated service delivery, with the goal of providing tailored, co-located, or well-coordinated services that are optimally convenient, seamless, and easy to navigate .
Multipurpose technologies include methods that are effective not only in HIV prevention but also serve other key purposes, such as contraception or preventing other sexually transmitted infections . As discussed above, the economic evaluation and costing of such methods needs to apportion cost and benefits appropriately.
Specific HIV prevention targets
In order to model global estimates or the impact and resource needs for the HIV response over the next years, specific prevention targets have been proposed [3,50] and are described more fully in the S1 Text. However, these should be seen as global targets for what needs to be reached if we are to achieve the goal for ending AIDS by 2030.
The process to translate these targets into impact is described elsewhere and involves interpolation and imputation for missing data . The specific targets aim to promote the principles encapsulated in the wording of the overarching target. They should allow national planners to define nationally appropriate targets for their own priorities and populations.
Policy, implementation, and next steps
The new targets adopted for the global HIV response are ambitious and innovative. They outline principles and priorities for national programmes to change the course of their HIV programme to maximise the chances of reaching the global sustainable development goals by 2030.
These targets have major implications for programmes. The overarching target moves away from linear cascades for specific tools, focusing instead on the proportion of people with access and who are able to choose to use appropriate prevention methods. By setting ambitious targets for all HIV services, the divisions between treatment and prevention are reduced; the major contribution of viral load suppression to incidence reduction is acknowledged; and primary prevention is given more visibility and priority. Prioritisation of prevention requires greater use of subnational and local data sources and models and implies better estimation of the size of different key populations as well as stronger monitoring and evaluation of delivery of interventions. Enhanced surveillance systems will also detect new localised outbreaks of HIV in real time allowing appropriate streamlined course corrections to be made.
The HIV service targets, including these prevention principles and targets, are an integral part of the whole package of targets within the global HIV strategy. Increasingly, HIV services will need to be integrated within the larger health sector and within the context of universal health coverage. These prevention efforts will not succeed unless there are strong links with human rights and clear intersections with efforts to reduce structural and societal barriers .
The new framing of prevention emphasising inequalities, agency, and local data for decision-making will prevent new infections, reduce deaths, and stigma and discrimination and as a core element of the new Global HIV Strategy can restore the trajectory to end AIDS as a public health threat by 2030. Furthermore, the focus on person-centred approaches has already reinforced resilience in the face of the Coronavirus Disease 2019 (COVID-19) pandemic .
The prevention principles and targets offer an agenda for action, the next challenge is to ensure that sufficient resources, human, financial, and advocacy are committed to deliver for the future.
We acknowledge the wide-ranging inputs and discussions during the technical meetings of the UNAIDS 2025 prevention targets Working Group, including: Aher, Abhina (AIDS Alliance India), Anoma, Camille Kacou (Espace Confiance (Côte d’Ivoire), Baggaley, Rachel (WHO HIV Department), Benzaken, Adèle (Independent expert), Bhattacharjee, Parinita (University of Manitoba), Caceres, Carlos (Universidad Peruana Cayetano Heredia), Castellanos, Erika (Global Action for Trans Equality (GATE)), Cassolato, Matteo (Frontline AIDS), Chang, Judy (International Network of People who Use Drugs (INPUD), Chicuecue, Noela (Ministry of Health, Mozambique), Ciupagea, Monica (HIV/AIDS Section, UNODC), Dalal, Shona (WHO HIV Department), Deryabina, Anna (ICAP, Central Asia), El-Sadr, Wafaa (Columbia University), Garnett, Geoff (Bill and Melinda Gates Foundation), Grulich, Andrew (The Kirby Institute, UNSW), Hayes, Richard (LSHTM), Johnson, Saul (Genesis Analytics), Jones, Chris (Mann Global Health), Mathenge, John (Health Options for Young Men on HIV/AIDS/STI), McCartney, Daniel (IPPF). Morgan-Thomas, Ruth (NSWP), Pulerwitz, Julie (Population Council), Radix, Asa (Callen-Lorde Community Health Center, New York University), Roshchupkin, Gennady (Eurasian Coalition on Male Health (ECOM)), Salah, Ehab (HIV/AIDS Section, UNODC), Sladden, Tim (UNFPA), Stoner, Marie (Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina), Stover, John (Avenir Health), Taslim, Aditia (Rumah Cemara), Vickerman, Peter (Bristol Medical School: Population Health Sciences), Wanjiku Njenga, Lucy (Positive Young Women Voices), Warren, Mitchell (AVAC) Benedikt, Clemens (UNAIDS), Coleman, Rosalind (UNAIDS), Fontaine, Chris (UNAIDS), Izazola, Jose Antonio (UNAIDS), Lamontagne, Erik (UNAIDS), Semini, Iris (UNAIDS), Sprague, Laurel (UNAIDS), Wagan, Hege (UNAIDS).
- 1. United Nations, Department of Economic and Social Affairs. Ensure healthy lives and promote well-being for all at all ages. [cited 2022 Jul 17] Available from: https://sdgs.un.org/goals/goal3.
- 2. De Lay PR, Benzaken A, Karim QA, Aliyu S, Amole C, Ayala G, et al. Ending AIDS as a public health threat by 2030: Time to reset targets for 2025. PLoS Med. 2021;18(6):e1003649. pmid:34101728; PMCID: PMC8219148.
- 3. UNAIDS. Global AIDS Strategy 2021–2026. [cited 2022 Jul 17] Available from: https://www.unaids.org/en/resources/documents/2021/2021-2026-global-AIDS-strategy.
- 4. UNAIDS. 2014 Fast Track Targets. [cited 2022 Jul 17] Available from: https://www.unaids.org/sites/default/files/media_asset/JC2686_WAD2014report_en.pdf.
- 5. UNAIDS. Global AIDS Update 2021. [cited 2022 Jul 17] Available from: https://www.unaids.org/sites/default/files/media_asset/2021-global-aids-update_en.pdf.
- 6. Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, Degen O, et al. PARTNER Study Group. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. Lancet. 2019;393(10189):2428–2438. Epub 2019 May 2 pmid:31056293.
- 7. Bavinton BR, Pinto AN, Phanuphak N, Grinsztejn B, Prestage GP, Zablotska-Manos IB, et al. Opposites Attract Study Group. Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study. Lancet HIV. 2018;5(8):e438–e447. Epub 2018 Jul 17. Erratum in: Lancet HIV. 2018 Oct;5(10):e545. pmid:30025681.
- 8. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. iPrEx Study Team. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587–99. Epub 2010 Nov 23. pmid:21091279; PMCID: PMC3079639.
- 9. Molina JM, Capitant C, Spire B, Pialoux G, Cotte L, Charreau I, et al. ANRS IPERGAY Study Group. On-Demand Preexposure Prophylaxis in Men at High Risk for HIV-1 Infection. N Engl J Med. 2015;373(23):2237–2246. Epub 2015 Dec 1 pmid:26624850.
- 10. Ryan KE, Asselin J, Fairley CK, Armishaw J, Lal L, Nguyen L, et al. PrEPX Study team. Trends in Human Immunodeficiency Virus and Sexually Transmitted Infection Testing Among Gay, Bisexual, and Other Men Who Have Sex With Men After Rapid Scale-up of Preexposure Prophylaxis in Victoria, Australia. Sex Transm Dis. 2020;47(8):516–524. pmid:32658175; PMCID: PMC7357541.
- 11. Landovitz RJ, Donnell D, Clement ME, Hanscom B, Cottle L, Coelho L, et al. HPTN 083 Study Team. Cabotegravir for HIV Prevention in Cisgender Men and Transgender Women. N Engl J Med. 2021;385(7):595–608. pmid:34379922; PMCID: PMC8448593.
- 12. Delany-Moretlwe S, Hughes JP, Bock P, Ouma SG, Hunidzarira P, Kalonji D, et al. HPTN 084 study group. Cabotegravir for the prevention of HIV-1 in women: results from HPTN 084, a phase 3, randomised clinical trial. Lancet. 2022;399(10337):1779–1789. Epub 2022 Apr 1. Erratum in: Lancet. 2022 May 7;399(10337):1778. pmid:35378077; PMCID: PMC9077443.
- 13. Nel A, van Niekerk N, Kapiga S, Bekker LG, Gama C, Gill K, et al. Ring Study Team. Safety and Efficacy of a Dapivirine Vaginal Ring for HIV Prevention in Women. N Engl J Med. 2016;375(22):2133–2143. pmid:27959766.
- 14. Baeten JM, Palanee-Phillips T, Brown ER, Schwartz K, Soto-Torres LE, Govender V, et al. MTN-020–ASPIRE Study Team. Use of a Vaginal Ring Containing Dapivirine for HIV-1 Prevention in Women. N Engl J Med. 2016;375(22):2121–2132. Epub 2016 Feb 22. pmid:26900902; PMCID: PMC4993693.
- 15. Ratmann O, Grabowski MK, Hall M, Golubchik T, Wymant C, Abeler-Dörner L, et al. PANGEA Consortium and Rakai Health Sciences Program. Inferring HIV-1 transmission networks and sources of epidemic spread in Africa with deep-sequence phylogenetic analysis. Nat Commun. 2019;10(1):1411. pmid:30926780; PMCID: PMC6441045.
- 16. Eaton JW, Dwyer-Lindgren L, Gutreuter S, O’Driscoll M, Stevens O, Bajaj S, et al. Naomi: a new modelling tool for estimating HIV epidemic indicators at the district level in sub-Saharan Africa. J Int AIDS Soc. 2021;24(Suppl 5):e25788. pmid:34546657; PMCID: PMC8454682.
- 17. Hall M, Golubchik T, Bonsall D, <Abeler-Dörner L, Limbada M, Kosloff B, et al. On behalf of the HPTN 071 (PopART) Phylogenetics protocol team and the PANGEA protocol team. Demographic characteristics of sources of HIV-1 transmission in Zambia [preprint]. [cited 2022 Jul 17] Available from: https://www.medrxiv.org/content/medrxiv/early/2021/10/07/2021.10.04.21263560.full.pdf.
- 18. UNAIDS. 90-90-90 Treatment Target. [cited 2022 Jul 17] Available from: https://www.unaids.org/en/90-90-90.
- 19. Frescura L, Godfrey-Faussett P, Feizzadeh A A, El-Sadr W, Syarif O, Ghys PD. On behalf of the 2025 testing treatment target Working Group. Achieving the 95 95 95 targets for all: A pathway to ending AIDS. PLoS ONE. 2022;17(8):e0272405. pmid:35925943; PMCID: PMC9352102.
- 20. Godfrey-Faussett P. The HIV prevention cascade: more smoke than thunder? Lancet HIV. 2016;3(7):e286–8. pmid:27365202.
- 21. Nanteza BM, Makumbi FE, Gray RH, Serwadda D, Yeh PT, Kennedy CE. Enhancers and barriers to uptake of male circumcision services in Northern Uganda: a qualitative study. AIDS Care. 2020;32(8):1061–1068. Epub 2019 Dec 4. pmid:31795737; PMCID: PMC8362660.
- 22. Hensen B, Fearon E, Schaap A, Lewis JJ, Weiss HA, Tembo M, et al. Application of an HIV Prevention Cascade to Identify Gaps in Increasing Coverage of Voluntary Medical Male Circumcision Services in 42 Rural Zambian Communities. AIDS Behav. 2019;23(5):1095–1103. pmid:30737610.
- 23. Reza-Paul S, Steen R, Maiya R, Lorway R, Wi TE, Wheeler T, et al. Sex Worker Community-led Interventions Interrupt Sexually Transmitted Infection/Human Immunodeficiency Virus Transmission and Improve Human Immunodeficiency Virus Cascade Outcomes: A Program Review from South India. Sex Transm Dis. 2019;46(8):556–562. pmid:31295225; PMCID: PMC6629169.
- 24. Atun R, Silva S, Knaul FM. Innovative financing instruments for global health 2002–15: a systematic analysis. Lancet Glob Health. 2017;5(7):e720–e726. pmid:28619230
- 25. Holt M, Broady TR, Mao L, Chan C, Rule J, Ellard J, et al. Increasing preexposure prophylaxis use and ‘net prevention coverage’ in behavioural surveillance of Australian gay and bisexual men. AIDS. 2021;35:835–840. pmid:33587442
- 26. Gomez A, Loar R, Kramer AE, Garnett GP. Reaching and targeting more effectively: the application of market segmentation to improve HIV prevention programmes. J Int AIDS Soc. 2019;22(Suppl 4):e25318. pmid:31328397; PMCID: PMC6643068.
- 27. Reed JB, Shrestha P, Were D, Chakare T, Mutegi J, Wakhutu B, et al. HIV PrEP is more than ART-lite: Longitudinal study of real-world PrEP services data identifies missing measures meaningful to HIV prevention programming. J Int AIDS Soc. 2021;24(10):e25827. pmid:34648678; PMCID: PMC8516366.
- 28. Eakle R, Bothma R, Bourne A, Gumede S, Motsosi K, Rees H. “I am still negative”: Female sex workers’ perspectives on uptake and use of daily pre-exposure prophylaxis for HIV prevention in South Africa. PLoS ONE. 2019;14(4):e0212271. pmid:30964874; PMCID: PMC6456175.
- 29. Celum CL, Delany-Moretlwe S, McConnell M, van Rooyen H, Bekker LG, Kurth A, et al. Rethinking HIV prevention to prepare for oral PrEP implementation for young African women. J Int AIDS Soc. 2015;18(4 Suppl 3):20227. pmid:26198350; PMCID: PMC4509892.
- 30. Phillips AN, Bershteyn A, Revill P, Bansi-Matharu L, Kripke K, Boily MC, et al. HIV Modelling Consortium. Cost-effectiveness of easy-access, risk-informed oral pre-exposure prophylaxis in HIV epidemics in sub-Saharan Africa: a modelling study. Lancet HIV. 2022;9(5):e353–e362. pmid:35489378; PMCID: PMC9065367.
- 31. Brown AE, Mohammed H, Ogaz D, Kirwan PD, Yung M, Nash SG, et al. Fall in new HIV diagnoses among men who have sex with men (MSM) at selected London sexual health clinics since early 2015: testing or treatment or pre-exposure prophylaxis (PrEP)? Euro Surveill. 2017;22(25):30553. pmid:28662762; PMCID: PMC5490453.
- 32. Grulich AE, Guy R, Amin J, Jin F, Selvey C, Holden J, et al. Expanded PrEP Implementation in Communities New South Wales (EPIC-NSW) research group. Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study. Lancet HIV. 2018;5(11):e629–e637. Epub 2018 Oct 17 pmid:30343026.
- 33. Mounzer KC, Fusco JS, Hsu RK, Brunet L, Vannappagari V, Frost KR, et al. Are We Hitting the Target? HIV Pre-Exposure Prophylaxis from 2012 to 2020 in the OPERA Cohort. AIDS Patient Care STDs. 2021;35(11):419–427. Epub 2021 Oct 4. pmid:34609897.
- 34. Coburn BJ, Okano JT, Blower S. Using geospatial mapping to design HIV elimination strategies for sub-Saharan Africa. Sci Transl Med. 2017;9(383):eaag0019. pmid:28356504; PMCID: PMC5734867.
- 35. UNAIDS. HIV sub-national estimates viewer. [cited 2022 Jul 17] Available from: https://naomi-spectrum.unaids.org/.
- 36. Case KK, Gomez GB, Hallett TB. The impact, cost and cost-effectiveness of oral pre-exposure prophylaxis in sub-Saharan Africa: a scoping review of modelling contributions and way forward. J Int AIDS Soc. 2019;22(9):e25390. pmid:31538407; PMCID: PMC6753289.
- 37. Peebles K, Palanee-Phillips T, Balkus JE, Beesham I, Makkan H, Deese J, et al. Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium. Age-Specific Risk Scores Do Not Improve HIV-1 Prediction Among Women in South Africa. J Acquir Immune Defic Syndr. 2020;85(2):156–164. pmid:32701820; PMCID: PMC7495976.
- 38. Dettinger JC, Kinuthia J, Pintye J, Mwongeli N, Gómez L, Richardson BA, et al. PrEP Implementation for Mothers in Antenatal Care (PrIMA): study protocol of a cluster randomised trial. BMJ Open. 2019;9(3):e025122. pmid:30850409; PMCID: PMC6430021.
- 39. Justman J, Reed JB, Bicego G, Donnell D, Li K, Bock N, et al. Swaziland HIV Incidence Measurement Survey (SHIMS): a prospective national cohort study. Lancet HIV. 2017;4(2):e83–e92. Epub 2016 Nov 16. pmid:27863998; PMCID: PMC5291824.
- 40. Weiss KM, Prasad P, Sanchez T, Goodreau SM, Jenness SM. Association between HIV PrEP indications and use in a national sexual network study of US men who have sex with men. J Int AIDS Soc. 2021;24(10):e25826. pmid:34605174; PMCID: PMC8488229.
- 41. Shannon K, Strathdee SA, Goldenberg SM, Duff P, Mwangi P, Rusakova M, et al. Global epidemiology of HIV among female sex workers: influence of structural determinants. Lancet. 2015;385(9962):55–71. Epub 2014 Jul 22. pmid:25059947; PMCID: PMC4297548.
- 42. Meulbroek M, Dalmau-Bueno A, Saz J, Marazzi G, Pérez F, Coll J, et al. Falling HIV incidence in a community clinic cohort of men who have sex with men and transgender women in Barcelona, Spain. Int J STD AIDS. 2020;31(9):841–848. Epub 2020 Jul 5. pmid:32623981.
- 43. Stelzle D, Godfrey-Faussett P, Jia C, Amiesimaka O, Mahy M, Castor D, et al. Estimating HIV pre-exposure prophylaxis need and impact in Malawi, Mozambique and Zambia: A geospatial and risk-based analysis. PLoS Med. 2021;18(1):e1003482. pmid:33428611; PMCID: PMC7799816.
- 44. Massud I, Ruone S, Zlotorzynska M, Haaland R, Mills P, Cong ME, et al. Single oral dose for HIV pre or post-exposure prophylaxis: user desirability and biological efficacy in macaques. EBioMedicine. 2020;58:102894. Epub 2020 Jul 21. pmid:32707451; PMCID: PMC7381488.
- 45. Joshi K, Lessler J, Olawore O, Loevinsohn G, Bushey S, Tobian AAR, et al. Declining HIV incidence in sub-Saharan Africa: a systematic review and meta-analysis of empiric data. J Int AIDS Soc. 2021;24(10):e25818. pmid:34672104
- 46. Ochonye B, Folayan MO, Fatusi AO, Emmanuel G, Adepoju O, Ajidagba B, et al. Satisfaction with use of public health and peer-led facilities for HIV prevention services by key populations in Nigeria. BMC Health Serv Res. 2019;19(1):856. pmid:31752853; PMCID: PMC6868772.
- 47. Stangl AL, Pliakas T, Izazola-Licea JA, Ayala G, Beattie TS, Ferguson L, et al. Removing the societal and legal impediments to the HIV response: an evidence-based framework for 2025 and beyond PLoS ONE. 2022;17(2):e0264249. eCollection 2022. pmid:35192663
- 48. Bulstra CA, Hontelez JAC, Otto M, Stepanova A, Lamontagne E, Yakusik A, et al. UNAIDS Expert Group on Integration Integrating HIV services and other health services: A systematic review and meta-analysis. PLoS Med. 2021;18(11):e1003836. eCollection 2021 Nov.
- 49. Young Holt B, Dellplain L, Creinin MD, Peine KJ, Romano J, Hemmerling A. A strategic action framework for multipurpose prevention technologies combining contraceptive hormones and antiretroviral drugs to prevent pregnancy and HIV. Eur J Contracept Reprod Health Care. 2018;23(5):326–334. Epub 2018 Sep 24. pmid:30247084.
- 50. Stover J, Glaubius R, Teng Y, Kelly S, Brown T, Hallett TB, et al. Modeling the epidemiological impact of the UNAIDS 2025 targets to end AIDS as a public health threat by 2030. PLoS Med. 2021;18(10):e1003831. pmid:34662333; PMCID: PMC8559943.