UNAIDS 90-90-90: the fourth 90

Written by Robert

“Fourth what?” I hear you ask.

If you haven’t read about the UNAIDS 90-90-90 initiative you may have no clue what I mean by the fourth 90.1 So, before we get to that, let’s deal with 90-90-90.

The 90-90-90 initiative

In 2013, the Programme Co-ordinating Board of UNAIDS (the United Nation’s HIV department) requested that UNAIDS support country and region-led efforts to establish new targets for HIV treatment. After a series of consultations around the world, UNAIDS created and launched an ambitious plan called 90-90-90.1

Its goals are simple. By 2020, they aimed to ensure that:1

  • 90% of all people living with HIV would know their HIV status
  • 90% of all people diagnosed with HIV would be receiving sustained antiretroviral therapy (ART)
  • 90% of all people receiving ART would have an undetectable HIV viral load

Previous UNAIDS targets sought to achieve incremental progress in the scale up of ART globally. They aimed to get 3 million people on HIV treatment in low- and middle-income countries by 2005 and subsequently 15 million by 2015.2,3

A further leap was made in 2016, when the World Health Organization (WHO) adopted a new Global Health Sector Strategy on HIV for 2016–2021.4 It established 15 ambitious targets, including the 90-90-90 target for HIV. The WHO strategy calls for person-centred chronic care for people living with HIV, implicitly acknowledging that viral suppression is not the ultimate goal of treatment.4

The aim of current strategies is considerably bolder than previous targets – to end the AIDS epidemic as a public health threat by 2030, within the context of ensuring healthy lives and promoting well-being for all at all ages.4,5 90-90-90 takes a big step in that direction.

Substantial global progress has been made towards attaining the 90-90-90 targets over the past seven years.6,7 A number of countries have reported that they have achieved or surpassed one or more of the 90 targets.7 However, the progress has been too slow for the target to be reached globally this year and the COVID-19 pandemic has further dampened progress toward the goal.

The UK is one of the few countries in the world to have reached and exceeded all of the UNAIDS 90-90-90 targets, having reached all three 90s in late 2018. Of the 103,800 people estimated to be living with HIV in the UK in 2018, 93% were diagnosed. Of people diagnosed, 97% were receiving treatment and 97% of those people receiving treatment had an undetectable viral load.8

These three targets established by UNAIDS are important as they ensure that people diagnosed and on effective therapy are likely to be healthy and cannot pass HIV on. But, they are concerned purely with clinical outcomes. The 90-90-90 initiative does not provide an explicit target for health-related quality of life. Some argue it:9

    “fails to take into account the needs of people living with HIV who have     achieved viral suppression but still must contend with other intense challenges     such as serious non-communicable diseases, depression, anxiety, financial     stress, and experiences of or apprehension about HIV-related discrimination.”

It has been proposed that a fourth 90, which encompasses co-morbidities (additional conditions affecting a person living with HIV) and self-perceived quality of life, is needed. This would provide a target that is more reflective of person-centred chronic care. It acknowledges that having an undetectable viral load is not the only measure of successful treatment.9

What is the fourth 90?

A group of HIV researchers, clinicians and openly HIV-positive activists – led by Jeffrey Lazarus (Head of the Health Systems Research Group at The Barcelona Institute for Global Health) – published a paper which proposed adding a fourth 90 to the testing and treatment targets.9

The fourth 90 sets out to ‘ensure that 90% of people with viral suppression have good health-related quality of life’. This, they argued, would ensure that we moved beyond thinking of success in purely clinical terms. It embodies the aspiration to secure a high quality of life for people living with HIV.9

The group argued that the UNAIDS strategy did “not provide targets for the concept of ensuring healthy lives and promoting well-being”. They suggested that good health-related quality of life for people living with HIV should consider two key areas: comorbidities and self-perceived quality of life.9

Comorbidities and the fourth 90

A large body of research has raised questions about whether people living with HIV are at elevated risk of non-HIV specific diseases such as kidney disease, heart disease and various cancers. A higher rate of comorbidities in people living with HIV is concentrated in two groups of people:10–13

  • Those who began taking ART during the earliest phase of the HIV treatment era (mid 1990s to 2000)
  • Those who have experienced more severe immunosuppression, which is common among people diagnosed at a later stage of HIV  

More people taking ART are living into their fifties, sixties and beyond. This means that HCPs will be increasingly confronted with scenarios in which multiple health conditions need to be managed and multiple medicines need to be prescribed simultaneously.

Self-perceived quality of life and the fourth 90

People living with HIV with an undetectable viral load still report high levels of symptoms such as fatigue and energy loss, insomnia, sadness and depression, sexual dysfunction and changes in appearance.14

One study compared more than 3,000 UK-based people living with HIV with more than 7,000 members of the general population. It reported that health-related quality of life scores were significantly lower among the people living with HIV – 75% of whom had an undetectable viral load. These scores remained significantly lower even when the analysis only included virally suppressed people living with HIV.15

The writers argued that “addressing these and other related concerns is essential in order to ensure that the vision of well-being put forth by the WHO strategy becomes a reality”.9

Professor Jeffrey Lazarus, lead author of the fourth 90 paper commented that some of the WHO strategy “might even be considered visionary in terms of how they seek to address the needs of people living with HIV beyond viral suppression. Nevertheless, two issues have not been addressed. One is an explicit target for health-related quality of life – our proposed fourth 90. The other is policy and operational guidance for how to achieve the fourth 90, simply how could it be measured.” He underlined that, “depression, anxiety, financial stress, fear of transmitting HIV to others, uncertainty about starting a family, and experiences of or apprehension about HIV-related discrimination” negatively impacts the quality of life of people living with HIV. With the aim of the fourth 90 being a global initiative, Lazarus recommended that “health systems everywhere need to become more integrated and people-centred”.9

Response to the fourth 90

Criticism of the way the fourth 90 was initially conceived can be found on social media.

On 3rd October 2018, Professor Jeffrey Lazarus published a blog stating:16

    “This may be surprising to hear from researchers, but we don’t mind getting     things wrong from time to time. Being wrong draws us into interesting     conversations with people who have different skills and perspectives. It also     reminds us that advancing public health is a shared enterprise. Many     stakeholders in the HIV field have found fault with how the piece     conceptualised the fourth 90 target to complement the UNAIDS ‘3 90s’ target.”

The problem is summed up in the diagram below.1,9,16


Adapted from: UNAIDS, 2014.
Fig. 1 The ‘fourth 90’: proposed revision to the UNAIDS 90-90-90 targets

Commentators have questioned why good health-related quality of life should only be a relevant target for virally suppressed people living with HIV.

In his blog, Lazarus stated that “it clearly shouldn’t”. He clarified that “in presentations and discussions about how to move the HIV care agenda beyond a narrow focus on treatment to suppress viral replication, it has become routine for us and other stakeholders to talk about establishing a health-related quality of life target for all people living with HIV from the point of diagnosis onwards.”16

Lazarus has since suggested a new model to ensure a broader group of people living with HIV are achieving good health-related quality of life.16


In May 2019, UNAIDS and Manchester’s LGBT Foundation launched an 82-question online survey on happiness, sex and quality of life for LGBTI people.17,18 It featured questions on health-related quality of life (HRQL). This was the first time the topic had been addressed according to a report published in the medical journal, The Lancet in June 2019.19 The move was welcomed by those who believe that a fourth 90 should be added to the current UNAIDS 90-90-90 target. The survey was aimed at all lesbian, gay, bisexual, transgender, and intersex (LGBTI) people and was not specific to HIV. That said, 11% of respondents identified as living with HIV.19

Topics surrounding HRQL covered in the survey included:18

  • ‘Outness’
  • Family support
  • Sexual satisfaction
  • Physical health
  • Happiness
  • Self-esteem
  • The internalisation of homophobia

UNAIDS says that this survey is trying to determine whether scores on these measures are correlated with risk-taking behaviours that drive HIV infection and other health risks.19

Join the debate

It’s clear that the debate around a fourth 90 is still very much alive. With the new strategy from the WHO and the recent UNAIDS online survey, it seems that targets for high quality of life among people living with HIV are finally being established.

If you’d like to join the debate and contribute your ideas about the fourth 90, you can do so on Twitter using the hashtags #4th90 and #BeyondViralSuppression.

Find out more about living with HIV and how exercise and diet have a positive impact.    

  1. 90-90-90: An ambitious treatment target to help end the AIDS epidemic. Available at: https://www.unaids.org/sites/default/files/media_asset/90-90-90_en.pdf [Accessed: August 2020].
  2. The 3 by 5 Initiative. Available at: https://www.who.int/3by5/en/ [Accessed: August 2020].
  3. “15 by 15”: A global target achieved. Available at: https://www.unaids.org/
     [Accessed: August 2020].
  4. Global Health Sector Strategy on HIV 2016-2012. 2016 Available at: https://apps.who.int/iris/bitstream/handle/10665/246178/WHO-HIV-2016.05-eng.pdf;jsessionid=AB177BD2F48F2D8F4BD0954BF5FCCC01?sequence=1 [Accessed: August 2020].
  5. AIDS and the sustainable development goals. Available at:  https://www.unaids.org/en/AIDS_SDGs [Accessed: August 2020].
  6. Marsh K, et al. AIDS. 2019;33:S213­–S226.
  7. Global AIDS update 2020. Seizing the moment: Tackling entrenched inequalities to end pandemics. Available at: https://www.unaids.org/sites/default/files/media_asset/2020_global-aids-report_en.pdf  [Accessed: August 2020].
  8. HIV in the UK: towards zero HIV transmissions by 2030. Press Release. 2020. Available at: https://www.gov.uk/government/news/hiv-in-the-uk-towards-zero-hiv-transmissions-by-2030 [Accessed: August 2020].
  9. Lazarus J, et al. BMC Med. 2016;14:94.
  10. Costagliola D. Curr Opin HIV AIDS. 2014;9: 294–301.
  11. Kooij K, et al. AIDS. 2016;30:1771–1780.
  12. Schouten J, et al. Clin Infect Dis. 2014;59:1787–1797.
  13. Schouten J, et al. AIDS. 2016;30:1027–1038.
  14. Erdbeer G, et al. J Int AIDS Soc. 2014;17:19673.
  15. Miners A, et al. Lancet HIV. 2014;1:e32–40.
  16. Depicting a New Target For the HIV Response: How Do You See the ‘Fourth 90’? Available at: https://www.isglobal.org/en/healthisglobal/-/custom-blog-portlet/visually-depicting-a-new-target-for-the-hiv-response-how-do-you-see-the-fourth-90-/5511380/0 [Accessed: August 2020].
  17. UNAIDS and the LGBT Foundation launch groundbreaking study on happiness, sex and quality of life for LGBTI people. Available at: https://www.unaids.org/en/resources/presscentre/

    [Accessed: August 2020].
  18. 1st Global LGBT Foundation and UNAIDS Survey on Happiness, Sex and Quality of life. Available at: https://www.research.net/r/LGBTHappinessResearch [Accessed: August 2020].
  19. Webster P. Lancet. 2019;393:2188.
Previous Next