At a crossroads: confronting setbacks and advancing the 95-95-95 HIV targets in sub-Saharan Africa

Abstract

Sub-Saharan Africa (SSA) remains at the epicentre of the global HIV epidemic and faces a decisive moment in its journey toward achieving the UNAIDS 95-95-95 targets. This review aims to provide a comprehensive overview of the progress toward these targets in SSA, identifying key challenges, barriers to viral load suppression, and potential strategies to improve treatment adherence and health outcomes. These goals—ensuring that 95% of people living with HIV know their status, 95% of those diagnosed are receiving treatment, and 95% of those receiving treatment achieve VLS—represent a bold vision to end HIV as a public health threat by 2030. However, across the region, progress is threatened by persistent structural barriers, entrenched stigma, health system weaknesses, and recent global funding disruptions, including the 2025 freeze on U.S. foreign aid. This review explores the multifaceted obstacles that continue to hinder the HIV response in SSA, from testing gaps to challenges in care retention and VLS, particularly among vulnerable populations. It further examines the potential consequences of funding cuts for health system resilience and epidemic control. Emphasising the need for equity-driven, locally adapted, and innovative strategies—such as community-based service delivery, digital health tools, long-acting therapies, and integrated care models—this article argues for renewed political commitment, sustainable financing, and stronger local and global partnerships. When setbacks loom large, this piece calls for urgent, coordinated action to protect progress, address persistent inequities, and secure a future where epidemic control is truly within reach.

Introduction

The UNAIDS 95-95-95 targets represent an ambitious and crucial vision in the global fight against HIV. This initiative aims not only to transform HIV care but also to end the epidemic as a public health threat. By setting the goal for 2030, these targets aim to ensure that at least 95% of people living with HIV (PLHIV) are aware of their HIV status, that 95% of those diagnosed receive antiretroviral therapy (ART), and that 95% of those receiving ART achieve sustained viral load suppression (VLS) [1]. These three steps are interdependent and essential for reducing the transmission of the virus and improving the quality of life of affected individuals.

However, despite remarkable progress in certain regions, sub-Saharan Africa (SSA) still faces significant challenges [2]. Being home to a substantial number of PLHIV globally, the region encounters distinct structural, social, and economic obstacles in meeting its targets. The hurdles in SSA extend beyond medical realms; they are intricately intertwined with public health, social justice, and sustainable development issues. Furthermore, recent policy changes, such as the U.S. freeze on HIV funding in February 2025, have introduced additional challenges that threaten to undermine progress in the fight against HIV/AIDS [3].

For many communities in SSA, particularly those in rural and remote areas, access to HIV screening, treatment, and VLS remains limited. Enduring negative perceptions of HIV further prevent many people from knowing their status. Linking people to care and retaining them in treatment are also major challenges, as PLHIV can face financial, logistical, and social barriers that compromise their adherence to care. The fight to achieve these goals in SSA represents a crucial test of the world’s ability to mobilise resources, innovate, and collaborate equitably to make a significant and lasting impact.

This review aims to provide a comprehensive overview of the progress toward the UNAIDS 95-95-95 targets in SSA, identifying key challenges, barriers to VLS, and potential strategies to improve treatment adherence and health outcomes. As a traditional narrative review, no formal systematic review protocol was followed; relevant literature was identified through targeted searches in PubMed, Google Scholar, and UNAIDS/WHO databases for English-language publications from January 2010 to July 2025. Sources included peer-reviewed articles, national surveillance reports, and policy documents addressing HIV testing, treatment, and VLS in SSA.

Unearthing barriers to the first 95: HIV testing

The first 95-95-95 objective, where 95% of PLHIV are aware of their status, is crucial in curbing virus transmission [1]. Nevertheless, in SSA, numerous intricate barriers impede this goal. Deep-seated prejudice linked to HIV deters many individuals from getting tested, as fears of discrimination and social isolation remain common, especially in communities where misconceptions about the virus are widespread [4].

In addition, in rural areas, the limited health infrastructure makes access to screening difficult. Testing facilities are often concentrated in urban areas, forcing people in remote regions to travel long distances. This physical inaccessibility is compounded by financial constraints, such as transport costs and loss of income [5, 6]. Furthermore, health systems frequently lack qualified staff and material resources to provide effective screening services [7].

Some populations in SSA remain particularly hard to reach. For example, men are less inclined to seek healthcare at facilities, largely because of cultural norms linking healthcare with women and children [8]. Young people, migrant workers and marginalized groups such as refugees are also frequently excluded [4].

Innovative approaches are needed to overcome these obstacles. Home, community, and self-testing can broaden access to diagnosis by reaching individuals in their communities, thereby reducing logistical constraints [9, 10]. Using social networks and trusted community relationships can help counter negative perceptions and encourage HIV testing [11, 12].

Education and awareness-raising are crucial in reducing prejudices about HIV and encouraging testing. Targeted campaigns tailored to cultural specificities and endorsed by community leaders can foster positive attitudes and increase the demand for testing. Ultimately, achieving the first 95 in SSA necessitates an integrated approach that combines awareness-raising, decentralization, and technological innovations to ensure that screening is accessible and embraced by all.

Ensuring linkage to care and retention in treatment

Once an HIV diagnosis has been made, linking patients to care and ensuring that they remain in care is crucial for achieving the second 95-95-95 objective [1]. In SSA, despite advancements in access to ART, numerous obstacles hinder the continuity of care. The task is not only to initiate patients on treatment but also to maintain their adherence in the long term.

The first obstacle is the weakness of health infrastructures, particularly in rural areas. Establishments are often underequipped and underfunded, with stock-outs of medicines and a lack of qualified staff [13, 14]. Long journeys and transport costs discourage patients from returning for regular consultations, which compromises their adherence to treatment [15, 16].

Another major challenge lies in the social prejudice surrounding HIV. Hostile attitudes in the community—and at times among healthcare providers—lead some patients to avoid seeking care for fear of exposure or judgment. Training healthcare staff to offer non-discriminatory support is essential to encourage patient retention [17, 18].

Socioeconomic difficulties also aggravate the situation. Poverty and food insecurity can lead patients to abandon treatment when their immediate survival needs take precedence [19]. A lack of social support can reinforce this isolation [20]. Community support networks and self-help groups can provide moral support and practical advice to help patients stay involved in their treatment.

Innovative, person-centred approaches such as strength-based case management and peer navigation have shown promise in improving linkage to and retention in care. These models enhance patient engagement by harnessing individual strengths and fostering trust through peer support, which is particularly effective in vulnerable and hard-to-reach populations [21, 22]. Similarly, structured interventions that emphasise personalised support, empowerment, and community engagement have proven effective in improving both initial linkage to HIV care and long-term retention. Decentralized and differentiated service delivery models—such as adherence clubs, community drug distribution points, and mobile outreach—should be integrated as components of a comprehensive care framework rather than standalone interventions [23, 24]. Linking HIV services with other essential health services, including non-communicable diseases (NCDs) management, sexual and reproductive health, mental health support, and social services such as education and vocational training, allows providers to reduce fragmentation, address broader determinants of health, and mitigate stigma. Embedding digital tools, such as SMS or WhatsApp reminders, further supports adherence and continuity of care by overcoming geographic and financial barriers [25, 26].

Integrating holistic services that address the psychological, medical, and social needs of PLHIV has also shown positive impacts on retention. Tailored approaches, including intensified clinical follow-up, community ART refill programmes, and teleconsultations, are particularly beneficial for individuals with complex health or social situations [23, 24, 27, 28]. To ensure sustainability and scalability, these interventions must be supported by robust national policies, community engagement, and adequate funding mechanisms. Collectively, such strategies contribute significantly to achieving the second “95” and ensuring continuity of care across the HIV treatment cascade.

Conquering barriers to viral load suppression

Achieving the third target of the UNAIDS 95-95-95 goals—ensuring that 95% of PLHIV on ART achieve sustained VLS—is essential to curbing HIV transmission and improving health outcomes [1]. However, this objective remains particularly challenging in SSA, where socioeconomic barriers continue to affect ART adherence.

Persistent obstacles such as stigma, discrimination, food insecurity, and unstable living conditions hinder consistent ART use [18, 19]. Additionally, drug-related side effects can further compromise adherence [29]. These challenges underscore the need for continuous psychosocial support, patient education, and differentiated care models tailored to individual circumstances.

A critical concern in the region is the emergence of resistance to ART, often stemming from treatment interruptions or inconsistent ART availability [30]. Resistance significantly undermines therapeutic efficacy and necessitates costly second- or third-line regimens, which are frequently less accessible. Addressing this issue requires robust systems for resistance surveillance, uninterrupted drug supply chains, and adherence support interventions.

Particularly concerning is the gap in VLS among children and adolescents. While adult populations in several SSA settings are approaching the 95% VLS target, children and adolescents continue to lag behind, as highlighted by Han et al. [31]. A recent systematic review and meta-analysis estimated that more than one in four children and adolescents on ART in SSA have an unsuppressed viral load (26.47%, 95% CI 23.06–29.87), with rates remaining high across both age groups. Factors contributing to this include younger age (< 5 years), male sex, rural residence, orphan status, attendance at a level 1 or 2 health-care facility, undisclosed HIV status, poor ART adherence, advanced WHO clinical stage of HIV, low CD4 cell counts, history of opportunistic infections, nevirapine-based treatment regimen, drug substitution history, and lack of co-trimoxazole prophylaxis, among others [32]. Age-specific challenges—including dependency on caregivers, limited pediatric formulations, and psychosocial vulnerabilities—necessitate targeted strategies.

Access to routine viral load monitoring is another major constraint due to limited infrastructure, human resource shortages, and logistical barriers. Innovative solutions such as point-of-care testing, mobile laboratories, and public‒private partnerships can help expand access and improve timely detection of treatment failure or drug resistance [33, 34].

Importantly, recent advances in HIV treatment offer new opportunities to improve adherence and VLS outcomes. Long-acting injectable regimens—such as cabotegravir and rilpivirine administered monthly or every two months—have shown promising efficacy and acceptability, particularly among individuals facing adherence challenges with daily oral regimens [35, 36]. The latest WHO guidance supports the use of these long-acting formulations as part of differentiated service delivery models, particularly for populations with adherence difficulties or those requiring discretion and convenience [37].

Holistic, person-centred approaches remain key to achieving and sustaining VLS [38, 39]. This includes comprehensive counselling, peer navigation, integrating HIV services into primary health care—especially in rural and underserved areas—and community-led initiatives that challenge social prejudice and foster empowerment.

Achieving the third 95 requires a combination of biomedical innovation, health system strengthening, and social support. Long-acting regimens, improved monitoring tools, and tailored service delivery models represent essential components of this multifaceted effort to ensure sustained VLS for all PLHIV in SSA [40–42].

Shifting the future: how funding cuts threaten HIV programmes in sub-Saharan Africa and what it means for global health security

Progress in HIV prevention and treatment in SSA is at risk because of potential funding cuts to key international programmes, particularly the President’s Emergency Plan for AIDS Relief (PEPFAR). On January 20, 2025, Executive Order 14,169 imposed a 90-day freeze on all U.S. foreign aid obligations and disbursements, including existing programmes [43]. A stop-work order issued on January 24 halted PEPFAR-supported service delivery. In response, a limited waiver granted on February 1 allowed the continuation of urgent HIV treatment services, including ART, HIV testing and counselling, management of tuberculosis, laboratory support, and prevention of mother-to-child transmission—with PrEP limited to pregnant and breastfeeding women [3]. However, broader PrEP access, maternal and child health, family planning, and full tuberculosis services were excluded. A further directive on February 7 barred South Africa from exemption, raising serious concerns about the continuity of HIV services [3]. In low-resource settings unable to offset such disruptions, these measures jeopardize the sustainability of HIV response efforts and threaten to reverse hard-won gains.

The impact of these funding reductions extends beyond individual patients to the broader public health landscape. Without sustained investment, key populations—defined by UNAIDS as those disproportionately affected by HIV, including men who have sex with men, sex workers, transgender people, people who inject drugs, and incarcerated individuals [4]—face heightened vulnerability. Interruptions in ART supply chains, reductions in outreach and harm reduction programmes, and weakening of health system infrastructure compromise the continuity of care for these groups. Sexual minorities, including LGBTQI + people and young female sex workers, also face compounded risks due to widespread stigma, discrimination, and violence, all of which hinder their access to essential HIV services [4, 44]. A decline in funding may result in increased HIV transmission and treatment interruptions, thereby undermining progress toward the UNAIDS 95-95-95 targets and jeopardizing epidemic control in SSA. Modelling studies have quantified the potential impact of funding disruptions. Hontelez et al. [45] projected that a 90-day PEPFAR funding freeze across seven SSA countries could have resulted in 60–74 thousand excess HIV deaths and 35–103 thousand additional infections between 2025 and 2030, depending on programme continuity scenarios. Similarly, Gandhi et al. [46] estimated that abrupt cutbacks in South Africa could lead to 286 000 to 565 000 additional infections over 10 years, along with significant losses in life-years for PLHIV. These findings highlight the magnitude of the threat posed by temporary or prolonged funding interruptions.

Given these potential consequences of funding interruptions, reinforcing multisectoral coordination becomes critical to mitigate risks and sustain HIV programme gains. Strengthening multisectoral coordination is central to sustaining HIV gains, particularly in the face of international donor funding cuts. Highly coordinated services—spanning healthcare, education, social development, and community support—can improve health outcomes by breaking down provider silos and reducing the burden on patients to navigate fragmented systems. At the local, provincial, and national levels, effective coordination maximises available resources, avoids duplication of efforts, and ensures that HIV care is embedded within broader development and health agendas. This approach also offers a pathway to sustaining progress when external funding is reduced, by leveraging domestic resources and shared infrastructures.

Effective coordination not only strengthens local HIV responses but also contributes to broader global health security, as setbacks in SSA could cascade to other infectious disease programmes. Global health security is at stake. SSA remains a region with high HIV prevalence, and any setbacks in the fight against the virus could have cascading effects on other infectious disease programmes, including tuberculosis and hepatitis. Strengthening health systems to withstand funding fluctuations is essential, but without strategic and continued international support, the progress made in the past two decades is at risk of being undone. Advocacy, policy shifts, and alternative financing mechanisms must be urgently explored to ensure that financial constraints do not undermine the fight against HIV and the broader goal of global health equity.

While financial stability is essential, structural and sociodemographic factors present additional challenges to achieving the 95-95-95 targets. Beyond funding issues, structural and sociodemographic factors further complicate efforts to achieve the 95-95-95 targets. Understanding these geographic and population-specific barriers is essential to complement financial strategies and ensure equitable access to HIV services across SSA.

Addressing geographic and sociodemographic constraints

SSA is vast and diverse and presents unique challenges that complicate the achievement of 95-95-95 targets. Geographic and socio-demographic diversity affects access to HIV testing, treatment, and follow-up, requiring tailored approaches to reach vulnerable populations [47].

Rural and isolated areas are often challenging to access due to a lack of transport and healthcare infrastructure. Patients must travel long distances to access care, which hinders screening and treatment continuity. Mobile clinics, telemedicine, and community health centres are potential solutions for overcoming these barriers [48].

Socio-demographic constraints, such as mobility due to migration and conflict, complicate the continuity of care. People on the move often have limited access to healthcare services [49]. Cross-border coordination efforts are needed to ensure uninterrupted access to care [50].

Cultural and socioeconomic factors also influence access to care. Gender norms, poverty, and social exclusion remain key factors influencing the decision to seek treatment [51]. A localised and flexible approach that integrates decentralised infrastructure and services, as well as financial support and cultural education strategies, is essential to meet these challenges and make progress towards the 95-95-95 targets.

These geographic and sociodemographic challenges also influence HIV prevention efforts. Limited access to health facilities, mobility, and social barriers hinder the delivery and uptake of preventive interventions, highlighting the need for targeted strategies to reduce new infections.

Bridging the HIV prevention gap: a critical challenge for sub-Saharan Africa

To complement treatment and retention efforts, effective HIV prevention remains a cornerstone in achieving the UNAIDS 95-95-95 targets, particularly in SSA, which accounts for two-thirds of global HIV cases [4]. While traditional prevention strategies—such as condoms, pre- and postexposure prophylaxis (PrEP and PEP), and prevention of mother‒child transmission (PMTCT)—have proven effective, their accessibility remains limited in rural and underserved areas owing to stigma, cost, and health system weaknesses.

New biomedical technologies, especially long-acting injectable PrEP (e.g., cabotegravir, lenacapavir), represent major breakthroughs. Clinical trials have demonstrated its superior efficacy compared with daily oral PrEP, with significantly reduced adherence concerns [52, 53]. However, translating this innovation into impact in SSA is limited by high costs, cold chain logistics, limited regulatory approvals, and the need for regular clinical follow-up—factors that exacerbate existing inequities [54].

Comprehensive HIV prevention requires more than biomedical tools. Integrating sexuality education into school curricula is essential to empower adolescents, particularly girls, who bear a disproportionate burden of new infections [55]. The effectiveness of HIV programmes is strongly influenced by socio-political determinants and the broader cultural context. Factors such as poverty, gender inequality, legal environments that criminalise key populations, inequitable resource distribution, and weak intersectoral coordination can undermine service uptake and retention. Addressing these barriers requires multi-level strategies that extend beyond the health sector—engaging education systems, social protection agencies, and community leadership structures—to create enabling environments for prevention, treatment, and long-term care. Finally, strong political commitment and sustainable financing are crucial to support the deployment of new technologies alongside existing, community-based interventions, ensuring equitable access and maximizing impact [56, 57].

Without addressing both the scientific and systemic dimensions of prevention, SSA risks missing a historic opportunity to bend the curve of the epidemic.

Embracing innovative and localized solutions for a brighter future

To achieve the 95-95-95 targets in SSA, solutions tailored to local circumstances are needed [4]. Geographic and socioeconomic disparities call for innovative approaches, particularly through digital technologies and telehealth. Mobile phones facilitate screening, awareness-raising, and support for treatment adherence through appointment reminders and advice [58].

Geospatial mapping enables the targeting of interventions in epidemic ‘hot spots’, optimizing the deployment of mobile clinics and ART distribution. Involving local communities through peer support groups and community leaders strengthens the battle against stigma and enhances ART adherence [59].

The decentralisation of healthcare, with community-based delivery of services, facilitates access to health services, particularly in rural areas. Public‒private partnerships and financial innovations further support access to care and treatment [34, 60]. These solutions, integrated with culturally sensitive approaches, are essential for achieving a lasting impact against HIV.

Integrating HIV programmes within holistic health systems

While HIV remains a pressing public health priority, addressing it in isolation risks neglecting the broader health needs of PLHIV and their communities. Across SSA, there is an urgent need to move away from siloed approaches toward integrated, people-centred health systems that address both communicable and NCDs. This shift is particularly important given the growing burden of NCDs such as diabetes, hypertension, and mental health disorders, which increasingly co-exist with HIV. Treating HIV as one component of a broader chronic disease care package creates opportunities to strengthen health systems, improve efficiency, and enhance patient outcomes [61, 62].

A notable example of this paradigm shift is the transformation of the Desmond Tutu HIV Foundation into the Desmond Tutu Health Foundation. As reported by the University of Cape Town, this change “represents the widening scope of the organisation’s work in public health research and community-driven health responses” [63]. This evolution reflects a growing recognition that HIV services should be embedded within comprehensive health and social care frameworks that address the full spectrum of individual and community needs. Such an approach fosters health system resilience, reduces stigma, and ensures that investments in HIV care contribute to broader public health gains. This direction is supported by multiple studies demonstrating the feasibility and benefits of integrating HIV and NCD care within the same facilities, offering joint screening services, and leveraging existing HIV platforms for broader healthcare delivery [64, 65]. Integrated approaches have been shown to improve patient retention, increase service efficiency, and address the social and economic determinants of health. In contexts of shrinking donor funding, such integration also provides a cost-effective pathway to sustain progress toward the 95-95-95 targets while strengthening overall health system capacity.

Conclusion and recommendations

Achieving 95-95-95 targets in SSA remains a monumental yet attainable goal. Progress has been supported by biomedical innovations, community-centred strategies, and growing integration of HIV care into broader health systems. However, persistent geographic and socio-demographic inequalities, health system weaknesses, and funding uncertainties—most recently exemplified by the temporary freeze of U.S. foreign aid—continue to threaten these gains. In addition to biomedical innovations and community-centred strategies, ensuring the sustainability of the HIV response requires robust and resilient health systems. In light of recent international funding uncertainties, notably the temporary freeze of U.S. foreign aid, there is an urgent need to prioritize domestic resource mobilisation, improve health system efficiency, and leverage digital technologies for service delivery. Policymakers and implementers must address both structural and operational barriers while ensuring that the HIV response remains embedded in broader health system reforms.

Strengthening local and international partnerships, optimising supply chain management, and integrating HIV care into broader health system reforms are essential strategies to safeguard progress. Without decisive action, the region risks a resurgence in HIV incidence, erosion of hard-won gains in child and maternal health, and setbacks in broader health system strengthening—threatening to reverse decades of progress. To safeguard hard-won gains and address identified challenges, we recommend prioritising domestic resource mobilisation to reduce reliance on external funding, leveraging digital technologies to enhance service delivery and monitoring, strengthening local and international partnerships for coordinated action, optimising supply chain management to ensure uninterrupted access to diagnostics and treatment, and expanding decentralised, community-based services to reach underserved populations. In addition, targeted strategies should be implemented, such as scaling up PrEP for adolescent girls in rural regions, piloting telemedicine in cross-border communities, implementing contingency plans to mitigate the impact of funding freezes, and facilitating cross-border ART continuation agreements to address adherence challenges among mobile populations.

By addressing persistent geographic and socio-demographic inequalities through inclusive and adaptive approaches, SSA can continue progressing toward epidemic control and an HIV-free future. Ultimately, the sustainability of the HIV response depends on embedding HIV services within resilient, integrated health systems capable of addressing the full spectrum of health needs—including NCDs and other chronic conditions—while actively engaging communities and sectors beyond health. This narrative review did not include primary data collection or meta-analysis, which may limit the comprehensiveness of quantitative estimates. Future studies should evaluate the scalability and cost-effectiveness of digital health interventions, explore innovative financing mechanisms for sustainable HIV responses, and assess strategies to close persistent gaps among marginalized populations. Understanding how integrated, people-centred health system approaches influence HIV outcomes across diverse SSA contexts will be critical not only for achieving the 95-95-95 targets but also for building equitable and sustainable healthcare systems for all.

Abbreviations

ART 

Antiretroviral Therapy

HIV

Human Immunodeficiency Virus

NCD

Non-communicable Diseases

PEP

Post-exposure Prophylaxis

PEPFAR

President’s Emergency Plan for AIDS Relief

PLHIV

People living with HIV

PMTCT

Prevention of Mother-to-Child Transmission

PrEP

Pre-exposure Prophylaxis

SSA

Sub-Saharan Africa

VLS

Viral Load Suppression

Author contributions

O.M. and K.G. jointly conceptualized the article, reviewed the literature, contributed to writing and critical revisions, and approved the final manuscript for submission.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

Not applicable.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.