The successful scaling-up of antiretroviral therapy globally has many lessons for advancing universal health coverage: progress at risk

Background
The expansion of antiretroviral therapy (ART) over the past twenty years is one of the most significant achievements in public health. It has transformed HIV from a life-threatening to a chronically manageable condition. This study aims to identify the successes and challenges in scaling up ART over the past two decades and derive key lessons to inform the universal health coverage (UHC) agenda.

Methods
The World Health Organization’s (WHO) Global Health Observatory database was used to extract data on ART coverage. We analysed ART coverage data for all countries in the six WHO Regions (Africa, the Americas, Eastern Mediterranean, Europe, Southeast Asia, and Western Pacific) of the world from 2000 to 2023. We also examined the association between ART coverage and UHC for reproductive, maternal, neonatal, and child health services in the African region. A trend analysis of HIV funding from 2000 to 2023 was also conducted using the data from the National AIDS Spending Assessment. A literature review was conducted to identify the factors that facilitate or hinder the expansion of ART, along with key insights for the UHC agenda.

Results
ART coverage has increased significantly across all regions, from 2% in 2000 to 77% in 2023. Africa experienced the most remarkable growth, rising from 0% in 2000 to 82% in 2023. ART coverage positively correlates with improvements in reproductive, maternal, neonatal, and child health services. However, there are notable disparities in ART coverage across regions, with Africa leading but with significant variation between countries, while the Eastern Mediterranean Region lags. A slowdown in ART coverage growth has been observed since 2020, reflecting challenges in sustaining progress as countries near universal coverage and struggle to reach marginalized or criminalized populations with limited access to healthcare. Additionally, global HIV funding, which peaked in 2017, has plateaued and declined by 2023. The successful scaling up of ART relies on strong political leadership, health system strengthening, community engagement, multi-sectoral actions, and global health initiatives. Key lessons for UHC include maintaining political commitment, strengthening health systems, reducing financial barriers, engaging communities and other sectors, and ensuring long-term financial sustainability.

Conclusions
The global scale-up of ART has been a major public health success, though disparities remain, and the rate of growth of ART coverage has slowed since 2020 due to financial instability, shifting global health priorities, and the COVID-19 pandemic. These gains are thus now at risk. Moving forward, strong political leadership, resilient health systems, community engagement, multi-sectoral collaboration, and sustainable financing are essential for maintaining and expanding ART coverage. These lessons are critical for advancing the UHC agenda.