The 2030 Agenda for Sustainable Development was adopted by the United Nations general assembly in September 2015. The agenda encompasses internationally agreed development aspirations – the Sustainable Development Goals (SDGs). The health targets of the SDGs are not merely ambitious in themselves; they are configured with a very considerable range of other, hugely expensive global issues: 17 goals and 169 targets covering nearly every important aspect of human well-being, both physical and relational. Within the health sphere, by the end of the SDGs in 2030, the ambition is that the AIDS epidemic and other communicable diseases should have been ended, child and infant mortality should be significantly reduced, and universal health coverage with financial protection should be in place for all. But the Joint United Nations Programme on HIV/AIDS (UNAIDS) 5-year ‘Fast Track’ plan for front-loading resources in order to build on progress against the HIV/AIDS pandemic is already faltering – surely evidence of the squeeze being exerted by the most urgent non-health issues (eg, SDG 13: climate action), together with an unpropitious political climate for Official Development Assistance generally. Whatever political embarrassment it might provoke, we must confront the inescapable conclusion that the SDGs are aspirational rather than a compulsory commitment to a programme: the hard choices will become larger in number and more anguished. …