Contribution of community-based organizations in the improvement of Joint United Nations Program on HIV and AIDS 90-90-90: case of the Yaoundé Central Hospital

Community-based organizations (CBOs) are one of the initiatives implemented in Cameroon to improve access to antiretroviral treatment and influence retention in treatment centers. Despite its importance in the decongestion of patients in health facilities, we do not have data to evaluate the overall impact of these organizations. We conducted a two-part observational study. The first part was a descriptive cross-sectional study, where we included patients screened and initiated on anti-retroviral treatment (ART) either by the approved Treatment center (ATC) of Yaoundé Central Hospital (YCH) or by any of our CBOs in 2020. Then, the second part was a retrospective cohort-type study including patients from the 2015 cohort followed up from 2018 to 2020 in order to assess viral load suppression. As regards the first "90", 7,234 screening tests were performed by CBOs in 2020 out of the 28,302 screening tests registered at the YCH, giving a contribution of 25.6%. From the 7,234 screening tests performed by CBOs, 314 people had an HIV-positive result and 230 (73.34%) were linked to ART through CBOs. From the 28,302 screening tests performed at YCH, 1,089 people had an HIV-positive test, and only 354 (32.50%) were linked to ART, giving a significant difference in the link to ART (P-value < 0.00). Concerning the 3rd ''90'', the viral load suppression rates were respectively in CBOs and at YCH of (95.12% vs 90.54%, RR= 0.51; P-value= 0.27 at 12 months); (95.96% vs 95.34%, relative risk (RR)= 0.85; P-value= 0.81 at 24 months); and (96.91% vs 94.15%, RR= 0.52; P-value = 0.24 at 36 months). In conclusion, we say that the follow-up of patients living with HIV in the community does not negatively affect the evolution of the disease as one might think.

The HIV care continuum of Guinea-Bissau; Progress towards the UNAIDS 90-90-90 targets for HIV-1 and HIV-2

OBJECTIVE

In the 2020 UNAIDS HIV treatment goals, 90% of people living with HIV (PLHIV) should be diagnosed, 90% of these should receive antiretroviral treatment (ART) and 90% of these should be virally suppressed. We aimed to evaluate whether Guinea-Bissau fulfills the 2020 treatment goals for both for HIV-1 and HIV-2.

DESIGN

By combining data from a general population survey, treatment records from HIV clinics across Guinea-Bissau and a biobank from patients attending the largest HIV clinics in Bissau, we estimated each column of the 90-90-90 cascade.

METHOD

2601 participated in the survey and were used to estimate the proportion of PLHIV who knew their HIV status and the proportion of PLHIV on ART. Answers given in the survey was verified with treatment records from HIV clinics. We measured viral load from biobank materials from HIV patients and estimated the proportion of virally suppressed PLHIV.

RESULT

19.1% of PLHIV indicated to be aware of their HIV status. Of these, 48.5% received ART, and 76.4% of these were virally suppressed. For HIV-1 and HIV-1/2 the results were 21.2%, 40.9% and 75.1%. For HIV-2 the results were 15.9%, 63.6% and 80.7%. 26.9% of all HIV-1 infected in the survey were virologically suppressed, indicating that a much higher number of HIV-1 infected were aware of their status and on treatment.

CONCLUSION

Guinea-Bissau lags severely behind both the global and regional progress. Improvement in both testing and treating HIV is necessary to improve the quality of care.

Roadmap for Achieving Universal Antiretroviral Treatment

Modern antiretroviral therapy safely, potently, and durably suppresses human immunodeficiency virus (HIV) that, if left untreated, predictably causes acquired immunodeficiency syndrome (AIDS), which has been responsible for tens of millions of deaths globally since it was described in 1981. In one of the most extraordinary medical success stories in modern times, a combination of pioneering basic science, innovative drug development, and ambitious public health programming resulted in access to lifesaving, safe drugs, taken as an oral tablet daily, for most of the world. However, substantial challenges remain in the fields of prevention, timely access to diagnosis, and treatment, especially in pediatric and adolescent patients. As HIV-positive adults age, treating their comorbidities will require understanding the course of different chronic diseases complicated by HIV-related and antiretroviral toxicities and finding potential treatments. Finally, new long-acting antiretrovirals on the horizon promise exciting new options in both the prevention and treatment fields.

Global Health Facility-Based Interventions to Achieve UNAIDS 90-90-90: A Systematic Review and Narrative Analysis

To evaluate whether health facility-based HIV interventions align with UNAIDS 90-90-90 targets, we performed a systematic review through the lens of UNAIDS targets. We searched 11 databases, retrieving 5201 citations with 26 eligible studies classified by country income and UNAIDS target. We analyzed whether reporting of study outcome metrics was in line with UNAIDS targets using a standardized extraction form and results were summarized in a narrative synthesis given data heterogeneity. We also assessed the quality of randomized trials with the Cochrane Risk of Bias Tool and observational studies with the Newcastle-Ottawa Scale. Stratification of interventions by country income level revealed themes in successful interventions that provide insight for scale-up in similar resource contexts. Few studies reported outcomes using metrics according to UNAIDS targets. Standardization of reporting according to the UNAIDS framework could facilitate comparability of interventions and inform country-level progress on an international scale.

Progress Toward the 90-90-90 HIV Targets in Zimbabwe and Identifying Those Left Behind

OBJECTIVE

We present findings from the nationally representative Zimbabwe Population-based HIV Impact Assessment that characterize Zimbabwe's progress toward the Joint United Nations Programme on HIV/AIDS 90-90-90 targets.

DESIGN

We conducted a cross-sectional household survey.

METHODS

Consenting adults and children in the household were eligible to participate in Zimbabwe Population-based HIV Impact Assessment (October 2015-August 2016). Participants completed face-to-face interviews and provided blood for HIV, CD4, viral load, and syphilis testing. Viral load suppression (VLS) was defined as HIV RNA <1000 copies/mL. HIV-positive specimens were tested for the presence of selected antiretroviral drugs. Data were weighted. Analysis was restricted to HIV-positive adults aged 15-64 years.

RESULTS

We enrolled 11,098 men and 14,033 women aged 15-64 years. HIV prevalence was 14.1%. Of those living with HIV, 76.8% (95% confidence interval [CI]: 74.9 to 78.7) were aware of their HIV status or had detectable antiretroviral levels. Of these, 88.4% (95% CI: 87.1 to 89.7) were receiving antiretroviral therapy (ART), and of these people, 85.3% (95% CI: 83.4 to 87.1) had VLS. Male sex age 15-34 years and having 1 or more sexual partners were associated with being unaware of one's HIV-positive status. Age <50 years and not taking cotrimoxazole were associated with being less likely to be being both aware and taking ART. Male sex, age <50 years, and taking cotrimoxazole were associated with being on ART but not having VLS.

CONCLUSIONS

Zimbabwe has made great strides toward epidemic control. Focusing resources on case finding, particularly among men, people aged <35 years, and sexually active individuals can help Zimbabwe attain 90-90-90 targets.

Estimating the First 90 of the UNAIDS 90-90-90 Goal: A Review

Estimating the population with undiagnosed HIV (PUHIV) is the most methodologically challenging aspect of evaluating 90-90-90 goals. The objective of this review is to discuss assumptions, strengths, and shortcomings of currently available methods of this estimation. Articles from 2000 to 2018 on methods to estimate PUHIV were reviewed. Back-calculation methods including CD4 depletion and test–retest use diagnosis CD4 count, or previous testing history to determine likely infection time thus, providing an estimate of PUHIV for previous years. Biomarker methods use immunoassays to differentiate recent from older infections. Statistical techniques treat HIV status as missing data and impute data for models of infection. Lastly, population surveys using HIV rapid testing most accurately calculates the current HIV prevalence. Although multiple methods exist to estimate the number of PUHIV, the appropriate method for future applications depends on multiple factors, namely data availability and population of interest.

Effectiveness of the Sista2Sista programme in improving HIV and other sexual and reproductive health outcomes among vulnerable adolescent girls and young women in Zimbabwe

Background: In Zimbabwe, adolescent girls and young women (AGYW) experience high rates of HIV and other sexual and reproductive health challenges. In 2013, the Zimbabwe Ministry of Health and Child Care partnered with the United Nations Population Fund to implement the Sista2Sista programme, a structured peer group intervention aimed at improving health outcomes among vulnerable in- and out-of-school AGYW.Methods: Programme data was analysed for 91 612 AGYW aged 10-24 years old who participated in Sista2Sista from 2013 to 2019. Logistic regression was used to determine odds ratios (OR) and evaluate programme exposure as a factor in a set of defined variables.Results: 58 471 AGYW (63.82%) graduated from the Sista2Sista programme by completing at least 30 of 40 exercises. Graduates were more likely to take an HIV test (2.78 OR 95% CI 2.52-3.10), less likely to get married (0.63 OR 95% CI 0.55-0.73) and less likely to drop out of school (0.60 OR 95% CI 0.53-0.69). At higher thresholds of programme completion, additional positive outcomes were observed. Participants who completed all 40 exercises were more likely to return to school (1.41 OR 95% CI 1.18-1.69), more likely to use contraception (1.38 OR 95% CI 1.21-1.56), more likely to report sexual abuse (1.76 OR 95% CI 1.17-2.66), and less likely to become pregnant as adolescents (0.41 OR 95% CI 0.24-0.72). Individual counselling improved the likelihood of programme graduation.Conclusions: The Sista2Sista programme had a positive effect on HIV and other sexual health outcomes among vulnerable AGYW in Zimbabwe. Strategies to improve graduation rates should be explored.

Gaps in HIV Testing and Treatment Among Female Sex Workers in Lae and Mt. Hagen, Papua New Guinea

We conducted biobehavioral surveys among female sex workers (FSW) in Lae and Mt. Hagen, Papua New Guinea (January-December 2017). Respondent-driven sampling was used to recruit FSW aged ≥ 12 years, who were assigned female sex at birth, who spoke English or Tok Pisin, and who sold or exchanged sex for money, goods, or services in the last 6 months. When adjusted for viral suppression, 48.9% of FSW Lae and 61.9% in Mt. Hagen were aware of their HIV positive status. Of these women, 95.3% in Lae and 98.9% in Mt. Hagen were on antiretroviral therapy, and of these, 83.5% in Lae and 87.0% in Mt. Hagen had suppressed viral load. Renewed efforts are needed to increase HIV testing among FSW and provide support to FSW on treatment in both cities to attain viral suppression.

Long-term Experience and Outcomes of Programmatic Antiretroviral Therapy for Human Immunodeficiency Virus Type 2 Infection in Senegal, West Africa

BACKGROUND

Programmatic treatment outcome data for people living with human immunodeficiency virus type 2 (HIV-2) in West Africa, where the virus is most prevalent, are scarce.

METHODS

Adults with HIV-2 initiating or receiving antiretroviral therapy (ART) through the Senegalese national AIDS program were invited to participate in this prospective, longitudinal observational cohort study. We analyzed HIV-2 viral loads, CD4 cell counts, antiretroviral drug resistance, loss to follow-up, and mortality. We also examined changes in treatment guidelines over time and assessed progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets for HIV-2.

RESULTS

We enrolled 291 participants at 2 sites for 926.0 person-years of follow-up over 13 years. Median follow-up time was 2.2 years per participant. There were 21 deaths reported (7.2%), and 117 individuals (40.2%) were lost to follow-up, including 43 (14.7%) who had an initial visit but never returned for follow-up. CD4 counts and HIV-2 viral suppression (< 50 copies/mL) at enrollment increased over calendar time. Over the study period, 76.7% of plasma viral loads for participants receiving ART were suppressed, and median CD4 gain was 84 cells/μL in participants' first 2 years on study. Since the UNAIDS 90-90-90 strategy was published, 88.1% of viral loads were suppressed. Fifteen percent of patients experienced virologic failure with no known resistance mutations, while 56% had evidence of multiclass drug resistance.

CONCLUSIONS

Participants in the Senegalese national AIDS program are initiating ART earlier in the course of disease, and more modern therapeutic regimens have improved outcomes among those receiving therapy. Despite these achievements, HIV-2 treatment remains suboptimal, and significant challenges to improving care remain.

Depression symptoms, HIV testing, linkage to ART, and viral suppression among women in a high HIV burden district in KwaZulu-Natal, South Africa: A cross-sectional household study

Achieving the UNAIDS 90-90-90 targets by 2020 is contingent on identifying and addressing mental health challenges that may affect HIV testing and treatment-related behaviors. This study is based on survey data from KwaZulu-Natal, South Africa (2014–2015). HIV positive women who reported higher depression scores had a lower odds of having tested previously for HIV (15–25 years: AOR = 0.90, 95% CI [0.83, 0.98]; 26–49 years: AOR = 0.90, 95% CI [0.84, 0.96]). Because HIV testing behavior represents a gateway to treatment, the findings suggest mental health may be one challenge to attaining the UNAIDS 90-90-90 targets.

Urgent need to improve programmatic management of patients with HIV failing first-line antiretroviral therapy

Introduction

Delayed identification and response to virologic failure in case of first-line antiretroviral therapy (ART) in resource-limited settings is a threat to the health of HIV-infected patients. There is a need for the implementation of an effective, standardized response pathway in the public sector.

Discussion

We evaluated published cohorts describing virologic failure on first-line ART. We focused on gaps in the detection and management of treatment failure, and posited ways to close these gaps, keeping in mind scalability and standardization. Specific shortcomings repeatedly recorded included early loss to follow-up (>20%) after recognized first-line ART virologic failure; frequent delays in confirmatory viral load testing; and excessive time between the confirmation of first-line ART failure and initiation of second-line ART, which exceeded 1 year in some cases. Strategies emphasizing patient tracing, resistance testing, drug concentration monitoring, adherence interventions, and streamlined response pathways for those failing therapy are further discussed.

Conclusion

Comprehensive, evidence-based, clinical operational plans must be devised based on findings from existing research and further tested through implementation science research. Until this standard of evidence is available and implemented, high rates of losses from delays in appropriate switch to second-line ART will remain unacceptably common and a threat to the success of global HIV treatment programs.

Quantifying alcohol use among Ecuadorian human immunodeficiency virus positive individuals and assessing alcohol as an independent risk factor for human immunodeficiency virus: A case control study STROBE

Alcohol abuse has been identified as a risk factor for contracting human immunodeficiency virus (HIV) and accelerating disease progression. Our study aims to determine alcohol consumption rates among Ecuadorian HIV positive (HIV+) patients prior to diagnosis to evaluate its impact as an independent risk factor for contracting HIV. Additionally, we will examine post-diagnosis consumption rates among the HIV+ population.We provided anonymous questionnaires to 300 HIV+ patients and 600 internal medicine patients at 3 hospitals in Quito, Ecuador. Questionnaires quantified alcohol usage prior to HIV diagnosis, at time of diagnosis, and post-diagnosis while accounting for other potential HIV risk factors. We then determined frequencies of alcohol consumption and confounding variables. Finally, we performed a multivariable logistic regression controlling for confounders to determine the statistical significance of alcohol consumption as an independent risk factor for HIV.Our results showed increased odds for contracting HIV among those who drank daily (OR 5.3, CI 2.0-14.0) and those who consumed 6 or more alcoholic beverages on days they drank (OR 5.0, CI 3.1-8.2). Through multivariable analysis, we found that abstaining from binge drinking was a protective factor with an OR 0.5 (0.3-0.96). The percentage of HIV+ patients abstaining from alcohol increased from 30% twelve months prior to diagnosis to 57% after diagnosis.Our results show that alcohol abuse significantly increases the risk of contracting HIV. We found that prior to diagnosis, HIV patients consistently drank more frequently and a greater amount than the control group. Alcohol use significantly decreased among HIV+ patients after diagnosis.

Evidence of sociodemographic heterogeneity across the HIV treatment cascade and progress towards 90-90-90 in sub-Saharan Africa - a systematic review and meta-analysis

Introduction

Heterogeneity of sociodemographics and risk behaviours across the HIV treatment cascade could influence the public health impact of universal ART in sub‐Saharan Africa if those not virologically suppressed are more likely to be part of a risk group contributing to onward infections. Sociodemographic and risk heterogeneity across the treatment cascade has not yet been comprehensively described or quantified and we seek to systematically review and synthesize research on this topic among adults in Africa.

Methods

We conducted a systematic review of peer‐reviewed literature in Embase and MEDLINE databases as well as grey literature sources published in English between 2014 and 2018. We included studies that included people living with HIV (PLHIV) aged ≥15 years, and reported a 90‐90‐90 outcome: awareness of HIV‐positive status, ART use among those diagnosed or viral suppression among those on ART. We summarized measures of association between sociodemographics, within each outcome, and as a composite measure of population‐wide viral suppression.

Results and discussion

From 3533 screened titles, we extracted data from 92 studies (50 peer‐reviewed, 42 grey sources). Of included studies, 32 reported on awareness, 53 on ART use, 32 on viral suppression and 23 on population‐wide viral suppression. The majority of studies were conducted in South Africa, Uganda, and Malawi and reported data for age and gender. When stratified, PLHIV ages 15 to 24 years had lower median achievement of the treatment cascade (60‐49‐81), as compared to PLHIV ≥25 years (70‐63‐91). Men also had lower median achievement of the treatment cascade (66‐72‐85), compared to women (79‐76‐89). For population‐wide viral suppression, women aged ≥45 years had achieved the 73% target, while the lowest medians were among 15‐ to 24‐year‐old men (37%) and women (49%).

Conclusions

Considerable heterogeneity exists by age and gender for achieving the HIV 90‐90‐90 treatment goals. These results may inform delivery of HIV testing and treatment in sub‐Saharan Africa, as targeting youth and men could be a strategic way to maximize the population‐level impact of ART.

Expansion of HIV testing in Eswatini: stakeholder perspectives on reaching the first 90

Achieving the United Nations' 90-90-90 goals has proven challenging in most settings and the ambitious 95-95-95 goals seem even more elusive. However, in Eswatini - a lower-middle-income country in sub-Saharan Africa with the highest HIV prevalence in the world - an estimated 92% of people living with HIV know their status. We conducted 26 in-depth interviews with stakeholders from policy, implementation, donor, local advocacy and academic sectors to elicit the facilitators and inhibitors to HIV testing uptake in Eswatini. Background data and related reports and policy documents (n = 57) were also reviewed. Essential facilitators included good governance via institutional and national budgetary commitments, which often led to swift adoption of globally recommended programs and standards. The integration of HIV testing into all points of care fostered a sense that testing was part of routine care, which reduced stigma. Challenges, however, centred on social norms that disadvantage certain groups with high ongoing HIV risk (such as key populations, adolescent girls and young women), a heavy reliance on external donor funding, and stigma that had subsided but nevertheless persisted. Amid concerns about whether the 90-90-90 targets could be achieved by 2020, the experience of Eswatini provides tangible insights into factors that have successfully influenced HIV testing uptake and may thus prove informative for other countries.

Point-of-care viral load monitoring: outcomes from a decentralized HIV programme in Malawi

Introduction

Routinely monitoring the HIV viral load (VL) of people living with HIV (PLHIV) on anti‐retroviral therapy (ART) facilitates intensive adherence counselling and faster ART regimen switch when treatment failure is indicated. Yet standard VL‐testing in centralized laboratories can be time‐intensive and logistically difficult in low‐resource settings. This paper evaluates the outcomes of the first four years of routine VL‐monitoring using Point‐of‐Care technology, implemented by Médecins Sans Frontières (MSF) in rural clinics in Malawi.

Methods

We conducted a retrospective cohort analysis of patients eligible for routine VL‐ testing between 2013 and 2017 in four decentralized ART‐clinics and the district hospital in Chiradzulu, Malawi. We assessed VL‐testing coverage and the treatment failure cascade (from suspected failure (first VL>1000 copies/mL) to VL suppression post regimen switch). We used descriptive statistics and multivariate logistic regression to assess factors associated with suspected failure.

Results and Discussion

Among 21,400 eligible patients, VL‐testing coverage was 85% and VL suppression was found in 89% of those tested. In the decentralized clinics, 88% of test results were reviewed on the same day as blood collection, whereas in the district hospital the median turnaround‐time for results was 85 days. Among first‐line ART patients with suspected failure (N = 1544), 30% suppressed (VL<1000 copies/mL), 35% were treatment failures (confirmed by subsequent VL‐testing) and 35% had incomplete VL follow‐up. Among treatment failures, 80% (N = 540) were switched to a second‐line regimen, with a higher switching rate in the decentralized clinics than in the district hospital (86% vs. 67%, p < 0.01) and a shorter median time‐to‐switch (6.8 months vs. 9.7 months, p < 0.01). Similarly, the post‐switch VL‐testing rate was markedly higher in the decentralized clinics (61% vs. 26%, p < 0.01). Overall, 79% of patients with a post‐switch VL‐test were suppressed.

Conclusions

Viral load testing at the point‐of‐care in Chiradzulu, Malawi achieved high coverage and good drug regimen switch rates among those identified as treatment failures. In decentralized clinics, same‐day test results and shorter time‐to‐switch illustrated the game‐changing potential of POC‐based VL‐testing. Nevertheless, gaps were identified along all steps of the failure cascade. Regular staff training, continuous monitoring and creating demand are essential to the success of routine VL‐testing.

The Impact of ACA and Medicaid Expansion on Progress Toward UNAIDS 90-90-90 Goals

PURPOSE OF REVIEW

Passage of the Affordable Care Act (ACA) in 2010 and subsequent Medicaid expansion has influenced access to HIV treatment and care in the USA. This review aims to evaluate whether the implementation of these policies has impacted progress toward UNAIDS 90-90-90 goals.

RECENT FINDINGS

Preliminary evidence has emerged suggesting that the ACA and Medicaid expansion has increased the likelihood of HIV testing and diagnosis, reduced the number of people unaware of HIV infection, and increased the number of people on antiretroviral therapy (ART) who are virally suppressed. While the ACA is associated with some progress toward 90-90-90 goals, more years of data after policy implementation are needed for robust analysis. Methods including difference-in-differences, instrumental variables, and propensity scores are recommended to minimize bias from unmeasured confounders and make causal inference about non-random Medicaid expansion among states.

Re-thinking Linkage to Care in the Era of Universal Test and Treat: Insights from Implementation and Behavioral Science for Achieving the Second 90

To successfully link to care, persons living with HIV must negotiate a complex series of processes from HIV diagnosis through initial engagement with HIV care systems and providers. Despite the complexity involved, linkage to care is often oversimplified and portrayed as a single referral step. In this article, we offer a new conceptual framework for linkage to care, tailored to the current universal test and treat era that presents linkage to care as its own nuanced pathway within the larger HIV care cascade. Conceptualizing linkage to care in this way may help better identify and specify processes posing a barrier to linkage, and allow for the development of targeted implementation and behavioral science-based approaches to address them. Such approaches are likely to be most relevant to programmatic and clinical settings with limited resources and high HIV burden.

Community-based antiretroviral therapy (ART) delivery for female sex workers in Tanzania: intervention model and baseline findings

To increase linkage to and retention in antiretroviral therapy (ART) care, we piloted a community-based, ART service delivery intervention for female sex workers (FSWs). At baseline, we recruited and collected data from 617 FSWs (intervention: 309; comparison: 308) who were HIV positive and not on ART. This paper presents (1) the description of the intervention model, and (2) key descriptive and bivariate-level findings of the baseline FSW cohort. The data showed more than half of FSWs had a non-paying sex partner, and less than one-third used a condom at last sex with paying and non-paying clients, which suggest potentially high levels of HIV transmission. In addition, there is a gap in HIV testing and treatment because one-third learned about their HIV-positive status only at study enrollment, and among FSWs who had known their status for more than a month, half had not registered in care. This substantiates the importance of timely HIV diagnosis and treatment. A community-based ART program may serve as an important strategy in closing the HIV care and treatment gap for FSWs.

The 2016 HIV diagnosis and care cascade in New South Wales, Australia: meeting the UNAIDS 90-90-90 targets

Introduction

The HIV Strategy in New South Wales (NSW) Australia aims to virtually eliminate HIV transmission by 2020. We estimated the 2016 HIV diagnosis and care cascade for the state of NSW, with a focus on introducing population‐based data to improve data quality and assess progress towards the UNAIDS 90‐90‐90 targets.

Methods

To estimate the number of people living with diagnosed HIV (PLDHIV) we used NSW data from the Australian National HIV Registry, enhanced by surveillance among people recently diagnosed with HIV to improve migration estimates. The number of undiagnosed PLHIV was estimated using back‐projection modelling by CD4 count at diagnosis. De‐duplicated prescription claims data were obtained from the Australian Pharmaceutical Benefits Scheme (PBS), and were combined with an estimate for those ineligible, to determine the number of PLDHIV on antiretroviral therapy (ART). Data from a clinic network with 87% coverage of PLDHIV in NSW enabled the estimation of the number on ART who had HIV suppression.

Results and discussion

We estimated that 10,110 PLHIV resided in NSW in 2016 (range 8400 to 11,720), among whom 9230 (91.3%) were diagnosed, and 8490 (92.0% of those diagnosed) were receiving ART. Among PLDHIV receiving ART, 8020 (94.5%) had suppressed viral load (<200 HIV‐1 RNA copies/mL). Overall, 79.3% of all PLHIV had HIV virological suppression.

Conclusion

NSW has met each of the UNAIDS 90‐90‐90 targets. The enhanced surveillance methods and data collection systems improved data quality. Measuring and meeting the 90‐90‐90 targets is feasible and could be achieved in comparable parts of the world.

Demographic and risk group heterogeneity across the UNAIDS 90-90-90 targets: a systematic review and meta-analysis protocol

BACKGROUND

Despite policies for universal HIV testing and treatment (UTT) regardless of CD4 count, there are still 1.8 million new HIV infections and 1 million AIDS-related deaths annually. The UNAIDS 90-90-90 goals target suppression of HIV viral load in 73% of all HIV-infected people worldwide by 2030. However, achieving these targets may not lead to expected reductions in HIV incidence if the remaining 27% (persons with unsuppressed viral load) are the drivers of HIV transmission through high-risk behaviors. We aim to conduct a systematic review and meta-analysis to understand the demographics, mobility, geographic distribution, and risk profile of adults who are not virologically suppressed in sub-Saharan Africa in the era of UTT.

METHODS

We will review the published and grey literature for study sources that contain data on demographic and behavioral strata of virologically suppressed and unsuppressed populations since 2014. We will search PubMed and Embase using four sets of search terms tailored to identify characteristics associated with virological suppression (or lack thereof) and each of the individual 90-90-90 goals. Record screening and data abstraction will be done independently and in duplicate. We will use random effects meta-regression analyses to estimate the distribution of demographic and risk features among groups not virologically suppressed and for each individual 90-90-90 goal.

DISCUSSION

The results of our review will help elucidate factors associated with failure to achieve virological suppression in sub-Saharan Africa, as well as factors associated with failure to achieve each of the 90-90-90 goals. These data will help quantify the population-level effects of current HIV treatment interventions to improve strategies for maximizing virological suppression and ending the HIV epidemic.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018089505 .

Treatment as Prevention for HIV Infection: Current Data, Challenges, and Global Perspectives

In 2008, the Swiss National AIDS Commission issued a statement about the safety of HIV treatment in terms of reduced transmission in serodiscordant couples to reduce transmission in serodiscordant couples. This was subjected to debate until 2011 when the HIV prevention trial network 052 published the first randomized study about HIV transmission in serodiscordant couples, where no transmission was observed when the infected person was under effective antiretroviral treatment (ART). Later, the Partners of People on ART-A New Evaluation of the Risks (PARTNER) and the opposites attract studies, which first involved a large number of men who have sex with men (MSM), also showed no transmission, even in condomless receptive anal intercourse (CLAI). In this article, we first review the major studies' data showing the efficacy of ART in HIV transmission in serodiscordant couples at public health scale. Second, we discuss the implications and challenges behind the treatment as prevention strategy regarding the 90-90-90 UNAIDS targets to end the HIV epidemic.We now have strong evidence that ART reduces the risk of transmission of HIV from a positive partner to their negative partner. However, far beyond ART, combining prevention policies is crucial to avoid a new increase in the overall HIV incidence.

Low Case Finding Among Men and Poor Viral Load Suppression Among Adolescents Are Impeding Namibia's Ability to Achieve UNAIDS 90-90-90 Targets

Background

In 2015, Namibia implemented an Acceleration Plan to address the high burden of HIV (13.0% adult prevalence and 216 311 people living with HIV [PLHIV]) and achieve the UNAIDS 90-90-90 targets by 2020. We provide an update on Namibia's overall progress toward achieving these targets and estimate the percent reduction in HIV incidence since 2010.

Methods

Data sources include the 2013 Namibia Demographic and Health Survey (2013 NDHS), the national electronic patient monitoring system, and laboratory data from the Namibian Institute of Pathology. These sources were used to estimate (1) the percentage of PLHIV who know their HIV status, (2) the percentage of PLHIV on antiretroviral therapy (ART), (3) the percentage of patients on ART with suppressed viral loads, and (4) the percent reduction in HIV incidence.

Results

In the 2013 NDHS, knowledge of HIV status was higher among HIV-positive women 91.8% (95% confidence interval [CI], 89.4%-93.7%) than HIV-positive men 82.5% (95% CI, 78.1%-86.1%). At the end of 2016, an estimated 88.3% (95% CI, 86.3%-90.1%) of PLHIV knew their status, and 165 939 (76.7%) PLHIV were active on ART. The viral load suppression rate among those on ART was 87%, and it was highest among ≥20-year-olds (90%) and lowest among 15-19-year-olds (68%). HIV incidence has declined by 21% since 2010.

Conclusions

With 76.7% of PLHIV on ART and 87% of those on ART virally suppressed, Namibia is on track to achieve UNAIDS 90-90-90 targets by 2020. Innovative strategies are needed to improve HIV case identification among men and adherence to ART among youth.

Statewide Evaluation of New HIV Diagnoses in Rhode Island: Implications for Prevention

OBJECTIVES

Patterns of HIV transmission vary widely across demographic groups. Identifying and engaging these groups are necessary to prevent new infections and diagnose disease among people who are unaware of their infection. The objective of this study was to determine characteristics of newly diagnosed individuals across an entire state to determine patterns of HIV transmission.

METHODS

We evaluated data on people with new HIV diagnoses in Rhode Island from 2013 through 2015. We performed a latent class analysis (LCA) to identify underlying demographic and behavioral characteristics of people with newly diagnosed HIV.

RESULTS

Of 167 people with new HIV diagnoses interviewed in Rhode Island from 2013 through 2015, 132 (79%) were male, 84 (50%) were nonwhite, 112 (67%) were men who have sex with men (MSM), 112 (67%) were born in the United States, and 61 (37%) were born in Rhode Island. LCA revealed 2 major classes. Of the 98 people in class 1, 96% were male, 85% were MSM, 80% were white, 94% were born in the United States, and 80% believed they acquired HIV in Rhode Island. Class 2 was 63% male and 69% Hispanic/Latino; 29% were born in the United States, and 61% believed they acquired HIV in Rhode Island.

CONCLUSIONS

Most new HIV diagnoses in Rhode Island were among MSM born in the United States, and a substantial number were likely infected in-state. People with newly diagnosed HIV who were foreign-born, including Hispanic/Latino and heterosexual groups, were less likely to have acquired HIV in Rhode Island than were MSM. HIV prevention approaches, including pre-exposure prophylaxis, should be adapted to the needs of specific groups. Rhode Island offers lessons for other states focused on eliminating HIV transmission.

Achieving Viral Suppression in 90% of People Living With Human Immunodeficiency Virus on Antiretroviral Therapy in Low- and Middle-Income Countries: Progress, Challenges, and Opportunities

Although significant progress has been made, the latest data from low- and middle-income countries show substantial gaps in reaching the third "90%" (viral suppression) of the UNAIDS 90-90-90 goals, especially among vulnerable and key populations. This article discusses critical gaps and promising, evidence-based solutions. There is no simple and/or single approach to achieve the last 90%. This will require multifaceted, scalable strategies that engage people living with human immunodeficiency virus, motivate long-term treatment adherence, and are community-entrenched and ‑supported, cost-effective, and tailored to a wide range of global communities.

Two diseases, same person: moving toward a combined HIV and tuberculosis continuum of care

The human immunodeficiency virus (HIV) and Mycobacterium tuberculosis syndemic remains a global public health threat. Separate HIV and tuberculosis (TB) global targets have been set; however, success will depend on achieving combined disease control objectives and care continua. The objective of this study was to review available policy, budgets, and data to reconceptualize TB and HIV disease control objectives by combining HIV and TB care continua. For 22 World Health Organization (WHO) TB and TB/HIV priority countries, we used 2015 data from the HIV90-90-90watch website, UNAIDS AIDSinfo, and WHO 2016 and 2017 Global TB Reports. Global resources available in TB and HIV/TB activities for 2003-2017 were collected from publicly available sources. In 22 high-burden countries, people living with HIV on antiretroviral therapy ranged from 9 to 70%; viral suppression was 38-63%. TB treatment success ranged from 71 to 94% with 14 (81% HIV/TB burden) countries above 80% TB treatment success. From 2003 to 2017, reported global international and domestic resources for HIV-associated TB and TB averaged $2.85 billion per year; the total for 2003-2017 was 43 billion dollars. Reviewing combined HIV and TB targets demonstrate disease control progress and challenges. Using an integrated HIV and TB continuum supports HIV and TB disease control efforts focused on improving both individual and public health.

Progress towards the United Nations 90-90-90 and 95-95-95 targets: the experience in British Columbia, Canada

Introduction

Antiretroviral therapy (ART) scale‐up is central to the global strategy to control the HIV/AIDS pandemic. To accelerate efforts towards ending the AIDS epidemic, the Joint United Nations Programme on HIV/AIDS released the 90‐90‐90 and 95‐95‐95 targets, which have recently been approved by the United Nations (UN). This study characterizes the province of British Columbia (BC)'s progress towards achieving the UN targets, predicts a trajectory up to 2030 according to each of the individual steps (i.e. %Diagnosed, %On ART and %Virologically Suppressed), and identifies the population sub‐groups at higher risk of not achieving these targets.

Methods

The analyses were based on linked individual‐level datasets of people living with HIV (PLWH) in BC, aged ≥18 months, from 2000 to 2013. Using past trends in HIV prevalence and of each individual UN targets, we forecasted these outcomes until 2030 via generalized additive models. We ran a second set of analyses to assess the associations between individual demographic and behavioural factors and each of the individual steps of the UN targets. Lastly, we performed sensitivity analyses to account for uncertainty associated with prevalence estimates and suppression definitions.

Results

Among the estimated 10666 PLWH in BC in 2013, 82% were diagnosed, 76% of those diagnosed were on ART and 83% of those on ART were virologically suppressed. We identified that females, PLWH aged <30 years and those with unknown risk or who self‐identify as having a history of injection drug use were the population subgroups that experienced the most challenge in engaging on ART and achieving viral suppression. Our model projections suggest that BC will achieve 90%‐91%‐90% and 97%‐99%‐97% by 2020 and 2030 respectively.

Conclusions

As we approach 2020, BC is rapidly moving towards achieving the UN targets. However, region‐specific challenges persist. Identification of remaining regional challenges will be essential to achieving the proposed UN targets and therefore fulfilling the promise to end AIDS as a pandemic by 2030.

"I will take ARVs once my body deteriorates": an analysis of Swazi men's perceptions and acceptability of Test and Start

Swaziland has the highest HIV prevalence in the world. To mitigate the spread and devastation caused by HIV and to improve the wellbeing of people living with HIV, the country has adopted the latest available HIV prevention campaigns, including "Test and Start". Because evidence from randomised controlled trials has demonstrated a significant risk reduction in HIV transmission when HIV-positive people start antiretroviral therapy (ART) early, Swaziland aims to find these people and link them to treatment. This study presents findings regarding the perceptions of this promising HIV-prevention intervention among men aged 17-69 years. A combination of qualitative methods including focus group discussions (12), in-depth interviews (17), informal conversations and participant observation (21) were used to collect data in two peri-urban communities in 2013-2014. Findings illustrate that men still fear taking an HIV test because of a relatively high probability of a positive test which some still interpret as a death sentence. Other potential barriers to the effectiveness of Test and Start programmes include lack of hospitality in hospitals, fear of starting treatment early related to side effects of ART, poverty, and lack of trust in the financial stability of the Swazi government. We argue that several social factors need to be considered for the Test and Start programme to be more effective.

Evidence of reduced treatment adherence among HIV infected paediatric and adolescent populations in Nairobi at the onset of the UNAIDS Universal Test and Treat Program

OBJECTIVE

We conducted a retrospective cohort study to evaluate the efficacy of the World Health Organization (WHO) "Universal Test and Treat" (UTT) policy, initiated in Kenya in September 2016. Under this policy, every human immunodeficiency virus (HIV)-infected person should be initiated on antiretroviral therapy (ART). We compared intra- and inter-group viral suppression and ART adherence rates for pre-UTT (initiated on ART in March-August 2016) and UTT groups (initiated in September 2016). The study was conducted in a community outreach Program in Nairobi with 3500 HIV-infected children enrolled.

RESULTS

122 children and adolescents were initiated on first-line ART pre-UTT, and 197 during the UTT period. The 6 month viral suppression rate was 79.7% pre-UTT versus 76.6% UTT (P < 0.05). Suboptimal adherence was higher in the UTT than pre-UTT period (88 of 197, 44.7% and 44 of 122, 34%; P < 0.001). The decrease in adherence was greater among orphans (91.7% pre-UTT and 87.2% UTT, P = 0.001) and children 11-18 years. Our results show that successful implementation of the UTT policy in Africa is challenged by an increased risk of suboptimal adherence. There is a need to develop extra strategies to support adherence, especially among orphans and teenagers.

When patients fail UNAIDS' last 90 - the "failure cascade" beyond 90-90-90 in rural Lesotho, Southern Africa: a prospective cohort study

Introduction: HIV-infected individuals on first-line antiretroviral therapy (ART) in resource-limited settings who do not achieve the last “90” (viral suppression) enter a complex care cascade: enhanced adherence counselling (EAC), repetition of viral load (VL) and switch to second-line ART aiming to achieve resuppression. This study describes the “failure cascade” in patients in Lesotho.

Methods: Patients aged ≥16 years on first-line ART at 10 facilities in rural Lesotho received a first-time VL in June 2014. Those with VL ≥80 copies/mL were included in a cohort. The care cascade was assessed at four points: attendance of EAC, result of follow-up VL after EAC, switch to second-line in case of sustained unsuppressed VL and outcome 18 months after the initial unsuppressed VL. Multivariate logistic regression was used to assess predictors of being retained in care with viral resuppression at follow-up.

Results: Out of 1563 patients who underwent first-time VL, 138 (8.8%) had unsuppressed VL in June 2014. Out of these, 124 (90%) attended EAC and 116 (84%) had follow-up VL (4 died, 2 transferred out, 11 lost, 5 switched to second-line before follow-up VL). Among the 116 with follow-up VL, 36 (31%) achieved resuppression. Out of the 80 with sustained unsuppressed VL, 58 were switched to second-line, the remaining continued first line. At 18 months’ follow-up in December 2015, out of the initially 138 with unsuppressed VL, 56 (41%) were in care and virally suppressed, 37 (27%) were in care with unsuppressed VL and the remaining 45 (33%) were lost, dead, transferred to another clinic or without documented VL. Achieving viral resuppression after EAC (adjusted odds ratio (aOR): 5.02; 95% confidence interval: 1.14–22.09; p = 0.033) and being switched to second-line in case of sustained viremia after EAC (aOR: 7.17; 1.90–27.04; p = 0.004) were associated with being retained in care and virally suppressed at 18 months of follow-up. Age, gender, education, time on ART and level of VL were not associated.

Conclusions: In this study in rural Lesotho, outcomes along the “failure cascade” were poor. To improve outcomes in this vulnerable patient group who fails the last “90”, programmes need to focus on timely EAC and switch to second line for cases with continuous viremia despite EAC.

90-90-90-Plus: Maintaining Adherence to Antiretroviral Therapies

Medication adherence is the "Plus" in the global challenge to have 90% of HIV-infected individuals tested, 90% of those who are HIV positive treated, and 90% of those treated achieve an undetectable viral load. The latter indicates viral suppression, the goal for clinicians treating people living with HIV (PLWH). The comparative importance of different psychosocial scales in predicting the level of antiretroviral adherence, however, has been little studied. Using data from a cross-sectional study of medication adherence with an international convenience sample of 1811 PLWH, we categorized respondent medication adherence as None (0%), Low (1-60%), Moderate (61-94%), and High (95-100%) adherence based on self-report. The survey contained 13 psychosocial scales/indices, all of which were correlated with one another (p < 0.05 or less) and had differing degrees of association with the levels of adherence. Controlling for the influence of race, gender, education, and ability to pay for care, all scales/indices were associated with adherence, with the exception of Berger's perceived stigma scale. Using forward selection stepwise regression, we found that adherence self-efficacy, depression, stressful life events, and perceived stigma were significant predictors of medication adherence. Among the demographic variables entered into the model, nonwhite race was associated with double the odds of being in the None rather than in the High adherence category, suggesting these individuals may require additional support. In addition, asking about self-efficacy, depression, stigma, and stressful life events also will be beneficial in identifying patients requiring greater adherence support. This support is essential to medication adherence, the Plus to 90-90-90.

Antiretroviral therapy related adverse effects: Can sub-Saharan Africa cope with the new "test and treat" policy of the World Health Organization?

BACKGROUND

Recent studies have shown that early antiretroviral therapy (ART) initiation results in significant HIV transmission reduction. This is the rationale behind the "test and treat" policy of the World Health Organization (WHO). Implementation of this policy will lead to an increased incidence of ART-related adverse effects, especially in sub-Saharan Africa (SSA). Is the region yet ready to cope with such a challenging issue?

MAIN BODY

The introduction and widespread use of ART have drastically changed the natural history of HIV/AIDS, but exposure to ART leads to serious medication-related adverse effects mainly explained by mitochondrial toxicities, and the situation will get worse in the near future. Indeed, ART is associated with an increased risk of developing cardiovascular disease, lipodystrophy, prediabetes and overt diabetes, insulin resistance and hyperlactatemia/lactic acidosis. The prevalence of these disorders is already high in SSA, and the situation will be exacerbated by the implementation of the new WHO recommendations. Most SSA countries are characterized by (extreme) poverty, very weak health systems, inadequate and low quality of health services, inaccessibility to existing health facilities, lack of (qualified) health personnel, lack of adequate equipment, inaccessibility and unaffordability of medicines, and heavy workload in a context of a double burden of disease. Additionally, there is dearth of data on the incidence and predictive factors of ART-related adverse effects in SSA, to anticipate on strategies that should be put in place to prevent the occurrence of these conditions or properly estimate the upcoming burden and prepare an adequate response plan. These are required if we are to anticipate and effectively prevent this upcoming burden.

CONCLUSION

While SSA would be the first region to experience the huge benefits of implementing the "test and treat" policy of the WHO, the region is not yet prepared to manage the consequential increased burden of ART-related toxic and metabolic complications. Urgent measures should be taken to fill the lacunae if SSA is not to become over-burdened by the consequences of the "test and treat" policy.

Epidemiological impact of achieving UNAIDS 90-90-90 targets for HIV care in India: a modelling study

OBJECTIVE

Recent UNAIDS '90-90-90' targets propose that to end the HIV epidemic by 2030, 90% of persons living with HIV (PLWH) worldwide should know their diagnosis, 90% of diagnosed PLWH should be on antiretroviral therapy (ART) and 90% of PLWH on ART should be virally suppressed by 2020. We sought to quantify the epidemiological impact of achieving these targets in India.

METHODS

We constructed a dynamic-transmission model of the Indian HIV epidemic to project HIV infections and AIDS-related deaths that would occur in India over 15 years. We considered several scenarios: continuation of current care engagement (with early ART initiation), achieving 90-90-90 targets on time and delaying achievement by 5 or 10 years.

RESULTS

In the base case, assuming continuation of current care engagement, we project 794 000 (95% uncertainty range (UR) 571 000-1 104 000) HIV infections and 689 000 (95% UR 468 000-976 000) AIDS-related deaths in India over 15 years. In this scenario, nearly half of PLWH diagnosed would fail to achieve viral suppression by 2030. With achievement of 90-90-90 targets, India could avert 392 000 (95% UR 248 000-559 000) transmissions (48% reduction) and 414 000 (95% UR 260 000-598 000) AIDS-related deaths (59% reduction) compared to the base-case scenario. Furthermore, fewer than 20 000 (95% UR 12 000-30 000) HIV infections would occur in 2030. Delaying achievement of targets resulted in a similar reduction in HIV incidence by 2030 but at the cost of excess overall infections and mortality.

CONCLUSIONS

India can halve the epidemiological burden of HIV over 15 years with achievement of the UNAIDS 90-90-90 targets. Reaching the targets on time will require comprehensive healthcare strengthening, especially in early diagnosis and treatment, expanded access to second-line and third-line ART and long-term retention in care.

The 90 90 90 strategy to end the HIV Pandemic by 2030: Can the supply chain handle it?

Introduction

UNAIDS “90-90-90” strategy calls for 90% of HIV-infected individuals to be diagnosed by 2020, 90% of whom will be on anti-retroviral therapy (ART) and 90% of whom will achieve sustained virologic suppression. Reaching these targets by 2020 will reduce the HIV epidemic to a low-level endemic disease by 2030. However, moving the global response towards this universal test and treat model will pose huge challenges to public health systems in resource-limited settings, including global and local supply chain systems. These challenges are especially acute in Africa, which accounts for over 70% of the persons affected by HIV.

Discussion

From a supply chain perspective, each of the “90's” has possible complications and roadblocks towards realizing the promise envisioned by 90-90-90. For instance, ensuring that 90% of HIV-infected persons know their status will require a large increase in access to HIV tests compared with what is currently available. To ensure that there are enough anti-retrovirals available to treat the nearly 25 million people that will require them by 2020 represents a near doubling of the ARV supplied to treat the 13 million currently on treatment. Similarly, to monitor those on treatment means an unprecedented scale-up of viral load testing throughout Africa.

Conclusions

Larger issues include whether the capacity exists at the local level to handle these commodities when they arrive in the most severely affected countries, including considerations of the human resources and costs needed to make this strategy effective. We believe that such “real world” analysis of proposed strategies and policies is essential to ensure their most effective implementation.

Getting the balance right: Scaling-up treatment and prevention

The goals of the international response to control the HIV epidemic include high antiretroviral therapy (ART) coverage with HIV viral suppression, as well as reduction of new infections. ART use at individual and population levels reduces HIV morbidity and mortality and likely reduces HIV incidence. HIV viral suppression requires high levels of ART adherence, which necessitates support through behavioural and structural interventions to optimise effectiveness of the use of ART for prevention. Many people living with HIV remain unaware that they are HIV-infected, and HIV transmission risk is high during early infection, therefore ART expansion should be accompanied by other interventions in order to achieve the promise of treatment for prevention. Biomedical and behavioural prevention efforts focused on HIV-uninfected individuals at substantial risk of HIV acquisition are also needed to control the epidemic. Maintaining prevention programming is essential during the scale up of ART to reduce HIV transmission.