Research Article: Monitoring HIV Treatment and the Health Sector Cascade: From Treatment Numbers to Impact

Date Published: April 11, 2017

Publisher: Springer US

Author(s): Daniel Low-Beer, Michel Beusenberg, Chika Hayashi, Txema Calleja, Kimberly Marsh, Awandha Mamahit, Theresa Babovic, Gottfried Hirnschall.


Although not originally part of the MDGs, HIV treatment has been at the center of global HIV reporting since 2003, marked by achievement of the target of 15 million people receiving treatment before 2015 and 18.2 million (16.1–19.0 million) by mid 2016. Monitoring of treatment has been strengthened with harmonized partner reporting and accountability with regular, annual reports. Beyond treatment numbers, increasingly measures of treatment adherence, retention and outcomes have been reported though with varying quality and completeness. However, with the sustainable development goals (SDGs), monitoring treatment is changing in three important ways. First, treatment monitoring is shifting from numbers to coverage and gaps in a cascade of services to achieve universal access. Secondly, this requires greater emphasis on disaggregated, individual level patient and case monitoring systems, which can better support linkage, retention and chronic, long term care. Thirdly, the prevention, testing and treatment cascade with a clear results chain, links treatment numbers to impact, in terms of reduced viral load, mortality and incidence. This agenda will require a greater contribution of routine impact evaluation alongside monitoring, with treatment seen as part of a cascade of services to ensure impact on mortality and incidence. In conclusion, the shift from monitoring treatment numbers to treatment linked to universal access to prevention, testing and treatment and impact on mortality and incidence, will be critical to monitor, evaluate, and improve HIV programs as part of the SDGs.

Partial Text

In 2000, HIV treatment monitoring and targets were not at the center of the UN General Assembly Resolution on AIDS [1]. There was divided commitment to global treatment, and despite over 500,000 people on treatment globally, only 11,000 received ARVs in Africa [2]. With the support of civil society and government leaders, together with new funding sources, PEPFAR and the Global Fund to fight AIDS, TB and malaria, treatment numbers and targets became central to HIV global monitoring.

In the very first few years following UNGASS [1], there were no agreed global targets for treatment, and similarly access to treatment was also not global and did not for example address the treatment needs in Africa or low-income countries.

A number of key components have been identified which drove the setting, accountability and progress towards treatment targets [2]:Political commitment and partnerships were focused on targets—raising financing and promoting accountability for these targets.A public health approach was put into practice—the targets were supported by a package of HIV services and guidance.Civil society extended the HIV response into communities—civil society advocated for global targets, reduced treatment prices, and supported the expansion of services into communities.Funding was mobilized and costs were reduced—global commitments were followed through with financing partnerships, domestic funding also increased substantially, and treatment costs reduced by 90%.Innovations in science and implementation were widely used—global technical and implementation guidance was adapted over time as new science and implementation experience was harnessed.Data was improved and increasingly drove decisions—targets were set at global and country levels and supported by investments in data, so that global targets went together with investment in country M&E systems.

The achievement of the treatment goals for 2015 have been followed by the challenge to achieve the 90, 90, 90 goals by 2020, requiring treatment linked to testing, retention and viral suppression, supported by more granular district and patient level reporting systems [11, 13, 14].

The period 2000–2015 was a remarkable period for treatment monitoring and access. The setting of clear global targets, standardized and harmonized reporting, and accountability mechanisms with regular reporting and analysis at global and country levels, provided a significant focus for global access. The target of 15 million people on treatment was reached before 2015, with Africa closing the relative gap compared to other regions, a distinctive achievement in health and development.




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