Research Article: Status and methodology of publicly available national HIV care continua and 90-90-90 targets: A systematic review

Date Published: April 4, 2017

Publisher: Public Library of Science

Author(s): Reuben Granich, Somya Gupta, Irene Hall, John Aberle-Grasse, Shannon Hader, Jonathan Mermin, Matthias Egger

Abstract: BackgroundIn 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) issued treatment goals for human immunodeficiency virus (HIV). The 90-90-90 target specifies that by 2020, 90% of individuals living with HIV will know their HIV status, 90% of people with diagnosed HIV infection will receive antiretroviral treatment (ART), and 90% of those taking ART will be virally suppressed. Consistent methods and routine reporting in the public domain will be necessary for tracking progress towards the 90-90-90 target.Methods and findingsFor the period 2010–2016, we searched PubMed, UNAIDS country progress reports, World Health Organization (WHO), UNAIDS reports, national surveillance and program reports, United States President’s Emergency Plan for AIDS Relief (PEPFAR) Country Operational Plans, and conference presentations and/or abstracts for the latest available national HIV care continuum in the public domain. Continua of care included the number and proportion of people living with HIV (PLHIV) who are diagnosed, on ART, and virally suppressed out of the estimated number of PLHIV. We ranked the described methods for indicators to derive high-, medium-, and low-quality continuum. For 2010–2016, we identified 53 national care continua with viral suppression estimates representing 19.7 million (54%) of the 2015 global estimate of PLHIV. Of the 53, 6 (with 2% of global burden) were high quality, using standard surveillance methods to derive an overall denominator and program data from national cohorts for estimating steps in the continuum. Only nine countries in sub-Saharan Africa had care continua with viral suppression estimates. Of the 53 countries, the average proportion of the aggregate of PLHIV from all countries on ART was 48%, and the proportion of PLHIV who were virally suppressed was 40%. Seven countries (Sweden, Cambodia, United Kingdom, Switzerland, Denmark, Rwanda, and Namibia) were within 12% and 10% of achieving the 90-90-90 target for “on ART” and for “viral suppression,” respectively. The limitations to consider when interpreting the results include significant variation in methods used to determine national continua and the possibility that complete continua were not available through our comprehensive search of the public domain.ConclusionsRelatively few complete national continua of care are available in the public domain, and there is considerable variation in the methods for determining progress towards the 90-90-90 target. Despite bearing the highest HIV burden, national care continua from sub-Saharan Africa were less likely to be in the public domain. A standardized monitoring and evaluation approach could improve the use of scarce resources to achieve 90-90-90 through improved transparency, accountability, and efficiency.

Partial Text: In 2003, the World Health Organization (WHO) “3 by 5” initiative called for providing 3 million people living with HIV in low- and middle-income countries with antiretroviral treatment (ART) by the end of 2005 [1]. Despite considerable skepticism regarding the advisability and feasibility of expanding access to ART, by June 2016 around 18.2 million, or 49% of people living with HIV, were taking ART [2]. Efforts to expand access to treatment are supported by scientific evidence that treatment prevents illness and death, reduces human immunodeficiency virus (HIV) transmission, and can decrease health care costs [3–6]. Ensuring access to care and successful viral suppression is a challenge. Although hundreds of millions of HIV tests have been performed, one of the most important barriers to earlier ART and viral suppression is limited HIV diagnosis among people living with HIV, of whom only 60% had been diagnosed as of 2015 [7]. Initiation of ART has primarily relied on CD4 cell count measurement, with access to the more useful viral load monitoring increasing only recently. The importance of accelerating access to diagnosis, treatment, and viral suppression as significant elements in ending the epidemic prompted the Joint UN Program on HIV/AIDS (UNAIDS) to release the HIV 90-90-90 target [8]. The target specifies that by 2020, 90% of individuals living with HIV will be diagnosed and know their HIV status, 90% of people with diagnosed HIV infection will receive sustained ART, and 90% of those on ART will be virally suppressed [8]. The target has been set as a minimum, with 95-95-95 by 2030 being envisioned as the target after 2020.

We used standard methods to search the public domain for the latest complete or near-complete national care continua (Fig 1). We used the national continua and accompanying methods to evaluate progress towards achieving the 90-90-90 target. In October 2016, we searched PubMed, UNAIDS and WHO reports, national surveillance and program reports, PEPFAR 2016 Country Operational Plans, and conference presentations and/or abstracts for national HIV continua of care for the period 2010–2016. The Google-based search strategy included the keywords (HIV OR AIDS) AND (treatment) AND (cascade OR continuum of care OR care continuum OR continua OR spectrum of care OR 90-90-90 OR viral suppression) for data published in the public domain. Although the search terms were in English and most of the sources were in English, some of the UNAIDS and/or country reports were in French or Spanish. We also searched the following conferences: International AIDS Society (IAS) Conference on HIV Science of 2015 and 2016, the Conference on Retroviruses and Opportunistic Infections of 2015 and of 2016, and the IAPAC Treatment as Prevention and Pre-exposure Prophylaxis Evidence Summit. We also included the following online databases: and

The PubMed search located 1,482 studies, which yielded 34 reported national care continua or cascades for all PLHIV (Fig 1). The wider Internet search located 127 reported national care continua. In case of multiple continua for an individual country, we used the most recently reported care continua to reduce the eligible number of care continua from 161 to 97. Of the 97, we excluded 15 care continua that were from secondhand reports and/or reported as preliminary and unconfirmed national figures. Of the 82 remaining care continua, we abstracted data on the four indicators. For the three countries missing estimates of PLHIV, we completed this portion of the care continuum using UNAIDS estimates [28,29]. The 29 continua that did not have data to calculate viral load suppression among PLHIV were excluded from further analysis and quality assessment. National care continua from 53 countries with viral suppression estimates were analyzed in detail. Of these, 9 care continua did not include the methods for determining the HIV diagnosis, on ART, and viral suppression indicators. Of these, we contacted the authors and obtained the methods for 2 continua.

Estimating national HIV continuum of care helps to guide the global and local HIV response, and our study found that many national HIV programs have published their continuum for everyone living with HIV [9,10,13,14,21–23]. Recognizing the importance of expanding treatment, international donors, including PEPFAR and GFATM, are supporting efforts to achieve the 90-90-90 target and care continua to improve accountability and ensure impact [30]. Our findings suggest that the substantial investment in expanding access to HIV diagnosis and treatment has resulted in significant progress towards the 90-90-90 target. The review also highlights that despite this investment, there is a lack of complete data available in the public domain coupled with a nonstandardized approach to determining national continua. The missing data and lack of standardization makes it difficult to determine with confidence whether many countries are on track to achieve the 90-90-90 target. However, although some of the program care continua data may be unavailable or unclear, recent population-based studies suggest that HIV program performance may be better than reported and treatment expansion has had a significant impact on viral suppression and HIV incidence [31].



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