Implementation remains a challenge

Achieving the 90-90-90 targets is feasible

Von Carine Weiss

Get Tested! Know your HIV Status! Frequently heard slogans connected to the “90-90-90” targets introduced by UNAIDS in 2014. Many people thought the 90-90-90 targets were impossible to reach. But we were able to witness a fast acceleration of HIV treatment in the last few years.

Achieving the 90-90-90 targets is feasible

MMS/aidsfocus.ch conference 2017: HIV Test and Treat: Are the 90 - 90 - 90 targets set for 2020 within reach? (Photo: Daniel Rhis)

 

The 90-90-90 targets intend that, by 2020, 90% of people who are infected with HIV will be diagnosed, 90% of people who are diagnosed will receive antiretroviral treatment and the virus in 90% of those receiving this treatment will be suppressed. If we meet these targets, the goal of achieving the end of AIDS by 2030 is still within reach (1).

The 90-90-90 concept is intended to galvanise national and global action to control HIV and end the AIDS epidemic by 2030. One crucial part of this plan is to deliver HIV treatment to all who need it.

If we fail to achieve these targets by 2020, then it is unlikely that an end to AIDS will be achieved by 2030, according to Dr Badara Samb, Director of the Office of Special Initiatives at UNAIDS. At the MMS/aidsfocus.ch conference in 2017, Dr Samb also said that the initiative requires at least 26 billion US dollars. However, at present only 19 billion has been made available. Let’s go the extra mile and invest another 7 billion dollars.

Political will reaffirmed at the HLM in New York

I would like to restate that during the High Level Meeting in New York last June 2016, world leaders at the United Nations agreed to mobilise all possible resources to reach the 90-90-90 targets by 2020.

“Ensuring access to testing and treatment in the fight against HIV and AIDS

60 (a): Commit to 90-90-90 treatment targets, and to ensuring that 30 million people living with HIV access treatment by 2020 with special emphasis on providing 1.6 million children (0-14 years of age) with antiretroviral therapy by 2018 and that children, adolescents and adults living with HIV know their status and are immediately offered and sustained on affordable and accessible quality treatment to ensure viral load suppression and underscore in this regard the urgency of closing the testing gap” Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the Fight against HIV and to End the AIDS Epidemic by 2030 (2)

Test and Treat policy by WHO

Under new guidelines introduced by the World Health Organisation (WHO) in 2014, everyone diagnosed as HIV-positive should receive treatment regardless of the CD4 count. This means that everyone testing positive for HIV will be eligible for antiretroviral therapy (ART), and will no longer need to wait for their immune system to become weakened to below a certain threshold before they can start treatment. These HIV guidelines from WHO are a necessary step towards reaching the UNAIDS goal of 90-90-90. This policy offers the possibility to push the limits of the medicine supply chain and to promote accurate supply forecasting and improved reactive capacity at a national level, all important prerequisites for reaching and maintaining people on treatment.

WHO’s test and treat policy has had a massive impact and the scientific evidence is irrefutable. But implementation poses a lot of challenges both in the prevention and care continuum, especially in resource limited settings.

The 90–90–90 targets and the HIV testing and treatment cascade are two ways of looking at the same data but the measurements are different which might lead to confusion. For each of the 90–90–90 targets, the denominator is different. The first 90 value (70%) is the denominator for the second 90, and the second 90 value (77%) is the denominator for the third 90. For the testing and treatment cascade the denominator for each step remains the same: all people living with HIV (see the graphic here).

Sweden the first country to achieve the 90-90-90 targets

Several factors have contributed to Sweden’s success in achieving the 90-90-90 targets for diagnosis, treatment and viral suppression: the country has a low HIV prevalence; in addition, the necessary legislation is in place to oblige laboratories and clinicians to report new HIV cases and patients to attend follow-up appointments. Sweden also has specialist treatment centres with multi-disciplinary teams, provides free access to ART and enjoys a high level of adherence to national guidelines by care providers (adapted to the WHO policy of test and treat in 2014) (3).

African countries such as Rwanda (85-90-85), Zimbabwe (74-87-86) and Malawi (73-89-91) are also well on track (UNAIDS data 2016).

 

MMS/aidsfocus.ch conference 2017: HIV Test and Treat: Are the 90 - 90 - 90 targets set for 2020 within reach? (Photo: Daniel Rhis)

 

We need to tackle stigmatisation and discrimination if we want to achieve the 90-90-90 targets

In 2014 Vietnam was the first Asian country to adopt the UNAIDS 90-90-90 targets; in 2015 it also adopted the WHO test and treat policy. Putting theory into practice remains, however, a challenge. The HIV epidemic is concentrated among key populations such as men who have sex with men (MSM), intravenous drug users, female sex workers and the sexual partners of members of these groups (4). Stigmatisation of these people hinders access to health services for testing and treatment.

Switzerland, for example, faces the problem of late testers and is therefore encountering issues with reaching the “first” 90. Especially in resource limited settings we require an extra supply of medicine to avoid procurement issues and prevent stocks from running out (the “second” 90). The last 90 refers to the suppression of the viral load – keeping people in treatment. Adherence to this poses its own challenges and requires long-term resources. 

No size fits all!

These examples demonstrate some of the difficulties with regards to the 90-90-90 targets which aim to get the HIV epidemic under control. The concept of universal test and treat is an ambitious idea and difficult to implement. Many people thought they were impossible to reach

There is no standard programme to hand – led by UNAIDS, each country needs to adapt its own strategy according to its HIV statistics and epidemic. Know your epidemic, know your response! (5)

In addition we cannot emphasis enough to target children, women and girls, young people and key populations. We must engage with men differently. Men are being left behind in the push to 90–90–90, in turn affecting the lives of women and children.

And as long as we fail to address the human rights’ barriers for HIV test and treat we will not achieve the end of AIDS by 2030.

References

1)   Ending AIDS Progress towards the  90–90–90 targets http://www.unaids.org/en/resources/campaigns/globalAIDSupdate2017

2)   Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the Fight against HIV and to End the AIDS Epidemic by 2030; page 14

3)   Gisslén M et al. Sweden, the first country to achieve the Joint United Nations Programme on HIV/AIDS (UNAIDS)/World Health Organization (WHO) 90-90-90 continuum of HIV care targets. HIV Medicine https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5347969/

4)   Horter S et al. “Life is so easy on ART, once you accept it”: Acceptance, denial and linkage to HIV care in Shiselweni, Swaziland. Social Science & Medicine 176: 52-59, 2017.

5)   UNAIDS, 2014 UNAIDS 90–90–90-An Ambitious Treatment Target to Help End the AIDS Epidemic [WWW Document] URL  (2014) http://www.unaids.org/en/resources/documents/2014/90-90-90 (accessed 28.03.2017)

6)   WHO. Guidelines on HIV self-testing and partner notification Supplement to consolidated guidelines on HIV testing services (2016). http://www.who.int/hiv/pub/vct/hiv-self-testing-guidelines/en/

7)   UNAIDS. Practical guidelines for intensifying HIV prevention: towards universal access. 2007. http://data.unaids.org/pub/manual/2007/20070306_prevention_guidelines_towards_universal_access_en.pdf (accessed 19 May, 2017).

8)   What’s the difference? Understanding measures of progress towards 90–90–90 http://www.unaids.org/sites/default/files/measures-progress-90-90-90.pdf

 

Carine Weiss

Carine Weiss is project leader at Medicus Mundi Switzerland.