Tuesday, November 17, 2015

Are the ambitious UNAIDS 90-90-90 targets for 2020 realistic and achievable, considering the end goal of ending the AIDS epidemic by 2030?

By Alan Brand - 18 August 2015

Ending the AIDS epidemic is more than a historic obligation to the 39 million people who have died of the disease. It also represents a momentous opportunity to lay the foundation for a healthier, more just and equitable world for future generations. Ending the AIDS epidemic will inspire broader global health and development efforts, demonstrating what can be achieved through global solidarity, evidence-based action and multi-sectoral partnerships.

Although many strategies will be needed to close the book on the AIDS epidemic, one thing is certain. It will be impossible to end the epidemic without bringing HIV treatment to all who need it.

As the world contemplates the way forward following the 2015 deadline for the targets and commitments in the 2011 Political Declaration on HIV and AIDS, a final target is needed to drive progress towards the concluding chapter of the AIDS epidemic, promote accountability and unite diverse stakeholders in a common effort. Whereas previous AIDS targets sought to achieve incremental progress in the response, the aim in the post-2015 era is nothing less than the end of the AIDS epidemic by 2030.

In December 2013, the UNAIDS Programme Coordinating Board called on UNAIDS to support country- and region-led efforts to establish new targets for HIV treatment scale-up beyond 2015. In response, stakeholder consultations on new targets have been held in all regions of the world. At the global level, stakeholders assembled in a variety of thematic consultations focused on civil society, laboratory medicine, paediatric HIV treatment, adolescents and other key issues.

Powerful momentum is now building towards a new narrative on HIV treatment and a new, final, ambitious, but achievable target:
  • ·        By 2020, 90% of all people living with HIV will know their HIV status.
  • ·  By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
  • ·        By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.

A personal researched perspective on the 90-90-90 UNAIDS targets.

The Benefits of Knowing Your Status
Knowing ones HIV status is no longer a death sentence and as such like many other health conditions testing and screening is the first step to living a healthy life. Knowing your status is empowering oneself  through the gaining of knowledge while engaging with medical practitioners who specialise in HIV treatment and care so that regular monitoring of the effects of the HI virus on one’s immune system will ensure that you can initiate treatment at the most effective time. It also ensures that one has the ability to find psychological support through support networks and support groups and hence one is fully able to take responsibility for one’s life. Not knowing ones status denies one the ability to make these important choices and is simply foolishness. Some of the benefits of knowing your status include:
  •  Knowing your HIV status will help you to reduce the risk of transmitting the virus to others
  • Knowing your HIV status can alleviate the stress and anxiety of thinking that you may be infected but not knowing your actual HIV status.
  • If you test negative for HIV, you can make decisions and take steps that will help you remain HIV negative.
  • If you test positive for HIV, you can seek medical treatment earlier. Early medical treatment can slow the progress of HIV and delay the onset of AIDS. Pregnant women who test positive for HIV can take action to prevent their baby from becoming infected with HIV

Point-of-care Testing
HIV-related point-of-care testing (POCT) technologies have become widely available, and they serve as a catalyst to attaining the UNAIDS-led 90-90-90 HIV treatment targets by improving access to diagnostics in resource-limited countries. The treatment targets aim to accomplish specific goals by 2020 – the first 90-target being that 90% of people living with HIV know their HIV status. Increasing access and maintaining the high-quality of POCT is essential to better patient outcomes and achieving an AIDS-free generation.

In its continued efforts to improve the quality of POCT, the African Society for Laboratory Medicine (ASLM) recently partnered with the World Health Organization (SEARO and WPRO regional offices), PEPFAR, the US Centres for Disease Control and Prevention (CDC), and other global partners, to organise a regional consultation in Phnom Penh, Cambodia, aimed at improving the quality of HIV and syphilis POCT.

A new 'Phnom Penh Statement' gives momentum to the global conversation aimed at improving access and increasing the quality of HIV testing. The Statement endorses the UNAIDS 90-90-90 HIV treatment targets and captures the principle of the rapid test quality improvement initiatives under way in Africa.

The benefits of early and sustained antiretroviral therapy
Viral suppression is defined as, literally, suppressing or reducing the function and replication of a virus. When discussing antiretroviral therapy for HIV, a regimen is considered to be highly successful if it reduces a person's viral load to undetectable levels. The term "viral load" refers to the number of copies of HIV per mL of blood, i.e. the amount of virus in the blood.

In general, people with HIV need to use a combined antiretroviral therapy (cART - also known as highly active antiretroviral therapy or HAART) to achieve long term viral suppression - where the level of circulating virus in the blood remain quite low or undetectable.

Benefits: - Prevention of transmission:
Antiretroviral therapy (ART) for HIV infection provides lasting protection against the sexual transmission of the virus from infected men and women to their HIV-uninfected sexual partners, investigators from the HIV Prevention Trials Network (HPTN) have reported at the 8th International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention in Vancouver, Canada in July 2015.

Benefits: - Improved health for the HIV infected individual:
People, who start antiretroviral therapy (ART) immediately after HIV diagnosis, while their CD4 cell count is still high, rather than waiting until it falls below 350 cells/mm3 have a significantly lower risk of illness and death, according to long-awaited findings from the START trial. The final study results were presented on Monday at the Eighth International AIDS Society Conference (IAS 2015) in Vancouver, Canada, and published simultaneously in the July 20 advance edition of the New England Journal of Medicine.

These findings suggest that HIV causes persistent immune system damage soon after infection, and "clearly indicate that ART should be provided for everyone regardless of CD4 count,"

It is well known that starting ART before CD4 cell counts fall to low levels dramatically reduces the frequency of opportunistic illness and improves survival. A growing body of evidence shows that earlier treatment is associated with decreased disease progression and death, as well as minimising the risk of onward transmission of HIV.

Viral suppression a key to the success of the UNAIDS targets?
To be successful, HIV test-and-treat programs in South Africa need to focus more on getting patients to return for ongoing treatment. Fewer than half of patients who tested HIV-positive at a Johannesburg, South Africa, clinic returned to complete eligibility testing for antiretroviral therapy (ART), according to a new study. The study, published in the journal PLOS ONE, tracked 380 patients who had tested positive for HIV. Researchers found no evidence that 142 of them returned for a blood draw—a CD4 count measuring levels of infection-fighting white-blood cells—that would determine eligibility for ART treatment. Of the remaining 238, only about 39 percent completed eligibility testing for ART within three months.

Of those who had blood tests showing they were eligible for ART treatment, 88 percent initiated ART within six months. Among the 185 patients in that ART cohort, 22 transferred out and were excluded from further analysis. Of the remaining 163, 81 percent were retained in care through two years of treatment. About 9 percent of the patients who either never had a blood draw or never returned to the clinic were known to have died.

Factors contributing to dropping out from and returning to HIV treatment
Dropping out was associated with drug/alcohol use, unstable housing/homelessness, psychiatric disorders, incarceration, problems with HIV medications, inability to accept the diagnosis, relocation, stigma, problems with the clinic, and forgetfulness.

Returning to obtain assistance and treatment was associated with health concerns, substance abuse treatment/recovery, stable housing, and incarceration/release, positive feelings about the clinic, spirituality, and assistance from family/relocation.

Patients aged between 15 and 24 years are significantly more likely to drop out of HIV care compared to individuals in other age groups. The research was conducted in four sub-Saharan African countries and involved patients newly entered HIV care or initiating antiretroviral therapy (ART) between 2005 and 2010. Patients in the 15- to 24-years age group were significantly more likely to be lost to follow-up compared to both younger and older age groups.

This study provides important insights on program outcomes previously not sufficiently described. In addition to confirming attrition 1 year after starting ART the study found that youth were substantially more likely than young adolescents and older adults to die or be lost to follow-up before initiating ART.

These findings suggest that test-and-treat programs must focus on retention, particularly in the pre-ART period, in order to reduce morbidity, mortality, and transmission.

The tools and strategies now exist to end the AIDS epidemic by 2030. However, getting there requires unprecedented action now to scale up early antiretroviral therapy, as delay will merely allow the epidemic to continue to outpace the response. While new thinking and new ways of operating will be needed to achieve these ambitious targets, the partnerships that have enabled the AIDS response to make history provide a firm foundation on which to embark on a worldwide effort to end the AIDS epidemic by 2030. Hence the 90-90-90 UNAIDS targets for 2020 are key to achieving this goal and although ambitious can be achieved. 

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