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

Abstract

Background: In 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 findings: For 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.

Conclusions: Relatively 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.

Fig 1. Search flow diagram.

WHO, World Health Organization; UNAIDS, Joint UN Programme on HIV/AIDS; PEPFAR, the US President’s Emergency Plan for AIDS Relief. For 2010–2016, 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. The 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. The search was designed to identify the most recent officially reported or sanctioned national continua of care available in the public domain. Search inclusive of results as of November 30, 2016.

Fig 2. Maps showing the proportion of PLHIV diagnosed positive, on ART, and with viral suppression in 53 countries.

Countries in white were not included in this analysis (see methods for exclusion criteria). Maps are available from www.freeworldmaps.net.

Fig 3. Top seven countries within 12% and 10% of achieving the 90-90-90 target for on ART and for viral suppression, respectively.

Note: the blue line denotes the first 90 target of 90% of PLHIV diagnosed, the red line denotes the second 90 target of 81% of PLHIV on ART, and the green line denotes the third 90 target of 73% PLHIV with viral suppression. * denotes high-quality continuum, ** denotes medium-quality continuum, *** denotes low-quality continuum.

Fig 4. Country progress toward the 90-90-90 target: Proportion of PLHIV diagnosed and on ART for 53 countries.

Note: the figure includes 53 countries. The numbers in the figure above correspond to the number for the countries with continuum with viral suppression as listed in Table 1. The proportion of PLHIV with diagnosed infection was not available for 11 countries. Note that this graph is meant to illustrate progress and does not calculate correlation between the variables as they are not independent.

Fig 5. Country progress toward 90-90-90 target: Proportion of PLHIV on ART and with viral suppression for 53 countries.

The data points in the figure were not labeled with numbers, as they are clustered and overlapping. Note that this graph does not show correlation between the variables as they are not independently determined—the graph is only meant to portray progress for the two variables towards the target.