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Commentary•7 March 2017•
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UNAIDS 90–90–90 TARGETS TO END THE AIDS EPIDEMIC BY 2020 ARE NOT REALISTIC:
COMMENT ON “CAN THE UNAIDS 90–90–90 TARGET BE ACHIEVED? A SYSTEMATIC ANALYSIS OF
NATIONAL HIV TREATMENT CASCADES”

Author affiliations

•

Luchuo Engelbert Bain1

,

Clovis Nkoke2

,

Jean Jacques N Noubiap3

.
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SUMMARY BOX

 * Achieving the United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 targets
   will require a viral load-informed care to ensure optimal HIV clinical
   follow-up and resistance monitoring—this in turn will require significant
   mobilisation of resources.

 * Maintaining a constant drug supply to satisfy the growing number of potential
   patients to be put on treatment with current funding trends is almost
   unattainable.

 * Poor quality and non-uniform data collection tools of the various indicators
   render evaluation of the evolution of the HIV pandemic extremely difficult.

 * The UNAIDS 90–90–90 agenda is non-inclusive, disease specific and might
   contribute to weakening health systems which are already challenged by the
   double burden of communicable and non-communicable diseases.

There is indisputable evidence regarding the remarkable success over the past
two decades in reducing HIV associated morbidity, mortality, transmission,
stigma and improving the quality of life of people living with HIV.1 In 2014,
the Joint United Nations Programme on HIV/AIDS (UNAIDS) and partners launched
the 90–90–90 targets; the aim was to diagnose 90% of all HIV-positive persons,
provide antiretroviral therapy (ART) for 90% of those diagnosed, and achieve
viral suppression for 90% of those treated by 2020. This is estimated to result
in 73% of people with HIV achieving viral suppression, a crucial step in ending
the AIDS epidemic by 2030.2 However, 36.9 million people are living with HIV
today and about 2.1 million new infections were recorded in 2015.3 This high
rate of new infections continues to fuel the epidemic. Reports from national HIV
programmes suggest that the 90–90–90 targets agenda for 2020 risks are
unrealistic.4

Early placement of patients on combined ART (cART) and achievement of viral load
suppression reduces mortality and HIV transmission and improves quality of
life.1 Getting over 90% of people with HIV to know their status can therefore
plausibly help achieve the 90–90–90 targets. However, in a recent systematic
analysis of national HIV treatment cascades from 69 countries by Levi et al4 in
BMJ Global Health, none of the countries had met the 90–90–90 targets. They
found that diagnosis (target one—90% of all HIV-positive people diagnosed)
ranged from 87% (the Netherlands) to 11% (Yemen). Treatment coverage (target
two—81% of all HIV-positive people on ART) ranged from 71% (Switzerland) to 3%
(Afghanistan). Viral suppression (target three—73% of all HIV-positive people
virally suppressed) was between 68% (Switzerland) and 7% (China). In 2014/2015,
of the 36.9 million of people with HIV globally, only 54% were diagnosed, 41%
were on ART and 32% were virally suppressed, demonstrating that we are still
very far from achieving the 90–90–90 targets. The lowest achievement rates were
in low income and middle income countries (LMICs).

Levi et al4 adequately highlighted the gaps in HIV diagnosis and provision of
cART, which may be unattainable under the ambitious UNAIDS 90–90–90 targets
given the current trends. However, the targets only make sense if HIV testing is
performed under acceptable conditions and appropriate interventions to ensure
linkage to care after testing are put in place. Improving the quality of
counselling could ameliorate linkage to care, trust and compliance.5 It is no
news that social workers and trained psychosocial support staff remain scarce if
not inexistent in most healthcare facilities that manage patients with HIV.
Without refuting the fact that HIV-associated stigma has reduced significantly
worldwide, it still constitutes a hindrance to optimal care, even in developed
countries.6–8

Putting adequate and holistic interventions in place requires good data. Levi et
al4 identified lack of good quality data, as well as its non-uniformity, which
renders cross-national comparisons difficult. Of the 196 eligible countries,
they only found available data on 69 countries for analysis. Paediatric HIV care
remains a core hindrance to achieving the 90–90–90 targets. With unacceptably
high numbers of HIV-infected children who are not on treatment9 and potential
new HIV-infected patients who will be diagnosed and consequently deserve
treatment with expanded screening, it is questionable if health systems will be
able to meet the demand for and ensure the continuous supply of cART.4 Periodic
unavailability of drugs is a key driver of drug resistance. Resistance to
first-line therapy is already here, and could get worse if immediate and
appropriate action is not taken.10 ,11

Early detection of treatment failure, adherence counselling and appropriate
switching to second-line therapy are key strengths of a viral load monitored
model.11 Investing and ensuring the sustainability of a viral load-informed care
and monitoring model10 ,11 must be a priority. This, of course, shall involve
mobilisation of resources. Unfortunately, global health challenges go far beyond
HIV, and many other leading causes of death and disability also deserve
increased attention. Priority setting and health system reforms to manage HIV as
a chronic disease must be upheld in government agendas of LMICs.

Indeed, non-communicable diseases (NCDs) are set to overtake HIV and other
infectious diseases as the top killers in low-income countries (LICs) by 2030.
These countries are still ill-prepared to cope with the rising epidemic of
cardiovascular diseases (CVDs) and NCDs in general.12 Despite the increasing
burden of diabetes mellitus and CVDs in the HIV population, even HIV clinics in
these settings are unprepared for the diagnosis and management of NCDs in the
context of HIV care.13 Considering the already huge and increasing burden on
health systems of diseases other than HIV, inclusive approaches are needed to
provide integrated care for both infectious diseases and NCDs to populations at
the primary healthcare level. A disease-specific agenda focusing on HIV is
therefore self-destructive. Moreover, meeting the future resource needs for ART
scale-up under the 90–90–90 scenario (US$18 billion per year globally) will
require significant additional resource mobilisation, which may jeopardise
funding of other health programmes. Large gaps exist across countries with
respect to meeting targets, with highly affected and LIC lagging behind.4

Indeed, before ending the HIV epidemic by 2030, the 90–90–90 strategy would have
significantly weakened health systems and impeded the fight against the rising
NCDs burden in LICs. Active research and development of community friendly
interventions are highly needed.14 This can lead to an increase in screening
rates; also, early identification of patients lost to follow-up and addressing
of special psychosocial concerns could be achieved.14 Getting good and uniform
data constitutes a priority to better monitor, plan and act appropriately within
the context of evolving towards meeting these, for the moment elusive targets,
especially in LMICs.4 Although Levi et al4 did not explore linkage to care and
retention in their systematic analysis, they highlighted the fact that placement
of diagnosed persons on ART shall constitute a key barrier to attaining the
90–90–90 targets in most LMICs. However, political will, appropriate planning
and obtaining required funds could be game changers towards reaching these
goals.


FOOTNOTES

 * Handling editor: Seye Abimbola.

 * Contributors: LEB conceived the initial idea and wrote the initial
   manuscript. CN and JJNN actively participated in the writing of the
   manuscript. All authors have read and agreed on the final version of the
   paper.

 * Competing interests: None declared.

 * Provenance and peer review: Not commissioned; internally peer reviewed.

 * Data sharing statement: No additional data are available.


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REFERENCES

 1.  Maartens G, Celum C, Lewin SR, et al. HIV infection: epidemiology,
     pathogenesis, treatment, and prevention. Lancet 2014; 384:258–71.
     
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     doi:10.1007/s11904-016-0325-9•Google Scholar

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PUBLICATION HISTORY

 * Received: 29 October 2016
 * Accepted: 6 January 2017
 * First Published: 7 March 2017


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