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

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          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          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.

          Abstract

          In a systematic review, Reuben Granich and colleagues assess the quality and comparability of publicly available data on national HIV care continua and progress towards the 90-90-90 targets.

          Author summary

          Why was this study done?
          • Treatment prevents human immunodeficiency virus (HIV) illness, death, and transmission, prompting the Joint UN Program on HIV/AIDS (UNAIDS) to issue the 90-90-90 target.

          • 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.

          • Our review aims to answer three critical questions: (1) What data for national continua of care are available in the public domain? (2) What is the quality and comparability of the information presented? and (3) How close are we to achieving the UNAIDS 90-90-90 targets?

          What did the researchers do and find?
          • For the period 2010–2016, we searched the public domain for the latest available national HIV care continuum with the number and proportion of people living with HIV (PLHIV) who are diagnosed, on ART, and virally suppressed.

          • We found 53 national care continua with viral suppression estimates (representing 54% of the 2015 global estimate of PLHIV), and the average proportion of PLHIV on ART and the average proportion of PLHIV who were virally suppressed were 48% and 40%, respectively.

          • Although seven countries (Sweden, Cambodia, UK, Switzerland, Denmark, Rwanda, and Namibia) had reached or were within 12% and 10% of achieving the 90-90-90 target for “on ART” and for “viral suppression,” only 9 countries in sub-Saharan Africa had care continua with viral suppression estimates in the public domain.

          • Limitations include significant variation in the methods used to determine national continua and the possibility that complete continua were not available through our comprehensive search of the public domain.

          What do these findings mean?
          • Many countries are progressing toward and will likely achieve 90-90-90; however, it will be important to use consistent and accurate methods to report on progress.

          • Relatively few complete national continua of care are available in the public domain, and there is wide variation in the methods for determining progress towards the 90-90-90 target.

          • Despite bearing the highest HIV burden, complete 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.

          Related collections

          Most cited references 9

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          Optimizing the engagement of care cascade: a critical step to maximize the impact of HIV treatment as prevention.

          At present, data from mathematical models, ecologic studies and a clinical trial demonstrate that use of combination antiretroviral therapy (cART) can markedly reduce HIV transmission. Expansion of cART uptake (Treatment as Prevention) is a critical component of biomedical interventions to prevent HIV transmission. Successful implementation is dependent on identifying undiagnosed individuals, linking and retaining them in care and initiating durable and potent cART regimens. This continuum is encapsulated within the framework of the 'Test and Treat', or 'Seek, Test, Treat and Retain' strategies. Currently only 19-28% of all HIV-infected individuals in the USA are estimated to be virologically suppressed. Optimizing the engagement of care cascade represents a critical step to maximize the individual and societal impact of cART and therefore deliver on the promise of HIV Treatment as Prevention.
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            • Record: found
            • Abstract: not found
            • Article: not found

            The HIV care cascade through time.

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              • Record: found
              • Abstract: found
              • Article: not found

              The HIV care continuum in Latin America: challenges and opportunities.

              Combination antiretroviral therapy (ART), also known as highly active antiretroviral therapy, provides clinical and immunological benefits for people living with HIV and is an effective strategy to prevent HIV transmission at the individual level. Early initiation of ART as part of a test and treat approach might decrease HIV transmission at the population level, but to do so the HIV continuum of care, from diagnosis to viral suppression, should be optimised. Access to ART has improved greatly in Latin America, and about 600,000 people are on treatment. However, health-care systems are deficient in different stages of the HIV continuum of care, and in some cases only a small proportion of individuals achieve the desired outcome of virological suppression. At present, data for most Latin American countries are not sufficient to build reliable metrics. Available data and estimates show that many people living with HIV in Latin America are unaware of their status, are diagnosed late, and enter into care late. Stigma, administrative barriers, and economic limitations seem to be important determinants of late diagnosis and failure to be linked to and retained in care. Policy makers need reliable data to optimise the HIV care continuum and improve individual-based and population-based outcomes of ART in Latin America.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                plos
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, CA USA )
                1549-1277
                1549-1676
                4 April 2017
                April 2017
                : 14
                : 4
                Affiliations
                [1 ]International Association of Providers of AIDS Care, Washington, D.C., United States of America
                [2 ]Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
                University of Berne, SWITZERLAND
                Author notes

                The authors have declared that no competing interests exist.

                • Conceptualization: RG SG IH JAG SH JM.

                • Data curation: SG RG.

                • Formal analysis: RG SG IH JAG SH JM.

                • Investigation: RG SG IH JAG SH JM.

                • Methodology: RG SG.

                • Visualization: SG RG.

                • Writing – original draft: RG SG IH JAG SH JM.

                • Writing – review & editing: RG SG IH JAG SH JM.

                Article
                PMEDICINE-D-16-02608
                10.1371/journal.pmed.1002253
                5380306
                28376085

                This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                Page count
                Figures: 5, Tables: 2, Pages: 21
                Product
                Funding
                The authors received no specific funding for this work.
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                Custom metadata
                Data are all contained in the paper and supporting information. Data are available on the following website: www.hiv90-90-90watch.org. Results reflect data in the public domain as of November 2016. New continua and 90-90-90 data will be regularly posted on the www.hiv90-90-90watch.org website.

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