Only six
countries, representing just 2% of the global HIV burden, have high quality
data reporting on the HIV care continuum and progress towards the UNAIDS
90-90-90 target, investigators report in PLOS
Medicine
. The study also showed that only nine countries in sub-Saharan
Africa have surveillance data for viral suppression. Globally, an estimated 48%
of all HIV-positive individuals are now on antiretroviral therapy (ART), with 40% of
all people with HIV virally suppressed.

“Our findings
suggest that the substantial investment in expanding access to HIV diagnosis
and treatment has resulted in significant progress towards the 90-90-90 target,”
comment the investigators. “The review also highlights that despite this
investment, there is a lack of complete data available in the pubic domain
coupled with a nonstandardized approach to determining national continua.” The
authors assert that standardised monitoring and evaluation would improve use of
scarce resources towards achieving the 90-90-90 target through improved
transparency, accountability and efficiency.

By June 2016, an
estimated 18.2 million people – 48% of HIV-positive individuals globally –
were taking antiretrovirals. People doing well on antiretrovirals have an
excellent prognosis and individuals with sustained viral suppression are
uninfectious. The importance of further expanding coverage of HIV treatment and
care is recognised in the UNAIDS 90-90-90 target. This envisages that by 2020,
90% of all HIV-positive individuals will be diagnosed, 90% of diagnosed
individuals will be taking ART and 90% of ART-treated people will have viral
suppression. The realisation of these targets would mean that 73% of all
HIV-positive individuals will be virally suppressed, sufficient to achieve
control of the global epidemic. But these targets are just a beginning – a
95-95-95 target is the aspiration for 2030.

High quality and
accurate surveillance data are needed to assess global and national progress
towards the 90-90-90 target.

A team of investigators
therefore designed a study with three aims:

1. What data for
national HIV care continua are available in the public domain?

2. What is the
quality and comparability of the published data?

3. How close are
we to achieving the 90-90-90 target?

In October 2016,
they searched for publicly available studies and reports published between
2010 and 20116 reporting on individual countries’ HIV care continuum (including the
number and proportion of individuals with HIV who were diagnosed, on ART and
virally suppressed).

Reports were
classified according to their quality and methodology as high, medium or low.

HIV care continua
were available for 82 countries, 92% of the global disease burden, with 53
countries, covering 54% of the global HIV-positive population, reporting on
viral suppression. Of countries reporting on viral suppression, 13 were
European, 15 were from North and South America, 15 were from Asia, nine were from
Africa, and one was in Oceania (Australia).

The nine sub-Saharan African countries with data on viral suppression were Kenya, Malawi,
Mauritius, Namibia, Rwanda, South Africa, Swaziland, Uganda and Zimbabwe,
collectively representing 35% of the global HIV burden.

The first of the
“90” targets – diagnosis – had been achieved by four countries: Denmark,
Kazakhstan, Romania and Sweden. Only one of these countries, Sweden, had also
achieved the second and third targets, with 90% of diagnosed people on ART
and 90% of treated people virally suppressed.

However, six other
countries – Cambodia, UK, Switzerland, Denmark, Rwanda and Namibia – were
within 10 to 12% of achieving all three targets. The proportion of people diagnosed was between 70 and 89% in 18 countries, ART coverage among
diagnosed people was between 70 and 89% in 14 countries and viral suppression was
between 50 and 72% in 14 countries.

Overall, the 53
countries averaged 48% of all people with HIV on ART and 40% virally
suppressed. When restricted to people in the care continuum, the proportions
increased to 52% and 43% respectively, The nine sub-Saharan African countries
averaged 54% of people with HIV on ART and 44% virally suppressed.

As regards
quality, reports from six countries (2% of global disease burden) were rated as
high, 28 (15% of disease burden) as medium and 14 (36% of disease burden) as
low. A further five countries (below 1% of disease burden) had reports that
could not be rated because of missing data.

“Despite ongoing
efforts and considerable investments to improve monitoring and evaluation, our
review highlights the need for improved standardization across countries to
accurately track progress towards epidemic control,” conclude the authors.
“Publishing high-quality continua care data in the public domain could improve
efficiency, transparency, and accountability and is essential to focus scarce
resources on achieving 90-90-90 and epidemic control.”