Progress and Gaps in Scaling Up Universal HIV Treatment in Africa
Antiretroviral therapy (ART) works to prevent progression to AIDS, illness, death and new infections. Today's ART is potent, durable and generally very well tolerated. Since 2012, ART has been recommended for all people living with HIV (PLHIV) in the United States and several other high income countries, and in 2015, the World Health Organization similarly recommended ART for all, regardless of CD4 count or clinical status, to prevent disease and new infections. Fast tracking HIV responses will save countless lives and prevent millions of new infections. Yet, hundreds of thousands of PLHIV in the U.S. and millions of PLHIV around the world have not been tested for HIV, are not receiving ART or have not achieved viral suppression -- failing to successfully navigate the HIV care continuum.
In recognizing the urgent need to improve the care continuum, in 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) proposed the 90-90-90 targets for the year 2020: that 90% of PLHIV would know their status, 90% of diagnosed PLHIV would receive ART and 90% of those on ART would have viral suppression. Because no jurisdiction had yet come close to achieving these goals, 90-90-90 was greeted with concern that the targets were too ambitious, and some questioned the wisdom of setting the bar so high. But others seized on the targets to directly address the barriers to testing, ART and viral suppression. In the current issue of UNAIDS Science Now, several key clinical studies are reviewed that highlight the progress made and formidable gaps left to address.
Two papers reported the results of the gigantic PopART clinical trial, where door-to-door delivery of combination HIV prevention and universal HIV testing and treatment by community health workers was field tested in over 120,000 people in nearly 47,000 households in the heavily impacted countries of Zambia and South Africa: "What Works -- Reaching Universal HIV Testing: Lessons From HPTN 071 (PopART) Trial in Zambia" and "A Universal Testing and Treatment Intervention to Improve HIV Control: One-Year Results From Intervention Communities in Zambia in the HPTN 071 (PopART) Cluster-Randomised Trial." In the trial, 83.5% of individuals accepted the intervention and nearly all of these accepted HIV counseling and testing. While young people remain disproportionately at risk for HIV infection in Africa, the study found that 18-24 year-olds were more likely to accept counseling and testing. Impressively, knowledge of sero-status among PLHIV increased from 50% to 90%, demonstrating that, even at this scale, attaining high levels of HIV testing (and the first of the UNAIDS 90-90-90 targets) is indeed possible.
The PopART intervention also worked to nearly double the number of people receiving ART. The estimated proportion of known PLHIV on ART increased overall from 53-54% to 73-74% -- but stayed short of the 90% coverage goal. The authors note that this increase in ART use took 12 months to achieve, indicating that uptake of ART did not occur immediately after knowledge of HIV status, and fewer younger PLHIV than older PLHIV took ART.
A separate study from KwaZulu-Natal, South Africa examined the causes of loss to clinic follow up (LTFU) in 3200 PLHIV on ART in fifteen primary health centers. The study found that about half of the 820 people initially classified as "lost to follow up" (LTFU) were actually in care; a third were still in care, and others had returned to care shortly thereafter. Young men (18-35 years-old), people with CD4 counts less than 200 or those who recently started ART were more likely to be truly LFTU.
Scaling up testing and universal treatment is hoped to decrease the number of PLHIV who have untreated advanced HIV disease (CD4 counts ≤ 200). A recent massive analysis showed significantly improving trends in CD4 count at ART initiation among 694,000 PLHIV in ten high burden countries from 2004-2015. In Haiti, Mozambique and Namibia, prevalence of advanced disease at ART initiation decreased from 75% to 34%, 73% to 37% and 80% to 41%, respectively. Significant declines in prevalence of advanced disease were also reported in Nigeria, Swaziland, Uganda, Vietnam and Zimbabwe. Despite these encouraging news, about one in three individuals still started ART with advanced disease and AIDS.
These studies show the feasibility of scaling up HIV testing, care and treatment, yet point out areas that need our immediate attention. Two nations (Sweden and Denmark) have already achieved 90-90-90 targets, as have the cities of Amsterdam, Melbourne, New York and Seattle. But significant hurdles exist. As of July 2017, only 57 countries have adopted universal HIV testing, and HIV viral load testing remains unavailable in many places. Understanding the facilitators and barriers to the utilization of HIV services is urgently needed, as evidenced by the relatively poor utilization of services by young adults in Africa. Stigmatization, discrimination and criminalization of PLHIV and HIV-affected communities remain global issues that also must be addressed. We're now half way from the launch of the UNAIDS 90-90-90 targets to when the clock strikes midnight on 2020, and the scientific and clinical communities have made significant progress in scaling up HIV testing, care and treatment. If we're successful, AIDS will become a rare disease and new HIV infections uncommon.
Benjamin Young, M.D., Ph.D., is senior vice president and chief medical officer of the International Association of Providers of AIDS Care (IAPAC) and provides care for people living with HIV at APEX Family Medicine in Denver. IAPAC, along with UNAIDS and UN-Habitat, lead the Fast-Track Cities Initiative, which aims to accelerate the goal of 90-90-90, specifically in high HIV burden cities.