The European region of the World Health Organization (WHO) is close to achieving the UNAIDS 90-90-90 target, according to research published in the Journal of Acquired Immune Deficiency Syndromes. Data collected in 2016 showed that, overall, 81% of people with HIV had been diagnosed, 84% of diagnosed people were on antiretroviral therapy (ART) and 88% of ART-treated people were virally suppressed. But there was significant variation between European regions and also between countries within sub-regions. Overall, Eastern Europe generally had low rates of diagnosis, ART coverage and viral suppression. Several countries also reported difficulties submitting accurate and comprehensive surveillance data.
“A number of countries in the eastern subregion are lagging behind, possibly reflecting the younger epidemics in some,” comment the authors. “Given the substantial heterogeneity in estimates for each stage within subregions, the focus should be on each country’s continuum rather than those of the subregion within which it is located.”
In 2014, UNAIDS set the target of ending the HIV epidemic by 2030. They estimated that this was possible if the so-called “90-90-90” targets for engagement with key stages in the HIV care continuum were achieved by 2020: 90% of individuals with HIV diagnosed; 90% on diagnosed individuals on ART; 90% of ART-treated individuals virally suppressed.
Approximately 7% of global HIV infections are located in the WHO European region. Investigators from the European Centre for Disease Prevention and Control (ECDC) wanted to estimate progress in the European region towards achievement of the 90-90-90 target. In 2016, they sent questionnaires to health authorities in all 55 countries in the WHO European region. Each country was asked to report on total HIV prevalence; the proportion of people who were diagnosed; the percentage of diagnosed people who were on ART; and the proportion of people taking anti-HIV drugs who had an undetectable viral load. The investigators also enquired about difficulties which countries faced in gathering and submitting surveillance data.
An overall European estimates of progress towards the 90-90-90 goal was provided by the investigators, who also reported on data according to sub-region: West, Central and East.
The response rate was high with 48 of the 55 countries (87%) submitting some surveillance data. However, Russia, which has a fast-growing HIV epidemic, was among the countries which did not respond. The authors suggest that their data on engagement with the care continuum in Eastern Europe is therefore likely to be optimistic.
A total of 44 countries provided information about patient engagement with the HIV care continuum (diagnosis, treatment, viral suppression). A total of 29 countries provided information on all four stages (total prevalence, plus engagement with the care continuum).
The investigators estimated that there were approximately 1,200,000 people living with HIV in the 37 countries that provided data on HIV prevalence. This translated into an overall European HIV prevalence of 0.19%, ranging from 0.02% in Slovakia to 0.84% in Estonia.
A total of 37 countries reported on total prevalence and diagnosis. The rate of diagnosis ranged from a low of 38% in Tajikistan to 98% in Romania. Three countries reporting meeting the UNAIDS 90% diagnosis target (Denmark, Romania and Sweden).
The proportion on ART in the 40 countries reporting numbers was between 27% in Latvia and 96% in Malta and the UK. In all, eight countries met this UNAIDS 90% target.
The percentage of people with an undetectable viral load in the 31 countries reporting on ART coverage and viral suppression ranged from 32% in Albania and Tajikistan to 97% in Switzerland. Eleven countries reported meeting the third of the UNAIDS 90% targets.
A total of 29 countries provided data on each of the 90-90-90 targets. In the European region overall, 81% of people were diagnosed, 84% were on ART and 88% were virally suppressed. But engagement with the HIV care continuum differed according to European sub-region:
- 84-88-90 in Western Europe
- 84-69-62 in Central Europe
- 57-45-57 in Eastern Europe.
Applying these levels of engagement with key stages in the HIV care continuum to the entire HIV-positive population in each sub-region showed overall rates of suppression were 66% in Western Europe, 36% in Central Europe and 14% in Eastern Europe. Moreover, there was considerable variability between engagement in care and outcomes between countries within sub-regions.
Two countries (Denmark and Sweden) reported meeting all of the 90-90-90 targets. The UK reported that it met the UNAIDS target of 73% of all HIV-positive individuals with viral suppression.
Key challenges preventing the gathering and submission of surveillance data included:
- Absence of a single source for all stages of the care continuum
- Shortage of expertise
- Lack of financial and human resources.
The authors believe their findings show that more must be done to improve rates of HIV diagnosis and ART coverage.
“It is difficult to envisage that a country can achieve 90-90-90 if it is unable to produce an accurate estimate of this measure,” they conclude. “Priority needs to be given to resources which allow countries to address the challenge of producing robust continuum estimates and tracking progress toward achieving that goal.”
Porter K et al. Substantial heterogeneity in progress toward reaching the 90-90-90 HIV target in the WHO European Region. J Acquire Immune Defic Syndr, 79: 28-37, 2018. (Full text freely available).