Reaching UNAIDS HIV treatment targets could avert millions of deaths and new infections

Achieving UNAIDS 90-90-90 targets for getting more people with HIV diagnosed and on antiretroviral therapy (ART) in two of the hardest-hit countries – Nigeria and South Africa – could avert more than 3 million deaths, according to a study published in the July 6 edition of PLOS ONE. The new Fast-Track Cities Initiative aims to help make this goal a reality in the highest-burden cities.

Current World Health Organization (WHO) guidelines recommend offering ART to everyone whose CD4 cell count falls below 500 cells/mm³, but preliminary results from the START trial show that earlier treatment is even more beneficial. Updated WHO guidelines will be released next week at the International AIDS Society conference in Vancouver, Canada.

The international community has made major progress in expanding global access to treatment, as described in a new UNAIDS report. But while 15 million people with HIV are now on ART, more than 20 million people remain untreated and therefore at risk of disease progression and onward transmission of the virus.

Reuben Granich of the International Association of Providers of AIDS Care (IAPAC) and colleagues examined trends in HIV and AIDS epidemiology between 1990 – before the introduction of effective combination ART – and 2013.

The study authors used the UNAIDS AIDSinfo database to look at HIV incidence and prevalence, AIDS deaths, annual AIDS death rates, ART coverage and ratios of AIDS deaths-to-treatment and HIV infections-to-treatment for the 30 countries with the highest AIDS mortality burden, comparing them to data from high-income countries.

The researchers then used a mathematical model to project the number of AIDS deaths during 1990-2020 for Nigeria and South Africa using four treatment scenarios: 1) no ART; 2) maintaining current ART coverage; 3) 90% ART coverage based on 2013 WHO guidelines; and 4) reaching the 90-90-90 target by 2020.

The UNAIDS 90-90-90 target is that 90% of people with HIV should know their status, 90% of these should be on ART and 90% of these should have undetectable viral load. Mathematical modelling indicates that meeting these goals by 2020 could virtual eliminate the HIV/AIDS pandemic by 2030, defined as a greater than 90% decrease in disease burden including incidence, morbidity and mortality.

In 2013, there were an estimated 1.3 million AIDS-related deaths in the 30 countries with the highest AIDS mortality burden, representing 87% of all such deaths. All but three of these countries (Brazil, Ukraine and Haiti) were in either sub-Saharan Africa or Asia and the Pacific.

Five sub-Saharan African countries had the highest AIDS death rates per 1000 people with HIV: Central African Republic (91), South Sudan (82), Ivory Coast (75), Cameroon (72) and Chad (71) – about 8-10 times higher than rates in high-income countries.

Eight countries – India and seven countries in sub-Saharan Africa – accounted for 58% of all global AIDS deaths. The top two countries – Nigeria and South Africa – accounted for more than a quarter of all such deaths (27%).

In South Africa – which has invested considerable resources to expand HIV testing and treatment – ART coverage reached nearly 42% by 2013, and AIDS-related deaths and new HIV infections are sharply declining. In Nigeria, however, ART coverage is increasing only slowly and remained below 20% in 2013; new infections are declining, but the number of AIDS-related deaths is still rising.

The researchers calculated that in 2013 ART averted an estimated 1,051,354 deaths in South Africa and 422,448 deaths in Nigeria. The model projected that increasing ART coverage in these two countries to meet the 90-90-90 targets by 2020 could avert 2.2 million deaths in South Africa and 1.2 million in Nigeria.

Global access to ART has expanded from thousands of people in 2000 to millions today, but treatment coverage is still uneven and much remains to be done, the study authors noted in their discussion. For example, sub-Saharan Africa and Asia and the Pacific together account for 90% of global AIDS mortality, but as treatment access has increased, those regions have seen deaths decline by 39% and 26%, respectively, since 2005. In contrast, AIDS deaths have increased by 66% in the Middle East and North Africa.

"Although these gains are impressive and we are likely to reach the target of 15 million people on ART by end of 2015" – which has in fact occurred, according to the latest UNAIDS report – "our analyses found very high death rates in many settings, low ART coverage and significantly high rates of AIDS-related deaths," they wrote. "These findings are grounds for serious concern and for re-thinking our current approach to preventing AIDS-related mortality."

"Access to ART has a direct impact on an individual’s risk of death, and the country where one lives has a significant impact on death rates and life expectancy," they continued. "In some lower income countries, people living with HIV have 10 to 20 times higher death rates than those living in some higher income countries. Indeed, the stark differences in annual death rates between higher income countries in North America and Western Europe and lower income countries raise important ethical, equity, and human rights issues."

Among the 30 countries with the highest AIDS mortality burden, 12 have reached the 'tipping point' where the number of people starting treatment exceeds annual AIDS-related deaths, the researchers noted. For successful HIV elimination, the number of transmissions from an HIV-positive person within their lifetime (the basic reproduction number or R₀) will have to fall below 1. Today the median number of transmissions in sub-Sahara Africa is 4.6. If the 90-90-90 targets are achieved, this should fall below 1 in 70% of sub-Saharan countries and below 2 in the remaining countries, "making elimination easy to achieve by other high-impact prevention methods," they predicted.

In an effort to reduce the geographic disparity in treatment coverage and mortality, IAPAC, UNAIDS, UN-Habitat and mayors from various cities recently launched the Fast-Track Cities Initiative, which will focus on rapidly achieving the 90-90-90 targets in the highest-burden cities.

"Over the past decade the expansion of access to ART averted millions of deaths," the authors concluded. "Reaching the proposed UN 90-90-90 target by 2020 will prevent additional morbidity, mortality and HIV transmission. Despite progress, high-burden countries will need to accelerate access to ART treatment to avert millions of premature AIDS deaths and new HIV infections."