Monitoring of progress towards 90-90-90 blighted by poor quality reporting

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.”