Comment
90-90-90: how do we get there? The 2012 world AIDS conference in Washington DC heralded the ”beginning of the end of AIDS“ and “an AIDS free generation” as the benefits of antiretroviral therapy (ART) and combination prevention became evident.1 2 years later at AIDS 2014 in Melbourne the focus of stepping up the pace was reinvigorated by new 2020 targets released by UNAIDS.2 These targets call for 90% of people living with HIV to know their status, 90% of diagnosed people to receive ART, and 90% of people receiving ART to be virologically suppressed. Intended to drive progress and close the treatment gap, these ambitious goals have important implications for the HIV response. The cascade of care from HIV diagnosis through to successful treatment is now central to the monitoring of the HIV epidemic and identification of steps where intervention would have the greatest effect. The UNAIDS targets translate into 81% of people with HIV receiving ART and 73% achieving virological suppression. Given that the highest current reported national ART coverage is 67% in the UK and 62% in Botswana,3 achieving these goals will be challenging in all settings. Resource-limited settings often have large centrally managed HIV programmes providing ART with a public health model based on national guidelines. Low median CD4 count at commencement of ART suggests that symptomatic clinical illness drives access to services in these settings.4 Theoretically, these centrally funded and managed programmes have the potential to implement changes and measure their effects over time, but these responses can be limited by incomplete data. In highincome countries with individualised care models the cascade of care over time, place, and subpopulations is often poorly understood. Those with adequate virological suppression might be a subpopulation with favourable characteristics that improve engagement in care compared with those who are undiagnosed and untreated. Furthermore, health-care systems in richer countries might do well in areas such as retention before ART and access to care,5 but lower-income countries likely outperform their richer neighbours in delivery of early treatment when HIV is diagnosed and ART is available, in retention in care of treated patients, and in adherence to ART. www.thelancet.com/hiv Vol 1 October 2014
Examples of these lessons or successful interventions aimed at maximising steps in the cascade from lower income countries are numerous. They include efforts to make HIV testing available in the home, an intervention that diagnosed people with HIV in western Kenya at a median CD4 count of 323 cells per μL compared with 190–210 cells per μL for voluntary or providerinitiated testing programmes.6 Furthermore, successful interventions at the individual or clinic levels have shown how ART care can be delivered with a nurse-led model with appropriate training and support.7,8 Data from larger programmes show the success of non-physicianled care with a combination of nurses, physicians, and medical assistants rather than purely physician-led models.9 As clinics encounter more people requiring ART, adherence clubs at which medication supply and patient-led discussion groups are overseen by counsellors have improved retention in care for patients established on ART with stable disease.10 Lower-income countries are also reporting successful interventions aimed at later steps in the cascade to improve ART adherence and virological suppression with technology-based interventions such as regular phone text messaging reminders or the use of web-connected pill boxes that trigger reminder text messages if they are not opened.11,12 The 90-90-90 target is substantively higher than that currently achieved in the cascade of HIV care in any setting. Measuring and reporting the cascade consistently is needed for meaningful comparisons and translation of successful interventions to different settings. Further research to characterise populations most likely to leave the different steps of the cascade and low cost rapid assessments of the cascade based on individual level data are urgently needed to reach the new goals and an AIDS free generation. James H McMahon, Nicholas Medland Infectious Diseases Unit, Alfred Hospital (JHM), Monash University (JHM, NM), Burnet Institute (JHM), and Melbourne Sexual Health Centre (NM), Melbourne, VIC, Australia JHM is an investigator in clinical trials sponsored by ViiV Healthcare, Gilead, BristolMyers Squibb, Pfizer, and Merck Sharp & Dohme. JHM’s institution has received payment for consultancy to Gilead. NM declares no competing interests. 1 2
The Lancet. The beginning of the end of AIDS? Lancet 2012; 380: 1967. UNAIDS. Ambitious treatment targets: writing the final chapter of the AIDS epidemic. http://www.unaids.org/en/media/unaids/contentassets/ documents/unaidspublication/2014/JC2670_UNAIDS_Treatment_ Targets_en.pdf (accessed Sept 10, 2014).
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Hill A, Pozniak A, Raymond A, Heath K, Ford N. Higher antiretroviral treatment coverage is associated with lower HIV infection rates: analysis of 51 low and middle-income countries. International AIDS Conference; Melbourne, Australia; July 20–25, 2014 (abstr LBPE29). Lahuerta M, Wu Y, Hoffman S, et al. Advanced HIV disease at entry into HIV care and initiation of antiretroviral therapy during 2006–2011: findings from four sub-saharan African countries. Clin Infect Dis 2014; 58: 432–41. Rosen S, Fox MP. Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Med 2011; 8: e1001056. Wachira J, Kimaiyo S, Ndege S, Mamlin J, Braitstein P. What is the impact of home-based HIV counseling and testing on the clinical status of newly enrolled adults in a large HIV care program in Western Kenya? Clin Infect Dis 2012; 54: 275–81. Sanne I, Orrell C, Fox MP, et al. Nurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): a randomised non-inferiority trial. Lancet 2010; 376: 33–40. Fairall L, Bachmann MO, Lombard C, et al. Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): a pragmatic, parallel, cluster-randomised trial. Lancet 2012; 380: 889–98.
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McGuire M, Ben Farhat J, Pedrono G, et al. Task-sharing of HIV care and ART initiation: evaluation of a mixed-care non-physician provider model for ART delivery in rural Malawi. PLoS One 2013; 8: e74090. Luque-Fernandez MA, Van Cutsem G, Goemaere E, et al. Effectiveness of patient adherence groups as a model of care for stable patients on antiretroviral therapy in Khayelitsha, Cape Town, South Africa. PLoS One 2013; 8: e56088. Lester RT, Ritvo P, Mills EJ, et al. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet 2010; 376: 1838–45. Sabin L, Bachman-DeSilva M, Vian T, et al. Improving adherence to antiretroviral therapy through real-time feedback: the China Adherence Through Technology Study (CATS). International AIDS Conference; Melbourne, Australia; July 20–25, 2014 (abstr #WEPDB0104).
www.thelancet.com/hiv Vol 1 October 2014