The results of a new study in the Journal of the American Medical Association (JAMA) provide strong evidence that the goals of the United Nation’s Program on HIV/AIDS (UNAIDS) are indeed possible.
By now, every clinician treating HIV knows these numbers: 90, 90, and 90.
Although on the surface these numbers seem redundant, they actually, of course, refer to the stated goals of the United Nation’s Program on HIV/AIDS (UNAIDS), which establish the objectives that 90% of those living with HIV/AIDS will be aware of their status, that 90% will be receiving antiretroviral therapy (ART), and that 90% of those on ART will have viral suppression—all by 2020. To get close to these figures, it’s understood that educational outreach efforts are needed to encourage populations to get tested, and that access to treatment for these populations will need to be improved.
Thankfully, there is some evidence that implementation of testing and treatment programs can be effective. Most recently, this has been demonstrated in a study published on June 6, 2017 by the Journal of the American Medical Association (JAMA). For their project, researchers from the School of Public Health at the University of California, Berkeley, University of California-San Francisco, and Harvard T.H. Chan School of Public Health in Boston along with teams from the Infectious Diseases Research Collaboration in Kampala, Uganda (Makarere University), and the Kenya Medical Research Institute in Nairobi assessed the impact of innovative testing and treatment programs at 16 rural clinics set up in Kenya (n=6) and Uganda (n=10). Their findings serve as interim data for the ongoing SEARCH Study (Sustainable East Africa Research on Community Health).
In all, the study followed 77,774 residents of the region who underwent HIV testing at the 16 centers and followed them for a period of 2 years. All of the study participants had their HIV serostatus and plasma HIV RNA levels assessed annually during multidisease health campaigns or via home-based testing (to avoid the stigma of clinic visits). Those who tested positive for HIV were offered ART “using a streamlined delivery model designed to reduce structural barriers, improve patient-clinician relationships, and enhance patient knowledge and attitudes about HIV.” This model included establishing close relationships between clinical staff and patients, and other unique approaches.
Baseline HIV prevalence was 10.3% among the study participants, and 44.7% of those who were HIV positive had viral suppression at baseline. After 2 years of the streamlined ART treatment, 80.2% of the HIV positive participants had viral suppression. Furthermore, 2 years into the program, 95.9% of all HIV-positive individuals had been previously diagnosed, and 93.4% of those previously diagnosed had received ART. Finally, 89.5% of those treated had achieved viral suppression. These numbers, obviously, effectively reflect the stated objectives of UNAIDS.
Unfortunately, the authors of the JAMA paper were unable to respond to requests for comment, as they are still working in the field in East Africa. However, in a commentary that accompanied their findings, Carlos del Rio, MD, and Wendy S. Armstrong, MD, of the Emory Center for AIDS Research in Atlanta write, “This study shows that the UNAIDS 90-90-90 goals can be achieved in a relatively short time in rural settings in Eastern Africa. Importantly, these results highlight some strategies that may be critical to success both in East Africa and in affected communities around the world. First, integrating HIV testing into a multidisease strategy at alternative nonstigmatizing sites (ie, a community health fair rather than in a clinic) may be critical to increase HIV testing uptake. Second, patient-centered care with not only immediate appointments but a more personal approach may help patients link with and remain in care. In this study, patients were introduced to clinical staff, given a phone number and transport voucher, offered flexible hours, and were tracked including appointment reminders. These measures require additional clinic infrastructure and are often deemed nonessential when clinic resources are stretched, but must be considered with widespread scale-up.”
Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous healthcare-related publications. He is the former editor of Infectious Disease Special Edition.