Need to 'Step Up the Pace' to Reach Global 2020 UNAIDS Goals

Marcia Frellick

October 27, 2016

GLASGOW, United Kingdom — Although several countries are close to meeting the UNAIDS HIV targets for 2020, global progress is just past the halfway point, according to Julio Montaner, MD, director of the BC Center for Excellence in HIV/AIDS in Vancouver, British Columbia, Canada.

"This is really very problematic; 2020 is around the corner, and I'm afraid that if we don't step up the pace, we're not going to get there," he said here at HIV Drug Therapy 2016.

The 90-90-90 plan states that by 2020, 90% of those infected with HIV should know their status, 90% of those (81% of the total) should be receiving antiretroviral therapy, and 90% of those (73% of the total) should be virally suppressed. If these targets are achieved, AIDS could be eliminated as a public health threat by 2030, according to UNAIDS.

Although there are pockets of success, the current totals are not 90%, 81%, and 73%, they are 57%, 46%, and 38%, Dr Montaner reported.

In British Columbia, Dr Montaner's home base, there was political support for the treatment for all people infected with HIV well before guidelines recommended it, he explained. As a result, the incidence of HIV, which had been rising rapidly before 1996, declined significantly.

But it wasn't until the 2000s, when researchers began actively engaging with the community and treating infected people early with antiretroviral therapy, that the AIDS numbers dropped to the consistently low levels seen today in British Columbia. The province currently stands at 82-81-95 and should cross the 90-90-90 threshold in a couple of years, Dr Montaner said.

 
For every 1% increase in coverage, you have a 1% decrease in HIV incidence. Dr Julio Montaner
 

"For every 1% increase in coverage, you have a 1% decrease in HIV incidence," he explained, adding that proactive treatment has halted mother-to-child transmission in British Columbia.

"We have seen not a single case of a child infected at birth in the last 15 years, since treatment as prevention has been in place," he said.

The 90-90-90 goals, proposed by Dr Montaner and adopted by UNAIDS, were based on the success of this strategy.

There are similar success stories in other regions. The fact that Botswana is rapidly approaching the threshold (Lancet HIV. 2016;3:e221-e230) shows that these targets are within reach even in resource-strapped countries, he pointed out. And according to the US President's Emergency Plan for AIDS Relief (PEPFAR), Rwanda will meet the threshold in the next calendar year.

Disparities in Access to Antiretroviral Therapy

But there are wide regional disparities in access to antiretroviral therapy, said Kamilla Grønborg Laut, MD, a PhD student at the University of Copenhagen in Denmark, who presented updates from the prospective observational EuroSIDA cohort study.

The EuroSIDA researchers are looking at five regions in Europe — Western, Southern, Northern, East Central, and Eastern — over three 2-year periods: 2004 and 2005; 2009 and 2010; and 2014 and 2015.

In the 35 countries covered in the EuroSIDA cohort, the use of antiretroviral therapy increased from 68.0% to 82.4% over 10 years. And during that time, the portion of patients virally suppressed increased from 75.5% to almost 87%.

However, patterns were very different in different regions, Dr Grønborg Laut reported.

For example, in 2014 and 2015, people in Western Europe were more likely to be virally suppressed than people in other regions.

The pace of progress is different as well. In Eastern Europe, antiretroviral coverage was relatively low in 2004 and 2005, but 10 years later, 15 times as many people in the region were receiving treatment, she reported.

"Eastern Europe is definitely the region that has experienced the largest improvements, but it's still lagging behind all other regions in ART coverage and the proportion virologically suppressed," Dr Grønborg Laut told Medscape Medical News.

"That's likely because of differences in health structure, economy, politics, and stigma," she pointed out.

Even in Canada, progress is very different in the different provinces and territories. Saskatchewan, for instance, where the HIV epidemic is driven by injection drug use, is struggling to reach the goals, Dr Montaner reported.

And in the United States, black men who have sex with men are at a great disadvantage when it comes to accessing services, he added.

Shared Responsibility

Switzerland got an early start with treatment as prevention, said Manuel Battegay, MD, from University Hospital Basel. A very organized program has helped the country surpass two of the UNAIDS goals.

Almost 96% of people who have been diagnosed are receiving antiretroviral therapy and are virally suppressed, he told Medscape Medical News. In contrast, diagnosis has been more difficult; no more than 70% of infected people have been diagnosed, he reported.

But the responsibility for prevention and treatment should not rely solely on a government's commitment to fighting the disease or on the way the treatment-as-prevention program is organized in a particular region, Dr Battegay pointed out.

People at increased risk for HIV must actively work to protect themselves from the disease and get tested, he explained. The responsibility has to be shared by patients, pharmaceutical companies, and governments.

 
We are in it for a generation, at the very least, if we're going to use treatment as prevention to control morbidity, mortality, and transmission. Dr Julio Montaner
 

Despite individual successes, a piecemeal effort won't work in shutting down AIDS, said Dr Montaner. For other disease-control efforts, he pointed out, as soon as a solution is close, the funding dries up because people think the problem has been solved. He said he fears this will happen with HIV.

"We need to be clear," he said. "We are in it for a generation, at the very least, if we're going to use treatment as prevention to control morbidity, mortality, and transmission."

Dr Montaner has received support from grants paid to his institution by the British Columbia Ministry of Health and by the US National Institutes of Health. In addition, limited unrestricted funding was paid to his institution by AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck, and ViiV Healthcare. Dr Grønborg Laut and Dr Battegay have disclosed no relevant financial relationships.

HIV Drug Therapy 2016. Presented October 24, 2016.

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