Empirical evidence that achievement of UNAIDS 90-90-90 can deliver promised HIV elimination?

The achievement of the UNAIDS 90-90-90 targets would reduce levels of viral suppression amongst HIV+ people to 73% by 2020. The target is set at this ambitious level because, modelers suggest, it would bring about the elimination of HIV by 2030. In sub-Saharan Africa the challenge seems so great – especially in regard to the element of engagement and retention in treatment (Mountainous Challenge/STI/blogs; Wringe & Skovdal/STI) that the question of whether the necessary interventions would really bring about the proposed goal of the elimination of HIV – of whether the modelers are right – disappears off the horizon.

Results of the recent Rakai Community Cohort Study (Grabowski & Chang (G&C) from 30 communities (17,879 persons) in Uganda, over the course of 12 surveys undertaken between 1999 and 2016, show the following trends. First, an increase in viral load suppression amongst HIV+ individuals since ART scale-up from 42% (2009) to 75% (2016), and in voluntary male circumcision since the beginning of the study from 15% (1999) to 59% (2016). But also – apparently as a result of these interventions – a decline in HIV incidence from 1.17 cases per 100 person-years in the period before scale-up to 0.66 cases per 100 person-years in 2016. Some indication of how much this may be due to ART as against circumcision is suggested by difference between the decline amongst men (who have benefited from both interventions), which reached 0.46 in 2016, and women (who have benefited – at this stage – largely from ART), which reached 0.68. The contribution of consistent condom use has evidently had little to do with the decline, since it has remained largely unchanged since the inception of the study.

As regards viral load suppression, this population has met the UNAIDS target and is presumably on course. However, incidence per 100 person-years needs to reach 0.1, according to the modelers, for elimination to be achieved. The working-through of the epidemiological effects of already achieved levels of circumcision to the female population should further help things on their way. Moreover, the UNAIDS target of 80% circumcision may be achieved in the coming years.

The authors claim this is the first study to demonstrate the population level effect of the combination strategy for HIV prevention. How far are its encouraging conclusions generalizable? It is true that with high coverage of testing services (98%) the conditions in Rakai are favourable; yet data from the National AIDS Control Programme of Uganda indicate that the dramatic scale-up of the combination strategy has been replicated more widely, with ART coverage of 68% and circumcision at 54% (as opposed to 69% and 59% respectively for Rakai). In other sub-Saharan countries, the picture may be rather different (Wringe & Skovdal/STI) – though data from the Swaziland HIV incidence measurement survey 2017 shows a comparable relationship between relatively steep increase in viral suppression and a decline in incidence (Achieving UNAIDS 90-90-90: More haste, less speed/STI/blogs; SHIMS 2).

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