From Africa to Georgia: What We Have Learned From the 90-90-90 Treatment for All Initiative Carlos del Rio, MD Professor of Global Health Rollins School of Public Health Professor of Medicine Emory University School of Medicine Atlanta, Georgia Learning Objectives After attending this presentation, learners will be able to: Describe the 90-90-90 goals List interventions developed in Africa that are applicable to the US Describe the value of investments in global health research Slide 3 of 27 Slide 4 of 27 What is 90-90-90? A UNAIDS initiative launched at the 20 th International AIDS Conference in Melbourne in 2014 setting HIV targets for 2020. 90-90-90 targets are focused on improving the care continuum and emphasize viral suppression as the major goal of care for people living with HIV. The 90-90-90 targets have become the central pillar of the global quest to end AIDS. 90-90-90 shifts the global approach to HIV treatment from focusing on the number of people on antiretroviral therapy towards the importance of maximizing viral suppression at a population level.
Slide 5 of 27 What is 90-90-90? 73% of all living with HIV being virally suppressed WHO: http://www.who.int/mediacentre/factsheets/fs310/en/ Antiretroviral drugs are the cornerstone Improving the quality of life for PLWHA and decreasing transmission of HIV rely on antiretrovirals Slide 6 of 27 Where are we globally in 2018? 44% of all living with HIV being virally suppressed Slide 7 of 27
Slide 8 of 27 Where are we in the US? 49% of all living with HIV being virally suppressed 90-90-90 for some key populations Slide 9 of 27 Who has reached 90-90-90? Botswana Cambodia Denmark Iceland Singapore Sweden UK Slide 10 of 27
Slide 11 of 27 Achieving the First 90 Despite scale-up of HIV testing, knowledge of serostatus still has significant room for improvement. This is particularly true for young people and men. Closing the gap will require: * Prioritizing HIV testing * New technologies * Innovative service delivery strategies Slide 12 of 27 HIV Testing in the US 15% of PLWHA in the US in 2015 were unaware of their infection. * Range from 5.7% - 18.5% across states * 50.5% of undiagnosed infections in the South * Southern states have a higher % unaware Median delay from infection to Dx: 3 years HIV tested in prior 12 months: * 71% of MSM * 58% of PWID * 41% of heterosexuals at risk MMWR 2017 HIV Testing lessons from Africa Rapid Testing Couples Counseling and Testing Slide 13 of 27
Slide 14 of 27 HIV Testing CVCT Intervention developed by Dr. Susan Allen in Africa. Almost 2/3 of incident HIV infections in SSA occur among stable HIV serodiscordant couples. Shown to decrease transmission. Despite estimates that most HIV transmissions among gay/bisexual men occur in main partnerships, no proven interventions were available to reduce risks of HIV infections in these couples. HIV Testing CHCT Slide 15 of 27 HIV Testing CHCT 100 80 60 40 20 CHTC ivct Slide 16 of 27 0 IPV Relationship dissolution Outside sex partners
Slide 17 of 27 HIV Testing Testing Together https://effectiveinterventions.cdc.gov/en/highimpactprevention/publichealthstrategies/testing-together Achieving the Second 90 Adoption of a treat all approach and same-day initiation will be critical for success. This will require rapid expansion of proven models for linking newly diagnosed people to care and redesign of clinic operations to improve efficiency, empower clients and expedite treatment uptake. * Strategic use of CHWs & differentiated care Lessons from SEARCH and PopART studies must be implemented Slide 18 of 27 Linkage to care lessons from Africa SEARCH RapIT Slide 19 of 27
Slide 20 of 27 HIV Testing SEARCH SEARCH Sustainable East African Research in Community Health Cluster randomized trial in Kenya and Uganda Test and treat strategy vs country specific standards in 32 matched rural communities Intervention communities: - Annual multidisease community health campaign (HIV, DM, HTN) + home-based testing - HIV+: facilitated linkage to care with immediate appts, personal staff introductions, clinician phone number, 1-time transport voucher, tracking of individuals who did not link, streamlined ART with flexible hours, reminders, HIV RNA measures, etc. HIV Testing SEARCH Slide 21 of 27 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cascade coverage among prevalent HIV+ 96% 97% 91% 94% 80% 86% 89% 90% 70% % HIV+ w/ Prior Dx % Prior Dx ever on ART 90% target % Ever on ART w/ Supp Baseline Follow Up Year 1 Follow Up Year 2 Petersen, JAMA 2017 Linkage to Care RapIT Starting ART in initial visit in SA increased ART uptake by 36% and viral suppression by 26% Slide 22 of 27
Slide 23 of 27 Linkage to Care REACH Pre-REACH, N=117 Post-REACH, N=90 Days to 1 st scheduled provider visit 15 (7, 20) 4 (1, 7) Days to 1 st attended provider visit 17 (7, 26) 5 (2, 8) Days to ART start 21 (12, 31) 7 (3, 17) 67 days 41 days Slide 24 of 27 Achieving the Third 90 Support patient adherence to treatment and implementing strategies to reduce the number of patients lost to follow-up: * Peer support groups * SMS reminders * Differentiated care * Patient-friendly clinical environments Expansion of viral load testing is also critically important: * Point-of-care technologies What got us here, won t get us there Slide 25 of 27 "There is also high interest in developing differentiated care for other groups of PLHIV including pregnant women, PLHIV with advanced HIV disease, adolescents, men, migrant and mobile populations, and key populations, such as men who have sex with men, sex workers, and people who inject drugs"
Slide 26 of 27 NIH Program announcement The goal of this funding opportunity announcement (FOA) is to translate and adapt the most successful global, evidence-based HIV-related service provision strategies to marginalized populations in the United States (U.S.) with a substantial risk of HIV-infection and AIDS. The ultimate goal, is to produce improvements in HIV-related health outcomes in these key populations through strategies that successfully and durably reach them with timely HIV testing, prevention and treatment technologies that lead to the achievement of the UNAIDS 90-90-90 benchmarks: by 2020, 90 percent of all people living with HIV will know their HIV status, 90 percent of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90 percent of all people receiving antiretroviral therapy will have viral suppression. Conclusions If we are to achieve the goals of the NHAS innovative approaches will be needed as doing the same thing we have been doing will not get us there. PEPFAR strategies to deliver quality care and treatment vary by country, but focus on strengthening health care infrastructure and service delivery to provide quality care. Interventions have been primarily clinic-based, with community-outreach services for patients who are lost-to-follow-up and for testing initiatives. Lessons be learned from interventions to improve HIV care in Sub- Saharan Africa can improve medical care in the US. Slide 27 of 27