Results from population-based HIV impact surveys provide insight into where investments are needed

AMSTERDAM/GENEVA, 22 July 2018—Cameroon, Côte d’Ivoire, and South Africa have released new survey data on progress towards the 2020 targets. The Cameroon and Côte d’Ivoire population-based HIV impact assessment (PHIA) surveys and the South African survey all studied knowledge of HIV status, new HIV infections, condom use, voluntary medical male circumcision, antiretroviral therapy coverage, viral suppression and other indicators. 

In South Africa, which has the largest HIV epidemic in the world with more than 7 million people living with HIV and the largest treatment programme in the world with 4.4 million people on antiretroviral therapy, the new data combined with similar data from an earlier survey indicate that there has been a 40% reduction in the rate of new adult HIV infections between 2010 and 2017.

“These surveys are incredibly important and play a vital role in helping countries to review and refine their HIV programming to make sure that the right services are reaching people affected by HIV,” said Michel Sidibé Executive Director of UNAIDS.

The survey data confirm UNAIDS estimates which indicate that South Africa has also improved treatment coverage and is very close to reaching the 90-90-90* treatment targets. It found that 85% of people living with HIV knew their HIV status, 71% of people who knew their status were accessing antiretroviral treatment and 86% of people who were accessing treatment had supressed viral loads.

Viral load suppression among all people living with HIV in Cameroon and Côte d’Ivoire however was less than 50% reflecting low treatment coverage. The two countries are far from reaching the 90-90-90 targets at 47%, 91% and 80% and 37%, 88% and 76% respectively.

The largest difference between the southern African country and the two western and central African countries is observed in knowledge of HIV status, indicating that HIV testing services need to be significantly scaled up in west and central Africa.

The PHIA surveys provide key information for identifying characteristics of the populations that are not receiving services. In Cameroon, viral load suppression varied by province from 28% to 63%. In South Africa less than 50% of children and young men (ages 15-34 years) living with HIV had suppressed viral load (compared to 67% among the women aged 15-49). These data will provide critical information to allow programme managers to direct their responses to the populations and locations most in need of services.

The PHIA surveys, were led by Columbia University in collaboration with country governments and supported by the United States President’s Emergency Plan for AIDS Relief. The South African survey was conducted by the Human Sciences Research Council

* 90% of people living with HIV know their HIV status, 90% of people who know their status are receiving antiretroviral treatment, and 90% of people on treatment have suppressed viral loads.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

Estimating how many people living with HIV are on treatment is vital to keeping track of the success or otherwise of the global AIDS response. HIV treatment not only keeps people alive, but, through reducing the viral load of a person, greatly reduces the chance that a person living with HIV will transmit the virus to someone else.

UNAIDS published its latest estimates of the number of people living with HIV accessing antiretroviral therapy in its new report, Miles to go. An estimated 21.7 million [19.1–22.6 million] people of the 36.9 million [31.1–43.9 million] people living with HIV at the end of 2017 were on HIV treatment.

A total of 143 countries submitted the data that UNAIDS used to compile the estimate, representing 91% of all people estimated to be on treatment worldwide. Those 143 countries supply actual counts of people on treatment, not estimates, although estimates are used for those few countries that do not supply counts. Countries report their numbers of people on treatment—both adults and children, disaggregated by sex—through the Global AIDS Monitoring tool every six months. Similar data are included in the Spectrum epidemiological estimation software.

UNAIDS provides technical assistance and training to public health officials and clinical officers—the people who compile the numbers in the countries—to ensure that their reports on treatment coverage are accurate. In addition, every year, in partnership with the United Nations Children’s Fund, the World Health Organization and other partners that support the delivery of HIV treatment services, UNAIDS reviews and validates the treatment numbers reported through both the Global AIDS Monitoring tool and Spectrum.

When UNAIDS’ estimates of treatment coverage in countries are compared with estimates of treatment coverage made in Population-Based HIV Impact Assessments (PHIA) and other surveys, similar levels of treatment coverage are seen (see the attached graph).

In 2017, UNAIDS carried out a triangulation of data as a way to confirm or deny the results of its annual data collection. That analysis sought to answer a simple question: are enough antiretroviral medicines produced and bought to treat the number of people reported to be on antiretroviral therapy?

At the end of 2016, 19.4 million people globally were on antiretroviral therapy, with an estimated 14.1 million people accessing treatment in generic-accessible low- and middle-income countries.

A study of the exports and domestic procurement of antiretroviral medicines in 2016 from India showed 11.4 million person-years of treatment. When the generic antiretroviral medicines produced in other countries were included, an estimate of 14.2 million–16.2 million person-years on treatment was made—sufficient to treat the 14.1 million people in generic-accessible low- and middle-income countries.

In 2018, UNAIDS partnered with the World Health Organization, the Global Fund to Fight AIDS, Tuberculosis and Malaria and selected technical partners and ministries of health in 28 countries, most of which are in sub-Saharan Africa, to conduct data quality reviews of reported treatment numbers and, where over- or undercounting is found, to correct current and historical reports of treatment numbers. Previous data quality reviews since 2016 have been used to adjust estimates, for example by taking into account people who transfer from one clinic to another, but are reported by both clinics, or people who have died, left care or emigrated but are not identified and removed from treatment registries.

More details on the methods for calculating the number of people on treatment can be found in the annex on the methods in Miles to go, while details of how the triangulation was undertaken can be found in a publication published on an earlier triangulation exercise.

The International Association of Providers of AIDS Care (IAPAC) hosted its 2018 Controlling the HIV Epidemic Summit in Geneva, Switzerland, on 3 and 4 May. Speakers at the summit discussed new metrics for assessing progress in national and subnational HIV responses as well as scaling up HIV services to include other health conditions, such as tuberculosis.

Soumya Swaminathan, the Deputy Director-General of the World Health Organization, gave the keynote address, emphasizing the importance of integrating and linking health services. For example, people living with HIV should have access to testing and treatment of noncommunicable diseases.

Tim Martineau, UNAIDS Deputy Executive Director, Programme, a.i., highlighted that in mid-2017 nearly 21 million people had access to treatment, but 15.8 million still did not. In addition, as of 2016, new HIV infections were off the 2020 target of fewer than 500 000 infections per year. He stressed that more needs to be done for key populations and young women and adolescent girls. 

Deborah Birx, United States Global AIDS Coordinator and Special Representative for Global Health Diplomacy, explained how the United States President’s Emergency Plan for AIDS Relief zeroed in on 13 countries for epidemic control. Resources alone, she said, cannot bring about change. Political will, government commitment, reducing stigma and data analysis are key to ending AIDS. Once core policies are adopted based on programme needs and gaps, with community involvement, countries can really scale up national efforts, she said.

All agreed that one size does not fit all. The response has to be tailored to countries and segments of the population. Among the encouraging strategies are HIV self-testing kits, increasing nurses’ responsibilities, male corners where male nurses and doctors provide care and treatment and same-day treatment for people testing HIV-positive in order to avoid a second visit to health centres.  

Quotes

Experts from India and around the world recently discussed new ways of carrying out HIV surveillance and making estimates on the HIV epidemic in India.

Opening the consultation, the Director General of Health Services of India, B.D. Athani, said, “Disease surveillance is the stethoscope of a public health professional and an extremely important public health function.”

The consultation heard about in-country pilot projects and other initiatives being planned. Steps being taken to strengthen the quality of data and enable their better use were highlighted, as were efforts that are being made to improve the interface between the various information systems for HIV surveillance.

Technical sessions on HIV surveillance, including the importance of integrated surveillance for HIV, tuberculosis, hepatitis and syphilis, and on making HIV estimates were held throughout the four-day event.

“The use of data is fundamental to enabling an efficient and sustained public health response. Three questions remain critical in this regard: what data shall be collected, how it shall be collected and how it should be used to help the design and implementation of an effective response,” said S. Venkatesh, the Deputy Director General of the Indian National AIDS Control Programme.

During a session on making district-level HIV estimates, the different methods of how estimates could be made were examined. The participants agreed that, for inter-district comparability and consistency, just one method should be used to generate district estimates. Determining the best method would require further analysis of the strengths and limitations of all of them, however.

During the consultation, Bilali Camara, the UNAIDS Country Director for India, noted the importance for the AIDS response of having granular information on locations and populations.

A presentation on key population size estimates included a novel pilot for virtual mapping using social media in an ethical and cost-effective way, which was recognized as the methodology of the future. The consultation also heard that India should collect behavioural information through so-called polling booth surveys—whereby information on behaviours can be collected anonymously—and other innovative approaches.

Sessions on each of the technical areas began with international experts sharing the broad global framework and guidelines. They highlighted approaches adopted by different countries and the practical considerations for each approach. The participants agreed that data from surveillance, estimates and programmes represent different pieces of information that together provide a better perspective on the HIV epidemic and response—each piece is important and should not be seen in isolation.

The consultation was held on 21–24 March in New Delhi, India. It was organized by India’s National AIDS Control Organization in collaboration with UNAIDS, the World Health Organization and the United States Centers for Disease Control and Prevention, whose experts were joined by national experts from the Indian Council of Medical Research institutes and others. Recommendations from the consultation will be compiled into a road map for implementation by the National AIDS Control Programme.