90-90-90 in the Asia Pacific – what’s it going to take?Heath Paynter
In 2013, UNAIDS introduced the ‘90-90-90’ targets. An ambitious framework for global HIV and AIDS reduction, the targets aspire that by 2020:
- 90% of all people living with HIV (PLHIV) know their HIV status.
- 90% of all people diagnosed with HIV are receiving sustained antiretroviral therapy (ART).
- 90% of people receiving antiretroviral therapy (ART) are virally suppressed (i.e. the amount of HIV in a person’s blood is reduced to an undetectable and, therefore, untransmittable level).
Many countries in the Asia-Pacific region have made progress on HIV and should be commended for their efforts. However, many are still unlikely to reach their targets by next year. Of the eight countries involved in AFAO’s Sustainability of HIV Services for Key Populations in Asia (SKPA) program (Bhutan, Laos, Malaysia, Mongolia, Papua New Guinea, the Philippines, Sri Lanka and Timor-Leste), Malaysia is the only country to have met a 90-90-90 goal (90.1% of PLHIV know their status), although Laos, Papua New Guinea, the Philippines and Sri Lanka could quite promisingly meet the same goal (Table 1) . However, coverage needs to be viewed with caution. It is dependent on estimates of PLHIV who know their status. Only recently, Malaysia revised the estimate up (which will reduce the percentage of people who know their status) and in the Philippines, only a small percentage of men who have sex with men (MSM). know their status. Thus, the estimated total number of people who know their status is likely to be an overestimate of the actual number of people who know their status.
Table 1: the estimated number of PLHIV, the percentage of PLHIV who know their status, percentage of all PLHIV on ART, and the percentage of all PLHIV with viral suppression across SKPA countries.
|Country||Number of PLHIV||% of PLHIV aware of status||% of all PLHIV receiving ART||% of all PLHIV with viral suppression|
|Papua New Guinea||48,000||72%||55%||Unknown|
With 2020 looming, most countries, realistically, will not achieve these targets. By looking at how countries are falling short against these targets, a clearer diagnosis of what is lacking, and what needs to be done can be articulated. One key issue that prevents this, however, is when there is a serious paucity in data. A number of SKPA countries do not have sufficient information to report the percentage of ART recipients with suppressed viral loads. The absence of this critical piece of strategic information is problematic. When a country’s systems that capture this data can’t do so accurately there is a risk that many PLHIV’s health could be compromised and efforts to prevent HIV transmission undermined
So, what will it take for these countries to be on track?
Of course, the path will look different for each country. There are vast differences in the epidemiological, developmental and socio-political factors that characterise the epidemic in each setting. Nevertheless, we do have evidence-informed, best practice models for the reduction of HIV transmission, and treatment and support of PLHIV. These are by no means silver-bullet solutions, but they give us clear frameworks to structure national HIV responses.
We know that robust and up-to-date epidemiological, behavioural and social data are essential for tracking performance and ensuring the needs of populations most affected by HIV are being met. At-risk populations require access to a broad package of services (condoms, PrEP, PEP, testing facilities, sterile injecting equipment, ART) and must be empowered to make choices to protect themselves and others. In the presence of declining international aid, sustainable domestic financing mechanisms will be needed for the continued implementation of HIV reduction programs and the longevity of civil society organisations. Scaled up and active civil society organisations are crucial for meaningful efforts to reduce HIV transmission and represent the needs of key populations (including men who have sex with men, transgender people, people who inject drugs, sex workers, prisoners and women and children). Discriminatory and stigmatising laws, policies and attitudes towards PLHIV and key populations must be reformed, particularly those that restrict access to HIV-related, harm reduction and other health services.
None of this will be easy, and the precise implementation of these schemes will vary depending on the context of each country. Addressing these factors will be at the heart of a successful strategy to reach the 90-90-90 targets. Informed by these realities, the SKPA program has been tailored to respond to the localised needs and values of, and challenges faced by communities in the region. It is a program working in concert with other initiatives in the region to deliver complementary interventions. Read more about the program on AFAO’s website here.