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Sweden Becomes First Country to Achieve UNAIDS 90-90-90 Targets

Sweden has become the first country to achieve the UNAIDS/World Health Organization (WHO) 90-90-90 targets, research published in the August 18 advance edition of HIV Medicine shows. At the end of 2015, 90% of HIV cases in Sweden were diagnosed, 99.8% of people were linked to care, and 95% of people taking antiretroviral therapy for at least 6 months had a viral load below 50 copies/mL.

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Big Increase in Proportion of HIV+ People with Viral Suppression in US

The proportion of people living with HIV receiving care in the U.S. who accessed antiretroviral therapy (ART) and achieved viral suppression increased substantially between 2009 and 2013, according to research published in the May 20 online edition of AIDS.

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AIDS 2016: Mapping Local HIV Epidemics Can Help Target Resources to Areas with Greatest Need

Global health agencies have recently put a new emphasis on geography. UNAIDS has called for programs to focus on "location and population." PEPFAR (the U.S. President's Emergency Plan for AIDS Relief) says there is a "need to do the right things in the right places at the right time." The Global Fund believes there is a need to "target resources to areas with the greatest need." But how can these principles be applied in practice? Speakers at the 21st International AIDS Conference (AIDS 2016) last month in Durban outlined examples of how maps and geographical analyses have helped improve HIV services in the U.S. and South Africa.

[Produced in collaboration with Aidsmap.com]

Mapping HIV in the U.S.

Travis Sanchez from Emory University in Atlanta introduced AIDSVu, a set of interactive, online maps that allows users to visually explore the HIV epidemic in the U.S. By making it readily accessible to policy-makers, it has been used to better target limited healthcare and HIV prevention resources.

For example, Sanchez showed maps of Chicago, showing rates of diagnosed HIV in different parts of the city, broken down by ethnic group. As expected, rates among black people are higher than among whites, and this is the case throughout the city. But the map highlighted some unexpected clusters of cases -- high rates among white people in some predominantly black zip codes in the city’s south-central area, as well as high rates among black people in some predominantly white zip codes in the northeast of the city.

In Philadelphia, health officials used HIV prevalence data at the census-tract level (the most detailed unit available, covering a neighborhood with a few thousand residents) in order to target door-to-door testing campaigns. "This is really about targeting local resources in the local communities that need them most," Sanchez said.

While mapping rural Alabama, it became clear that a number of counties with high rates of HIV were also designated as "Health Professional Shortage Areas." With HIV concentrated in deprived populations that have limited access to transportation to medical facilities further afield, there is a potential for people to drop out of care and have uncontrolled viral load. In response, health officials set up a telemedicine service so that primary care clinics in the underserved areas could be linked with medical providers elsewhere in Alabama. A web-based video link (a bit like a Skype call) allows patients to receive medical care and counseling at a distance. 

In Atlanta, the mapping demonstrated how HIV and poverty overlapped. Looking into the data in more detail, "hot spots" of poor linkage to care and low rates of viral suppression were identified. While some areas of high HIV prevalence were served by HIV treatment facilities, several other hot spots were far from medical facilities, with low rates of car ownership and poor public transportation links.

Sanchez said that mapping these relationships had been "transformational" in helping local officials identify the structural barriers to care and prepare the local Strategy to End AIDS. The plans place emphasis on creating patient-friendly systems that facilitate entry into care, including transportation support.

Mapping in South Africa

Frank Tanser from the Africa Centre for Population Heath has been intensively studying a rural, poor area of KwaZulu-Natal in South Africa. His mapping shows that HIV incidence, HIV prevalence, and deaths are far from evenly distributed, with all 3 highly concentrated in informal settlements and peri-urban areas bordering a major highway.

"I think these maps speak to the tyranny of averages," Tanser said. Rather than spreading healthcare resources evenly across all areas, there’s an opportunity to use this "incredible spatial heterogeneity" to focus investment on the most vulnerable populations and so bring epidemics under control, he said.

The maps have identified "hot spots" in which a significant proportion of people have uncontrolled HIV -- in some specific locations, more than 1 in 4 adults in the general population have a detectable viral load. Such communities may not only have a high burden of HIV themselves, but may also be driving onward transmission in the wider geographical area.

Phylogenetic analysis (examining the genetic links between HIV in different individuals) suggests that a high proportion of new infections in other communities can be linked back to individuals living in the "hot spot" communities beside the highway. Transportation and migration are likely to play an important part in this.

Targeting resources so as to improve the treatment cascade in these specific locations could have a disproportionate impact on the larger epidemic, Tanser suggested.

Overcoming Data Limitations

The examples presented at the conference depend on rich sources of data. AIDSVu links extensive data collected by American public health agencies with socioeconomic information from the U.S. census. The Africa Centre conducts intensive HIV surveillance activities within a 20 by 20 km area. How then can the approach be applied in settings where such resources are not available?

Tanser said that insights derived from studies, such as the relationship between distance to health facilities and HIV prevalence, would likely be applicable elsewhere. Other urban and peri-urban informal settlements in African countries are likely to be "hot spots." Those located near major transport routes are especially likely to contribute to new infections, but can also be easily reached by health providers.

One important gap in routinely collected data is that it rarely records details that would identify individuals as members of key populations, such as sex workers or people who inject drugs. As a result, key populations tend to be invisible in many spatial analyses although they may cluster in specific areas. Tanser said that there was potential to apply geographical analyses to key populations (using respondent-driven sampling) but that there could be sensitivities when mapping stigmatized and criminalized groups.

Closing the session, Gesine Meyer-Rath said that funders were often very interested in mapping, as targeting could mean that financial resources could be used more efficiently. This could be a way of justifying spending less. But she said that the same data could also be used by activists and members of affected communities to demand services where they really are needed.

8/23/16

References

Using Geospatial Analysis for Effective HIV Programming. 21st International AIDS Conference. Durban, July 18-22, 2016. Session THSY05.

T Sanchez. The direct programme impacts of publicly available tools to visualize spatial patterns in HIV infection in the United States: the AIDSVu experience. 21st International AIDS Conference. Durban, July 18-22, 2016. Presentation THSY0503.

F Tanser. Application of geospatial analyses to reveal targets for intervention: results from a population-based cohort in rural KwaZulu-Natal, South Africa. 21st International AIDS Conference. Durban, July 18-22, 2016. Presentation THSY0504.

Model Suggests There Are Fewer People with HIV in U.S. and More on Treatment

A study comparing recorded diagnoses of HIV with subsequent records of viral load and CD4 T-cell tests suggests that the number of people living with HIV in the U.S. could have been overestimated by as much as 45% -- and the proportion who are on antiretroviral therapy (ART) with undetectable viral loads could have been underestimated by as much as 50%. There could be as few as 820,000 people with HIV in the U.S. compared with the normally accepted figure of 1.2 million -- and up to 55% of those could be on ART and virally suppressed, compared with the most commonly quoted figure of 30%.

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AIDS 2016: HIV Viral Load Pilot Study Shows Roll-Out Will Depend on an Educated Workforce

For viral load testing to prevent HIV treatment failure, drug resistance, and onward transmission, treatment programs will need to invest in better record-keeping and clinic procedures, human resources, demand creation, and decentralization of second-line treatment provision, a large pilot study of viral load test provision in southern Africa has found. Findings were presented last month at the 21st International AIDS Conference (AIDS 2016) in Durban.

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CROI 2016: Personalized Counseling Improves Rate of Entry into HIV Care

Entry into HIV care can be increased by around 40% if people receive a point-of-care CD4 test and counseling sessions to overcome personal barriers to seeking HIV care, according to a large randomized study in South Africa presented at the Conference on Retroviruses and Opportunistic Infections (CROI 2016) last month in Boston. However, the study also found that only half of the people who received the most effective linkage intervention and who were in need of immediate treatment made it onto antiretroviral therapy (ART) within 6 months of their HIV diagnosis, highlighting the need for further improvements in linkage to HIV care.

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