90-90-90 by 2020

One year ago, UNAIDS announced an ambitious goal: by the year 2020, 90% of all HIV infected persons would be identified, 90% would be in treatment, and 90% would have an “undetectable” HIV RNA level. This goal is based on many important principals, and, if successful, will be a major step in ending the worldwide HIV epidemic. In fact, it is estimated that new infections would fall by 70%.

I believe it is worth examining this goal, piece by piece, identifying barriers to its success, and detailing how far we are from achieving this goal. 

First, getting tested voluntarily for HIV is an excellent idea. Early diagnosis decreases the number of individuals likely to be exposed to HIV, assuming that risk behavior continues. In addition, being diagnosed with HIV infection often is associated with a reduction of risk behavior. The CDC in 2006, revised its recommendations for HIV testing, emphasizing the importance of making HIV testing part of routine medical care. And while most states have made testing “easier,” only New York mandates that all health care providers offer HIV testing as part of routine medical care. Specifically, the law in New York states that “HIV testing must be offered to all persons between the ages of 13 and 64 receiving hospital or primary care services with limited exceptions noted in the law.”¹ In other states, HIV testing of non-pregnant individuals still relies too much on individuals requesting to be tested.

After diagnosis, linkage to care and retention in care are critical steps in getting 90% of those diagnosed on treatment and getting 90% of those on treatment to an “undetectable” HIV RNA level. In New York, the law requires that any health care provider who tests an individual for HIV “provide or arrange for an appointment for follow-up HIV care for those who test positive and who agree to have such an appointment made.”¹ However, even in New York, there is no requirement that health care providers document that the HIV-infected person attended the follow-up appointment.

Worldwide, it is estimated that only 50% of HIV-infected persons have received a diagnosis, and only 40% are in care. Unfortunately, the situation in the US is not much better. In 2012, the last year for which statistics are available, the CDC estimates that 87% of all HIV-infected persons have been diagnosed. However, only 39% are in care, only 36% have been prescribed therapy, and only 30% are virologically suppressed (based on data from the National HIV Surveillance System). Clearly the biggest barrier to getting to 90% undetectable, at least in the US, is linkage to care. I believe that all of us in the health care profession need to work with our hospitals, other institutions, and medical societies to address ways to improve linkage to care rates. Failure to do so will likely result in the US lagging substantially behind the rest of the world in getting HIV-infected persons into care.

References:

1. New York State Department of Health. Information for a healthy New York. Accessed 16 November 2015.