90-90-90 treatment target

UNAIDS and the One Million Community Health Workers (1mCHW) initiative have announced a major strategic partnership to support the achievement of the 90–90–90 treatment target and to lay the foundation for sustainable health and development.

The new partnership emerged at a high-level meeting of eight African health ministers and other stakeholders in Addis Ababa, Ethiopia, held on 1 February, which focused on the 90–90–90 treatment target and human resources for health. The participants of the meeting called for the world to leverage the aim of achieving the 90–90–90 treatment target to strengthen human resources for health.

In his opening address, Marc Angel, UNAIDS champion for the 90-90-90 treatment target, told participants that increased human resources for health would be essential.     

“Achieving the 90-90-90 target requires health workers, specific expertise and laboratories equipped with the necessary materials,” said Mr Angel.

Jeffrey Sachs, director of the Earth Institute at New York’s Columbia University and founder of the 1mCHW initiative, emphasized his commitment to the 90–90–90 treatment target. As the United Nations Secretary-General’s Special Adviser on the Sustainable Development Goals (SDGs), Mr Sachs pledged to place 90–90–90 at the centre of advocacy for the SDGs.

“The 90–90–90 effort of UNAIDS is historic: a rigorous, scientific and bold approach to end the AIDS epidemic,” Mr Sachs said. “The end of AIDS is within reach, and community health workers will play a pivotal role in empowering communities to end deaths from AIDS and to break the transmission of the virus. The 1 Million Community Health Worker campaign is honoured to join UNAIDS in its path-breaking programme.”

Cosponsored by UNAIDS, the African Union and Ethiopia’s Ministry of Health, the meeting revealed both strong support for the 90–90–90 treatment target and agreement that it offers a unique opportunity to recruit and mobilize hundreds of thousands of community health workers.

“Ethiopia will spare no efforts to reach the 90–90–90 treatment target,” said Kesetebirhan Admasu, Ethiopia’s Minister of Health. “We are determined to relegate AIDS to the books of history.”

To reach the 90–90–90 treatment target, the number of people accessing antiretroviral therapy will need roughly to double over the next five years. While HIV programmes have pioneered innovative strategies to enhance the efficiency of service delivery, it is clear that reaching the target will require expanding the number of health workers available to deliver HIV services.

However, many African countries, as well as countries in other regions, have an acute shortage of health workers. Although Africa accounts for 25% of the global health burden, the region is home to only 3% of all health workers.

To ease health worker shortages, the meeting focused on the importance of training and employing trained, provisioned, supervised and remunerated community health workers to expand access to HIV services. “We must reinforce the interface between communities and the service provider,” said UNAIDS Executive Director Michel Sidibé. “We need to use communities and civil society organizations to reach people who are difficult to reach.”

The 1mCHW campaign unites more than 150 organizations worldwide in a major global effort to recruit and deploy trained, equipped, supervised and remunerated community health workers, with particular attention to especially underserved rural communities.

Countries such as Ethiopia, Ghana and Malawi have already taken major steps to train and deploy community health workers to deliver community-based health services. Ethiopia, for example, has trained tens of thousands of health extension workers, who have substantially increased access to good-quality health services. Creation of the community health worker programme in Ethiopia has been associated with a 19-year increase in life expectancy over two decades. Ghana is in the process of deploying 20 000 community health workers in a national scale-up effort. 

Other countries are moving to emulate these successful national efforts to expand human resources for health. Lesotho, for example, is embarking on a national effort to create a cadre of health extension workers, with mentoring provided by Ethiopia and Malawi.

Much of the discussion during the one-day meeting focused on how the push to achieve the 90–90–90 treatment target can help drive a sustainable expansion of human resources for health. The global effort to achieve the 90–90–90 treatment target will involve the delivery of simplified, decentralized care to millions of healthy people living with HIV. Self-care, including through such innovations as peer-driven adherence clubs and community distribution of antiretroviral therapy, will play a vital role in the delivery of HIV chronic care management.

Community health workers will be essential for providing these simplified, decentralized services. The Fast-Track approach calls for a sharp increase in financing for community service delivery and an increase in the proportion of HIV services that are delivered through community channels from 5% currently to 30%.

The same community-centred models that will be critical for ending the AIDS epidemic as a public health threat also have a potentially key role to play in addressing the other health targets in the SDGs. Community health workers mobilized through the push to achieve the 90–90–90 treatment target can also help in the delivery of other important health services. Similarly, the chronic care models generated by HIV treatment scale-up are applicable to the management of the growing burden of noncommunicable diseases, such as hypertension and diabetes.

Although the road map for action is clear on 90–90–90 and the health workforce, financing remains a potential obstacle, as investments will be needed for training, supervision and compensation for community workers. There was agreement among health ministers and other participants that mobilizing the necessary investments for expanding the health workforce will require both increased domestic outlays and further increases in international assistance. Mr Sachs called for the creation of a fund for strengthening health systems.

“Here in Africa, we must commit our own domestic resources for health,” said Olawale Maiyegun, Director of Social Affairs for the African Union Commission. “We must live up to our commitments in the Abuja Declaration to dedicate at least 15% of our domestic budget to health.”

“Health is not a cost,” Mr Sidibé said. “Health is not expenditure. Health is an investment. If we scale up, we can bring the epidemic to an end. Yet if we don’t come up with the resources we need, AIDS will rebound, and all our investments in the last 30 years will be lost.”

In planning the meeting, the cosponsors worked with the World Health Organization, the African Society for Laboratory Medicine, the International Association of Providers of AIDS Care, the International Federation of Red Cross and Red Crescent Societies, the Office of the United States Global AIDS Coordinator, Columbia University, the Sustainable Development Solutions Network, the One Million Community Health Workers campaign and the Government of Luxembourg.

The ambitious HIV treatment target set for 2020 greatly influenced governments and partners in their approach to the AIDS response, said senior officials of Luxembourg and UNAIDS at a briefing for diplomatic missions in Geneva, Switzerland, on 9 November.

Efforts to scale up treatment in the next five years are crucial to ending the AIDS epidemic. The 90–90–90 treatment target for 2020 calls for 90% of people living with HIV to know their HIV status, 90% of people who know their HIV-positive status to access antiretroviral treatment and 90% of people on treatment to have suppressed viral loads.

Unlike earlier treatment targets, which focused solely on the number of people starting HIV treatment, 90–90–90 focuses on the ultimate aim of HIV treatment—viral suppression, which significantly reduces both the risk of HIV-related illness and death and the risk of HIV transmission.

At the briefing, speakers from UNAIDS and Luxembourg outlined priority areas to implement 90–90–90. They reiterated that the political will and the scientific tools exist to end the AIDS epidemic. Success has been achieved in different areas and regions of the world, but more needs to be done to ensure that no one is left behind and to close the treatment gap for children.

Luxembourg, a longstanding supporter of UNAIDS, became a strategic partner this year in the push to end the AIDS epidemic as a public health threat by 2030. The alliance between UNAIDS and Luxembourg aims to leverage the therapeutic and preventive benefits of antiretroviral therapy.

At the briefing, Marc Angel of Luxembourg was appointed as a UNAIDS champion for the 90–90–90 treatment target. He has been an AIDS advocate for more than 25 years.

As a member of the Chamber of Deputies of Luxembourg since 2004, Mr Angel serves as the Chairman of the Committee for Foreign and European Affairs, for Defence, for Cooperation and Development and for Immigration of the Luxembourg Parliament.

Leading HIV researchers describing results from multiple clinical trials in sub-Saharan Africa report that innovative service delivery models are achieving results across the HIV treatment cascade that approach or exceed the 90–90–90 target.

Study results were presented at an all-day workshop hosted by the British Columbia Centre for Excellence in HIV/AIDS and the Division of AIDS at the University of British Columbia, prior to the opening of the 8th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Vancouver, Canada. The studies are being undertaken in a number of high-burden countries in sub-Saharan Africa, including Botswana, Kenya, Malawi, South Africa, Swaziland, Uganda and Zambia.

“These exceptional clinical trial results show yet again how innovation is driving progress in the AIDS response,” said UNAIDS Executive Director Michel Sidibé. “The results demonstrate that the 90–90–90 target is more than a dream. It is entirely feasible.”

Diane Havlir, of the University of California, San Francisco, presented interim results from the Sustainable East Africa Research for Community Health (SEARCH) trial in more than 30 rural communities in Kenya and Uganda. Having enrolled more than 334 000 people, the SEARCH trial is evaluating a multicomponent programme, including use of community-centred, multidisease campaigns to provide HIV testing and link HIV-positive individuals to immediate initiation of antiretroviral therapy.

At a population level, the SEARCH programme has achieved 90% knowledge of HIV status. Among participants living with HIV, more than 90% of people in Uganda and 83% in Kenya are receiving antiretroviral therapy. At 24 weeks, 92% of trial participants who have initiated antiretroviral therapy have achieved viral suppression.

Similarly encouraging, although preliminary, results were reported from the PopART trial by Richard Hayes of the London School of Hygiene and Tropical Medicine. Working in 21 communities, the trial is evaluating a combination HIV prevention package that includes repeated rounds of community-level HIV testing and immediate initiation of antiretroviral therapy for all people who are diagnosed HIV-positive. Among more than 115 000 community members enumerated in the trial, 90% of all men living with HIV and 92% of all women living with HIV were aware of their HIV status following the PopART programme. Among people with an HIV diagnosis, 62% of men and 65% of women were receiving antiretroviral therapy, highlighting the need to further strengthen linkage to care for people living with HIV. Data on rates of viral suppression among PopART participations will be available next year.

Max Essex, of the Harvard University School of Public Health, presented baseline findings for the Botswana Combination Prevention Protocol. Mr Essex and his colleagues have found that 79% of all people living with HIV in Botswana knew their HIV status as of mid-2015, 86% of adults who have been diagnosed with HIV were receiving antiretroviral therapy and 96% of people receiving antiretroviral therapy had achieved viral suppression.

Comparably impressive results have been achieved by a Médicins Sans Frontières (MSF) programme in the District of Chiradzulu in Malawi, according to David Maman of MSF. In Chiradzulu, 77% of all people living with HIV know their HIV status, 84% of people with an HIV diagnosis are receiving antiretroviral therapy and 91% of people receiving antiretroviral therapy have achieved viral suppression.

François Dabis, of the Bordeaux School of Public Health, described preliminary results from a separate trial in the Hlabisa district in KwaZulu-Natal, South Africa, of a test-and-treat initiative that includes six-month rounds of community-level testing and establishment of antiretroviral treatment sites in all communities in the study. Among more than 26 000 people in the study communities, 85% know their HIV status. Among HIV-diagnosed people reached by the programme, 86% are receiving antiretroviral therapy. Study results indicate that linkage to care remains suboptimal and an important focus of further work and innovation.

Several important themes emerged from these study findings. Researchers emphasized the importance and value of engaging and collaborating with local communities in developing programme approaches tailored to local needs and circumstances. Most of the studies have also taken multidisciplinary approaches to the development, monitoring and evaluation of programmes, involving social scientists, economists and community representatives as well as clinicians and biostatisticians.