Much Still to be Done as Country Progresses Towards Reaching 90.90.90 Targets. 2/11/2017

Published by THEOBSEVER

Swaziland’s HIV response is at a tipping point at this moment.

 The irony is that this is happening at a time when we should be rightly celebrating the results of the Swaziland HIV Incidence Measurement Survey 2  (SHIMS2 which concluded that between 2011 and 2016, HIV incidence has decreased by nearly half (44 per cent) among adults aged 18-49, from 2.5 in 2011 to 1.4 in 2016; HIV prevalence has stabilised within 30-32 per cent within the adult population aged 18-49 ; and that viral load suppression doubled – from 34.8 in 2011 to 71.3 in 2016, regardless of awareness of HIV status and ART use.

Then there is the remarkable progress towards achieving 90.90.90 targets, only launched in 2014 at the 20th International AIDS Conference in Melbourne, Australia, which  reflects a fundamental shift in the world’s approach to HIV treatment, moving it away from a focus in the number of people accessing ART and towards maximising viral load suppression among PLHIV as well as HIV prevention. Remarkablythe country hit 85/87/92 in the three 90s, respectively.

Ordinarily, the news should be celebrated - even wildly, might I add. But wait a minute.

 The country is magnifying the accomplishments but taking the success in, with a pinch of salt, because, “We understand that the gains made, can easily be reversed. We are challenged to manage them and move forward, thus have to guard against complacency” noted NERCHA Director Khanyakwezwe Mabuza when addressing an Editors Forum recently. Just as Andy Grove warned that success breeds complacency, which breeds failure, and therefore only the paranoid survive, Mabuza notes the need to systematically sustain the country’s successes.

The NERCHA director quickly acknowledged that the gains were achieved through global solidarity and shared responsibility. He noted that the greatest challenge the country faces right now, is the flat-lining of resources which have remained stagnant, in the last three years.

Over this period, the government of Swaziland has been steadily increasing its share of funding, contributing 48 per cent of total resources in the current financial year (up from 39 per  cent in 2011/2012). Three major donors – the US government, the Global Fund and Médecins Sans Frontières (MSF) make up the bulk of the other half. The US government is the largest bilateral donor, funding 30 per cent of Swaziland’s AIDS response in 2017. 

Mabuza explained that the resources have not necessarily dropped as others have said, but there is need to remain vigilant as if the status quo could take a turn for the worse, then it would be déjà vu - doom and gloom all over again. More people would get newly infected with HIV and the absence of treatment would see an increase in lives lost through AIDS-related deaths would be seen. Mabuza emphasised, therefore, that without more domestic investment and international assistance, the country remains in a precarious position where the gains can be reversed overnight.

Reaching the 90.90.90 targets: a global perspective

As the world approaches the midway point between the 2014 launch of the 90.90.90 targets and their December 2020 deadline, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has reviewed the progress made. The data show that substantial progress has been made.

More than two-thirds of all PLHIV globally knew their status in 2016. Among those who knew their HIV status, 77 per cent were accessing ART, and 82 per cent of the people on treatment had suppressed viral loads. Amid this progress, a major milestone was reached in 2016. For the first time, more than half of all PLHIV (53 per cent) were accessing ART.

The acceleration of HIV testing and treatment – within a comprehensive approach that includes condoms, voluntary medical male circumcision (VMMC), pre-exposure prophylaxis (PrEP), and efforts to protect human rights and establish an enabling environment for service delivery – has contributed to a 32 per cent global decline in AIDS-related deaths and a 16 per cent global decline in new HIV infections between 2010 and 2016.

In eastern and southern Africa, the region most affected by the epidemic, gains across the three 90s have been particularly striking, bringing the region to a level of progress comparable to Latin America. Fully achieving the 90.90.90 targets translates into 73 per cent of all PLHIV being virally suppressed. Across the globe, seven countries had already achieved or exceeded this level of viral load suppression by 2016 – Botswana, Cambodia, Denmark, Iceland, Singapore, Sweden and the United Kingdom of Great Britain and Northern Ireland. An additional 11 countries were near the 73 per cent  threshold, including Swaziland.

The ‘Last Mile’

There is much to do for the country to fully achieve the 90.90.90 targets, as well as end AIDS as a public health threat. For the three 90s, it includes:

  • The first 90 - Knowledge of HIV status is the first step in the cascade, and when it is low, subsequent efforts to enrol PLHIV into care and to initiate and sustain treatment are affected. There have been significant increases in the annual number of HIV tests, from 180 433 to 410 947. The progress made in improving knowledge of HIV status, however, is lower than progress in other areas of the cascade. There are gaps in knowledge of HIV statusamong young people (66.1 per cent in ages 15-24) and men. Closing the gaps requires making HIV testing an increased priority and taking full advantage of new technologies and innovative service strategies. The rapid roll-out and promotion of HIV self-testing (currently being piloted in the Shiselweni region) is one of several strategies for moving the locus of testing from health facilities to community settings.
  • The second 90 – There are 171 266 PLHIV on ART. The ‘Test and Start” approach, along with increased investment in scaled-up community-based strategies is critical to achieving the second 90.

This, however, requires rapid expansion of proven models for linking newly diagnosed individuals to care and refining clinic operations to improve efficiency, empower clients and expedite treatment uptake.

  • The third 90 – 91.9 per cent of those who self-report use of ART are virally suppressed - 92 per cent females and 91 per cent males.

This shows that most people accessing ART obtain excellent clinical outcomes. Still, important opportunities exist to improve and maintain rates of viral suppression. It is critical for treatment programmes to establish community-centred strategies and systems that support patient adherence to treatment and reduce the number of patients lost to follow-up. Strategies that use peers and trained community health workers generally achieve retention rates and treatment outcomes that are comparable – or even superior – to those reported by the mainstream health facilities.

Other concerning issues

Available data shows that gaps in the 90.90.90 continuum are greater for men, young people and key populations. Harmful masculine gender norms contribute to greater risk-taking and poorer uptake of health services among men. Consent laws and insufficient access to comprehensive sexuality education deny young people the services and knowledge they need.

Key populations often face criminalisation and high levels of stigma and discrimination. Closing gaps in service coverage requires intensified efforts to convince men to reject harmful versions of masculinity, and to reach and empower women and girls, young people and key populations, to enhance their agency and to ensure their human rights are respected and protected. Addressing stigma, discrimination and human rights violations at all levels, through enabling a protective and empowering legal environment and strong rule of law, is imperative to reaching the ultimate destination of a Swaziland without an AIDS epidemic.

The challenge, therefore, is not to drop the ball now!

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