Code: MOAD01, MOAD0102
Title: 90-90-90: Delivering on the Targets
Date: Monday, 20 July 2015
Time: 16:30-18:00
Room: Ballroom C-D
Can the UNAIDS 90-90-90 target be
reached?
Analysis of national HIV treatment cascades
Jacob Levi1 & Alice Raymond1; Anton Pozniak2; Pietro Vernazza3; Philipp Kohler3; Andrew Hill2
1Imperial
College London, Department of Public Health, London, United Kingdom
Stephens Centre, Chelsea and Westminster Hospital, London, UK
3Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital of St. Gallen, Switzerland
2St
UNAIDS 90-90-90:
HIV Treatment Targets for 2020 with Global Estimates (2014)
Target 1:
90% of HIV+ people
diagnosed
100%
80%
36.9
million
Target 2:
90% of diagnosed
people on ART
90%
33.2
million
60%
Target 3:
90% of people on
ART with HIV
RNA suppression
81%
29.5
million
73%
26.9
million
40%
20%
0%
HIV Positive People
Diagnosed
On ART
Viral Suppression
Ref: The Joint United Nations Programme on HIV/AIDS. 90-90-90 An ambitious treatment target to help end the AIDS epidemic. 2014; JC2684
(Numbers as of March 2015) How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE FROM THE AIDS
RESPONSE July 2015.
Global Estimates (2014-15) vs the Gap
to reach 90-90-90 Targets
100%
80%
36.9
million
Breakpoint 1:
13.4 million
Undiagnosed
53%
60%
19.8
million
40%
20%
Breakpoint 2:
14.9 million
not treated
41%
15.0
million
Breakpoint 3:
15.3 million
Not Virally
Supressed
32%*
11.6*
million
0%
HIV Positive People
Diagnosed
On ART
Viral Suppression <1000
(ITT)*
Ref: On ART = March 2015. How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE FROM THE AIDS
RESPONSE July 2015. * Average viral suppression% Intention to Treat LMIC rate from a Systematic Review by McMahon J. et al. Viral suppression
after 12 months of antiretroviral therapy in low-and middle-income countries: a systematic review." Bulletin of the World Health Organization 91.5
(2013): 377-385.
Methods – Countries and 1 region included
 11 full HIV treatment cascades:
 9 Partial cascades from:
o Switzerland
o Australia
o Denmark
o UK
o Canada (British Columbia)
o Netherlands
o Rwanda
o France
o Belgium
o Brazil
o Cuba
o Average of countries from the Subo Columbia
Saharan African Region*
o Ukraine
o USA
o Kyrgyzstan
o Georgia
o Vietnam
o Estonia
o Russia
(Full = reports percentage and number of
people for all 3 UNAIDS targets and quotes
(Partial = does not report percentages or
the viral suppression cut-off used.
numbers for all 3 UNAIDS targets or does not
report viral suppression test cut-off used.
*Average Sub-Saharan African Region: UNAIDS estimates & percentages from an average from 30 countries - How Aids Changed
Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 lessons of hope from the AIDS response July 2015. *(Only 15 – 49 yr olds)
Methods - Definitions
 Estimates of six stages for each full cascade:
1.
2.
3.
4.
5.
6.
Total number of people living with HIV
Diagnosed as HIV positive
Linked to care
Retention in care
On Antiretroviral Therapy
Viral Suppression <1000 RNA copies/ml
o
(Undetectable HIV RNA <40-400)
 Definitions varied for each of the 6 categories between countries
 Breakpoint: >10% drop between successive UNAIDS targets in the cascade
 Sources: National reports, UNAIDS Database, Peer-reviewed articles, Conference
proceedings.
Cascade of HIV care – Switzerland 2012
100%
Breakpoint 1
15,700
81%
80%
12,700
12,600
80%
79%
12,300
60%
Breakpoint 2
71%
11,200
68%
10,700
40%
20%
0%
HIV Positive People
Diagnosed
Linked to care
Retained in Care
On ART
Ref: Kohler P, Schmidt JA, Ledergerber B, Vernazza LP. Estimates of HIV prevalence,
proportion of diagnosed patients and quality of treatment in Switzerland. 2014.
Viral Supression <200
copies/ml
Cascade of HIV care – Russia 2013
100%
1,363,330
80%
Breakpoint 1
60%
49%
668,032
40%
38%
515,403
35%
Breakpoint 2
481,783
20%
12%
156,858
0%
HIV Positive People
Diagnosed
Linked to care
Retained in Care
On ART
Ref: Pokrovskaya, A., et al The cascade of HIV care in Russia, 2011–2013. Journal of the International AIDS
Society 2014;17(4). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4224814/pdf/JIAS-17-19506.pdf
Breakpoint 3
9%
127,054
<1000 copies
Undetectable HIV RNA
Target 1 – Percentage of all HIV+ People Diagnosed
- Methodology
 Target 1 depends on the approach used to estimate:
1. The number of all HIV + people living in that country
2. The number tested and found to be HIV+
 Back-calculation method used to estimate total HIV epidemic size
 Heterogeneity of cascade study type:
oCross Sectional or Longitudinal cohorts (or combined approach)
• Loss to follow up
• Double counting
• Expensive
• Generalized vs. Focused Epidemics
oVarying testing policies (2010 – 2014)
Target 1 – Percentage of all HIV+ People Diagnosed
- Results
100%
90%
87% 86% 86% 85%
84%
80%
81% 80% 79%
76% 75%
73% 71%
70%
UNAIDS Target 1:
90% of all HIV+
people diagnosed
70%
60%
52% 51%
49%
50%
45% 44%
40%
30%
20%
10%
0%
Estonia
Australia
USA
Denmark
Switzerland
France
Brazil
Vietnam
United
Kingdom
Cuba
Netherlands
British
Columbia
(Canada)
Kyrgyzstan
Georgia
Sub Saharan
Africa
Russia
(*SSA = Regional average
From 30 countries)
Columbia
Ukraine
Target 1 – Percentage of all HIV+ People Diagnosed
- Results
100%
90%
87% 86% 86% 85%
84%
80%
81% 80% 79%
76% 75%
73% 71%
70%
UNAIDS Target 1:
90% of all HIV+
people diagnosed
70%
60%
52% 51%
49%
50%
45% 44%
40%
30%
20%
10%
0%
Estonia
Australia
USA
Denmark
Switzerland
France
Brazil
Vietnam
United
Kingdom
Cuba
Netherlands
British
Columbia
(Canada)
Kyrgyzstan
Georgia
Sub Saharan
Africa
Russia
(*SSA = Regional average
From 30 countries)
Columbia
Ukraine
Target 2 – Percentage of all HIV+ People on ART
- Methodology
 Estimates of the % on ART were calculated from:
o Pharmacy records
o Governmental drug purchases
o Healthcare dispensary records
• Adjusted for PEP & PrEP
• Various ART regimens were not differentiated
 Linkage and Retention definitions were highly heterogeneous
 Neither linkage nor retention categories have UNAIDS 90-90-90 targets
o Both are essential for getting people on treatment after diagnosis
o May need more attention
 Treatment initiation guidelines vary (2010 – 2014)
 Now START trial & WHO – test and treat
 Eligibility and Adherence sometimes reported
Target 2 – Percentage of all HIV+ People on ART
- Results
100%
UNAIDS Target 2:
81% of all HIV+ people on ART
90%
80%
71%
70%
60%
68% 66%
64% 63% 62%
60%
51%
50%
48%
42% 41%
40%
37%
33% 29%
30%
28% 26%
22%
20%
19%
11%
10%
0%
Switzerland
United
Kingdom
Australia
Netherlands
Rwanda
Denmark
France
British
Columbia
(Canada)
Brazil
Sub Saharan
Africa
Cuba
(*SSA = Regional average
From 30 countries)
USA
Columbia
Estonia
Vietnam
Georgia
Ukraine
Kyrgyzstan
Russia
Target 2 – Percentage of all HIV+ People on ART
- Results
100%
UNAIDS Target 2:
81% of all HIV+ people on ART
90%
80%
71%
70%
60%
68% 66%
64% 63% 62%
60%
51%
50%
48%
42% 41%
40%
37%
33% 29%
30%
28% 26%
22%
20%
19%
11%
10%
0%
Switzerland
United
Kingdom
Australia
Netherlands
Rwanda
Denmark
France
British
Columbia
(Canada)
Brazil
Sub Saharan
Africa
Cuba
(*SSA = Regional average
From 30 countries)
USA
Columbia
Estonia
Vietnam
Georgia
Ukraine
Kyrgyzstan
Russia
Target 3 – Percentage of all HIV+ People with HIV RNA suppression
- Methodology
 UNAIDS 90-90-90 target = 73% of all HIV+ people achieving “viral suppression”
o <1000 RNA copies/ml
 Some countries use “undetectable HIV RNA” as their definition or final target
o <40 to <500 RNA copies/ml
 Various HIV RNA tests used with different “Undetectable” cut offs
 This changes the final percentage found to be “successfully treated”
 This must be taken into account when comparing cascades
o E.g. Brazil
o <50 RNA copies/ml = 35% “Undetectable HIV RNA”
o <1000 RNA copies/ml = 40% “Suppressed”
Target 3 – Percentage of HIV+ People with HIV RNA suppression
- Results
100%
UNAIDS Target 3:
73% of all HIV+ people
achieving viral suppression
90%
80%
70%
68%
62% 61%
59% 58%
60%
52% 52%
50%
40%
40%
35%
30%
32% 30% 30%
23%
20%
20% 19%
17%
9%
10%
0%
Switzerland
<200
Australia
<400
United
Kingdom
<200
Denmark Netherlands
<500
<200
Rwanda
<40
France
<50
Brazil
<1000
British Sub Saharan Cuba
Columbia
Africa (N/A)
(Canada) <400 to <40
<50
(*SSA = Regional average
From 30 countries)
USA
<200
Columbia
(N/A)
Georgia
<400
Estonia
<200
Ukraine
(NA)
Russia
<1000
Target 3 – Percentage of HIV+ People with HIV RNA suppression
- Results
100%
UNAIDS Target 3:
73% of all HIV+ people
achieving viral suppression
90%
80%
70%
68%
62% 61%
59% 58%
60%
52% 52%
50%
40%
40%
35%
30%
32% 30% 30%
23%
20%
20% 19%
17%
9%
10%
0%
Switzerland
<200
Australia
<400
United
Kingdom
<200
Denmark Netherlands
<500
<200
Rwanda
<40
France
<50
Brazil
<1000
British Sub Saharan Cuba
Columbia
Africa (N/A)
(Canada) <400 to <40
<50
(*SSA = Regional average
From 30 countries)
USA
<200
Columbia
(N/A)
Georgia
<400
Estonia
<200
Ukraine
(NA)
Russia
<1000
Target 1 versus Target 2:
Rates of diagnosis and those diagnosed on treatment, by
country
UNAIDS 90-90-90
Target 2
100%
Percent of diagnosed people on ART
90%
80%
Average of
30* Sub-Saharan
Columbia African countries
70%
60%
50%
Ukraine
United Switzerland
Kingdom
Australia
Netherlands France
UNAIDS
90-90-90
Target 1
Denmark Rwanda
British Columbia
(Canada)
Brazil
Cuba
Georgia
USA
40%
Vietnam
Estonia
Make a new version with the T1 and T2 labels removed
Russia
Kyrgyzstan
20% Make flags smaller (see previous versions – yours are too wide)
30%
10%
0%
X and y axis labels are too small. Axes need to be thicker
0%
10%
20%
30%
40%
50%
Percentage of all HIV + people diagnosed
60%
70%
80%
90%
100%
*30 countries with data on GAPRP and DHS data, 2008 - 2014 (How Aids
Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15
lessons of hope from the AIDS response July 2015
Target 2 vs Target 3:
Percentage of diagnosed people on ART,
versus HIV RNA suppression when on ART
UNAIDS 90-90-90
Target 3
% of those on ART achieving viral suppression
100%
Denmark
Australia
Belgium
90%
France
Russia
USA
Ukraine
80%
Switzerland
Netherlands
Brazil
United
Kingdom
Rwanda
70%
Columbia
Georgia
Estonia
Cuba
Average from
British Columbia 18* Sub-Saharan
(Canada)
African countries
(15 – 49)
60%
UNAIDS
90-90-90
Target 2
50%
40%
30%
20%
10%
0%
0%
10%
20%
30%
40%
50%
% of those diagnosed on ART
60%
70%
80%
90%
100%
*Average from: Botswana, Burkina Faso, Mali, Cameroon, Cote
d’ivoire, Kenya, Senegal, Uganda, Malawi, Mozambigue, Nigeria,
Senegal, South Africa, Tanzania, Uganda, Zimbabwe, Zambia.
Conclusions
• No country or region analysed so far met the final UNAIDS 90-90-90 coverage target of 73%
of HIV positive people achieving undetectable HIV RNA.
• Large disparities were identified between countries
• All Western European countries achieved viral suppression for over >50% of HIV+ people
• All Eastern European countries achieved viral suppression for under <20% of HIV+ people
FAST TRACK: 95%-95%-95% by 2030
•
Diagnosis is the largest breakpoint globally - Testing should be focussed on
•
To facilitate comparisons between countries a standardized reporting method should be implemented
•
This will allow us to better identify breakpoints and to prioritize resources and inform policy
Thank You
Reference for full cascades
References for partial cascades
1 – Targets: Joint United Nations Programme on HIV/AIDS (UNAIDS). (2014). The gap report. Geneva: UNAIDS. 2014;
JC2684
1 – Rwanda: Sabin Nsanzimana, HIV care continuum in Rwanda: a cross-sectional
analysis of the national programme. Lancet HIV 27 March 2015; 2: e208–15
2 – Global Cascade: How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE
FROM THE AIDS RESPONSE July 2015. *Viral suppression. <1000 copies/ml after 12 months on Intention To Treat Analysis.
McMahon J. et al. Viral suppression after 12 months of antiretroviral therapy in low-and middle-income countries: a
systematic review." Figure 2. Bulletin of the World Health Organization 91.5 (2013): 377-385.
2 – Denmark: M Helleberg et al. HIV Care in the Swedish-Danish HIV Cohort 1995-2010
Closing the Gaps. e72257. PLoS ONE. Report number: 8 (8); Aug 15 2013.
3 – Switzerland: Kohler P, Schmidt JA, Ledergerber B, Vernazza LP. Estimates of HIV prevalence,
proportion of diagnosed patients and quality of treatment in Switzerland. 2014.
4 – Australia: The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance
Report 2014 UNSW Sydney: The Kirby Institute for infection and immunity in society
3 – British Columbia: B Nosyk et al. STOP HIV/AIDS Study Group. The cascade of HIV care
in British Columbia, Canada, 1996-2011: a population-based retrospective cohort study.
The Lancet Infectious diseases 2014(1) 40-49
4 – Cuba: Ministry of Public Health of Cuba. Computerized HIV/AIDS Registry, 2013.
From: Antiretroviral Treatment in the Spotlight: A Public Health Analysis in Latin America
and the Caribbean 2013. Page 39. Figure 19. Washington, DC: PAHO, 2013. ISBN 978-9275-11806-1
5 – United Kingdom: Public Health England. HIV in the United Kingdom: 2014 Report. London: Public Health England. 2014.
6 – Netherlands: V Sighem A et al. Monitoring Programme report 2014: Human Immunodeficiency Virus (HIV) infection in
the Netherland. 2014
7 – France: Supervie V CD. The spectrum of engagement in HIV care in France: strengths and gaps. Atlanta, USA: 20th
Conference on Retroviruses and Opportunistic Infections.; March 2013
8 – British Columbia: B Nosyk et al. STOP HIV/AIDS Study Group. The cascade of HIV care in British Columbia, Canada,
1996-2011: a population-based retrospective cohort study. The Lancet Infectious diseases 2014(1) 40-49
9 – Sub Saharan Africa:How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 lessons of hope
from the AIDS response July 2015
5 – Ukraine: Michel Kazatchkine United Nations Switzerland Oral Presentation, HIV Drug
Therapy, November 2014 Glasgow, Special Envoy for HIV/AIDS in Eastern Europe and
Central Asia, Geneva. Drug use, HIV, HCV and TB: major interlinked challenges in Eastern
Europe and Central Asia. Slide 12. Nov 3rd 2014
6 – Columbia: Government of Colombia, Ministry of Health and Social Protection, 2014.
90-90-90 An ambitious treatment target to help end the AIDS epidemic JC2684 October
2014 (UNAIDS). Fig 21, Page 25
7 – Vietnam: WHO/UNAIDS Meeting Report. National HIV/AIDS and STI Programme
Managers Meeting of Asian Countries in Western Pacific Region. Feb, 2013, Kunming,
China. Page 21, Fig 4. Cascade of HIV diagnosis, care and treatment in Viet Nam (2012) .
Estimates by Ministry of Health, Viet Nam, Administration for HIV/AIDS Control (VAAC)
10 – USA: H Bradley et al: HIV Diagnosis, Care, and Treatment Among Persons Living with HIV —USA, 2011.
11 - Georgia: Chkhartishvili N, Sharavdze L, Chokoshvili O, DeHovitz J, Del Rio C, Tsertsvadze T. The cascade of care in the
Eastern European country of Georgia. HIV medicine 2015;16(1) 62-66.
12 – Estonia: Kaja-Triin Laisaar, et al. Engagement in the Continuum of HIV Care in Estonia. 9th International Conference on
HIV Treatment and Prevention Adherence June 2014;Miami page 29.
13 – Russia: Pokrovskaya, A. et al The cascade of HIV care in Russia, 2011–2013. Journal of the International AIDS Society
2014;17(4)
8 – Kyrgyzstan: M Mansfeld, M Ristol and G Likatavicius HIV Programme Review in
Kyrgyzstan Evaluation report, December 2012 (WHO Collaborating Centre for HIV and
Viral Hepatitis). Figure 1, page 11
9 – Belgium: Van Beckhoven et al. Factors associated with the continuum of care of HIVinfected patients in Belgium. Abstracts of the HIV Drug Therapy Glasgow Congress 2014
Journal of the International AIDS Society November 2nd 2014, 17(Suppl 3):19534. Abstract
P002
Cascade of HIV care – Australia 2013
100%
26,764
86%
80%
23,097
Breakpoint 1
78%
20,788
76%
20,369
60%
Breakpoint 2
66%
17,661
62%
16,584
40%
20%
0%
HIV Positive People
Diagnosed
Linked to care
Retained in Care
On ART
Ref: The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia Annual
Surveillance Report 2014 UNSW Sydney: The Kirby Institute for infection and immunity in society.
<400 copies
Undetectable HIV
RNA
Cascade of HIV care – United Kingdom 2013
100%
107,800
Breakpoint 1
76%
80%
81,510
74%
79,880
60%
70%
65,928
75,886
68%
73,290
61%
57,072
65,961
40%
20%
0%
HIV Positive People
Diagnosed
<200 copies
Undetectable
HIV
Ref: Public Health England. HIV in the United Kingdom: 2014 Report. London: Public Health England. 2014.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377194/2014_PHE_HIV_annual_r RNA
eport_19_11_2014.pdf
Linked to care
Retained in Care
On ART
Cascade of HIV care – Netherlands 2013
100%
25,000
76%
80%
19,065
60%
Breakpoint 1
71%
Breakpoint 2
64%
17,750
16,081
58%
14,602
40%
20%
0%
HIV Positive People
Diagnosed and Linked
N/A
Retained in Care
On ART
to Care
Ref: V Sighem A et al. Monitoring Programme report 2014: Human Immunodefificeny Virus
(HIV) infection in the Netherland. 2014 http://www.hiv-monitoring.nl/english/
Viral Supression <200
copies/ml
Cascade of HIV care – France 2010
100%
149,900
81%
Breakpoint 1
80%
74%
Breakpoint 2
121,100
111,150
60%
60%
90,100
Breakpoint 3
52%
77,400
40%
20%
0%
HIV Positive People
Diagnosed
Linked to care
Retained in Care
On ART
<50 copies
Ref: Supervie V CD. The spectrum of engagement in HIV care in France: strengths and gaps. Atlanta, Undetectable HIV RNA
USA: 20th Conference on Retroviruses and Opportunistic Infections.; March
2013http://www.sante.gouv.fr/IMG/pdf/Rapport_Morlat_2013_Mise_en_ligne.pdf
Cascade of HIV care – British Columbia (CA 2011)
100%
11,700
Breakpoint 1
80%
71%
8,308
60%
67%
7,801
Breakpoint 2
57%
6,688
40%
51%
Breakpoint 3
5,975
35%
4,054
20%
0%
HIV Positive People
Diagnosed
Linked to care
Retained in Care
On ART
Ref: National HIV Figures (71,300 PLWHIV) applied to the percentages from B Nosyk et al. STOP HIV/AIDS Study
Group. The cascade of HIV care in British Columbia, Canada, 1996-2011: a population-based retrospective cohort
study. The Lancet Infectious diseases 2014(1) 40-49.
Viral Supression <50
copies/ml
Cascada del Continuo de Atención y Tratamiento - Brasil
Cascade of HIV care – Brazil 2013
100%
Breakpoint 1
734,000
80%
80%
589,000
Breakpoint 2
73%
537,000
60%
61%
448,000
<1000
RNA
Breakpoint 3 copies
293,000
48%
355,000
40%
40%
35%
255,000
<50
copies/ml
20%
0%
HIV Positive People
Diagnosed
Linked to care
Retained in Care
On ART
Ref: Marco Antonio De Avila. Cascade of continuous care in Brazil. Brazilian Ministry of
Health, STD/AIDS epidemiological report, Ano III, numero 1, October 2014, Brasilia, Brazil.
Viral Supression
<1000 copies/ml
Cascade of HIV care – Sub-Saharan Africa 2013
(15 – 45 years old)
100%
80%
23.5
million
Viral suppression Data from: Botswana, Burkina Faso,
Mali, Cameroon, Cote d’ivoire, Kenya, Senegal,
Uganda, Malawi, Mozambigue, Nigeria, Senegal,
Breakpoint 1
28.35
Million
60%
51%
Breakpoint 2
43%
12.0
million
40%
Breakpoint 3
10.0
million
20%
32%
7.5
million
0%
HIV Positive People
(All ages)
Diagnosed
(Age 15 - 49)
Linked to care
Retained in care
On ART
Reference: How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 lessons of hope
from the AIDS response July 2015
Viral Supression
(<500, <350, <200)
Cascade of HIV care – United States 2011
100%
1,201,100
86%
Breakpoint 1
Breakpoint 2
1,032,900
80%
60%
40%
478,000
40%
37%
441,661
14,6023
Breakpoint
30%
361,746
20%
0%
HIV Positive People
Diagnosed
Linked to care
Retained in care
On ART
Ref: H Bradley et al: HIV Diagnosis, Care, and Treatment Among Persons Living with HIV —USA,
2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a5.htm?s_cid=mm6347a5_w#tab1
Viral Supression <200
copies/ml
Cascade of HIV care – Georgia 2012
100%
4,900
Breakpoint 1
80%
60%
Breakpoint 2
52%
2,548
40%
44%
2,135
38%
1,847
20%
26%
1,273
Breakpoint 3
20%
985
0%
HIV Positive People
Diagnosed
Linked to care
Retained in Care
On ART
<400 copies
Undetectable HIV RNA
Ref: Chkhartishvili N, Sharavdze L, Chokoshvili O, DeHovitz J, Del Rio C, Tsertsvadze T. The cascade of care
in the Eastern European country of Georgia. HIV medicine 2015;16(1) 62-66.
Cascade of HIV care – Estonia 2013
100%
9,279
87%
Breakpoint 1
8,073
80%
Breakpoint 2
59%
60%
5,474
40%
33%
3,062
20%
29%
Breakpoint 3
19%
2,691
1,763
0%
HIV Positive People
Diagnosed
Linked to care
Retained in Care
On ART
<200 copies
Undetectable HIV RNA
Ref: Kaja-Triin Laisaar, et al. Engagement in the Continuum of HIV Care in Estonia. 9th International Conference on
HIV Treatment and Prevention Adherence June 2014;Miami page 29.
http://www.euro.who.int/__data/assets/pdf_file/0008/255671/HIVAIDS-treatment-and-care-in-Estonia.pdf
Cascade of HIV care – Rwanda 2013
100%
90%
86%
Breakpoint 2
204,899
80%
183,515
176,174
63%
Breakpoint 3
60%
52%
129,405
40%
106,371
20%
0%
Living with HIV
Diagnosed
Linked to care
Retained in care
On ART
Virologically
suppressed <40
Ref: Sabin Nsanzimana, HIV care continuum in Rwanda: a cross-sectional analysis of the national programme. Lancet
copies/ml
HIV 27 March 2015; 2: e208–15 & Elul B et al. (2013) High Levels of Adherence and Viral Suppression in a Nationally
Representative Sample of HIV-Infected Adults on Antiretroviral Therapy for 6, 12 and 18 Months in Rwanda. PLoS
ONE 8(1): e53586. doi:10.1371/ journal.pone.0053586
Cascade of HIV care – Denmark 2010
120%
Breakpoint 1
Breakpoint 2
100%
80%
85%
5,519
6,500
81%
5,243
75%
4,857
60%
62%
4,029
59%
3,863
40%
20%
0%
HIV Positive People
Diagnosed
Linked to care
In care
On ART
Ref: Total number of HIV + people estimated from UNAIDS. Diagnosed - M Helleberg et al. HIV Care in the
Swedish-Danish HIV Cohort 1995-2010 Closing the Gaps. e72257. PLoS ONE. Report number: 8 (8); Aug 15
Viral Supression <500
copies/ml
Cascade of HIV care – Belgium 2010
100%
12,989
80%
11,684
Unknown
Breakpoint 2
90%
82%
12,446
72%
69%
9,367
60%
8,928
40%
20%
0%
HIV Positive People
Diagnosed
Linked to care
Retained in Care
On ART
Viral Supression <500
copies/ml
Ref: Van Beckhoven et al. Factors associated with the continuum of care of HIV infected patients in Belgium.
Abstracts of the HIV Drug Therapy Glasgow Congress 2014 Journal of the International AIDS Society November
2nd 2014, 17(Suppl 3):19534. Abstract P002
Cascade of HIV care – Cuba 2012
100%
Breakpoint 1
19,626
75%
80%
14,648
60%
69%
65%
13,494
12,849
Breakpoint 2
41%
40%
Breakpoint 3
8,102
30%
5,898
20%
0%
Living with HIV
Diagnosed
Linked to care
Retained in care
On ART
Ref: Ministry of Public Health of Cuba. Computerized HIV/AIDS Registry, 2013. From: Antiretroviral Treatment in the
Spotlight: A Public Health Analysis in Latin America and the Caribbean 2013. Page 39. Figure 19. Washington, DC:
PAHO, 2013. ISBN 978-92-75-11806-1
Virologically
suppressed
Cascade of HIV care – Columbia 2013
Breakpoint 1
100%
Breakpoint 2
80%
60%
45%
49,522
38%
40%
33%
Breakpoint 3
23%
20%
0%
Living with HIV
Diagnosed
Linked to care
Retained in care
On ART
Ref: Source: Government of Colombia, Ministry of Health and Social Protection, 2014. 90-90-90 An ambitious
treatment target to help end the AIDS epidemic JC2684 October 2014 (UNAIDS). Fig 21, Page 25
Virologically
suppressed
Cascade of HIV care – Ukraine 2012
100%
Breakpoint 1
237,903
80%
60%
Breakpoint 2
44%
44,318
40%
104,540
24%
20%
57,066
22%
Breakpoint 3
53,163
17%
41,520
0%
Living with HIV
Diagnosed
Linked to care
Retained in care
On ART
Ref: Michel Kazatchkine United Nations Switzerland Oral Presentation, HIV Drug Therapy, November 2014
Glasgow, Special Envoy for HIV/AIDS in Eastern Europe and Central Asia, Geneva. Drug use, HIV, HCV and TB:
major interlinked challenges in Eastern Europe and Central Asia. Slide 12. Nov 3rd 2014
Virologically
suppressed
Cascade of HIV care – Kyrgyzstan 2014
100%
Breakpoint 1
8,021
80%
70%
Breakpoint 2
5,642
60%
49,522
40%
44,318
31%
2,480
20%
19%
1,501
0%
Living with HIV
Diagnosed
Linked to care
Retained in care
On ART
Ref: M Mansfeld, M Ristol and G Likatavicius HIV Programme Review in Kyrgyzstan Evaluation report,
December 2012 (WHO Collaborating Centre for HIV and Viral Hepatitis). Figure 1, page 11
Virologically
suppressed
Cascade of HIV care – Vietnam 2012
100%
Breakpoint 1
256,845
79%
80%
Breakpoint 2
201,703
60%
129,405
40%
28%
72,711
20%
0%
Living with HIV
Diagnosed
Linked to care
Retained in care
On ART
Virologically
suppressed
Ref: WHO/UNAIDS Meeting Report. National HIV/AIDS and STI Programme Managers Meeting of Asian Countries in
Western Pacific Region. Feb, 2013, Kunming, China. Page 21, Fig 4. Cascade of HIV diagnosis, care and treatment in
Viet Nam (2012) . Estimates by Ministry of Health, Viet Nam, Administration for HIV/AIDS Control (VAAC)
Cascade of HIV care – British Columbia (CA 2011)
100%
71,300
Breakpoint 1
80%
71%
50,629
60%
67%
47,536
Breakpoint 2
57%
51%
40,713
40%
Breakpoint 3
36,411
35%
24,670
20%
0%
HIV Positive People
Diagnosed
Linked to care
Retained in Care
On ART
Ref: National HIV Figures (71,300 PLWHIV) applied to the percentages from B Nosyk et al. STOP HIV/AIDS Study
Group. The cascade of HIV care in British Columbia, Canada, 1996-2011: a population-based retrospective cohort
study. The Lancet Infectious diseases 2014(1) 40-49.
Viral Supression <50
copies/ml
Cascade Standardization Tools
Refs:
http://www.aidsdatahub.org/sites/default/files/highlight-reference/document/Metrics_for_monitoring_the_cascade_2014.pdf
http://applications.emro.who.int/dsaf/EMROPUB_2014_EN_1639.pdf
http://www.unaids.org/sites/default/files/media_asset/JC2702_GARPR2015guidelines_en.pdf