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Preplanned Studies: Progress Towards the 90-90-90 Targets for Controlling HIV — China, 2018

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  • Summary

    What is already known about this topic?

    Since the Joint United Nations Programme on HIV and AIDS (UNAIDS) announced the 90-90-90 targets to control the global HIV epidemic in 2014, many countries have undertaken innovative measures to achieve this goal. The National Center for AIDS/STD Control and Prevention (NCAIDS) of China CDC convenes experts annually to evaluate the national progress towards these indicators. The most recent progress of 90-90-90 targets in China has not been previously published.

    What is added by this report?

    At the end of 2018, the percentage of living with HIV (PLWH) who had received a confirmed HIV diagnosis in China was 68.9% (61.5%-78.3%). The antiretroviral treatment coverage of diagnosed PLWH was 83.4%, and among patients on treatment for at least 12 months, 94.2% achieved viral suppression. This provides most recent progress of 90-90-90 target in China.

    What are the implications for public health practice?

    China has made significant strides in curbing the HIV epidemic, but analysis on progress for the first 90 target for HIV testing remains out of reach. Innovative testing strategies may need to be developed to ensure that more PLWH can be identified.

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  • [1] UNAIDS. Global AIDS Monitoring 2018. 2017; http://www.unaids.org/sites/default/files/media_asset/global-aids-monitoring_en.pdf.http://www.unaids.org/sites/default/files/media_asset/global-aids-monitoring_en.pdf
    [2] Zhao Y, McGoogan JM, Wu Z. The Benefits of Immediate ART. Vol. 18, Journal of the International Association of Providers of AIDS Care. SAGE Publications Inc.; 2019. https://doi.org/10.1177/2325958219831714.https://doi.org/10.1177/2325958219831714
    [3] Mao Y, Wu Z, Poundstone K, Wang C, Qin Q, Ma Y, et al. Development of a unified web-based national HIV/AIDS information system in China. Int J Epidemiol 2010;39(SUPPL.2). https://doi.org/10.1093/ije/dyq213.https://doi.org/10.1093/ije/dyq213
    [4] Ma Y, Dou Z, Guo W, Mao Y, Zhang F, McGoogan JM, et al. The Human Immunodeficiency Virus Care Continuum in China: 1985-2015. Clin Infect Dis 2018;66(6):833-9. https://doi.org/10.1093/cid/cix911.https://doi.org/10.1093/cid/cix911
    [5] Marsh K, Eaton JW, Mahy M, Sabin K, Autenrieth C, Wanyeki I, et al. Global, regional and country-level 90-90-90 estimates for 2018: assessing progress towards the 2020 target. AIDS 2019; 9. http://dx.doi.org/10.1097/qad.0000000000002355.
    [6] Ndashimye E, Arts EJ. The urgent need for more potent antiretroviral therapy in low-income countries to achieve UNAIDS 90-90-90 and complete eradication of AIDS by 2030. Vol. 8, Infectious Diseases of Poverty. BioMed Central Ltd 2019. http://dx.doi.org/10.1186/s40249-019-0573-1CrossRef
    [7] Tun W, Go V, Yansaneh A. Implementation Science: Helping to Accelerate Progress Toward Achieving the 90-90-90 Goal. Vol. 23, AIDS and Behavior. Springer New York LLC 2019;115-9. https://doi.org/10.1007/s10461-019-02649-8.https://doi.org/10.1007/s10461-019-02649-8
    [8] Labhardt ND, Ringera I, Lejone TI, Klimkait T, Muhairwe J, Amstutz A, et al. Effect of offering same-day ART vs usual health facility referral during home-based HIV testing on linkage to care and viral suppression among adults with HIV in Lesotho: The CASCADE randomized clinical trial. In: JAMA - Journal of the American Medical Association. American Medical Association; 2018. p. 1103-12. https://doi.org/10.1001/jama.2018.1818.https://doi.org/10.1001/jama.2018.1818
    [9] Wu Z, Zhao Y, Ge X, Mao Y, Tang Z, Shi CX, et al. Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention. PLoS Med 2015;12(9). https://doi.org/10.1371/journal.pmed.1001874.https://doi.org/10.1371/journal.pmed.1001874
    [10] Dave S, Peter T, Fogarty C, Karatzas N, Belinsky N, Pai NP. Which community-based HIV initiatives are effective in achieving UNAIDS 90-90-90 targets? A systematic review and meta-analysis of evidence (2007-2018). PLoS One 2019;14(7). http://dx.doi.org/10.1371/journal.pone.0219826CrossRef
  • FIGURE 1.  Number of total HIV tests performed and number of newly diagnosed PLWH from 2014 to 2018.

    FIGURE 2.  ART coverage and viral suppression from 2014 to 2018.

    TABLE 1.  Definitions of the 90-90-90 targets, calculated each calendar year using CRIMS data.

    Numerator Denominator
    First 90%: Diagnosis Number of surviving PLWH with a confirmed HIV diagnosis, taken from CRIMS. Number of PLWH estimated through Spectrum modelling, figures were taken from the joint estimation group.
    Second 90%: Treatment Number of PLWH on ART, taken from CRIMS. Number of surviving PLWH with a confirmed HIV diagnosis, taken from CRIMS.
    Third 90%: Viral Suppression Number of PLWH with viral load ≤1,000 copies/mL, taken from CRIMS. Number of PLWH on ART for at least 12 months and at least one viral load test result*, taken from CRIMS.
    * The calculation of the third 90% is different from the UNAIDS recommendation. The Chinese National Free Antiretroviral Treatment Program provides free viral load testing once a year. Patients newly initiated on ART may not have received a viral load test by the end of the reporting period (4).
    Download: CSV

    TABLE 2.  China’s continuum of HIV care, 2014–2018

    Items 2014 2015 2016 2017 2018
    Total survival number of PLWH 500,679 577,423 664,751 758,610 861,042
    PLWH on ART 295,358 386,756 494,657 609,829 718,499
    Patients on ART eligible for viral load testing 216,576 285,237 359,337 447,720 573,992
    Patients on ART with ≥1 viral load test result 197,735 263,712 255,924 362,970 512,499
    Patients with suppressed viral load 179,807 241,003 237,696 339,510 482,954
    Download: CSV

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Progress Towards the 90-90-90 Targets for Controlling HIV — China, 2018

View author affiliation

Summary

What is already known about this topic?

Since the Joint United Nations Programme on HIV and AIDS (UNAIDS) announced the 90-90-90 targets to control the global HIV epidemic in 2014, many countries have undertaken innovative measures to achieve this goal. The National Center for AIDS/STD Control and Prevention (NCAIDS) of China CDC convenes experts annually to evaluate the national progress towards these indicators. The most recent progress of 90-90-90 targets in China has not been previously published.

What is added by this report?

At the end of 2018, the percentage of living with HIV (PLWH) who had received a confirmed HIV diagnosis in China was 68.9% (61.5%-78.3%). The antiretroviral treatment coverage of diagnosed PLWH was 83.4%, and among patients on treatment for at least 12 months, 94.2% achieved viral suppression. This provides most recent progress of 90-90-90 target in China.

What are the implications for public health practice?

China has made significant strides in curbing the HIV epidemic, but analysis on progress for the first 90 target for HIV testing remains out of reach. Innovative testing strategies may need to be developed to ensure that more PLWH can be identified.

  • 1. National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
  • Corresponding author:

    Mengjie Han, mjhan@chinaaids.cn

    doi: 10.46234/ccdcw2019.003
  • In 2014, the Joint United Nations Programme on HIV and AIDS (UNAIDS) established the 90-90-90 targets, which sets the goal that by 2020, 90% of all people living with HIV (PLWH) should be aware of their HIV status, 90% of all diagnosed PLWH should be accessing antiretroviral therapy (ART), and 90% of all patients receiving ART should have suppressed viral loads (1). Correspondingly, the Chinese government developed an action plan for 2016-2020 to meet the 90-90-90 targets and to control the national HIV epidemic. As part of this effort, the Chinese National Free Antiretroviral Treatment Program eliminated the CD4 cell count eligibility threshold and began offering free treatment to all PLWH starting in 2016 (2).

    Every year, the National Center for AIDS/STD Control and Prevention (NCAIDS) of Chinese Center for Disease Control and Prevention, compiles data from the nationwide HIV/AIDS Comprehensive Response Information Management System (CRIMS) (3) and convenes experts to evaluate the state of the epidemic and the national response (Table 1). Data on China’s progress towards the 90-90-90 targets are shared with international organizations, including UNAIDS and the World Health Organization (WHO). As of the end of 2018, estimates for the three target indicators stand at 68.9% (61.5%-78.3%), 83.4%, 94.2%, respectively. Progress towards the first 90% target lags behind the second and third targets. Testing strategies need to be tailored and strengthened so that more PLWH can be screened and diagnosed in a timely manner.

    Numerator Denominator
    First 90%: Diagnosis Number of surviving PLWH with a confirmed HIV diagnosis, taken from CRIMS. Number of PLWH estimated through Spectrum modelling, figures were taken from the joint estimation group.
    Second 90%: Treatment Number of PLWH on ART, taken from CRIMS. Number of surviving PLWH with a confirmed HIV diagnosis, taken from CRIMS.
    Third 90%: Viral Suppression Number of PLWH with viral load ≤1,000 copies/mL, taken from CRIMS. Number of PLWH on ART for at least 12 months and at least one viral load test result*, taken from CRIMS.
    * The calculation of the third 90% is different from the UNAIDS recommendation. The Chinese National Free Antiretroviral Treatment Program provides free viral load testing once a year. Patients newly initiated on ART may not have received a viral load test by the end of the reporting period (4).

    Table 1.  Definitions of the 90-90-90 targets, calculated each calendar year using CRIMS data.

    The number of HIV tests performed annually has increased from 128 million in 2014 to 241 million in 2018 (Figure 1). For this same period, CRIMS data report that the total survival number of PLWH with a confirmed diagnosis increased from 500,679 to 861,042 (Table 2), and the number of newly diagnosed cases per calendar year rose from 103,501 in 2014 to 148,589 in 2018 (Figure 1). CRIMS data on the care continuum are presented in Table 2. A joint assessment by NCAIDS, UNAIDS and WHO used Spectrum modelling to estimate that at the end of 2018, the total number of PLWH in China was 1,250,000 (1,100,000-1,400,000). The percentage of PLWH with a confirmed HIV diagnosis at the end of 2018 in China was 68.9% (61.5%-78.3%). There were an estimated 81,000 (60,000-105,000) new infections in 2018 and the estimated national prevalence in 2018 is 0.090% (0.079%-0.101%).

    Figure 1.  Number of total HIV tests performed and number of newly diagnosed PLWH from 2014 to 2018.

    Items 2014 2015 2016 2017 2018
    Total survival number of PLWH 500,679 577,423 664,751 758,610 861,042
    PLWH on ART 295,358 386,756 494,657 609,829 718,499
    Patients on ART eligible for viral load testing 216,576 285,237 359,337 447,720 573,992
    Patients on ART with ≥1 viral load test result 197,735 263,712 255,924 362,970 512,499
    Patients with suppressed viral load 179,807 241,003 237,696 339,510 482,954

    Table 2.  China’s continuum of HIV care, 2014–2018

    The number of people receiving ART increased from 295,358 in 2014 to 718,499 in 2018 (Table 2), corresponding to treatment coverage of 59.0% in 2014 and 83.4% in 2018 (Figure 2). Over 90% of patients on ART for over 12 months have suppressed viral loads, and this percentage rose to 94.2% in 2018.

    Figure 2.  ART coverage and viral suppression from 2014 to 2018.

    • In 2018, UNAIDS presented an update on the global progress towards the 90-90-90 targets: 79% (67%-92%) of all PLWH globally knew their HIV status. Among those who knew their HIV status, 78% (69%-82%) were accessing antiretroviral therapy, and 86% (72%-92%) of PLWH on ART had suppressed viral loads. Fifteen countries reported meeting the targets in 2018 (5).

      Although China can be credited for substantial recent progress, the challenges remain in achieving 90-90-90 targets. Data show that there is a large gap to meeting the first 90% target. This indicates that there is insufficient access to testing for those who already infected with HIV. New approaches to testing should be investigated and implemented, including additional focus on self-testing, partner testing, and promoting testing-seeking behavior strategies. National HIV testing outreach campaigns will also be intensified to increase awareness and uptake of HIV testing among key populations at risk. Through investing in new policies and programs, earlier HIV detection and prevention of further transmission can be achieved.

      While China’s ART coverage is relatively favorable among low- and middle-income countries (6), improvements are necessary in the treatment and care services system (7). A major priority is to reduce the time between HIV diagnosis and ART initiation (8). Patients who are diagnosed late at low CD4 cell counts and advanced disease progression should be offered immediate and/or accelerated ART initiation (2). Previous research has shown that structural interventions to simplify the algorithm between screening and treatment initiation can reduce mortality, and the implementation of such interventions should continue to be expanded nationally (9). Maintaining timely linkage to care and high treatment retention rates is crucial to improving overall health outcomes (9).

      Finally, the increased involvement of community-based organizations has led to greater HIV awareness, program participation, and improved HIV-related outcomes. Specifically, initiatives led by community-based organizations can increase HIV testing uptake and decrease HIV-related mortality and virologic failure (10). Additional investment in collaborations between health authorities and community-based organizations can yield significant benefits.

      The findings in this report are subject to some limitations. First, the number of PLWH estimated through modelling methods may be affected by available parameters and complex circumstances. Second, China’s national treatment program only provides free viral load testing on a once per year basis post-ART initiation. Thus, only the viral loads of patients who have been treated for more than one year and have successfully accessed viral load testing are capable of being observed. This introduces bias into the national viral suppression estimates because patients who failed treatment are also more likely to not receive a viral load test. However, CRIMS is a robust and comprehensive case reporting system with national coverage and up-to-date clinical information on all diagnosed PLWH in China (3), and we have confidence in the overall findings.

      China has made significant strides in the fight against HIV. Yet, in light of the geographic diversity of the epidemic and the complexity in addressing disparate population needs, many challenges still exist. Tremendous efforts need to be sustained in order to curb transmission. Proportional budget allocations, healthcare system reform and expansion, reduction in HIV stigma, and additional emphasis on key populations are needed for China to achieve the 90-90-90 targets.

    • The authors would like to thank all participants of the national program evaluation. Many thanks to Cynthia X. Shi from Yale University for reviewing and editing the manuscript. This work was supported by the China National AIDS Program.

      All authors have completed and submitted the ICMJE form; no potential conflicts of interest were disclosed.

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