In 2014, UNAIDS released the 90-90-90 objectives: 90% of persons living with HIV (PLHIV) are identified, 90% of known PLHIV (or 82% of all) are on sustained ART, of whom 90% (or 73% of all) are virally suppressed by 2020. In September 2015, WHO released guidance endorsing ‘Treat All’ as a critical strategy for epidemic control. Reaching 73% viral suppression by 2020 implicitly assumes that ‘Start All’ will facilitate a rapid increase in the identification of PLHIV to reach the first step in the cascade. We reviewed Malawi’s national data on PMTCT Option B+ as an early ‘Treat All’ model to understand progress towards 90-90-90 in a defined population.
The Malawi Ministry of Health collects, validates and publishes all HIV program data on a quarterly basis (www.hiv.health.gov.mw). Quarterly report data was analyzed to compare the six month period prior to implementation of Option B+ with the same six month period four years later. Comparisons on cascade coverage were made using the Spectrum model population denominator as the point of comparison for each 90. The contributions of initiation and retention were separated under the 2nd 90, and those lost to follow-up were considered not to be virally suppressed.
Between 2011 and 2015, the proportion of all estimated pregnant PLHIV who knew their HIV status increased from 49% to 80%. The proportion of known positive and on ART increased from 6.5% to 98%, or 78% of all pregnant PLHIV nationally. Retention on ART at 12 months was 72% (56% of all), and of the 23% of ART patients who received a routine VL test, 85% were virally suppressed (or 48% of all), resulting in Malawi attaining an estimated 80-56-48 on the 90-90-90 cascade, compared to 49-3-2 in 2011 (Figure 1).
Use of the 90-90-90 cascade to monitor progress towards epidemic control provides clear programmatic insight. “Treat all” under Option B+ in Malawi resulted in rapid and demonstrable progress towards achieving the 90-90-90 objectives, both in ART initiation and viral suppression. However, even in this easy-to-access population with high ANC attendance, the first 90 was not reached. To accomplish 90-90-90 nationally, a proactive approach is required to reach the first 90, not reliance on existing testing coverage and service delivery models. Under the 2nd 90 it is important to ensure both ART initiation and ART retention are monitored, in order to ensure appropriate interventions to increase coverage are implemented.