Editorial: Can we end HIV as a public health problem globally? Progress towards achieving the UNAIDS 90–90–90 goals No abstract available

Reaching 90–90–90 in Botswana Purpose of review Botswana, a small country in southern Africa, has had a very high prevalence of HIV since about 1995. It seems important to analyze the response of this country to help us understand how it became one of the first nations to achieve the 90–90–90 targets. Recent findings Botswana began a national program for treatment of HIV/AIDS with ARVs in 2002. Initially established in the four largest population centers, it expanded to more than 30 sites throughout the country by 2004. Also in 2004, an ‘opt out’ system for HIV testing was introduced. The government-sponsored ARV regimen for initiation was ZDV/3TC/EFV until 2008, then TDF/FTC/EFV until 2016, when it became TDF/FTC/DTG along with the introduction of treatment for all. Levels of both acquired and transmitted drug resistance have been low. In late 2013, we began the Ya Tsie or Botswana Combination Prevention Project (BCCP), a cluster randomized trial for 100 000 exurban and rural adults in 30 villages that included enhanced testing, linkage to care, and ARV treatment for 15 intervention villages, one in each pair. A 20% baseline survey in 2013–2015 revealed 29% prevalence and values that were already close to 90–90–90. With 83.3% of HIV-positive adults knowing they were infected, 87.4% of those knowing they were infected already on ARV, and 96.5% of those on ARV in complete viral suppression, this represented a combined value of 70.2% toward the target of 73%. By best estimates, incidence fell by about 30% over the 29-month period of the trial, which is compatible with Botswana reaching a 90% reduction in incidence in 10 years as proposed by the UNAIDS model. On the basis of an end-of-study survey in three intervention villages, we estimate that Botswana could reach 95–95–95 by 2019. Summary These results illustrate that it is possible to reach 90–90–90 in countries with very high HIV prevalence.

Reaching 90–90–90 in rural communities in East Africa: lessons from the Sustainable East Africa Research in Community Health Trial Purpose of review There is an urgent need to understand new population-level approaches that achieve high levels of treatment and viral suppression for persons living with HIV. Recent findings The SEARCH Universal test and treat (UTT) trial conducted in Kenya and Uganda aimed to reduce HIV incidence and improve community health. SEARCH offered HIV and multidisease testing at health fairs followed by home testing for nonparticipants in 32 communities, each with approximately 10 000 persons. In the 16 intervention communities, UNAIDS 90–90–90 targets were achieved within 3 years, reaching ‘92–95–90’ and 79% population-level viral suppression. HIV incidence declined by 32% between year 1 and 3 of follow-up. Key principles of SEARCH's approach included community engagement, integration of HIV with multidisease services, rapid ART start upon HIV diagnosis, and patient-centered, streamlined care. SEARCH's community health approach also reduced HIV mortality, annual TB incidence, and uncontrolled hypertension compared with a country standard of care. Population-level viral suppression increased beyond the UNAIDS 73% target in women and men and reached levels well above recent country estimates across much of sub-Saharan Africa. Summary SEARCH provides one example of how to rapidly surpass UNAIDS 90–90–90 targets while addressing community health on the path to HIV epidemic control.

Is reaching 90–90–90 enough to end AIDS? Lessons from Amsterdam Purpose of review Although cities present opportunities for infectious pathogens such as HIV to spread, public health infrastructure within these cities also provides opportunities to design effective approaches to eliminate transmission of these pathogens. The HIV Transmission Elimination AMsterdam (H-TEAM) Initiative, a consortium of relevant stakeholders involved in HIV prevention and care, designed an integrated approach to curb the HIV epidemic in Amsterdam, including providing preexposure prophylaxis (PrEP), increasing awareness of acute HIV infection, offering same-day test and treat, and improving indicator disease-driven HIV testing. Recent findings In 2013, approximately 230 people in Amsterdam were newly diagnosed with HIV, largely belonging to one of two key affected populations, namely MSM and people with a migration background. Since the start of H-TEAM in 2014, a decrease in new diagnoses was observed (130 in 2017), with an increasing proportion of MSM who had been diagnosed with a recent infection. Summary The H-TEAM shows that a city-based concerted effort is feasible. However, major challenges remain, such as reducing the number of late HIV diagnoses, and identifying and providing appropriate services to a diminishing group of individuals who are likely the source of transmission.

Can the United States achieve 90–90–90? Purpose of review To summarize recent trends in knowledge of HIV status, care and viral suppression, and the status of implementation of relevant contextual requirements for the United States to achieve the 90–90–90 goals. Recently, the US government announced a plan to decrease HIV incidence by over 90% by 2030. Reaching this goal may require higher targets than 90–90–90. Recent findings The United States is on course to reach 90–90–90 goals in the near future, with 86% of persons with HIV aware of their infection, 74% of persons with diagnosed infection in care, and 83% of persons in care with viral suppression in 2016. Some high-burden subnational jurisdictions have already achieved these goals. Summary The United States is likely to reach 90–90–90 targets in the near future. However, to reduce HIV incidence by at least 90% by 2030, the United States will need to rapidly meet the new 95–95–95 targets and deploy a comprehensive strategy with novel approaches to testing, retaining persons with HIV on treatment, and preventing new infections with preexposure prophylaxis and comprehensive syringe services programs.

Challenges of reaching 90–90–90 in the Southern United States Purpose of review More than half of new HIV diagnoses occur in the Southern United States where the epidemic disproportionately affects persons of color. Although other areas of the country are seeing dramatic declines in the number of new cases, the progress in the South lags behind. This review will examine the reasons for that disparity. Many are unique to the South. Recent findings Despite advances in antiretroviral therapy for HIV, many in the South are not benefiting from these medications, at either a personal or public health level. The reasons are complex and include lack of access to healthcare, lower levels of funding than other areas of the country, stigma, structural racism, increased barriers due to social determinants of health, coexisting mental health disorders, substance use disorders and sexually transmitted diseases and insufficient workforce capacity to meet the needs of those living with HIV. Summary These findings should underline the need for investment in the South for a holistic healthcare approach to persons living with HIV including supporting basic needs such as access to food, transportation and housing. Prioritization among politicians for policy and systems changes and approaches to decrease stigma and enhance education about HIV will be key.

Harnessing digital data and data science to achieve 90–90–90 goals to end the HIV epidemic Purpose of review Effective public health interventions depend on timely, accurate surveillance. Harnessing digital data (including internet searches, social media, and online media) and data science is an emerging approach to complement traditional surveillance in public health but has been underutilized in HIV prevention and treatment. Recent findings We highlight recent examples that illustrate how social media data can be applied to HIV surveillance and prevention interventions. Summary To achieve 90–90–90 goals to end the HIV epidemic, we encourage traditional public health researchers to partner with data scientists to supplement HIV surveillance programs with social media analytics to refine estimates of HIV infections and key populations at risk and to identify subgroups and regions where prevention and treatment efforts need to be bolstered. We also encourage interdisciplinary teams to design interventions to promote HIV prevention and linkage to care by leveraging digital media, such as search engines and social media, that have the potential to reach millions of people instantaneously.

The first 90: the gateway to prevention and care: opening slowly, but not for all Purpose of review Knowledge of HIV status is the gateway to HIV treatment and prevention, and optimizing this pillar is essential to bend the curve of the HIV epidemic toward zero new infections. This review will discuss the epidemiology of serostatus awareness, including disparities among key populations, and explore interventions and societal barriers. Recent findings Rates of serostatus awareness have improved overall; however, progress is lagging in many regions, nations and populations, with substantial disparities seen among key populations. These populations and their partners now contribute the majority of new infections, fueling the epidemic. Data support a variety of interventions that have demonstrated effectiveness in increasing new diagnoses, particularly among underserved populations. Structural and societal barriers such as stigma, discriminatory laws and policies, and social determinants of health disproportionately affect key populations, and these must be addressed to achieve equity and end the epidemic. Summary According to United Nations Programme on HIV/AIDS (UNAIDS), the pace of progress toward epidemic control has slowed. Achieving substantial increases in serostatus awareness to meet 2020 and 2030 UNAIDS goals will require attacking complex societal barriers while bringing evidence-based interventions to scale in each nation and key population. A robust advocacy effort is now needed as political will and funding wane.

Reaching the second 90: the strategies for linkage to care and antiretroviral therapy initiation Purpose of review We present recent literature describing interventions for linkage to HIV care in the era of Universal Test and Treat (UTT) policies. We also provide information for ongoing studies of linkage to care strategies registered with ClinicalTrials.gov. Recent findings Differentiated service delivery for linkage to care involves implementing strategies that simplify and adapt HIV services to better serve individual needs and reduce unnecessary burdens on the health system. Recent strategies have focused not only on clinic-based populations testing for HIV but also emphasize community-based services and HIV self-testing, which create different challenges for linkage to the healthcare system. Some recent developments in linkage to care strategies include: case management, care integration with other desirable health services, financial incentives, home-based, and peer-led services. The demonstrated strategies have varying levels of success and engagement in care; further work is needed to address ongoing barriers in HIV care. Summary Progress towards meeting the 90–90–90 benchmarks has left gaps in linkage to care that require care-system development to facilitate increased access to care under UTT policies. Most notably, new strategies will need to focus on addressing the distinct needs of key populations and bolstering linkage to care from community-based and self-testing services.