Current State of Global HIV Care Continua Reuben Granich 1, Somya Gupta 1, Irene Hall 2, John Aberle-Grasse 2, Shannon Hader 2, Jonathan Mermin 2 1)International Association of Providers of AIDS Care 2)Centers for Disease Control and Prevention

90 % Know statusOn treatment Virally suppressed 90 % 81 % 73 % and Continuum of Care Targets

Identification (127) 31 continuum identified through PubMed search 96 continuum identified through UNAIDS country reports, WHO reports, PEPFAR* country operational plans, national reports, and conference papers Screening (80) 80 recent continuum selected ( ) 47 older and/or duplicate continuum excluded Data analysis (70)* For 70 continuum, data were collected on the 4 key continuum indicators and each indicator was graded on methods 10 continuum were excluded: 6 continuum reported preliminary/ unconfirmed national figures 4 continuum were from second hand reports without sources Methods review (45)** 45 continuum graded based on methodology used for indicators 25 continuum that did not have viral suppression estimates and/or had data discrepancies excluded Methodology *Over past month the available continua for Africa nearly tripled as a result of PEPFAR open data effort **2015 Global HIV burden: 54% *2015 Global HIV burden 82%

People living with HIV diagnosed positive ( ) UNAIDS target 90% 90%-100% 70-89% Below 70% Not available No continuum in public domain Of the 70 countries, data were available for 42 countries for this indicator

People living with HIV on ART ( ) UNAIDS target 81% 81%-100% 60-80% Below 60% Not available No continuum in public domain Of the 70 countries, data were available for 68 countries for this indicator

People living with HIV with viral suppression ( ) UNAIDS target 73% 73%-100% 50-72% Below 50% Not available No continuum in public domain Of the 70 countries, data were available for 45 countries for this indicator

Mapping on ART and viral suppression targets (45 countries) ART coverage >81% and viral suppression >73% ART coverage 60-80% and viral suppression 50-72% ART coverage <60% and viral suppression <50%

UNAIDS target: 81% UNAIDS target: 90% Proportion of people living with HIV diagnosed and on ART TARGET Of 70 countries, data from 42 countries

UNAIDS target: 73% UNAIDS target: 81% Proportion of people living with HIV on ART and with viral suppression TARGET Of 70, data from 45 countries with on ART and viral supression

Countries reporting more than 70% of people living with diagnosed HIV ( ) 90% 20 countries >70%

Countries reporting more than 60% of people living with HIV on ART ( ) 81% 15 countries >60%

Countries reporting more than 50% of people living with HIV with viral suppression ( ) 73% 14 countries >50%

Top 14 countries with >50% viral suppression ( )

Documenting and grading continua methods

Source: ART CD4 cell count initiation for asymptomatic people (120 countries) 2015 WHO Recommendation : Irrespective of CD4 count <200, <250 or <300 <350 <500 >500 Irrespective of CD4 count

Availability of Viral Load Recommended and widely available Recommended only for monitoring treatment failureRecommended with limited availability Recommended (availability unknown) No recommendation (limited availability) Not recommended Source:

Limitations Limited to most recent care continua available in public domain---some cascades may have been missed Africa is missing complete continua Lack of data for people diagnosed and viral load Data may exist but is missing from public domain Methods for determining continua are different across countries (apples and oranges) Continua provide a snapshot but do not capture individual and cohort outcomes well

glass is half full! Benchmarking Continua in public domain from Africa nearly tripled over last six months Some countries are close to (and it is only 2016) Policy is changing to test and treat Countries using targets PEPFAR and Global Fund are backing test and treat and Viral load access is increasing Community is embracing earlier treatment

Thank you

Source: published policy ART CD4 cell count initiation criteria in Africa 2015 WHO Recommendation : Irrespective of CD4 count <200 <350 <500 Irrespective of CD4 count

Objectives and methodology: “wiki strategy” Objective: Compare national ART guidelines for 157 countries with WHO 2015 guidelines Published guidelines from 120 countries and recommendations from 53 countries AIDSTAR-One database UNAIDS regional support team Web search Ministry of Health officials Recommendation on ART initiation criteria and monitoring for different target population abstracted Search end date: July 2016

ART initiation for asymptomatic people ART initiation criteria No. of Countries People with HIV (2015) Countries Irrespective of CD4 count 22 5,132,000 (14%) Argentina, Australia, Austria, Botswana, Brazil, British Columbia (Canada), France, Germany, Italy, Japan, Korea (Republic), Lesotho, Malawi, Maldives, Mexico, Montenegro, the Netherlands, Romania, Spain, Thailand, Turkey, United Kingdom, United States Consider for > ,000 (0.1%)Greece, Guyana, Hong Kong, Norway ≤ ,580,000 (53%) Algeria, Bangladesh, Bhutan, Bolivia, Burundi, Cambodia, Cameroon, Chile, Colombia, Democratic Republic of Congo, Ecuador, El Salvador, Ethiopia, Fiji, Gabon, Haiti, Honduras, Kenya, Madagascar, Mali, Mauritania, Moldova, Myanmar, Namibia, Nepal, Oman, Pakistan, Poland, Rwanda, South Africa, South Sudan, Sri Lanka, Sudan, Swaziland, Tanzania, Tunisia, Uganda, Ukraine, Uruguay, Venezuela, Viet Nam, Zambia, Zimbabwe ≤350 (consider for CD4 ≤ 500) 4 136,000 (0.4%) Belize, Costa Rica, Finland, Guinea ≤ ,533,000 (28.7%) Afghanistan, Angola, Benin, Burkina Faso, Canada, China, Cote d’Ivoire, Croatia, Djibouti, Dominican Republic, Ghana, Guatemala, India, Indonesia, Jamaica, Kazakhstan, Latvia, Malaysia, Marshall Islands, Morocco, Mozambique, Nicaragua, Niger, Nigeria, Panama, Papua New Guinea, Paraguay, Peru, Portugal, Samoa, Sierra Leone, Sweden, Switzerland, Timor-Leste, Tuvalu, Vanuatu ≤ (<0.1%) Macedonia ≤200 (consider for CD4 ≤ 350) 5 1,466,000 (4%) Belarus, Cape Verde, Cuba, Estonia, Russia ≤ ,000 (0.4%) Comoros, Lao PDR, Liberia, Philippines, Senegal Source: published policy

Irrespective ART eligibility criteria and proportion of people living with HIV with viral suppression Data for 45 countries

Merriam-Webster Definition Feasible 1: Capable of being done or carried out Synonym – POSSIBLE, PRACTICABLE, POSSIBLE, ACHIEVABLE