LetterHIV

Comment on “Using geospatial mapping to design HIV elimination strategies for sub-Saharan Africa”

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Science Translational Medicine  02 Aug 2017:
Vol. 9, Issue 401, eaan5435
DOI: 10.1126/scitranslmed.aan5435

Abstract

A recent study showed how geospatial mapping can be used to improve Lesotho’s HIV treatment program to achieve the 90-90-90 targets set by the United Nations but incorrectly describes “treatment as prevention” as the UN’s strategy for a successful national AIDS response.

We appreciate the work by Coburn and colleagues to use geospatial mapping of data to improve the efficiency of providing antiretroviral therapy to people living with HIV in Lesotho, a country in sub-Saharan Africa (1). Since 2013, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has called on countries to use location- and population-specific data analysis to help focus HIV services on the locations and populations in greatest need (www.unaids.org/sites/default/files/media_asset/LocationLocation_en.pdf). However, we note with concern several statements made by Coburn and colleagues that misrepresent the policy and programmatic advice of the United Nations. We are also alarmed by some of the conclusions drawn by the authors, which appear to suggest that denial of life-saving medicines to areas with low density of infection is required to defeat the AIDS epidemic in Lesotho. Had the authors included additional variables within the mapping framework and considered ongoing innovations in HIV service delivery, they might have come to different conclusions.

The authors incorrectly assert that UNAIDS proposes “treatment as prevention” as a “global strategy for eliminating HIV.” Since 2011, when the extensive preventative benefits of antiretroviral therapy were confirmed by the HPTN 052 trial (2), UNAIDS has continued to advocate for a combination HIV prevention approach, including antiretroviral therapy for viral suppression, condoms, behavioral and structural interventions, preexposure prophylaxis, sterile needle and syringe programs, and voluntary medical male circumcision, with appropriate focus on specific populations (www.unaids.org/sites/default/files/media_asset/20151019_JC2766_Fast-tracking_combination_prevention.pdf). UNAIDS does not view “treatment as prevention” as a singular strategy for the response to HIV.

In 2014, UNAIDS and its partners introduced the 90-90-90 targets (www.unaids.org/sites/default/files/media_asset/90-90-90_en.pdf). UNAIDS called on countries to achieve the following by 2020: 90% of all people living with HIV know their HIV status; 90% of all people with diagnosed HIV infection receive sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy achieve viral suppression. Full achievement of the targets within a country translates to 90% of all people living with HIV aware of their HIV status, 81% of all people living with HIV accessing treatment, and 73% of all people living with HIV sustaining viral suppression. However, Coburn and colleagues state that “UNAIDS’s minimum elimination coverage” for antiretroviral therapy is “~70%” of people living with HIV, which is significantly lower than the 81% required under the second of the three 90s. In addition, “eliminating HIV” is neither the objective of the 90-90-90 targets nor the larger UNAIDS strategy. The UNAIDS strategy calls for countries to achieve several targets by 2020, including 90-90-90 and high coverage of primary prevention and other services, as well as the empowerment of young people and the elimination of AIDS-related discrimination, gender inequality, and gender-based violence through legislation and structural interventions (www.unaids.org/sites/default/files/media_asset/20151027_UNAIDS_PCB37_15_18_EN_rev1.pdf). Projections from modeling analyses suggest that achieving these targets by 2020 can put countries on track to “ending AIDS as a public health threat by 2030,” which has been defined as a 90% reduction in HIV incidence and AIDS-related mortality compared to the 2010 levels (3).

UNAIDS and its partners are supporting countries to produce geospatial models of epidemiological, behavioral, and program data to guide an optimal geographic distribution of resources and delivery of services. These models estimate the geographic distribution of people living with HIV by population characteristics, such as age groups and sex, and at granular levels through the incorporation of geo-located surveillance data and facility-level HIV prevalence and treatment data (4). A critical aspect of these models is the measure of uncertainty around each estimate. The inclusion of uncertainty bounds allows program managers who are distributing resources based on these models to understand the strength of each estimate.

The exclusion of the current geographic distribution of antiretroviral therapy in the Coburn et al. study’s mapping framework is particularly problematic, because it implies that HIV treatment programs are starting from zero in Lesotho. However, country data reported to UNAIDS show that the coverage of antiretroviral therapy (all ages) has increased by 83% since 2010, reaching 53% (48 to 57%) of all people living with HIV at the end of 2016. At the subnational level, antiretroviral therapy coverage (all ages) in 2016 ranged from 18% in Quthing district to 56% in Butha-Buthe district (5). No district is close to reaching universal access to treatment, and national year-on-year trends do not suggest that a plateau has been reached. Clearly, treatment efforts in Lesotho are not starting from zero.

Coburn and colleagues also question whether achieving 70% treatment coverage in Lesotho is feasible—much less than the 81% coverage that Lesotho and other United Nations member states have committed to achieving by 2020. The achievements in some districts in Lesotho and in some countries in the region suggest that achieving 81% coverage by 2020 is entirely possible. Still, on the basis of their assumption to the contrary, Coburn et al. propose to reduce the catchment area of Lesotho’s treatment program to favor areas of higher population density at the expense of people living in rural areas. This amounts to denying antiretroviral therapy to people living with HIV in sparsely populated, relatively low-prevalence areas and condemning them to an early death.

Not long ago, many believed that large-scale provision of antiretroviral therapy in low- and middle-income countries was not feasible. Recent history in Lesotho and elsewhere has proven otherwise. We believe that rapid rollout of innovations in HIV testing, such as community-based HIV testing, self-testing, and partner notification, as well as community delivery of antiretroviral therapy in rural areas, guided by geospatial data, could help to overcome the challenges described by Coburn and colleagues and keep Lesotho on track to achieve the 90-90-90 targets and, ultimately, the end of AIDS as a public health threat.

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