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Best Practices for Attaining and Surpassing 90-90-90 from Select Fast-Track Cities
Since the launch of the Fast-Track Cities network in December 2014, more than 350 cities around the world committed to attain and surpass the United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets. These programmatic targets translate into 90% of people living with HIV (PLHIV) knowing their status, 90% of PLHIV who know their status receiving antiretroviral therapy (ART), and 90% PLHIV on ART achieving HIV viral suppression¹, which confers both therapeutic and preventative benefits.² A fourth target of eliminating HIV-related and intersectional stigma aims to eliminate a major barrier to accessing and utilizing HIV services by and improve the overall quality of life for individuals living with and affected by HIV.
Fast-Track Cities have leveraged political will and commitment, facilitated meaningful community engagement, and deployed data-driven approaches to equitably achieve single- and double-digit percentage point increases across the three 90 targets. Many Fast-Track Cities have attained one or more of the 90 targets and some have even surpassed them, serving as a proof of concept for the world’s first global initiative focused primarily on accelerating urban HIV responses.
The International Association of Providers of AIDS Care (IAPAC) collected and validated through a peer-review process a series of Fast-Track City best practices utilizing the World Health Organization (WHO) definition of a best practice as “exemplary public health practices that have achieved results, and which need to be scaled up so as to benefit more people.” This HIV Policy Brief entitled, “Best Practices for Attaining and Surpassing 90-90-90 for Select Fast-Track Cities,” summarizes a series of best practices from Lagos State (Nigeria), Bangkok (Thailand), London (UK), San Francisco (USA), and São Paulo (Brazil). Three of the best practices are specific to the three 90 targets, a fourth best practice is related to the zero-stigma target with a focus on eliminating stigma affecting key populations, and a fifth best practice addresses quality of life as it relates to whole-health supporting PLHIV.
A more ambitious set of programmatic, service delivery, and integration targets form the basis for the new UN Global AIDS Strategy (2021-2026).³ However, the lessons learned during the 90-90-90 era are clearly applicable to inform the way forward as Fast-Track Cities worldwide work to action the UN Global AIDS Strategy (2021-2026) targets.
Lagos State: HIV Self-Testing
First 90 Target: 90% of PLHIV Know Their Status
The first 90 target measures the percentage of PLHIV who are aware of their status using estimated number of PLHIV as the denominator. The estimated number of PLHIV in Lagos State is 120,000,4 with adolescents between 10-19 years of age accounting for 8% of the total.5 The baseline assessment for the city’s first 90 target in 2015 found that only 57% of PLHIV were aware of their HIV status. The number of PLHIV knowledgeable about their HIV status increased by 25 percentage points to 82% in 2020. Among the most notable strategic interventions that contributed to this first 90 target percentage point increase was the introduction of HIV self-testing (HIVST).
Nigeria incorporated HIVST into its National HIV/AIDS Strategic Framework (2019-2021) as a policy and programmatic priority to expand the country’s HIV testing coverage.6 In line with the national framework, Lagos State prioritized HIVST as a strategic Fast-Track City intervention. One approach was to leverage political commitment for the 90-90-90 targets by facilitating the First Lady of Lagos State’s personal engagement to increase awareness of HIVST kits. Lagos State also involved affected communities (e.g., female sex workers, men who have sex with men [MSM]) in planning, designing, and implementing HIVST as a strategic intervention, which the World Health Organization (WHO) recommends as critical to improving the outcome and effectiveness of the HIVST kit rollout.7
Additionally, Lagos States focused attention on key populations, including adolescents and young people (AYP), which have been identified as hard-to-reach populations.8 The Lagos State AIDS Control Agency (LSACA) collaborated with the Ministry of Education as well as the Ministry of Youth and Social Development to roll out an HIV prevention campaign in secondary and tertiary youth centers and re-activated HIV education in the 354 junior public schools with the goal of generating demand for HIVST. Moreover, LSACA partnered with the Ministry of Youth and Social Development to disseminate HIVST kits, including educational materials and condoms, in 31 youth centers and trained youth officers in these centers to deliver HIV counseling and testing services.8 Additionally, knowledge on general HIV among youth accessing HIVST services at the youth centers increased by 50%.8 Data regarding HIVST uptake among AYP are pending.
Bangkok: Same-Day ART Initiation
Second 90 Target: 90% of PLHIV Who Know Their Status Are on ART
The second 90 target is measured as the percentage of PLHIV who know their status and are on ART. In Thailand’s capital city, Bangkok, 96% of the estimated 82,608 PLHIV in the city are reported as knowing their HIV status.9 Conferring both therapeutic and preventative benefits, virologically suppressive ART reduces HIV-related morbidity and averts AIDS-related deaths,10 as well as prevents sexual transmission of HIV to sero-different partners.10 Placing PLHIV on ART as soon after their HIV diagnosis, with adequate support for them to achieve viral suppression, is the foundation for same-day ART initiation. The baseline assessment for Bangkok’s second 90 target in 2016 found that only 57% of PLHIV who were aware of their HIV status were on ART.
Through a series of strategic interventions, notably same-day ART (SDART) at the Thai Red Cross Anonymous Clinic (TRCAC), the largest HIV testing clinic in Bangkok, the number of PLHIV knowledgeable about their HIV status who were on ART increased by 20 percentage points to 77% in 2020.
TRCAC implemented SDART in 2017 in an effort to address low ART initiation levels. In comparison to the prior system which used a complex process to link PLHIV with a positive diagnosis to hospitals for ART initiation, SDART allows eligible PLHIV to start ART at TRCAC on the same day of HIV diagnosis. It also provides ART for clients who were previously diagnosed but had not started treatment. The SDART process takes 2.5 months in total and involves two patient visits: one immediately after diagnosis involving baseline tests, a psychological evaluation, and a chest x-ray to determine SDART eligibility; and another two to three weeks after ART initiation to assess the patient’s response to treatment and modify the antiretroviral regimen, as needed, before the patient is ultimately linked to a long-term ART maintenance facility. The program is implemented by a multidisciplinary team of counselors, peer navigators, nurses, and physicians. Ahead of ART initiation, nurses take medical histories and physicians conduct physical evaluations to ascertain the patient’s readiness to start ART. Counselors are charged with psychosocial evaluation and pre- and post-test counselling. Peer navigators provide PLHIV continuous support throughout the SDART process through counselling and logistical assistance with insurance schemes and linkage to long-term facilities. Since the implementation of SDART, clients are approximately four times as likely to start ART and two times more likely to be virally suppressed compared to the prior hospital-focused standard of care.
London: Keep Doing it, London
Third 90 Target: 90% of PLHIV on ART Achieving Viral Suppression
The third 90 target relates to the percentage of PLHIV who know their HIV status, are on ART, and achieve viral suppression. Achieving viral suppression requires a supportive clinical and social environment for PLHIV and is critical to reducing HIV-related morbidity and averting AIDS-related deaths.
Moreover, when a person who is living with HIV reaches an undetectable viral load, they cannot transmit the virus sexually to sero-different partners, which is referred colloquially as U=U, or undetectable equals untransmittable. Many factors can influence an individual’s ability to achieve optimal ART adherence, which requires PLHIV-centered retention and re-engagement in HIV care practices. London was one of the first cities to surpass the 90-90-90 targets, a feat they achieved prior to joining the Fast-Track Cities initiative in 2018; and have now surpassed the new 95-95-95 targets, including an increase in the third 90 target from 96% (2018) in the year London became a Fast-Track City to 97% in 2019.11
Core to London’s third 90 target success is a focus on U=U, a de-stigmatizing message that bolsters ART adherence, retention in care, and viral suppression as a method of reducing new HIV infections. The London HIV Prevention Program, a city-wide health promotion initiative managed by Lambeth Council on behalf of London’s 32 boroughs, launched the campaign “Do it London” in 2015 to promote combination HIV prevention, including testing, condoms, and pre-exposure prophylaxis (PrEP), with an additional focus on U=U in 2017.8,15 This campaign also promoted the importance of retention in care and ART adherence to sustain viral suppression and prevent new HIV infections.8,15 The availability of universal HIV treatment provided free of charge by the UK’s National Health Service (NHS),16 coupled with education around U=U and support for PLHIV to remain engaged in care, can be attributed to London’s successes in attaining and surpassing both the 90-90-90 and 95-95-95 targets.
São Paulo: Transgender Outreach
Zero Stigma Target: Key Populations
Stigma – both HIV-specific and intersectional in nature – is a major challenge for PLHIV and is pervasive throughout the continua of HIV prevention and care. For example, gender identity- and HIV status-related stigma collide with structural barriers that attenuate the ability of key populations to access and utilize HIV and other health services. Eliminating health disparities caused by stigma is a critical objective of the zero stigma target and is an important contributor to achieving the 90-90-90 targets. The 2014 baseline 90-90-90 targets assessment for São Paulo found that 82% of PLHIV knew their HIV status, 59% of whom knew their status were on ART, and 78% of whom had achieved viral suppression.17 Improving outreach to transgender populations was among a series of interventions that resulted in a 5-percentage point increase in the municipality’s first 90 target (to 87% in 2018), a 13-percentage point increase in its second 90 target (to 72% in 2018), and a 17-percentage point increase in its third 90 target (to 95% in 2018).17
The Instituto Cultural Barong, a non-governmental organization (NGO), promotes sexual and reproductive health and addresses HIV and other sexually transmitted infections (STIs) among LGBTQ+ populations in São Paulo. Their work actively engages affected communities and responds to the needs of transgender and other LGBTQ+ populations.18 Their successes in addressing stigma are largely attributable to partnerships within the community, as well as with the Municipality of São Paulo, São Paulo State AIDS Program, hospitals and clinics, law enforcement bodies, and the general public.18,19 For example, Barong, jointly with the municipality, organized a pageant for transgender individuals, and on another occasion co-hosted with the municipality a communications skills-building workshop for transgender populations.18
Barong conducts outreach in areas frequented by transgender individuals as well as transgender sex workers, and it uses mobile services to expand access to HIV and STI tests to this marginalized community. During the COVID-19 pandemic, Barong implemented “Projeto Balaio,” a project aimed at ensuring the continuity of HIV treatment, but also to close gaps in access to other essential health and social services.19
Through the project, Barong worked jointly with the São Paulo State AIDS Program and the Emílio Ribas Hospital to identify transgender PLHIV whose access to ART was disrupted by the COVID-19 pandemic and implemented home ART delivery. Barong also collaborated with the Outpatient Clinic for Integral Health of Transgender Populations to reach and deliver services to transgender PLHIV, including hormone therapy.19 Barong’s model demonstrates that forging meaningful engagement and partnerships with affected communities is an effective strategy to address persistent HIV and intersectional stigma, thus removing barriers preventing transgender and other LGBTQ+ populations from accessing and utilizing life-saving and -enhancing HIV and other health services.
San Francisco: Golden Compass
Quality of Life: Aging with HIV
A holistic approach to improving quality of life is essential to upholding the dignity and facilitating the well-being of all persons living with HIV. Following many years during which an HIV diagnosis translated into an automatic “death sentence” for so many PLHIV, potent ART ushered in an era in which PLHIV who achieve viral suppression on ART can expect to live near-normal lifespans. However, this lifespan extension presents unique challenges, particularly for aging populations of PLHIV and notably in cities such as San Francisco, which was an early epicenter of the global HIV pandemic. A focused approach to managing older adults living with HIV has been a focus of the city’s HIV response, as 71% of PLHIV in San Francisco are age 50 and above.20 City health officials credit this approach with contributing to a 10-percentage point increase in its second 90 target (to 80% in 2019), and a 1-percentage point increase in its first and third 90 targets (to 94% with respect to both targets in 2019).21
The Golden Compass program is one of the first HIV and aging programs in the United States. The program is housed in San Francisco’s Ward 86, a safety-net clinic for the city of San Francisco that provides comprehensive medical and psychosocial services to approximately 2,400 low-income and uninsured patients, of which 1,200 are age 50 or older.19
The program was designed with input from patients and clinical providers at Ward 86 and efficiently draws primarily from existing resources. The concept behind the program is “helping people living with HIV navigate their golden years,” with compass points focused on specific challenges: 1) heart and mind (Northern point), addressing cardiovascular disease and cognitive concerns; 2) bones and strength (Eastern Point), focused on bone health and physical function; 3) dental, hearing, and vision (Western Point), focused on appropriate screenings and linkage to dental, audiology, and vision services; and 4) networking and navigation (Southern Point), addressing social isolation and community-building.19 The program is multidisciplinary, with its implementation involving clinicians, pharmacists, and social workers. The core staff additionally work with community partners to receive and make referrals to social and mental health services. In the first 1.5 years of the program more than 200 patients participated in one or more program components, and preliminary analyses have demonstrated a greater than 90% acceptability of the program components among staff and clients. Preliminary data also show improvement in patient-reported health and psychosocial outcomes. Moreover, patients have self-reported improvements in their overall health and appreciate the additional benefit of fostering new connections through group classes and community-building.19
This HIV Policy Brief is made possible through support from Gilead Sciences.
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19. The Golden Compass Program. Overview of the initial implementation of a comprehensive program for older adults living with HIV. J Int Assoc Provid AIDS Care. 2020; 19:2325958220935267
20. HIV Epidemiology Annual Report 2020. San Francisco: San Francisco Department of Public Health; 2020. https://www.sfdph.org/dph/fi les/reports/RptsHIVAIDS/AnnualReport2020-Purple_20210817Web.pdf
21. Fast-Track Cities Data Visualization Chart – San Francisco. Washington, DC: IAPAC; https://fast-trackcities.org/cities/san-francisco