The effect of 90-90-90 on HIV-1 incidence and mortality in eSwatini: a mathematical modelling study

Abstract

Background The rapid scale-up of antiretroviral therapy (ART) towards the UNAIDS 90-90-90 goals over the last decade has sparked considerable debate as to whether universal test and treat can end the HIV-1 epidemic in sub-Saharan Africa. We aimed to develop a network transmission model, calibrated to capture age-specific and sex-specific gaps in the scale-up of ART, to estimate the historical and future effect of attaining and surpassing the UNAIDS 90-90-90 treatment targets on HIV-1 incidence and mortality, and to assess whether these interventions will be enough to achieve epidemic control (incidence of 1 infection per 1000 person-years) by 2030.Methods We used eSwatini (formerly Swaziland) as a case study to develop our model. We used data on HIV prevalence by 5-year age bins, sex, and year from the 2007 Swaziland Demographic Health Survey (SDHS), the 2011 Swaziland HIV Incidence Measurement Survey, and the 2016 Swaziland Population Health Impact Assessment (PHIA) survey. We estimated the point prevalence of ART coverage among all HIV-infected individuals by age, sex, and year. Age-specific data on the prevalence of male circumcision from the SDHS and PHIA surveys were used as model inputs for traditional male circumcision and scale-up of voluntary medical male circumcision (VMMC). We calibrated our model using publicly available data on demographics; HIV prevalence by 5-year age bins, sex, and year; and ART coverage by age, sex, and year. We modelled the effects of five scenarios (historical scale-up of ART and VMMC [status quo], no ART or VMMC, no ART, age-targeted 90-90-90, and 100% ART initiation) to quantify the contribution of ART scale-up to declines in HIV incidence and mortality in individuals aged 15-49 by 2016, 2030, and 2050. Findings Between 2010 and 2016, status-quo ART scale-up among adults (aged 15-49 years) in eSwatini (from 34•0% in 2010 to 74•1% in 2016) reduced HIV incidence by 43•57% (95% credible interval 39•71 to 46•36) and HIV mortality by 56•17% (54•06 to 58•92) among individuals aged 15-49 years, with larger reductions in incidence among men and mortality among women. Holding 2016 ART coverage levels by age and sex into the future, by 2030 adult HIV incidence would fall to 1•09 (0•87 to 1•29) per 100 person-years, 1•42 (1•13 to 1•71) per 100 person-years among women and 0•79 (0•63 to 0•94) per 100 person-years among men. Achieving the 90-90-90 targets evenly by age and sex would further reduce incidence beyond status-quo ART, primarily among individuals aged 15-24 years (an additional 17•37% [7•33 to 26•12] reduction between 2016 and 2030), with only modest additional incidence reductions in adults aged 35-49 years (1•99% [-5•09 to 7•74]). Achieving 100% ART initiation among all people living with HIV within an average of 6 months from infection-an upper bound of plausible treatment effect-would reduce adult HIV incidence to 0•73 infections (0•55 to 0•92) per 100 person-years by 2030 and 0•46 (0•33 to 0•59) per 100 person-years by 2050.Interpretation Scale-up of ART over the last dec...

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“…For instance, it is estimated that in the United States between 2014 and 2018 syphilis, chlamydia, and gonorrhea have increased in incidence by 71%, 19%, and 63%, respectively [1]. In contrast, HIV incidence has been decreasing worldwide [2], in part due to the UNAIDS 90-90-90 strategy [3].…”

How universal does universal test and treat have to be?

“…UNAIDS and the BaiHuaLin alliance of people living with HIV, with support of the Chinese National Center for AIDS/STD Control and Prevention, did a survey among people living with HIV in China in February, 2020. 5,6 Among this population, 32•6% were at risk of ART discontinuation and about 48•6% did not know where to get antiviral drugs in the near future. 5,6 People living with HIV who are faced with ART discontinuation not only could undergo physical health deterioration but also might suffer great psychological pressure.…”

“…4 However, until UTT community-based trial results began to be reported 4 years ago, it remained unclear to what extent this remarkable increase in coverage translated into HIV prevention. In The Lancet HIV, Adam Akullian and colleagues 5 report that ART scale-up in eSwatini, which has the world's highest HIV prevalence, has largely been a success story, dramatically reducing adult HIV incidence and mortality. Using a mathematical model calibrated with demographic, HIV prevalence, and ART coverage data, they estimate that adult mortality decreased by more than 50% and HIV incidence by more than 40%, between 2010 and 2016.…”

“…Although Akullian and colleagues' findings indicate that UTT in isolation cannot control HIV in eSwatini, expanded access to ART has decreased HIV transmission. 5 As always with HIV, the details of the epidemic and the overlap between individuals who access interventions and those who are transmitting most efficiently is crucial, as Akullian and colleagues highlight. Access to timely health care is a human right and so ART should be available to all those who would benefit.…”

“…developed nine structurally different models of the South African How universal does universal test and treat have to be? Comment www.thelancet.com/hiv Vol 7 Comparison of predictions of the impact of universal test and treat (UTT) on HIV incidence (A) Granich and colleagues' 2009 model predicting epidemic control with UTT 2 and (B) Akullian and colleagues'model predicting substantial reductions in HIV incidence with ART scale-up but no epidemic control for decades to come 5. The epidemic control threshold used by both studies is an incidence of less than 0•1 per 100 person-years.Figures 2,5modified with permission from the authors and Elsevier Ltd.…”