Sweden has become
the first country to achieve the UNAIDS/World Health Organization (WHO) 90-90-90 target, research published
in HIV Medicine shows. At the end of
2015, 90% of HIV cases in Sweden were diagnosed, 99.8% of people were linked
to care and 95% of people taking antiretrovirals for at least six months
had a viral load below 50 copies/ml.
“We believe that
Sweden is the first country to achieve the UNAIDS/WHO 90-90-90 goal,” comment
the investigators.
Antiretroviral
therapy (ART) has dramatically reduced rates of HIV-related illness and death and the
infectiousness of people taking treatment.
For people to
benefit fully from treatment they must engage with a multi-step care cascade:
diagnosis, linkage to care, engagement with care, initiation of ART and viral
suppression.
However, in many
settings, even in richer countries, sup-optimal levels of engagement with HIV
care mean that many people are not benefitting from ART, meaning there are
avoidable HIV-related deaths and there continues to be high rates of new
infections.
In October 2014,
the 90-90-90 treatment goals were launched. These proposed that by
2020, 90% of people with HIV will be diagnosed, 90% of diagnosed people
will be in care; 90% of people receiving care will have durable HIV
suppression. Achievement of the 90-90-90 targets will mean that at least 73% of
all people with HIV have viral suppression, a large enough proportion
to have a major impact on rates of HIV-related mortality and new infections.
Investigators from
Sweden used nationally collected data to determine the country’s progress to
achievement of the 90-90-90 target.
Information on
people in care was obtained from the Swedish InfCare HIV Cohort Study. By the
end of 2015, data on 6946 diagnosed individuals were included in the study’s
database.
Surveillance data
from the Public Health Agency of Sweden indicated that 90% of people with HIV living in Sweden have been diagnosed.
All new HIV
diagnoses are reported to the Public Health Agency by both the testing
laboratory and the treating physician. To estimate linkage to care, the
investigators reviewed all new HIV diagnoses reported in 2014. Out of 471
cases, 469 were linked to care, meaning that 99.8% of people newly diagnosed
with HIV in 2014 were linked to HIV care.
To estimate
retention in care, the investigators reviewed 661 people who entered into
care in 2013 and 2014. At the end of 2015, 612 of these individuals were still
receiving care. Analysis of the people who had apparently dropped out of care
indicated that 29 individuals had moved abroad and eleven had died.
Nine individuals had no laboratory follow-up in the previous nine months and
were therefore considered lost to follow-up. Therefore, 603 of 621 people
(97%) were linked and retained in care.
At the end of
2015, 6605 of the 6946 people (95%) in the InfCare data were on ART. A
total of 6395 people had been taking ART for at least six months and 95% of
these individuals had a viral load below 50 copies/ml. The proportion increased
to 98% when 200 copies/ml was used as the cut-off for viral suppression.
“In summary, the
UNAIDS/WHO 90-90-90 coverage target of 73% of HIV-infected individuals with
undetectable HIV RNA has been achieved, with 90% of all those infected
diagnosed, 83% of those infected on ART, and 78% of those infected with a
suppressed viral load (< 50 copies/ml),” comment the authors.
They suggest there
are several reasons for Sweden’s success:
- Small size of the epidemic.
- Legislation that obliges
laboratories and clinicians to report new HIV cases and patients to keep
follow-up appointments.
- Linkage of patients to
specialist treatment centres with multi-disciplinary teams.
- Free access to ART.
- High level of adherence to
national guidelines by care providers; since 2014, these guidelines have
recommended ART for all HIV-positive people.
“We should not be content with these good results, but should
continue to improve prevention strategies and increase our efforts to diagnose
those still unaware of their infection,” conclude the authors.