The document discusses HIV treatment cascades which show the proportion of people living with HIV who are diagnosed, treated, and virally suppressed. It provides examples of cascades for HIV care in the UK and US in 2014-2015. The UNAIDS 90-90-90 targets aim to have by 2020, 90% of people with HIV diagnosed, 90% of those diagnosed on antiretroviral therapy, and 90% of those treated virally suppressed. The document notes current global estimates are far from these targets and outlines the gaps that need to be addressed to meet them by 2020 in order to end the AIDS epidemic. It also discusses the World Health Organization's goal of ending AIDS as a public health threat by 2030

1. The HIV cascade
Laura Waters
Mortimer Market Centre
CNWL NHS Trust

2. What are cascades?
• A broad overview of how well a given condition is
managed
• Trials and many observational studies focus on
treatment outcomes, excluding those untreated or
undiagnosed
• “95% of people treated for condition X had good
outcomes”
• Cascades show the whole picture and where the
gaps are….

3. Cascade of care for condition X
60% 58% 56%
50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
With condition Diagnosed In care Treated Optimally
treated
100%

4. Cascade of care for condition Y
90%
50%
40%
35%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
With condition Diagnosed In care Treated Optimally
treated
100%

5. UK cascade of HIV care 2014
83%
75%
70%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
HIV-infected Diagnosed On ART Undetectable VL
Based on 1.2 million people living with HIV
Delpech V at al. Abstract O2; BHIVA conference April 20-22 2016.

6. USA: continuum of care 2011
86%
40%
37%
30%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Diagnosed In care Prescribed ART Virally suppressed
https://www.aids.gov/federal-resources/policies/care-continuum/
Based on 1.2 million people living with HIV

7. USA cascade of hypertension:
69.8m of 227.6m hypertensive
94%
78%
73%
50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hypertensive Source of care Aware Treated Controlled
100%
Wozniak G et al. J Clin Hypertens (Greenwich). 2016 Mar;18(3):232-9.

8. Cascades can also be….
• Aspirational!
• The basis of public health interventions….

10. What is 90-90-90?
• December 2013:
– The UNAIDS Programme Coordinating Board called on
UNAIDS to establish new targets for HIV treatment scale-
up beyond 2015
• The following goals were agreed in 2014:
– By 2020, 90% of all people living with HIV will know their
HIV status.
– By 2020, 90% of all people with diagnosed HIV infection
will receive sustained antiretroviral therapy.
– By 2020, 90% of all people receiving antiretroviral therapy
will have viral suppression.

11. 90-90-90
73%

12. What does that mean?
• 73% of all PLWH on suppressive ART would be a 2-3
fold increase compared with 2014 estimates
• Modelling suggests that achieving these targets by
2020 will end the AIDS epidemic by 2030

13. Ref: The Joint United Nations Programme on HIV/AIDS. 90-90-90 An ambitious treatment target to help end the AIDS epidemic. 2014; JC2684
(Numbers as of March 2015) How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE FROM THE AIDS
RESPONSE July 2015.
Target 1:
90% of HIV+ people
diagnosed
Target 2:
90% of diagnosed
people on ART
Target 3:
90% of people on
ART with HIV
RNA suppression90%
81%
73%
0%
20%
40%
60%
80%
100%
HIV Positive People Diagnosed On ART Viral Suppression
36.9
million
33.2
million 29.5
million 26.9
million
UNAIDS 90-90-90: HIV Treatment Targets
for 2020 with Global Estimates (2014)

14. 53%
41%
32%*
0%
20%
40%
60%
80%
100%
HIV Positive People Diagnosed On ART Viral Suppression <1000
(ITT)*
36.9
million
19.8
million
15.0
million
11.6*
million
Ref: On ART = March 2015. How Aids Changed Everything. Fact Sheet. UNAIDS 2015. MDG 6: 15 YEARS, 15 LESSONS OF HOPE FROM THE AIDS
RESPONSE July 2015. * Average viral suppression% Intention to Treat LMIC rate from a Systematic Review by McMahon J. et al. Viral suppression
after 12 months of antiretroviral therapy in low-and middle-income countries: a systematic review." Bulletin of the World Health Organization 91.5
(2013): 377-385.
Breakpoint 1:
13.4 million
Undiagnosed Breakpoint 2:
14.9 million
not treated
Breakpoint 3:
15.3 million
Not Virally
Supressed
Global Estimates (2014-15) vs the Gap
to reach 90-90-90 Targets

15. UNAIDS: 90-90-90
90%90%
90%
90% 90%
UNAIDS. 90–90–90: an ambitious treatment target to help end the AIDS epidemic. 2014.
http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf. Accessed 29th June 2016
Diagnosed On treatment Undetectable What about
those on ART
& ‘stable’??
?

16. May 2016:
World Health Assembly’s 69th session
• Approved a new Global Health Sector Strategy on
HIV for 2016–2021
• Goal is “to end the AIDS epidemic as a public health
threat by 2030”
“zero new HIV infections, zero HIV-related deaths and zero HIV-
related discrimination in a world where people living with HIV
are able to live long and healthy lives”
“to end the AIDS epidemic as a public health threat by 2030,
within the context of ensuring healthy lives and promoting
well-being for all at all ages”
World Health Organization. Draft global health sector strategy on HIV, 2016–2021 [Draft 01.12.2015]. 2015.
http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_31-en.pdf?ua=1. Acceessed 29th June 2016

17. UNAIDS: 90-90-90-90?
90%90%
90%
90% 90% 90%
Lazarus JV et al. BMC Med. 2016; 14: 94. Adapted from UNAIDS. 90–90–90: an ambitious treatment target to help end the AIDS epidemic. 2014.
http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf. Accessed 29th June 2016
Diagnosed On treatment Undetectable Good health-
related QoL

18. Thank you!
?lwaters@nhs.net
@drlaurajwaters