Title

Risk heterogeneity across the 90-90-90: Evidence supporting new strategies to strengthen the effectiveness of Universal Test and Treat

Code

MOSA41

Session Type

Non-Commercial Satellite

Venue

Hall 11A

Date Time

Monday 23 July, 14:45 - 16:45

Chair:

Adam Akullian, Institute for Disease Modeling (IDM) / University of Washington, United States

Organizer:

Bill & Melinda Gates Foundation

The 90-90-90 goals, widely embraced across sub-Saharan Africa, have galvanized an unprecedented scale-up of ART, saving millions of lives and substantially reducing the burden of HIV. Despite this progress, declines in HIV incidence have stagnated in many high-burden settings. Substantial uncertainty surrounds the population-level effectiveness of universal test and treat (UTT), given limited data on the transmission potential of unsuppressed fractions across epidemic settings. This session will present evidence on the demographic profile, risk behaviors, and mobility patterns of individuals across the treatment and care cascade, and will provide a critical analysis of the epidemiologic mechanisms that may undermine 90-90-90 in the era of UTT.

14:45	Welcome & Overview Charles Holmes, Georgetown University, United States

14:50	Risk heterogeneity across the 90-90-90: A systematic review Dylan Green, University of Washington, United States	Slides

15:05	Modeling demographic disparities in the 90-90-90 targets in Swaziland Adam Akullian, Institute for Disease Modeling (IDM) / University of Washington, United States	Slides

15:20	Combination HIV prevention in Rakai, Uganda: Progress, Challenges, and Opportunities Kate Grabowski, Johns Hopkins, United States	Slides

15:35	Q&A

15:50	Panel Discussion Kate Grabowski, Johns Hopkins, United States

16:15	Q&A with Panel

16:30	Closing Remarks

AUTHOR

James Hargreaves

SUMMARY

This session posed the question – is getting to 90:90:90 enough? If there is risk differentiation among those who are successfully treated and those who are not, on the basis of age, gender, behaviour, mobility and other characteristics, will this reduce the impact of treatment scale up on prevention

HIGHLIGHTS

In a systematic review (53 papers, 17 countries in Africa) no studies reported a 90 measure disaggregated by sexual behaviour. Younger people and men were less likely to be diagnosed and on treatment. In eSwatini data suggest ART scale up is consistent with incidence falls. If we could be successful in targeting age grops, this should address incidence reduction gaps. In Rakia prevention scale up including ART and VMMC had impressive effects, but still not reaching incidence reduction goals. ART use lower among 15-29years olds with high sexual risk behaviours, and also in migrants among whom incidence has not declined. Fishing communities are sinks not sources for HIV. Discussion key points included issues cross sectional cascades, programmatic experiences, key populations, the importance of the last time someone was in a health centre, men being hard to find, late presenters and younger people crucial.

CRITICAL ASSESSMENT

This session addressed an important question that has been neglected to date. The “tyranny of averages” was discussed at the start and lay behind the whole session. Differentiated targets for the cascade were discussed as it will be essential to ensure treatment scale up is equitable and that the impact on incidence is tracked.