90-90-90 Prevention Plan to End the HIV Epidemic
In 2020, when the global public health community gathered to assess the progress of the 90-90-90 plan put forth by UNAIDS, a novel pandemic framed the conversation, dimming the ambitious goal of ending the epidemic by 2030. The 90-90-90 plan was introduced by UNAIDS to push new targets of HIV treatment beyond 2015: 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (treatment); 90% of all people receiving antiretroviral therapy will have viral suppression (Bain, Nkoke, and Noubiap, 2017). An update from UNAIDS explained there was “good progress, but the world is off-track” from achieving previously set goals for 2020. By UNAIDS’ estimates, 81% of people living with HIV know their status, 67% of people living with HIV are on treatment, and 59% people living with HIV are virally suppressed (UNAIDS, 2020). These are difficult numbers to comprehend because of the global scale by which UNAIDS acts on. However, the framework of the 90-90-90 has made ending the HIV epidemic a possibility.
The focus of the 90-90-90 plan is on HIV treatment. While HIV treatment as prevention is a promising facet to ending the HIV epidemic, the goal of supporting people who are susceptible to HIV infection through modern modalities of prevention is crucial. Pre-exposure Prophylaxis (PrEP) is a medication, oral or injectable, that prevents HIV infection upon exposure. The iPrEx trial completed in 2010 by the NIAID demonstrated that daily Truvada as PrEP in Men who have sex with Men (MSM) who had detectable drug levels had a 92% lower risk of acquiring HIV compared to those on the placebo (Grant et al., 2010). Other subsequent trials in other key populations most susceptible to HIV confirmed PrEP’s effectiveness (Baeten et al., 2012; Wheeler et al., 2018). Since PrEP’s introduction as Truvada in 2012, the percentage of people on PrEP has increased dramatically. In 2012, there were approximately 8,768 PrEP users, while pharmaceutical prescription data from 2016 shows 77,120 PrEP users in the United States (AIDSVu, 2018).
UNAIDS projects that if three million people were taking oral PrEP, new HIV infections would be reduced by 500,000 (Samuel, 2021). As of 2019, however, there were 630,000 people across 76 countries who received oral PrEP at least once (WHO, 2019). Although this estimate may not fully represent the scale of PrEP implementation and its complexities, there is concern with how far off target PrEP use is globally.
As of early 2022, there exists no parallel plan to the 90-90-90 goals of HIV treatment prepared by UNAIDS that addresses improving prevention strategies, such as PrEP.
Based on the similar targets of the 90-90-90 plan for HIV treatment, I suggest the following for a 90-90-90 plan for HIV prevention:
90% of all people susceptible to HIV to know their HIV status
90% of all people are who are eligible for PrEP receive a PrEP modality, oral or injectable
90% of individuals utilizing PrEP sustain uptake
In my first proposed target, I use the term “susceptible” in this context to refer to behavior that increases the likelihood of exposing oneself to HIV, which can include sexual behavior and or use of injection drugs. My criteria expand on the 90-90-90 plan for HIV treatment to include “all people” who are susceptible to HIV, which encompasses all populations of people are sexually active under CDC and WHO guidelines for HIV screening (CDC, 2020; WHO, 2019). In the US, this logically pairs with the next 90% in the 90-90-90 plan for HIV prevention as the CDC now requires physicians to provide information on PrEP for all sexually active patients (Boerner, 2021).
The next two targets deviate from the 90-90-90 plan for HIV treatment and build upon more robust metrics of ending the epidemic.
The second target ensures that 90% of all people who are eligible for PrEP, which includes the knowledge of an individual’s HIV status, receive a PrEP modality (oral or injectable). Eligibility is based on screening criteria that is controlled at the federal level in the United States. Currently, PrEP is widely available through generic and name-brand oral medications, including Truvada and its generic, and Descovy. In addition, with the recent FDA approval in the US, name-brand Apretude is the first injectable form of PrEP that will soon be available to eligible consumers (FDA, 2021).
Although PrEP in its different modalities has been proven to be effective in preventing HIV transmission upon exposure through sexual behavior, the availability of PrEP and uptake by key populations has been minimal globally. Furthermore, PrEP in the US has not been approved for people who use or inject drugs based on a lack of clinical evidence, even though the Bangkok trial out of Thailand demonstrated comparable levels of efficacy compared to exposure through sexual behavior (Choopanya, 2013).
PrEP, whether a daily oral pill or every two-month injection, requires extensive ancillary services, including laboratory tests and counseling. These necessary components to maintaining PrEP uptake amounts to difficulty in implementing PrEP programs in areas where there is a lack of healthcare infrastructure and or cultural competency to the populations who most readily access PrEP services, including the LGBTQ+ community, especially trans-identifying individuals, those engaged in sex work, and people who inject drugs..
The metrics to demonstrate meeting this second target may appear illusive. However, if there are electronic medical systems that capture robust pharmaceutical and patient data, there is potential to leverage this second target to promote HIV prevention. There is also opportunity within this second target to further clarify “receive” in metric outcomes, which may include initial prescriptions or linkage to prevention and follow through.
The third target reflects the need from the 90-90-90 plan for HIV treatment to address their own third target. Currently, the 90-90-90 plan for HIV treatment would like to achieve 90% viral suppression. Although achieving viral suppression is pertinent to HIV treatment, there are opportunities after viral suppression to have an increased viral load. For instance, a patient may fall out of care, or a patient could fail a drug regimen after a development of viral resistance. Hence, the objective of 90% suppression fails to incorporate the necessary retention of viral suppression over the lifetime of an individual living with HIV. The third target of the 90-90-90 HIV prevention plan addresses these pitfalls.
With the objective of this third target, there is an emphasis on the importance of retention and evaluation of a person susceptible to HIV taking PrEP. The term “sustain” in this third target refers to the ability for someone on PrEP to continue the use of PrEP if they engage in susceptible behaviors that may expose them to HIV. Possible metrics may include drug dosage monitoring within patient samples, patient adherence to appointments, and adjusting HIV prevention tools depending on changes in sexual patterns, such as entering a monogamous relationship.
The 90-90-90 plan for HIV prevention that I am proposing is a theoretical framework by which UNAIDS and other organizations fighting the HIV epidemic can adapt to improve outcomes related to PrEP. This plan reflects the need for HIV prevention to survey the HIV status of all people susceptible to HIV, screen eligibility for PrEP and ensure patients maintain PrEP uptake. There is a great opportunity to create a parallel initiative to end the HIV epidemic.
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