A tale of two countries: progress towards UNAIDS 90‐90‐90 targets in Botswana and Australia

Abstract

UNAIDS 90‐90‐90 targets and Fast‐Track commitments are presented as precursors to ending the AIDS epidemic by 2030, through effecting a 90% reduction in new HIV infections and AIDS‐related deaths from 2010 levels (HIV epidemic control). Botswana, a low to middle‐income country with the third‐highest HIV prevalence, and Australia, a low‐prevalence high‐income country with an epidemic concentrated among men who have sex with men (MSM), have made significant strides towards achieving the UNAIDS 90‐90‐90 targets. These two countries provide lessons for different epidemic settings. This paper discusses the lessons that can be drawn from Botswana and Australia with respect to their success in HIV testing, treatment, viral suppression and other HIV prevention strategies for HIV epidemic control. Botswana and Australia are on target to achieving the 90‐90‐90 targets for HIV epidemic control, made possible by comprehensive HIV testing and treatment programmes in the two countries. As of 2015, 70% of all people assumed to be living with HIV had viral suppression in Botswana and Australia. However, HIV incidence remains above one per cent in the general population in Botswana and in MSM in Australia. The two countries have demonstrated that rapid HIV testing that is accessible and targeted at key and vulnerable populations is required in order to continue identifying new HIV infections. All citizens living with HIV in both countries are eligible for antiretroviral therapy (ART) and viral load monitoring through government‐funded programmes. Notwithstanding their success in reducing HIV transmission to date, programmes in both countries must continue to be supported at current levels to maintain epidemic suppression. Scaled HIV testing, linkage to care, universal ART, monitoring patients on treatment over and above strengthened HIV prevention strategies (e.g. male circumcision and pre‐exposure prophylaxis) will all continue to require funding. The progress that Botswana and Australia have made towards meeting the 90‐90‐90 targets is commendable. However, in order to reduce HIV incidence significantly towards 2030, there is a need for sustained HIV testing, linkage to care and high treatment coverage. Botswana and Australia provide useful lessons for developing countries with generalized epidemics and high‐income countries with concentrated epidemics.

Rapid initiation of antiretroviral therapy at HIV diagnosis: definition, process, knowledge gaps

“…In LMICs, rapid‐start ART is working towards the UNAIDS 90‐90‐90 goal , although there are some signs that rapid‐start ART may not meet targets for long‐term viral suppression . This may be a consequence of restricted access to viral load monitoring, relatively inefficient ART regimens, poor linkage to/retention in care and limited care provision rather than the speed of ART initiation per se .…”

Modelling the impact of migrants on the success of the HIV care and treatment program in Botswana

“…Botswana has a free nationally funded HIV care and treatment program that covers all citizens; the system is considered to be highly successful, with Botswana being reported to be close to reaching the 90-90-90 targets. The government of Botswana funds at least 60% of its HIV response budget, which is expected to rise to USD339 million in 2030 [15,16]. In 2018, Botswana had 86% of citizens living with HIV diagnosed, 95% of people diagnosed on antiretroviral therapy (ART), and 95% viral suppression among those on ART (i.e.…”

The HIV epidemic in Latin America: a time to reflect on the history of success and the challenges ahead

“…Strategies to demedicalize HIV counselling and testing services to make them accessible for hard‐to‐reach vulnerable groups and the implementation of proven self‐testing models will be essential to achieve the target of having 90% of PLHIV being aware of their status – the first 90. This may require legislative and administrative changes in many Latin American countries in addition to increasing funds to allow for scale‐up of testing strategies, immediate linkage and same‐day ART initiation programmes with simplified, integrase inhibitor‐based regimens .…”