Gaps and opportunities: measuring the key population cascade through surveys and services to guide the HIV response

Abstract

IntroductionThe UNAIDS 90‐90‐90 targets to diagnose 90% of people living with HIV, put 90% of them on treatment, and for 90% of them to have suppressed viral load have focused the international HIV response on the goal of eliminating HIV by 2030. They are also a constructive tool for measuring progress toward reaching this goal but their utility is dependent upon data availability. Though more than 25% of new infections are among key populations (KP)‐ sex workers, men who have sex with men, transgender people, people who inject drugs, and prisoners‐ and their sex partners, there is a dearth of treatment cascade data for KP. We assess the availability of cascade data and review the opportunities offered by biobehavioral and programme data to inform the HIV response.DiscussionThe emphasis on the collection of treatment cascade data among the general population in higher prevalence countries has not led to a similar increase in the availability of cascade data for KP. The limited data available for KP highlight large gaps in service uptake across the cascade, particularly in the first 90, awareness of HIV status. Biobehavioral surveys (BBS), with linked population size estimation, provide population‐based data on the treatment cascade and should be conducted every two to three years in locations with services for KP. With the inclusion of viral load testing, these surveys are able to monitor the entire treatment cascade among KP regardless of whether these populations access HIV services targeting the general population or KP. BBS also reach people accessing services and those who do not, thereby providing a unique opportunity to learn about barriers to service uptake including stigma and discrimination. At the same time high‐quality programme data can play a complementary role in identifying missed opportunities that can be addressed in real‐time.ConclusionsData are more important than ever for guiding the HIV response toward reaching 90‐90‐90 targets and eliminating HIV, particularly in the face of decreased funding for HIV and specifically for KP. Timely high‐quality BBS data can be triangulated with high‐quality programme data to provide a comprehensive picture of the epidemic response for KP.

Research priorities to inform “Treat All” policy implementation for people living with HIV in sub‐Saharan Africa: a consensus statement from the International epidemiology Databases to Evaluate AIDS (IeDEA)

“… Context : To achieve the “first 90” target, timely estimates of the number and proportion of persons with undiagnosed HIV infection are critical for countries to ensure that HIV testing programmes are targeted appropriately and efficiently . One recent study that analysed population‐based Demographic and Health Survey (DHS) data from 16 SSA countries estimated that only 54% of people living with HIV (range across countries 26% to 84%) were aware of their status, contributing to delays in care enrollment and ART initiation .…”

“…men who have sex with men [MSM], sex workers [SW], people who inject drugs [PWID], etc.) is difficult in contexts with unknown population size estimates . Research approaches : Population‐based studies, such as demographic and health surveys that evaluate the implementation of testing services, frequent (annual) targeted HIV sero‐prevalence surveys in sub‐national geographic areas, and biobehavioural surveys , may be necessary for monitoring this population‐level metric. Surveys should report estimates disaggregated by sex and age, with finer age disaggregations (e.g.…”

National HIV testing and diagnosis coverage in sub-Saharan Africa: a new modeling tool for estimating the “first 90” from program and survey data

“…Key populations are important to overall transmission dynamics in several countries [56][57][58][59] and the sustainable control of HIV epidemics also hinges on also achieving the 90-90-90 targets in these groups [60] . The general framework outlined above could in theory be used to monitor awareness status for key populations, but additional challenges related to representativeness of key population surveys, among others, are expected [13] .…”

“…UNAIDS has previously estimated the change in knowledge of status over time in countries with survey data by applying additional increases in knowledge of status proportional to the scale-up in ART coverage between the current reporting year and the year of the last survey [12] . However, there is a need to better estimate progress towards the "first 90" in relation to changes in ART coverage and HTS program efforts [13] . For example, the relationship between ART coverage and knowledge of status has likely changed as a function of eligibility for treatment initiation.…”

Building the evidence base to optimize the impact of key population programming across the HIV cascade

“…The supplement opens with a commentary by Hakim et al . in which the authors make the case for why we need better key population cascade data and how we can get it . They argue that targeted bio‐behavioural surveys represent an important source of data to guide the epidemic response but have been underutilised to monitor and inform key population service delivery efforts.…”