www.thelancet.com / hiv Vol 11 April 2024
聯合國愛滋病規劃署 90-90-90 目標在十年前提出時，被描述為積極進取、雄心勃勃且令人畏懼。 Madisa Mine 及其同事在《剌胳針愛滋病毒》中提供了經驗證據，證明波札那是全球愛滋病毒感染率最高的國家之一（五分之一的成年人感染愛滋病毒），該國已在2021 年實現了95-95-95 的目標，即在 2025 年最後期限之前4 年。 第五次波札那愛滋病影響調查 (BAIS V) 顯示，92% 的愛滋病毒感染者的病毒受到抑制，高於 86% 的目標（從 95-95-95 推斷）。 除了波札那外，史瓦濟蘭、盧安達和坦尚尼亞也實現了95-95-95 目標，撒哈拉以南非洲的另外8 個國家也即將實現這些目標。這些成就值得稱讚，並且應該結合實際情況並評估實現此類計畫成功的途徑。
學習有效的經驗，包括如何擴大和調整愛滋病毒計畫，將是推動愛滋病毒應對措施向前發展的關鍵，不僅在波札那，而且亦是在全球。 這些成功不能歸因於單一因素。基於對初級衛生保健的承諾，波札那制定了該地區最早的免費和普遍治療計畫（即 2002 年的 Masa 計畫）。 該國很早就顯示，達到 90-90-90 是可以實現的，並且是第一個因走上消除垂直傳播道路而獲得世界衛生組織銀級認證的愛滋病毒高負擔國家。 波札那除了自2003 年以來由美國總統愛滋病緊急救援計畫 (PEPFAR) 所提供的超過10 億美元的支持外，還使用自己的國庫為其應對措施提供資金。該國實施了所謂的「Treat All」策略，並於 2016 年改用以多替拉韋為基礎的一線治療方案 (a dolutegravir-based first line regimen)。最後，波札那通過了廣泛的保護性法律， 包括同性伴侶關係的除罪化。
我和同事強調了愛滋病毒治療和照護方面持續存在的不平等現象。 儘管總體上達到了 95-95-95 的目標，但一些人群卻仍然落後。 目前的愛滋病毒檢測和服務提供方法上意味著年輕人尚未達到95-95-95 的目標（15-24 歲的感染個體當中只有77% 的人病毒受到抑制），這是許多國家的共同特徵。數據顯示，有愛滋病毒感染和持續傳播風險的個體，例如重點族群（例如女性性工作者、男男性行為者等），這些數據往往揭示了他們在愛滋病毒認知、治療和病毒抑制水平上的差異。 當他們被忽視時，衛生系統可能會長期存在著不平等——在以人口為基礎的調查中，例如BAIS V，關鍵人群的成員通常不會被納入或無法被識別。這些不平等顯示，實現總體規劃目標本身並不是目的——可持續減少愛滋病毒感染數量才是目標，並且是透過縮小預防和治療方面上的所有差距來實現的。 應明確地考慮愛滋病毒感染和傳播風險的異質性及其與獲得預防和治療上的交會點。 95-95-95目標並不是當地疫情控制的唯一重要指標－對初級預防的投資更甚。
事實證明，自 2000 年代初以來，BAIS V 等具有全國代表性的調查在為政策提供資訊、制定計畫和審查計畫覆蓋範圍的不平等方面上極其有用。 我們認為，實現和維持流行病控制需要補充使用強大的適應性監測系統，以幫助確定可能導致愛滋病毒感染和進一步傳播上的預防和治療之差距。 例如，監測未來的愛滋病毒發生率［目前 BAIS V 中估計為 0·2%（95% CI 0·0–0·4）］，若僅使用全國調查將需要大幅增加樣本規模，這將涉及更多的資源。 在波札那，愛滋病毒計畫中使用唯一標識符意味著透過關鍵事件（例如愛滋病毒檢測、診斷、連結、存留、病毒抑制或死亡）的照護軌跡可以對服務及其跨人口群體的差距進行精細監控。 隨著愛滋病毒總體發生率持續下降，感染風險可能集中在那些在有效預防和治療方面持續遇到障礙的群體。以重點人口為中心的專門調查（例如關鍵人口調查）將繼續發揮重要作用，為規劃和介入措施提供資訊。對其他尚未達到 95-95-95 目標且傳播集中於關鍵族群的非洲國家，目前已經採用了以重點人口為中心的調查。
在實現或接近 95-95-95 里程碑的過程中，撒哈拉以南非洲的 13 個國家已經為全球愛滋病毒應對的下一階段制定了道路。 未來的道路可能是雄心勃勃、積極進取、令人生畏的，重點是減少不平等、為策略監控提供資源，並學習有效的做法，以便在未來的確定性和不確定性狀態中維持所取得的成果。
MM-G 和 SM 都得到加拿大第二級研究主席團的支持，並獲得了聯合國愛滋病規劃署的差旅支持。 MM-G 擁有加拿大衛生研究院和 Wellcome Trust 的資助，以及加拿大公共衛生局和 UNAIDS 的合約協議。 SM 擁有加拿大衛生研究院和國立衛生研究院的資助。
*Mathieu Maheu-Giroux、Sharmistha Mishra mathieu.maheu-giroux@mcgill.ca麥基爾大學流行病學和生物統計學系，加拿大蒙特婁 H3A 1G1，QC (MM-G)； 多倫多大學，加拿大安大略省多倫多市 (SM)； Unity Health Toronto, 多倫多, 安大略省, 加拿大 (SM)
Evidence with 95-95-95 that ambitious is feasible
www.thelancet.com/hiv Vol 11 April 2024
When proposed a decade ago, the UNAIDS 90-90-90 targets were described as aggressive, ambitious, and daunting.1 Nevertheless, these milestones have had a profound effect on HIV responses, galvanizing efforts globally. In The Lancet HIV, Madisa Mine and colleagues2 provide empirical evidence that Botswana, which has one of the highest global prevalences of HIV (one in five adults are living with HIV), has achieved the 95-95-95 targets in 2021, 4 years ahead of the 2025 deadline. The Fifth Botswana AIDS Impact Survey (BAIS V) showed that 92% of people living with HIV were virally suppressed, which is above the 86% goal (extrapolated from 95-95-95). In addition to Botswana, Eswatini, Rwanda, and Tanzania have also met the 95-95-95 targets, and an additional eight countries in sub-Saharan Africa are close to achieving them. These achievements are laudable and the pathways to such programmatic successes should be contextualised and evaluated.
Learning from what worked, including how HIV programmes were scaled and adapted, will be key to informing resilient HIV responses moving forward, not just in Botswana, but globally. Such successes cannot be attributed to a single factor. Building on its commitment to primary health care, Botswana established the earliest free and universal treatment programmes in the region (ie, the Masa programme in 2002). The country showed early on that getting to 90-90-90 was achievable and is the first high HIV-burden country to receive the silver-tier certification from WHO for being on the path to elimination of vertical transmission. Botswana funded its response using its own coffer, in addition to more than US$1 billion in support since 2003 from the US President’s Emergency Plan for AIDS Relief (PEPFAR). The country implemented the so-called Treat All strategy and switched to a dolutegravir-based first line regimen in 2016. Finally, Botswana adopted broadly protective laws, including decriminalisation of same-sex partnerships.
Mine and colleagues highlighted the persistence of inequalities in HIV treatment and care. Despite reaching the 95-95-95 targets overall, some populations continue to be left behind. Current approaches to HIV testing and service delivery mean that young people have yet to reach the 95-95-95 targets (77% of individuals aged 15–24 years were virally suppressed), a feature common to many countries. Furthermore, where data are available, they often reveal disparities in levels of HIV awareness, treatment, and viral suppression among individuals at disproportionate risk of HIV acquisition and onward transmission, such as key populations (eg, female sex workers, men who have sex with men, among others). Inequalities can be perpetuated by health systems when they are not seen—members of key populations are not often included or identifiable in population-based surveys, such as BAIS V. These inequalities show that reaching an overall programmatic target is not an end in itself— sustainable reductions in the number of HIV acquisitions is the goal and is achieved through closing all gaps in prevention and treatment. Heterogeneity in the risk of HIV acquisitions and transmission, and its intersection with access to prevention and treatment, should be explicitly considered. The 95-95-95 targets are not the sole indicators of importance for local epidemic control—investments in primary prevention matter.
Nationally representative surveys, such as BAIS V, have proven extremely useful in informing policy, developing programmes, and examining inequalities in programme coverage since the early 2000s. We believe that reaching and sustaining epidemic control will require complementary use of strong and adaptive surveillance systems to help to identify the prevention and treatment gaps that could lead to HIV acquisition and onward transmission. For instance, monitoring HIV incidence in the future, which is currently estimated to be 0·2% (95% CI 0·0–0·4) in BAIS V, using solely national surveys would require drastic increases in sample sizes that would involve substantially more resources. In Botswana, the use of unique identifiers within the HIV programme means that the care trajectory through key events (eg, HIV testing, diagnosis, linkage, retention, viral suppression, or death) allows for granular monitoring of services and their gaps across demographic groups. As overall HIV incidence continues to decline, risk of acquisition might concentrate in groups who experience ongoing barriers to effective prevention and treatment. Dedicated population-focused surveys (eg, key population surveys) will continue to have an important role to inform programmes and interventions. The use of population-focused surveys is already the case in other African countries that have yet to reach the 95-95-95 targets, and where transmission is concentrated among key populations.
In achieving or nearing the 95-95-95 milestones, 13 countries in sub-Saharan Africa have set a path for the next phase of the global HIV response. The path ahead can be ambitious, aggressive, and daunting by focusing on reducing inequalities, resourcing strategic surveillance, and learning from what worked well to sustain the gains made amid future certainties and uncertainties.
MM-G and SM are both supported by Tier II Canada Research Chairs and have received travel support from UNAIDS. MM-G holds grants from the Canadian Institutes of Health Research and the Wellcome Trust, and contractual agreements from the Public Health Agency of Canada and UNAIDS. SM holds grants from the Canadian Institutes of Health Research and National Institutes of Health.
*Mathieu Maheu-Giroux, Sharmistha Mishra mathieu.maheu-giroux@mcgill.ca Department of Epidemiology and Biostatistics, McGill University, Montréal H3A 1G1, QC, Canada (MM-G); University of Toronto, Toronto, ON, Canada (SM); Unity Health Toronto, Toronto, ON, Canada (SM)