the 90-90-90 goals and fast- track cities - a success...

The 90-90-90 Goals and Fast-Track Cities - A Success Story

Amanda D. Castel, MD, MPH

Kigali, Rwanda – December 2, 2019

▪ July 2014 – City initiative discussed by UNAIDS, IAPAC & Mayors at AIDS 2014

▪ August 2014 – Partnership between UNAIDS, IAPAC, UN-Habitat & Paris

▪ December 2014 – Fast-Track Cities launched World AIDS Day 2014 in Paris

o 26 cities signed Paris Declaration on Fast-Track Cities on December 1, 2014

o 300+ cities have joined the Fast-Track Cities network as of October 2019

The Fast-Track Cities Initiative

RIGHT PLACE, RIGHT THING

RIGHT PLACE

▪ 200 cities account for ~60% of PLHIV

▪ 1 city may account for ≥40% of PLHIV

▪ Signing enough cities in a country to have impact on national HIV epidemic (e.g., Brazil, South Africa, UK, USA, etc.)

▪ “Laboratories of innovation”

▪ Local accountability for response

▪ Targeted responses using geolocated data

RIGHT THING

▪ Prioritize 90-90-90 on trajectory to GTZ

▪ Leverage political will/action

▪ Address health inequalities

▪ Reach key & vulnerable populations

▪ Close care & prevention continua gaps

o Stigma/discrimination

o Testing/link to care/treatment/suppression

o PrEP as adjunct to treatment as prevention

o Quality of life & quality of care

PARIS DECLARATION 2.0

▪ Getting to zero

▪ U=U, MIPA, GIPA

▪ HIV prevention

o Primary HIV prevention

o Biomedical (PrEP)

▪ Syndemic conditions

o Mental health

o Substance use

▪ Comorbidities associated with aging

▪ TB 90-90-90

▪ HBV & HCV elimination

MAKING IT OFFICIAL

▪ Political Commitment – Mayors & other elected official(s) sign Paris Declaration on Fast-Track Cities committing to attain 90-90-90 & zero stigma/discrimination targets

▪ Technical Handshake –Cities report HIV care continuum & 90-90-90 data under accountability framework leveraging transparent use of programmatic data

o Health departments supported to generate & monitor data

o Cities supported to develop 90-90-90 implementation strategies

• Convening stakeholder consultations

• Meaningful engagement of PLHIV communities

▪ Process involves multiple jurisdictions, as needed

o National departments/ministries of health

o Counties, states, provinces, districts, etc.

DATA FOR ACTION▪ Baseline data generation

o HIV care continuum

o 90-90-90 data

o Other data

▪ City dashboards

o Monitor progress

o Promote stakeholder accountability

o Map HIV services

o Communicate momentum

▪ Implementation planning

o Revise existing or develop new city/municipal plans

▪ Capacity-building for providers

o HIV care/prevention continua

o Undetectable=Untransmittable

▪ Stigma elimination

o Clinician trainings

o Health facility action plans

▪ Community education

o Data for advocacy

o Healthy living with HIV

▪ PLHIV QoL & QoC assessments

IAPAC INTERVENTIONS

IAPAC INTERVENTIONS (continued)

▪ Regional, national & local workshops

o Sharing best practices

o Communities of learning

▪ Fast-Track Cities conference

o September 2019 – London

o September 2020 – Lisbon

▪ Best practices repository

▪ Implementation science

o e-course for clinician & community researchers

o Implementation science studies

o Testing/linkage to HIV care

o Retention in HIV care

o Adopting policies and innovations

DATA FOR IMPACT

79%86%

92%

57%

72%78%79% 76% 76%

2016 2017 2018

Bangkok

51% 48%55%

73%

44%

58%66%

73%

85% 87%

73%

96%

2015 2016 2017 2018

Kyiv

90%92%

94%

88%90%

93%

82%83%

85%

2016 2017 2018

Rwanda

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PLHIV Diagnosed PLHIV Diagnosed onART

PLHIV on ART VirallySuppressed

Baseline (2014) Current (2018)

Baseline 2014: 66-57-76

Current 2018: 92-78-76

1st 90: 26 percentage points improvement

2nd 90: 21 percentage points improvement

BANGKOK – 90-90-90 TARGETS

Programmatic Prioritization ▪ Improved HIV and KP estimation and used the data to

identify gaps▪ Initiated and supported KP-led health services▪ Rolled out rapid, targeted PrEP provision for KPs▪ Initiated same-day ART, with outreach to KPs▪ Used innovations to reach KPs and vulnerable youth ▪ Scaled up system-wide stigma reduction in health settings

Resource Allocation ▪ Increased domestic funding for KP-led organizations ▪ Approved budget to provide ART to undocumented

migrants and non-Thai residents

Political Advocacy▪ Utilized data city progress towards 90-90-90 targets

Stakeholder Coordination▪ Established Steering Committee that developed and

endorsed roadmap to achieve 90-90-90 targets

BANGKOK – IMPLEMENTATION PLANNING

Baseline 2015: 51-44-85

Current 2018: 73-73-96

1st 90: 22 percentage points improvement

2nd 90: 29 percentage points improvement

3rd 90: 11 percentage points improvement

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PLHIV Diagnosed PLHIV on ART PLHIV VirallySuppressedBaseline (2015) Current (2018)

KYIV – 90-90-90 TARGETS

The amount of funds

proposed for the

implementation of the

Program

KYIV FAST-TRACK CITIES 2017-2021 BUDGET Total costs for the

implementation of

the Program2017 2018 2019 2020 2021

The volume of resources,

including everything:264289,62 407489,55 249522,62 48703,36 53238,8 1460264,65

National budget 87920,16 185712,54 273632,70

Budget of Kyiv 41753,66 48373,21 46665,72 48703,36 53238,80 238734,75

Funds from other sources 134615,80 173403,80 202856,90 215427,60 221593,10 947897,20

Programmatic Prioritization▪ Approved 2017-2021 targets

▪ Decentralized testing, ART delivery

▪ Increased public-private partnerships

▪ Rolled out PrEP, prevention for KPs

▪ Launched National HIV Testing

Strategy for 2019-2030

Political Advocacy▪ Sustained political commitment from

Mayor and Deputy Mayor

Community Mobilization▪ Established intersectoral

partnerships, including significant

representation from community

KYIV – IMPLEMENTATION PLANNING

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PLHIV Diagnosed PLHIV Diagnosed onART

PLHIV on ART VirallySuppressed

Baseline (2016) Current (2018)

Baseline (2016): 90-88-82 Current (2018): 94-93-85

1st 90: 4 percentage points improvement2nd 90: 5 percentage points improvement 3rd 90: 3 percentage points improvement

RWANDA– 90-90-90 TARGETS

RWANDA– 90-90-90 TARGETS

84

989091 94

89

0

10

20

30

40

50

60

70

80

90

100

PLHIV Diagnosed PLHIV Diagnosedon ART

PLHIV on ARTVirally Suppressed

90-90-90 Targets for Rwanda and Kigali, 2019

Rwanda Kigali

Programmatic Prioritization ▪ Revised and updated HIV/STI guidelines▪ Focus on CSW, adolescent girls and young women

Resource Allocation ▪ Increased access to youth-friendly centers for sexual and

reproductive health services▪ Established condom dispensaries in hotspots

Political Advocacy ▪ Emphasis on multi-sectoral response locally, nationally, and globally▪ Coordination with Kigali mayor and mayors in 3 districts

Community Mobilization ▪ Working with faith-based organizations▪ Coordinated human rights advocacy meeting inclusive of training

Stakeholder Coordination ▪ United stakeholders at sector and district-level to ensure

coordinated response

KIGALI, RWANDA– IMPLEMENTATION PLANNING

Stigma and Discrimination

Results from the Fast Track Cities Quality of Life Survey

Development and fielding made possible through support from Viiv Healthcare

Stigma and Discrimination among Persons Living with HIV

• Reducing HIV‐related stigma and discrimination is a necessary step towards achieving global 90-90-90 goals

• Stigma results in barriers to HIV testing, lack of disclosure, difficulties across the care continuum

• Social determinants (e.g., poverty), laws and policies (e.g., criminalization) also add to stigmatization and discrimination against PLWH

Sources: Lazarus JV et al. BMC Medicine 2016 14:94; Grossman C et al. JIAS 2013 16:3S2.

Fast-Track Cities & Quality of Life

The Fast-Track Cities initiative takes a holistic approach to programmatictarget attainment, recognizing the importance of improving the health-related quality of life (HR-QOL) of people living with HIV (PLHIV) by:

▪ Exploring the social, political, and economic factors affecting the overall wellbeing of PLHIV

▪ Using QoL indicators to measure and understand the barriers to quality of life among PLHIV

▪ Leveraging QoL data to inform the HIV response

OVERALL WELLBEING

Emotional wellbeing:

mental health, contentment, self-concept,

stress, outlook...

Physical wellbeing: overall health, activities of

daily living, cognitive

impairments…

SOCIAL PARTICIPATION AND INTERPERSONAL

RELATIONSHIPS

Social inclusion: engagement and

roles in community, support

networks/services, stigma and

discrimination…

Interpersonal relationships: support,

maintaining relationships,

disclosure, sexual quality of life…

BASIC NEEDS AND QUALITY OF HEALTH

SERVICES

Economic/Structural:

employment, education, housing, financial, food

security, access to healthcare

Survey Areas of Focus

Methods▪ Cross sectional one-time online self-administered survey

▪ Survey included 20 Fast-Track Cities

▪ A target sample size of 300 participants per city

▪ 45 questions adapted from the following validated tools:

– WHOQoL Survey ─ WHOQoL Survey HIV

– IAPAC ATLIS Survey ─ People Living with HIV Stigma Index

– CDC HRQoL ─ MOS-HIV

– Integrated HIV Bio-behavioral Surveillance (IBBS) Survey

▪ Translated into 8 languages to minimize confounding: French, Spanish, Portuguese, Romanian, Dutch, German, Thai, and Greek

Cities Included In Survey

EUROPE AFRICA NORTH AMERICALATIN AMERICA AND

THE CARIBEANASIA/Pacific

Athens Berlin LisbonMadrid

Bamako Dar es Salaam

Durban Nairobi

Miami New York City

Montreal

Buenos AiresSalvador de Bahia

SantiagoBangkok

KEY FINDINGS

The majority of study participants were male, except in African countries where women outnumber men two to one.

EUROPE(17%)

AFRICA(35%)

NORTH AMERICA(12%)

LATIN AMERICA &CARIBEAN

(29%)

ASIAPACIFIC

(7%)

Total number of respondents to date:

3206

68%

38%

18%13%

24%

30%

60%

70%

87%

76%

2% 1%

11%

Africa North America Asia/Pacific Europe Latin America

Respondent Sex Distribution

Female

Male

Transgender

About 40% of respondents have been living with HIV or AIDS for greater

than ten years.

7%5%

33%

8%

16%

22%

10%

25%27%

35%36%

26%

14%

24%21%

34%

59%

28%

40%

27%

Africa NorthAmerica

Asia/Pacific Europe Latin America

Length of time since diagnosis of HIV

> 1 year ago 1-4 years ago 5-9 years ago 10+ years ago

Majority of respondents (80%) reported being consistently on ART,

with lowest levels reported in Africa.

60%

61%

86%

90%

86%

33%

35%

4%

7%

9%

Africa

North America

Asia/Pacific

Europe

Latin America

Distribution of Respondents on ART

Yes, but miss doses Consistently on ART

Almost one third (32%) of the respondents indicated having disclosed their status to family members. Disclosure to friends (30%) and members of the community (20%) was slightly

higher in North America and Europe compared to other regions.

25%

33%

15%

15%

9%

2%

Family members

Friends

Spouse/intimate

Community members

Employer/Colleagues

Never disclosed

Europe

24%

28%

15%

24%

8%

1%

Family members

Friends

Spouse/intimate

Community members

Employer/Colleagues

Never disclosed

North America

36%

21%

19%

10%

9%

5%

Family members

Friends

Spouse/intimate

Community members

Employer/Colleagues

Never disclosed

Africa

36%

30%

18%

6%

5%

4%

Family members

Friends

Spouse/intimate

Community members

Employer/Colleagues

Never disclosed

Latin America

38%

16%

21%

5%

9%

12%

Family members

Friends

Spouse/intimate

Community members

Employer/Colleagues

Never disclosed

Asia/Pacific Percentages for disclosure to family was

higher among respondents from African,

Asian, and Latin American regions (37%).

Disclosure to community members (7%)

and at the workplace (8%) was lower than

in other regions.

51%48%

14%

29%

24%

Africa NorthAmerica

Asia/Pacific Europe LatinAmerica

Respondents Experiencing Stigma and/or Discrimination By Their Community

36%

15% 15%

20%

11%

Africa NorthAmerica

Asia/Pacific Europe LatinAmerica

Respondents Experiencing Stigma and/or Discrimination By A Healthcare Facility Or

Healthcare Worker

Though stigma and discrimination was an issue across all regions, respondents in African countries more frequently reported experiencing stigma and/or

discrimination in both their communities (51%) and healthcare facilities (36%).

Many respondents (40%) reported having a positive outlook on life, with African respondents less likely to report a positive outlook when compared to other regions.

27%

43%

48%

35%37%

31%

25% 24%

29%27%

Africa North America Asia/Pacific Europe Latin America

Respondents Reporting a Positive and "Moderately" Positive Outlook On Life

Positive

Moderately positive

Most respondents (approx. 40%) reported being

satisfied with their overall quality of life. One quarter

were “very” satisfied.

Responses were similar across all

regions.

42%

49%45%

37%

43%

Africa North America Asia/Pacific Europe Latin America

Distribution of Respondent Overall Quality of Life

Very satisfied Satisfied

Conclusions

• Progress toward achieving 90-90-90 is underway and we have the science, community support, and political commitment to achieve these goals

• Cities are critical to the success of these efforts and are uniquely positioned to help attain local, national and global goals

• We need a comprehensive approach which includes improving the quality of life for people living with and vulnerable to HIV, and eliminating stigma and discrimination to ensure access to life saving treatment and programs for everyone

Beyond viral suppression (Lazarus JV et al. BMC Medicine 2016 14:94)

Source: Paris Declaration

Acknowledgements

IAPAC• José M Zuniga • Imane Sidibé• Sindhu Ravishankar • Christopher Duncombe UNAIDS• Dr. Paula Munderi• Dr. Laurel Sprague • Christoforos Mallouris• Andrea Boccardi Vidarte• Luisa Cabral

• ViiV– Konstantinos Lykopoulos

• ICW– Florence Anam

• Partners at FTC Survey sites• FTC Mayors, Key Opinion Leaders and

partners

www.fast-trackcities.org