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