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HIV in Europe and Central Asia: progress in 2018 towards meeting the UNAIDS 90-90-90 targets

In 2018, 52 of 55 European and Central Asian countries reported data against the UNAIDS 90–90–90 targets. Overall, 80% of people living with HIV (PLHIV) were diagnosed, of whom 64% received treatment and 86% treated were virally suppressed. Subregional outcomes varied: West (87%–91%–93%), Centre (83%–73%–75%) and East (76%–46%–78%). Overall, 43% of all PLHIV were virally suppressed; intensive efforts are needed to meet the 2020 target of 73%.


The Dublin Declaration on Partnership to Fight HIV/AIDS
Between January and March 2018, the European Centre for Disease Prevention and Control (ECDC) disseminated an online survey to the 55 countries of Europe and Central Asia that comprise the World Health Organization (WHO) European Region, to monitor the implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS [2]. Countries provided estimates of the number and proportion of people within a defined four-stage continuum of care for the most recent year available (Box) [3,4].
Countries also specified the year to which the estimates related, data sources and collection methods and uncertainty bounds for each continuum stage.
Where necessary, data were supplemented using Global AIDS Monitoring (GAM) indicators collected by UNAIDS. Data were validated by countries between May and November 2018 and updated accordingly.

Definitions and analyses
The global 90-90-90 targets are assessed as percentages of each previous stage of the continuum. The 'substantive target' is defined as the percentage of all PLHIV who are virally suppressed, making 73% the target (Figure 1). The global targets include countries reporting at least two consecutive stages but the substantive target only includes countries reporting all four stages of the continuum. Data were presented by WHO European subregion (West, Centre and East) which categorises countries in Europe and Central Asia in to three geographic areas by HIV epidemic type [5]. At the (sub)regional level, analyses were undertaken after summing each continuum stage across countries [3]. Data were compared with that previously submitted through the Dublin Declaration survey [3,6,7].

Key findings
In 2018, 52 of 55 countries completed the survey with 34 providing data across all four continuum stages (compared with 29 in 2016) and 42 providing at least two consecutive stages (compared with 41 in 2016). In 2018, progress towards the global 90-90-90 targets in Europe and Central Asia stands at 80%-64%-86%. In the West subregion, 87%-91%-93% was achieved with equivalent figures at 83%-73%-75% and 76%-46%-78% in the Centre and East, respectively. In countries in the European Union/European Economic Area (EU/EEA), which includes countries from each of the subregions, the progress stands at 86%-91%-92%. The number and proportion in each continuum stage are presented in the Table. For countries that provided data for both years (n = 25), performance can be compared between 2016 and 2018 ( Figure 2); outcomes improved from 82%-85%-89% to 85%-89%-91% for the global targets, respectively. Overall 69% of all PLHIV were virally suppressed in 2018 compared with 62% in 2016. Improvements in the substantive targets were observed in all subregions (the 1% decline in percentage diagnosed in the Centre subregion is likely due to a revision of the estimate of undiagnosed PLHIV). Viral suppression among all PLHIV was 74% (West), 45% (Centre) and 25% (East) in 2018, compared with 67%, 34% and 16% in 2016, respectively.
The number of people with transmissible levels of virus can be calculated by adding the number of PLHIV estimated to be undiagnosed, diagnosed but untreated and treated but not virally suppressed (for countries providing all four stages. An estimated 57% (1.2 million/2.1 million) PLHIV are presumed to have transmissible levels of virus in 2018. Of which, an estimated 36% were undiagnosed, 51% were diagnosed but untreated and 13% were treated but had unsuppressed viral load ( Figure 3). By subregion, 16% of people with presumed transmissible levels of virus lived in the West, 1% in the Centre and 83% in the East. Excluding Russia (which constituted 60% of all PLHIV with transmissible levels of virus in the entire Region) the figures become 41%, 3% and 56%, respectively.

Discussion
There has been substantial progress towards achieving the global UNAIDS targets across Europe and Central Asia and improvements have been recognised across all three WHO subregions. Despite this, only two-fifths of all PLHIV across the Region are estimated to be virally suppressed in 2018. While the West subregion exceeded the 73% substantive target, only around a half (Centre) and a quarter (East) of PLHIV are virally suppressed. The substantial progress between 2016 and 2018 is indicative of the improvements that can be made on a Regional scale in a short amount of time; this should provide reassurance and incentive to other global Regions that still have much work in order to meet the 90-90-90 ambition [8].
Each country should assess its progress against 90-90-90 targets and compare outcomes against Regional performance to drive further improvement. Only 34 of 55 countries provided data on all four continuum stages. Improved data availability is crucial to better monitor the effectiveness of their public health response to HIV. Countries that are unable to monitor the continuum of care need support to develop the infrastructure and data flows to enable them to do so. Improvements in ART access are likely to have positively influenced the outcomes.

Figure 1
The continuum of HIV care as envisaged by the 90-90-90 UNAIDS targets by 2020  It is unclear whether current progress has impacted on HIV transmission. Recent modelling suggests a viral suppression rate of 90% among all PLHIV must be reached to reduce incidence [10]. This indicates intensive efforts are required before transmission begins to fall. However, the West subregion, which has met the substantive target, has provided a favourable context in which reductions in HIV transmission are apparent among gay and bisexual men in some settings [11][12][13][14].
It is likely further declines will be observed when preexposure prophylaxis (PrEP) is fully implemented to those most at need.  (Tables A and  B) [4]. The estimated number of PLHIV (including number with transmissible virus) underrepresents the true Regional situation since they are presented only where countries report data.  A major limitation is that percentage values mask absolute numbers of PLHIV. We recommend that assessment of the 90-90-90 targets must incorporate the number of PLHIV. The analysis of the estimated number of people living with transmissible levels of virus provides further insights. For instance, the high proportion of people with transmissible virus is exacerbated by the large size of the Russian and Ukrainian epidemic. Furthermore, in the United Kingdom, France and Germany, the proportion of people with transmissible HIV is low but masks significant absolute numbers, which impedes efforts to reduce HIV incidence. It is also important to ascertain outcomes for key populations which are known to experience stark inequalities within and between countries [15].
It is crucial not to rest content with meeting the 90-90-90 targets. Each 'last 10 percent' includes people especially marginalised from healthcare services. Beyond the 90-90-90 ambition, intensive efforts in policy and service implementation are vital if the ultimate aim of 'getting to zero' is to become reality. *This designation is without prejudice to positions on status, and is in line with UNSC 1244 and the ICJ Opinion on the Kosovo Declaration of Independence.

Figure 3
Distribution of people with transmissible levels of virus, by WHO subregion a , and Europe and Central Asia overall, 2018