Abstract
IntroductionIn 2014, city leaders from around the world endorsed the Paris Declaration on Fast‐Track Cities, pledging to achieve the 2020 and 2030 HIV targets championed by UNAIDS. The City of Johannesburg – one of South Africa's metropolitan municipalities and also a health district – has over 600,000 people living with HIV (PLHIV), more than any other city worldwide. We estimate what it would take in terms of programmatic targets and costs for the City of Johannesburg to meet the Fast‐Track targets, and demonstrate the impact that this would have.MethodsWe applied the Optima HIV epidemic and resource allocation model to demographic, epidemiological and behavioural data on 26 sub‐populations in Johannesburg. We used data on programme costs and coverage to produce baseline projections. We calculated how many people must be diagnosed, put onto treatment and maintained with viral suppression to achieve the 2020 and 2030 targets. We also estimated how treatment needs – and therefore fiscal commitments – could be reduced if the treatment targets are combined with primary HIV prevention interventions (voluntary medical male circumcision (VMMC), an expanded condom programme, and comprehensive packages for female sex workers (FSW) and young females).ResultsIf current programmatic coverage were maintained, Johannesburg could expect 303,000 new infections and 96,000 AIDS‐related deaths between 2017 and 2030 and 769,000 PLHIV by 2030. Achieving the Fast‐Track targets would require an additional 135,000 diagnoses and 232,000 people on treatment by 2020 (an increase in around 80% over 2016 treatment numbers), but would avert 176,000 infections and 56,500 deaths by 2030. Assuming stable ART unit costs, this would require ZAR 29 billion (USD 2.15 billion) in cumulative treatment investments over the 14 years to 2030. Plausible scale‐ups of other proven interventions (VMMC, condom distribution and FSW strategies) could yield additional reductions in new infections (between 4 and 15%), and in overall treatment investment needs. Scaling up VMMC in line with national targets is found to be cost‐effective in the medium term.ConclusionsThe scale‐up in testing and treatment programmes over this decade has been rapid, but these efforts must be doubled to reach 2020 targets. Strategic investments in proven interventions will help Johannesburg achieve the treatment targets and be on track to end AIDS by 2030.
Highlights
In 2014, city leaders from around the world endorsed the Paris Declaration on Fast-Track Cities, pledging to achieve the 2020 and 2030 HIV targets championed by UNAIDS
The Fast-Track targets, ubiquitous in the HIV field, state that by 2020, 90% of all people living with HIV (PLHIV) will know their HIV status, 90% of all people with diagnosed HIV infection will receive antiretroviral therapy (ART), and 90% of all people receiving ART will be virally suppressed (90-90-90 targets), with these percentages increasing to 95% by 2030 (95-95-95 targets)
The crucial role that cities will play in achieving the Fast-Track targets [4] is relevant in South Africa; both Johannesburg and Durban metropolitan municipalities are estimated to have more than 500,000 PLHIV, which would qualify them for positions in the top 25 countries in the world according to HIV burden if they were counted alongside nations (2013 UNAIDS estimates [5]; Figure 1)
Summary
In 2014, city leaders from around the world endorsed the Paris Declaration on Fast-Track Cities, pledging to achieve the 2020 and 2030 HIV targets championed by UNAIDS [1]. Mathematical models have proven useful in answering questions of this type, and a multitude of different modelling frameworks have been developed in response, both for South Africa [16] and more generally [17] To understand what it will take for the City of Johannesburg to achieve the Fast-Track targets, we adapted the Optima HIV epidemic and resource allocation model in order to capture the key aspects of the HIV care and treatment cascade [18]. The Optima HIV model has been successfully applied in many countries to assess the impact and optimize the allocation of HIV programme spending [19], it has yet to be used for a detailed analysis of the care and treatment cascade, largely due to a lack of comprehensive data For this analysis, we sought data from a number of sources, including clinic-level data, cohort studies, national reports, and a novel record-linkage analysis providing comprehensive viral load and CD4 data for Johannesburg. Using these data in our specially tailored model, we estimate what it would take in terms of programmatic targets and investments for the City of Johannesburg to meet the Fast-Track targets, and estimate the epidemiological impact that this would have
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