Status and methodology of publicly available national HIV care continua and 90-90-90 targets: A systematic review.

BACKGROUND: In 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) issued treatment goals for human immunodeficiency virus (HIV). The 90-90-90 target specifies that by 2020, 90% of individuals living with HIV will know their HIV status, 90% of people with diagnosed HIV infection will receive antiretroviral treatment (ART), and 90% of those taking ART will be virally suppressed. Consistent methods and routine reporting in the public domain will be necessary for tracking progress towards the 90-90-90 target. METHODS AND FINDINGS: For the period 2010-2016, we searched PubMed, UNAIDS country progress reports, World Health Organization (WHO), UNAIDS reports, national surveillance and program reports, United States President's Emergency Plan for AIDS Relief (PEPFAR) Country Operational Plans, and conference presentations and/or abstracts for the latest available national HIV care continuum in the public domain. Continua of care included the number and proportion of people living with HIV (PLHIV) who are diagnosed, on ART, and virally suppressed out of the estimated number of PLHIV. We ranked the described methods for indicators to derive high-, medium-, and low-quality continuum. For 2010-2016, we identified 53 national care continua with viral suppression estimates representing 19.7 million (54%) of the 2015 global estimate of PLHIV. Of the 53, 6 (with 2% of global burden) were high quality, using standard surveillance methods to derive an overall denominator and program data from national cohorts for estimating steps in the continuum. Only nine countries in sub-Saharan Africa had care continua with viral suppression estimates. Of the 53 countries, the average proportion of the aggregate of PLHIV from all countries on ART was 48%, and the proportion of PLHIV who were virally suppressed was 40%. Seven countries (Sweden, Cambodia, United Kingdom, Switzerland, Denmark, Rwanda, and Namibia) were within 12% and 10% of achieving the 90-90-90 target for "on ART" and for "viral suppression," respectively. The limitations to consider when interpreting the results include significant variation in methods used to determine national continua and the possibility that complete continua were not available through our comprehensive search of the public domain. CONCLUSIONS: Relatively few complete national continua of care are available in the public domain, and there is considerable variation in the methods for determining progress towards the 90-90-90 target. Despite bearing the highest HIV burden, national care continua from sub-Saharan Africa were less likely to be in the public domain. A standardized monitoring and evaluation approach could improve the use of scarce resources to achieve 90-90-90 through improved transparency, accountability, and efficiency.

HIV Diagnoses, Prevalence and Outcomes in Nine Southern States.

A group of nine states in the Southern United States, hereafter referred to as the targeted states, has experienced particularly high HIV diagnosis and case fatality rates. To provide additional information about the HIV burden in this region, we used CDC HIV surveillance data to examine characteristics of individuals diagnosed with HIV in the targeted states (2011), 5-year HIV and AIDS survival, and deaths among persons living with HIV (2010). We used multivariable analyses to explore the influence of residing in the targeted states at diagnosis on deaths among persons living with HIV after adjustment for demographics and transmission risk. In 2011, the targeted states had a higher HIV diagnosis rate (24.5/100,000 population) than the US overall (18.0/100,000) and higher proportions than other regions of individuals diagnosed with HIV who were black, female, younger, and living in suburban and rural areas. Furthermore, the targeted states had lower HIV and AIDS survival proportions (0.85, 0.73, respectively) than the US overall (0.86, 0.77, respectively) and the highest death rate among persons living with HIV of any US region. Regional differences in demographics and transmission risk did not explain the higher death rate among persons living with HIV in the targeted states indicating that other factors contribute to this disparity. Differences in characteristics and outcomes of individuals with HIV in the targeted states are critical to consider when creating strategies to address HIV in the region, as are other factors identified in previous research to be prominent in the region including poverty and stigma.

Prevalence of undiagnosed HIV infection among persons aged ≥13 years--National HIV Surveillance System, United States, 2005-2008.

In the United States, approximately 1.1 million adults and adolescents are living with human immunodeficiency virus (HIV) infection and, each year, another 50,000 become infected. At the end of 2008, approximately 20% of the persons living with HIV had an undiagnosed infection. Of those living with HIV at the end of 2008, nearly two thirds were racial/ethnic minorities and half were men who have sex with men (MSM). In 2007, HIV ranked fifth as a leading cause of death among persons aged 35-44 years in the United States but third among blacks or African Americans in this age group. In 40 states with longstanding confidential name-based HIV surveillance systems, 33% of the estimated 41,768 adults and adolescents diagnosed with HIV infection in 2008 developed acquired immunodeficiency syndrome (AIDS) within 1 year and, of these, 44% received their initial diagnosis in an acute care setting, suggesting that they received HIV testing late in the course of the infection. HIV-infected persons who are unaware of their infection or who receive a late diagnosis cannot benefit fully from timely initiation of therapy and are more likely to experience HIV-related morbidity and premature mortality. In addition, persons unaware of their infection are more likely to transmit HIV to others because of a higher prevalence of high-risk sexual behaviors and higher levels of viral RNA that continue to replicate without appropriate antiretroviral treatment.

Melatonin accelerates the process of wound repair in full-thickness incisional wounds.

The pineal gland hormone melatonin is known to have both anti-inflammatory and immunomodulatory effects. Given this, we propose that melatonin is an ideal candidate to enhance the process of wound healing. The present study assessed the effects of exogenously administered melatonin (1.2 mg/kg intra-dermal), on scar formation using a full-thickness incisional rat model of dermal wound healing. Melatonin treatment significantly improved the quality of scarring, both in terms of maturity and orientation of collagen fibres. An increase in nitric oxide synthase (NOS) activity and therefore nitric oxide production is detrimental during inflammation but is favourable during granulation tissue formation. Melatonin treatment significantly decreased inducible NOS (iNOS) activity during the acute inflammatory phase but significantly increased iNOS activity during the resolving phase. Cyclooxygenase-2, which has been shown to have anti-inflammatory effects, was elevated in the melatonin-treated rats following wounding. In addition, melatonin treatment also accelerated the angiogenic process, increasing the formation of new blood vessels and elevating the level of vascular endothelial growth factor protein expression during granulation tissue formation. Melatonin treatment increased arginase activity (which generates proline, a building block for collagen synthesis) from earlier time points. The protein profiles of hemoxygenase-1 (HO-1) and HO-2 isoforms, vital participants in the repair process, were also up-regulated upon melatonin treatment. This study has therefore demonstrated, for the first time, that melatonin can significantly improve the quality of wound healing and scar formation.

Effects of epicatechin gallate on wound healing and scar formation in a full thickness incisional wound healing model in rats.

Catechins are naturally occurring polyphenolic compounds with putative anti-inflammatory, antioxidant and free radical scavenging effects in vitro. However, their potential effects in vivo have not been established. Therefore we have investigated the effects of the catechin epicatechin gallate (ECG), on scar formation in a full thickness incisional model of wound healing in rats. ECG showed a significant improvement in the quality of scar formation both in terms of maturity and orientation of the collagen fibers. An increase in inducible nitric oxide synthase and cyclooxygenase-2 and a decrease in arginase-I activity and protein levels were observed at earlier time points. In addition, an increase in the number of new blood vessels was observed in the ECG-treated group. This correlated with the protein levels of vascular endothelial growth factor, the most potent angiogenic protein known. This study has therefore demonstrated, for the first time, that catechins, namely ECG, can significantly improve the quality of wound healing and scar formation. These effects may in part be due to an acceleration of the angiogenic response and an up-regulation of the enzymes nitric oxide synthase and cyclooxygenase.