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DOI: 10.1111/hiv.

12431
© 2016 The Authors. HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association. HIV Medicine (2017), 18, 305--307
SHORT COMMUNICATION

Sweden, the first country to achieve the Joint United Nations


Programme on HIV/AIDS (UNAIDS)/World Health
Organization (WHO) 90-90-90 continuum of HIV care targets
M Gisslen,1 V Svedhem,2 L Lindborg,3 L Flamholc,4 H Norrgren,5 S Wendahl,6 M Axelsson7 and A S€ onnerborg2,8
1
Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 2Department
of Infectious Diseases, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden, 3Department of
Infectious Diseases/Venh€alsan, South General Hospital, Stockholm, Sweden, 4Department of Infectious Diseases, Skane
University Hospital, Malm€o, Sweden, 5Department of Clinical Sciences Lund, Lund University, Lund, Sweden,
6
Department of Infectious Diseases, Sunderby Hospital, Lulea, Sweden, 7Public Health Agency of Sweden, Solna, Sweden
8
and Department of Clinical Microbiology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden

Objectives
The Joint United Nations Programme on HIV/AIDS (UNAIDS)/World Health Organization (WHO)
90-90-90 goals propose that 90% of all people living with HIV should know their HIV status, 90%
of those diagnosed should receive antiretroviral therapy (ART), and 90% of those should have
durable viral suppression. We have estimated the continuum of HIV care for the entire HIV-1-
infected population in Sweden.
Methods
The Swedish InfCare HIV Cohort Study collects viral loads, CD4 counts, and viral sequences, along
with demographic and clinical data, through an electronic clinical decision support system. Almost
100% of those diagnosed with HIV infection are included in the database, corresponding to 6946
diagnosed subjects living with HIV-1 in Sweden by 31 December 2015.
Results
Using HIV surveillance data reported to the Public Health Agency of Sweden, it was estimated that
10% of all HIV-infected subjects in Sweden remain undiagnosed. Among all diagnosed patients,
99.8% were linked to care and 97.1% of those remained in care. On 31 December 2015, 6605 of
6946 patients (95.1%) were on ART. A total of 6395 had been on treatment for at least 6 months
and 6053 of those (94.7%) had a viral load < 50 HIV-1 RNA copies/mL.
Conclusions
The 2014 UNAIDS/WHO 90-90-90 goals for HIV care means that > 73% of all patients living with
HIV should be virologically suppressed by 2020. Sweden has already achieved this target, with 78%
suppression, and is the first country reported to meet all the UNAIDS/WHO 90-90-90 goals.
Keywords: antiretroviral treatment, continuum of care, HIV, treatment cascade
Accepted 9 June 2016

Introduction treated patients. For viral suppression, a good clinical


outcome, and a significant public health impact, HIV-in-
Antiretroviral therapy (ART) has dramatically reduced the fected individuals must meet several targets along the
HIV-related mortality, morbidity, and infectiousness of HIV care continuum. In October 2014, the UNAIDS/WHO
90-90-90 treatment goals proposed that by 2020 90% of
all people living with HIV should know their HIV status,
Correspondence: Dr Magnus Gisslen, Department of Infectious Diseases,
Sahlgrenska Academy, University of Gothenburg, SE-416 85 Gothenburg, Swe- 90% of those diagnosed should receive ART, and 90% of
den. Tel: +46 31 3434000; fax: +46 31 847813; e-mail: magnus.gisslen@gu.se those should have durable viraological suppression. When
This is an open access article under the terms of the Creative Commons this three-part target is achieved, at least 73% of all HIV-
Attribution-NonCommercial-NoDerivs License, which permits use and infected people world-wide will be virally suppressed – a
distribution in any medium, provided the original work is properly cited, two- to three-fold increase over current estimates [1].
the use is non-commercial and no modifications or adaptations are made.

305
306 M Gisslen et al.

The process of achieving viral suppression proceeds physician. To estimate linkage to care, we manually
through a five-stage administration cascade of care or reviewed all cases reported from 1 January to 31 Decem-
HIV care continuum: diagnosis, linkage to care, retention ber 2014. Out of 471 cases, 469 were entered into InfCare
in care, administration of ART, and viral suppression. HIV and linked to an HIV care centre. One patient with
It has been estimated that, of all the HIV-infected tuberculosis at diagnosis was admitted to an infectious
individuals in the USA, approximately 14% are unaware disease clinic, but left the country prior to being dis-
of their infection, and only 19% to 30% are virally charged from the hospital or visiting the HIV clinic.
suppressed [2,3]. Another patient was diagnosed by a forensic medical
In 2014, Raymond et al. [4] reported large disparities in department and never included in InfCare HIV, and there-
HIV treatment cascades between eight (mostly European) fore considered lost to follow-up. Thus, 99.8% of patients
countries. The percentage of infected people with unde- diagnosed with HIV during 2014 were linked to HIV care.
tectable HIV RNA ranged from 20% in Georgia to 59% in To study retention in care, we analysed 661 new cases
Denmark. In a recent analysis of 12 national-level treat- entered into InfCare HIV in 2013 to 2014. In December
ment cascades, none achieved the UNAIDS goal of 73% of 2015, 612 were still active in InfCare HIV and had ongo-
all HIV-infected individuals having a suppressed viral load. ing contact with a national HIV centre. Out of 49 deregis-
Switzerland was closest at 68%, followed by Australia tered subjects, 40 had either moved abroad (n = 29) or
(62%) and the UK (61%) [5]. Switzerland reported that 19% died (n = 11) and were thus excluded. Nine patients were
of people living with HIV were unaware of their infection, lost to follow-up. Another nine with no registered labora-
but linkage to and retention in care were high; 91% of tory HIV monitoring during the last 9 months were con-
those in care received ART, and 93% of them had a viral sidered lost to follow-up. Accordingly, 603 of 621
load < 50 HIV-1 RNA copies/mL [6]. patients (97.1%) were linked and retained in care.
We have estimated the continuum of HIV care for the On 31 December 2015, 6605 of 6946 patients (95.1%)
entire HIV-1-infected population in Sweden. were on ART. A total of 6395 had been on treatment for
at least 6 months and 6053 of those (94.7%) had a viral
load < 50 copies/mL. Ninety-eight patients on treatment
Methods and results had a viral load > 200 copies/mL, giving 98.5% with a
The Swedish InfCare HIV Cohort Study, established in viral load < 200 copies/mL. Most patients with HIV RNA
2003, collects viral loads, CD4 cell counts, and viral between 50 and 200 copies/mL (n = 244) were assumed
sequences, along with demographic and clinical data, to have had a viral blip and would probably be
through an electronic clinical decision support system suppressed at the next measurement [9].
(InfCare HIVâ, Stockholm, Sweden). The implementation
was finalized in all HIV care centres in 2008 [7]. The per-
Conclusions
centages of patients diagnosed with HIV and linked to
care are included in the InfCare HIV database, corre- The Swedish continuum of HIV care is shown in Figure 1.
sponding to 6946 diagnosed subjects living with HIV-1 in In summary, the UNAIDS/WHO 90-90-90 coverage target
Sweden by 31 December 2015. of 73% of HIV-infected individuals with undetectable
The six levels within the spectrum of engagement in HIV RNA has been achieved, with 90% of all those
HIV care [6] were separately analysed: infected diagnosed, 83% of those infected on ART, and
78% of those infected with a suppressed viral load
(1) HIV-infected;
(< 50 copies/mL).
(2) HIV-diagnosed;
Several factors probably contribute to these favourable
(3) linked to care;
results. Sweden is a low-endemic country, with < 8000
(4) retained in care;
individuals estimated to be HIV-infected; the Swedish
(5) on ART;
Communicable Diseases Act obliges laboratories and clin-
(6) having suppressed viral load (< 50 copies/mL).
ics to report cases and patients must keep appointments
Using HIV surveillance data, the Public Health Agency and submit to tests that health care providers consider
of Sweden has recently estimated that 90% of those in necessary; all HIV-infected patients are linked to special-
Sweden infected with HIV have been diagnosed [8], so that ized HIV care centres with dedicated multidisciplinary
< 8000 individuals are now living with HIV in Sweden. teams of physicians, nurses, and social workers; the
All new HIV diagnoses are reported to the Public InfCare HIV clinical database facilitates high-quality care
Health Agency by both the laboratory and the treating and treatment; ART is prescribed free of charge for the

© 2016 The Authors. HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association. HIV Medicine (2017), 18, 305--307
Swedish continuum of HIV care 307

Acknowledgements
This work was supported by the Swedish Research Coun-
cil (2012-3476), Stockholm County Council (20130042),
and Sahlgrenska University Hospital (ALFGBG-430271).

References
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© 2016 The Authors. HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association. HIV Medicine (2017), 18, 305--307

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