Current Status In Kedir City Towards 90-90-90 Unaids Target (A Case study of Pesantren 1 Health Center)

Introduction In 2016, UN Member States committed to reduce new HIV infections to fewer than 500,000 annually by 2020, a 75% reduction compared with 2010, reduce AIDS-related deaths to fewer than 500 000 globally as a means of ending AIDS by 2030. The main UNAIDS 2020 target is to ensure that 90% of the people living with HIV know their status, 90% of the people living with HIV (who know their HIV status as positive) are already on ART treatment, 90% of people on treatment are virally suppressed. The objective of the study is to determine the current situation towards the 2020 90-9-90 UNAIDS target and the factors associated with HIV viral load suppression at Pesantren 1 Health center Method The study was a cross sectional study at Pesantren 1 Health Center in Kediri city. The researcher collected secondary data at from the January 2018 till May 2019, carried in depth interviews, then determined the percentage of HIV positive patients that did a HIV test and received their results as Positive, the percentage of HIV positive patients that started ART treatment, the percentage of HIV positive patients that have viral load suppression from the viral load tests done. The researcher used the chi square analysis to determine the significant factors that may determine viral suppression that are already on ART treatment and then applied the binary logistic regression to determine the significant factors that determine viral suppression among the HIV positive patients that are already on ART treatment. Results The progress towards the 90-90-90 UNAIDS target was at 2.4%, 93.4%, 20.5%. The time taken by the HIV positive patient to start ART treatment from the time of confirmation of HIV positive and the time taken to take the first viral load test from the time when this patient started ART treatment were significantly influencing Viral load suppression. Conclusion scale up case-detection creating


Introduction
HIV still remains a major public health threat with over 35 million deaths and counting, and in 2016, there were still over two million infections (Unaids, 2016c). However HIV treatment can dramatically extend the lifespan of people living with HIV and effectively prevent HIV transmission (UNAIDS, 2014). In 2016, United Nations Member States committed to reducing new HIV infections to fewer than 500,000 annually by 2020, a 75% reduction compared with 2010, reduce AIDS-related deaths to fewer than 500 000 globally, eliminate HIV-related stigma and discrimination and ending AIDS as a public health threat by 2030 (Unaids, 2016a;WHO, 2016b). The discovery of effective treatment with antiretroviral therapy (ART) in 1996 and subsequent evidence regarding the prevention of illness, death and transmission transformed the epidemic from an unending, unmitigated disaster into something that could be prevented and even ended (Das M, Chu PL, Santos GMi, Scheer S, Vittinghoff E, 2010). One of the 2030 sustainable Development Goals (SDGs) is to achieve the 95-95-95 HIV treatment and having less than 200,000 new HIV infections (UNAIDS, 2015). However, the main 2020 target for UNAIDS is to ensure that 90% of the people living with HIV know their status, 90% of the people living with HIV (who know their HIV status as positive) are already on ART treatment, 90% of people on treatment are virally suppressed (UNAIDS, 2017). Attaining this target would mean that, by 2020, 73% of all people living with HIV will have suppressed viral loads (UNAIDS, 2016). Data from 146 countries show that some have achieved declines in new HIV infections among adults of 50% or more over the last 10 years, while many others have not made measurable progress, and yet others have experienced worrying increases in new HIV infections (Unaids, 2016b). Asia and the Pacific is expected to experience almost 480,000 new HIV infections in 2030 if coverage remains at 2013 levels, compared to fewer than 97,000 infections under the 90-90-90 Fast-Track response (UNAIDS, 2014). In 2015, of the 36.7 million people living with HIV globally, an estimated 60% knew their HIV status, 46% were on antiretroviral therapy, and 38% had achieved viral suppression (Unaids, 2016b). In 2015, more than 14.5 million of the 36.7 million (43%) people living with HIV do not know their HIV status. About 54% of the people living with HIV have not yet started Antiretroviral treatment and only an estimated 38% of people living with HIV worldwide are virally suppressed (Unaids, 2016b). Of late, globally, there 37.9 million people having HIV by 2018 and 23.3 million where already accessing ART treatment (62%) (UNAIDS, 2019a). In the Asia and the pacific region, 5.9 million were estimated to be having HIV of which 3.2 million where accessing ART treatment by 2018 (UNAIDS, 2019a). In 2017, East Java (Jawa Timur) had the highest number of HIV cases in Indonesia (Kementerian Kesehatan RI, 2018b). By 2018, about 8.1 million people did not know that they were living with HIV (UNAIDS, 2019a). In 2018, 79% of people living with HIV knew their status. Among people who knew their status, 78% were accessing treatment. And among people accessing treatment, 86% were virally suppressed. (UNAIDS, 2019a). Of all people living with HIV, 79% knew their status, 62% were accessing treatment and 53% were virally suppressed in 2018 (UNAIDS, 2019a). For the first time in 2017, the number of people living with HIV accessing treatment exceeded the number of people not yet n treatment (UNAIDS, 2019b). Indonesia being among the thirty-five countries accounting for more than 90% of the people becoming newly infected with HIV have been designated Fast-Track countries, it requires intensive action to mitigate the epidemic (WHO, 2016b). In the Asia and the Pacific region, 5 million people were living with HIV in 2014, 90% were in six countries: China, India, Indonesia, Myanmar, Thailand and Viet Nam. Women account for a growing proportion of new HIV infections, up from 17% in 1990to 34% in 2014(Unaids, 2016c. China, India and Indonesia account for 78% of people newly infected with HIV in the region. These three countries, plus Pakistan and Vietnam, are among the UNAIDS FastTrack countries (Unaids, 2016c). The number of people with HIV/AIDS at the age of ≥ 15 in Indonesia was estimated and projected to reach 628,492 people in 2017, with the number of new infections as many as 46,357 people and mortality of 40,468 people (Estimation and Projection of HIV/AIDS in Indonesia for the period of 2015-2020, Ministry of Health RI) (Kementerian Kesehatan RI, 2018a). Surabaya and Jakarta are among the cities that account for 1.1 million people living with HIV (Unaids, 2016c). The preventative effect of antiretroviral therapy has been limited because 40% of people living with HIV do not know their HIV status and 62% of people living with HIV are not virally suppressed well shy of the 90-90-90 target. In other words, nearly two thirds of people living with HIV could transmit the virus unless they are provided with prevention tools and empowered to use them (Unaids, 2016b). The likelihood of transmitting HIV from a person living with HIV who is on antiretroviral therapy (ART) and has achieved a suppressed HIV viral load in his/her blood for at least six months is extremely low The continued expansion of ART and support for sustainable viral suppression will make it possible to significantly reduce transmission and eliminate HIV in the general public (Del Romero J, Castilla J, Hernando V, Rodríguez C, 2010;Arkell C, 2018;Centers for Disease Control and Prevention, 2018;Granich R, Gupta S, Wollmers M, Ruffner M, 2018). In PLHIV, viral load (expressed as HIV RNA copies/mL of blood) is a direct indicator of viral replication (Bvochora T, Satyanarayana S, Takarinda KC, Bara H, Chonzi P, Komtenza B, Clemence D, 2019). Viral load tests prevent patients being unnecessarily switched to more expensive medicines or left to continue on ineffective therapy that can lead to drug resistance and ultimately death (UNAIDS, 2016). World Health Organization (WHO) recommends viral load testing to be the preferred monitoring tool for diagnosing and confirming antiretroviral therapy failure (WHO, 2013(WHO, , 2016a David E, Tom E, 2018). Strong adherence to antiretroviral therapy suppresses viral load to undetectable levels within people living with HIV, greatly reducing the risk of transmitting the virus to others (Das M, Chu PL, Santos GMi, Scheer S, Vittinghoff E, 2010;Saravanan et al., 2016;Globerman J, Gogolishvili D, 2017). Timely initiation of treatment and sustained engagement in HIV care are important to achieving viral load suppression, which is a key marker for successful treatment (Public Health Agency of Canada, 2016) (O'Connor J, Smith C, Lampe FC, Johnson MA, Chadwick DR, Nelson M, Dunn D, Winston A, Post FA, Sabin C, 2017). Since Tb is the leading cause of death among people living of AIDS, All people living with TB should have access to HIV testing and antiretroviral therapy (UNAIDS, 2019b). As we come closer to 2020, there was need to assess the progress of Pesantren 1 health center towards the UNAIDS 90-90-90 target. The aim of the study was to analyze the progress of the UNAIDS 90-90-90 target, that 90% of the people living with HIV know their status, 90% of the people living with HIV (who know their HIV status as positive) are already on ART treatment, 90% of people on treatment are virally suppressed in Kediri city, a case study of Pesantran 1 health center. It also analyzed the factors that determine viral load suppression among HIV patients that are on care at Pesantren 1 health center.

Methods Of Study
The study was a cross sectional analytic (Quantitative) study at Pesantran 1 Health Center, Kediri city. The researcher selected Pesentran 1 Health Center from Kediri city because it has the largest number of HIV patients in Kediri city. The population of study included all HIV patients at Pesentran 1 Health center and the HIV patients that are on ART treatment and have taken atleast one Viral load test were selected for further analysis of the factors associated with Viral load suppression at Pesantren 1 Health center.

Data collection
The researcher collected secondary data at the health center from the year 2018 till May 2019, and also carried in depth interviews on two key informants; the Health worker that works on HIV patients in the HIV unit at Pesantren 1 health center, a member of the Peer Support Group in Kediri city to determine the reasons behind the results/findings. The researcher collected the total number of patients that have visited the number of HIV positive patients that have visited the health center, total number of patients that were referred to the HIV unit to do a HIV test, total number of patients that actually did the HIV test and received their results, total number of patients that started ART treatment, total number of patients that have at least one successful viral load test. The researcher then determined the percentage of HIV positive patients that did a HIV test and received their results as Positive, the percentage of HIV positive patients that started ART treatment, the percentage of HIV positive patients that have viral load suppression from the viral load tests done. Viral load suppression was recorded if there are less than 40 copies of the virus per ml (Arkell C, 2018). Patients that were referred to the HIV unit to take a HIV test The researcher analyzed using the bivariate analysis to determine the significant factors that may determine viral suppression among the HIV positive patients that are already on ART treatment. The factors analyzed include: Gender, Marital status, level of education, level of employment, risk factor, time taken to take the first load test, Tuberculosis status, time taken to start ART treatment from the time of confirmation of HIV positive, Adherence, regiment (First line, second line or third line), WHO clinical status. However in determining relationship of the independent factors to influence viral load suppression, the researcher restricted the analysis to those who had at least one viral load testing. The researcher used a Pearson chi square analysis for determining the significance of the relationship of the: Gender, Marital status, level of education, level of employment, risk factor staus, Tuberculosis status, Adherence, ART regimen (First line, second line or third line), WHO clinical status to viral load suppression, change in body weight while on ART and one way ANOVA to determine the significance of the relationship of Age, time taken to start ART treatment from the time of confirmation of HIV positive and time taken to take the first load test to achieve viral load suppression. Then, later a binary logistic regression was run for the significant variables to determine how they influence viral load suppression. Data was analyzed in Microsoft Excel and Stata 14.2.

Results
The progress of Pesantran 1 health center towards the 90-90-90 UNAIDS target in 2020 is summarized in Table 1 and Figure 1 below.   (150)   The results showed that the more the time taken by the HIV positive patient to start ART treatment from the time of confirmation of HIV positive, the less likely (Odds ratio = 0.974, < 1) the HIV positive patient is likely to have a viral load suppression. They also showed that the more the time taken by the HIV positive patient to take the first viral load test from the time when this patient started ART treatment, the less likely (Odds ratio = 0.852, < 1) the HIV positive patient is likely to have a viral load suppression.

Discussion
There are several factors associated with achieving each of the 90-90-90 targets.
Reaching the first target will require efforts to increase the uptake of HIV testing by   It is also important to note that only 10 out of the 29 patients were assessed for adherence of which 7 patients had viral load suppression, only one patient out of four was on ART had Tuberculosis (Pulmonary TB) and was virally suppressed.
However, social conditions related to poverty, limited viral load testing points, lack of access to support services can decrease the degree to which individuals remain engaged in care. Issues related to privacy and stigma may also impede access to and retention in care. Therefore, it is critical to continue to work towards creating supportive environments that address social determinants, decrease stigma and discrimination, and reduce barriers to prevention, treatment, care and support. It is still worrying that achieving the 90 90 90 by 2020 targets will still leave 27% of people living with HIV with unsuppressed viral loads in 2020, so expanded investments in proven HIV prevention strategies will be critical to hopes for ending the AIDS epidemic (UNAIDS, 2014).
The major strength of this study was that it was the first study to determine progress towards the 2020 90-90-90 UNAIDS target and also conclude that the time taken by the HIV positive patient to start ART treatment from the time of confirmation of HIV positive and the time taken by the HIV positive patient to take the first viral load test from the time when this patient started ART treatment were significant factors to influence viral load suppression among HIV positive patients. The other strength was use of routine programme data that is always updated over time with information collected about all patients who were on ART at this health center without any exclusion. We collected data from the main e-database called System Informasi HIV AIDS (SIHA) which is the first/ primary source of information on all HIV patients used across all the health centers and hospitals in Indonesia. These primary records are routinely audited by the Ministry of Health (Dinas Kesehatan) for its accuracy and consistency. Therefore, we strongly believe that the data collected in our study reflects what is happening in reality at this health center.
The main challenge / limitation in the study was that it was difficult to determine the total number of patients that had ever visited the hospital, the total number of patients that have ever been referred to the HIV unit to HIV counseling and testing , the total number of patients that have ever tested for HIV at the HIV unit. The other limitation was that the study methodology involved analysis of only secondary data of patient records in the SIHA database, and hence our analysis and interpretation of the data are limited to only those variables that are routinely collected from patients/care givers and captured in the patient records.

Funding
The study did not get any financial support

Ethical issues
Ethical clearance and permission for the study was obtained from East Java Political and National Unity Agency (Bakesbangpol), Ministry of Health Kediri city in collaboration with Faculty of Public Health Universitas Airlangga.

Conflict of Interest
We declare no conflict of interest Figures Figure 1 The Progress towards 90-90-90 UNAIDS target