People living with HIV who have suppressed viral loads

Export Indicator

Number and percentage of people living with HIV who have suppressed viral loads at the end of the reporting period
What it measures
Individual-level viral load is the recommended measure of antiretroviral therapy efficacy and indicates treatment adherence and the risk of transmitting HIV. A viral load threshold of <1000 copies/mL defines treatment success according to the 2016 WHO consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. People with viral load test results below the threshold should be considered as having suppressed viral loads.
Rationale

Viral suppression among people living with HIV is one of the 10 global indicators in the 2015 WHO consolidated strategic information guidelines for HIV in the health sector. This indicator also helps monitor the third 90 of the UNAIDS 90–90–90 target: that 90% of the people receiving antiretroviral therapy will have suppressed viral loads by 2020.

Numerator

Number of people living with HIV in the reporting period with suppressed viral loads (≤1000 copies/mL)

Denominator

Estimated number of people living with HIV

Calculation

Numerator/denominator

 

Method of measurement

Viral suppression is defined as <1000 copies/mL. For countries with other thresholds (such as undetectable, <50 copies/mL or <400 copies/mL), preliminary evidence from several studies suggests that the proportion of those with 50 copies/ml or above and less than 1000 copies/ml is small, so no adjustment is required. The testing threshold value should be reported for levels other than <1000 copies/mL in the Additional Information Box of the reporting tool.

Viral load suppression may be measured using two different data sources: (1) clinical and programme data or (2) nationally representative surveys. Countries should report data from whichever source is most recent and nationally representative.

Starting in 2018, countries monitoring Indicator 1.4 are encouraged to use Spectrum to calculate this value. Otherwise, please contact UNAIDS if you require technical assistance to estimate the numbers of people who have suppressed viral loads.

 

1. Routine viral load suppression tests from people on antiretroviral treatment collected through clinical or laboratory registers or case surveillance

For the numerator. Countries should report the actual or estimated number of people nationally who have suppressed viral loads during the reporting period (see On reporting the actual or estimated number of people nationally who have a suppressed viral load from clinical and programme data for more information).

Viral load testing should be routine rather than episodic: for example, a person’s results should not be included if testing was done prior to treatment initiation or when treatment failure was suspected.

If viral load is tested repeatedly for a person during the year, only the last routine test result should be used.

For the denominator. Estimation models such as Spectrum are the preferred source for the number of people living with HIV. If models other than Spectrum are used, documentation of the estimation method and uncertainty bounds should be provided.

On reporting the actual or estimated number of people nationally who have a suppressed viral load from clinical and programme data. For countries that report in Table 1 of the GAM reporting tool that viral load testing is fully accessible to all people on treatment, the actual number of people with suppressed viral loads among those on treatment and living with HIV should be reported. UNAIDS defined “fully accessible” as a situation where all people on antiretroviral treatment have access to viral load testing who are eligible for testing (typically people who have been on treatment for 6 months or more). The number of people reported to be tested among those on treatment typically should be above 90%.

In instances where countries report that viral load testing is partially accessible but nationally representative of the untested population, the numerator must be estimated. To derive a national estimate, viral load testing coverage among those on treatment typically should be between 50% and 90%. To construct the estimated national value, the proportion of people suppressed among those tested is multiplied by the number of people receiving antiretroviral therapy. Countries using data where viral load testing coverage is less than 50% should provide additional details on their representativeness.

Example: a country with an estimate of 100 000 people living with HIV has routine viral load tests for 12 000 of the 24 000 people receiving antiretroviral therapy. The viral load testing coverage is 50%, and the country deems the data to be nationally representative. Of the 12 000 people tested, 10 000 people have suppressed viral loads. The estimated national number of people living with HIV who have suppressed viral loads is 20 000 [(10 000/12 000) x 24 000].

For countries that report that viral load suppression testing is either (a) partially accessible and not representative of the untested population or (b) not routinely available, only the number of routine viral load tests should be reported. It is not possible to estimate the percentage of people living with HIV or those on treatment who are virally suppressed when viral load testing is not routinely accessible.

Important: Countries that have undertaken data quality assessments or reviews that monitor the extent to which facilities are able to accurately report the number of people who have suppressed viral load during reporting periods should adjust programme numerator data to account for these inconsistencies. UNAIDS will work with countries to agree on a set of best practices specific to the country for adjusting reported programme data. These adjustments should be described in the “Additional information box” and the year the data quality review was done should be provided in the available box.

 

2.     Recent nationally-representative population surveys

For the numerator. The proportion reported to have suppressed viral loads among people testing positive in the survey should be multiplied by the total number of people estimated to be living with HIV nationally to obtain the total number of people who have a suppressed viral load. This value may slightly overstate the number of people who are virally suppressed among those on treatment, since some people who naturally suppress the virus and are not on treatment will be included.

Note: Countries using survey data should still report on the number of people on treatment with routine viral load tests during the reporting period.

For the denominator. Estimation models such as Spectrum are the preferred source for the number of people living with HIV. If models other than Spectrum are used, documentation of the estimation method and uncertainty bounds should be provided.

 

3.     Early warning indicators of HIV drug resistance surveys

For the numerator. The proportion of those reported to have suppressed viral loads among people in the survey should be multiplied by the total number of people on antiretroviral treatment nationally; this will provide the total number of people who have a suppressed viral load. Either the 12- or 48-month cohort data may be used.

Note: Countries using survey data should still report on the number of people on treatment with routine viral load tests during the reporting period.

For the denominator. Estimation models such as Spectrum are the preferred source for the number of people living with HIV. If models other than Spectrum are used, documentation of the estimation method and uncertainty bounds should be provided.

 

Measurement frequency

Annually

Disaggregation
  • 0–14 years for children and 15 years and older by sex (men and women) for adults; data reported for unknown age or sex should be allocated to the age and sex disaggregated data cells using the same distribution of the data with known age and sex. These adjustments should be noted in the box providing additional information.
  • As available. Disaggregation by detailed age and sex: <1 year, 1–4 years, 5–9 years and 10–14 years for children and 15–19 years, 20–24 years, 25–49 years and 50+ years by sex (men and women) for adults
  • Cities and other administrative area of importance 
Additional information requested
Provide city-specific data for this indicator. Space has been created in the data entry sheet to provide information for the capital city as well as one or two other key cities of high epidemiological relevance: for example, those that have the highest HIV burden or have committed to ending AIDS by 2030.
Strengths and weaknesses

When viral load suppression testing data are collected from all people receiving antiretroviral therapy or a nationally representative sample, this measurement provides important information on adherence, treatment efficacy and transmission risk at the individual and programme levels. In addition to this indicator, countries collecting data on retention and viral suppression at 12 months among cohorts may find it useful to triangulate these different measures to describe the impact of effective antiretroviral therapy.

Despite the indicator’s importance, several challenges may arise in accurately monitoring it using currently available programme data. First, because viral load monitoring capacity is being scaled up but remains limited in low-income setting, estimates of viral load suppression may not be representative of the untested population when measured through programme data. This is especially the case if the proportion of people newly initiating treatment is high or if scale-up of testing is biased to higher or lower performing sites. By assuming that the levels of viral load suppression are the same in the tested and untested population when testing coverage is not complete, progress toward the 90–90–90 targets may be overstated.

A second challenge arising from the currently available programme data is that viral load testing may be performed selectively to determine when to initiate treatment or to identify possible treatment failures. The data reported from the viral load testing of people suspected of treatment failure will underestimate viral load suppression levels. UNAIDS recommends that countries closely review reported data to exclude non-routine testing.

A third challenge when using routine programme data is that viral load testing data are only reported for the subset of people who are on antiretroviral treatment. This may underestimate overall population-level suppression since people who naturally suppress the virus will not be included in the numerator. UNAIDS is examining available evidence from cohorts and population surveys to better quantify and adjust for this final value when reporting on global and regional progress towards Indicator 1.4. 

Further information

UNAIDS, WHO. Guidelines on monitoring the impact of the HIV epidemic using population-based surveys. Geneva: World Health Organization; 2015 (http://www.who.int/hiv/pub/guidelines/si-guidelines-population-survey/en).

Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Recommendations for a public health approach—second edition. Geneva: World Health Organization; 2016 (http://www.who.int/hiv/pub/arv/arv-2016/en).

Consolidated strategic information guidelines for HIV in the health sector. Geneva: World Health Organization; 2015 (http://www.who.int/hiv/pub/guidelines/strategic-information-guidelines/en).

WHO guidance on treatment and care (http://www.who.int/hiv/topics/treatment/en/index.html).