People living with HIV who have suppressed viral loads

Export Indicator

Percentage and number of adults and children 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 (to estimate viral load suppression coverage);
 
OR
 
Estimated number of people living with HIV who are on treatment (to determine progress towards the third 90).
Calculation
Numerator/denominator
 
Note: Starting in 2018, countries with a population of more than 250 000 will report on this indicator within Spectrum. Results will be imported into the GAM reporting tool once the national file is finalized. Reporting on detailed age and sex groups will still be done using the GAM reporting tool.

 

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 further adjustment is required.
 
Viral load suppression may be measured using three different data sources: (1) clinical and programme data; (2) nationally representative surveys (such as the PHIAs); or (3) early warning indicators of HIV drug resistance surveys. Countries should report data from whichever source is most recent and nationally representative.
 
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 the section below titled “Reporting the actual or estimated number of people nationally who have a suppressed viral load” for more information).
 
Viral load testing data 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. UNAIDS will work with countries to develop a Spectrum model that matches the estimate of people living with HIV if estimates other than those produced through Spectrum are used.
 
For more information on estimating the number of people living with HIV who are on treatment as part of calculating the third 90, please see Indicator 1.2.
 
Reporting the actual or estimated number of people nationally who have a suppressed viral load from clinical and programme data. Whether countries use actual or estimated numbers of people with suppressed viral load depends on coverage levels of viral load testing. As a result, the count of people with an annual, routine viral load test among those on treatment should be entered by all countries.
 
For countries where viral load testing coverage is 90% or greater, the actual number of people with suppressed viral loads among those on treatment and living with HIV should be reported. This assumes that people on treatment without a viral load test result are not yet suppressed.
 
For countries where viral load testing coverage is between 50% and 90%, the estimated number of people with suppressed viral loads may be reported. To derive this estimate, UNAIDS recommends that the proportion of people suppressed among those tested is multiplied by the number of people receiving antiretroviral therapy, where viral load suppression in the untested population is assumed to be the same as that in the tested population.
 
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 level of viral load suppression in the untested population to be like that among the tested population of people on treatment. 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].
 
Where viral load suppression in the untested population is not like that in the tested population, please contact UNAIDS for further discussion about approaches for estimating this count.
 
For countries that report that viral load suppression testing of less than 50%, only the number of routine viral load tests should be reported. It is not usually 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. Countries wishing to use data where with viral load testing coverage is less than 50% should discuss this with UNAIDS to determine whether the percentage of people suppressed in the tested population is of a similar level to those in the population with no access to testing.
 
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.
 
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. UNAIDS will work with countries to develop a Spectrum model that matches the estimate of people living with HIV if estimates other than those produced through Spectrum are used. For more information on estimating the number of people living with HIV who are on treatment as part of calculating the third 90, please see Indicator 1.2.
 
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. UNAIDS will work with countries to develop a Spectrum model that matches the estimate of people living with HIV if estimates other than those produced through Spectrum are used. For more information on estimating the number of people living with HIV who are on treatment as part of calculating the third 90, please see Indicator 1.2.
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; by gender (men, women, other gender) 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 GAM data entry tool to provide information for the capital city and one or two other key cities of high epidemiological relevance, such as those with the highest HIV burden or those that 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 settings, estimates of viral load suppression in the tested population 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).