Limitations of the UNAIDS 90-90-90 metrics: a simulation-based comparison of cross-sectional and longitudinal metrics for the HIV care continuum
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Authors
Edwards, Jessie K.
Salomon, Joshua A.
Lippman, Sheri A.
Bor, Jacobd
Chang, Angela Y.
Anglemyer, Andrew
Pettifor, Audrey
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Advisors
Date of Issue
2020-06-01
Date
Publisher
Wolters Kluwer Health
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Abstract
Design: The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 and other cross-sectional metrics can lead to potentially counterintuitive conclusions when used to evaluate health systems’ performance. This study demonstrates how time and population dynamics impact UNAIDS 90–90–90 metrics in comparison with a longitudinal analogue. Methods: We simulated a large cohort over 15 years. Everyone started out at risk for HIV, and then transitioned through the HIV care continuum based on fixed daily probabilities of acquiring HIV, learning status, entering care, initiating antiretroviral therapy (ART), and becoming virally suppressed, or dying. We varied the probability of ART initiation over three five-year periods (low, high, and low). We repeated the simulation with an increased probability of death. Results: The cross-sectional probability of being on ART among persons who were diagnosed responded relatively slowly to changes in the rate of ART initiation. Increases in ART initiation rates caused apparent declines in the cross-sectional probability of being virally suppressed among persons who had initiated ART, despite no changes in the rate of viral suppression. In some cases, higher mortality resulted in the cross-sectional metrics implying improved healthcare system performance. The longitudinal continuum was robust to these issues. Conclusion: The UNAIDS 90–90–90 care continuum may lead to incorrect inference when used to evaluate health systems performance. We recommend that evaluation of HIV care delivery include longitudinal care continuum metrics wherever possible.
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Article
Description
The article of record as published may be found at https://doi.org/10.1097/QAD.0000000000002502
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Operations Research (OR)
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Format
9 p.
Citation
Haber, Noah A., et al. "Limitations of the UNAIDS 90-90-90 metrics: a simulation-based comparison of cross-sectional and longitudinal metrics for the HIV care continuum." Aids 34.7 (2020): 1047-1055.
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This publication is a work of the U.S. Government as defined in Title 17, United States Code, Section 101. Copyright protection is not available for this work in the United States.