I started in NYC in 1985, working in HIV… and to see where we are right now is an incredible opportunity; an incredible chance to say that we really can change the course of this epidemic.
Michael Kharfen, of the DC Department of Health, explained that health outcomes across the cascade had already been improving before the city announced its 90-90-90-50 plan in June. Washington DC had already seen a 59% reduction in new diagnoses since 2007 and a 50% reduction in HIV mortality. With the expansion of routine testing in 2006, the estimated proportion of people living with HIV who are unaware of their diagnosis has gone from 50% to less than 5%.
Kharfen noted that the wording of the 90-90-90-50 plan, which did not have an official name at the time of the Summit, was being carefully considered so as not to send the wrong message about the project’s goals. “It’s hard to say that you’re coming up with a plan to end HIV or end AIDS when we still have thousands of people living with HIV,” he said. “It may sound like semantics but, [it’s important] to really get to the message that we are not trying to end those people who are still living with HIV, but that address that we can get to an ambitious goal of ending HIV.”
90-90-90-50 is an adaptation of the UN AIDS goals that, by the year 2020, 90% of all people living with HIV will know their HIV status, 90% of all people living with HIV will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression. The city has added an additional goal: a 50% reduction in new HIV cases by 2020. Kharfen noted that, while this plan is not as ambitious as getting to zero, it may be more realistic, saying, “I really believe that without a vaccine in our portfolio, to actually get to zero is going to be challenging. And therefore how do we set the right bar of expectations of what we can achieve?”
In terms of metrics, Kharfen stressed that, in his opinion, one of the most common metrics used to evaluate program success – retention in care – is not helpful. “Going to the doctor does not mean you’re being successful in your HIV treatment,” he said. Measures of adherence provide more information about whether treatment has been successful.
In terms of results, Kharfen noted that the average CD4 count at diagnosis is now 400, which is double the level reported in 2005; 86% of people diagnosed with HIV are now linked to care, and 60% of those in care have achieved viral suppression. Among 7,000 participants in a longitudinal cohort study funded by NIH, viral suppression has reached 80%. One million dollars of local funding has also been committed to scale-up PrEP access in Washington DC.
While Kharfen acknowledged that he had doubts about this project at the outset, he’s embraced it now because he thinks it will motivate the community to take the last steps to address HIV.