People living with HIV who have suppressed viral loads
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 World Health Organization (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.
Viral suppression among people living with HIV provides a benchmark for monitoring global targets over time and comparing progress across countries towards ending the AIDS epidemic. When considered as a proportion of the number of people on treatment (the numerator of Indicator 1.2), this indicator monitors the third 90 of the UNAIDS 90-90-90 targets: that 90% of the people receiving antiretroviral therapy will have suppressed viral loads by 2020.
Number of people living with HIV in the reporting period with suppressed viral loads (<1000 copies/mL)
Estimated number of people living with HIV (to estimate viral load suppression coverage);
Estimated number of people living with HIV who are on treatment (to determine progress towards the third 90).
Note: Starting in 2018, countries with a population of more than 250 000 will report on this indicator by broad age groups within Spectrum. Results will be imported into the Global AIDS Monitoring reporting tool once the national file is finalized. Reporting on cities and other administrative areas of importance will still be done using the Global AIDS Monitoring reporting tool.
Viral suppression is defined as <1000 copies/mL. For countries with other thresholds (such as undetectable, <50 copies/mL or <400 copies/mL), evidence from several studies suggests that the distribution of those with between 50 copies/ml and less than 1000 copies/ml may influence results, so further adjustment is required. Starting in 2019, UNAIDS recommends that countries adjust for lower threshold detection This is done according to the formula:
In this instance, y is the reported viral suppression level, t, is the alternative threshold that was used, and ɸ is the region-specific adjustment factor. This adjustment will be done automatically in Spectrum, if required.
Viral load suppression may be measured using three different data sources: (1) clinical and programme data; (2) nationally representative surveys (such as the Population-based HIV Impact Assessment [PHIA] and HIV drug resistance surveys); or (3) early warning indicators of HIV drug resistance surveys. Countries should report data from whichever source is most recent and nationally representative.
- 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 estimated number of people nationally who have suppressed viral loads during the reporting period if viral load testing coverage (i.e., the number of people routinely tested among all people on treatment) is 50% or greater.
For countries that report viral load testing coverage 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 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.
Countries should only include testing data that result from routine rather than targeted testing among those on treatment. 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 countries where viral load testing coverage is 50% or over, an estimated number of people with suppressed viral loads should be reported. This is calculated from the number suppressed among those tested, multiplied by the total number of people on treatment. This assumes that levels of suppression in the untested population are the same as those in the tested population. This assumption is supported by evidence from South Africa, which shows that although viral load information was frequently missing, estimates of viral suppression did not change substantially after adjusting for missing data.
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 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.
- Recent nationally representative population surveys (including household, acquired HIV drug resistance surveys or early warning indicators (EWI) survey of HIV drug resistance)
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 are not on treatment but naturally suppress the virus will be included. If using data from an acquired HIV drug resistance survey, either the 12- of 48-month cohort data may be used. Data from early warning indicators should only be used to generate national aggregate statistics if:
a) All clinics in a country - or a random sampling of clinics - reported early warning indicators data that includes at least 70% of the overall estimated sample size from the sampled clinics.
b) If convenient sampling of clinics was used, a national aggregate statistic can be reported if the data from the sampled clinics includes at least 70% of the eligible population in the country (see page 8 of the EWI annex - sampling guidance).
Note: Countries using survey data should still report on the number of people on treatment with routine viral load tests during the reporting period. Survey data should only be used if conducted in both children and adults.
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.
- 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.
Provide city-specific data for this indicator. Space has been created in the Global AIDS Monitoring 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.
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. 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 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 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 targeted, 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 1.3.
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. 2nd ed. Geneva: World Health Organization; 2016 (http://www.who.int/hiv/pub/arv/arv-2016/en).
Consolidated HIV strategic information guidelines: Driving impact through programme monitoring and management. Geneva: World Health Organization, 2020 (https://www.who.int/publications/i/item/consolidated-hiv-strategic-infor...)
Treatment and care. In: who.int [Internet]. Geneva: World Health Organization; c2019 (http://www.who.int/hiv/topics/treatment/en/index.html).
Consolidated guidelines on person-centred HIV patient monitoring and case surveillance. Annex 2.4.6: HIVDR EWI sampling, abstraction and reporting guidance. Geneva: World Health Organization; 2017 (https://www.who.int/hiv/pub/guidelines/WHO_Consolidated_Guidelines_Annex...).
Pillay T, Cornell M, Fox MP, Euvrard J, Fatti G, Technau KG et al. Recording of HIV viral loads and viral suppression in South African patients receiving antiretroviral treatment: a multicentre cohort study. Antivir Ther. 2020 Sep 22. doi: 10.3851/IMP3371. Epub ahead of print.
AV.3 PLHIV who have suppressed VL, 2020, WHO Consolidated HIV strategic information guidelines: driving impact through programme monitoring and management (https://www.who.int/publications/i/item/consolidated-hiv-strategic-information-guidelines).
TX_PVLS, PEPFAR, MER 2.0 (Version 2.4), September 2019, Monitoring, Evaluation, and Reporting (https://www.state.gov/wp-content/uploads/2019/10/PEPFAR-MER-Indicator-Reference-Guide-Version-2.4-FY20.pdf).