Shifting priorities along the HIV care cascade: the role of HIV viral load a decade into the 90-90-90 targets
File(s)
Author(s)
Edun, Olanrewaju Ayodele
Type
Thesis
Abstract
To accelerate progress toward ending AIDS as a public health threat by 2030, UNAIDS established the 90-90-90 HIV diagnosis and treatment targets in 2014, later revised to 95-95-95 in 2021. A decade after their introduction, progress has been substantial, with an estimated 86% of people living with HIV (PLHIV) diagnosed, 89% of those diagnosed on treatment, and 93% of those on treatment achieving viral suppression (VLS), as of 2023. As treatment coverage increases, diagnosed or treatment experienced but not virally suppressed PLHIV constitute a larger share of the HIV population, raising concerns that individuals on treatment but with residual viremia may become a major transmission source. This has prompted calls for lower thresholds for defining and monitoring VLS. Persistent challenges also remain for children and adolescents, who face difficulties related to learning about their HIV-positive status. This thesis analyses cohort data to identify the predictors and consequences of HIV status disclosure to children and adolescents and assesses how the timing and mode of disclosure influence treatment outcomes, mental health, and stigma. It also uses data from population-based household surveys in sub-Saharan Africa to evaluate the UNAIDS model for adjusting VLS thresholds to the common ≤1000 copies/mL benchmark and evaluates whether alternative statistical models perform better. Finally, the survey data are used to assess differences in sexual behaviour, viremia, and model the contribution of different PLHIV subgroups to transmission, including those with low-level viremia. The findings emphasize the need to support adolescents and their caregivers during disclosure and highlight gaps and proposes revision to the current methods for adjusting VLS estimates. Despite shifts in the cascade over the past decade, analysis identify that untreated PLHIV have higher levels of sexual risk behaviour and viremia and remain the highest contributors to transmission, underscoring the importance of prioritizing this group in prevention strategies.
Version
Open Access
Date Issued
2025-04-14
Date Awarded
01/11/2025
License URL
Advisor
Imai-Eaton, Jeffrey W.
Okell, Lucy
Shenderovich, Yulia
Sponsor
Wellcome Trust (London, England)
Grant Number
222376/Z/21/Z
Publisher Department
School of Public Health
Publisher Institution
Imperial College London
Qualification Level
Doctoral
Qualification Name
Doctor of Philosophy (PhD)