Progress towards the 2020 Fast Track targets in Eastern sub-Sahara Africa region and in Ethiopia; using Global Burden of Disease 2017data

Background Sustainable Development Goal (SDG) 3.3, targets to eliminate HIV from being a public health threat by 2030. For better tracking of this target interim Fast Track millstones for 2020 and composite complementary measures have been indicated. This study measured the Fast Track progress in Eastern sub-Saharan Africa (ESSA) region and in Ethiopia across ages using Global Burden of Disease (GBD) 2017 data. The analyzed the GBD 2017 data for the year 2010 to 2017 for Ethiopia and ESSA countries. GBD 2017 data sources were census, demographic and health surveys, prevention of mother-to-child HIV transmission and anti-retroviral treatment programs, sentinel surveillances and UNAIDS spectrum modeling. Age standardized and age specific HIV/AIDS incidence, prevalence, mortality, Disability Adjusted Life Years (DALYs), incidence:mortality ratio and incidence:prevalence ratio were calculated with corresponding 95% confidence limits.

3 national target but far behind achieving the target among the 15-49 age group.

Conclusion
The ESSA countries have made remarkable progress towards achieving the 75% HIV/AIDS mortality reduction target by 2020 since 2010, although they progress poorly in reducing HIV incidence. Having an incidence:prevalence ratio of less than 0.03, Ethiopia, Rwanda and Uganda are well heading towards epidemic control. The high HIV/AIDS mortality rate in Ethiopia for its incidence requires innovative strategies to bring undiagnosed cases to treatment and care services across age. For sustainable epidemic control, Ethiopian needs to build strong institutional capacity to generate strong evidence to support policy decision.

Background
Southern and Eastern Sub-Sahara Africa (ESSA) regions have been known to carry high burden of HIV/AIDS since the mid-1990s. In recent years, this situation is changing for the better. According to 2018 UNAIDS update, the burden of HIV/AIDS in the region has been steadily declining for the past 10 years [1]. In this regard, Ethiopia is leading the way and aims to control the HIV epidemic at national level. Ethiopia has reduced the adult HIV incidence by 70% in 2016 compared to 1990 and HIV/AIDS related mortality have declined by 84% in 2017 compared to the peak in 2005 [2]. Capitalizing on these sustained progresses, the ESSA countries have targeted to end the AIDS epidemic from being a public health threat by 2030 [1,3]. The United Nation General Assembly, set targets to reduce new HIV infection and HIV/AIDS related deaths by 75% by 2020 from the 2010 baseline as interim Fast Track millstone to achieve the 2030 SDG targets [4]. In line with this the current Ethiopian Health Sector Transformation Plan (HSTP) targets to reduce the adult HIV incidence by 60% and to reduce new HIV infections among children to zero from the 2010 baseline [5,6]. As we approach 2020, assessing progress towards the targets across the Eastern Sub-Sahara African countries is crucial to get insight how countries are performing and where efforts should be directed to achieve the targets.
Ethiopia is one of the countries long been known for having a generalized HIV epidemic fueled by unprotected sexual intercourse like many Eastern Sub-Saharan African countries. Currently, with adult HIV prevalence of 0.9%, Ethiopia has joined the counties having concentrated epidemic. Although, reducing HIV prevalence and incidence rates are big successes for the county, currently tracking new infection has presented a challenge and required extra efforts to identify highest contributors to new HIV infection, groups that carry highest burden and infected individuals who otherwise would have been missed with the existing system. To this end, the country has considered HIV/AIDS as one of the immediately notifiable diseases and established a case based surveillance system under the Public Health Emergency Management unit at the Ethiopian Public Health Institute (EPHI). Index testing is a family-based approach to HIV testing and service delivery not only helps to identify new cases but also enables parents, adolescents and children to access care as a unit and also have a potential to improve retention in treatment and care programs as it offers a convenient service for the family. Studies have shown high HIV positive yield through index testing [7,8].
The main drives of the HIV/AIDS epidemic in Ethiopia had been sexually active adults (15-49 years) and are the most crucial target for the national HIV/AIDS prevention and control efforts. These efforts have significantly contributed to the reduced national burden of HIV/AIDS and for the recoded positive progress the country has made. However, currently the situations on the ground seem to be changing. According to recent national data from urban HIV prevalence survey, the burden of HIV/AIDS is distributed across ages [9], which highlights the need for all-inclusive approaches. The survey uncovers the poor progress towards the 90-90-90 targets (to test 90% of the HIV cases, to put 90% of the tested 5 positive on treatment and to achieve a 90% viral suppression among those who received treatment by 2020) among adolescent and young adults, where only 48.2% were viral suppressed and the 50-64 years old adults that recorded the highest HIV prevalence (4.4%) [9]. Lack of reliable and comprehensive data on age specific burden on HIV/AIDS precludes the Ethiopian Federal Ministry of Health (FMOH) and the Federal HIV/AIDS Prevention and Control Office (FHAPCO) and other concerned stakeholders from understanding the magnitude of the problem to institute targeted responses. This paper intends to produce evidence for policy/decision makers to show age specific burden of HIV at the national level.
Outcome and impact indicators including incidence, mortality, prevalence and Disability Adjusted Life Years (DALYs) are commonly used measures for tracking progress, estimating disease burden as well as for equitable resource allocation, policy formulation and for developing strategies. Following the calming of the HIV/AIDS epidemic globally, the UNAIDS has suggested composite measures for better tracking of countries' progress towards the 2030 SDG target of ending AIDS as a public health threat [1]. These composite measures are incidence: mortality ratio, which measures annual change in the number of people living with HIV within a given population to forecast how current investments will impact future resource needs and incidence: prevalence ratio, which measures the average duration of time a person lives with HIV in an epidemic that remains stable over many years and helps to track progress towards the UNAIDS objective of "Preventing HIV infections and ensuring that HIV-positive people live long and healthy lives". Therefore, the objective of this paper is to track progress across selected ESSA countries towards the 2020 Fast Track millstones using outcome and impact indicators as well as UNAIDS suggested composite measures. The paper also presents estimates of age standardized and age specific burden of HIV/AIDS and progress that Ethiopia has made at 6 National level since 2001

Study settings
The Easter Sub-Saharan Africa (ESSA) region has carried highest HIV/AIDS burden in the world next to Southern Sub-Saharan African region. Currently, the region has demonstrated success in the prevention and control of the HIV/AIDS epidemic [1]. As part of the ESSA region, Ethiopia was one of the country hardest hit by the HIV epidemic. Yet, currently, the country is a leading example in controlling the HIV/AIDS epidemic. The country has achieved the Millennium Development Goal (MDG) 6 combating HIV/AIDS, recording a 90% HIV/AIDS reduction in HIV incidence between 2000 and 2015 [10]. With a population level HIV prevalence of 0.9%, Ethiopia has join countries having concentrated epidemic [3]. All these achievements did not happen in a vacuum. Country ownership of the HIV/AIDS prevention and control programs, strong political will and commitment have been instrumental for all the successes.
Ethiopia has been constantly updating its HIV/AIDS prevention and control interventions in line with global recommendations with some contextual adaptation [11][12][13][14]. The county has endorsed the UN Sustainable Development Goals (SDGs), which targets eradication of HIV/AIDS by 2030 from being a public health threat and its 2020 Fast Track interim millstones, which targets to test 90% of the HIV cases, to treat 90% of the tested and to achieve 90% viral suppression among those who received treatment. For attaining these goals, the country has developed an HIV/AIDS prevention and control roadmap, which targets 50% reduction in new HIV infection among adults by 2020 from the 2016 baseline [3].

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The National HV testing recommendations have shifted from Voluntary HIV Counseling and Testing (VCT) to Provider Initiated HIV Counseling and Testing (PICT), which has made HIV a routine test in antenatal setting and recently index testing has been introduced.
Enrollment to ART program has seen a departure from symptomatic/CD4 based to a 'test and treat' approach irrespective of CD4 cell count. Health facilities having HIV/AIDS diagnostic capacity such as CD4, viral load and Early Infant Diagnosing (EID) testing has become the norm not the exception.
In the past decade, Ethiopian has recorded significant improvement in basic health service coverage and is currently aiming for universal health coverage. Provision of free HIV/AIDS services including HIV testing, viral load, CD4, treatment and care in public health facilities have significantly increased access to and coverage of these services, which in turn contributed to the reduction in HIV incidence, prevalence and deaths. However, access and utilization of health services in general and HIV/AIDS care and treatment services in particular remain sub-optimal. According to HSTP midterm review, less than 50% of HIV positive women in Ethiopia have access to prophylaxis ART [5]. The situation is much worse in rural areas, where about 80% of the population live and in emerging subnational states/regions. According to current figures, over 20% of the HIV positive people do not know that they are HIV infected [3]. This is due to poor access to HIV testing, treatment and care services; poor health seeking behavior as well as due to sociocultural and structural barriers, which includes limitations to correctly map and reach out high risk groups.

Study Methods
The Ethiopian public health institute (EPHI) has established National Data Management for health (NDMC) in 2017. The goal of the center is to collect and archive available health and health related data; undertake in-depth data analysis by integrating different data 8 sources and applying robust statistical analytic methods; identify evidence gaps and The age-adjusted rates have taken into consideration demographic changes in the population, such as population growth and ageing.
This paper presents countries progress towards the 2020 interim Fast Track milestones that the United Nations General Assembly has proposed. These are a 75% reduction in incidence and mortality rates by 2020 from the 2010 baseline [1]. The study also used UNAIDS suggested complementary measures to estimate the burden of HIV/AIDS in a country and for tracking progress [1]. One of this is incidence:mortality ratio, which helps to track progress towards the SDG goal of ending AIDS as a public health threat by 2030.
Combining HIV incidence and mortality measures yield a dynamic measure of the annual change in the number of people living with HIV within a given population. The ratio helps to forecast how current investments will impact future resource needs. A ratio of > 1 indicates net increase in new HIV infections and the likely increase in the financial burden on the health system. A ratio of < 1 indicates net reduction in prevalent HIV cases due to mortality, and the likely decrease in financial burden on the health system. However, a ratio < 1 is undesirable. The other one is incidence: prevalence ratio, which indicates the average duration of time a person lives with HIV in an epidemic that remains stable over many years and helps to track progress towards the achievement of the UNAIDS objective of "Preventing HIV infections and ensuring that HIV-positive people live long and healthy lives". For this ratio, 0.03 has been selected by the UNAIDS as an epidemic transition benchmark, which corresponds to an average life expectancy after infection of 30 years.
The assumption is that with this average life expectancy, the total HIV prevalent cases will gradually fall if the number of incident cases are less than three per 100 people living Results F a s t T r a c k p r o g r e s s a c r o s s E a s t e r n S u b -S a h a r a n A f r i c a n ( E S S A ) c o u n t r i e s

Progress in reducing new HIV infection
To achieve SDG target 3.3, countries are expected to reduce new HIV infection by 75% between 2010 and 2020. The data has shown slow progress to achieve the 2020 millstone 11 in the ESSA region and it is less likely that the region would achieve the 2020 target.
Uganda has already achieved the 75% target set for to reduce HIV incidence by 2020.
Ethiopia has reduced the HIV incidence by 13.3% while Eritrea has recorded a 13.6% increases (Fig. 1).  Tracking Resource Need Using Incidence:mortality Ratio As shown in Fig. 3, the ESSA region and most ESSA countries have more people newly infected with HIV than those dying from HIV/AIDS, which gives a ratio of greater 1. By contrast, Ethiopia has more people dying from HIV/AIDS than those acquiring new HIV infections. In 2017, the age standardized incidence: mortality ratio for Ethiopia was 0.79, while 1.64 for Eastern Sub-Sahara Africa. Kenya, Rwanda, Tanzania and Uganda have a ratio of greater than one due to high rate of new infections and require more resource to address the problems.  (Table 1).

Discussion
The objectives of this study were to track progress towards 2020 Fast Track target, which is an interim millstones for the 2030 SDGs of "ending HIV from being a public health threat" [4] across Easter Sub-Saharan Africa countries and to estimate the burden of HIV/AIDS in Ethiopia across ages using GBD 2017 data. There has been slow progress in reducing HIV incidence across the ESSA region since 2010. The goal for reducing HIV/AIDS mortality by 75% by 2020 is within reach in most ESSA countries. Ethiopia, Rwanda and Uganda have achieved the incidence:mortality ratio of less than 0.03, which marks these countries are on track to meet the SDG 2030 target. In Ethiopia the HIV/AIDS mortality rate surpassed the incidence rate contrary to most ESSA countries, which contributed significantly to the reduction in HIV/AIDS prevalence. This is contrary to the UNAIDS's objective of "ensuring that HIV-positive people live long and healthy lives" and needs serious considerations. At national level understanding the burden of HIV and risk factors are priority areas to control pediatric and adolescent HIV/AIDS [20]. According to the findings, next to heterosexual contact, MTCT is the major contributor to new HIV infection in Ethiopia followed by having a large proportion of HIV positive adults over 50 years who are not virally suppressed. For sustainable epidemic control where Ethiopia is heading, the source of new infections need to be targeted and addressed and there is a need to build strong institutional capacity to track and monitor progress at national and local levels.
To achieve SDG target 3.3, countries are expected to reduce new HIV infection by 75% between 2010 and 2020 [1]. According to the findings, there has been slow progress to achieve the 2020 milestone across the ESSA region. Only Uganda has achieved the 75% target set to reduce HIV incidence by 2020. Ethiopia has reduced the HIV incidence only by 13.3% between 2010 and 2017 and is unlikely to achieve not only the 2020 Fast track target but also its own HSTP plan of reducing adult HIV incidence by 60% between 2010 and 2020 [5,6]. This is consistent with the HSTP midterm review findings, which highlighted poor progress to achieve the target set for HIV prevention and control and data gaps for progress monitoring [5,6].
The ESSA region has recorded 73% significant decline in HIV/AIDS related mortality between 2010 and 2017 and is more likely to achieve the Fast Track target by 2020. findings, Ethiopia has achieved the last two 90 s i.e putting more than 90% of the HIV diagnosed cases on ART and ensuring over 90% of the HIV/AIDS cases who received treatment achieved viral suppression among urban residents [9]. It is known that early initiation of ART and achieving significant viral suppression increases survival probability for patients infected with HIV. Despite these facts, the high mortality estimated in the present study could be attributed to the more than 40% undiagnosed HIV/AIDS cases.
According to the 2016 EDHS, about 60% of the population reported that they have never tested for HIV [21]. It is partly due to limited access to HIV testing, treatment and care services, limited access to health care services in some rural and remote areas and low health care utilization (poor health seeking behavior). Hence, at national level Ethiopia has intensified targeted HIV testing, index testing and CBS to address the aforementioned gaps and to identify 90% of the people who are HIV infected (to achieve the first 90).
In Ethiopia the HIV incidence among children under 5 years of age has shown a 77% decline between 2010 and 2017. Hence, the country is more likely to achieve the Zero new infection target set for 2020 but requires accelerate progress [5,6]. With regard to HIV incidence among adult (15-49 years), the recorded 12% increase by 2017 from the 2010 baseline is against the 60% reduction target the country has set for 2020. This requires to revisit current strategies and initiatives and to come up with innovative approaches to move fast forward [5,6].

Ethics approval and consent to participate
The manuscript used an open access GBD 2017 data from the Institutes of Health Metrics and Evaluation (IHME), University of Washington Health Data portal.

Consent for publication
"Not applicable"

Availability of data and materials
The datasets generated and/or analysed for the study are available in the IHME data repository and can be accessed directly from http://ghdx.healthdata.org/gbd-results-tool and has also submitted as supporting file with the manuscript.  Supplementary Files This is a list of supplementary files associated with the primary manuscript. Click to download. S1.xlsx