Given the widely observed successes of treatment rollout, the central question for the future of international AIDS policies, is how to build and to support conditions that promote sustainable wellbeing for those with HIV, while also dealing with immediate HIV policy imperatives [1]. Here I ask – does the HIV care cascade do this? One of the central international AIDS policy frameworks currently is Treatment as Prevention (TasP) [2,3]. It aims to both provide antiretroviral treatment to those who need it and to tackle a fundamental challenge in the global fight against the disease: preventing further spread of HIV. While increased access to antiretroviral treatment globally has allowed more and more to live longer lives, a recent UNAIDS report shows it is hard to control the epidemic by controlling new infections. Notwithstanding increased access to treatment and despite the observed decline in new infections, 1.8 million people were “[still] infected in 2017”; these mostly included women in Africa and key populations and their partners globally [4]. TasP aims to tackle the problem through new policies and intervention strategies. Its goal is operationalized by the global 90-90-90 targets that are to be achieved by 2020 that aim to “end the AIDS epidemic by 2030” [5]. The implementation mechanism of the policy is captured in the 90-90-90 label: “if 90% of all people living with HIV will know their HIV status and 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression by 2020” this will mean that “at least 73% of all people living with HIV worldwide will be virally suppressed” and according to “modelling [this] suggests that achieving these targets by 2020 will enable the world to end the AIDS epidemic by 2030” (5, p. 2). The implementation mechanism of the 90-90-90 targets is based on and uses the logic of the HIV care cascade. The logic is presented by Gardner at al. in their influential 2011 study reviewing HIV treatment and care in the US. They review the epidemiological data to “describe and quantify the spectrum of engagement in HIV care . . . and better understand how gaps in the continuum of HIV care affect virological outcomes in the United States” [6, p. 793]. This mapping exercise highlights gaps in the US system in terms of increasing HIV testing rates and keeping people in the care system once they are tested. This presents an analytical logic of the cascade by identifying suboptimal linkages within the “spectrum of engagement in HIV care” as “significant barriers” to achieving good treatment outcomes’ [6, p. 792]. They “posit that expanded testing and earlier treatment of HIV infection could markedly decrease ongoing HIV transmission” [6, p. 793]. The important basic insight in this analysis is that the potential of antiretroviral therapy to produce wellbeing and to achieve undetectable viral load is a function of how individuals living with HIV are located within the care system and provided support over time. The analytical lens of the care cascade provides a way to evaluate where the gaps are in the existing treatment, healthcare support for people with HIV [7–10]. The emerging causal narrative presents a sequential if then logic that begins with a positive testing result and ends with viral suppression in individuals. It is this causal pathway, emerging from the data analysis that has become the policy model framing TasP as to how policy interventions should be implemented to achieve the overall policy outcome of stopping the epidemic through individuals with HIV achieving viral suppression. The 90-90-90 policy uses this logic as the mechanism for global policy implementation by linking each stage of the cascade with quantifiable policy targets to be achieved. This mechanism creates compartmentalized research and policy that aim at each stage to isolate and focus on those individuals who are identified as not engaging with the health system, so that at the end, once policies produce expected results at each stage, the policy is supposed to produce cumulatively the overall outcome of viral suppression at population level, and so ending the epidemic. UNAIDS states that “[T] hese new targets address progress along the HIV cascade engagement in care, measuring the degree to which Seckinelgin H Journal of the International AIDS Society 2019, 22:e25259 http://onlinelibrary.wiley.com/doi/10.1002/jia2.25259/full | https://doi.org/10.1002/jia2.25259

中文翻译：

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艾滋病毒护理级联和艾滋病毒感染者的可持续福祉背景

鉴于广泛观察到的治疗推广成功，国际艾滋病政策未来的核心问题是如何建立和支持促进艾滋病毒感染者可持续福祉的条件，同时还要应对艾滋病毒政策的紧迫要求 [1]。我在这里问——艾滋病毒护理级联是否做到了这一点？目前的主要国际艾滋病政策框架之一是治疗即预防 (TasP) [2,3]。它旨在为有需要的人提供抗逆转录病毒治疗，并应对全球抗击这种疾病的根本挑战：防止艾滋病毒的进一步传播。虽然全球范围内获得抗逆转录病毒治疗的机会增加，使越来越多的人活得更久，但联合国艾滋病规划署最近的一份报告显示，很难通过控制新感染来控制这种流行病。尽管获得治疗的机会有所增加，尽管观察到新感染人数有所下降，但仍有 180 万人“[仍然] 在 2017 年受到感染”；其中主要包括非洲妇女和全球重点人群及其合作伙伴 [4]。TasP 旨在通过新的政策和干预策略来解决这个问题。其目标是到 2020 年实现的全球 90-90-90 目标，旨在“到 2030 年结束艾滋病流行”[5]。90-90-90 标签中捕获了该策略的实施机制：“如果到 2020 年，90% 的 HIV 感染者知道自己的 HIV 感染状况，90% 的确诊 HIV 感染者将接受持续的抗逆转录病毒治疗，90% 的接受抗逆转录病毒治疗的人将获得病毒抑制”，这将意味着“全世界至少有 73% 的 HIV 感染者将被病毒抑制”，并且根据“模型 [this] 表明，到 2020 年实现这些目标将使世界能够在 2030 年结束艾滋病流行”（5, p. 2 ）。90-90-90 目标的实施机制基于并使用了 HIV 关怀级联的逻辑。逻辑由 Gardner 等人提出。在他们有影响力的 2011 年研究中回顾了美国的 HIV 治疗和护理。他们审查流行病学数据以“描述和量化参与艾滋病毒护理的范围。. . 并更好地了解艾滋病毒护理连续性的差距如何影响美国的病毒学结果”[6, p. 793]。这项绘图工作突出了美国系统在提高 HIV 检测率和在人们接受检测后将其留在护理系统方面的差距。这通过将“参与艾滋病毒护理的范围”中的次优联系确定为实现良好治疗结果的“重大障碍”，提出了级联的分析逻辑 [6, p. 13]。792]。他们“假设扩大检测和早期治疗 HIV 感染可以显着减少正在进行的 HIV 传播”[6, p. 793]。该分析中重要的基本见解是，抗逆转录病毒疗法产生福祉和实现无法检测的病毒载量的潜力取决于 HIV 感染者如何在护理系统中定位并随着时间的推移提供支持。护理级联的分析镜头提供了一种评估艾滋病毒感染者现有治疗和医疗支持方面存在差距的方法[7-10]。新出现的因果叙述呈现了一个连续的如果那么逻辑，从阳性检测结果开始，以个体的病毒抑制结束。正是这个因果路径，从数据分析中出现的数据分析已成为制定 TasP 的政策模型，关于应如何实施政策干预以实现通过艾滋病毒感染者实现病毒抑制来阻止流行的总体政策结果。90-90-90 政策使用这种逻辑作为全球政策实施的机制，将级联的每个阶段与要实现的可量化政策目标联系起来。这种机制创建了针对每个阶段的划分研究和政策，以隔离和关注那些被确定为不参与卫生系统的个人，以便最终，一旦政策在每个阶段产生预期结果，该政策就应该在人群水平上累积产生病毒抑制的总体结果，从而结束流行。联合国艾滋病规划署指出，“[T] 这些新目标解决了 HIV 级联参与护理方面的进展，衡量了国际艾滋病协会 2019 年 22:e25259 http://onlinelibrary.wiley.com/doi/ 10.1002/jia2.25259/全| https://doi.org/10.1002/jia2.25259