Importance of HIV testing and linkage to care

Scaling up testing and linkage to care

Setting the scene

Dr Valerie DelpechHIV & STI Department, National Infection ServicePublic Health England

Talk outline

Why is testing for HIV and prompt link to care important

How well are we doing?

Achieving scale up of testing

Current HIV trends in England

Why is testing for HIV and prompt link to care important?

3 Current HIV trends in England

Early diagnosis and treatment of HIV means a normal life span and protection from passing on the virus

In Europe, where treatment is availablelate diagnosis main factor associated with premature deathNo one should die of AIDS in 2017

HIV without treatment

Xiao et al. Theoretical Biology and Medical Modelling (2017) 14:1DOI 10.1186/s12976-016-0047-0

Trends in estimated death rate per 1000 people living with HIV, 20012013.

Granich R, Gupta S, Hersh B, Williams B, Montaner J, et al. (2015) Trends in AIDS Deaths, New Infections and ART Coverage in the Top 30 Countries with the Highest AIDS Mortality Burden; 19902013. PLoS ONE 10(7): e0131353. doi:10.1371/journal.pone.0131353http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0131353

http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0131353

Figure 2

The Lancet Global Health 2015)

Copyright 2015 Nsanzimana et al. Open Access article distributed under the terms of CC BY-NC-SA T

Life expectancy among HIV-positive patients in Rwanda: a retrospective observational cohort studyNsanzimana et al

http://www.elsevier.com/termsandconditionsmailto:[email protected]:[email protected]

Key findings:

Of the 88,994 adults diagnosed with HIV between 1997-2012 in England & Wales, 5,302 (6.0%) had died by the end of 2012. (all-cause mortality 118 per 10 000 person-years)

People living with HIV had a mortality rate 6 times higher than the general population for all causes (SMR 57, 95% CI 5558)

late diagnosis was a strong predictor of death (hazard ratio [HR] 350,95% CI 313392).

57% of deaths occurred within 1 year of diagnosis and 23% of people who died were never linked to care (92% died within 1 year of diagnosis)

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New HIV diagnoses and one year mortality(prompt and late) among heterosexuals: UK

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New HIV diagnoses and one year mortality (prompt and late) among MSM: UK

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Treatment as Prevention

Treatment as Prevention

Granich RM et al, Lancet 2009; 373: 4857

Compelling Evidence MTCT and breastfeeding

Cohort of couples

Swiss statement

Ecological

RCT HPTN052

Modelling

PARTNER study

Early diagnosis and treatment safes lives

How are we doing? How do we know?

UNAIDS targets by 2020

90% People living with HIV know their status

90% of diagnosed on sustainable ART

90% of treated have a durable viral suppression

This would result in the end of AIDS and make HIV transmission rare by 2030

Are the UNAIDS goals achievable?Will it result in the end of AIDS and a near elimination of HIV?

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCOXu1Nu04sgCFYlxFAodf-8E-A&url=http://data.london.gov.uk/dataset/public-health-outcomes-framework-indicators&psig=AFQjCNFbFq5dHnxBqX5GY7q6FivbU30-9A&ust=1446027058307735http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCOXu1Nu04sgCFYlxFAodf-8E-A&url=http://data.london.gov.uk/dataset/public-health-outcomes-framework-indicators&psig=AFQjCNFbFq5dHnxBqX5GY7q6FivbU30-9A&ust=1446027058307735

We need good and timely data


Fig 2. Global AIDS-related death rate per 1000 people living with HIV in 2013.

Granich R, Gupta S, Hersh B, Williams B, Montaner J, et al. (2015) Trends in AIDS Deaths, New Infections and ART Coverage in the Top 30 Countries with the Highest AIDS Mortality Burden; 19902013. PLoS ONE 10(7): e0131353. doi:10.1371/journal.pone.0131353http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0131353

http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0131353

Current global estimates for the care cascadeLevi et al 2016*

Levi J, Raymond A, Pozniak A, Vernazza P, Kohler P, Hill A. Can the UNAIDS 90-90-90 target be achieved? A systematic analysis of national HIV treatment cascades. BMJ Glob Health 2016;

* Based on 69/196 countries 32 complete, 37 partial data

Reaching UNAIDS the 90 90 90 targets.

15 million on ART in 2015, up from 3million in 2005 Keep calm and carry on.

How are countries in Europe performing against the 90-90-90 treatment targets? N=16

90%81%

73%

ECDC. Thematic report: HIV continuum of care. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2014 progress report. Stockholm: ECDC; 2015.

Chart1

100100

7645

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52.166414

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non-EU/EEA

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Estimated nr living with HIV100100

Diagnosed7645

On ART59.2821.6

Viral suppression52.166414

How are European and Central Asian countries performing in ensuring people living with HIV are diagnosed and treated? Illustration Using cut points at 60%

Drew, Human Immunodeficiency Virus (HIV) Continuum of Care in Europe and Central Asia, HIV Medicine, 2016


Treatment policies: improving test and treat

Source: ECDC. The status of the HIV response in the European Union/European Economic Area, 2016. Stockholm: ECDC; 2017.

Scaling up testing and link to care and treatment

How much and how?

Is HIV testing among MSM delivered at scale in EU/EEA Member States? (n=30)

27 countries: HIV testing is delivered at scale for MSM

16 countries: Have data on uptake of HIV testing among MSM

5 countries: Data on uptake of HIV testing among sub-groups of MSM at increased risk

Source: Dublin monitoring 2015

Are there major gaps in HIV testing services for any of the following populations?

Key populations YES NO

Undocumented migrants 17 29

Migrants from high prevalence countries 13 33

MSM 11 35

Sex workers 10 36

PWID 7 39

Prisoners 5 41

Transgender people 2 44

What needs to happen?

Current HIV trends in England

00.10.20.30.40.50.60.70.80.9

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test rate +

test rate ++

base test rate(Currentsituation)

Years from infection

Proportion infected

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Phillips, AIDS 2015

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Number of new infectionsper year

2015 2020 2025 2030 Year

HIV incidence among MSM, Phillips 2015

test rate ++ ART 350

base test rate ART at diagnosistest rate + ART at diagnosistest rate ++ ART at diagnosis

test rate + ART at 350base test rate ART at 350

95% CIgiven for twolines to illustrateuncertaintyover mean effect

Scaling up testing & link to treatment and care Up to date testing and treatment guidelines Affordable drugs for governments and free for all diagnosed persons Commitment at every level Testing, diagnosis and care within a human rights framework Reduce barriers and promotion of good practice Testing strategies based on local epidemiology community engagement innovation making it easier to test close monitoring and evaluation at all levels

Strategies based on evidence and understanding of the local epidemiology

Presentation title - edit in Header and Footer

Prevalence of diagnosed HIV

infection by area of residence among

population aged 15-59: United Kingdom, 2015

Overall prevalence rate:2.26 (2.24-2.27) per 1,000

Geographical targeting

Late HIV diagnosis (CD4

Presentation title - edit in Header and Footer

Improvements in time to ART, UK


Greater inclusion and engagement of community

Community engagement Stigma and discrimination remains major barrier to testing, link

and retention in care and prevention efforts Need greater engagement of affected communities at every

level Tailored messages for individuals recognising diverse nature of

community Support peer-led initiatives and outreach programs Sustained funding for NGOs Provision of integrated and welcoming, non judging services in

partnership with NGOs

39 Presentation title - edit in Header and Footer


Experiences of stigma and discrimination in the last 12 months among women, 2015

Reported experiences of stigma and discrimination in the last 12 months in the health care setting, 2015

Promote sexual health among LGBT communities across the life course

Tackling homophobia and bullying Education in Schools Increase use of high-quality, coordinated

educational, clinical, and other preventive services

Increase knowledge, communication, and respectful attitudes regarding sexual health and drug and alcohol use

Promoting opportunities to discuss role of pleasure, satisfaction and ability to use drugs with the least harm

Increase healthy, responsible, and respectful sexual behaviors and relationships

Decrease adverse health outcomes, including HIV/STIs, viral hepatitis, and sexual violence

42Source: Douglas JM Jr, Fenton KA. Public Health Rep. 2013 Mar-Apr;128 Suppl 1:1-4


Combination approach to prevention

43 Current HIV trends in England

New HIV diagnoses in STI clinics in the UK, the beginning of a downturn in gay/bisexual men?

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Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3

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Gay/bisexual men Heterosexual men Heterosexual women

Situation Jan 2017 PHE Ongoing investigation

High rise in number of HIV tests among MSM particularly in some London clinics

Especially high rise in testing and sexual health screens among repeat testers

Associated with downturn in some STIs and HIV in recent months, decreased late diagnoses

Improvements in early ART and decrease in the number of men with unsuppressed viral load

Prep Use increasing

Most likely decrease in incidence due combination of interventions

We have the tools & know what to do scientific knowledge

Innovate and re-novate to simplify access to testing and treatment

better contextualise our knowledge for and engage communities

Expect constant change and refinement and big step changes

Advocate for generics and prevention funding

Tackle legal barriers and/or creatively circumvent them

Timely accurate information for setting policy and monitoring efforts is crucial

Greater engagement of public health working in partnership with health professionals and community

Prevention Tool kit, John Walter, 2015

In the 4th decade of the HIV epidemic


Teymur Noori, Anastasia Pharrisand Andrew Amato, ECDCCary James Terence Higgins Trust, HIV Prevention EnglandAndrew Phillips and colleagues at UCLAndrew Hill and colleagues at Imperial

Colleagues PHE: Anthony Nardone, Gwenda Hughes, Noel Gill, Kathy Lowndes, Owen Brigstock-Barron, Luis Guerra, Daniella De Angelis, Anne Presanis, Stefano Conti

HARS team Alison Brown, Meaghan Kall, Sara Croxford, Sandra Okala, Peter Kirwan, Cuong Chau, Matthew Hibbert, Jameel,Amrita Nick Cooper, Rajani Ragu, Janice Morgan, Adamma Agazhui, Zheng Yin

Thank you & Acknowledgements

Scaling up testing and linkage to careSetting the sceneTalk outlineSlide Number 3Early diagnosis and treatment of HIV means a normal life span and protection from passing on the virusSlide Number 5Slide Number 6Slide Number 7Slide Number 8Slide Number 9Slide Number 10New HIV diagnoses (prompt and late) among heterosexuals: UK New HIV diagnoses and one year mortality (prompt and late) among heterosexuals: UKNew HIV diagnoses (prompt and late) among MSM: UKNew HIV diagnoses and one year mortality (prompt and late) among MSM: UKSlide Number 15Treatment as PreventionEarly diagnosis and treatment safes livesHow are we doing? How do we know?Slide Number 18Slide Number 19Slide Number 20Slide Number 21Slide Number 22How are countries in Europe performing against the 90-90-90 treatment targets? N=16How are European and Central Asian countries performing in ensuring people living with HIV are diagnosed and treated? Illustration Using cut points at 60%Treatment policies: improving test and treat Slide Number 26Is HIV testing among MSM delivered at scale in EU/EEA Member States? (n=30)Are there major gaps in HIV testing services for any of the following populations?Slide Number 29Slide Number 30Slide Number 31Scaling up testing & link to treatment and careSlide Number 33Strategies based on evidence and understanding of the local epidemiologyPrevalence of diagnosed HIV infection by area of residence among population aged 15-59: United Kingdom, 2015Late HIV diagnosis (CD4

Importance of HIV testing and linkage to care

Health & Medicine

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