Fast-track the end of AIDS in the EU - practical evidence-based interventions.
Presentation by: Amanda Mocroft, UCL
In a two-day meeting under the auspices of the Maltese Presidency of the Council of the European Union (30-31 January 2017), HIV experts from across the European Union discussed how to reverse this trend and how to prepare Europe to achieve the set target of ending AIDS by 2030.
2. HIV continuum of care : A marker of
quality of HIV care
• Individual health benefits
o Reducing morbidity and
mortality
o Reducing HIV drug resistance
development/triple class ARV
failure
• Public health benefits
o Reduced transmission
o Containing/ending the epidemic
o Helps target local interventions
• Health disparities exist across
Europe in HIV
• Increasing interest in
comparing quality of care
across countries
o Understand the variation
o Identify gaps
o Target interventions
• Best practice; monitor own
performance
• Cost-effectiveness
• Highlight different challenges;
inform health policy
HIV Continuum : 90:90:90 Quality of HIV care
3. The 4-point continuum of care for HIV
0
20
40
60
80
100
Estimated
living with HIV
Diagnosed On ART Virally
suppressed
%
Stage of HIV disease
Left hand side Right hand side
• Processes and
information needed for
LHS or RHS of CoC vary
o Statistical modelling
o Accurate surveillance
and reporting systems
o Good clinical or cohort
data
• Approaches to improve %
on LHS or RHS and thus
achieve 90-90-90 are
different
4. Country Country’s own estimate
Article Year
On ART
* Of those retained in care;
§ Of those linked to care
On ART and suppressed
Switzerland Kohler AIDS 2015 2012 91% * 96%
Russia Pokrovskaya HIV Glasgow 2014, JIAS
17(Suppl 3):19506
2011-2013 32.6%*
30.4% §
81%
Denmark / Sweden Helleberg PLoS ONE 2013 2010 82.8% * 74.3%
Spain Diaz VI Congreso Nacional de GeSIDA 2014 2010/2013 Cohort data (CoRIS): / National
registry data
98.5% / 93.9*
86.1% / 84.6% §
Cohort data (CoRIS): 94%
National registry data: 92.9%
Georgia Chkhartishvili HIV medicine 2015 1989-2012 68.9% *
59.6% §
77.4%
UK HIV in the United Kingdom: 2014 Report.
London: Public Health England. 2014
2013 90% § 90%
Estonia Laisaar 9th international conference in HIV
treatment and prevention adherence
(abstract 337)
2013 87.9% *,
49.1% §
65.6%
France Supervie CROI 2013 2010 80.8% of those “in care” 85.9% of those on ART >6
months
Belgium Beckhoven BMC Infect Dis 2015 2011 84.6% * 83.4%
Ukraine Kazatchkine HIV Glasgow 2014,
JIAS 17(Suppl 3):19501
2012 40.6% of those in care 78.1%
Netherlands Monitoring report 2014, HIV Infection in
the Netherlands (www.hiv-monitoring.nl)
2014 90.6% *
84.3% §
90.8%
Ireland https://www.imo.ie/news-
media/publications/JulyAugust-2015-IMJ-
hr.pdf
2009-2010 84.6% * 94.3%
Romania UNAIDS/
http://www.cnlas.ro/images
/doc/30062015_eng.pdf
2014 81.7% * 53.7%
5. Using the EuroSIDA cohort to monitor
the right hand side of the continuum
of care
• Patients included from all
EuroSIDA clinics
• A priori defined 3 time
periods
o 2004/05 (1/1/04 – 31/12/05)
o 2009/10 (1/1/09 – 31/12/10)
o 2014/15 (1/1/14 – 31/12/15)
• In care during time period
• On cART; ≥3 antiretrovirals
• Virologically suppressed (VL <
500 cp/ml) among those on
cART
• In care, but no HIV-RNA
measurement in time period
assessed, considered
unsuppressed (missing =
failure)
Methods Definitions
6. Regions in the EuroSIDA study
• Western Europe (WE): Austria, Belgium, France, Germany, Luxembourg, Switzerland
• Southern Europe (SE): Argentina, Greece, Israel, Italy, Portugal, Spain
• Northern Europe (NE): Denmark, Finland, Iceland*, Ireland, Netherlands, Norway,
Sweden, United Kingdom
• East Central Europe (EC): Bosnia-
Herzegovina*,Croatia*, Czech Republic,
Hungary, Poland, Romania, Serbia,
Slovakia¤, Slovenia*
• Eastern Europe (EE): Belarus, Estonia,
Georgia*, Latvia, Lithuania, Russia,
Ukraine
* only included in 2014/15 cohort, ¤ only included in 2004/05 cohort
8. The RHS on the CoC in EuroSIDA
countries : 2004 - 2005
9. The RHS on the CoC in EuroSIDA
countries : 2004 - 2005
Right hand side of 90 / 90
/ 90 fulfilled in 2004/2005
NO countries in EuroSIDA
>90% of those under FU
on cART
>90% of those under FU
on cART virologically
suppressed
10. The RHS on the CoC in EuroSIDA
countries : 2004/05, 2009/10, 2014/15
2004/2005
2009/2010
11. The RHS on the CoC in EuroSIDA
countries : 2004/05, 2009/10, 2014/15
2004/2005
2009/2010
2014/2015
12. The RHS on the CoC in EuroSIDA
countries : 2004/05, 2009/10, 2014/15
2004/2005
2009/2010
2014/2015
In 2014-15, 6/35 (17%) countries reached levels
of cART-coverage and virological suppression
among those on cART that were above 90%.
Country-specific % of cART-coverage ranged
from 63% to 98%
Country specific % of virological suppression
ranged from 31% to 100%.
13. Strengths and weaknesses of approach
• Access to data from large
number of countries
• Data from countries without
national registries
• Access to complete data on
ART-coverage
• Standardized data collection
allows direct comparison
between countries
• Possibility of comparing
temporal trends
• EuroSIDA patients not
necessarily representative
of patients in the whole
country
• ”On cART among those in
care”, rather than among
those diagnosed
• Guidelines have changed
over time
• Not an adherence to
guidelines study
Strengths Weaknesses
14. Where are the gaps in knowledge?
• Ongoing projects to understand continuums of care and how
cohort data can supplement surveillance data
• Largely based on countries with strong national cohorts
including a large proportion of persons HIV+ within country
• Data in such cohorts likely to be similar to surveillance data
• Urgent need to capture the experiences of countries that have
smaller cohorts and less reliable surveillance system
o Such countries may have the largest numbers of HIV-positive persons,
together with poorer access to antiretroviral therapy and management
of HIV disease
16. Establishing a CoC module in RESPOND
• Establish methodology and approach for improving the monitoring of the
continuum of HIV care in countries across Europe
• Explore longitudinal measures of continuums as well as the optimal
definitions for viral suppression
• Focus on EU/EEA countries as well as Central Eastern and Eastern Europe,
where surveillance and cohort data are more limited
• Extending the experience, collaboration and network of the EuroSIDA
network and the Optimising Testing and Linkage to Care for HIV in Europe
(OptTEST) project
• Establish methodology, expertise and infrastructure for clinics to determine
their own continuum and contribute to national and regional continuums
• Once established, methods could be adopted by any clinic or country to
construct their own continuum
17. Providing technical support for
establishing continuum needed at
different levels at different clinics
Network can draw on experience from
• CHIP as WHO collaborating Centre
for HIV and viral hepatitis
• EuroSIDA network
• TESSy data
• Dublin declaration
• Modelling team at UCL (Phillips,
Nakagawa)
• Modelling team at PHE
Establishing PLWHIV for left hand side of continuum
• Workbook and Spectrum
• ECDC modelling tool
Working with
• Country stakeholders
• Surveillance teams
• Public health experts
• Clinical experts
• Cohort leads
• National HIV or clinical data
registries
Establishing a CoC module in RESPOND
• Proof of concept for how EuroSIDA
network can help individual
clinics/countries collect better
surveillance data for constructing
full CoC
• Providing support and assistance to
enable countries to use the ECDC
modelling tool
• RESPOND will work with each clinic
to have a complete overview of
• data available to identify gaps
in surveillance data
• how that can be improved
• investigate how to provide
data to RESPOND to enable
the RHS of CoC to be
established and monitored
• Linking clinic level data, knowledge
and public health needs and
knowledge is key
18. Country Clinic PLWHIV HIV Prevalence In EuroSIDA
(%) N (%)
Slovenia University Clinical Centre Ljubljana <1,000 0.04 34 (3.4)
Croatia University Hospital of Infectious Diseases 1,000 0.02 145 (14.5)
Estonia West-Tallinn Central Hospital 14,000 2.4 248 (1.8)
Hungary Szent László Hospital 4,100 (2011 est.) <0.1 217 (5.3)
Bosnia Klinicki centar Univerziteta, Sarajevo 245 0.006 42 (17.1)
Romania Dr. Victor Babes Hospital 16,000 (2011 est.) 0.1 151 (0.9)
Poland Wojewodzki Szpital Zakazny 30-35,000 <0.1% 1209 (3.5)
Ukraine Crimean Republican AIDS centre 223,000 0.58 486 (0.2)
Switzerland All clinics 15,200 0.2 722 (4.8)
Possible clinics and countries for establishing national
continuum of care : Proof of Concept
Establishing a CoC module in RESPOND
19. Summary and perspectives
• Using EuroSIDA data, we were able to directly compare data from
a large number of countries across Europe, including some with
no national registries.
• For the RHS of the CoC, we found persistent between-country
disparities in both the level of ART-coverage and virological
suppression, and in the rate of improvement over the last decade
• Aim to expand the EuroSIDA network and work program and
establish proof of concept via RESPOND in a CoC module
• Aim to help clinics and countries establish their own CoC as well
as improving surveillance data
20. Acknowledgements
• The entire EuroSIDA study group; details at
http://www.cphiv.dk/Studies/EuroSIDA/Study-group
• Kamilla Laut, Leah Shepherd
• Jens Lundgren, Dorthe Raben and Lene Ryom
21. Fast-track the end of AIDS in the EU
practical evidence-based interventions