Cofunded by the 2 nd Health Programme of the European Union T o t al 3 6 9 million 34 3 m illio n 41 4 m illion M i d d le E ast ID: 1022935
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1. HIV Testing<Presenter, date>Co-funded by the 2nd Health Programme of the European Union
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4. Total: 36.9 million [34.3 million – 41.4 million]Middle East & North Africa240 000[150 000 – 320 000]Sub-Saharan Africa25.8 million[24.0 million – 28.7 million]Eastern Europe& Central Asia1.5 million[1.3 million – 1.8 million]Asia and the Pacific5.0 million[4.5 million – 5.6 million]North America and Western and Central Europe2.4 million[1.5 million – 3.5 million]Latin America1.7 million[1.4 million – 2.0 million]Caribbean280 000[210 000 – 340 000]Number of adults and children living with HIV, 2014
5. New HIV diagnoses per 100 000 population, 2014, WHO European Region
6. New HIV diagnoses, 2014, EU/EEA> 20 10 to <202 to <10 < 2Not included or not reportingLiechtenstein Luxembourg MaltaNon-visible countriesRate per 100 000 populationEU/EEA rate 5.9 per 100 000** EU rate adjusted for reporting delay is 6.4 per 100 000
7. Rate of reported HIV diagnoses, by year of diagnosisWHO European Region, 2005-2014
8. Rate of reported HIV diagnoses, by year of diagnosisEU/EEA, 1984–2013Source: ECDC/WHO (2014). HIV/AIDS Surveillance in Europe, 2013
9. HIV prevalence, 2014, EU/EAA
10. HIV diagnoses, by mode of transmission, 2005-2014, WHO European Region
11. HIV diagnoses, by mode of transmission, 2005-2014, EU/EEAData is adjusted for reporting delay. Cases from Estonia and Poland excluded due to incomplete reporting on transmission mode during the period; cases from Italy and Spain excluded due to increasing national coverage over the period.Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014Injecting drug useHeterosexual (women)Heterosexual (Men)Sex between menMother-to-child transmissionOther/undetermined
12. Percentage of HIV diagnoses, by route of transmission, 2014, EU/EEA Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014
13. Percentage of new HIV diagnoses with known mode of transmission, by transmission route and country, EU/EEA, 2014 (n = 24,083)
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16. Why test for HIV?Reduced healthcare costsAvoiding the complications associated with untreated HIV, and thereby avoiding the resulting healthcare costs Reduced onward transmission to partnersRisk behaviour modificationEffective treatment results in an undetectable viral load, and means they are considered to be non-infectious to sexual partners Direct health benefits to the individual when able to access effective antiretroviral therapyDecreased morbidityDecreased mortality
17. Why test for HIV?Increasing HIV testing should lead to increased numbers of HIV diagnoses. This in turn should result in decreases in: individuals living with undiagnosed HIV individuals presenting with late stage disease
18. Reducing the number of people living with undiagnosed HIV
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20. > 50% 40 to 50%30 to <40% < 30%Not included or not reportingProportion of HIV cases diagnosed late (CD4<350 cells/mm3) 2014, EU/EEA*Among cases with CD4 count at diagnosis reportedLiechtenstein Luxembourg MaltaNon-visible countries
21. Late Diagnosis in Europe: Late presentation and CD4 count at HIV diagnosis 2000 – 2011 (COHERE)
22. 13 Late diagnosis in Europe, 2013
23. New HIV diagnoses, by CD4 cell count at diagnosis and transmission mode, EU/EEA, 2014Source: ECDC/WHO (2015). HIV/AIDS Surveillance in Europe, 2014>500 cells/mm3200 to <350 cells/mm3< 200 cells/mm3350 to <500 cells/mm3
24. Late diagnosis in <COUNTRY>, <YEAR>Please use this template if don’t have access to a country level data slide.See notes.10%42%48%28%Proportion without a reported CD4 count at diagnosisProportion diagnosed with a CD4 count >350 cells/uLProportion with a CD4 count indicating late diagnosisProportion with a CD4 count indicating advanced disease
25. www.testingweek.euwww.hiveurope.eu In <YEAR> <X%> of individuals diagnosed with HIV infection presented late (CD4 count <350 cells/uL) <Y%> presented very late (CD4< 200 cells/uL)Late HIV diagnosis, <COUNTRY, YEAR> Please use this template if don’t have access to a country level data slide. See notes
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28. Consequences of late diagnosisIncreased morbidity and mortalityIncreased healthcare costsIncreased onward transmission
29. www.testingweek.euwww.hiveurope.eu Increased mortality associated with late diagnosis
30. www.testingweek.euwww.hiveurope.eu Cumulative probability of death of people with HIV according to timing of diagnosis
31. Evidence shows that when individuals are diagnosed with HIV infection they decrease their risk behaviour. Increased risk of transmission of HIVHIV patients taking effective treatment are very unlikely to transmit HIV. People who remain undiagnosed do not have the advantage of either of these two factors.
32. Undiagnosed HIV and onward transmissionUSA modelling data
33. www.testingweek.euwww.hiveurope.eu Increased healthcare costsMedical costs associated with late diagnosis are up to 3.7 times as high as those associated with timely diagnosis and treatmentEven after 7 - 8 years, late diagnosis is still associated with higher cumulative expensesStudies suggest that HIV testing remains cost-effective as long as the undiagnosed HIV prevalence is above 0.1%
34. Increased healthcare costs
35. www.testingweek.euwww.hiveurope.eu Benefits of early diagnosis: access to treatment and careImproved treatment responseDecreased morbidity and mortalityDecreased onward transmissionDecreased healthcare costsImpacts societal costsEarlier HIV diagnosis is one of the most important factors associated with better life expectancyThe benefits of early HIV testing on morbidity and mortality:“With timely diagnosis, access to a variety of current drugs and good lifelong adherence, people with recently acquired infections can expect to have a life expectancy which is nearly the same as that of HIV negative individuals.”
36. CD4 at start of therapy impacts on immunological outcomeImproved treatment response with anti-retroviral (ARV) therapy
37. Adjusted relative risk of AIDS or death during the pre-HAART, early-HAART and late-HAART eras from the EuroSIDA Study1996, HAART became availableProportion of individuals with HIV infection dying in relation to introduction of HAART Pre-HAART: 14.6% Early-HAART: 7.4% Late-HAART: 1.5%
38. 878889909192939495969798990001020304050607080510152025301111987-1993zidovudine (1987)didanosine (1991)zalcitabine (1992)1994-2000stavudine (1994)lamivudine (1995)saquinavir (1995)ritonavir (1996)indinavir (1996)nevirapine (1996)nelfinavir (1997)delavirdine (1997)efavirenz (1998)abacavir (1998)amprenavir (1999)lopinavir/r (2000)2001-2007tenofovir (2001)enfuvirtide (2003)atazanavir (2003)emtricitabine (2003)fosamprenavir (2003)tipranavir (2005)darunavir (2006)maraviroc (2007)raltegravir (2007)2008-2014etravirine (2008)rilpivirine (2011)dolutegravir (2013)elvitegravir (2014)091413121110NRTI, Nucleoside reverse transcriptase inhibitorPI, protease inhibitorNNRTI, Non-nucleoside reverse transcriptase inhibitorCCR5 antagonist / Entry inhibitorIntegrase inhibitorAntiretroviral drug approval Year of FDA ApprovalTotal no.of drugs
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40. Missed opportunities for diagnosis Pérez Elías MJ, EACS 2013 PS8/3
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42. Frequently raised concerns about HIV testing At patient levelAt institutional/policy levelAt healthcare professional level
43. Patient level: potential barriersPatient level barriers vary from country to countryCross-cultural barriers include:Low risk perceptionFear of HIV infection and its health consequencesFear of disclosure DenialDifficulty accessing services
44. Healthcare provider level: potential barriers and concerns
45. Institutional level: potential barriers and ways to address concernsIncreased costsIt is cost effective if diagnose at least 1 person for every 1000 testedConsider the cost to the Institution of missed HIV diagnosis due to future higher costsPerceived low probability of finding new diagnosesPresent the HIDES resultsImpact on existing servicesSimplify consent procedures, opportunistic testingSimplify consent procedures, opportunistic testing
46. Policy and regulatory barriersThis slide to be locally adapted if there are potential policy and/or regulatory related barriers, for e.g. who can perform a test. Consider including information here about issues pertaining specifically to MSM, undocumented migrants’ access to healthcare and PWID in those countries this is a particular issue
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49. HIV Testing Strategies Focus on the person Focus on the setting Individuals in high risk groups MSM, PWID, BMEFocus on the locationAreas with high diagnosed sero-prevalence Focus on the conditionHIV indicator conditionsCommunityClinical
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53. HIV Indicator Condition Guided Testing Indicator conditions are conditions associated with an excess risk of being HIV-positive There is a growing evidence base for HIV prevalence in different indicator conditionsRoutine HIV testing is cost effective when the undiagnosed HIV prevalence in the target group >0.1%Indicator condition guided HIV testing is included in many HIV testing guidelines but there is very variable implementationThis was the driver for the HIV Indicator Diseases Across Europe Study (HIDES)
54. What is indicator condition guided HIV testing?This is an approach where healthcare professionals routinely offer an HIV test to all individuals presenting with an indicator condition because the condition is associated with undiagnosed HIV infection.Studies indicate that routine HIV testing is cost-effective when the undiagnosed HIV prevalence in individuals with a specific indicator condition is > 0.1%.The concept of indicator condition guided HIV testing is an approach whereby health care professionals can be encouraged to offer tests to patients based on the presence of an indicator condition rather than risk behaviour or group. This potentially addresses many of the barriers felt by patient and health care providers to HIV testing.
55. Indicator ConditionsCategoriesConditions which are AIDS defining 2.a Conditions associated with an undiagnosed HIV prevalence > 0.1% 2.b Other conditions which by expert opinion are considered likely to have an undiagnosed HIV prevalence of > 0.1%. Conditions where not identifying the presence of HIV infection may have significant adverse implications for the individual’s clinical management.The HIDES Study (HIV Indicator Diseases Across Europe Study) investigated the HIV prevalence within potential indicator conditions across Europe.
56. HIDES – Phase 2, 2012-2014Routine offer of HIV test to patients (18-65 yrs) presenting with indicator conditionPrimary endpoint: demonstration of previously undiagnosed HIV infection >0.1% in each indicator condition (IC) Disease AreaIndicator ConditionsMalignanciesLymphomaCervical dysplasia or cancer (CIN II and above)Anal dysplasia or cancer (AIN II and above)Primary lung cancerViral infectionsHepatitis B infectionHepatitis C infectionHepatitis B & C co-infectionOngoing mononucleosis-like illnessHaematological disordersLeucocytopaenia and / or thrombocytopaenia LymphadenopathyDermatologicalSevere psoriasisSeborrhoeic dermatitisOtherPneumonia (hospitalised)Peripheral neuropathy
57. Enrolment150 surveys were performed, across 42 clinical centres in 20 countries across four regions of Europe10,139 patients were enrolled668 participants were excluded Total of 9471 participantsRecruitment by regionNumber enrolled%Total9471100South5005.3Central94210.0North229724.3East573260.5
58. Characteristics of participantsParticipants 9471Male 54%Median age 37 years (IQR 29-49 years)White 87%Previous HIV test 14% - median time since last test: 1.3 years [IQR 0.4 – 3.2 years])Setting:Number enrolled%Total9471100Outpatient450047.5Inpatient356437.6Primary Care2702.9Unknown113712.0
59. HIV test positivity (overall)235/9471 individuals tested HIV positive HIV prevalence: 2.5% [95%CI 2.2 – 2.8]Marked variation by region:59RegionNumber enrolledNumber HIV+%95%CIAll94712352.52.2 – 2.8South500255.03.1 – 6.9Central942101.10.4 – 1.7North2297311.40.9 – 1.8East57321693.02.5 – 3.4
60. HIDES Phase 2 - HIV prevalence by indicator condition 95% CI > 0.1 95% CI < 0.1Tested7373440172218818417512991126133958827653144HIV+7391632612416131341000.1% and LL 95%CI>0.1%
61. HIDES Phase 2 - Odds of testing HIV+ by indicator condition (adjusted)Indicator Condition:PneumoniaCervical dysplasiaHepatitis BHepatitis CMononucleosis-like illnessLeuco / thrombocytopaeniaLymphadenopathyAll othersAdjusted odds of testing HIV+ (95% CI)Model adjusted for gender, ethnicity, previous HIV testing history, European region, setting, age, date, and number from centre
62. HIDES Phase 2 - Characteristics of newly diagnosed participants
63. ConclusionThere is an urgent need to increase HIV testing and diagnosis, so as to decrease both late presentation and the number of individuals with HIV infection who remain unaware of their status. This will decrease morbidity, mortality, transmissions and healthcare costs.Indicator condition based testing is an effective and efficient strategy within healthcare settings to expand HIV testing and more timely diagnosis