Reaching the 90-90-90 targets in Europe

Amanda MocroftUniversity College London

a.mocroft@ucl.ac.uk

HIV continuum of care : A marker of quality of HIV care

Individual health benefitso Reducing morbidity and

mortalityo Reducing HIV drug resistance

development/triple class ARV failure

Public health benefitso Reduced transmissiono Containing/ending the epidemico Helps target local interventions

Health disparities exist across Europe in HIV

Increasing interest in comparing quality of care across countrieso Understand the variationo Identify gapso Target interventions

Best practice; monitor own performance

Cost-effectiveness Highlight different challenges;

inform health policy

HIV Continuum : 90:90:90 Quality of HIV care

The 4-point continuum of care for HIV

0

20

40

60

80

100

Estimatedliving with HIV

Diagnosed On ART Virallysuppressed

%

Stage of HIV disease

Left hand side Right hand side

Processes and information needed for LHS or RHS of CoC varyo Statistical modellingo Accurate surveillance

and reporting systemso Good clinical or cohort

data Approaches to improve %

on LHS or RHS and thus achieve 90-90-90 are different

Country Countrys own estimate

Article YearOn 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):195062011-2013 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 data98.5% / 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):195012012 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%

https://www.imo.ie/news-media/publications/JulyAugust-2015-IMJ-hr.pdfhttp://www.cnlas.ro/images/doc/30062015_eng.pdf

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 periodso 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

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

Persons included

2004/05 2009/10 2014/15

N clinics 98 102 105

N patients 8,978 10,463 11,975

GenderMaleFemale

6,688 (74.5)2,290 (25.5)

7,539 (72.1)2,924 (27.9)

8,649 (72.2)3,326 (27.8)

Age, median (IQR)

40.8 (35.4, 47.7)

39.2 (32.4, 45.9)

37.8 (30.2, 44.5)

Infected viaMSM IDUHeterosexualOther

3,761 (41.9)2,090 (23.3)2,556 (28.5)

571 (6.4)

4,260 (40.7)2,138 (20.4)3,352 (32.0)

713 (6.8)

4,571 (38.2)2,744 (22.9)3,808 (31.8)

852 (7.1)

The RHS on the CoC in EuroSIDA countries : 2004 - 2005

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 virologicallysuppressed

The RHS on the CoC in EuroSIDA countries : 2004/05, 2009/10, 2014/15

2004/2005

2009/2010

The RHS on the CoC in EuroSIDA countries : 2004/05, 2009/10, 2014/15

2004/2005

2009/2010

2014/2015

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%.

Strengths and weaknesses of approach

Access to data from large number of countries

Data from countries withoutnational registries

Access to complete data on ART-coverage

Standardized data collectionallows direct comparisonbetween countries

Possibility of comparingtemporal 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

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 systemo Such countries may have the largest numbers of HIV-positive persons,

together with poorer access to antiretroviral therapy and management of HIV disease

Core data

HCV coinfected CoDe

PCV

INSTI

????

CoC

Quality / benchmarking

HSR reactions

PreP

HIV testing

TB

????

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 EuroSIDAnetwork 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

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

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

Country Clinic PLWHIV HIV Prevalence In EuroSIDA(%) N (%)

Slovenia University Clinical Centre Ljubljana

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

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

http://www.cphiv.dk/Studies/EuroSIDA/Study-group

Fast-track the end of AIDS in the EU practical evidence-based interventions

Fast-track the end of AIDS in the EU

practical evidence-based interventions

Reaching the 90-90-90 targets in EuropeHIV continuum of care : A marker of quality of HIV care The 4-point continuum of care for HIVSlide Number 4Using the EuroSIDA cohort to monitor the right hand side of the continuum of careRegions in the EuroSIDA studySlide Number 7Slide Number 8Slide Number 9Slide Number 10Slide Number 11Slide Number 12Strengths and weaknesses of approachSlide Number 14Slide Number 15Slide Number 16Slide Number 17Slide Number 18Summary and perspectivesSlide Number 20Slide Number 21