Reaching the 90-90-90 targets in Europe
Amanda MocroftUniversity College London
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
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