How to reduce HIV incidence in Europe · Proportion HIV diagnoses in migrants* by origin of report, EU/EEA 2017 Source: ECDC/WHO (2018). HIV/AIDS Surveillance in Europe 2018– 2017

How to reduce HIV incidence in Europe

Teymur Noori European Centre for Disease Prevention and Control (ECDC) 2nd Update on Clinical Topics in Antiretroviral Therapy workshop Barcelona, 30-31 May, 2019

No conflicts to disclose

Outline

Overview of the epidemiology of HIV in Europe and Central Asia

Pre-exposure prophylaxis

Progress toward achieving the 90-90-90 treatment targets

Are we on track to end AIDS by 2030?

Conclusions

Are we on track to end AIDS by 2030?

YES

NO

How WHO categorises the region into West, Centre and East

Source: ECDC/WHO (2018). HIV/AIDS Surveillance in Europe 2018– 2017 data

~160 000 persons were diagnosed with HIV in the WHO European Region in 2017

WEST 16%

≈ 22,400 cases

Rate = 6.4/100,000

CENTRE 4%

≈ 6,200 cases

Rate = 3.2/100,000

EAST 80%

≈ 130,000 cases

Rate = 51.1/100,000


MSM

IDU

HETERO

MSM

IDU

HETERO

MSM

IDU HETERO

47% born abroad

Distribution of new HIV diagnoses in 2017, by sub-region

10% born abroad

1% born abroad


HIV diagnoses, by route of transmission, 2008-2017, EU/EEA

Injecting drug use

Heterosexual (women)

Heterosexual (men)

Sex between men

Other/ undetermined

Vertical transmission

Data is adjusted for reporting delay. HIV diagnoses reported by Estonia and Poland excluded due to incomplete reporting on transmission mode during some years of the period; diagnoses reported by Germany, Italy and Spain excluded due to incomplete reporting during a portion of the period.


Countries showing declines in the rates of new HIV diagnosis reported in MSM, 2008-2017

0

2

4

6

8

10

12

14

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Rat

e o

f n

ew d

iagn

ose

s in

MSM

per

10

0 0

00

mal

e

po

pu

lati

on

Year of diagnosis

Belgium

Greece

Luxembourg

Netherlands

Spain

United Kingdom

Switzerland


Proportion of HIV diagnoses among natives and migrants* EU/EEA, 2017

41%

59%

Migrants

Natives


Data include only cases with known region of origin; No data were reported by Germany in 2017 and zero cases were reported among migrants in Hungary or Liechtenstein

*Migrants are all persons born outside

of the country in which they were

diagnosed

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

RomaniaLatvia

PolandBulgaria

LithuaniaSloveniaSlovakiaEstoniaCroatiaGreece

Czech Republic

PortugalItaly

SpainNetherlands

EU/EEAAustriaFinland

DenmarkFrance

United KingdomBelgium

CyprusIceland

NorwayMalta

IrelandLuxembourg

Sweden

Percentage

Sub-Saharan Africa

Central and eastern Europe

Western Europe

Latin America and Caribbean

South and south-east Asia

Other

Proportion HIV diagnoses in migrants* by origin of report, EU/EEA 2017


41%

*Migrants are all persons born outside

of the country in which they were

diagnosed

Where do migrants acquire HIV infection (prior to or after

arrival to the EU)?

Where do migrants get infected with HIV (prior to or after arrival to the EU)?

18%

Source: Rice BD, Elford J, Yin Z et al (2012). A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV in the UK. AIDS 26 (15): 1961-6

7%

Clinic-based estimate CD4-based estimate


18%


24%

7%

Clinic-based estimate CD4-based estimate

46%

Where do migrants get infected with HIV (prior to or after arrival to the EU)?


Source: Alvarez del-Arco, et al. High levels of post-migration HIV acquisition within nine European countries. AIDS, 2017.


Post-migration HIV acquisition (n=2249)


63% estimated

to have acquired HIV post-migration



63% estimated

to have acquired HIV post-migration

Why is this important?

Screening newly arrived migrants at point of entry is not enough

Some sub-populations of migrants are at-risk for HIV acquisition many years after arrival to the EU

Countries should develop and deliver targeted primary HIV prevention programmes to migrant populations at risk

− Including for those visiting friends and relatives


Estimated new HIV infections

0

500000

1000000

1500000

2000000

2500000

3000000

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

New

HIV

infe

ctio

ns

(glo

bal

)

Global

Source: UNAIDS 2018, ECDC/WHO, HIV Surveillance in Europe 2017, 2016 data

Estimated new HIV infections are decreasing globally

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

0

500000

1000000

1500000

2000000

2500000

3000000

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Euro

pe

and

su

b-r

egio

ns

New

HIV

infe

ctio

ns

(glo

bal

) Global

Europe and Central Asia


Estimated new HIV infections are decreasing globally but increasing in the European region

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

0

500000

1000000

1500000

2000000

2500000

3000000

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Euro

pe

and

su

b-r

egio

ns

New

HIV

infe

ctio

ns

(glo

bal

)

Global

Europe and Central Asia

West

Centre

East


Estimated new HIV infections are decreasing globally but increasing in the European region

Pre-exposure prophylaxis

Status of formal PrEP implementation in Europe March, 2019

Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.

What issues are limiting or preventing the implementation of PrEP in your country?

0% 20% 40% 60% 80% 100%

Drug resistance

Adherence

Concerns about lower condom use

Increases in STIs

Feasibility

Cost of service delivery

Limited tehnical capacity

Cost of the drug

Percentage of countries (n=33)

High importance Medium Importance Low importance

Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data. Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.

Hornet/ECDC survey on PrEP

(2017)

Are you currently taking PrEP?

98% 90%

No

Yes

10%

90%

n= 10,562 (excludes HIV-positive respondents and non-responders)

Source: A Bourne, B Alba, A Garner G Spiteri, A Pharris, T Noori. The use, and likelihood of using, HIV pre-exposure prophylaxis among men who have sex with men in Europe and Central Asia: findings from a 2017 large geosocial networking application survey. Sex Transm Infect 2019;0:1–6. doi:10.1136/sextrans-2018-053705

Where did you obtain PrEP?

34%

12% 30%

12%

5%

7% Physician

Research study

Internet

Friend

PEP

Other

54% informally using PrEP

n= 887 (unknowns excluded)


Does your sexual health physician/doctor know you are taking PrEP?

n=732 (excluding unknowns)

66%

34% Yes

No


I am very likely to use PrEP in the next 6 months n= 9680 HIV-negative persons responding whether they agreed with this statement

22%

44%

35%

Not on PrEP (n=8949)

Agree/Strongly agree

Not sure/don't know

Disagree/Strongly disagree

85%

11%

4%

On PrEP (n=731)

Agree/Strongly agree

Not sure/don't know

Disagree/Strongly disagree


Progress towards achieving the global 90-90-90 treatment target

Fast Track Targets by 2020

73%

of all people living with HIV

VIRALLY

SUPPRESSED

=

Target 1 Target 2 Target 3 Overall target

diagnosed with HIV

ON ART

living with HIV

DIAGNOSED

on ART

VIRALLY SUPPRESSED

73%


VIRALLY

SUPPRESSED

=

Target 1 Target 2 Target 3

diagnosed with HIV

ON ART

living with HIV

DIAGNOSED

on ART

VIRALLY SUPPRESSED

Overall target


Target reached Above regional average Below regional average

Progress toward achieving the 1st 90: 90% of all PLHIV who know their status (n=39)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Global target 90%

Overall percentage 80%

Source: Brown Alison E, Hayes Rosalie, Noori Teymur, Azad Yusef, Amato-Gauci Andrew J., Pharris Anastasia, Delpech Valerie C., the ECDC Dublin Declaration Monitoring Network. HIV in Europe and Central Asia: progress in 2018 towards meeting the UNAIDS 90-90-90 targets. Euro Surveill. 2018;23(48).

Progress toward achieving the 1st 90: Sub-regional variation: West, Centre, East

Range 74-93%

Range 46-90%

Range 48-94%


Proportion of persons diagnosed late* with HIV by demographic, EU/EEA, 2017

Age group (years) Transmission Region of origin Gender


49%

*Late diagnosed = CD4 <350 cells/mm3

at diagnosis

Decreasing estimated time from infection to diagnosis in the EU/EEA

Source: van Sighem Ard, Pharris Anastasia, Quinten Chantal, Noori Teymur, Amato-Gauci Andrew J. Reduction in undiagnosed HIV infection in the European Union/European Economic Area, 2012 to 2016. Euro Surveill. 2017;22(48):pii=17-00771.

Median time from infection to diagnosis is 2.9 years

Are new innovative approaches to HIV testing included in national HIV testing guidelines? (n=55)

Testing approaches Yes No No

response

Community-based testing delivered by trained medical staff

28 12 15

Community-based testing delivered by non-medical staff (e.g. trained lay people)

14 26 15

Home-sampling kits 4 36 15

Self-testing kits 9 32 14

Up from 2 in 2017



73%


VIRALLY

SUPPRESSED

=


diagnosed with HIV

ON ART

living with HIV

DIAGNOSED

on ART

VIRALLY SUPPRESSED

Overall target

Progress toward achieving the 2nd 90: 90% of those diagnosed on ART (n=39)


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Global target 90%



Progress toward achieving the 2nd 90: Significant sub-regional variation: West, Centre, East

Range 68-100%

Range 50-85%

Range 30-95%


4

29

48

16

10

5

28

8

1

1

0

5

10

15

20

25

30

35

40

45

50

55

2014 2015 2016 2018

Nr

of

cou

ntr

ies/

AR

T p

olic

y

200 cells/mm3

350 cells/mm3

500 cells/mm3

Initiation regardlessof CD4 count

ART initiation policies in European countries 2014 (n=49)


ART initiation policies in European countries 2014 (n=49)

4

29

48

16

10

5

28

8

1

1

0

5

10

15

20

25

30

35

40

45

50

55

2014 2015 2016 2018

Nr

of

cou

ntr

ies/

AR

T p

olic

y

200 cells/mm3

350 cells/mm3

500 cells/mm3



ART initiation policies in European countries 2014 (n=49), 2016 (n=47)

4

29

48

16

10

5

28

8

1

1

0

5

10

15

20

25

30

35

40

45

50

55

2014 2015 2016 2018

Nr

of

cou

ntr

ies/

AR

T p

olic

y

200 cells/mm3

350 cells/mm3

500 cells/mm3



4

29

48

16

10

5

28

8

1

1

0

5

10

15

20

25

30

35

40

45

50

55

2014 2015 2016 2018

Nr

of

cou

ntr

ies/

AR

T p

olic

y

200 cells/mm3

350 cells/mm3

500 cells/mm3


ART initiation policies in European countries 2014 (n=49), 2016 (n=47), 2018 (n=54)


Availability of ART for undocumented migrants 2018



73%


VIRALLY

SUPPRESSED

=


diagnosed with HIV

ON ART

living with HIV

DIAGNOSED

on ART

VIRALLY SUPPRESSED

Overall target

Progress toward achieving the 3rd 90: 90% of those on ART virally suppressed (n=34)


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Global target 90%



73%


VIRALLY

SUPPRESSED

=


diagnosed with HIV

ON ART

living with HIV

DIAGNOSED

on ART

VIRALLY SUPPRESSED

Overall target


Progress toward achieving the overall target: 73% of all PLHIV virally suppressed (n=33)


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Global target 73%


Target needed 90%


Progress toward achieving the overall 90-90-90 target: Significant sub-regional variation: West, Centre, East

Range 66-87%

Range 24-54%

Range 22-36%


Are we on track to end AIDS?

Are we on track to end AIDS? Incidence

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Esti

mat

ed

new

HIV

infe

ctio

ns

WHO European Region estimated infections 2020 target, WHO European Region

EU/EEA estimated infections 2020 target, EU/EEA


23,000

142,000

FAST-TRACK TARGET:

75% reduction in new infections by 2020

(baseline 2014)

Are we on track to end AIDS? Incidence

0

20000

40000

60000

80000

100000

120000

140000

160000

180000

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Esti

mat

ed

new

HIV

infe

ctio

ns

WHO European Region estimated infections 2020 target, WHO European Region

EU/EEA estimated infections 2020 target, EU/EEA


23,000

6,000

142,000

36,000

FAST-TRACK TARGET:

75% reduction in new infections by 2020

(baseline 2014)

80%

51%

43%

87%

80%

74%

83%

61%

46%

76%

34%

26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PLHIV Diagnosed On ART Virally Suppressed

90%

81%

73%

Are we on track to reach the 90-90-90 targets by 2020?

Global ART coverage = 59%


80%

51%

43%

87%

80%

74%

83%

61%

46%

76%

34%

26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


90%

81%

73%



80%

51%

43%

87%

80%

74%

83%

61%

46%

76%

34%

26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


90%

81%

73%



Distribution of people with transmissible levels of virus in the full region, reported in 2018

36%

51%

13%

N ≈ 1,200,000

People living with unsuppressed virus

Undiagnosed

Diagnosed but not on treatment

Treated but not virally supressed


Undiagnosed

Diagnosed but not on treatment

Treated but not virally supressed

WEST N ≈ 200,000

CENTRE N ≈ 15,000

EAST N ≈ 980,000

51%

31%

41%

28% 27%

21% 57%

31%

11%

N ≈ 1,200,000

People living with unsuppressed virus

Distribution of people with transmissible levels of virus by sub-region, reported in 2018


Conclusions

Europe is not on track to meet the target of a 75% reduction in new HIV infections by 2020

Some good news on 90-90-90 targets, but uneven progress across countries

Late diagnosis of HIV is still very common – testing coverage low

ON

TR

EATM

ENT

VIR

AL

SU

PP

RES

SIO

N

DIA

GN

OSE

D

PLH

IV

TESTING

LINKAGE TO CARE

RETENTION & ADHERENCE

SUPPORT

74% OF ALL PLHIV IN WEST ARE

VIRALLY SUPPRESSED

QUALITY OF LIFE

46% OF ALL PLHIV

IN CENTRE ARE VIRALLY SUPPRESSED

26% OF ALL PLHIV IN EAST ARE

VIRALLY SUPPRESSED

PREVENTION (PrEP, condoms, NSP, OST)

Priorities for action:

Acknowledgements

Dublin Declaration advisory group Kristi Ruutel (Estonia), Daniela Rojas Castro (France), Gesa Kupfer (Germany), Caroline Hurley (Ireland), Silke David (Netherlands), Arild Johan Myrberg (Norway), Isabel Aldir, Daniel Simoes (Portugal), Sladjana Baros (Serbia), Irene Klavs (Slovenia), Gabrella Hok (Sweden), Valerie Delpech, Alison Brown, Cary James (United

Kingdom), Olga Varetska (Ukraine), Jean-Luc Sion (European Commission), Dagmar Hedrich (EMCDDA), Taavi Erkkola, Kim Marsh (UNAIDS), Annemarie Stengaard (WHO Euro), Jordi Casabona (INEGRATE), Axel J. Schmidt (ESTICOM), Annabelle Gourlay, Kholoud Porter (EuroCoord).

Dublin Declaration focal points in Europe and Central Asia Cotelnic (Moldova), Alma Cicic, Aleksandra Marjanovic (Montenegro), Silke David (Netherlands), Arild Johan Myrberg (Norway), Anna Marzec- Bogusła(Poland),

Roland Bani (Albania), Jennifer Fernández Garcia (Andorra), Samvel Grigoryan, Arshak Papoyan (Armenia), Irene Rueckerl, Bernhard Benka, Robert Zangerle (Austria), Esmira Almammadova, Natig Zulfugarov (Azerbaijan), Inna Karabakh (Belarus), Andre Sasse, Dominique Van Beckhoven (Belgium), Dušan Kojić, Indira

Hodžić (Bosnia and Herzegovina), Tonka Varleva (Bulgaria), Jasmina Pavlic (Croatia), Ioannis Demetriades (Cyprus), Veronika Šikolová, Hana Janatova (Czech Republic), Jan Fouchard & Susan Cowan (Denmark), Kristi Rüütel, Liilia Lõhmus, Anna-Liisa Pääsukene (Estonia), Henrikki Brummer-Korvenkontio (Finland), Bernard

Faliu (France), Maia Tsereteli, Otar Chokoshvili, Ana Aslanikashvili (Georgia), Gesa Kupfer, Ulrich Marcus, (Germany), Dimitra Paraskeva, Vasilios Raftopoulos, Stavros Patrinos, (Greece), Maria Dudas, Katalin Szalay (Hungary), Guðrún Sigmundsdóttir, Þórólfur Guðnason (Iceland), Caroline Hurley, Fiona Lyons, Derval Igoe,

Helen Deely, (Ireland), Daniel Chemtob, Yana Roshal (Israel), Anna Caraglia, Francesco Maraglino, Barbara Suligoi, Lella Cosmaro, (Italy), Alla Yelizarieva, Aliya Bokazhanova (Kazakhstan), Laura Shehu, Pashk Buzhala (Kosovo*), Aikul Ismailova, Nazgul Asylalieva (Kyrgyzstan), Šarlote Konova (Latvia), Andrea Leibold, Marina

Jamnicki Abegg (Liechtenstein), Irma Caplinskiene (Lithuania), Patrick Hoffman, Pierre Weicherding (Luxembourg), Milena Stefanovic, Vladimir Mikic (FYROM), Jackie Maistre Melillo (Malta), Iulian Oltu, Svetlana Popovici, Tatiana wska, Iwona Wawer, Piotr Wysocki, Magdalena Rosinska (Poland), Isabel Aldir, Teresa Melo (Portugal), Mariana Mardarescu, Adrian Streinu-Cercel (Romania), Danijela Simic, Sladjana Baros (Serbia), Jan Mikas, Peter Truska, Helena Hudecová, (Slovakia),

Irena Klavs, Janez Tomažič (Slovenia), Begona Rodriquez Ortiz de Salazar (Spain), Louise Mannheimer, Gabriella Hok, (Sweden), Axel J. Schmidt, Sabine Basler (Switzerland), Zukhra Nurlaminova, Sayfuddin Karimov, Dilshod Sayburhonov (Tajikistan), Emel Özdemir Şahin (Turkey), Valerie Delpech & Alison Brown (United

Kingdom), Igor Kuzin (Ukraine) and Zulfiya Abdurakhimova (Uzbekistan).

HIV Surveillance focal points in the EU/EEA Daniela Schmid, Alexander Spina (Austria), Andre Sasse (Belgium), Tonka Varleva (Bulgaria), Tatjana Nemeth Blazic (Croatia); Maria Koliou (Cyprus), Marek Maly

(Czech Republic); Susan Cowan (Denmark), Kristi Ruutel (Estonia), Kirsi Liitsola (Finland), Florence Lot (France), Barbara Gunsenheimer-Bartmeyer (Germany), Georgios Nikolopoulos and Dimitra Paraskeva (Greece), Maria Dudas (Hungary), Gudrun Sigmundsdottir and Haraldur Briem (Iceland), Kate O’Donnell and Derval

Igoe (Ireland), Barbara Suligoi (Italy), Šarlote Konova (Latvia), Saulius Čaplinskas and Irma Čaplinskienė (Lithuania), Jean-Claude Schmit (Luxembourg), Jackie Maistre Melillo and Tanya Melillo (Malta), Eline Op de Coul (Netherlands), Hans Blystad (Norway), Magdalena Rosinska (Poland), Helena Cortes Martins (Portugal), Mariana Mardarescu (Romania), Peter Truska (Slovakia), Irena Klavs (Slovenia), Asuncion Diaz (Spain), Maria Axelsson (Sweden), Valerie Delpech (United Kingdom).

Thank you

Anastasia Pharris

Andrew Amato

Rosalie Hayes

Yusef Azad

Alison Brown

Valerie Delpech

[email protected]

@ECDC_HIVAIDS

Documents

How to reduce HIV incidence in Europe · Proportion HIV diagnoses in migrants* by origin of report, EU/EEA 2017 Source: ECDC/WHO (2018). HIV/AIDS Surveillance in Europe 2018– 2017