Human Immunodeficiency Virus Continuum of Care in 11 European Union Countries at the End of 2016 Overall and by Key Population: Have We Made Progress?

BACKGROUND: High uptake of antiretroviral treatment (ART) is essential to reduce human immunodeficiency virus (HIV) transmission and related mortality; however, gaps in care exist. We aimed to construct the continuum of HIV care (CoC) in 2016 in 11 European Union (EU) countries, overall and by key population and sex. To estimate progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, we compared 2016 to 2013 estimates for the same countries, representing 73% of the population in the region. METHODS: A CoC with the following 4 stages was constructed: number of people living with HIV (PLHIV); proportion of PLHIV diagnosed; proportion of those diagnosed who ever initiated ART; and proportion of those ever treated who achieved viral suppression at their last visit. RESULTS: We estimated that 87% of PLHIV were diagnosed; 92% of those diagnosed had ever initiated ART; and 91% of those ever on ART, or 73% of all PLHIV, were virally suppressed. Corresponding figures for men having sex with men were: 86%, 93%, 93%, 74%; for people who inject drugs: 94%, 88%, 85%, 70%; and for heterosexuals: 86%, 92%, 91%, 72%. The proportion suppressed of all PLHIV ranged from 59% to 86% across countries. CONCLUSIONS: The EU is close to the 90-90-90 target and achieved the UNAIDS target of 73% of all PLHIV virally suppressed, significant progress since 2013 when 60% of all PLHIV were virally suppressed. Strengthening of testing programs and treatment support, along with prevention interventions, are needed to achieve HIV epidemic control.

Antenatal HIV screening: results from the National Perinatal Survey, France, 2016.

BackgroundUniversal antenatal HIV screening programmes are an effective method of preventing mother-to-child transmission.AimsTo assess the coverage and yield of the French programme on a nationally representative sample of pregnant women, and predictive factors for being unscreened or missing information on the performance/ result of a HIV test.MethodsData came from the medical records of women included in the cross-sectional 2016 French National Perinatal Survey. We calculated odds ratios (OR) to identify factors for being unscreened for HIV and for missing information by multivariable analyses.ResultsOf 13,210 women, 12,782 (96.8%) were screened for HIV and 134 (1.0%) were not; information was missing for 294 (2.2%). HIV infection was newly diagnosed in 19/12,769 (0.15%) women screened. The OR for being unscreened was significantly higher in women in legally registered partnerships (OR: 1.3; 95% CI: 1.1-1.6), with 1-2 years of post-secondary schooling (OR: 1.6; 95% CI: 1.2-2.1), part-time employment (OR: 1.4; 95% CI: 1.1-1.8), inadequate antenatal care (OR: 1.9; 95% CI: 1.5-2.4) and receiving care from > 1 provider (OR: 1.8; 95% CI: 1.1-2.8). The OR of missing information was higher in multiparous women (OR: 1.4; 95% CI: 1.2-1.5) and women cared for by general practitioners (OR: 1.4; 95% CI: 1.1-1.9).ConclusionsThe French antenatal HIV screening programme is effective in detecting HIV among pregnant women. However, a few women are still not screened and awareness of the factors that predict this could contribute to improved screening levels.

[Epidemiology of HIV and the situation among older adults]. / Épidémiologie du VIH et situation chez les seniors.

Since the emergence of the human immunodeficiency virus at the beginning of the 1980s, the epidemic has spread extensively in all regions of the world. In France, there is still a significant number of new contaminations each year, mainly among men having sexual relations with men and heterosexuals born in Sub-Saharan Africa. The prevention efforts targeting the most exposed populations must be continued.

Are European HIV cohort data within EuroCoord representative of the diagnosed HIV population?

OBJECTIVE: HIV cohorts are an important source of clinical data for informing public health policies and programmes. However, the generalizability of cohort findings to the wider population of people diagnosed with HIV in each country remains unclear. In this work, we assessed the representativeness of six large national HIV cohorts within Europe. DESIGN AND METHODS: Individual-level cohort data were provided from national cohorts in France, Germany, Greece, Italy, Spain and the United Kingdom. Analysis focused on new HIV diagnoses reported to The European Surveillance System (TESSy) during three time periods (2000-2004, 2005-2009 and 2010-2013), to allow for temporal changes. Cohort and TESSy records were matched and compared by age, sex, transmission mode, region of origin and CD4+ cell count at diagnosis. The probability of being included in each cohort given demographic characteristics was estimated and used to generate weights inversely proportional to the probability of being included. RESULTS: Participating cohorts were generally representative of the national HIV-diagnosed population submitted to TESSy. However, people who inject drugs, those born in a country other than that reporting the data, those with low CD4 cell counts at diagnosis, and those more than 55 years were generally underrepresented in the cohorts examined. CONCLUSION: These European cohorts capture a representative sample of the HIV-diagnosed populations in each country; however some groups may be underrepresented.

Trends in human immunodeficiency virus diagnoses among men who have sex with men in North America, Western Europe, and Australia, 2000-2014.

PURPOSE: The aim of the article was to investigate recent trends in human immunodeficiency virus (HIV) diagnosis rates among men who have sex with men (MSM) in high-income countries in North America, Western Europe, and Australia. METHODS: Data on annual rates of HIV diagnoses among MSM aged 15 to 65 years from 2000 to 2014 were collected from 13 high-income countries. Joinpoint regression software was used to empirically determine country-specific trend periods. Trends in HIV diagnosis rates and in the proportion of diagnoses occurring in young MSM aged 15 to 24 years were analyzed using Poisson regression and log-binomial regression, respectively. RESULTS: Six countries experienced an increasing trend from 2000 to 2007-08 followed by either a stable or declining trend through 2014. Five countries had recently increasing trends, and two countries had one stable trend from 2000 to 2014. All 13 countries experienced increases in the proportion of diagnoses occurring in young MSM. CONCLUSIONS: Since 2008, half of the 13 high-income countries examined experienced stable or decreasing trends. Still, some countries continue to experience increasing HIV trends, and young MSM are increasingly represented among new diagnoses. Efforts to support early sexual health promotion, reduce barriers to pre-exposure prophylaxis, and improve care engagement for young MSM are critical to addressing current HIV trends.

Revealing geographical and population heterogeneity in HIV incidence, undiagnosed HIV prevalence and time to diagnosis to improve prevention and care: estimates for France.

INTRODUCTION: To close gaps in HIV prevention and care, knowledge about locations and populations most affected by HIV is essential. Here, we provide subnational and sub-population estimates of three key HIV epidemiological indicators, which have been unavailable for most settings. METHODS: We used surveillance data on newly diagnosed HIV cases from 2004 to 2014 and back-calculation modelling to estimate in France, at national and subnational levels, by exposure group and country of birth: the numbers of new HIV infections, the times to diagnosis, the numbers of undiagnosed HIV infections. The denominators used for rate calculations at national and subnational levels were based on population size (aged 18 to 64) estimates produced by the French National Institute of Statistics and Economic Studies and the latest national surveys on sexual behaviour and drug use. RESULTS: We estimated that, in 2014, national HIV incidence was 0.17‰ (95% confidence intervals (CI): 0.16 to 0.18) or 6607 (95% CI: 6057 to 7196) adults, undiagnosed HIV prevalence was 0.64‰ (95% CI: 0.57 to 0.70) or 24,197 (95% CI: 22,296 to 25,944) adults and median time to diagnosis over the 2011 to 2014 period was 3.3 years (interquartile range: 1.2 to 5.7). Three mainland regions, including the Paris region, out of the 27 French regions accounted for 56% of the total number of new and undiagnosed infections. Incidence and undiagnosed prevalence rates were 2- to 10-fold higher than the national rates in three overseas regions and in the Paris region (p-values < 0.001). Rates of incidence and undiagnosed prevalence were higher than the national rates for the following populations (p-values < 0.001): born-abroad men who have sex with men (MSM) (respectively, 108- and 78-fold), French-born MSM (62- and 44-fold), born-abroad persons who inject drugs (14- and 18-fold), sub-Saharan African-born heterosexuals (women 15- and 15-fold, men 11- and 13-fold). Importantly, affected populations varied from one region to another, and in regions apparently less impacted by HIV, some populations could be as impacted as those living in most impacted regions. CONCLUSIONS: In France, some regions and populations have been most impacted by HIV. Subnational and sub-population estimates of key indicators are not only essential to adapt, design implement and evaluate tailored HIV interventions in France, but also elsewhere where similar heterogeneity is likely to exist.

HIV surveillance combining an assay for identification of very recent infection and phylogenetic analyses on dried spots.

BACKGROUND: Transmitted/founder viruses isolated at the early stage of infection are indicators of the variants that are spreading within a population. The French reporting system for new HIV diagnoses is linked to a virological surveillance using dried serum spots. METHODS: We combined an immunoassay for very recent infection (less than 31 days) to a phylogenetic analysis of transmitted/founder viruses and sociodemographic information to analyze the dynamics of the HIV-1 epidemic during a 3-year period. Bayesian coalescent-based methods were used to explore the temporal and spatial dynamics of the identified clusters. RESULTS: Of 17 010 dried serum spots collected, 549 very recent infections were identified for which both env sequences and sociodemographic data were available. Non-B transmitted/founder viruses were found in 196 cases (35.7%), belonging to six subtypes and seven circulating recombinant forms. Forty-three dyads/clusters were identified (range 2-11 cases), including 107 individuals (19.5%), mainly MSM. The largest cluster involved MSM infected by a CRF02_AG variant. Reconstruction of viral migrations across time suggests that Paris was the major hub of dissemination. CONCLUSION: The study shows the feasibility of the surveillance of the HIV epidemic using this methodology. The observation of actively growing spatiotemporal clusters allows identification of specific networks that may be targets for intervention.

Impact of Male Circumcision among heterosexual HIV cases: comparisons between three low HIV prevalence countries.

BACKGROUND: Studies performed in high-HIV prevalence countries showed a strong epidemiological association between male circumcision (MC) and the prevention of HIV transmission. We estimated the potential impact of MC on the general heterosexual population in low-HIV prevalence countries. METHODS: Cross-national comparisons, including data on newly diagnosed HIV cases among heterosexuals living in Israel (where almost all males undergo MC), to similar data from the Netherlands and France (where <10 % of males are circumcised) were performed. National data from HIV registers and Bureaus of Statistics for the period of 2004-2010, global rates, rates by sex, age, and year of HIV-diagnosis were compared. MC and potential biases were examined. RESULTS: Annual rates of new HIV diagnoses per 100,000 were significantly lower in Israel compared to the Netherlands and France (for men: 0.26-0.70, 1.91-2.28, and 2.69-3.47, respectively; for women: 0.10-0.34, 1.10-2.10 and 2.41-3.08, respectively). Similarly, HIV-rates were much lower in Israel when comparing by age groups. Although Gross National Income per capita in 2010 was lower in Israel compared to the Netherlands and France, access to HIV testing and treatment were not different between countries. Also, the number of sexual-partners and condom-use in the general population showed a high similarity between the countries. CONCLUSIONS: The lower rate of HIV among heterosexuals in Israel compared to the Netherlands and France might be explained by MC routinely practiced in Israel, since other parameters of influence on HIV transmission were rather similar between the countries. However, recommendation for systematic MC in low HIV prevalence countries requires further investigations.

Combining the Estimated Date of HIV Infection with a Phylogenetic Cluster Study to Better Understand HIV Spread: Application in a Paris Neighbourhood.

OBJECTIVES: To relate socio-demographic and virological information to phylogenetic clustering in HIV infected patients in a limited geographical area and to evaluate the role of recently infected individuals in the spread of HIV. METHODS: HIV-1 pol sequences from newly diagnosed and treatment-naive patients receiving follow-up between 2008 and 2011 by physicians belonging to a health network in Paris were used to build a phylogenetic tree using neighbour-joining analysis. Time since infection was estimated by immunoassay to define recently infected patients (very early infected presenters, VEP). Data on socio-demographic, clinical and biological features in clustered and non-clustered patients were compared. Chains of infection structure was also analysed. RESULTS: 547 patients were included, 49 chains of infection containing 108 (20%) patients were identified by phylogenetic analysis. analysis. Eighty individuals formed pairs and 28 individuals were belonging to larger clusters. The median time between two successive HIV diagnoses in the same chain of infection was 248 days [CI = 176-320]. 34.7% of individuals were considered as VEP, and 27% of them were included in chains of infection. Multivariable analysis showed that belonging to a cluster was more frequent in VEP and those under 30 years old (OR: 3.65, 95 CI 1.49-8.95, p = 0.005 and OR: 2.42, 95% CI 1.05-5.85, p = 0.04 respectively). The prevalence of drug resistance was not associated with belonging to a pair or a cluster. Within chains, VEP were not grouped together more than chance predicted (p = 0.97). CONCLUSIONS: Most newly diagnosed patients did not belong to a chain of infection, confirming the importance of undiagnosed or untreated HIV infected individuals in transmission. Furthermore, clusters involving both recently infected individuals and longstanding infected individuals support a substantial role in transmission of the latter before diagnosis.

Characteristics of patients recently infected with HIV-1 non-B subtypes in France: a nested study within the mandatory notification system for new HIV diagnoses.

The presence of HIV-1 non-B subtypes in Western Europe is commonly attributed to migration of individuals from non-European countries, but the possible role of domestic infections with non-B subtypes is not well investigated. The French mandatory anonymous reporting system for HIV is linked to a virological surveillance using assays for recent infection (<6 months) and serotyping. During the first semester of years 2007 to 2010, any sample corresponding to a non-B recent infection was analyzed by sequencing a 415-bp env region, followed by phylogenetic analysis and search for transmission clusters. Two hundred thirty-three recent HIV-1 infections with non-B variants were identified. They involved 5 subtypes and 7 circulating recombinant forms (CRFs). Ninety-two cases (39.5%) were due to heterosexual transmissions, of which 39 occurred in patients born in France. Eighty-five cases (36.5%) were identified in men having sex with men (MSM). Forty-three recent non-B infections (18.5%) segregated into 14 clusters, MSM being involved in 11 of them. Clustered transmission events included 2 to 7 cases per cluster. The largest cluster involved MSM infected by a CRF02_AG variant. In conclusion, we found that the spread of non-B subtypes in France occurs in individuals of French origin and that MSM are particularly involved in this dynamic.

A three-source capture-recapture estimate of the number of new HIV diagnoses in children in France from 2003-2006 with multiple imputation of a variable of heterogeneous catchability.

BACKGROUND: Nearly all HIV infections in children worldwide are acquired through mother-to-child transmission (MTCT) during pregnancy, labour, delivery or breastfeeding. The objective of our study was to estimate the number and rate of new HIV diagnoses in children less than 13 years of age in mainland France from 2003-2006. METHODS: We performed a capture-recapture analysis based on three sources of information: the mandatory HIV case reporting (DOVIH), the French Perinatal Cohort (ANRS-EPF) and a laboratory-based surveillance of HIV (LaboVIH). The missing values of a variable of heterogeneous catchability were estimated through multiple imputation. Log-linear modelling provided estimates of the number of new HIV infections in children, taking into account dependencies between sources and variables of heterogeneous catchability. RESULTS: The three sources observed 216 new HIV diagnoses after record-linkage. The number of new HIV diagnoses in children was estimated at 387 (95%CI [271-503]) from 2003-2006, among whom 60% were born abroad. The estimated rate of new HIV diagnoses in children in mainland France was 9.1 per million in 2006 and was 38 times higher in children born abroad than in those born in France. The estimated completeness of the three sources combined was 55.8% (95% CI [42.9 - 79.7]) and varied according to the source; the completeness of DOVIH (28.4%) and ANRS-EPF (26.1%) were lower than that of LaboVIH (33.3%). CONCLUSION: Our study provided, for the first time, an estimated annual rate of new HIV diagnoses in children under 13 years old in mainland France. A more systematic HIV screening of pregnant women that is repeated during pregnancy among women likely to engage in risky behaviour is needed to optimise the prevention of MTCT. HIV screening for children who migrate from countries with high HIV prevalence to France could be recommended to facilitate early diagnosis and treatment.

Continuous spread of HIV-1 subtypes D and CRF01_AE in France from 2003 to 2009.

Among 61 and 35 patients who were infected in France by viruses of the rare clades D and CRF01_AE, respectively, approximately half of them originated from areas where HIV-1 is endemic, but the data showed that both clades have spread in the French indigenous population, particularly in men having sex with men (MSM).

Population-based HIV-1 incidence in France, 2003-08: a modelling analysis.

BACKGROUND: Routine national incidence testing with enzyme immunoassay for recent HIV-1 infections (EIA-RI) has been done in France since January, 2003. From the reported number of HIV infections diagnosed as recent, and accounting for testing patterns and under-reporting, we aimed to estimate the incidence of HIV infection in France in 2003-08. METHODS: We analysed reports from the French National Institute for Public Health Surveillance for patients who were newly diagnosed with HIV between January, 2003, and December, 2008. Missing data were imputed with multiple imputation. Patients were classified with non-recent or recent infection on the basis of an EIA-RI test, which was calibrated with serial measurements from HIV seroconverters from the French ANRS-PRIMO cohort. We used an adapted stratified extrapolation approach to calculate the number of new HIV infections in men who have sex with men (MSM), injecting drug users (IDUs), and heterosexual men and women by nationality. Population sizes were obtained from the national census and national behavioural studies. FINDINGS: After accounting for under-reporting, there were 6480 (95% CI 6190-6780) new diagnoses of HIV infection in France in 2008. We estimate that there were 6940 (6200-7690) new HIV infections in 2008, suggesting an HIV incidence of 17 per 100 000 person-years. In 2008, there were 3550 (3040-4050) new infections in heterosexuals (incidence of 9 per 100 000 person-years), 3320 (2830-3810) in MSM (incidence of 1006 per 100 000 person-years), and 70 (0-190) in IDUs (incidence of 86 per 100 000 person-years). Overall HIV incidence decreased between 2003 and 2008 (p<0·0001), but remained comparatively high and stable in MSM. INTERPRETATION: In France, HIV transmission disproportionately affects certain risk groups and seems to be out of control in the MSM population. Incidence should be tracked to monitor transmission dynamics in the various population risk groups and to help to target and assess prevention strategies. FUNDING: French National Institute for Public Health Surveillance (InVS) and French National Agency for Research on AIDS and Viral Hepatitis (ANRS).

Performance of an immunoassay at detecting recent infection among reported HIV diagnoses.

INTRODUCTION: An enzyme immunoassay to detect recent HIV-1 infection (EIA-RI) of less than 6 months is routinely performed on diagnoses reported to the National HIV case surveillance in France. We assessed the performance of the EIA-RI infection on this country population scale by measuring its agreement with other indicators of time since infection that were obtained through clinical, biological or testing history recorded on the surveillance reporting form. METHODS: We used data from the National HIV case surveillance from its debut in March 2003 to June 2007. Infection within 6 months was defined as a negative test reported within 6 months prior to diagnosis. We further ascertained this definition by adding information about of a symptomatic primary infection or biological evidence of recent seroconversion. Infection established for more than 6 months was defined when a positive test had occurred more than 6 months prior to the reported diagnosis. RESULTS: Time since infection could be ascertained in 6782 of 15, 331 (44.2%) HIV diagnoses. Assay sensitivity and specificity were 73.8 and 83.7%, respectively. Among the 1940 cases originating from Sub-Saharan Africa, sensitivity and specificity were 54.1 and 90.8%, respectively. DISCUSSION: Assessment of the performance of the EIA-RI on a large and heterogeneous population revealed two major findings--significant discrepancies in timing from infection near the 180-day cutoff, and a performance that depends on the geographic origin of patients. This has implications for estimating the assay window period and in the perspective of incidence estimation from HIV case surveillance.

Reemergence of the HIV epidemic among men who have sex with men in North America, Western Europe, and Australia, 1996-2005.

PURPOSE: To describe and contextualize changes in rates of human immunodeficiency virus (HIV) notifications in men who have sex with men (MSM) in eight countries (Australia, Canada, France, Germany, Netherlands, Spain, United Kingdom, and United States) from 1996-2005. METHODS: We analyzed trends in HIV notification rates from 1996-2000 and 2000-2005 by generalized linear regression and estimated annual percentage change (EAPC) in rates of HIV notifications. To interpret trends, we visually examined graphs of primary and secondary syphilis reports among MSM and the prevalence of recent HIV testing. RESULTS: The rate of HIV notifications among MSM declined 5.2% per year (95% confidence interval [CI]: -5.8%, -4.7%) from 1996-2000, and increased 3.3% per year (95% CI: +2.9%,+3.7%) from 2000-2005. During the period of increasing HIV diagnoses, increases in primary and secondary syphilis diagnoses occurred among MSM, but recent HIV testing among MSM did not seem to increase. CONCLUSIONS: After declining in the second half of the 1990s, HIV notification rates for MSM increased beginning in 2000. Increased HIV notifications in MSM are not wholly explained by changes in HIV testing. Urgent efforts are required to develop effective HIV prevention interventions for MSM, and implement them broadly in these countries.

Prevalence of HIV-2 and HIV-1 group O infections among new HIV diagnoses in France: 2003-2006.

French national surveillance of new HIV diagnoses included the collection of dried serum spots to identify HIV serotypes. Between January 2003 and June 2006, 10,184 new diagnoses were reported. The proportions of HIV-2 and HIV-1 group O infections were 1.8 and 0.1%, respectively. Most of these cases occurred in patients infected through heterosexual contact and originated from the corresponding endemic areas. Three cases of HIV-2 infections were reported in non-African men having sex with men.

Monitoring the dynamics of the HIV epidemic using assays for recent infection and serotyping among new HIV diagnoses: experience after 2 years in France.

BACKGROUND: New tools to better monitor dynamics of human immunodeficiency virus (HIV) transmission are needed. METHODS: National surveillance of newly HIV diagnoses included the collection of dried serum spots to identify both recent infections (<6 months) and HIV serotypes. Multivariate analyses were used to identify factors associated with recent infection and infection with non-B subtypes. RESULTS: Between 2003 and March 2005, 7902 new HIV diagnoses were reported. The overall proportion of recent infections was 24.9% (95% confidence interval, 23.8%-26.0%) and was highest among men who have sex with men (MSM; 46%). Recent infection was associated with being an MSM, <30 years old, of French nationality, and living in Paris. Nearly half of newly HIV-1 diagnoses were with non-B subtypes. The highest proportion of non-B infections was reported among African heterosexual persons (81%), but important proportions were reported among French heterosexual persons (34%) and MSM (12%). Being infected by a non-B subtype was independently associated with being African, <30 years old, heterosexual, and living in Paris. The proportion of HIV-2 infection was 1.9%, and 11 cases of HIV-1 group O infection were identified, mainly among West Africans. CONCLUSIONS: There is evidence of high levels of HIV transmission among MSM in France and transmission of non-B subtypes within the indigenous French population.

Human immunodeficiency virus serotyping on dried serum spots as a screening tool for the surveillance of the AIDS epidemic.

Many studies have demonstrated the utility of the dried blood spot (DBS) or dried plasma/serum spot (DSS) method for serological and molecular diagnosis of HIV infection. Here, we report on the description of a serotyping assay performed on DSS, and its application to a national surveillance program of HIV variants. We combined serotyping assays that we developed previously to discriminate between HIV-1 and HIV-2, between HIV-1 group O and HIV-1 group M, and between B and non-B subtypes of HIV-1 group M. The assays are based on antibody binding to either the immunodominant epitope of gp41 or the V3 domain of gp120 of these various types, groups and subtypes. Therefore, a unique enzyme-linked immunosorbent assay (ELISA) format applied to serum eluted from DSS allowed the simultaneous discrimination between infections caused by HIV-1 B, HIV-1 non-B, HIV-1 group O, and HIV-2. Together, this serotyping assay and an immunoassay for recent infection were used for a virological surveillance linked to the anonymous mandatory notification of HIV infection in France. The preliminary results of this virological surveillance allowed us to obtain estimates of the prevalence of the rare variants HIV-2 and HIV-1 group O. It also allowed identification of the two first cases of M/O dual infections reported outside the endemic group O region of the western part of equatorial Africa, and showed that non-B subtypes circulate widely in France, almost 50% of new HIV diagnoses in 2003 being due to these variants.