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Reducing the burden of undiagnosed HIV infection

Reducing the burden of undiagnosed HIV infection. Dr Valerie Delpech HIV & STI Department Centre for Infections HPA. Outline. New Diagnoses Overall trends in UK and International HIV Incidence UA STARHS Testing Impact on transmission. Trends in new diagnoses.

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Reducing the burden of undiagnosed HIV infection

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  1. Reducing the burden of undiagnosed HIV infection Dr Valerie Delpech HIV & STI Department Centre for Infections HPA

  2. Outline New Diagnoses Overall trends in UK and International HIV Incidence UA STARHS Testing Impact on transmission

  3. Trends in new diagnoses

  4. Summary of new HIV diagnoses trends in Northern Europe New HIV diagnoses Stabilising overall But Ongoing increases in MSM – (eg: Germany, France, UK, Netherlands). MSM remain the group most at acquiring HIV. Slow increase in number of heterosexuals acquiring HIV in the UK, particularly among black-African individuals – stable in France and Germany

  5. Summary continued • Prevalence • low in IDU <2% • High amongst black-African populations (>4%) • High amongst MSM (10% in major cities) • Good uptake of ARV with few AIDS cases and AIDS deaths • Late diagnosis and high proportion of persons unaware of their infection is major concern • Late diagnoses results in high risk of early death.

  6. New HIV diagnoses by prevention group, UK: 1999-2008 Proportional adjustment for missing information; 2008 also adjusted for reporting delay

  7. Factors Driving New HIV Diagnoses Testing Changes in Population size Improved reporting / methodological change New HIV Diagnoses Migration and travel Transmission (incidence)

  8. HIV Incidence

  9. Detecting Recent Infections S erological • All dependent firstly on a highly sensitive method to detect anti-HIV Ab • Secondly, a method in which the signal takes considerably longer to exceed a threshold beyond which it is a long-standing infection T esting A lgorithms R ecent H IV S eroconversion

  10. HIV Incidence in MSM attending 16 UAPMP STI clinics:BY REGION

  11. 51% 42% 55% 50% 40% 35% 15% 28% 34% 19% Incident infections on first diagnosis among MSM in Brighton 100 90 80 70 Non Incident 60 Number Incident infection 50 40 30 20 10 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year

  12. HIV testing

  13. HIV tests per 1,000 50 + 25 - 49 10 - 24 < 10 Not available EuroHIV HIV tests performed per thousand population,WHO European Region, 2005 ‡ § § § § § ‡ ‡ † ‡ § § * Or latest year: † 2002; ‡ 2003; § 2004

  14. Improving HIV testing: Sexual Health Strategy (2001-2011) By end 2004, all STI clinic attendees offered an HIV test on their first STI screening (and subsequently according to risk). Uptake by those offered HIV test should be 60% by the end of 2007 (surpassed). The proportion of HIV positive individuals leaving the GUM undiagnosed should be reduced by 50% by 2007 (not yet achieved).

  15. Estimated proportion of HIV-infected pregnant women diagnosed before delivery1 and of exposed infants becoming infected with HIV2, England & Scotland 1 Includes previously diagnosed and those diagnosed through antenatal testing 2 Assumes vertical transmission rate of 26.5% in undiagnosed women and 2.2% in diagnosed women 3 These data contain reports received by the end of June 2008, data for recent years is subject to reporting delay Unlinked anonymous prevalence monitoring National Study of HIV in Pregnancy and Childhood, ICH

  16. Sexual health screens and HIV tests at GUM clinics, E, W & NI Women Heterosexual men MSM STI data from genitourinary medicine clinics

  17. Median CD4 count at diagnosis by prevention group, UK: 1998-2007

  18. The proportion of heterosexuals attending sentinel GUM clinics receiving an HIV test and the fraction of HIV-infected heterosexuals remaining undiagnosed, UK Unlinked anonymous prevalence monitoring

  19. The proportion of MSM attending sentinel GUM clinics receiving an HIV test and the fraction of HIV-infected MSM remaining undiagnosed, UK Unlinked anonymous prevalence monitoring

  20. Undiagnosed Infection& late diagnosis

  21. Estimated number of adults (15 to 59 years) living with HIV (both diagnosed and undiagnosed) in the UK: 2007 MPES

  22. Prevalence of previously undiagnosed HIV infection, UK: 2007 Unlinked anonymous prevalence monitoring

  23. Estimated time between infection and diagnosis: people diagnosed in London in 2006 50% 40% 8.5 years 30% 6.2 years 4.2 years 20% 2 years 10% 0% Men who have sex White Heterosexuals Black African with men Heterosexuals * Estimates of median time from infection to each CD4 count category: 2 yrs, >499; 4.2 yrs, 350-499; 6.2 yrs, 200-349; 8.5 yrs, <200 Health Check “No Time To Wait”, CMO Annual report 2003 fig 2 http://www.publications.doh.gov.uk/cmo/annualreport2003/notime.htm

  24. Late HIV diagnosis and mortality in London: 2006 late diagnoses death within a year of HIV diagnosis (others) death within a year of HIV diagnosis (late diagnosis) 50 10 40 8 30 6 Percentage dying within a year (%) Proportion diagnosed late (%) 20 4 10 2 0 0 Homosexual & bisexual men Black Africans/black Caribbeans

  25. HIV prevention indicator • Each PCT to reduce late diagnosis of HIV to 15% by 2010-11 • Definition: CD4<200 • Baseline: average of late diagnoses for 2004-05 to increase numbers • Baseline of 34% means a halving of late diagnoses across London • Data collected and analysed by the HPA for NHS London • No differential targets by ethnic group/risk group

  26. Data for London SHA to performance manage London PCTs on late HIV diagnosis (the HIV Prevention Indicator) Map of proportion diagnosed late by PCT for 2007 (CD4 <200 cells per mm3)

  27. Expanding HIV testing

  28. GUM, antenatal service, TOP services, Drug dependency programmes, TB, Hepatitis B, hepatitis C and lymphoma services Populations where diagnosed prevalence > 2 per 1000 population Patients thought to be “at risk” of HIV infection HIV test monitoring: New Testing guidelines

  29. Rates of diagnosed HIV-infected adults (15+) seen for HIV-related care in the UK, by PCT of residence: 2007 London Data source: SOPHID

  30. Nov 2008 DH call for project proposals aimed at increasing the offer and uptake of voluntary HIV testing and reduce undiagnosed HIV Eight projects funded (7 in high prevalence areas) to run for 6-12 months Hospital setting (3) Community including GP (5) Evaluation Feasibility Acceptability Cost effectiveness Efficacy DH funded project in 2009

  31. Funded Projects Leicester • Routine testing 15-59 year olds • 3 hospitals • Medical admission units Brighton and Sussex • Routine testing 15-59 year olds • Acute general medicine • UA arm London • Routine testing 15-65 year olds • 3 hospitals • Emergency department, selected outpatients departments, acute medical unit Brighton and Hove • Routine testing 15-59 • New GP registrations

  32. Projects cont. London (Lewisham) • Comparison of 2 models • HIV testing in GP practices • Sheffield • Piloting home sampling • Includes internet use • London (THT) • Money transfer and African community shops • London (Metro Centre, West London Gay Men’s Project and Positive East) • HIV testing as part of a broader health screen within African communities • Peer-led and nurse lead initiatives for MSM testing

  33. Preventing Onward Transmission

  34. Socio-Political • Stigma and discrimination • Migration • Biological • Increasing pool • Late diagnosed • Undiagnosed fraction • Increasing STIs • Early seroconverters • ?Drug resistance • Risk context and behaviour • Stigma and discrimination • Increase risk behaviours • Changing sexual networks What is driving the HIV & STI epidemic in 2009 WRONG!!!

  35. ~25% Unaware of Infection Accounting for: ~54% of New Infections ~75% Aware of Infection ~46% of New Infections Disproportionate HIV transmission from those unaware of their infection Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006 Jun 26;20(10):1447-50.

  36. Treatment as prevention • Evidence • Serodiscordant studies (on ART & not) • Models (CA: need to increase persons on ART up to 75%) • Concerns • Ethics and feasibility • Treatment access • ART resistance • Adverse events (bio & behavioural) • Undiagnosed or ‘false negatives’ still drive the epidemic • BUT in line with Clinical guidelines

  37. Proportion of HIV-infected persons not on ARV by CD4 category: UK, 2006 11,595 4,983 29,165 9,894 n = 5,144 2,407 Proportion not on ARV 19% 18% 31% 30% 31% 31% CD4 cell count category Annual survey of HIV-infected persons accessing care

  38. Next steps Expanding testing a must – evaluate This will lead to earlier treatment Revisiting MSM health promotion strategies New interventions for black African and migrant populations Improving surveillance to better inform programs rollout STARHS testing to detect incident cases better monitoring of people in care

  39. Thank you Surveillance – Needs to guide and monitor prevention efforts

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