Fast-track the end of AI​​​DS in the EU - practical evidence-based interventions. Presentation by: Valerie Delpech, Public Health Engand In a two-day meeting under the auspices of the Maltese Presidency of the Council of the European Union (30-31 January 2017), HIV experts from across the European Union discussed how to reverse this trend and how to prepare Europe to achieve the set target of ending AIDS by 2030.

1. Scaling up testing and
linkage to care
Setting the scene
Dr Valerie Delpech
HIV & STI Department, National Infection Service
Public Health England

2. Talk outline
 Why is testing for HIV and prompt link to care important
 How well are we doing?
 Achieving scale up of testing
Current HIV trends in England

3. Why is testing for HIV and prompt link
to care important?
3 Current HIV trends in England

4. Early diagnosis and treatment of HIV
means a normal life span and
protection from passing on the virus

5. In Europe, where treatment is available
late diagnosis main factor associated
with premature death
No one should die of AIDS in 2017

6. HIV without treatment
Xiao et al. Theoretical Biology and Medical Modelling (2017) 14:1
DOI 10.1186/s12976-016-0047-0

7. Trends in estimated death rate per 1000 people
living with HIV, 2001–2013.
Granich R, Gupta S, Hersh B, Williams B, Montaner J, et al. (2015) Trends in AIDS Deaths, New Infections and ART Coverage in
the Top 30 Countries with the Highest AIDS Mortality Burden; 1990–2013. PLoS ONE 10(7): e0131353.
doi:10.1371/journal.pone.0131353
http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0131353

8. Trends in estimated death rate per 1000 people living with
HIV, 2001–2013.
Granich R, Gupta S, Hersh B, Williams B, Montaner J, et al. (2015) Trends in AIDS Deaths, New Infections and ART Coverage in
the Top 30 Countries with the Highest AIDS Mortality Burden; 1990–2013. PLoS ONE 10(7): e0131353.
doi:10.1371/journal.pone.0131353
http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0131353

9. Figure 2
The Lancet Global Health 2015)
Copyright © 2015 Nsanzimana et al. Open Access article distributed under the terms of CC BY-NC-SA T
Life expectancy among HIV-positive patients in Rwanda: a retrospective
observational cohort study
Nsanzimana et al

10. Key findings:
Of the 88,994 adults diagnosed with HIV between 1997-2012 in
England & Wales, 5,302 (6.0%) had died by the end of 2012.
(all-cause mortality 118 per 10 000 person-years)
 People living with HIV had a mortality rate 6 times higher than
the general population for all causes (SMR 5·7, 95% CI 5·5–5·8)
late diagnosis was a strong predictor of death (hazard ratio [HR]
3·50,95% CI 3·13–3·92).
57% of deaths occurred within 1 year of diagnosis and 23% of
people who died were never linked to care (92% died within 1
year of diagnosis)

11. 0
500
1,000
1,500
2,000
2,500
3,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Numberofdiagnoses
Year
Diagnosed promptly Diagnosed late (<350)
NewHIVdiagnoses
(promptandlate)amongheterosexuals:UK

12. NewHIVdiagnosesandoneyearmortality
(promptandlate)amongheterosexuals:UK
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
0
500
1,000
1,500
2,000
2,500
3,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Oneyearmortality(%)
Numberofdiagnoses
Year
Diagnosed promptly Diagnosed late (<350)
One year mortality (prompt) One year mortality (late)

13. NewHIVdiagnoses
(promptandlate)amongMSM:UK
0
500
1,000
1,500
2,000
2,500
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Numberofdiagnoses
Year
Diagnosed promptly Diagnosed late (<350)

14. NewHIVdiagnosesandoneyearmortality(promptand
late)amongMSM:UK
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
0
500
1,000
1,500
2,000
2,500
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Oneyearmortality(%)
Numberofdiagnoses
Year
Diagnosed promptly Diagnosed late (<350)
One year mortality (prompt) One year mortality (late)

15. Treatment as Prevention

16. Treatment as Prevention
Granich RM et al, Lancet
2009; 373: 48–57
Compelling Evidence
• MTCT and breastfeeding
• Cohort of couples
• Swiss statement
• Ecological
• RCT HPTN052
• Modelling
• PARTNER study

17. Early diagnosis and treatment
safes lives
How are we doing?
How do we know?

18. UNAIDS targets by 2020
• 90% People living with HIV know their
status
• 90% of diagnosed on sustainable ART
• 90% of treated have a durable viral
suppression
‘This would result in the end of AIDS and
make HIV transmission rare by 2030’
•Are the UNAIDS goals achievable?
•Will it result in the end of AIDS and a near elimination of
HIV?

19. We need good and timely data

20. Fig 2. Global AIDS-related death rate per 1000 people living with HIV in 2013.
Granich R, Gupta S, Hersh B, Williams B, Montaner J, et al. (2015) Trends in AIDS Deaths, New Infections and ART Coverage in
the Top 30 Countries with the Highest AIDS Mortality Burden; 1990–2013. PLoS ONE 10(7): e0131353.
doi:10.1371/journal.pone.0131353
http://journals.plos.org/plosone/article?id=info:doi/10.1371/journal.pone.0131353

21. Current global estimates for the care cascade
Levi et al 2016*
Levi J, Raymond A, Pozniak A, Vernazza P, Kohler P, Hill A. Can the UNAIDS 90-90-90 target be achieved? A systematic analysis
of national HIV treatment cascades. BMJ Glob Health 2016;
* Based on 69/196 countries – 32 complete, 37 partial data

22. Reaching UNAIDS the 90 90 90 targets….
15 million on ART in 2015, up from 3million in 2005
Keep calm and carry on….

23. How are countries in Europe performing
against the 90-90-90 treatment targets? N=16
90%
81%
73%
ECDC. Thematic report: HIV continuum of care. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in
Europe and Central Asia: 2014 progress report. Stockholm: ECDC; 2015.

24. How are European and CentralAsian countries
performing inensuring people livingwithHIV are
diagnosed and treated?
Illustration Using‘cutpoints’at60%
Drew, Human Immunodeficiency Virus (HIV) Continuum of Care in Europe and Central Asia, HIV Medicine, 2016

25. Treatment policies: improving
‘test and treat’
Source: ECDC. The status of the HIV response in the European Union/European Economic Area, 2016. Stockholm: ECDC; 2017.

26. Scaling up testing and link to care
and treatment
How much and how?

27. Is HIV testing among MSM delivered at scale
in EU/EEA Member States? (n=30)
27 countries: HIV testing is delivered at scale for MSM
16countries: Have data on uptake of HIV
testing among MSM
5 countries: Data on
uptake of HIV testing among
sub-groups of MSM at
increased risk
Source: Dublin monitoring 2015

28. Are there major gaps in HIV testing services
for any of the following populations?
Key populations YES NO
Undocumented migrants 17 29
Migrants from high prevalence countries 13 33
MSM 11 35
Sex workers 10 36
PWID 7 39
Prisoners 5 41
Transgender people 2 44

29. What needs to happen?

30. Current HIV trends in England
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
test rate +
test rate ++
base test rate
(Current
situation)
Years from infection
Proportion infected
0 1 2 3 4 5
Phillips, AIDS 2015

31. 0
1000
2000
3000
4000
5000
Number of new infections
per year
2015 2020 2025 2030
Year
HIV incidence among MSM, Phillips 2015
test rate ++ ART 350
base test rate ART at diagnosis
test rate + ART at diagnosis
test rate ++ ART at diagnosis
test rate + ART at 350
base test rate ART at 350
95% CI
given for two
lines to illustrate
uncertainty
over mean effect

32. Scaling up testing & link to
treatment and care
 Up to date testing and treatment guidelines
 Affordable drugs for governments and free for all diagnosed persons
 Commitment at every level
 Testing, diagnosis and care within a human rights framework
 Reduce barriers and promotion of good practice
 Testing strategies based on local epidemiology
 community engagement
 innovation – making it easier to test
 close monitoring and evaluation at all levels

34. Strategies based on evidence
and understanding of the local
epidemiology

35. Presentation title - edit in Header and Footer
Prevalence of
diagnosedHIV
infectionbyareaof
residenceamong
populationaged15-59:
UnitedKingdom, 2015
Overall prevalence rate:
2.26 (2.24-2.27) per 1,000
Geographical targeting

36. Late HIV diagnosis (CD4<350 at diagnosis)
by HIV service provider
36 Presentation title - edit in Header and Footer
• 127 trusts in England received newly-diagnosed adults in 2014
• 40% of these adults had a CD4<350 at diagnosis
• 34% (43/127) trusts were below the England benchmark
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1
4
7
10
13
16
19
22
25
28
31
34
37
40
43
46
49
52
55
58
61
64
67
70
73
76
79
82
85
88
91
94
97
100
103
106
109
112
115
118
121
124
127
All trusts: 40%

37. Presentation title - edit in Header and
Footer
Improvements in time to ART, UK

38. Greater inclusion and engagement of
community

39. Community engagement
• Stigma and discrimination remains major barrier to testing, link
and retention in care and prevention efforts
• Need greater engagement of affected communities at every
level
• Tailored messages for individuals recognising diverse nature of
community
• Support peer-led initiatives and outreach programs
• Sustained funding for NGOs
• Provision of integrated and welcoming, non judging services in
partnership with NGOs
39
Presentation title - edit in Header and
Footer

40. Experiences of stigma and
discrimination in the last 12 months
among women, 2015

41. Reported experiences of stigma and
discrimination in the last 12 months
in the health care setting, 2015

42. Promote sexual health among LGBT
communities across the life course
• Tackling homophobia and bullying
• Education in Schools
• Increase use of high-quality, coordinated
educational, clinical, and other preventive
services
• Increase knowledge, communication, and
respectful attitudes regarding sexual health and
drug and alcohol use
• Promoting opportunities to discuss role of
pleasure, satisfaction and ability to use drugs
with the least harm
• Increase healthy, responsible, and respectful
sexual behaviors and relationships
• Decrease adverse health outcomes, including
HIV/STIs, viral hepatitis, and sexual violence
42Source: Douglas JM Jr, Fenton KA. Public Health Rep. 2013 Mar-Apr;128 Suppl 1:1-4

43. Combination approach to
prevention
43 Current HIV trends in England

44. New HIV diagnoses in STI clinics in the UK,
the beginning of a downturn in gay/bisexual men?
0
100
200
300
400
500
600
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2012 2013 2014 2015 2016
Gay/bisexual men Heterosexual men Heterosexual women

45. Situation Jan 2017
• PHE Ongoing investigation
• High rise in number of HIV tests among MSM particularly in some London
clinics
• Especially high rise in testing and sexual health screens among repeat
testers
• Associated with downturn in some STIs and HIV in recent months,
decreased late diagnoses
• Improvements in early ART and decrease in the number of men with
unsuppressed viral load
• Prep Use increasing
• Most likely decrease in incidence due combination of interventions

46. • We have the tools & know what to do – scientific
knowledge
• Innovate and re-novate to simplify access to testing
and treatment
• better contextualise our knowledge for and engage
communities
• Expect constant change and refinement – and big step
changes
• Advocate for generics and prevention funding
• Tackle legal barriers and/or creatively circumvent them
• Timely accurate information for setting policy and
monitoring efforts is crucial
• Greater engagement of public health working in
partnership with health professionals and community
Prevention Tool kit,
John Walter, 2015
In the 4th decade of the HIV epidemic

47. TeymurNoori,AnastasiaPharrisand Andrew Amato,ECDC
CaryJames–TerenceHigginsTrust,HIVPreventionEngland
AndrewPhillips andcolleaguesatUCL
AndrewHillandcolleaguesatImperial
ColleaguesPHE:
AnthonyNardone,GwendaHughes,NoelGill,KathyLowndes,
OwenBrigstock-Barron,LuisGuerra,Daniella DeAngelis,AnnePresanis,Stefano
Conti
HARS team– AlisonBrown,MeaghanKall,SaraCroxford,SandraOkala,Peter
Kirwan,CuongChau,MatthewHibbert,Jameel,Amrita NickCooper,RajaniRagu,
JaniceMorgan,AdammaAgazhui,ZhengYin
Thank you &
Acknowledgements