Dr Tonio PiscopoConsultant Infectious Diseases

Mater Dei Hospital, MALTA

Scaling up HIV TreatmentThe Malta Experience

brief history2000

St Luke’s HospitalInfectious Disease Unit

HIV out-patients clinic

1994 Sir Paul Boffa Hospital

early ART days1996-2002

69 patients in clinic 33 patients on ART 29 Males 4 Females Age range: 12.5-64.9 yrs.

Clinical Audit of HIV diagnosis and management 2002. Mallia Azzopardi C, Piscopo T, Vincenti K

02468

1012141618

1996 1997 1998 1999 2000 2001 2002Year

No ofpatientsstarted onHAART peryear

HAART standard of care

ARTfree

suppression & durability

0

500

1000

1500

2000

2500

0 10 20 30 40D

ays

from

sta

rt o

f HA

AR

TIndividual patients

Patients with HIV viral load <400 copies/ml

by days from start of HAART

1

2

3

4

5

6

Years on HAART

HIV VL <400 copies/ml in 88% of all patients on HAART

17 patients (51%) of all patients on HAART) suppressed below 50 copies/ml

Piscopo T, Vincenti K, Mallia D, Mallia Azzopardi C. Durability of Highly Active Anti-Retroviral Therapy in the Maltese HIV Cohort. Malta Medical School Conference 2003.

2007Mater Dei Hospital

2 infectious disease consultants ID specialists and specialist

trainees clinical pharmacist hiv-experienced nurses support services

• public health; GU; obstetrics, paediatrics, mental health; labs

malta hiv clinic linkage: 1996-2016

479 patients made contact with service 35 patients died 139 patients left Malta for one reason or another 2 under Paediatric care

malta hiv cohort: 1996-2016

Non-Maltese58%

Maltese42%

n=471

Female24%

Male76%

Origin Gender

Malta HIV cohort data. 2016

malta hiv cohort: 1996-2016

Borg D. HIV: Clinical Manifestations and Treatment. Mater Dei Hospital 2014.

IVDU2%

Maternal0% Blood products

2%

Heterosexual46%

MSM50%

IVDU Maternal Blood products Heterosexual MSM

n=404key populations

0.5%

incidence: 1996-2016

12 1013 11 13

713

1013 14

2317

36

21 2227

33

26

4550 51

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

Number of referrals

Year

Malta HIV cohort data. 2016

2015-2016

05

101520253035

Malta Europe Africa Other

Area of provenance

2015 2016

Malta HIV cohort data. 2016

ART over time: 2003-2016

1

11

3

10

19 20 19 18

27 29

2327

5853

0

10

20

30

40

50

60

70

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

No of patients started on ART by year

2015: Change in guidelines

No of patients

breakdown of current ART by class

ART combination TOTALNNRTI-based regimen 95

PI-based regimen 156

INSTI-based regimen 20

CCR5 antag-based regimen 1

INSTI + PI-based regimen 2

INSTI +CCR5 antag-based regimen 1

NNRTI + PI-based regimen 2

Malta HIV cohort data. 2016

90-90-90 numbers on ART

Patients Number %ON ART 284 98.6OFF ART 4 1.4

Total no. of patients being actively followed up: 288

Malta HIV cohort data. 2016

90-90-90 viral suppression

Viral Load copies/ml <200 <200 (%) <50 <50 (%) <20 <20 (%)

SUPPRESSED 244 86.5 220 78.0 196 69.5NOT SUPPRESSED 38 13.5 62 22.0 86 30.5

Denominator All patients on treatment

Updated to January 2017

Adults only

ECDC meeting report. Optimising Analysis of the HIV continuum of Care in Europe. September 2015.

Target <200copies/ml

analysis of non-suppressed

1 1 12

1 12

1

4 4

12

4

13

0

2

4

6

8

10

12

14

1998 2001 2004 2005 2006 2007 2008 2009 2011 2012 2013 2014 2015 2016

No. of non-suppressed patients (38) by Year

Viral Load copies/ml <200 <200 (%)

SUPPRESSED 244 86.5

NOT SUPPRESSED 38 13.5

Malta HIV cohort data. 2016

resistance study: 2010-2015

89 resistance tests were requested 9 (10%) had confirmed ART resistance mutations

3 cases in treatment naïve patients

local resistance compares well with international studies resistance rates vary between 7.1 - 47.8%

Booth C et al. Prevalence and predictors of antiretroviral drug resistance in newly diagnosed HIV -1 infection. JAC Vol 59 (517-524). 2007.Richman DD et al. The prevalence of antiretroviral drug resistance in the United States. AIDS July 2004 Volume 18 (1193-1401).

Micallef Grimaud L et al. Assessment of antiretroviral drug resistance

mutations in HIV seropositive patients in Malta. Malta Medical School Conference 2015.

mother-to-child: 1996-2016 39 pregnancies

diagnosed before or during pregnancy 78% migrants

No transmission in 42 babies 2 positive babies:

1 mother refused testing (2006); 1 mother (migrant) presented late during labour (2016)

Micallef Grimaud L, Fsadni C, Mallia D, Pace D, Mallia Azzopardi C, Piscopo T. Management and Outcome of Pregnant HIV Seropositive Women in Malta. Malta Medical School Conference 2009.

Micallef Grimaud L, et al. Rate of mother-to-child transmission(MTCT) of HIV in the migrant population in Malta. MMSC2015

ART during pregnancy or asap after diagnosis intrapartum AZT if indicated babies also on ART

co-infection

hepatitis B all treated with an HBV active agent hepatitis C

2 patients who achieved an SVR 3 patients currently on Rx 10 patients being worked up

Malta HIV cohort data. 2016

H B VC IV V

challenges

achieving all the UNAIDS 90-90-90 targets earlier diagnosis of PLWHIV improve retention in care and follow-up expand upon currently available drug options further improve out-patient services continue transforming updated guidelines into action

Malta HIV care team

Thank You