Understanding temporal trends in HIV prevalence, incidence and ARV

Dr Valerie DelpechHead of HIV surveillancePublic Health England

How do we measure TasP at the population level?

2

Challenges of Test and Treat

• Efficacy versus effectiveness• Individual versus public health benefit

• Feasibility and acceptability

• Ethics

• Resistance and toxicity

• Role of primary HIV infection in transmission• MSM versus heterosexual epidemics

• Role of undiagnosed HIV in transmission

• Linkage to care and access to ART

3 3

• ?Elimination or ?decrease in incidence /new HIV

infections

• ?Elimination or ?reduction in AIDS deaths

• ?Impact on STIs

How do we monitor our successes and failures?

• Hard measures – ‘surveillance’ data in key populations

• new diagnosis, AIDS and non AIDS deaths

• late diagnosis, linkage and retention in care, testing and treatment uptake, viral suppression – ‘continuum of care

• STI rates, behavioural data

• Estimates

• incidence, undiagnosed infections

• Should NOT be used as ‘substitute’ for surveillance

What is successful Treatment as Prevention?

HIV Prevention Technologies Shown to Be Effective in Reducing HIV Incidence in Randomized Clinical Trials

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Granich RM et al, Lancet 2009; 373: 48–57

HIV incidence

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2000 2020 2040

British Columbia, Canada: Montaner et al (2010)

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Among approximately 77,600 persons living with diagnosed HIV infection in the UK

• 97% are linked to care after diagnosis within 3 months

• 95% are retained in care annually

• 92% of persons in need are on treatment (85% of all persons in care)

• 95% of persons on treatment achieve VL<200 copies/ml

9 Mortality and causes of death among women living with HIV in the UK in the era of HAART

Annual new HIV and AIDS diagnoses and deaths: UK, 1981-2012

First test for HIV

ART available

New HIV diagnoses in the UK by exposure category: 2003 - 2012

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2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

1000

2000

3000

4000

5000

6000

Sex between men (adjusted) Sex between men (observed)Heterosexual contact (adjusted) Heterosexual contact (observed)Injecting drug use (adjusted) Other (adjusted)Not reported

Year of first HIV diagnosis in the UK

Nu

mb

ers

of

new

HIV

dia

gn

ose

s

Uptake and HIV tests among MSM attending STI clinics, UK

CD 4 back-calculation method of annual HIV incidence in MSM: England & Wales 2001-2010

Birrell P.J. Gill O.N., Delpech V.C et al (2013). HIV incidence in men who have sex with men in England andWales 2001–10: a nationwide population study. The LancetID-D-12-0107 - S1473-3099(12)70341-9

HIV in the United Kingdom: 2013

Back-calculation estimate of HIV incidence and prevalence of undiagnosed infection among

MSM: UK, 2003-2012

SOPHIDMPES

Treatment cascade of adults living with HIV: United Kingdom, 2012

14 Treatment cascade of adults living with HIV: United Kingdom, 2011

HIV infected (n=98,400) HIV diagnosed Retained in care On treatment Undectable VL0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%100%

79%73%

69%62%

UK Continuum of care ‘cascade’

DATA SOURCES• Estimates of undiagnosed infections using Multi Parameter

Evidence Synthesis Model • Routine HIV surveillance data • UA programmes in key pops• Natsal – nationally representative sexual health survey• Behavioural data in key pops

• ‘In care’ data consists of linked comprehensive national data • new diagnoses • CD4 and VL laboratory data• Persons in HIV clinics - annual updates

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London

Less than 11-2>2

Prevalence of diagnosed HIV infection by region of residence among population aged 15-59 years: United Kingdom, 2011

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People living with HIV by diagnostic and treatment status, and number with detectable viral load, UK, 2006-2012

2008 2009 2010 2011 20120

20000

40000

60000

80000

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120000 Diagnosed and treated Diagnosed and untreated

Undiagnosed Number with VL>50 copies

HIV epidemic in the United Kingdom

19801982

19841986

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New HIV diagnoses

No.

First Year of HIV care is crucial

late diagnoseslink to carehigh uptake of ARThigh 1 yr mortality in late Dx

20 HIV in the United Kingdom: 2013

Late HIV diagnosis: Proportion* of adults diagnosed with a CD4 count <350 cells ,UK, 2012

HIV and STI Department, Health Protection Agency - Colindale

HIV and AIDS Reporting System

¹Prompt diagnosis: CD4 count ≥350 cells/mm³ within 91 days of diagnosis²Late diagnosis: CD4 count <350 cells/mm³ within three months of diagnosis³Percentage of patients known to have died within a year of diagnosis.

Prompt1 and late² HIV diagnosis in MSM with associated short-term mortality³: United Kingdom, 2002 - 2011

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0%

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bars

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-term

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ality

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(line)

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-term

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(line)

Exploration of the CD4 Data Warehouse – South Africa

Simbarashe Takuva, Adrian PunenAliison Brown, Valerie Delpech

Centre for HIV and STIs, National Institute for Communicable Diseases,

NHLS, Johannesburg.

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PLHIV in South Africa: Spectrum estimatePersons in HIV Care using CD4 as marker

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CD4 Count Distribution, SA2004-2012

24Source: CDW, 2013

HIV clinical dashboard

Individual based clinical outcome data at the local level

HIV clinical dashboard: England

Outcome name Measure England 2012Late diagnosis % newly diagnosed patients with a CD4 count

<350 cells/mm3 at diagnosis47%28% (CD4<200)

Linkage to care % newly diagnosed patients with a CD4 count test done within 28 days of diagnosis

89%(97% in 3 months)

Retention in care after diagnosis

% newly diagnosed patients retained in HIV care one year after diagnosis

95%

Retention in care of all patients

% of all patients retained in HIV care in the following year

85%

Immunological response

% of all patients seen for HIV care with a CD4 count > 350

85%(95%>200)

ART coverage % of patients in care on ARV 89 %Viral load suppression

% of patients with an undetectable viral load (VL<50 copies/ml) one year after initiating treatment

88%(95%<200)

Poster number: WEPE175

HIV Dashboard: Quality of care for newly-diagnosed by trust

27 Poster number: WEPE175

• 135 trusts in England• 5,808 newly-diagnosed

adults in 2012• 4,820 linked to HARS

cohort record

1 10 19 28 37 46 55 64 73 82 91 1001091181270%

20%

40%

60%

80%

100%

Figure 3. Retention in care among newly diagnosed adults

England mean (85%)

1 10 19 28 37 46 55 64 73 82 91 1001091181270%

20%

40%

60%

80%

100%

Figure 1. Late HIV diagnosis

CD4<350 (late) CD4<200 (very late)England mean (47%)

1 10 19 28 37 46 55 64 73 82 91 100 109 1180%

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

100%

Figure 2. Linkage to care after diagnosis

CD4 in 91 days CD4 in 28 daysEngland mean (89%)

Quality of care dashboard for all adults in care by Trust

28Poster number: WEPE175

1 10 19 28 37 46 55 64 73 82 91 1001091180%

20%

40%

60%

80%

100%

Figure 6. Viral load suppression 1 year after start of treatment

VL<200 VL<50 England mean (88%)

1 11 21 31 41 51 61 71 81 91 1011111211310%

20%

40%

60%

80%

100%

Figure 7. Immunological response after one year of care

CD4>200 CD4>350 England mean (85%)

1 11 21 31 41 51 61 71 81 91 1011111211310%

20%

40%

60%

80%

100%

Figure 4. Anual retention in among all adults

England mean (95%)

1 11 21 31 41 51 61 71 81 91 1011111211310%

20%

40%

60%

80%

100%

Figure 5. Antiretrovieral therapy coverage among adults with

CD4<350England mean (89%)

Conclusions and Public health relevance

• Successes (and failures) of public health policies including TasP can be measured using basic routine surveillance data for key risk groups and over time

• Accurate and comprehensive (representative) data and clear consistent methodologies are key for tracking progress

• HIV surveillance data should be linked to vital statistics death data

• CD4 data are extensively used to track the epidemic – • late diagnosis, link to care, retention in care, back-calculation estimates, as well

as evaluation of treatment guidelines, estimates of incidence and undiagnosed

• VL – provide insight into success of treatment programs and ongoing transmission

• Other markers are also important – STI and behavioural data

• Clinical dashboards at the local level in key populations provide accountability and can drive improvements

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NO ONE SHOULD DIE OF AIDS IN 2014

NO ONE

ANYWHERE 30

We gratefully acknowledge

all the persons living with HIV as well as

clinicians, health advisors, nurses,

microbiologists, public health practitioners,

data managers and other colleagues who

contribute to

the surveillance of HIV and STIs in the UK.

Thank-you