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García-Ruiz de Morales AG, Vivancos MJ, de Lagarde M, Ramírez Schacke M, Del Mar Arcos Rueda M, Orviz E, Curran A, Carmona-Torre F, Moreno S, Pérez-Elías MJ, Martínez-Sanz J. Transition times across the HIV care continuum in Spain from 2005 to 2022: a longitudinal cohort study. Lancet HIV 2024; 11:e470-e478. [PMID: 38824937 DOI: 10.1016/s2352-3018(24)00118-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Ending AIDS by 2030 requires improvements across all stages of the HIV care continuum. We used a longitudinal approach to assess changes in the HIV care continuum in Spain and transition probabilities across different stages. METHODS We used data from the prospective Cohort of the Spanish HIV/AIDS Research Network to analyse the time from diagnosis to linkage to care, linkage to care to antiretroviral therapy (ART), and ART to viral suppression in five calendar periods defined by milestones in ART, from 2005 to 2022. We used the Kaplan-Meier method and Cox proportional hazard models to estimate cumulative probabilities of stage transition within 1, 3, 6, and 12 months of stage eligibility, by period. FINDINGS We included 18 529 participants. Comparing the initial (2005-09) and final (2020-22) periods, time to linkage to care decreased from a median of 6·0 weeks to 1·3 weeks, time to ART initiation from 15·9 weeks to 0·4 weeks, and time to viral suppression from 13·3 weeks to 7·1 weeks. Adjusted hazard ratios for the comparison between the last period and the initial period were 3·1 (95% CI 2·8-3·4) for linkage to care within 1 month, 11·4 (10·1-12·3) for ART initiation within 1 month, and 2·2 (1·2-2·4) for viral suppression within 3 months. The aggregate proportion of late diagnoses was 38·6%, increasing after 2012 to 46·4% in the 2020-22 period. Same-day ART initiation increased from 18% to 39% from 2005 to 2022. The overall incidence rate of virological failure was 1·05 failures per 1000 person-years and showed a non-significant decline throughout the study. INTERPRETATION The great improvement in transition times through the HIV care cascade might put Spain on the verge of achieving the UNAIDS targets for HIV elimination. However, late diagnosis remains a challenge that should be addressed. FUNDING Instituto de Salud Carlos III and Spanish AIDS Research Network.
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Affiliation(s)
- Alejandro G García-Ruiz de Morales
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; University of Alcalá, Alcalá de Henares, Madrid, Spain
| | - María Jesús Vivancos
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - María de Lagarde
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Margarita Ramírez Schacke
- Department of Infectious Diseases, Hospital Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | - Eva Orviz
- Centro Sanitario Sandoval, Hospital Clínico San Carlos, Fundación para la Investigación Biomédica del Hospital Clínico San Carlos, Madrid, Spain
| | - Adrian Curran
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Francisco Carmona-Torre
- Biogipuzkoa Health Research Institute, Osakidetza Basque Health Service, Donostia University Hospital, Infectious Diseases Service, San Sebastián, Spain
| | - Santiago Moreno
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; University of Alcalá, Alcalá de Henares, Madrid, Spain
| | - María Jesús Pérez-Elías
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Javier Martínez-Sanz
- Department of Infectious Diseases, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.
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Wu X, Wu G, Ma P, Wang R, Li L, Sun Y, Xu J, Li Y, Zhang T, Li Q, Yang Y, Wang L, Xin X, Qiao Y, Fang B, Lu Z, Zhou X, Chen Y, Liu Q, Fu G, Wei H, Huang X, Su B, Wang H, Zou H. Immediate and long-term outcomes after treat-all among people living with HIV in China: an interrupted time series analysis. Infect Dis Poverty 2023; 12:73. [PMID: 37580822 PMCID: PMC10424386 DOI: 10.1186/s40249-023-01119-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/12/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND In 2003, China implemented free antiretroviral therapy (ART) for people living with HIV (PLHIV), establishing an eligibility threshold of CD4 < 200 cells/μl. Subsequently, the entry criteria were revised in 2012 (eligibility threshold: CD4 ≤ 350 cells/μl), 2014 (CD4 ≤ 500 cells/μl), and 2016 (treat-all). However, the impact of treat-all policy on HIV care and treatment indicators in China is unknown. We aimed to elucidate the immediate and long-term impact of the implementation of treat-all policy in China. METHODS Anonymized programmatic data on ART initiation and collection in PLHIV who newly started ART were retrieved between 1 January 2015 and 31 December 2019, from two provincial and municipal Centers for Disease Control and Prevention and ten major infectious disease hospitals specialized in HIV care in China. We used Poisson and quasi-Poisson segmented regression models to estimate the immediate and long-term impact of treat-all on three key indicators: monthly proportion of 30-day ART initiation, mean CD4 counts (cells/μl) at ART initiation, and mean estimated time from infection to diagnosis (year). We built separate models according to gender, age, route of transmission and region. RESULTS Monthly data on ART initiation and collection were available for 75,516 individuals [gender: 83.8% males; age: median 39 years, interquartile range (IQR): 28-53; region: 18.5% Northern China, 10.9% Northeastern China, 17.5% Southern China, 49.2% Southwestern China]. In the first month of treat-all, compared with the contemporaneous counterfactual, there was a significant increase in proportion of 30-day ART initiation [+ 12.6%, incidence rate ratio (IRR) = 1.126, 95% CI: 1.033-1.229; P = 0.007] and mean estimated time from infection to diagnosis (+ 7.0%, IRR = 1.070, 95% CI: 1.021-1.120; P = 0.004), while there was no significant change in mean CD4 at ART initiation (IRR = 0.990, 95% CI: 0.956-1.026; P = 0.585). By December 2019, the three outcomes were not significantly different from expected levels. In the stratified analysis, compared with the contemporaneous counterfactual, mean CD4 at ART initiation showed significant increases in Northern China (+ 3.3%, IRR = 1.033, 95% CI: 1.001-1.065; P = 0.041) and Northeastern China (+ 8.0%, IRR = 1.080, 95% CI: 1.003-1.164; P = 0.042) in the first month of treat-all; mean estimated time from infection to diagnosis showed significant increases in male (+ 5.6%, IRR = 1.056, 95% CI: 1.010-1.104; P = 0.016), female (+ 14.8%, IRR = 1.148, 95% CI: 1.062-1.240; P < 0.001), aged 26-35 (+ 5.3%, IRR = 1.053, 95% CI: 1.001-1.109; P = 0.048) and > 50 (+ 7.8%, IRR = 1.078, 95% CI: 1.000-1.161; P = 0.046), heterosexual transmission (+ 12.4%, IRR = 1.124, 95% CI: 1.042-1.213; P = 0.002) and Southwestern China (+ 12.9%, IRR = 1.129, 95% CI: 1.055-1.208; P < 0.001) in the first month of treat-all. CONCLUSIONS The implementation of treat-all policy in China was associated with a positive effect on HIV care and treatment outcomes. To advance the work of rapid ART, efforts should be made to streamline the testing and ART initiation process, provide comprehensive support services, and address the issue of uneven distribution of medical resources.
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Affiliation(s)
- Xinsheng Wu
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Guohui Wu
- Institute for AIDS/STD Control and Prevention, Chongqing Center for Disease Control and Prevention, Chongqing, People's Republic of China
| | - Ping Ma
- Department of Infectious Diseases, Tianjin Second People's Hospital, Tianjin, People's Republic of China
- Tianjin Association of STD/AIDS Prevention and Control, Tianjin, People's Republic of China
| | - Rugang Wang
- Dalian Public Health Clinical Center, Dalian, People's Republic of China
| | - Linghua Li
- Infectious Disease Center, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yinghui Sun
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Junjie Xu
- Clinical Research Academy, Peking University Shenzhen Hospital, Peking University, Shenzhen, People's Republic of China
| | - Yuwei Li
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Tong Zhang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No.8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing, 100069, People's Republic of China
| | - Quanmin Li
- Infectious Disease Center, Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yuecheng Yang
- Dehong Prefecture Center for Disease Control and Prevention, Dehong, People's Republic of China
| | - Lijing Wang
- Shijiazhuang Fifth Hospital, Shijiazhuang, People's Republic of China
| | - Xiaoli Xin
- No.6 People's Hospital of Shenyang, Shenyang, People's Republic of China
| | - Ying Qiao
- No.2 Hospital of Hohhot, Hohhot, People's Republic of China
| | - Bingxue Fang
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Zhen Lu
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Xinyi Zhou
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Yuanyi Chen
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Qi Liu
- Shenzhen Campus of Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
- School of Public Health (Shenzhen), Sun Yat-sen University, No. 66, Gongchang Road, Guangming District, Shenzhen, 518107, Guangdong, People's Republic of China
| | - Gengfeng Fu
- Department of STD/AIDS Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, People's Republic of China
| | - Hongxia Wei
- Department of Infectious Disease, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, 1-1 Zhongfu Road, Nanjing, 210036, Jiangsu, People's Republic of China.
| | - Xiaojie Huang
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No.8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing, 100069, People's Republic of China.
| | - Bin Su
- Clinical and Research Center for Infectious Diseases, Beijing Youan Hospital, Capital Medical University, No.8 Xitoutiao, Youanmenwai, Feng Tai District, Beijing, 100069, People's Republic of China.
| | - Hui Wang
- National Clinical Research Centre for Infectious Diseases, The Third People's Hospital of Shenzhen and The Second Affiliated Hospital of Southern, University of Science and Technology, Bulan Road 29#, Longgang District, Shenzhen, 518112, Guangdong, People's Republic of China.
| | - Huachun Zou
- School of Public Health, Fudan University, 130 Dongan Road, Xuhui District, Shanghai, 200032, People's Republic of China.
- School of Public Health, Southwest Medical University, Luzhou, People's Republic of China.
- Kirby Institute, University of New South Wales, Sydney, Australia.
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Traeger MW, Guy R, Asselin J, Patel P, Carter A, Wright EJ, Grulich A, McManus H, Fairley CK, Chow EPF, McNulty A, Finlayson R, Bell C, Owen L, Marshall L, Russell D, O'Donnell D, Donovan B, Hellard ME, Stoové MA. Real-world trends in incidence of bacterial sexually transmissible infections among gay and bisexual men using HIV pre-exposure prophylaxis (PrEP) in Australia following nationwide PrEP implementation: an analysis of sentinel surveillance data. THE LANCET. INFECTIOUS DISEASES 2022; 22:1231-1241. [PMID: 35643090 DOI: 10.1016/s1473-3099(22)00175-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Although data from large implementation trials suggest that sexually transmissible infection (STI) risk increases among gay and bisexual men who initiate HIV pre-exposure prophylaxis (PrEP), there are few data on the trends in population-level STI incidence in the years following widespread PrEP implementation. We aimed to describe trends in bacterial STI incidence among gay and bisexual men using PrEP across Australia in the context of broad PrEP availability through Australia's subsidised medicines scheme. METHODS We analysed linked clinical data from HIV-negative gay and bisexual men aged 16 years or older who had been prescribed PrEP across a sentinel surveillance clinical network, including 37 clinics in Australia, between Jan 1, 2016, and Dec 31, 2019. Patients were included if they had STI testing at least twice during the observation period. Repeat testing methods were used to calculate chlamydia, gonorrhoea, syphilis, and any STI incidence rates during individuals' periods of PrEP use. Incidence rate ratios (IRRs) for estimated change in incidence per half calendar year (6-month) period were calculated using negative binomial regression. Secondary analyses compared STI incidence rates across individuals initiating PrEP in each year from 2016 to 2019, as well as by length of time using PrEP (per each additional 6 months of PrEP use). FINDINGS 22 730 men were included in the analyses. During the observation period, 11 351 chlamydia infections were diagnosed in 6630 (30·1%) of 22 034 men over 25 991·2 person-years of PrEP use (incidence rate 43·7 cases [95% CI 42·9-44·5] per 100 person-years). Chlamydia incidence decreased from 48·7 cases per 100 person-years in July-December, 2016, to 42·0 cases per 100 person-years in July-December, 2019 (IRR for estimated change per 6-month period 0·98 [95% CI 0·97-0·99]; p=0·0031). 9391 gonorrhoea infections were diagnosed in 5885 (26·9%) of 21 845 men over 24 858·7 person-years of PrEP use (incidence rate 37·8 cases [95% CI 37·0-38·5] per 100 person-years). Gonorrhoea incidence decreased from 45·5 cases per 100 person-years in July-December, 2016, to 37·2 cases per 100 person-years in July-December, 2019 (IRR 0·97 [95% CI 0·96-0·98]; p<0·0001). Declines in chlamydia and gonorrhoea incidence were most prominent in the first 18 months of observation and incidence was stable thereafter. 2062 syphilis infections were diagnosed in 1488 (7·7%) of 19 262 men over 21 978·9 person-years of PrEP use (incidence rate 9·4 cases [95% CI 9·0-9·8] per 100 person-years). Syphilis incidence increased from 6·2 cases per 100 person-years in July-December, 2016, to 9·8 cases per 100 person-years in July-December, 2019 (IRR 1·08 [95% CI 1·05-1·10]; p<0·0001). INTERPRETATION Chlamydia and gonorrhoea incidence among gay and bisexual men using PrEP were highest in the early months of PrEP implementation in Australia and stabilised at slightly lower rates thereafter following wider PrEP uptake. Lower prospective STI risk among people initiating PrEP in later years contributed to the observed trends in STI incidence. Widespread PrEP implementation can contribute to increased STI screening and detection. FUNDING Australian Department of Health, National Health and Medical Research Council.
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Affiliation(s)
- Michael W Traeger
- Burnet Institute, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Rebecca Guy
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | | | - Prital Patel
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Allison Carter
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Australian Human Rights Institute, UNSW Sydney, Sydney, NSW, Australia; Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Edwina J Wright
- Burnet Institute, Melbourne, VIC, Australia; Department of Infectious Diseases, Alfred Health, Central Clinical School, Monash University, Melbourne, VIC, Australia; Peter Doherty Institute, Melbourne, VIC, Australia
| | | | | | - Christopher K Fairley
- Department of Infectious Diseases, Alfred Health, Central Clinical School, Monash University, Melbourne, VIC, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
| | - Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Anna McNulty
- School of Population Health, UNSW Sydney, Sydney, NSW, Australia; Sydney Sexual Health Centre, Sydney, NSW, Australia
| | | | | | - Louise Owen
- Tasmanian Sexual Health Service, Hobart, TAS, Australia
| | - Lewis Marshall
- Sexual Health Service, Fremantle Hospital, Fremantle, WA, Australia; University of Notre Dame Australia, Fremantle, WA, Australia; University of Western Australia, Perth, WA, Australia
| | - Darren Russell
- Cairns Sexual Health Centre, Cairns, QLD, Australia; James Cook University, Cairns, QLD, Australia
| | - Darryl O'Donnell
- Australian Federation of AIDS Organisations, Sydney, NSW, Australia
| | - Basil Donovan
- Kirby Institute, UNSW Sydney, Sydney, NSW, Australia; Sydney Sexual Health Centre, Sydney, NSW, Australia
| | - Margaret E Hellard
- Burnet Institute, Melbourne, VIC, Australia; Department of Infectious Diseases, Alfred Health, Central Clinical School, Monash University, Melbourne, VIC, Australia; Peter Doherty Institute, Melbourne, VIC, Australia
| | - Mark A Stoové
- Burnet Institute, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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