Potential impact on HIV incidence of higher HIV testing rates and earlier antiretroviral therapy initiation in MSM

Modelling HIV/AIDS epidemiological complexity: A scoping review of Agent-Based Models and their application

OBJECTIVE

To end the AIDS epidemic by 2030, despite the increasing poverty and inequalities, policies should be designed to deal with population heterogeneity and environmental changes. Bottom-up designs, such as the Agent-Based Model (ABM), can model these features, dealing with such complexity. HIV/AIDS has a complex dynamic of structural factors, risk behaviors, biomedical characteristics and interventions. All embedded in unequal, stigmatized and heterogeneous social structure. To understand how ABMs can model this complexity, we performed a scoping review of HIV applications, highlighting their potentialities.

METHODS

We searched on PubMed, Web of Science, and Scopus repositories following the PRISMA extension for scoping reviews. Our inclusion criteria were HIV/AIDS studies with an ABM application. We identified the main articles using a local co-citation analysis and categorized the overall literature aims, (sub)populations, regions, and if the papers declared the use of ODD protocol and limitations.

RESULTS

We found 154 articles. We identified eleven main papers, and discussed them using the overall category results. Most studies model Transmission Dynamics (37/154), about Men who have sex with Men (MSM) (41/154), or individuals living in the US or South Africa (84/154). Recent studies applied ABM to model PrEP interventions (17/154) and Racial Disparities (12/154). Only six papers declared the use of ODD Protocol (6/154), and 34/154 didn't mention the study limitations.

CONCLUSIONS

While ABM is among the most sophisticated techniques available to model HIV/AIDS complexity. Their applications are still restricted to some realities. However, researchers are challenged to think about social structure due model characteristics, the inclusion of these features is still restricted to case-specific. Data and computational power availability can enhance this feature providing insightful results.

Impact of voluntary testing on infectious disease epidemiology: A game theoretic approach

The World Health Organization recommends test-and-treat interventions to curb and even eliminate epidemics of HIV, viral hepatitis, and sexually transmitted infections (e.g., chlamydia, gonorrhea, syphilis and trichomoniasis). Epidemic models show these goals are achievable, provided the participation of individuals in test-and-treat interventions is sufficiently high. We combine epidemic models and game theoretic models to describe individual's decisions to get tested for infectious diseases within certain epidemiological contexts, and, implicitly, their voluntary participation to test-and-treat interventions. We develop three hybrid models, to discuss interventions against HIV, HCV, and sexually transmitted infections, and the potential behavioral response from the target population. Our findings are similar across diseases. Particularly, individuals use three distinct behavioral patterns relative to testing, based on their perceived costs for testing, besides the payoff for discovering their disease status. Firstly, if the cost of testing is too high, then individuals refrain from voluntary testing and get tested only if they are symptomatic. Secondly, if the cost is moderate, some individuals will test voluntarily, starting treatment if needed. Hence, the spread of the disease declines and the disease epidemiology is mitigated. Thirdly, the most beneficial testing behavior takes place as individuals perceive a per-test payoff that surpasses a certain threshold, every time they get tested. Consequently, individuals achieve high voluntary testing rates, which may result in the elimination of the epidemic, albeit on temporary basis. Trials and studies have attained different levels of participation and testing rates. To increase testing rates, they should provide each eligible individual with a payoff, above a given threshold, each time the individual tests voluntarily.

The effect of combination prevention strategies on HIV incidence among gay and bisexual men who have sex with men in the UK: a model-based analysis

BACKGROUND

In the UK, the number of new HIV diagnoses among gay and bisexual men who have sex with men (GBMSM) has decreased substantially. We aimed to understand the contribution of different interventions in reducing HIV incidence so far; to estimate future HIV incidence with continuation of current policies and with further scaling up of current interventions; and to estimate the maximum additional annual cost that should be spent towards these interventions for them to offer value for money.

METHODS

We calibrated a dynamic, individual-based, stochastic simulation model, the HIV Synthesis Model, to multiple sources of data on HIV among GBMSM aged 15 years or older in the UK. Primarily these were routine HIV surveillance data collected by the UK Health Security Agency. We compared HIV incidence in 2022 with the counterfactual incidence: if HIV testing rates stopped increasing in 2012 and the policy of antiretroviral therapy (ART) at diagnosis was not introduced in mid-2015; if pre-exposure prophylaxis (PrEP) was not introduced; if condom use was low from 2012 in all GBMSM, at levels similar to those observed in 1980; and in the first and second scenario combined. We also projected future outcomes under the assumption of continuation of current policies and considering increases in PrEP and HIV testing uptake and a decrease in condomless sex.

FINDINGS

Our model estimated a 77% (90% uncertainty interval [UI] 61-88) decline in HIV incidence since around 2014, with an estimated 597 infections ([90% UI 312-956]; 1·1 per 1000 person-years [90% UI 0·6-1·8]) in men aged 15-64 years in 2022. Both PrEP introduction and increased HIV testing with ART initiation at diagnosis each had a substantial effect on HIV incidence. Without PrEP introduction, we estimate there would have been 2·16 times the number of infections that actually occurred (90% UI 1·06-3·75) between 2012 and 2022; without increased HIV testing and ART initiation at diagnosis there would have been 2·18 times the number of infections that actually occurred (1·18-3·60), and if condomless sex was at the levels before the HIV epidemic, there would have been 2·27 times the number of infections that actually occurred (0·9-5·4). If rates of testing, ART use, and PrEP use remain as they are currently, there is a predicted decline in incidence to 388 HIV infections in 2025 (90% UI 226-650) and to 263 (137-433) in 2030. Increases in HIV testing and PrEP use were predicted to accelerate the decline in HIV incidence. Given the quality-adjusted life-year (QALY) benefit and a cost-effectiveness threshold of £30 000 per QALY gained, in order to be cost-effective an additional £1·62 million could be spent per year to increase testing levels by 34% (90% UI 25-46) and PrEP use by 55% (10-107). To achieve that, a 16% reduction in the cost of delivery of testing and PrEP would be required.

INTERPRETATION

Combination prevention, including a PrEP strategy, played a major role in the reduction in HIV incidence observed so far in the UK among GBMSM. Continuation of current activities should lead to a continued decline; however, it is unlikely to lead to reaching the target of fewer than 50 HIV infections per year among GBMSM by 2030. It will be important to reduce costs for testing and PrEP for their continued expansion to be cost-effective.

FUNDING

National Institute for Health Research under its Programme Grants for Applied Research Programme and Medical Research Council-UK Research and Innovation.

Motivations and Barriers to Routine HIV Testing Among Men Who Have Sex with Men in New York City

In-depth qualitative interviews explored the experiences and understandings of men 18-39 years old who have sex with men that could facilitate or prevent HIV testing and routine HIV testing. For many men who tested frequently, testing and routine testing were motivated by awareness of the benefit of prompt treatment; public health and provider encouragement to test periodically; responsibility towards sexual partners; and wanting to share a recent HIV-negative test result when seeking sex online. For some men, any testing was impeded by anxiety around possible HIV diagnosis that made testing a stressful occasion that required time and energy to prepare for. This anxiety was often compounded by stigma related to sex between men, having condomless sex, or having HIV. Routine testing could be further stigmatized as some men felt judged by testing providers or partners if they asked for a test or said they tested frequently. We describe efforts to promote testing and routine testing by countering fear and stigma associated with HIV and testing.

Predictors of HIV Among 1 Million Clients in High-Risk Male Populations in Tanzania

The World Health Organization identified men as an essential group to target with HIV testing and treatment strategies;: men who have sex with men (MSM) and male clients of female sex workers (CFSW) account for 35% of new HIV infections globally. Using a cross-sectional design from a community-based HIV prevention project in Tanzania (October 2015-September 2018) and multivariable logistic regression, we identified predictors of HIV seropositivity among men. Of 1,041,343 men on their initial visit to the project, 36,905 (3.5%) were MSM; 567,005 (54.5%) were CFSW; and 437,343 (42.0%) were other men living near hotspots (OMHA). Three predictors of HIV seropositivity emerged across all three groups: being uncircumcised, having sexually transmitted infection symptoms, and harmful drinking of alcohol before sex. Any reported form of gender-based violence among MSM and OMHA and inconsistent condom use among CFSW were associated with HIV seropositivity. These findings may inform community HIV strategies like self-testing, delivery of pre-exposure prophylaxis and antiretroviral therapy, and behavioral change communication targeting men at higher risk of infection.

HIV continuum of care: expanding scope beyond a cross-sectional view to include time analysis: a systematic review

INTRODUCTION

The continuum of care (CoC) model has been used to describe the main pillars of HIV care. This study aims to systematically review methods and elucidate gaps in the CoC analyses, especially in terms of the timing of the progression through steps, recognized nowadays as a critical parameter for an effective response to the epidemic.

METHODS

A PubMed and EMBASE databases search up to December 2019 resulted in 1918 articles, of which 209 were included in this review; 84 studies presented in major HIV conferences were also included. Studies that did not provide explicit definitions, modelling studies and those reporting only on metrics for subpopulations or factors affecting a CoC stage were excluded. Included articles reported results on 1 to 6 CoC stages.

RESULTS

Percentage treated and virally suppressed was reported in 78%, percentage diagnosed and retained in care in 58%, percentage linked to care in 54% and PLHIV in 36% of the articles. Information for all stages was provided in 23 studies. Only 6 articles use novel CoC estimates: One presents a dynamic CoC based on multistate analysis techniques, two base their time-to-next-stage estimates on a risk estimation method based on the cumulative incidence function, weighted for confounding and censoring and three studies estimated the HIV infection time based on mathematical modelling.

CONCLUSION

A limited number of studies provide elaborated time analyses of the CoC. Although time analyses lack the straightforward interpretation of the cross-sectional CoC, they provide valuable insights for the timely response to the HIV epidemic. A future goal would be to develop a model that retains the simplicity of the cross-sectional CoC but also incorporates timing between stages.

Trends in HIV incidence between 2013-2019 and association of baseline factors with subsequent incident HIV among gay, bisexual, and other men who have sex with men attending sexual health clinics in England: A prospective cohort study

BACKGROUND

Prospective cohort studies of incident HIV and associated factors among gay, bisexual, and other men who have sex with men (GBMSM) in the United Kingdom are lacking. We report time trends in and factors associated with HIV incidence between 2013 and 2019 among a cohort of GBMSM: the AURAH2 prospective study.

METHODS AND FINDINGS

Participants were recruited through 1 of 3 sexual health clinics in London and Brighton (July 2013 to April 2016) and self-completed a baseline paper questionnaire and subsequent 4-monthly and annual online questionnaires (March 2015 to March 2018), including information on sociodemographics, lifestyle, health and well-being, HIV status, sexual/HIV-related behaviours, and preexposure prophylaxis and postexposure prophylaxis (PrEP/PEP). Incident HIV was ascertained by linkage with national HIV surveillance data from Public Health England (PHE). We investigated the associations of HIV incidence with (1) baseline factors using mixed-effects Weibull proportional hazard models, unadjusted and adjusted for age, country of birth and ethnicity, sexuality, and education level; and (2) time-updated factors, using mixed-effects Poisson regression models. In total, 1,162 men (mean age 34 years, 82% white, 94% gay, 74% university-educated) were enrolled in the study. Thirty-three HIV seroconversions occurred over 4,618.9 person-years (PY) of follow-up: an overall HIV incidence rate (IR) of 0.71 (95% confidence interval (CI) 0.51 to 1.00) per 100 PY. Incidence declined from 1.47 (95% CI 0.48 to 4.57) per 100 PY in 2013/2014 to 0.25 (95% CI 0.08 to 0.78) per 100 PY in 2018/2019; average annual decline was 0.85-fold (p < 0.001). Baseline factors associated with HIV acquisition included the following: injection drug use (6/38 men who reported injection drug-acquired HIV; unadjusted conditional hazard ratio (HR) 27.96, 95% CI 6.99 to 111.85, p < 0.001), noninjection chemsex-related drug use (13/321; HR 6.45, 95% CI 1.84 to 22.64, p < 0.001), condomless anal sex (CLS) (26/741; HR 3.75, 95% CI 1.31 to 10·74, p = 0.014); higher number of CLS partners (HRs >10 partners [7/57]; 5 to 10 partners [5/60]; and 2 to 4 partners [11/293]: 14.04, 95% CI 4.11 to 47.98; 9.60, 95% CI 2.58 to 35.76; and 4.05, 95% CI 1.29 to 12.72, respectively, p < 0.001); CLS with HIV-positive partners (14/147; HR 6.45, 95% CI 3.15 to 13.22, p < 0.001), versatile CLS role (21/362; HR 6.35, 95% CI 2.18 to 18.51, p < 0.001), group sex (64/500; HR 8.81, 95% CI 3.07 to 25.24, p < 0.001), sex for drugs/money (4/55, HR 3.27, 95% CI 1.14 to 9.38, p = 0.027) (all in previous 3 months); previous 12-month report of a bacterial sexually transmitted infection (STI) diagnoses (21/440; HR 3.95, 95% CI 1.81 to 8.63, p < 0.001), and more than 10 new sexual partners (21/471, HRs 11 to 49, 50 to 99, and >100 new partners: 3.17, 95% CI 1.39 to 7.26; 4.40, 95% CI 1.35 to 14.29; and 4.84, 95% CI 1.05 to 22.4, respectively, p < 0.001). Results were broadly consistent for time-updated analysis (n = 622 men). The study's main limitation is that men may not be representative of the broader GBMSM population in England.

CONCLUSIONS

We observed a substantial decline in HIV incidence from 2013 to 2019 among GBMSM attending sexual health clinics. Injection drug use, chemsex use, and measures of high-risk sexual behaviour were strongly associated with incident HIV. Progress towards zero new infections could be achieved if combination HIV prevention including Test and Treat strategies and routine commissioning of a PrEP programme continues across the UK and reaches all at-risk populations.

Human Immunodeficiency Virus Continuum of Care in 11 European Union Countries at the End of 2016 Overall and by Key Population: Have We Made Progress?

Background

High uptake of antiretroviral treatment (ART) is essential to reduce human immunodeficiency virus (HIV) transmission and related mortality; however, gaps in care exist. We aimed to construct the continuum of HIV care (CoC) in 2016 in 11 European Union (EU) countries, overall and by key population and sex. To estimate progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, we compared 2016 to 2013 estimates for the same countries, representing 73% of the population in the region.

Methods

A CoC with the following 4 stages was constructed: number of people living with HIV (PLHIV); proportion of PLHIV diagnosed; proportion of those diagnosed who ever initiated ART; and proportion of those ever treated who achieved viral suppression at their last visit.

Results

We estimated that 87% of PLHIV were diagnosed; 92% of those diagnosed had ever initiated ART; and 91% of those ever on ART, or 73% of all PLHIV, were virally suppressed. Corresponding figures for men having sex with men were: 86%, 93%, 93%, 74%; for people who inject drugs: 94%, 88%, 85%, 70%; and for heterosexuals: 86%, 92%, 91%, 72%. The proportion suppressed of all PLHIV ranged from 59% to 86% across countries.

Conclusions

The EU is close to the 90-90-90 target and achieved the UNAIDS target of 73% of all PLHIV virally suppressed, significant progress since 2013 when 60% of all PLHIV were virally suppressed. Strengthening of testing programs and treatment support, along with prevention interventions, are needed to achieve HIV epidemic control.

Evidence of an Association of Increases in Pre-exposure Prophylaxis Coverage With Decreases in Human Immunodeficiency Virus Diagnosis Rates in the United States, 2012-2016

BACKGROUND

Annual human immunodeficiency virus (HIV) diagnoses in the United States (US) have plateaued since 2013. We assessed whether there is an association between uptake of pre-exposure prophylaxis (PrEP) and decreases in HIV diagnoses.

METHODS

We used 2012-2016 data from the US National HIV Surveillance System to estimate viral suppression (VS) and annual percentage change in diagnosis rate (EAPC) in 33 jurisdictions, and data from a national pharmacy database to estimate PrEP uptake. We used Poisson regression with random effects for state and year to estimate the association between PrEP coverage and EAPC: within jurisdictional quintiles grouped by changes in PrEP coverage, regressing EAPC on time; and among all jurisdictions, regressing EAPC on both time and jurisdictional changes in PrEP coverage with and without accounting for changes in VS.

RESULTS

From 2012 to 2016, across the 10 states with the greatest increases in PrEP coverage, the EAPC decreased 4.0% (95% confidence interval [CI], -5.2% to -2.9%). On average, across the states and District of Columbia, EAPC for a given year decreased by 1.1% (95% CI, -1.77% to -.49%) for an increase in PrEP coverage of 1 per 100 persons with indications. When controlling for VS, the state-specific EAPC for a given year decreased by 1.3% (95% CI, -2.12% to -.57%) for an increase in PrEP coverage of 1 per 100 persons with indications.

CONCLUSIONS

We found statistically significant associations between jurisdictional increases in PrEP coverage and decreases in EAPC independent of changes in VS, which supports bringing PrEP use to scale in the US to accelerate reductions in HIV infections.

Early ART Initiation Improves HIV Status Disclosure and Social Support in People Living with HIV, Linked to Care Within a Universal Test and Treat Program in Rural South Africa (ANRS 12249 TasP Trial)

We investigated the effect of early antiretroviral treatment (ART) initiation on HIV status disclosure and social support in a cluster-randomized, treatment-as-prevention (TasP) trial in rural South Africa. Individuals identified HIV-positive after home-based testing were referred to trial clinics where they were invited to initiate ART immediately irrespective of CD4 count (intervention arm) or following national guidelines (control arm). We used Poisson mixed effects models to assess the independent effects of (a) time since baseline clinical visit, (b) trial arm, and (c) ART initiation on HIV disclosure (n = 182) and social support (n = 152) among participants with a CD4 count > 500 cells/mm³ at baseline. Disclosure and social support significantly improved over follow-up in both arms. Disclosure was higher (incidence rate ratio [95% confidence interval]: 1.24 [1.04; 1.48]), and social support increased faster (1.22 [1.02; 1.46]) in the intervention arm than in the control arm. ART initiation improved both disclosure and social support (1.50 [1.28; 1.75] and 1.34 [1.12; 1.61], respectively), a stronger effect being seen in the intervention arm for social support (1.50 [1.12; 2.01]). Besides clinical benefits, early ART initiation may also improve psychosocial outcomes. This should further encourage countries to implement universal test-and-treat strategies.

Sustained, Low Prevalence of Undiagnosed HIV Among Gay and Bisexual Men in Sydney, Australia Coincident With Increased Testing and Pre-exposure Prophylaxis Use: Results From Repeated, Bio-Behavioral Studies 2014-2018

BACKGROUND

Gay and bisexual men with undiagnosed HIV contribute disproportionately to HIV transmission in Australia.

METHODS

In 2014 and 2018, we recruited men at gay venues and events in Sydney. Participants self-completed surveys and provided oral fluid samples for HIV testing. We calculated the prevalence of HIV and undiagnosed infection, and assessed changes in behavior, HIV testing, and the use of pre-exposure prophylaxis. We weighted the samples to adjust for differences in where participants were recruited between rounds. Two-sample tests of proportion were used to compare prevalence estimates and χ tests to assess differences between the samples.

RESULTS

In 2014, 944 men were recruited, and 890 men were recruited in 2018. In 2014, the weighted estimate of HIV prevalence was 6.1% [95% confidence intervals (CI): 4.6 to 7.6], of which 13.8% (95% CI: 5.0 to 22.7) was undiagnosed. In 2018, weighted HIV prevalence was 6.4% (95% CI: 4.8 to 8.0), of which 5.3% (95% CI: 0.5 to 11.1) was undiagnosed. Between 2014 and 2018 among all participants, men reporting at least 10 recent casual partners increased from 22.3% to 27.7% (P = 0.008), condomless anal intercourse with casual partners in the previous 6 months increased from 23.9% to 37.3% (P < 0.001), and sexually transmitted infection diagnoses in the previous year increased from 14.4% to 27.5% (P < 0.001). HIV testing and the use of pre-exposure prophylaxis in the previous 6 months increased from 49.6% to 56.3% (P = 0.004) and 2.0%-21.0% (P < 0.001), respectively.

CONCLUSIONS

Repeated, bio-behavioral surveillance suggests the prevalence of undiagnosed HIV remains low in Sydney, despite gay and bisexual men reporting more casual sex partners, condomless sex, and sexually transmitted infections.

Development and Evaluation of a Mobile App Designed to Increase HIV Testing and Pre-exposure Prophylaxis Use Among Young Men Who Have Sex With Men in the United States: Open Pilot Trial

BACKGROUND

HIV disproportionately affects young men who have sex with men (YMSM) in the United States. Uptake of evidence-based prevention strategies, including routine HIV testing and use of pre-exposure prophylaxis (PrEP), is suboptimal in this population. Novel methods for reaching YMSM are required.

OBJECTIVE

The aim of this study is to describe the development and evaluate the feasibility and acceptability of the MyChoices app, a mobile app designed to increase HIV testing and PrEP use among YMSM in the United States.

METHODS

Informed by the social cognitive theory, the MyChoices app was developed using an iterative process to increase HIV testing and PrEP uptake among YMSM. In 2017, beta theater testing was conducted in two US cities to garner feedback (n=4 groups; n=28 YMSM). These findings were used to refine MyChoices, which was then tested for initial acceptability and usability in a technical pilot (N=11 YMSM). Baseline and 2-month postbaseline assessments and exit interviews were completed. Transcripts were coded using a deductive approach, and thematic analysis was used to synthesize data; app acceptability and use data were also reported.

RESULTS

The MyChoices app includes personalized recommendations for HIV testing frequency and PrEP use; information on types of HIV tests and PrEP; ability to search for nearby HIV testing and PrEP care sites; and ability to order free home HIV and sexually transmitted infection test kits, condoms, and lube. In theater testing, YMSM described that MyChoices appears useful and that they would recommend it to peers. Participants liked the look and feel of the app and believed that the ability to search for and be pinged when near an HIV testing site would be beneficial. Some suggested that portions of the app felt repetitive and preferred using casual language rather than formal or medicalized terms. Following theater testing, the MyChoices app was refined, and participants in the technical pilot used the app, on average, 8 (SD 5.0; range 2-18) times over 2 months, with an average duration of 28 (SD 38.9) minutes per session. At the 2-month follow-up, the mean System Usability Scale (0-100) score was 71 (ie, above average; SD 11.8). Over 80% (9/11) of the participants reported that MyChoices was useful and 91% (10/11) said that they would recommend it to a friend. In exit interviews, there was a high level of acceptability for the content, interface, and features.

CONCLUSIONS

These data show the initial acceptability and user engagement of the MyChoices app. If future studies demonstrate efficacy in increasing HIV testing and PrEP uptake, the app is scalable to reach YMSM across the United States.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03179319; https://clinicaltrials.gov/ct2/show/NCT03179319.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/10694.

Recognizing Laboratory Medicine's Collaborative Role in Identifying and Eliminating Health Disparities

BACKGROUND

A health disparity is a health outcome that presents in a lesser or greater extent between populations. Health disparities in diseases are products of complex interactions between social, economic, and to a lesser extent, biological factors and can be mediated by structural racism and discriminatory policies. The objective of this review is to understand how both laboratorians and nonlaboratorians think about the relationship between laboratory medicine and health disparities and to highlight ways in which laboratory medicine can play a role in eliminating health disparities.

CONTENT

We developed an electronic survey from which we selected the top responses reported by the 215 participants to frame a discussion around why laboratorians perceive health disparities exists, and how they can reduce health disparities.

SUMMARY

We found that both laboratorians and nonlaboratorians feel that laboratory medicine can and should play a role in reducing health disparities using many tools already in use in the clinical laboratory. The skills of laboratory workers in data generation, the establishment of reference ranges, control over the presentation of laboratory results, generation of test menus, and the development of novel diagnostics may impact health disparities. Laboratorians' responses in our survey indicated that they felt that they could reduce health disparities by using laboratory data to proactively track in cooperation with healthcare providers individuals with chronic conditions to prevent acute events, ensuring gender and ethnic diversity in new clinical trials, including appropriate curriculum in laboratory medicine training, using equations and reference intervals based on physiological differences and participating in unconscious bias training.

Estimates of the HIV undiagnosed population in Belgium reveals higher prevalence for MSM with foreign nationality and for geographic areas hosting big cities

Introduction

Increasing our knowledge on geographic areas and key populations most affected by HIV is essential to improve prevention and care and to ensure a more focused HIV response. Here, we estimated the prevalence of undiagnosed HIV infections in Belgium and its distribution across geographic areas and exposure groups.

Methods

We used surveillance data on newly diagnosed HIV cases and a previously developed back‐calculation model to estimate number and prevalence rates (per 10000) of undiagnosed HIV infections by exposure group at national and subnational levels. Belgium consists of three regions: Flanders, Brussels‐Capital Region and Wallonia. We produced estimates for Brussels‐Capital Region and Wallonia. For Flanders, we produced estimates for two sub‐regional areas: the province of Antwerp and the other provinces, because Antwerp is the second largest city after Brussels. Population sizes were determined using data from the Belgian Statistical Office and surveys on sexual behaviour and drug use.

Results

In Belgium, in 2015, an estimated 2818 (95% confidence interval: 2494 to 3208) individuals were living with undiagnosed HIV, that is, 15% of individuals living with HIV. The Brussels‐Capital Region and the province of Antwerp, which host the two biggest cities, accounted for ~60% of the undiagnosed infections, and had the highest undiagnosed prevalence rates per 10000: 12.0 (9.4 to 15.3) and 7.4 (5.6 to 9.8) respectively. Individuals with foreign nationality accounted for 56% of the total number of undiagnosed infections, and were the most affected populations in all areas in terms of undiagnosed prevalence rates. Specifically, men who have sex with men (MSM) with non‐European nationality were the most affected population in the province of Antwerp (853.4 (408.2 to 1641.9) undiagnosed infections per 10000), the Brussels‐Capital Region (543.9 (289.1 to 1019.1)), and the other provinces of Flanders (691.7 (235.5 to 1442.2)), while in Wallonia, it was heterosexual women with Sub‐Saharan African nationality (132.2 (90.6 to 178.5)).

Conclusions

Geographic areas hosting the biggest cities in Belgium accounted for the vast majority of undiagnosed HIV infections and individuals with foreign nationality were the most affected, especially MSM with non‐European nationality. This should be accounted for when tailoring prevention and testing programs. Furthermore, MSM with foreign nationality require more attention in Belgium, and certainly more generally in Europe.

Who Do You Reach? A Norwegian Pilot Project on HIV Self-Testing that Targeted Men Who Have Sex with Men

HIV self-testing reduces barriers associated with other HIV testing services, such as concerns about confidentiality and inconvenience. This article demonstrates who might benefit from this approach to HIV testing by describing the characteristics of men who have sex with men (MSM) who took interest in a Norwegian pilot project on HIV self-testing. Of the MSM users, 27% reported that they had never been tested for HIV. Not disclosing one's same-sex sexuality, particularly among non-gay-identified MSM, was associated with a higher probability of never having been tested for HIV and choosing to test with an HIV self-test because of its anonymity. Never having been tested for HIV was also associated with a higher probability of choosing to test with an HIV self-test due to anonymity. The results suggest that the HIV self-tests' ability to reach MSM who otherwise would not be tested is partly because it is an anonymous HIV testing alternative.

Exploring Mechanisms of Action: Using a Testing Typology to Understand Intervention Performance in an HIV Self-Testing RCT in England and Wales

SELPHI involves two interventions: A provides one HIV self-testing (HIVST) kit; B offers 3-monthly repeat HIVST kits if participants report ongoing risk. A logic model underpinned by the Behaviour Change Wheel informed the design of the intervention. SELPHI recruited 10,135 cis-men and trans people in England and Wales, all reporting anal sex with a man. This paper explores how the interventions were experienced and the mechanisms of action leading to impact for different groups of trial participants. In-depth interviews with 37 cis-men who have sex with men (MSM) were used to inductively categorise participants based on sexual and HIV testing histories. Themes relating to intervention experiences and impacts were mapped onto SELPHI-hypothesised intermediate outcomes to consider intervention impacts. Three groups were identified: ‘inexperienced testers’ engaged with SELPHI to overcome motivational and social and physical opportunity testing barriers. For ‘pro self-testers’, testing frequency was constrained by psychological and social barriers and lack of opportunity. ‘Opportunistic adopters’ engaged in HIVST for novelty and convenience. Perceived impacts for inexperienced testers were most closely aligned with the logic model, but for opportunistic adopters there was little evidence of impact. Distinctive groups were discernible with divergent intervention experiences. Using COM-B as a model for understanding behaviour change in relation to HIVST, our results indicate how HIVST interventions could be adapted to respond to different needs based on the target population’s demographic and behavioural features.

HIV self-testing intervention experiences and kit usability: results from a qualitative study among men who have sex with men in the SELPHI (Self-Testing Public Health Intervention) randomized controlled trial in England and Wales

Objectives

SELPHI (HIV Self‐Testing Public Health Intervention) is the largest randomized controlled trial (RCT) of HIV self‐testing (HIVST) in a high‐income setting to date, and has recruited 10 000 men who have sex with men (cis‐ and transgender) and transgender women who have sex with men. This qualitative substudy aimed to explore how those utilizing self‐tests experience HIVST and the implications for further intervention development and scale‐up. This is the first qualitative study in Europe investigating experiences of HIVST among intervention users, and the first globally examining the experience of using blood‐based HIVST.

Methods

Thirty‐seven cisgender MSM SELPHI participants from across England and Wales were purposively recruited to the substudy, in which semi‐structured interviews were used to explore testing history, HIVST experiences and intervention preferences. Interviews were audio‐recorded, transcribed and analysed through a framework analysis.

Results

Men accessed the intervention because HIVST reduced barriers related to convenience, stigma and privacy concerns. Emotional responses had direct links to acceptability. Supportive intervention components increased engagement with testing and addressed supportive concerns. HIVST facilitated more frequent testing, with the potential to reduce sexually transmitted infection (STI) screening frequency. Substudy participants with an HIV‐positive result (n = 2) linked to care promptly and reported very high acceptability. Minor adverse outcomes (n = 2; relationship discord and fainting) did not reduce acceptability. Ease of use difficulties were with the lancet and the test processing stage.

Conclusions

Intervention components shaped acceptability, particularly in relation to overcoming a perceived lack of support. The intervention was broadly acceptable and usable; participants expressed an unexpected degree of enthusiasm for HIVST, including those with HIV‐positive results and individuals with minor adverse outcomes.

Effects of a Mobile Health Intervention to Promote HIV Self-testing with MSM in China: A Randomized Controlled Trial

This study tested a mobile health (mHealth) intervention program entitled WeTest, delivered via the WeChat mobile app, to promote oral HIV self-testing (HIVST) among MSM in Hefei, China. A total of 100 MSM participants enrolled, completed baseline assessment, were randomly assigned to intervention or control, and completed 6-month follow-up surveys. Intervention participants (n = 50) received two oral HIVST kits and access to WeTest, a private WeChat group which provided app-based messages and referrals to health services related to HIV. Control participants (n = 50) received two oral HIVST kits only. All participants received instructions to upload photographic results of their oral HIVST, which were sent to the project counselor via a secure WeChat online portal; immediate contact and referrals were made to any participants who tested HIV-positive. In GEE analyses adjusting for time effects and baseline confounders, intervention participants had significantly higher rates of HIV testing (adjusted rate ratio RR = 1.99, 95% confidence interval (CI) 1.07–3.84) and, in particular, higher rates of testing via oral HIVST (adjusted RR = 2.17, 95% CI 1.08–4.37) compared with the control group. Significant time effects were also found such that all participants, regardless of group allocation, had significantly higher rates of reporting consistent condom use with main partners (adjusted RR = 18.13, 95% CI 5.19–63.31) and with non-main partners (adjusted RR = 5.33, 95% CI 2.35–12.08). Findings from this study provide evidence for the feasibility, acceptability and preliminary effects of this mHealth approach to promoting oral HIVST among MSM in China.

Substantial Heterogeneity in Progress Toward Reaching the 90-90-90 HIV Target in the WHO European Region

Background:

Achieving the UNAIDS 90-90-90 target by 2020 is expected to end the HIV epidemic by 2030. We report on progress in the WHO European Region in meeting this target.

Methods:

The European Centre for Disease Prevention and Control (ECDC) sent questionnaires to 55 countries in 2016. We report estimates for 4 stages of the continuum of HIV care (living with HIV, diagnosed, treated, and virally suppressed), corresponding to the Joint United Nations Programme on HIV and AIDS (UNAIDS) target and explore differences by subregion and challenges with reporting data.

Findings:

Forty-four countries provided data for ≥1 stage, and 29 for all 4 stages. Estimated HIV prevalence was 0.19% (range 0.02%–0.84%, n = 37 countries providing stage 1 data). The proportion diagnosed of people living with HIV ranged from 38% to 98% (n = 37 reporting number of people living with HIV and diagnosed). The proportion on ART of those diagnosed ranged from 27% to 96% (n = 40 reporting numbers diagnosed and treated), and viral suppression rates ranged from 32% to 97% (n = 31 providing numbers treated and virally suppressed). The overall continuum of care estimate for 29 countries with complete data was 81-84-88, which differed by subregion: 84-88-90, 84-69-62, and 57-45-57 for the western, central, and eastern subregions, respectively. Challenges in reporting data included absence of a single data source for all stages, shortage of expertise, and lack of financial and human resources.

Conclusions:

There is an urgent need to strengthen HIV testing programs throughout Europe, particularly in the eastern subregion, and to remove constraints hampering access to testing and care. Recent changes to treatment guidelines should help reduce the numbers diagnosed not treated.

HIV Testing With and Without a Clinical Consultation Among Men Who Have Sex With Men: A Randomized Controlled Trial

BACKGROUND

Increasing the frequency of HIV testing among men who have sex with men (MSM) maximizes the preventive effect of antiretroviral therapy, by reducing time to diagnosis and treatment.

SETTING

Melbourne Sexual Health Centre, Australia.

METHODS

This randomized controlled trial evaluated whether access to testing, without seeing a clinician would increase testing frequency. MSM attending for HIV testing between July 2014 and April 2015 were randomized in 1:1 ratio to the intervention arm (access to HIV and syphilis testing at 300 pathology centers, without requiring consultations) or the control arm (consultation at every test), without blinding. The primary outcome was the incidence of HIV testing over 12 months.

RESULTS

Of 443 men referred, 422 were randomized, 3 HIV positives at baseline were excluded, and 419 were analyzed. Of 208 control, 202 (97.1%) and 200 (94.8%) of 211 intervention group members were followed to 12 months. The intervention group had 453 tests in 205.6 person-years, incidence rate was 2.2 (95% confidence interval [CI]: 2.0 to 2.4) tests per year. The control group had 432 tests during 204.0 person-years, incidence rate was 2.1 (95% CI: 1.9 to 2.3) tests per year, and incidence rate ratio was 1.04 (95% CI: 0.89 to 1.2; P = 0.63). The annual rate of consultations was as follows: intervention, 1.61 (95% CI: 1.44 to 1.79); controls, 2.12 (95% CI: 1.92 to 2.33); rate ratio, 0.76 (95% CI: 0.65 to 0.88; P = 0.0001). There was no difference in quality of life scores (P = 0.61).

CONCLUSIONS

MSM permitted HIV and syphilis testing outside of clinical consultations did not test more frequently than controls but had 24% fewer consultations, reducing service demand.

TRIAL REGISTRATION

ACTRN12614000760673.

Treatment as prevention enrolling at least 75% of individuals on ART will be needed to significantly reduce HIV prevalence in a HIV cohort

BACKGROUND

"Treatment as Prevention" (TasP) aims to reduce new HIV infections through higher enrolment on suppressive antiretroviral therapy (ART).

OBJECTIVES

We studied the current epidemic and possible impact of TasP in a French HIV cohort including MSM and migrant subjects.

STUDY DESIGN

Socio-demographic, clinical and laboratory variables were collected during the follow-up of 6995 HIV-infected patients. The numbers of individuals living with HIV in each year were estimated from diagnoses up to that year minus recorded deaths. Patients were classified according to gender, transmission mode, country of birth and treatment status.

RESULTS

The cohort includes 6995 individuals diagnosed from 1985 to 2015, of whom 72% were men. Unprotected sexual intercourse was the main mode of transmission. Women were more likely to be migrants (45% versus 13%), whereas men were more likely to have been born in France (52% versus 27%). Diagnoses were more correlated with untreated than treated prevalence in each group. MSM diagnoses was strongly correlated to untreated prevalence whatever the country of birth (p < 0.0001). However, heterosexual diagnoses were better correlated with prevalence within individual country groups (b = 0.29 female diagnoses/year per untreated male born in France, compared to b = 0.73 for foreigners). Using these transmission rates, mathematical modelling estimated that enrolling 75% of untreated individuals per year would decrease diagnoses ten-fold by 2021.

CONCLUSIONS

Enrolling at least 75% of individuals on ART is necessary to substantially impact numbers of new HIV infections in this cohort. Treatment as prevention will actually be effective to reduce HIV prevalence.

A novel Bayesian approach to predicting reductions in HIV incidence following increased testing interventions among gay, bisexual and other men who have sex with men in Vancouver, Canada

Increasing HIV testing rates among high-risk groups should lead to increased numbers of cases being detected. Coupled with effective treatment and behavioural change among individuals with detected infection, increased testing should also reduce onward incidence of HIV in the population. However, it can be difficult to predict the strengths of these effects and thus the overall impact of testing. We construct a mathematical model of an ongoing HIV epidemic in a population of gay, bisexual and other men who have sex with men. The model incorporates different levels of infection risk, testing habits and awareness of HIV status among members of the population. We introduce a novel Bayesian analysis that is able to incorporate potentially unreliable sexual health survey data along with firm clinical diagnosis data. We parameterize the model using survey and diagnostic data drawn from a population of men in Vancouver, Canada. We predict that increasing testing frequency will yield a small-scale but long-term impact on the epidemic in terms of new infections averted, as well as a large short-term impact on numbers of detected cases. These effects are predicted to occur even when a testing intervention is short-lived. We show that a short-lived but intensive testing campaign can potentially produce many of the same benefits as a campaign that is less intensive but of longer duration.

Preferences for HIV testing services among men who have sex with men in the UK: A discrete choice experiment

BACKGROUND

In the UK, approximately 4,200 men who have sex with men (MSM) are living with HIV but remain undiagnosed. Maximising the number of high-risk people testing for HIV is key to ensuring prompt treatment and preventing onward infection. This study assessed how different HIV test characteristics affect the choice of testing option, including remote testing (HIV self-testing or HIV self-sampling), in the UK, a country with universal access to healthcare.

METHODS AND FINDINGS

Between 3 April and 11 May 2017, a cross-sectional online-questionnaire-based discrete choice experiment (DCE) was conducted in which respondents who expressed an interest in online material used by MSM were asked to imagine that they were at risk of HIV infection and to choose between different hypothetical HIV testing options, including the option not to test. A variety of different testing options with different defining characteristics were described so that the independent preference for each characteristic could be valued. The characteristics included where each test is taken, the sampling method, how the test is obtained, whether infections other than HIV are tested for, test accuracy, the cost of the test, the infection window period, and how long it takes to receive the test result. Participants were recruited and completed the instrument online, in order to include those not currently engaged with healthcare services. The main analysis was conducted using a latent class model (LCM), with results displayed as odds ratios (ORs) and probabilities. The ORs indicate the strength of preference for one characteristic relative to another (base) characteristic. In total, 620 respondents answered the DCE questions. Most respondents reported that they were white (93%) and were either gay or bisexual (99%). The LCM showed that there were 2 classes within the respondent sample that appeared to have different preferences for the testing options. The first group, which was likely to contain 86% of respondents, had a strong preference for face-to-face tests by healthcare professionals (HCPs) compared to remote testing (OR 6.4; 95% CI 5.6, 7.4) and viewed not testing as less preferable than remote testing (OR 0.10; 95% CI 0.09, 0.11). In the second group, which was likely to include 14% of participants, not testing was viewed as less desirable than remote testing (OR 0.56; 95% CI 0.53, 0.59) as were tests by HCPs compared to remote testing (OR 0.23; 95% CI 0.15, 0.36). In both classes, free remote tests instead of each test costing £30 was the test characteristic with the largest impact on the choice of testing option. Participants in the second group were more likely to have never previously tested and to be non-white than participants in the first group. The main study limitations were that the sample was recruited solely via social media, the study advert was viewed only by people expressing an interest in online material used by MSM, and the choices in the experiment were hypothetical rather than observed in the real world.

CONCLUSIONS

Our results suggest that preferences in the context we examined are broadly dichotomous. One group, containing the majority of MSM, appears comfortable testing for HIV but prefers face-to-face testing by HCPs rather than remote testing. The other group is much smaller, but contains MSM who are more likely to be at high infection risk. For these people, the availability of remote testing has the potential to significantly increase net testing rates, particularly if provided for free.

A mathematical model of biomedical interventions for HIV prevention among men who have sex with men in China

Background

The new HIV treatment guidelines in China recommend antiretroviral therapy (ART) for all people living with HIV, but significant gaps in implementation still exist. Pre-exposure prophylaxis (PrEP) can effectively reduce the risk of HIV transmission among men who have sex with men (MSM). This study assessed the epidemiological impact and cost effectiveness of PrEP, enhanced biomedical interventions and their combination among MSM in China.

Methods

A deterministic mathematical model was developed and projected over 20 years to assess the impact of the PrEP, biomedical interventions and their combinations. Incidence and prevalence of HIV were measured, and cost-effectiveness was assessed using incremental cost (international dollars, Int.$) per quality-adjusted life year (QALY) gained.

Results

A total of 0.78 million new HIV infections were estimated to occur over the next 20 years if no additional interventions are implemented among MSM. The PrEP-only strategy covering 25–75% of HIV-negative high-risk MSM can prevent 0.09–0.20 million (12.1–25.7%) new infections, at a cost of 17,277–18,452 Int.$/QALY. The optimal cost-effectiveness path is from test-and-treat to the combination strategy of test-and-treat and PrEP. Some strategies could almost eliminate new HIV infections over the next 20 years.

Conclusions

PrEP, test-and-treat, and their combinations among MSM are effective and cost-effective relative to current policy. PrEP is an important and cost-effective addition to current policy in China.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3516-8) contains supplementary material, which is available to authorized users.

Antiretroviral treatment indications and adherence to the German-Austrian treatment initiation guidelines in the German ClinSurv HIV Cohort between 1999 and 2016

PURPOSE

The aim of the study was to assess guideline adherence to combined antiretroviral therapy (ART) in the German ClinSurv HIV Cohort and the real-life impact of the Strategic Timing of Antiretroviral Therapy (START) study, to identify patients not treated as recommended by new guidelines.

METHODS

We used data from the multicenter ClinSurv cohort of the Robert-Koch-Institute (RKI) between 1999 and 2016. Inclusion criteria were people living with HIV/AIDS, ≥ 18 years of age and cART naïve at the first visit (FV). Adherence was defined as starting cART within 6 months of crossing the CD4⁺ T cell threshold as suggested by the German-Austrian treatment guidelines. Logistic regression was used to identify factors associated with non-adherence.

RESULTS

11,817 patients met the inclusion criteria. We observed an overall adherence rate of 60%, in patients with treatment indication who started cART timely between 2002 and 2015. Adherence rate increased constantly, demonstrating a potential increase in patients, with treatment indication, starting cART within 6 months of presentation from 55% in 2008 to 94% in 2015. Patients reporting injection drug use (OR 2.18, 95% CI 1.70-2.95) and patients between 18 years and 39 years of age at the time of their first visit (OR 2.89, 95% CI 1.35-6.18) were identified as risk groups associated with non-adherence.

CONCLUSION

The majority of patients below the CD4⁺ T cell count threshold of applicable guidelines initiated treatment within 6 months. We observed a slowly diminishing proportion of patients not starting cART timely. Delayed treatment was more frequent in patients reporting injection drug use.

HIV in Europe and Central Asia: progress in 2018 towards meeting the UNAIDS 90-90-90 targets

In 2018, 52 of 55 European and Central Asian countries reported data against the UNAIDS 90-90-90 targets. Overall, 80% of people living with HIV (PLHIV) were diagnosed, of whom 64% received treatment and 86% treated were virally suppressed. Subregional outcomes varied: West (87%-91%-93%), Centre (83%-73%-75%) and East (76%-46%-78%). Overall, 43% of all PLHIV were virally suppressed; intensive efforts are needed to meet the 2020 target of 73%.

Protocol, rationale and design of SELPHI: a randomised controlled trial assessing whether offering free HIV self-testing kits via the internet increases the rate of HIV diagnosis

BACKGROUND

Among men who have sex with men (MSM) in the UK, an estimated 28% have never tested for HIV and only 27% of those at higher risk test at least every 6 months. HIV self-testing (HIVST), where the person takes their own blood/saliva sample and processes it themselves, offers the opportunity to remove many structural and social barriers to testing. Although several randomised controlled trials are assessing the impact of providing HIVST on rates of HIV testing, none are addressing whether this results in increased rates of HIV diagnoses that link to clinical care. Linking to care is the critical outcome because it is the only way to access antiretroviral treatment (ART). We describe here the design of a large, internet-based randomised controlled trial of HIVST, called SELPHI, which aims to inform this key question.

METHODS/DESIGN

The SELPHI study, which is ongoing is promoted via social networking website and app advertising, and aims to enroll HIV negative men, trans men and trans women, aged over 16 years, who are living in England and Wales. Apart from the physical delivery of the test kits, all trial processes, including recruitment, take place online. In a two-stage randomisation, participants are first randomised (3:2) to receive a free baseline HIVST or no free baseline HIVST. At 3 months, participants allocated to receive a baseline HIVST (and meeting further eligibility criteria) are subsequently randomised (1:1) to receive the offer of regular (every 3 months) free HIVST, with testing reminders, versus no such offer. The primary outcome from both randomisations is a laboratory-confirmed HIV diagnosis, ascertained via linkage to a national HIV surveillance database.

DISCUSSION

SELPHI will provide the first reliable evidence on whether offering free HIVST via the internet increases rates of confirmed HIV diagnoses and linkage to clinical care. The two randomisations reflect the dual objectives of detecting prevalent infections (possibly long-standing) and the more rapid diagnosis of incident HIV infections. It is anticipated that the results of SELPHI will inform future access to HIV self-testing provision in the UK.

TRIAL REGISTRATION

DOI 10.1186/ISRCTN20312003 registered 24/10/2016.

Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK

OBJECTIVES

Our objective was to present recent trends in the UK HIV epidemic (2007-2016) and the public health response.

METHODS

HIV diagnoses and clinical markers were extracted from the HIV and AIDS Reporting System; HIV testing data in sexual health services (SHS) were taken from GUMCAD STI Surveillance System. HIV data were modelled to estimate the incidence in men who have sex with men (MSM) and post-migration HIV acquisition in heterosexuals. Office for National Statistics (ONS) data enabled mortality rates to be calculated.

RESULTS

New HIV diagnoses have declined in heterosexuals as a result of decreasing numbers of migrants from high HIV prevalence countries entering the UK. Among MSM, the number of HIV diagnoses fell from 3570 in 2015 to 2810 in 2016 (and from 1554 to 1096 in London). Preceding the decline in HIV diagnoses, modelled estimates indicate that transmission began to fall in 2012, from 2800 [credible interval (CrI) 2300-3200] to 1700 (CrI 900-2700) in 2016. The crude mortality rate among people promptly diagnosed with HIV infection was comparable to that in the general population (1.22 vs. 1.39 per 1000 aged 15-59 years, respectively). The number of MSM tested for HIV at SHS increased annually; 28% of MSM who were tested in 2016 had been tested in the preceding year. In 2016, 76% of people started antiretroviral therapy within 90 days of diagnosis (33% in 2007).

CONCLUSIONS

The dual successes of the HIV transmission decline in MSM and reduced mortality are attributable to frequent HIV testing and prompt treatment (combination prevention). Progress towards the elimination of HIV transmission, AIDS and HIV-related deaths could be achieved if combination prevention, including pre-exposure prophylaxis, is replicated for all populations.

The people living with HIV stigma survey UK 2015: HIV-related sexual rejection and other experiences of stigma and discrimination among gay and heterosexual men

We aim to understand the difference in stigma and discrimination, in particular sexual rejection, experienced between gay and heterosexual men living with HIV in the UK. The People Living with HIV StigmaSurvey UK 2015 recruited a convenience sample of persons with HIV through over 120 cross sector community organisations and 46 HIV clinics to complete an online survey. 1162 men completed the survey, 969 (83%) gay men and 193 (17%) heterosexual men, 92% were on antiretroviral therapy. Compared to heterosexual men, gay men were significantly more likely to report worrying about workplace treatment in relation to their HIV (21% vs. 11%), worrying about HIV-related sexual rejection (42% vs 21%), avoiding sex because of their HIV status (37% vs. 23%), and experiencing HIV-related sexual rejection (27% vs. 9%) in the past 12 months. In a multivariate logistic regression controlling for other sociodemographic factors, being gay was a predictor of reporting HIV-related sexual rejection in the past 12 months (aOR 2.17, CI 1.16, 4.02). Both gay and heterosexual men living with HIV experienced stigma and discrimination in the past 12 months, and this was higher for gay men in terms of HIV-related sexual rejection. Due to the high proportion of men reporting sexual rejection, greater awareness and education of the low risk of transmission of HIV among people on effective treatment is needed to reduce stigma and sexual prejudice towards people living with HIV.

Can we afford to offer pre-exposure prophylaxis to MSM in Catalonia? Cost-effectiveness analysis and budget impact assessment

Pre-exposure prophylaxis (PrEP) effectiveness has been well established. This study aims to assess the cost-effectiveness of providing PrEP, estimate the number of eligible MSM, and its budget impact in Catalonia. Cost-effectiveness analysis compared costs of on daily basis and "on demand" PrEP to prevent one infection with lifetime costs of one HIV infection. We estimated the total cost of providing PrEP by estimating number of eligible MSM, and included in the budget impact assessment antiretroviral and laboratory costs. Costs were lower for the on-demand PrEP group by €64015.1 and the incremental benefit was nearly 15 life-years and 17 quality-adjusted life-years gained. The incremental cost-effectiveness ratio (ICER) was cost-effective at €6281.62 when undiscounted PrEP was given daily. On-demand PrEP can be considered cost-saving in 20 years if the price is reduced by 90%. The number of eligible MSM in Catalonia ranges from 5,989 to 10,972. At current antiretroviral costs, the annual cost would range between €25.3-46.7 million/year (on demand PrEP), and €42.9-78.7 million/year (daily basis PrEP). PrEP is most cost-effective if targeted towards groups with high incidence rates of over 3%/year. Beneficial ICER depends on reducing the current price of Truvada® and ensuring that effectiveness is maintained at high levels.

Cost-effectiveness of pre-exposure prophylaxis for HIV prevention in men who have sex with men in the UK: a modelling study and health economic evaluation

BACKGROUND

In the UK, HIV incidence among men who have sex with men (MSM) has remained high for several years, despite widespread use of antiretroviral therapy and high rates of virological suppression. Pre-exposure prophylaxis (PrEP) has been shown to be highly effective in preventing further infections in MSM, but its cost-effectiveness is uncertain.

METHODS

In this modelling study and economic evaluation, we calibrated a dynamic, individual-based stochastic model, the HIV Synthesis Model, to multiple data sources (surveillance data provided by Public Health England and data from a large, nationally representative survey, Natsal-3) on HIV among MSM in the UK. We did a probabilistic sensitivity analysis (sampling 22 key parameters) along with a range of univariate sensitivity analyses to evaluate the introduction of a PrEP programme with sexual event-based use of emtricitabine and tenofovir for MSM who had condomless anal sexual intercourse in the previous 3 months, a negative HIV test at baseline, and a negative HIV test in the preceding year. The main model outcomes were the number of HIV infections, quality-adjusted life-years (QALYs), and costs.

FINDINGS

Introduction of such a PrEP programme, with around 4000 MSM initiated on PrEP by the end of the first year and almost 40 000 by the end of the 15th year, would result in a total cost saving (£1·0 billion discounted), avert 25% of HIV infections (42% of which would be directly because of PrEP), and lead to a gain of 40 000 discounted QALYs over an 80-year time horizon. This result was particularly sensitive to the time horizon chosen, the cost of antiretroviral drugs (for treatment and PrEP), and the underlying trend in condomless sex.

INTERPRETATION

This analysis suggests that the introduction of a PrEP programme for MSM in the UK is cost-effective and possibly cost-saving in the long term. A reduction in the cost of antiretroviral drugs (including the drugs used for PrEP) would substantially shorten the time for cost savings to be realised.

FUNDING

National Institute for Health Research.

Are there any differences between different testing sites? A cross-sectional study of a Norwegian low-threshold HIV testing service for men who have sex with men

OBJECTIVE

To describe a Norwegian low-threshold HIV testing service targeting men who have sex with men (MSM).

DESIGN AND SETTING

After the HIV testing consultation, all users of the HIV testing service were invited to answer the study questionnaire. The study setting included the sites where testing was performed, that is, the testing service's office in Oslo, cruising areas, bars/clubs and in hotels in other Norwegian cities.

PARTICIPANTS

MSM users of the testing service.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data were collected on demographics, HIV testing and sexual behaviour as well as the participant's motivations for choosing to take an HIV test at this low-threshold HIV testing service. The data are stratified by testing site.

RESULTS

1577 HIV testing consultations were performed, the study sample consisted of 732 MSM users. 11 tested positive for HIV. 21.7% had a non-western background, 27.1% reported having a non-gay sexual orientation. 21.9% had 10 or more male sexual partners during the last year, 27.9% reported also having had a female sexual partner. 56.4% reported having practised unprotected anal intercourse during the last 6 months. 20.1% had never tested for HIV before. Most of these user characteristics varied by testing sites.

CONCLUSIONS

The Norwegian low-threshold testing service recruits target groups that are otherwise hard to reach with HIV testing. This may indicate that the testing service contributes to increase HIV testing rates among MSM in Norway.

Socio-demographic Characteristics, Sexual and Test-Seeking Behaviours Amongst Men Who have Sex with Both Men and Women: Results from a Bio-behavioural Survey in 13 European Cities

Within the MSM population, men who have sex with both men and women (MSMW) are identified as a high-risk group both worldwide and in Europe. In a multi-centred bio-behavioural cross-sectional study, we aimed to assess the relationship(s) between socio-demographic factors, stigma, sexual behavioural patterns, test seeking behaviour and sero-status amongst MSMW. A multi-level analysis was conducted to identify factors associated with being MSMW versus Men who have Sex with Men Only (MSMO). A total of 4901 MSM were enrolled across the 13 study sites. Participants were categorised as MSMW in the 12.64% of the cases. Factors such as educational status, perceived homonegativity, testing facilities knowledge and HIV testing lifetime seem to be relevant factors when characterising the MSMW group. The results highlight the vulnerability of MSMW and the wide spectrum of risky behavioural and psycho-social patterns, particularly in terms of HIV testing, 'outness', and perceived stigma.

Implications for a policy of initiating antiretroviral therapy in people diagnosed with human immunodeficiency virus: the CAPRA research programme

Background

More than 100,000 people in the UK are living with a human immunodeficiency virus (HIV) infection. There are currently estimated to be around 4000 people newly infected in the UK per year, mostly men who have sex with men (MSM). It has become increasingly clear that antiretroviral therapy (ART) used to treat people infected with HIV also has a profound effect on infectivity. At the initiation of the programme, it was the policy in the UK to initiate ART in people when their cluster of differentiation 4 (CD4) count was approaching 350/µl.

Objectives

To assess what would be the effectiveness and cost-effectiveness of a policy of immediate initiation of ART at diagnosis among MSM, taking into account the potential reductions in new infections.

Design

We calibrated an individual-based model of HIV transmission, progression and the effect of ART in MSM, informed by a series of studies on sexual behaviour in relation to ART use and the transmission risk in people with viral suppression on ART, and by surveillance data collected by Public Health England.

Setting, participants and interventions

The series of studies used to inform the model included (1) the Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) study, a cross-sectional self-administered questionnaire study of people diagnosed with HIV attending eight HIV outpatient clinics in the UK (2011–12); (2) the Cognitive Impairment in People with HIV in the European Region (CIPHER) study, a study of levels of neurocognitive impairment in HIV-positive ASTRA participants and people from HIV clinics in Rome, Copenhagen and Minsk; (3) the Attitudes to, and Understanding of, Risk of Acquisition of HIV (AURAH) study, a cross-sectional self-administered questionnaire study of individuals who have not been diagnosed as HIV-positive attending 20 genitourinary medicine clinics across the UK (2013–14); (4) a substudy of sexual behaviour among individuals enrolled in an open-label multicentre international randomised trial (from 2013) of immediate versus deferred ART (to CD4 cell counts of 350/µl) in people with CD4 cell counts of > 500/µl [the Strategic Timing of Antiretroviral Therapy (START) trial]; and (5) Partners of People on ART: a new Evaluation of the Risks (PARTNER), an observational multicentre longitudinal study of HIV serodifferent heterosexual and MSM couples, in which the HIV-positive partner is on ART (2010–14).

Main outcome measures

The main outcome measures were the clinical effectiveness and cost-effectiveness of a policy of immediate initiation of ART at diagnosis.

Results

Based on data from studies (i)–(v), we estimated from our modelling work that increases in condomless sex (CLS) among MSM as a whole may explain the increase in HIV infection incidence in MSM epidemics over a time when ART coverage and viral suppression increased, demonstrating the limiting effects of non-condom use on the HIV epidemic among MSM. Accordingly, an increase in the overall proportion of MSM living with HIV who are virally suppressed on ART from the current level of < 60% to 90% without increases in CLS was required to achieve a reduction in the incidence of HIV among MSM to < 1 per 1000 person-years. The incremental cost-effectiveness ratio associated with the fourfold increase in levels of HIV testing and ART at diagnosis required to provide this increase from < 60% to 90% was £20,000 if we assumed continuation of current ART prices. However, this value falls to £3500 if we assume that ART prices will fall to 20% of their current cost as a result of the introduction of generic drugs. Therefore, our evaluation suggests that ART initiation at diagnosis is likely to be highly cost-effective in MSM at a population level, particularly accounting for future lower ART costs as generic drugs are used. The impact will be much greater if levels of HIV testing can be enhanced.

Limitations

It was necessary to make some assumptions beyond the available data in order to extrapolate cost-effectiveness through modelling.

Conclusions

Our findings suggest that ART initiation at diagnosis is likely to be cost-effective in MSM. Of note, after this programme of work was completed, results from the main START trial demonstrated benefit in ART initiation even in people with CD4 cell counts of > 500/µl, supporting ART initiation in people diagnosed with a HIV infection.

Future work

There is a need for future research into the means of increasing the frequency with which MSM test for HIV.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Cost-effectiveness of screening for HIV in primary care: a health economics modelling analysis

Background

Early HIV diagnosis reduces morbidity, mortality, the probability of onward transmission, and their associated costs, but might increase cost because of earlier initiation of antiretroviral treatment (ART). We investigated this trade-off by estimating the cost-effectiveness of HIV screening in primary care.

Methods

We modelled the effect of the four-times higher diagnosis rate observed in the intervention arm of the RHIVA2 randomised controlled trial done in Hackney, London (UK), a borough with high HIV prevalence (≥0·2% adult prevalence). We constructed a dynamic, compartmental model representing incidence of infection and the effect of screening for HIV in general practices in Hackney. We assessed cost-effectiveness of the RHIVA2 trial by fitting model diagnosis rates to the trial data, parameterising with epidemiological and behavioural data from the literature when required, using trial testing costs and projecting future costs of treatment.

Findings

Over a 40 year time horizon, incremental cost-effectiveness ratios were £22 201 (95% credible interval 12 662–132 452) per quality-adjusted life-year (QALY) gained, £372 207 (268 162–1 903 385) per death averted, and £628 874 (434 902–4 740 724) per HIV transmission averted. Under this model scenario, with UK cost data, RHIVA2 would reach the upper National Institute for Health and Care Excellence cost-effectiveness threshold (about £30 000 per QALY gained) after 33 years. Scenarios using cost data from Canada (which indicate prolonged and even higher health-care costs for patients diagnosed late) suggest this threshold could be reached in as little as 13 years.

Interpretation

Screening for HIV in primary care has important public health benefits as well as clinical benefits. We predict it to be cost-effective in the UK in the medium term. However, this intervention might be cost-effective far sooner, and even cost-saving, in settings where long-term health-care costs of late-diagnosed patients in high-prevalence regions are much higher (≥60%) than those of patients diagnosed earlier. Screening for HIV in primary care is cost-effective and should be promoted.

Funding

NHS City and Hackney, UK Department of Health, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care.

An epidemiological modelling study to estimate the composition of HIV-positive populations including migrants from endemic settings

OBJECTIVE

Migrants account for a significant number of people living with HIV in Europe, and it is important to fully consider this population in national estimates. Using a novel approach with the UK as an example, we present key public health measures of the HIV epidemic, taking into account both in-country infections and infections likely to have been acquired abroad.

DESIGN

Mathematical model calibrated to extensive data sources.

METHODS

An individual-based stochastic simulation model is used to calibrate to routinely collected surveillance data in the UK. Data on number of new HIV diagnoses, number of deaths, CD4 cell count at diagnosis, as well as time of arrival into the UK for migrants and the annual number of people receiving care were used.

RESULTS

An estimated 106 400 (90% plausibility range: 88 700-124 600) people were living with HIV in the UK in 2013. Twenty-three percent of these people, 24 600 (15 000-36 200) were estimated to be undiagnosed; this number has remained stable over the last decade. An estimated 32% of the total undiagnosed population had CD4 cell count less than 350 cells/μl in 2013. Twenty-five and 23% of black African men and women heterosexuals living with HIV were undiagnosed respectively.

CONCLUSION

We have shown a working example to characterize the HIV population in a European context which incorporates migrants from countries with generalized epidemics. Despite all aspects of HIV care being free and widely available to anyone in need in the UK, there is still a substantial number of people who are not yet diagnosed and thus not in care.

Pre-exposure prophylaxis: a useful tool to prevent human immunodeficiency virus infection?

The aim of preventive measures against human immunodeficiency virus (HIV) is to reduce the incidence of HIV infection in the general population and in high-risk groups, such as men having sex with men (MSM), and to reduce the risk that a given individual will contract or spread the virus. Male and female condoms, post-exposure prophylaxis and circumcision are preventive methods currently recognized or promoted worldwide. Although modest success has been reported in a phase-III vaccine trial, other methods are being evaluated, such as vaginal and rectal microbicides, and pre-exposure prophylaxis (PrEP). Herein, we discuss results from prevention trials, especially those focusing on PrEP and particularly on recent results from 'on-demand' PrEP regimens. The efficacy of PrEP (rates of 0%-86%) is strongly correlated with adherence and plasma concentrations of antiretrovirals. Adverse events are rare. Selection of emtricitabine-resistant strains is mainly reported in individuals with an undiagnosed HIV infection using PrEP. PrEP is now strongly recommended in WHO prevention programmes for individuals at substantial risk for HIV with a view to controlling this epidemic by 2030.

Systematic review of mobile health behavioural interventions to improve uptake of HIV testing for vulnerable and key populations

Introduction This systematic narrative review examined the empirical evidence on the effectiveness of mobile health (mHealth) behavioural interventions designed to increase the uptake of HIV testing among vulnerable and key populations. Methods MEDLINE/PubMed, Embase, Web of Science, and Global Health electronic databases were searched. Studies were eligible for inclusion if they were published between 2005 and 2015, evaluated an mHealth intervention, and reported an outcome relating to HIV testing. We also reviewed the bibliographies of retrieved studies for other relevant citations. The methodological rigor of selected articles was assessed, and narrative analyses were used to synthesize findings from mixed methodologies. Results A total of seven articles met the inclusion criteria. Most mHealth interventions employed a text-messaging feature and were conducted in middle- and high-income countries. The methodological rigor was moderate among studies. The current literature suggests that mHealth interventions can have significant positive effects on HIV testing initiation among vulnerable and key populations, as well as the general public. In some cases, null results were observed. Qualitative themes relating to the use of mobile technologies to increase HIV testing included the benefits of having low-cost, confidential, and motivational communication. Reported barriers included cellular network restrictions, poor linkages with physical testing services, and limited knowledge of appropriate text-messaging dose. Discussion MHealth interventions may prove beneficial in reducing the proportion of undiagnosed persons living with HIV, particularly among vulnerable and key populations. However, more rigorous and tailored interventions are needed to assess the effectiveness of widespread use.

Attitudes to and Understanding of Risk of Acquisition of HIV Over Time: Design and Methods for an Internet-based Prospective Cohort Study Among UK Men Who Have Sex With Men (the AURAH2 Study)

Background

The annual number of new human immunodeficiency virus (HIV) infections among men who have sex with men (MSM) has risen in the United Kingdom and, of those who are HIV positive, the proportion undiagnosed is high.

Objective

The prospective AURAH2 study aims to assess factors associated with HIV acquisition among MSM in the United Kingdom and to investigate changes over time within individuals in sexual behavior and HIV-testing practices.

Methods

AURAH2 is a prospective study among MSM without diagnosed HIV, aiming to recruit up to 1000 sexually active MSM attending sexual health clinics in London and Brighton in the United Kingdom. Participants complete an initial paper-based questionnaire, followed by online follow-up questionnaires every 4 months collecting sociodemographic, health and behavioral data, including sexual behavior, recreational and other drug use, HIV testing practices, and pre-exposure prophylaxis use, over a planned 3-year period.

Results

The study is ongoing.

Conclusions

The results from AURAH2 study will provide important insight into established and emerging risk behaviors that may be associated with acquisition of HIV in MSM in the United Kingdom, changes over time within individuals in sexual behavior, and information on HIV testing practices. These data will be crucial to inform future HIV prevention strategies.

Primary HIV infection: a medical and public health emergency requiring rapid specialist management

Primary HIV infection (PHI) refers to the first six months following HIV acquisition and represents a unique opportunity for expedited diagnosis, and consideration of rapid antiretroviral therapy (ART) initiation to improve immune function, reduce the size of the viral reservoir and limit the risk of onward viral transmission. Failure to diagnose and rapidly treat individuals with PHI has significant individual and public health implications. The Strategic Timing of AntiRetroviral Treatment trial recently identified a clinical benefit of immediate ART over deferral of treatment according to CD4 count threshold, and has led to rapid changes in World Health Organization and specialist national guidelines. For all individuals living with HIV, the offer of immediate therapy irrespective of CD4 count is now recommended. This paper summarises the presentation and management of PHI, incorporating current research and guideline changes and discusses the role of PHI in onward transmission.

HIV infection

More than 75 million people worldwide have been infected with human immunodeficiency virus (HIV), and there are now approximately 37 million individuals living with the infection. Untreated HIV replication causes progressive CD4(+) T cell loss and a wide range of immunological abnormalities, leading to an increased risk of infectious and oncological complications. HIV infection also contributes to cardiovascular disease, bone disease, renal and hepatic dysfunction and several other common morbidities. Antiretroviral drugs are highly effective at inhibiting HIV replication, and for individuals who can access and adhere to these drugs, combination antiretroviral therapy leads to durable (and probably lifelong) suppression of viral replication. Viral suppression enables immune recovery and the near elimination of the risk for developing acquired immune deficiency syndrome (AIDS). Despite effective treatment, HIV-infected individuals have a higher than expected risk of heart, bone, liver, kidney and neurological disease. When used optimally by an infected (or by an uninfected) person, antiretroviral drugs can virtually eliminate the risk of HIV transmission. Despite major advances in prevention sciences, HIV transmission remains common in many vulnerable populations, including men who have sex with men, injection drug users and sex workers. Owing to a lack of widespread HIV testing and the costs and toxicities associated with antiretroviral drugs, the majority of the infected population is not on effective antiretroviral therapy. To reverse the pandemic, improved prevention, treatment and implementation approaches are necessary.