Overcoming obstacles to late presentation for HIV infection in Europe

Using the Lifeworld Approach to Improve HIV Testing

Major guidelines for HIV recommend that testing should be provided in a way that is adapted to the lifeworld of groups at risk. However, precise definitions as to what adaption to the lifeworld means are missing. Therefore, this research project evaluated how the lifeworld approach can be operationalized in regard to HIV testing and how voluntary counseling and testing services can use this approach to improve efficacy. A survey for VCT providers in Germany showed a limited number of factors influencing the adaption to the lifeworld of groups at risk. The opening hours, the number of languages used in public relations, and the comfort of the waiting zone are important for all clients. For men who have sex with men, information material for use in social networks and peer volunteers are relevant. Intravenous drug users are concerned with participation, (low) costs, and counseling. For migrants, continuing staff training and anonymity are important.

The HepHIV 2017 Conference in Malta: joining forces for the earlier diagnosis of HIV and viral hepatitis

OBJECTIVES

The objective of the article is to provide an overview of the results of the HepHIV 2017 Conference organized by the HIV in Europe initiative under the Maltese EU Presidency in January 2017.

METHODS

A thourough review of all conference presentations (oral and poster presentations) was performed to retrieve the key outcomes of the conference.

RESULTS

The key result from the conference was a call to action summarising key priorities in HIV and viral hepatitis testing and linkage to care. This included improving monitoring of viral hepatitis and HIV, mixing testing strategies and ensuring policy support. The important contribution and outcomes of EU funded projects OptTEST and EuroHIVEdat was highlighted.

CONCLUSION

An integrated approach to earlier testing and linkage to care across diseases is needed in Europe and the HepHIV conferences create an important forum to reach this aim.

Estimating time of HIV-1 infection from next-generation sequence diversity

Estimating the time since infection (TI) in newly diagnosed HIV-1 patients is challenging, but important to understand the epidemiology of the infection. Here we explore the utility of virus diversity estimated by next-generation sequencing (NGS) as novel biomarker by using a recent genome-wide longitudinal dataset obtained from 11 untreated HIV-1-infected patients with known dates of infection. The results were validated on a second dataset from 31 patients. Virus diversity increased linearly with time, particularly at 3rd codon positions, with little inter-patient variation. The precision of the TI estimate improved with increasing sequencing depth, showing that diversity in NGS data yields superior estimates to the number of ambiguous sites in Sanger sequences, which is one of the alternative biomarkers. The full advantage of deep NGS was utilized with continuous diversity measures such as average pairwise distance or site entropy, rather than the fraction of polymorphic sites. The precision depended on the genomic region and codon position and was highest when 3rd codon positions in the entire pol gene were used. For these data, TI estimates had a mean absolute error of around 1 year. The error increased only slightly from around 0.6 years at a TI of 6 months to around 1.1 years at 6 years. Our results show that virus diversity determined by NGS can be used to estimate time since HIV-1 infection many years after the infection, in contrast to most alternative biomarkers. We provide the regression coefficients as well as web tool for TI estimation.

HIV-1 establishes a chronic infection, which may last for many years before the infected person is diagnosed. The resulting uncertainty in the date of infection leads to difficulties in estimating the number of infected but undiagnosed persons as well as the number of new infections, which is necessary for developing appropriate public health policies and interventions. Such estimates would be much easier if the time since HIV-1 infection for newly diagnosed cases could be accurately estimated. Three types of biomarkers have been shown to contain information about the time since HIV-1 infection, but unfortunately, they only distinguish between recent and long-term infections (concentration of HIV-1-specific antibodies) or are imprecise (immune status as measured by levels of CD4+ T-lymphocytes and viral sequence diversity measured by polymorphisms in Sanger sequences). In this paper, we show that recent advances in sequencing technologies, i.e. the development of next generation sequencing, enable significantly more precise determination of the time since HIV-1 infection, even many years after the infection event. This is a significant advance which could translate into more effective HIV-1 prevention.

[Indicator condition guided human immunodeficiency virus requesting in primary health care: results of a collaboration]

INTRODUCTION

The search of HIV infected patients guided by indicator conditions (IC) is a strategy used to increase the early detection of HIV. The objective is to analyze whether a collaboration to raise awareness of the importance of early detection of HIV in 3 primary care centers influenced the proportion of HIV serology requested.

METHODS

Multicenter retrospective study was conducted comparing the baseline and a post-collaboration period. The collaboration consisted of training sessions and participation in the HIDES study (years 2009-2010). Patients between 18 and 64 years old with newly diagnosed herpes zoster, seborrheic eczema, mononucleosis syndrome, and leucopenia/thrombocytopenia in 3 primary care centers in 2008 (baseline period) and 2012 (post-collaboration period). The sociodemographic variables, HIV risk conditions, requests for HIV serology, and outcomes were evaluated.

RESULTS

A total of 1,219 ICs were included (558 in 2008 and 661 in 2012). In 2008 the number of HIV tests in patients with an IC was 3.9%, and rose to 11.8% in 2012 (P<.0001). The HIV infection rate was 2.2% (95% CI: 0.4-7.3) (n=2). It was estimated that 25 new cases (12 in 2008 and 13 in 2012) would have been diagnosed if they had performed the test on all patients with IC. Predictors of HIV request were, having an IC in 2012, a younger age, having an mononucleosis syndrome, and not being Spanish.

CONCLUSIONS

The HIV request demand tripled, after the collaboration with primary care centers, however in 88% the test was not requested, resulting in diagnostic losses. New strategies are needed to raise awareness of the importance of early detection of HIV.

Update on HIV in Western Europe

HIV infection in Western Europe is mainly concentrated among men who have sex with men, heterosexuals who acquired HIV from sub-Saharan African countries, and in people who inject drugs. The rate of newly diagnosed cases of HIV has remained roughly stable since 2004 whereas the number of people living with HIV has slowly increased due to new infections and the success of antiretroviral therapy in prolonging life. An ageing population is gradually emerging that will require additional care. There are large differences across countries in HIV testing rates, proportions of people who present to care with low CD4+ cell counts, accessibility to treatment and care, and rates of retention once in care. Improved collection of HIV surveillance data will benefit countries and help to understand their epidemic better. However, social inequalities experienced by people with HIV still remain in some regions and urgently need to be addressed.

Time trends and correlates of late presentation for HIV care in Northern Greece during the decade 2000 to 2010

BACKGROUND

The aim of our study was to assess the extent of late presentation for HIV care in Northern Greece during the period 2000 to 2010 and to explore correlations aiming to provide guidance for future interventions.

METHODS

HIV-positive patients with no prior history of HIV care at presentation and with a CD4 T cell count within three months from the first confirmatory Western blot result were eligible for this study. Late presentation and advanced HIV disease were defined in concordance with the recommendations of the European Late Presenter Consensus working group. Time trends in presentation status and risk factors linked to late presentation and advanced HIV disease were identified in multivariable logistic regression models. Additional analyses after multiple imputation of missing values were performed to assess the robustness of our findings.

RESULTS

The status at presentation was evaluated for 631 eligible HIV-positive individuals. Overall, 52.5% (95% CI: 48.6% to 56.4%) of patients presented late for HIV care and 31.2% (95% CI: 27.6% to 34.8%) presented with advanced HIV disease. Time trends were consistent with an improvement in the presentation status of our study population (p<0.001). Risk factors associated with late presentation in multivariable logistic regression were intravenous drug use, heterosexual HIV transmission, immigrant status and age at diagnosis.

CONCLUSIONS

Despite the trend for improvement, a significant proportion of newly diagnosed HIV-positive patients present late for care. Targeted interventions with focus on social groups such as the elderly, persons who inject drugs, immigrants and individuals at risk for heterosexual HIV transmission are mandated.