Continuum of HIV care in the EU/EEA: Findings from Dublin Declaration monitoring

Teymur Noori, ECDCMalta Presidency HIV technical meeting 30-31 January 2017

Outline

Continuum of care in EU/EEA countries (Dublin Declaration)

ECDC/EuroCoord collaboration on the continuum of care

Monitoring a 4-point continuum

PLHI

V

DIAG

NO

SED

LIN

KAGE

TO

CAR

E

RETE

NTI

ON

ON

ART

ON

TR

EATM

ENT

VIRA

L

SUPP

RESS

ION

Monitoring viral

suppression

Monitoring quality of

care

90 90

90

Data availability on the continuum in the EU/EEADublin 2014 (n=27) vs 2016 (n=29)

Source: Preliminary data reported to ECDC in 2016 as part of Dublin Declaration reporting.

No stages PLHIV Diagnosed On ART Viral suppression All stages0

5

10

15

20

25

30

3

16

25

23

19

11

1

20

28

25

20

17

Nr o

f cou

ntrie

s rep

ortin

g

2016

2014

Fast Track Targets

73%of all PLHIV will

have durable viral suppression

=

Target 1 Target 2 Target 3 Target 4

Fast Track Targets

73%of all PLHIV will

have durable viral suppression

=

Target 1 Target 2 Target 3 Target 4

Romania

Denmark

SwedenIta

ly

Austria

Netherla

nds

Luxe

mbourg

Hungary

United Kingdom

Germany

Belgium

Estonia

France

Spain

Slovakia

Greece

Portugal

Croatia

Bulgaria

Poland0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% o

f PLH

IV d

iagn

osed

EU average 83%

90% UNAIDS target

Progress toward achieving the first 90:Target: 90% of all PLHIV who know their status (n=20)

Source: Preliminary data reported to ECDC in 2016 as part of Dublin Declaration reporting.

Too many people living with HIV have not yet been diagnosed

Pharris A, Quinten C, Noori T, Amato-Gauci AJ, van Sighem A, the ECDC HIV/AIDS Surveillance and Dublin Declaration Monitoring Networks. Estimating HIV incidence and number of undiagnosed individuals living with HIV in the European Union/European Economic Area, 2015. Euro Surveill. 2016;21(48):pii=30417. DOI: http://dx.doi.org/10.2807/1560-7917.ES.2016.21.48.30417

Fast Track Targets

73%of all PLHIV will

have durable viral suppression

=

Target 1 Target 2 Target 3 Target 4

Progress toward achieving the second 90:Target: 90% of those diagnosed on ART (n=25)

United Kingd

om

Sweden

DenmarkSp

ain

Slovenia

France

Croatia

Netherlands

Austria

Germany

Belgium

Romania

Malta

Luxe

mbourgIta

ly

Finland

Czech

Republic

Greece

Portuga

l

Poland

Hungary

Estonia

Bulgaria

Latvia

Lithuan

ia0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%90% UNAIDS target

EU average 83%

Source: Preliminary data reported to ECDC in 2016 as part of Dublin Declaration reporting.

Policies on ART initiation in EU/EEA countries 2014 and 2016

2015

Source: ECDC. The status of the HIV response in the European Union/European Economic Area, 2016. Stockholm: ECDC; 2017.

Number of people on ART in the EU/EEA 2015

2009125 732

2011167 814

2013 190 175

2015308 008

Source: GARPR and Dublin Declaration monitoring data.

Treatment scale-up in the 15 EU/EEA countries* with available ART data 2009-2015

*Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Germany, Estonia, Finland, Hungary, Lithuania, Poland, Romania, Spain, Sweden, United Kingdom

588 000 (28 EU/EEA countries)

Too many people with diagnosed HIV infection are not yet on treatment

Source: ECDC. The status of the HIV response in the European Union/European Economic Area, 2016. Stockholm: ECDC; 2017.

Fast Track Targets

73%of all PLHIV will

have durable viral suppression

=

Target 1 Target 2 Target 3 Target 4

Belgium

Sweden

United Kingdom

Denmark

Finland

Hungary

Germany

Netherla

nds

Luxe

mbourg

France

Spain

Croatia

Italy

Bulgaria

Czech Republic

Slovenia

Portugal

Austria

Greece

Romania 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Progress toward achieving the third 90:Target: 90% of those on ART virally suppressed (n=20)

90% UNAIDS target

EU average 89%

Source: ECDC. The status of the HIV response in the European union/European economic Area, 2016. Stockholm. ECDC: 2017.

Fast Track Targets

73%of all PLHIV will

have durable viral suppression

=

Target 1 Target 2 Target 3 Target 4

Progress toward achieving the 90-90-90:Target: 73% of all PLHIV virally suppressed (n=17)

Sweden

Denmark

United Kingdom

Netherla

nds

France

Belgium

Germany

Spain

Luxe

mbourg

Austria

Italy

Croatia

Hungary

Greece

Romania

Portugal

Bulgaria

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

73% UNAIDS target

EU average 63%

Can we produce an EU/EEA continuum of care estimate based on country reported data?

Variability of data availability, quality, sources and measurement have historically made it difficult to compare and combine results across countries

But…

EuroCoord/ECDC collaboration on estimating the continuum of care

ECDC project with UCL & EuroCoord on estimating the continuum of care through surveillance and cohort data

Using standard definitions and high quality data sources

Bringing together HIV surveillance and cohort leads

Clinical/cohort dataPublic health data

Country Surveillance leads Cohort leadsAustria Daniela Schmid Robert Zangerle

Belgium Andre Sasse/Dominique Van Beckhoven Andre Sasse/Dominique Van Beckhoven

Denmark Susan Cowan Niels Obel

France Florence Lot/Francoise Cazein Dominique Costagliola/Virginie Supervie

Germany Barbara Bartmeyer Barbara Bartmeyer

Greece Georgios Nikolopoulos Giota Touloumi

Italy Barbara Suligoi Antonella d’ Arminio Monforte/Enrico Girardi

Netherlands Eline Op de Coul Peter Reiss/Ard van Sighem

Spain Mercedes Diez/Asuncion Diaz Julia Del Amo/Vicky Hernando

Sweden Maria Axelsson Anders Sӧnnerborg

United Kingdom Valerie Delpech Caroline Sabin

Surveillance and cohort leads in participating countries

These 11 countries have a combined population of 378.6 million (74% of the EU’s population)

The estimated number PLHIV in these 11 countries = 670 000 (≈80% of all PLHIV in the EU/EEA)

Estimates for HIV continuum using standardised definitions and surveillance/cohort data

PLHIV Diagnosed On ART Viral suppression0%

20%

40%

60%

80%

100%

84%*

71%*

60%*

84%**

84%**

85%**

*Percentages out of all PLHIV by end 2013 **Percentages out of the previous step

Gourlay et al. 2016. The HIV continuum of care in European Union countries in 2013: data and challenges. Accepted for publication.

Continuum of care estimates in the EU/EEADublin vs clinical cohort estimates

90%

81%

73%

Source: Preliminary data reported to ECDC in 2016 as part of Dublin Declaration reporting.

PLHIV Diagnosed On ART Viral suppression0%

20%

40%

60%

80%

100%

83%

69%63%

84%

71%

60%

Dublin continuum

Cohort continuum

Conclusions Monitoring of the continuum of care

– Availability of continuum of care data has increased– The quality of the data is improving, more standardised and comparable– Main data gaps: PLHIV (stage 1) and viral load suppression (stage 4)

On an EU/EEA level it may appear that we are close to reaching the stand-alone 90-90-90 targets

89%VIRALLY

SUPPRESSED

83% ON ART

83%DIAGNOSED

Conclusions Monitoring of the continuum of care

– Availability of continuum of care data has increased– The quality of the data is improving, more standardised and comparable– Main data gaps: PLHIV (stage 1) and viral load suppression (stage 4)

On an EU/EEA level it may appear that we are close to reaching the stand-alone 90-90-90 targets, but of all PLHIV

37%NOT VIRALLY SUPPRESSED

31% NOT ON ART

17%UNDIAGNOSED

Detectable=

Infectious=

Transmittable

AcknowledgementsDublin Declaration advisory group

Irene Rueckerl (Austria), Florence Lot, Daniela Rojas Castro, Richard Stranz (France), Gesa Kupfer (Germany), Derval Igoe (Ireland), Lella Cosmaro (Italy), Silke David, Eline Op De Coul (Netherlands), Arild Johan Myrberg (Norway), Olivia Castillo (Spain), Maria Axelsson (Sweden), Valerie Delpech, Alison Brown, Cary James, Brian Rice (United Kingdom), Velina Pendalovska (European Commission), Klaudia Palczak and Dagmar Hedrich (EMCDDA), Taavi Erkkola, Kim Marsh (UNAIDS) and Annemarie Steengard (WHO Regional Office for Europe).

Dublin Declaration focal points in Europe and Central AsiaRoland Bani (Albania), Montse Gessé (Andorra), Samvel Grigoryan (Armenia), Irene Rueckerl, Bernhard Benka (Austria), Esmira Almammadova (Azerbaijan), Inna Karabakh (Belarus), Andre Sasse, Dominique Van Beckhoven (Belgium), Šerifa Godinjak (Bosnia and Herzegovina), Tonka Varleva (Bulgaria), Jasmina Pavlic (Croatia), Ioannis Demetriades (Cyprus), Veronika Šikolová, Hana Janatova (Czech Republic), Jan Fouchard (Denmark), Kristi Rüütel, Liilia Lõhmus, Anna-Liisa Pääsukene (Estonia), Henrikki Brummer-Korvenkontio (Finland), Bernard Faliu (France), Tamar Kikvidze (Georgia), Gesa Kupfer, Ulrich Marcus, (Germany), Vasileia Konte, Chryssoula Botsi, Jenny Kremastinou, Theodoros Papadimitriou (Greece), Katalin Szalay (Hungary), Guðrún Sigmundsdóttir (Iceland), Derval Igoe (Ireland), Daniel Chemtob (Israel), Maria Grazia Pompa, Anna Caraglia, Barbara Suligoi, Laura Camoni, Stefania D’Amato, Anna Maria Luzi, Anna Colucci, Marco Floridia, Alessandra Cerioli, Lella Cosmaro, Massimo Oldrini, Laura Rancilio, Maria Stagnitta, Michele Breveglieri, Margherita Errico (Italy), Irina Ivanovna Petrenko (Kazakhstan), Laura Shehu, Pashk Buzhala, Bajram Maxhuni (Kosovo*), Dzhainagul Baiyzbekova (Kyrgyzstan), Šarlote Konova (Latvia), Irma Caplinskiene (Lithuania), Patrick Hoffman (Luxembourg), Jackie Maistre Melillo (Malta), Violeta Teutu (Moldova), Aleksandra Marjanovic (Montenegro), Silke David (Netherlands), Arild Johan Myrberg (Norway), Iwona Wawer, Piotr Wysocki, Adam Adamus (Poland), Antonio Diniz, Teresa Melo (Portugal), Mariana Mardarescu (Romania), Danijela Simic, Sladjana Baros (Serbia), Peter Truska (Slovakia), Irena Klavs (Slovenia), Olivia Castillo (Spain), Maria Axelsson (Sweden), Stefan Enggist, Axel Schmidt (Switzerland), Muratboky Beknazarov (Tajikistan), Nurcan Ersöz (Turkey), Valerie Delpech (United Kingdom), Igor Kuzin (Ukraine) and Zulfiya Abdurakhimova (Uzbekistan).

HIV Surveillance focal points in the EU/EEADaniela Schmid, Alexander Spina (Austria), Andre Sasse (Belgium), Tonka Varleva (Bulgaria), Tatjana Nemeth Blazic (Croatia); Maria Koliou (Cyprus), Marek Maly (Czech Republic); Susan Cowan (Denmark), Kristi Ruutel (Estonia), Kirsi Liitsola (Finland), Florence Lot (France), Barbara Gunsenheimer-Bartmeyer (Germany), Georgios Nikolopoulos and Dimitra Paraskeva (Greece), Maria Dudas (Hungary), Gudrun Sigmundsdottir and Haraldur Briem (Iceland), Kate O’Donnell and Derval Igoe (Ireland), Barbara Suligoi (Italy), Šarlote Konova (Latvia), Saulius Čaplinskas and Irma Čaplinskienė (Lithuania), : Jean-Claude Schmit (Luxembourg), Jackie Maistre Melillo and Tanya Melillo (Malta), Eline Op de Coul (Netherlands), Hans Blystad (Norway), Magdalena Rosinska (Poland), Helena Cortes Martins (Portugal), Mariana Mardarescu (Romania), Peter Truska (Slovakia), Irena Klavs (Slovenia), Asuncion Diaz (Spain), Maria Axelsson (Sweden), Valerie Delpech (United Kingdom).

EuroCoord/ECDC project collaboratorsDaniela Schmid, Robert Zangerle (Austria), Andre Sasse, Dominique Van Beckhoven (Belgium), Susan Cowan, Niels Obel (Denmark), Florence Lot, Francoise Cazein, Dominique Costagliola, Virginie Supervie (France), Barbara Bartmeyer (Germany), Georgios Nikolopoulos, Giota Touloumi (Greece), Barbara Suligoi, Antonella d’ Arminio Monforte, Enrico Girardi (Italy), Eline Op de Coul, Peter Reiss, Ard van Sighem (Netherlands), Mercedes Diez, Asuncion Diaz, Julia Del Amo (Spain), Maria Axelsson, Anders Sӧnnerborg (Sweden), Valerie Delpech, Sara Croxford, Caroline Sabin (United Kingdom)

Thank youAnastasia PharrisCaroline Daamen

Kathy AttawellDavid Hales

Annabelle GourlayKholoud PorterAndrew Amato

teymur.noori@ecdc.europa.eu