Europe is tackling HIV head on | Popgen Tech
European public health authorities have met a formidable opponent in the race to end the AIDS epidemic by 2030: late HIV.
At last count, slightly more than half of diagnoses in European Union (EU)/European Economic Area (EEA) countries were associated with a CD4 cell count <350 cells/mm3, of which 35% were considered advanced (that is, presenting for care with an AIDS-defining disease or indicator condition, regardless of CD4 cell count). Both factors meet the late HIV – or “late presenting” – definition endorsed in 2009 by the European Center for Disease Prevention and Control (ECDC) and World Health Organization (WHO).
However, many cases appear to have been captured during seroconversion (when CD4 counts have decreased to levels below 350/mm3 temporary), hampering public health authorities’ efforts to understand and accurately track whether key benchmarks, such as testing, treatment and care linkage, are being met directly, locally and nationally across EU/EEA countries and the UK.
“We felt that there was a need to harmonize the approach across European countries,” Annemarie Rinder Stengaard, MSc, a public health research project coordinator at the Center of Excellence for Health, Immunity and Infections (CHIP) at the University of Copenhagen in Denmark and member of the EuroTEST HIV Late Diagnosis Definition Working Group, told Medscape Medical News.
The Working Group of European HIV experts met last spring to review current late HIV diagnosis and, through outreach efforts to 53 national HIV surveillance contact points in the WHO European Region, gain a better understanding of the diagnostic data needed to reclassify current late possible HIV diagnosis.
The effort led to a revised consensus definition of late HIV, according to the Working Group Communication published in a special supplement published this month in HIV Medicine. The new definition changed existing wording from “late presentation to late diagnosis” to account for cases requiring reclassification. The Working Group also determined that evidence of recent infection should be hierarchically considered and reclassified as “not late” based on 1) laboratory evidence of recent infections; 2) last negative HIV test ≤12 months from diagnosis; 3) clinical evidence of acute infection.
“Part of our definition is just to sort out the public health indicator to correctly classify cases,” said co-author Anastasia Pharris, RN, MPH, an ECDC HIV expert and EuroTEST working group member. Pharris also noted that the previous definition would exclude people with evidence that they were previously diagnosed in another country before moving to their current country of residence.
“We think the updates have now captured reality in a way that allows us to monitor [the situation] over time,” she said.
Although primarily intended for public health surveillance, a redefined definition of late diagnosis may also be useful at the clinical level, especially for clinicians less familiar with late HIV.
“You just can’t look at the CD4 count in isolation for a number of reasons,” said Lina Rosengren-Hovee, MD, MPH, a physician and infectious disease epidemiologist at the University of North Carolina-Chapel Hill. Medscape Medical News. Although not involved in the EuroTEST group efforts, Rosengren-Hovee emphasized that the definitional changes are important.
“Everyone’s baseline CD4 count is different; there is a range of ‘normal,'” she explained. “I try to give advice [and] encourage other doctors not to check CD4 counts because it doesn’t reflect that patient’s immune system or acute illness, and it really doesn’t tell you anything about how they’re doing in terms of their HIV.”
Let HIV also challenge in the US
In 2014, the US Centers for Disease Control and Infection (CDC) took steps to facilitate early diagnosis of HIV by monitoring early cases (when the virus is likely to be transmitted) separately from advanced cases, a CDC spokesperson explained. Medscape Medical News in an email.
These efforts included recommendations to laboratories to take advantage of fourth-generation HIV tests to detect the p24 antigen (which appears earlier as antibodies in the blood), differentiation tests that distinguish HIV-1 from HIV-2, and nucleic acid tests (NATs) track. which identifies false positives and facilitates early detection.
At the same time, the CDC also published a revised case definition that classified HIV infections on a continuum from stage 0 (an acute infection identified by a negative HIV test ≤6 months from diagnosis) to stage 3 (AIDS), and thereby eliminating a need. to distinguish between suspected and definite opportunistic infections. Cases may also be classified as “unknown” if they do not fit stages 0-3.
“These efforts have made it possible to classify and monitor acute HIV cases separately from advanced HIV cases,” the CDC spokesperson said. Nevertheless, like its European counterparts, late diagnosis remained a challenge in the US. According to 2020 surveillance data, 7% (1953 of 28,422) of HIV diagnoses were stage 0, while 21% (6105 of 28,422) were stage III.
Different testing strategies may be the key
Late HIV diagnosis is associated with increased morbidity and early death, and the risk of continued transmission has raised questions about the types of strategies needed to prevent these cases.
One consideration may be what Inês Vaz-Pinto, MD, an HIV-AIDS Functional Unit specialist at the Hospital de Cacais in Lisbon, Portugal referred to as “opportunistic screening.” Vaz-Pinto co-authored a study published in the HIV Medicine December supplement that looked at the impact of opportunistic screening in the emergency department (ED) on late diagnosis.
“We decided to call our project an opportunistic screening strategy because we [took] advantage of two things that have already occurred: 1) the patient is already in the hospital, namely in the ED, and 2) the patient is being blooded for whatever reason got him to the ED in the first place,” said she explained by email.
Between September 2018 and September 2021, Vaz-Pinto and colleagues implemented the automated HIV screening program in patients presenting to the ED with a pre-existing physician order for a blood test; an electronic health record automatically generated patients eligible for screening who were offered an HIV test at the time of the blood draw or the ability to opt out.
Of the 43,153 patients who visited the ED, 88.9% (38,357) were identified as eligible and ultimately received HIV testing; most were aged 40-64 years, and two-thirds were of Portuguese origin.
Vaz-Pinto said that compared to a historical group of patients who presented in the previous screening period (2015-2018), late HIV presentation in the ED setting was reduced from 78.4% to 39.1%. In addition, the researchers also observed a 20.5% decrease in patients representing previously missed opportunities for HIV diagnosis.
“By using an automated screening program, we have eliminated the human factor from the whole equation of screening,” she said, which “we know represents one of the major barriers to HIV testing.”
The automated process does not rely on patient or clinician initiative to manage HIV testing, nor does it place an extra burden on ED staff, she added. Most importantly, however, “opt-out strategies help normalize HIV testing.”
This past April, the UK’s National Health Service (NHS) implemented a routine HIV opt-out program within 33 hospital EDs, offering people discrete tests for HIV and hepatitis B and C to reach people who would otherwise not encounter blood not. -borne virus testing opportunities.
“They picked up more than 800 cases in 100 days, which is a lot for the United Kingdom,” said the University of Denmark’s Stengaard, “and they picked up more than 100 people who were lost to care.”
This is where you can find those intersections between settings where HIV testing would not automatically be considered and people who did not believe they were at risk, she further explained.
Simon Collins, an HIV advocate, co-founder of UK-based treatment activist group HIV i-Base, and co-author of an editorial accompanying the December HIV Medicine supplement, also pointed out that people who are in the most difficult [situations] are those who have gone years without testing, often because they turned it down when offered.
But, “much more common is that they had health problems, they went to doctors, especially primary care doctors, even with indicator diseases, and they didn’t give HIV tests,” he said. Medscape Medical News.
Can early self-testing help?
“When it comes to HIV testing, it has to be a multifaceted approach; the more modalities we have, the more people we’re going to reach, right?” said Rosengren-Hovee.
To that end, the CDC recently awarded $8.3 million to an Emory University-led collaborative program — Together TakeMeHome — that builds on a pilot project launched in March 2020.
“We have a much better understanding of the benefits of early intervention with treatments on long-term outcomes—the closer to the time of HIV infection that we identify someone, the better,” says Patrick Sullivan, PhD, DVM, professor of epidemiology at Emory University in Atlanta, Georgia, and a primary investigator of the Together TakeMeHome initiative.
“I think the CDC is doing the right thing in terms of programmatically trying to be innovative, to get people who benefit from screening testing as early as possible,” he said.
This is especially true of key targets for the program, which include Black, Hispanic, Latino, and Southern communities, all of whom experience a higher risk of HIV.
Meanwhile, back in the UK, the 100 day opt-in study showed what can be achieved with a little ingenuity.
“The UK has done a good job of treating late diagnosis as a critical event; they have a good health system with good record keeping so they can look back and say, ‘When did this person seek care for perhaps related issues and not being offered an HIV test, [and] how can we improve?’ Pharris noted.
“It’s important to get the public health actors and clinicians and the community all involved because they have different pieces of the puzzle to make it work,” she added.
The EuroTEST initiative receives funding from Gilead Sciences, Merck MSD, ViiV Healthcare and the European Center for Disease Prevention and Control. Stengaard, Pharris, Collins and Rosengren-Hovee report no relevant financial relationships.
HIV Med. Published online 8 November 2022. Full text
HIV Med. Published online 1 November 2022. Full text
HIV Med. Published online 17 November 2022. Editorial
Liz Scherer is an independent journalist specializing in infectious and emerging diseases, cannabinoid therapeutics, neurology, oncology and women’s health.