HIV Care in the Swedish-Danish HIV Cohort 1995-2010, Closing the Gaps

Abstract

BackgroundSuccessful treatment reduces morbidity, mortality and transmission of HIV. We evaluated trends in the treatment status of HIV infected individuals enrolled in care in Sweden and Denmark during the years 1995-2010. Our aim was to assess the proportion of HIV-infected individuals who received services along the continuum of care in Denmark in 2010, and to discuss the findings in relation to the organization of the health care system.MethodsWe analyzed CD4 counts and viral loads (VL) among all HIV patients enrolled in the cohort. For each month of the study period we estimated the proportions of patients who 1) had initiated highly active antiretroviral treatment (HAART) and had VL<500 copies/mL, 2) were not eligible for HAART, 3) had initiated HAART but had VL≥500 copies/mL, 4) were eligible for, but had not initiated HAART and 5) had initiated HAART but no VL monitoring for >13 months or 6) no HAART or monitoring of CD4 for >13 months. Patients fulfilling criteria 1 or 2 were considered successfully managed.ResultsThe proportion of successfully managed patients continued to increase throughout the study period and reached 83% in 2010, 92% of Swedish/Danish men who have sex with men and heterosexual patients, but only 74% of immigrants and 78% of injection drug users were successfully managed due to higher rates of inadequate monitoring in the latter two groups. In 2010, 70% of all individuals diagnosed with HIV in Denmark were virally suppressed.ConclusionIn a public health care system with free access to specialized care, successful management of the majority of HIV patients is achievable. Interventions tailored to retain immigrants and injection drug users in care are needed to further reduce the proportion of sub-optimally treated HIV patients.

Sweden, the first country to achieve the Joint United Nations Programme on HIV/AIDS (UNAIDS)/World Health Organization (WHO) 90‐90‐90 continuum of HIV care targets

“…The implementation was finalized in all HIV care centres in 2008 7. The percentages of patients diagnosed with HIV and linked to care are included in the InfCare HIV database, corresponding to 6946 diagnosed subjects living with HIV‐1 in Sweden by 31 December 2015.…”

Temporal Trends in the Swedish HIV-1 Epidemic: Increase in Non-B Subtypes and Recombinant Forms over Three Decades

“…Also, differences in the coverage rate and efficacy of ART may lead to a relative decrease in the number of persons infected by HIV-1B strains within the country since undetectable viremia due to ART is associated with minimal contagiousness [25]. Thus, although the general coverage rate in Sweden is presently high, >90%, the proportion of successfully treated MSM is even higher than among heterosexually infected individuals [24]. Considering the actual change in proportions over calendar years and the analysis predictions, the recombinant forms will probably dominate by the year 2015 among newly diagnosed patients in Sweden.…”

HIV treatment cascade in MSM, people who inject drugs, and sex workers

“…In a cohort of Swedish and Danish PLWH[70], PWID were less likely to be “successfully managed” (viral suppression among those eligible for ART or at least annual CD4 testing among those ineligible) than MSM or heterosexuals (78% among PWID vs 92%). PWID initiate care later than those who do not inject drugs, as found by a study in Vietnam where PWID started ART at 69 CD4+ cells/mm 3 compared to 96 CD4+ cells/mm 3 among non-injectors[71].…”

“…In a cohort of Swedish and Danish PLWH[70], in 2010, 92.6% of Swedish/Danish MSM (vs. 91.0% among Swedish/Danish heterosexual males) and 74.2% of immigrant MSM (vs. 70.9% of immigrant heterosexual males) were virally suppressed or receiving annual CD4 counts if not yet on ART. In Belgium, MSM were less likely to have undiagnosed HIV infection and more likely to be retained in care than heterosexual populations[72].…”