Missed opportunities of HIV pre-exposure prophylaxis in France: a retrospective analysis in the French DAT’AIDS cohort

Abstract

BackgroundHIV pre-exposure prophylaxis (PrEP) was implemented in France in November 2015 based on individual-level risk factors for HIV infection. We evaluated the proportion of missed opportunities for PrEP among newly HIV-diagnosed people entering the Dat’AIDS cohort in 2016.MethodsMulticenter retrospective analysis in 15 French HIV clinical centers of patients with a new diagnosis of HIV infection. Among them we differentiated patients according to the estimated date of infection: those occurring in the PrEP area (a previous negative HIV test in the last 12 months or those with an incomplete HIV-1 western blot (WB) with no HIV-1 anti-Pol-antibody at time of HIV diagnosis) and those in the pre-PrEP area (older infections). Epidemiological, biological and clinical data at HIV diagnosis were collected. Clinicians retrospectively identified potential eligibility for PrEP based on individual-level risk factors for HIV infection among those infected in the PrEP area.ResultsAmong 966 patients with a new HIV diagnosis, 225 (23.3%) were infected in the PrEP area and 121 (53.8%) had complete data allowing evaluation of PrEP eligibility. Among them, 110 (91%) would have been eligible for PrEP, median age 31 years, with 68 (75.6%) born in France and 10 (11.1%) in Central/West Africa, with more than one previous STI in 19 (15.7%). The main eligibility criteria for PrEP were being a man who had sex with men or transgender 91 (82.7%) with at least one of the following criteria: unprotected anal sex with ≥2 partners in the last 6 months: 67 (60.9%); bacterial sexually transmitted infection in the last 12 months: 33 (30%); Use of psychoactive substances in a sexual context (chemsex): 16 (14.5%). PrEP was indicated for other HIV risk factors in 25 (22.7%).ConclusionWith 91% (110/121) of patients infected in the PrEP area eligible for PrEP, this study highlights the high potential of PrEP in avoiding new infection in France but also shows a persistent delay in HIV testing. Thus, an important limit on PrEP implementation in France could be insufficient screening and care access.

Spectrum and Incidence Trends of AIDS- and Non–AIDS-Defining Cancers between 2010 and 2015 in the French Dat'AIDS Cohort

“…Higher ICC risk was also reported in three American studies covering different time periods, from 1996 to 2012 (8), 1996 to 2010 (25) and during 20 years until 2015 (26). The persistence of higher risk observed in our study may be partly explained by (i) the low cervical HPV clearance rate in women living with HIV (WLWH) (27); (ii) a delay in HIV testing leading to late HIV diagnosis (28,29); (iii) an insufficient access to ICC screening, despite a recent French study showing most adequate access in WLWH than in the French general population (30); and (iv) a past or persistent severe immunosuppression (23), which concerned five of our 16 patients (35%). Our data confirm the need to maintain differentiated recommendations for ICC screening in HIV-positive women, particularly in those with strong immunosuppression or low nadir CD4.…”

Kaposi sarcoma among people living with HIV in the French DAT’AIDS cohort between 2010 and 2015

“…However, more relevantly, this analysis highlights the need to differentiate KS occurrence circumstances in the post‐ART period, half of them occurring in patients not on ART, of whom 41 had concomitant HIV diagnosis. These patients fulfilled the criteria defining late presenters among HIV‐infected people, a situation that has remained common around the world, including in France as we reported recently, and which increases patient morbidity and mortality and limits the effectiveness of all subsequent steps in the cascade of HIV care …”

Perceptions, motivations, and beliefs about HIV risk and pre-exposure prophylaxis (PrEP) among participants in a nurse-led PrEP service (PrEP-RN)

“…As a result, patients with reduced risk of HIV acquisition based on HIV correlates (e.g., a gay man who reports consistent condom use during sex) might be prioritized for PrEP because they belong to a group with elevated HIV prevalence [ 1 ]. Conversely, persons within the same group who have objective risk indicators (e.g., a gay man with a sexual partner recently diagnosed with HIV) or who might be at elevated risk for HIV, but belong to a group with lower HIV prevalence (e.g., a heterosexual woman diagnosed with infectious syphilis) might be less considered for PrEP [ 9 – 11 ]. These nuances between individual and population-level risk indicators can make it difficult for healthcare providers to determine who might benefit from PrEP.…”