Potential impact on HIV incidence of higher HIV testing rates and earlier antiretroviral therapy initiation in MSM

Phillips, Andrew; Cambiano, Valentina; Miners, Alec; Lampe, Fiona; Rodger, Alison; Nakagawa, Fumiyo; Brown, Alison E; Gill, O Nöel; Angelis, Daniela De; Elford, Jonathan; Hart, Graham; Johnson, Anne M; Lundgren, Jens D; Collins, Simon; Delpech, Valérie

doi:10.1097/qad.0000000000000767

Cited by 50 publications

(41 citation statements)

References 27 publications

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“…AIDS 2015;29:1855-62. 1 The human immunodeficiency virus (HIV) is endemic in men who have sex with men (MSM) in many settings, including the UK. 2 Antiretroviral therapy (ART) is now highly successful in reversing the effects of HIV and has led to death rates in successfully treated people that are not much greater than those of the general population.…”

Section: Synopsismentioning

confidence: 99%

“…In this programme of research we performed five separate empirical studies ( Figure 1). These studies addressed (1) The cost-effectiveness was estimated using an individual-based simulation model calibrated to data from studies 1-5. Our cost-effectiveness modelling consisted of two phases.…”

Section: Synopsismentioning

confidence: 99%

“…The work was reported in two papers. 1,14 The first concentrated on understanding influences on the epidemic up to 2012 and described the structure and calibration of the model of HIV transmission, progression and the effect of ART that was developed for this. The model was then used to help us understand the relative influences of sexual risk behaviour change, rates of HIV testing and ART-induced virological suppression on HIV infection incidence up to 2012.…”

Section: Sexual Risk Behaviour In People Enrolled In the Start Trialmentioning

confidence: 99%

“…The model was then used to help us understand the relative influences of sexual risk behaviour change, rates of HIV testing and ART-induced virological suppression on HIV infection incidence up to 2012. 1 In the second paper we used the model to project future HIV infection incidence and other outcomes over the next 20 years, along with an economic analysis. 14 In the model we reconstruct sexual risk behaviour, HIV transmission, progression and the effect of ART for the population of MSM in the UK from 1980 to 2010 using an individual-based stochastic computer simulation model, which captures the key underlying mechanisms that determine these processes (model adapted from that used in Phillips et al, 58 itself developed from earlier versions [59][60][61] ).…”

Section: Sexual Risk Behaviour In People Enrolled In the Start Trialmentioning

confidence: 99%

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Implications for a policy of initiating antiretroviral therapy in people diagnosed with human immunodeficiency virus: the CAPRA research programme

Miltz

Phillips

Speakman

et al. 2017

Programme Grants Appl Res

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BackgroundMore than 100,000 people in the UK are living with a human immunodeficiency virus (HIV) infection. There are currently estimated to be around 4000 people newly infected in the UK per year, mostly men who have sex with men (MSM). It has become increasingly clear that antiretroviral therapy (ART) used to treat people infected with HIV also has a profound effect on infectivity. At the initiation of the programme, it was the policy in the UK to initiate ART in people when their cluster of differentiation 4 (CD4) count was approaching 350/µl.ObjectivesTo assess what would be the effectiveness and cost-effectiveness of a policy of immediate initiation of ART at diagnosis among MSM, taking into account the potential reductions in new infections.DesignWe calibrated an individual-based model of HIV transmission, progression and the effect of ART in MSM, informed by a series of studies on sexual behaviour in relation to ART use and the transmission risk in people with viral suppression on ART, and by surveillance data collected by Public Health England.Setting, participants and interventionsThe series of studies used to inform the model included (1) the Antiretrovirals, Sexual Transmission Risk and Attitudes (ASTRA) study, a cross-sectional self-administered questionnaire study of people diagnosed with HIV attending eight HIV outpatient clinics in the UK (2011–12); (2) the Cognitive Impairment in People with HIV in the European Region (CIPHER) study, a study of levels of neurocognitive impairment in HIV-positive ASTRA participants and people from HIV clinics in Rome, Copenhagen and Minsk; (3) the Attitudes to, and Understanding of, Risk of Acquisition of HIV (AURAH) study, a cross-sectional self-administered questionnaire study of individuals who have not been diagnosed as HIV-positive attending 20 genitourinary medicine clinics across the UK (2013–14); (4) a substudy of sexual behaviour among individuals enrolled in an open-label multicentre international randomised trial (from 2013) of immediate versus deferred ART (to CD4 cell counts of 350/µl) in people with CD4 cell counts of > 500/µl [the Strategic Timing of Antiretroviral Therapy (START) trial]; and (5) Partners of People on ART: a new Evaluation of the Risks (PARTNER), an observational multicentre longitudinal study of HIV serodifferent heterosexual and MSM couples, in which the HIV-positive partner is on ART (2010–14).Main outcome measuresThe main outcome measures were the clinical effectiveness and cost-effectiveness of a policy of immediate initiation of ART at diagnosis.ResultsBased on data from studies (i)–(v), we estimated from our modelling work that increases in condomless sex (CLS) among MSM as a whole may explain the increase in HIV infection incidence in MSM epidemics over a time when ART coverage and viral suppression increased, demonstrating the limiting effects of non-condom use on the HIV epidemic among MSM. Accordingly, an increase in the overall proportion of MSM living with HIV who are virally suppressed on ART from the current level of < 60% to 90% without increases in CLS was required to achieve a reduction in the incidence of HIV among MSM to < 1 per 1000 person-years. The incremental cost-effectiveness ratio associated with the fourfold increase in levels of HIV testing and ART at diagnosis required to provide this increase from < 60% to 90% was £20,000 if we assumed continuation of current ART prices. However, this value falls to £3500 if we assume that ART prices will fall to 20% of their current cost as a result of the introduction of generic drugs. Therefore, our evaluation suggests that ART initiation at diagnosis is likely to be highly cost-effective in MSM at a population level, particularly accounting for future lower ART costs as generic drugs are used. The impact will be much greater if levels of HIV testing can be enhanced.LimitationsIt was necessary to make some assumptions beyond the available data in order to extrapolate cost-effectiveness through modelling.ConclusionsOur findings suggest that ART initiation at diagnosis is likely to be cost-effective in MSM. Of note, after this programme of work was completed, results from the main START trial demonstrated benefit in ART initiation even in people with CD4 cell counts of > 500/µl, supporting ART initiation in people diagnosed with a HIV infection.Future workThere is a need for future research into the means of increasing the frequency with which MSM test for HIV.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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Section: Synopsismentioning

confidence: 99%

Section: Synopsismentioning

confidence: 99%

Section: Sexual Risk Behaviour In People Enrolled In the Start Trialmentioning

confidence: 99%

Section: Sexual Risk Behaviour In People Enrolled In the Start Trialmentioning

confidence: 99%

See 2 more Smart Citations

Implications for a policy of initiating antiretroviral therapy in people diagnosed with human immunodeficiency virus: the CAPRA research programme

Miltz

Phillips

Speakman

et al. 2017

Programme Grants Appl Res

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“…31,32 Indeed mathematical models suggest that PHI could be responsible for over half of all new HIV infections in focused epidemics such as the UK. 7 The use of ART in HIVpositive individuals is the most effective tool to prevent onward viral transmission among HIV serodifferent heterosexual and MSM couples. Recent PEP guidelines advise six months virological suppression before the infection transmission risk is too low to justify PEP provision.…”

Section: Prevention Of Hiv Transmissionmentioning

confidence: 99%

Primary HIV infection: a medical and public health emergency requiring rapid specialist management

Fidler

Fox

2016

Clinical Medicine

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Estimates of the HIV undiagnosed population in Belgium reveals higher prevalence for MSM with foreign nationality and for geographic areas hosting big cities

et al. 2019

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Introduction Increasing our knowledge on geographic areas and key populations most affected by HIV is essential to improve prevention and care and to ensure a more focused HIV response. Here, we estimated the prevalence of undiagnosed HIV infections in Belgium and its distribution across geographic areas and exposure groups. Methods We used surveillance data on newly diagnosed HIV cases and a previously developed back‐calculation model to estimate number and prevalence rates (per 10000) of undiagnosed HIV infections by exposure group at national and subnational levels. Belgium consists of three regions: Flanders, Brussels‐Capital Region and Wallonia. We produced estimates for Brussels‐Capital Region and Wallonia. For Flanders, we produced estimates for two sub‐regional areas: the province of Antwerp and the other provinces, because Antwerp is the second largest city after Brussels. Population sizes were determined using data from the Belgian Statistical Office and surveys on sexual behaviour and drug use. Results In Belgium, in 2015, an estimated 2818 (95% confidence interval: 2494 to 3208) individuals were living with undiagnosed HIV, that is, 15% of individuals living with HIV. The Brussels‐Capital Region and the province of Antwerp, which host the two biggest cities, accounted for ~60% of the undiagnosed infections, and had the highest undiagnosed prevalence rates per 10000: 12.0 (9.4 to 15.3) and 7.4 (5.6 to 9.8) respectively. Individuals with foreign nationality accounted for 56% of the total number of undiagnosed infections, and were the most affected populations in all areas in terms of undiagnosed prevalence rates. Specifically, men who have sex with men (MSM) with non‐European nationality were the most affected population in the province of Antwerp (853.4 (408.2 to 1641.9) undiagnosed infections per 10000), the Brussels‐Capital Region (543.9 (289.1 to 1019.1)), and the other provinces of Flanders (691.7 (235.5 to 1442.2)), while in Wallonia, it was heterosexual women with Sub‐Saharan African nationality (132.2 (90.6 to 178.5)). Conclusions Geographic areas hosting the biggest cities in Belgium accounted for the vast majority of undiagnosed HIV infections and individuals with foreign nationality were the most affected, especially MSM with non‐European nationality. This should be accounted for when tailoring prevention and testing programs. Furthermore, MSM with foreign nationality require more attention in Belgium, and certainly more generally in Europe.

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Potential impact on HIV incidence of higher HIV testing rates and earlier antiretroviral therapy initiation in MSM

Abstract: Supplemental Digital Content is available in the text

Cited by 50 publications

References 27 publications

Implications for a policy of initiating antiretroviral therapy in people diagnosed with human immunodeficiency virus: the CAPRA research programme

Implications for a policy of initiating antiretroviral therapy in people diagnosed with human immunodeficiency virus: the CAPRA research programme

Primary HIV infection: a medical and public health emergency requiring rapid specialist management

Estimates of the HIV undiagnosed population in Belgium reveals higher prevalence for MSM with foreign nationality and for geographic areas hosting big cities

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