Reduction in undiagnosed HIV infection in the European Union/European Economic Area, 2012 to 2016

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1 Rpid communictions Reduction in undignosed HIV infection in the Europen Union/Europen Economic Are, 212 to 216 Ard vn Sighem¹, Anstsi Phrris², Chntl Quinten², Teymur Noori², Andrew J Amto-Guci², the ECDC HIV/AIDS Surveillnce nd Dublin Declrtion Monitoring Networks³ 1. Stichting HIV Monitoring, Amsterdm, the Netherlnds 2. Europen Centre for Disese Prevention nd Control (ECDC), Stockholm, Sweden 3. The members of the networks re listed t the end of the rticle Correspondence: Anstsi Phrris (nstsi.phrris@ecdc.europ.eu) Cittion style for this rticle: vn Sighem Ard, Phrris Anstsi, Quinten Chntl, Noori Teymur, Amto-Guci Andrew J, the ECDC HIV/AIDS Surveillnce nd Dublin Declrtion Monitoring Networks. Reduction in undignosed HIV infection in the Europen Union/Europen Economic Are, 212 to 216. Euro Surveill. 217;22(48):pii= doi.org/1.287/ es Article submitted on 17 Nov 217 / ccepted on 29 Nov 217 / published on 29 Nov 217 It is well-documented tht erly HIV dignosis nd linkge to cre reduces morbidity nd mortlity s well s HIV trnsmission. We estimted the medin time from HIV infection to dignosis in the Europen Union/ Europen Economic Are (EU/EEA) t 2.9 yers in 216, with regionl vrition. Despite evidence of decline in the number of people living with undignosed HIV in the EU/EEA, mny remin undignosed, including 33% with more dvnced HIV infection (CD4 < 35 cells/ mm 3 ). HIV remins n importnt public helth issue ffecting the 31 countries of the Europen Union nd Europen Economic Are (EU/EEA) [1]. In 215, it ws estimted tht c 12, people (15% of those living with HIV in the EU/EEA) were living with undignosed HIV infection [2]. In order to understnd regionl vritions in (i) HIV incidence, (ii) time to HIV dignosis, nd (iii) the number of people living with undignosed HIV, we nlysed HIV nd AIDS surveillnce dt from 23 through 216. Clcultion of 216 estimtes Annully, HIV surveillnce dt re reported by EU/EEA countries to dtbse for HIV/AIDS tht is coordinted jointly by the Europen Centre for Disese Prevention nd Control (ECDC) nd the World Helth Orgniztion (WHO) Regionl Office for Europe within the Europen Surveillnce System (TESSy) [1]. Countries were grouped into four geogrphicl regions (Est, South, West, North) (Figure 1) bsed on United Ntions definition [3]. For those countries lcking dt on CD4 count t dignosis, the distribution of CD4 count in the region they belonged to ws ssumed to be representtive. When grouping countries, the epidemic chrcteristics cross countries were pooled nd similr probbility of dignosis by CD4 cell count ctegory for ll countries within tht region ws ssumed. Annul dt on HIV dignoses reported to TESSy for were djusted for reporting dely nd under-reporting. Dt were djusted for non-ntionl coverge of some countries reporting systems ( for Itly nd for Spin) nd cses (3%) tht hd been previously reported s dignosed were excluded. Dt were then strtified by the presence of concurrent AIDS dignosis nd, for people without concurrent AIDS, by CD4 cell count levels t the time of dignosis i.e. 5, , 2 349, < 2 cells/mm 3 [4]. The incidence method in the Europen Centre for Disese Prevention nd Control (ECDC) HIV Modelling Tool version 1.3. ws used for ech region in 216 to estimte the (i) HIV incidence, (ii) medin time from infection to dignosis, nd (iii) number of people living with HIV who were not yet dignosed [5,6]. HIV incidence in 216 In 216, 29,444 cses of HIV were dignosed nd reported in the EU/EEA, resulting in notifiction rte of 5.9 per 1, popultion when djusted for reporting dely [1]. Rtes in hd rnged from 6.5 to 6.7 nd in 216, for the first time in decde, there ws cler decline in the rte of new HIV dignoses t EU/EEA level lthough rtes in 11 of 31 EU/EEA countries hve continued to increse. 1

2 Figure 1 Regions used in the nlysis of undignosed HIV infections, Europen Union/Europen Economic Are, 216 Est North South West Non EU/EEA Luxembourg Mlt Liechtenstein EU/EEA: Europen Union/Europen Economic Are. In 216, the estimted number of new HIV infections (incidence rte) ws lower thn the number of new dignoses (notifiction rte) nd ws 3.6 per 1, popultion (95% confidence intervl (CI): ) for the EU/EEA overll. This differed substntilly between the four regions: the highest estimted incidence rte ws in the West (5.2/1, popultion; 95% CI: ) nd South (3.8; 95% CI: ) nd it ws lower in the North (2.2; 95% CI: ) nd Est (1.7; 95% CI ). Medin time from infection to dignosis The medin time from infection to dignosis ws estimted to hve declined in the EU/EEA overll nd in ll four regions between 212 nd 216. In 216, the EU/EEA medin ws 2.9 yers (interqurtile rnge: ) with some vrition by region: South (3.6 yers), Est (3. yers), West (2.6 yers) nd North (2.2 yers) (Figure 2). The estimted undignosed number of people living with HIV in 216 ws highest in the South nd West (38, nd 36,7, respectively), compred with 17,5 in the North nd 9,1 in the Est (Figure 3). Over the period the number of people estimted to be living with undignosed HIV declined in the EU/EEA overll, from n estimted 132,2 in 212 to 11,4 in 216. This decline ws observed in ll four regions, with reltively more rpid decline in the South nd prticulrly in recent yers in the North. In 216, this resulted in lower estimted proportions of people living with undignosed HIV in the South, North nd West (11.%, 11.3%, nd 12.1%, respectively) nd higher proportion in the Est (16.8%). 2

3 Figure 2 Expected medin time from HIV infection to dignosis by yer of infection, Europen Union/ Europen Economic Are nd regions, Figure 3 Estimted number of undignosed HIV infections, EU/ EEA nd regions, A. EU/EEA Estimted medin time to dignosis (yers) Est West South North EU/EEA We estimted tht 45% of those living with undignosed HIV in the EU/EEA in 216 hd CD4 cell count of > 5 cells/mm 3, which suggests reltively shorter durtion of infection in this group (Figure 4). Conversely, 33% hd n estimted CD4 cell count of < 35 cells/mm 3, indicting longer durtion of HIV infection. Recency of infection vried by region, with the highest proportion of more recent infections observed in the West (51%) nd the highest proportion of infections of longer durtion in the South (37%). Discussion nd conclusions Our nlysis provides evidence of decline in the number of people living with undignosed HIV during the lst 5 yers in the EU/EEA. This decrese ws more evident in the South nd North regions. This my be ssocited with observed ntionl-level declines in reported HIV notifictions nd newly cquired infections, evidence of more frequent testing nd erlier dignosis in some countries [7-1]. With notifiction rte of 5.9 per 1, popultion nd n estimted incidence of 3.6 per 1,, it ppers tht currently more individuls in the EU/EEA re being dignosed thn re newly infected with HIV. Between 212 nd 216, the yerly dignosed frction (yerly number of new dignoses/(yerly number of new dignoses + estimted number of undignosed people living with HIV)) incresed from 2% to 23% [11]. This suggests tht testing ctivities re gining ground on the hidden epidemic. If our estimtes re ccurte, if incidence does not increse unexpectedly, nd if testing ptterns remin stble or increse, this should result in further reductions in the number of undignosed people living with HIV nd indicte Estimted number of people living with undignosed HIV Estimted number of people living with undignosed HIV 15, 1, 5, 6, 5, 4, 3, 2, 1, B. Regions Est South North West 95% CI CI: confidence intervl; EU/EEA: Europen Union/ Europen Economic Are. progress towrds chieving the globl 22 trget of 9% of people living with HIV in the EU/EEA being dignosed [12]. Currently there is heterogeneity cross regions with regrd to this trget, with fster proportionl declines in the number of people living with undignosed HIV in the South nd North regions. The highest proportions of people living with undignosed HIV re in the countries in the Est region of the EU/ EEA. Despite the welcome nd positive trend in reduced numbers of undignosed infections, we estimted tht it tkes medin of 2.9 yers from infection to dignosis, nd even more thn 3 yers in some regions of the EU/EEA. Shorter time to dignosis is well-correlted with higher CD4 cell count t dignosis in the vrious regions; while the reverse is lso true. It is well documented tht erly HIV dignosis nd rpid linkge to ntiretrovirl tretment for HIV results in lower HIVrelted morbidity nd mortlity for individuls infected [13], nd in reduced HIV trnsmission t popultionlevel [14]. Diversifying nd stremlining HIV testing progrmmes my improve ccess nd uptke. Effective wys of doing this include ugmenting routine testing 3

4 Figure 4 CD4 cell count in people living with undignosed HIV, EU/EEA nd regions, 216 % per CD4 cell count in people living with undignosed HIV EU/EEA West North Est South 5 cells/mm 3 EU/EEA: Europen Union/ Europen Economic Are. <35 cells/mm 3 for helth conditions ssocited with HIV ( indictor condition-guided testing ), incresing HIV testing during screening for other sexully trnsmitted infections, nd continuing to expnd community-bsed testing, self-testing/home-smpling, nd prtner notifiction [15-17]. Our nlysis is subject to severl importnt limittions. First, it is bsed on surveillnce dt nd, while the qulity of EU/EEA surveillnce dt re generlly good nd continue to improve yer-on-yer, some countries do not report CD4 cell count t dignosis. Our ssumption tht the distribution of CD4 cell count ws the sme in these countries s for others in the sme region could hve resulted in less robust estimtes by region. Second, the effect of migrtion on HIV incidence nd the undignosed number is complex nd this ws not ccounted for in this nlysis. Third, there is substntil vrition in epidemic ptterns within the four regions nd overll results for region cnnot be directly pplied to the individul countries within it with confidence. Often estimtes for the region were hevily influenced by the countries with lrger popultion within the region. Still, our exercise points to the diversity of HIV incidence nd in the undignosed popultion cross Europe nd underlines the need for incresed vilbility of robust ntionl estimtes to guide nd evlute testing nd prevention prctice. This nlysis provides evidence tht, lthough ptterns cross Europe re diverse, there ppers to be positive trend towrds lower numbers of people living with undignosed HIV over time. Still, differences cross the EU/EEA persist nd these trends re not seen to the sme extent in ll the four regions nlysed. We found tht substntil number of people re living with undignosed HIV in the EU/EEA, tht 33% of these hve more dvnced HIV infection, nd tht the medin time from infection to dignosis is still nerly 3 yers. Together this indictes tht dditionl efforts re needed to increse the vilbility nd uptke of HIV testing nd rpid linkge to HIV tretment in countries in the EU/EEA. The ECDC HIV/AIDS Surveillnce nd Dublin Declrtion Monitoring Networks ECDC HIV/AIDS Surveillnce nd Dublin Declrtion Monitoring Networks include: Austri: Dniel Schmid, Irene Rueckerl, Robert Zngerle; Belgium: Andre Ssse, Dominique Vn Beckhoven, Frédéric Denuw; Bulgri: Tonk Vrlev, Vyr Georgiev; Croti: Ttjn Nemeth Blzic, Jsmin Pvlic, Josip Begovc; Cyprus: Mri Koliou, Linos Hdjihnns, Ann Demetriou; Czech Republic: Mrek Mly, Vrtislv Němeček, Veronik Šikolová; Denmrk: Susn Cown, Jn Fouchrd; Estoni: Kristi Rüütel, Ann- Liis Pääsukene; Finlnd: Kirsi Liitsol, Mik Slminen, Henrikki Brummer- Korvenkontio; Frnce: Frnçoise Czein, Josine Pillonel, Florence Lot, Jen- Christophe Comboroure; Germny: Brbr Gunsenheimer-Brtmeyer, Mtthis n der Heiden, Ges Kupfer, Ulrich Mrcus; Greece: Vsilios Rftopoulos, Stvros Ptrinos, Vsilei Konte; Hungry: Mri Duds, Ktlin Szly; Icelnd: Hrldur Briem, Gudrun Sigmundsdottir; Irelnd: Dervl Igoe, Kte O Donnell, Croline Hurley, Fion Lyons; Itly: Brbr Suligoi, Ann Crgli; Ltvi: Šrlote Konov; Liechtenstein: Sbine Erne; Lithuni: Irm Čplinskienė; Luxembourg: Aurelie Fischer, Ptrick Hoffmnn; Mlt: Jckie Mistre Melillo, Tny Melillo; Netherlnds: Eline Op de Coul, Silke Dvid; Norwy: Hns Blystd, Arild John Myrberg; Polnd: Mgdlen Rosinsk, Iwon Wwer; Portugl: Isbel Aldir, Helen Cortes Mrtins, Teres Melo; Romni: Mrin Mrdrescu; Slovki: Peter Trusk, Jn Miks; Sloveni: Iren Klvs; Spin: Asuncion Diz, Olivier Nuñez, Olivi Cstillo; Sweden: Mri Axelsson, Anders Sönnerborg; United Kingdom: Peter Kirwn, Cuong Chu, Sndr Okl, Alison Brown, Vlerie Delpech. Acknowledgements We would like to thnk Annemrie Stengrd from the WHO Regionl Office for Europe; nd ECDC collegues, nmely Vlentin Lzdin, Phillip Zucs, Denis Coulombier, nd Mike Ctchpole. Conflict of interest None declred. Authors contributions The ECDC HIV/AIDS Surveillnce nd Dublin Declrtion networks supplied the dt nd provided comments on the mnuscript. All co-uthors developed the concept of the mnuscript. AvS crried out the modelling nlysis. AP wrote the first drft. AP nd AvS responded to reviewers comments. All uthors hve red nd pproved the finl mnuscript. References 4

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