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Mind the Gaps Undiagnosed HIV, lost-to-follow up and undertreated HIV in Australia

Mind the Gaps Undiagnosed HIV, lost-to-follow up and undertreated HIV in Australia. Mark Stoov è Centre for Population Health, Burnet Institute Department of Epidemiology and Preventive Medicine, Monash University. Overview. . What are the gaps in data? Undiagnosed HIV in Aust

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Mind the Gaps Undiagnosed HIV, lost-to-follow up and undertreated HIV in Australia

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  1. Mind the Gaps Undiagnosed HIV, lost-to-follow up and undertreated HIV in Australia Mark StoovèCentre for Population Health, Burnet Institute Department of Epidemiology and Preventive Medicine, Monash University

  2. Overview  • What are the gaps in data? • Undiagnosed HIV in Aust • HIV testing patterns Test and treat – HIV treatment as prevention? • What do we know? • HIV testing patterns in MSM in Aust • Barriers to testing • Undiagnosed HIV internationally & Aust • Implications for HIV epidemiology • What could be proposed to address data gaps & improve service access & delivery? • National study of unrecognised infection • National HIV testing policy • Community-based and POCTs

  3. ‘Test and treat’ – HIV treatment as prevention • Emerging as a key HIV prevention strategy globally •  testing,  detection, maximise # on treatment • ART  viral replication/viral load,  P(HIV transmission) • Observational 1,2 & ecological evidence3 • Prompted calls for mass voluntary testing & expanded treatment4 • Challenge • Increase proportion ever tested • Increase frequency of testing – particularly in high-risk 1. Yirrell et al. Epidemiology & Infection 2004,132:693-698. 2. Chadborn et al.AIDS 2005,19:513-520. 3. Murphy et al.Communicable Disease & Public Health 2001,4:33-37 4. Granich et al.Lancet 2009,373:48-57

  4. What do we know – HIV testing patterns Men reporting lifetime HIV testing, Sydney GCPS • Increase proportion ever tested

  5. What do we know – HIV testing patterns Time since last HIV test, Sydney GCPS • Increase frequency of testing – particularly in high-risk

  6. What do we know – HIV testing patterns From VPCNSS:5 • Of the MSM requiring annual HIV testing, re-testing rates at 1y were 35% • Among higher risk MSM, 6-monthly HIV re-testing rates were 15% • Limited data available Is this frequent enough & reliability of self-report? 5. Guy et al., Sex Transm Infect, 2010.

  7. What do we know – barriers to testing Reasons for not testing/barriers among those never tested:6 • believing they were low risk (60.7%) • did not know where to get tested (41.9%) • appointments; not wanting to be seen at a sexual health centre;difficulties finding gay-friendly GP;stigma; trust/ doctors’ confidentiality; not bulk billing/testing costs; preferring not to know their HIV status 6. Prestage, et al., Pleasure and Sexual Health: The PASH Study. 2009, NCHECR.

  8. What do we know – barriers to testing Barriers to testing:6 • returning for test results and convenience • not having an illness or symptoms • not having changed partners • fear of diagnosis and letting other people know. Indicated more frequent testing if current testing policies changed to allow rapid testing or outreach testing made more available. Predictors of recent HIV testing (GCPS):7 • younger age • gay-identifying and gay community-attached • UAI,  sexual partners, sexual partner is HIV-positive 6. Prestage, et al., Pleasure and Sexual Health: The PASH Study. 2009, NCHECR 7.Jin et al., HIV Med, 2002. 3(4): p. 271-6

  9. What do we know – undiagnosed infection internationally Williamson (2008)5 • 5 UK cities, 2003-2005, 3501 venue-recruited MSM • 318/3501 (9.1%) HIV positive • 131/318 (41.2%) self-reported negative/unsure (undiagnosed infection) • Compared to HIV neg men, undiagnosed reported greater risk of UAIC (OR = 2.2; 95%CI = 1.17–4.20) Dodd et al (2004)6 • 5 UK cities, 2000, 1206 venue-recruited MSM • 132/1206 (10.9%) HIV positive • 43/132 (32.5%) self-reported negative/unsure (undiagnosed infection) 5. Williamson et al., AIDS, 2008, 22, 1063–70. 6. Dodds et al., Sex Transm Infect 2004;80:236-240

  10. What do we know – undiagnosed infection internationally Campsmith et al (2008)7 • Prevalence/% undiagnosed estimated for 2006 from cumulative incidence • 1,106,400 PLWHA – 21.0% undiagnosed • 532,000 MSM PLWHA, 23.5% undiagnosed 7. Campsmith et al., Epidemiology & Social Science, 2010, 53, 619–24.

  11. What do we know – undiagnosed infection in Australia Two bio-behavioural studies [1] Birrell et al., 2010: • Brisbane/Toowoomba, 2007 • 465 MSM, recruited from gay bars/clubs & SOPVs, survey plus oral fluid • 33/465 (7.1%) self-reported HIV positive • 41/465 (8.8%) tested HIV positive • 8/41 (19.5%) undiagnosed HIV • All reported history of HIV testing • 7 reported last HIV test < six months 5. Birrell et al., Sexual Health, 2010, 7, 11–16.

  12. What do we know – undiagnosed infection in Australia Two bio-behavioural studies [2] Pedrana et al., 2009: • Melbourne, 2008 • 765 MSM (including high caseload clinics), 639 recruited from gay bars/clubs & SOPVs, survey plus oral fluid • 42/639 (6.6%) self-reported HIV positive • 61/639 (9.5%; 95%CI 7.4-12.1) tested HIV positive • 19/61 (31.1%; 95%CI 19.9-44.3) undiagnosed HIV • 6/19 (31.6%) reported never tested • 7/19 (36.8%) reported last HIV test < 12 months 8. Pedrana et al., online: http://www.burnet.edu.au/home/cph/current/suckit/results

  13. What do we know – undiagnosed infection in Australia Two bio-behavioural studies [2] Pedrana et al., 2009: • Planned NHMRC application for National study (NCHSR/Burnet) 8. Pedrana et al., online: http://www.burnet.edu.au/home/cph/current/suckit/results

  14. What do we know – implications for HIV epidemiology State of play in 2006:9 • Estimated 19,500 HIV infections among MSM, 13% undiagnosed • HIV prevalence among MSM ~10.5% • 19% of HIV infections were transmitted from the estimated 3% of MSM with PHI • 31% of new infections transmitted by the 10-13% of undiagnosed MSM Projections: “Various interventions could change epidemic trajectories. Projections ... most sensitive to changes in assumptions regarding rates of STIs & rates of condom use ... increasing HIV testing and ART during primary HIV infection would have some effect, albeit more modest, on decreasing future HIV incidence.” 9. Wilson et al., Mathematical models to investigate recent trends in HIV notifications among men who have sex with men in Australia, 2008, NCHECR

  15. Improving service access & delivery – Current HIV Testing Policy Directed by the National HIV Testing Policy10, governed by the DoHA. Outlines 6 guiding principles for testing: • Confidential, voluntary informed testing fundamental to HIV/AIDS response; • Testing is of the highest possible standard; • Testing is of benefit to the person being tested; • Testing accessible to all those at risk of HIV infection; • Testing critical to understanding epidemiology of HIV; • testing is critical to interruption of transmission. 10. DoHA 2006 National HIV Testing Policy, 2006: Canberra.

  16. Improving service access & delivery – Current HIV Testing Policy • Debate regarding the provision of rapid testing in community settings • Some advocating a review of the current HIV testing policy to a support rapid tests for point-of-care screening in both clinical and community based settings11-14. 11. Chen et al. Sexual Health, 2009. 6(1): p. 1-3. 12. Keen et al. Policy briefing paper on Rapid HIV Testing. 2010, AFAO: Sydney. 13. Fairley. Australasian HIV/AIDS Conference. 2010, ASHM: Sydney. 14. Keen, P., HIV/AIDS Conference. 2010, ASHM: Sydney.

  17. Systematic review - community-based HIV testing services for MSM • 33 papers, 44 services – 27/44 US, 12/44 Europe • 11/44 exclusively servicing MSM • Testing outcomes: • median proportion never tested for HIV = 17.7% (range:5.0-34.7%) • median HIV positivity = 3.9% (range:0.0-60.0%) • median return rate confirmatory testing = 79.5% (range:22.7-100%) • higher in community-based organisation services (81.1%) and lower in outreach models (44%). • Other outcomes reported: • Service operations (staffing, hours etc), clinical governance, training, promotion, testing protocols/referral pathways, counselling/ communicating results, performance of rapid tests acceptability, cost effectiveness

  18. Summary • Self-reported HIV testing rates high: • Sufficiently high (frequency)? • Reliability? • More data needed • Barriers to testing – perceived risk, structural impediments of current testing environments, gay community attachment • International and local data suggests meaningful proportion of undiagnosed HIV • More data needed, greater #s, geographic etc diversity • Modelling suggests disproportionate contribution to HIV incidence (undiagnosed and PHI) • Modifying and current testing policy and refining models of testing (POCT, outreach, referral etc). * Acknowledgements Alisa Pedrana, Rebecca Guy

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