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Toward Zero Infections
Progress (or Not) Toward Zero Infections in 2030: My Take From EACS

Released: November 22, 2021

Expiration: November 21, 2022

Tristan J. Barber
Tristan J. Barber, MA, MD, FRCP
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Engagement in Care and Virologic Suppression Is Lacking in Europe
Engagement in care resulting in improved rates of virologic suppression was a key theme at the 2021 European AIDS Conference meeting, which took place both virtually and in person in London, United Kingdom. The need for improvement in rates of virologic suppression among persons with HIV was demonstrated by Teymur Noori from the European Centre for Disease Prevention and Control in a plenary session. He described the number of those in the European region who currently have transmissible virus (ie, unsuppressed viral replication). In this region, approximately 36% of those with HIV have unsuppressed virus; this represents a clear obstruction to any path to the UNAIDS goal of zero new infections by 2030. In addition to inadequate testing coverage, it also was noted that in many countries—even within Europe—there is no access to antiretroviral therapy for undocumented migrants.

Several other posters focused on engagement in care and treatment cascades in different parts of the world. For example, Valerie Delpech presented data showing that among 87,410 adults seen for care in the United Kingdom in 2018, 11,655 (13.3%) were nonregular attendees at a clinic. In total, 6.9% of these nonregular attendees had HIV-1 RNA >200 copies/mL within the previous 12 months of their last attendance, compared with 3.8% of those with regular attendance. The concern is that these nonregular attendees have the potential to affect onward transmissions and sustain the rate of new diagnoses.

Elizabeth Hamlyn presented data from London looking at 2 large clinics to try to establish the true number of those lost to follow-up among those marked as not attending for routine care. When the clinic loses contact with patients, it is not known whether they are in care elsewhere or have disengaged from care. In total, 665 registered patients across both sites had not attended for >12 months. Using a cross-referencing system via national public health databases, it was shown that 417 (63%) of these 665 people with HIV were not currently accessing HIV care elsewhere in the United Kingdom. Another 39 patients could not be matched in the database, and only 209 of the 665 patients were identified as attending another HIV service in the United Kingdom. Therefore, most patients not seen for more than 1 year were confirmed as truly lost to follow-up and therefore deemed at risk, both of development of AIDS and onward transmission.

Mental Health Issues in Persons With HIV May Translate to Decreased Engagement in Care
In southern Europe, Dimitra Tsakona presented data on the cascade of care in Greece, where they have begun to incorporate frailty and quality-of-life measures as part of their assessments. Data were presented on 477 people with HIV attending a clinic at 6 different sites. The mean age was 44 years (standard deviation: 11.2) and 84% were men. Although most were virologically suppressed, the authors concluded their quality of life remained an issue. The presence of ≥1 frailty measure in almost one third of virally suppressed people with HIV with a good quality-of-life score was identified, and it was noted that the prevalence of anxiety and depression requires attention. These factors may ultimately have an impact on the overall treatment cascade.

Finally, Daniel Simões presented data on mental health and access to mental health services for people with HIV in the WHO European Region. An exploratory, online cross-sectional survey was conducted and made available in 7 languages. In total, 646 people with HIV responded, and 389 were from European Union/European Economic Area (EU/EEA) countries. Although 55% of the sample self-reported symptoms or a diagnosis of a mental health condition after their HIV diagnosis, less than one third (31.7% EU/EEA or 23.2% non-EU/EEA) reported having received treatment for these conditions. Some 30.9% of respondents reported “somewhat good” mental health status and 37.8% reported “average” mental health status, but more than 50% of respondents self-reported multiple symptoms commonly associated with depression. Particularly concerning were the 42.7% EU/EEA or 52.4% non-EU/EEA respondents reporting suicidal ideation or self-harm at some point in their lives. More than 50% of respondents reported HIV had a negative impact on their self-image, their ability to engage in social relationships, and their sex life. More than 50% also reported that HIV stigma had a negative impact on their mental health. COVID-19 had an additional negative impact. These results show a very high burden of mental health issues among people with HIV in all of Europe, alongside low levels of access to support services. This may affect the ability of people with HIV to engage in care and to maintain adherence to antiretroviral therapy.

Call to Action
We must act now for wider HIV testing and to ensure that all those with HIV have access to antiretroviral therapy, as well as being supported in care for both their physical and mental health. Without these, the number of people with HIV who have unsuppressed virus will continue to translate to onward transmissions, and the goal of eliminating HIV transmission by 2030 may remain just out of reach.

Your Thoughts?
Is your clinic having trouble with loss to follow-up? How are you managing that? Share your ideas in the comments below.

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Approximately what percentage of the patients in your clinic on ART are virologically suppressed?
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