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HIV Drug Therapy: Australia Performs Best in HIV Treatment Cascade -- 62% Undetectable Viral Load

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Australia and northern European countries are doing far better than North America at retaining people living with HIV in care and achieving viral suppression, according to a comprehensive survey of treatment cascades in high-income countries presented this week at the International Congress on Drug Therapy in HIV Infection in Glasgow.

[Produced in collaboration with Aidsmap.com]

However, even in the best-performing countries, viral suppression falls short of the aspirational target recently set by UNAIDS, and the survey identified country-specific weaknesses in performance. In the U.K., diagnosis of HIV infection is the major weakness preventing higher rates of viral suppression in the population living with HIV, whereas linkage to care emerged as the primary weakness in the U.S.

People taking HIV therapy who have an undetectable viral load have a low risk of disease progression and onward HIV transmission. However, a large number of individuals are not benefiting from antiretroviral treatment because they are not engaged with the so-called "treatment cascade." This has 5 stages: diagnosis, linkage to care, retention in care, initiation of HIV therapy, adherence to therapy, and achievement of an undetectable viral load.

UNAIDS has recently proposed a 90/90/90 target in order to reduce transmission and obtain the maximum benefit from antiretroviral therapy (ART). The target calls for 90% of people living with HIV to be diagnosed, for 90% of those diagnosed to be linked to care and taking antiretroviral treatment, and for 90% of people taking antiretroviral therapy to have undetectable viral load. If this target could be achieved, around three-quarters of all people living with HIV would have suppressed viral load (73%).

In order to judge the gap between reality and the new target, investigators from the U.K. sought to establish the proportion of patients with HIV who were retained at each stage of the cascade in 8 high-income countries: U.S., U.K., France, Denmark, the Netherlands, Australia, and Canada (British Columbia). Key points where a break in the cascade -- a fall-off of 19% compared to the previous stage -- were identified. Break points indicate areas where national treatment programs are under-performing.

Data sources included national and UNAIDS surveillance reports, articles in peer reviewed journals, and conference presentations.

The proportion of all HIV positive patients with an undetectable viral load ranged from 62% in Australia to a low of just 25% in the U.S. In Denmark, the U.K., the Netherlands, and France, over 50% of patients had undetectable viral load (59%, 58%, 53%, and 52%, respectively). In British Columbia, just over one- third (35%) of all patients had undetectable viral load.

 

Living with HIV

Diagnosed

Linked to care

In care

On ART

Adherent

<50

Australia

27,674

86%

78%

76%

66%

 N/A

62%

Denmark

6,500

85%

81%

75%

62%

 N/A

59%

U.K.

98,400

N/A

79%

70%

67%

 N/A

58%

Netherlands

25,000

N/A

73%

68%

59%

 N/A

53%

France

149,000

81%

N/A

74%

 

60%

52%

British Columbia

72,000

71%

67%

57%

51%

44%

35%

U.S.

1,148,000

82%

66%

37%

33%

 N/A

25%

Note: discrepancies in data provided indicate differences in national surveillance criteria.

Remarkably, a higher proportion of patients in sub-Saharan African countries were shown to have undetectable viral load than patients in the U.S. (29% vs. 25%).

Every country -- even those with the best outcomes -- had attrition at each stage of the treatment cascade. For instance, in Australia, 86% of patients were diagnosed, 78% were linked to care, 76% were retained in care, 66% were on HIV therapy, and 62% had undetectable viral load.

Important breaks in the cascade were identified in several countries. In the U.K. and the Netherlands, this was the high number of people (21%-27%) not linked to care. For France and Canada, the break point was undiagnosed infections (19%-29%). In the U.S., there was a big gap between the proportion of patients linked to care (66%) and the percentage retained in care (37%).

The investigators believe the different break points in the cascade are due to underlying inequalities in HIV care between countries.

11/6/14

Reference

A Raymond, A Hill, and A Pozniak. Large disparities in HIV treatment cascades between eight European and high-income countries: analysis of break points. International Congress of Drug Therapy in HIV Infection. Glasgow, November 2-6, 2014. Abstract O237.