France on its way to drastically reduce new HIV infections

Drastic decreases in the time it takes people to move through the HIV cascade of care in France are reported in Clinical Infectious Diseases. Median time from diagnosis to viral control has been reduced from around eight months to two months, thus shortening the period during which people can pass the virus to others.

The HIV cascade of care refers to the stepwise progression of people with HIV through their care pathway, from HIV diagnosis to viral suppression. Key steps in the cascade are measured in the UNAIDS 95-95-95 targets.

Dr Lise Cuzin from the University of Martinique and colleagues from other French centres wanted to describe the median time from HIV diagnosis to controlled viral load, as well as median times between each step of the HIV cascade of care in 2009-2019. To better understand the results, the study was conducted against the background of changes in healthcare such as the recommendation to treat anyone with HIV, regardless of CD4 cell counts in 2013, and second-generation integrase inhibitors being made available in 2014.

For this research, the investigators used the Dat’AIDS study: an ongoing prospective cohort that includes around half the people receiving HIV care in France. People with HIV starting care at infectious disease clinics in French public hospitals (where the large majority of people with HIV in France are followed) were included in the analysis.

The following cascade transition steps were assessed:

• Linkage to care: time from HIV diagnosis (usually done outside infectious disease clinics) to the first CD4 cell count or viral load measurement (usually done in clinics).
• Time from linkage to care to the first antiretroviral prescription.
• Time to controlled viral load: from the first antiretroviral prescription to the first viral load result below 200 copies.

The total time from HIV diagnosis to viral load control was also analysed. However, the study did not assess time from HIV acquisition to diagnosis, which can only be estimated, since dates of infection are not usually known.

Results

Twenty-nine clinics in France and two of its overseas territories contributed to the study. Data from 16,864 patients, registered soon after diagnosis and at the time of linkage to care, were analysed.

Overall, patients were predominantly men (72%). Among those recently diagnosed and linked to care, the proportion who were gay and bisexual men born in France decreased significantly to 30% in 2018-2019, from around 35% in the previous three periods, which could reflect the positive impact of U=U and PrEP. Meanwhile, the proportion of gay and bisexual men born abroad doubled from 6% in 2009-2011 to 13% in 2018-2019, probably showing an increasing uptake of HIV testing, but also hinting at a low uptake of PrEP, in these communities.

The proportion of women in the cohort increased from 27% in 2009-2011 to 30% in 2018-2019, while that of people born abroad decreased from 58% to 47% within the same periods.

Turning to the cascade of care, the investigators found that:

• 15,110 people (90% of those linked-to-care) started antiretrovirals.
• 14,392 people (95% of those treated, 85% of those linked-to-care) achieved viral control.
• 11,970 people (83% of those virally controlled, 79% of those treated, and 71% of those linked to care) still had viral control one year later.

Among the 16,864 study participants, the median time from HIV diagnosis to controlled viral load drastically decreased from 254 days [interquartile range 127-745] in 2009-2011 to 73 days [48-132] in 2018-2019.

Transition from HIV diagnosis to linkage to care was made in a median time of 13 days [3-42] in 2009-2011, then decreasing by more than half to six days [0-14] in 2018-2019. By 2018-2019, a quarter of people were linked to care on the day they were diagnosed.  

From linkage to care to antiretroviral prescription, the transition was made in a median of 67 days [17-414] in 2009-2011, reducing to 13 days [5-26] in 2018-2019. By 2018-2019, 15% of people had their first antiretroviral prescriptions on the day of linkage to care.

Median time from antiretroviral prescription to controlled viral load decreased from 83 days [35-130] in 2009-2011, to 38 days [28-90] in 2018-2019. This latter finding probably reflects, in part, the increasing use of more potent integrase inhibitors: 63% in 2018-2019, compared to 8% in 2009-2011.

Based on U=U and on previous studies, the major reductions in time from HIV diagnosis to controlled viral load in people with HIV will most likely reduce HIV transmission in the country. According to Cuzin and colleagues, these outcomes were made possible in a country with unrestricted access to care and policy makers who follow scientific evidence. However, they also highlight how important it is to develop better HIV testing strategies, improve knowledge on the benefits of rapid access to HIV treatment and offer better support for underserved populations, in order to confront the challenge of delayed HIV diagnosis.

Also, Cuzin and colleagues call for universal access to healthcare to be maintained in France at a time when some political leaders are pushing for more restrictive policies toward migrants. “Advocating for human rights for migrants and a full inclusion of LGBTQI+ minorities is the most crucial issue,” they say.