Expanding antiretroviral treatment to cover all people with HIV and reaching the second and third of the UNAIDS 90-90-90 targets have resulted in big falls in the proportion of people in France diagnosed with primary or recent HIV infection, investigators report in Clinical Infectious Diseases. Between 2013 and 2017, the proportion of newly diagnosed people entering care with primary HIV infection fell by a third, and over the same period, there was a 25% reduction in the proportion with either primary or recent HIV infection.
This is the latest of a number of studies to show that a test and treat strategy and attainment of the 90-90-90 targets leads to major reductions in the rate of new HIV infections. In 2014, UNAIDS adopted the 90-90-90 targets for 2020 – 90% of people with HIV diagnosed; 90% of diagnosed individuals on antiretroviral therapy; 90% of those on antiretrovirals virally suppressed. It was projected that attainment of these targets would achieve substantial reductions in onward HIV transmissions and HIV-related deaths. In 2016, the more ambitious goal of 95-95-95 was set to “end AIDS” by 2030.
In 2013, France became one of the first countries to recommend universal antiretroviral treatment for people with HIV, regardless of CD4 cell count.
Adrien Le Guillou and colleagues wanted to determine the impact of this policy change and the attainment of two of the UNAIDS targets on the epidemiology of new HIV infections in France.
They therefore designed a study tracking the rate of primary and recent HIV infections between 2007 and 2017. Their evidence came from 23 treatment centres involved in the Dat’AIDS cohort study. During the study period, these centres provided care to approximately 62,000 people with HIV – about half of all HIV cases in France.
Individuals diagnosed with symptoms of HIV seroconversion were defined as having primary HIV infection. All individuals with a CD4 cell count of 500 or above were classified as having recent HIV infection.
A total of 20,263 individuals entered the cohort over the study period. Of these, 10% had primary HIV infection, with 36% having primary and/or recent infection.
Over the ten years of the study, the proportion of individuals in the cohort treated with antiretrovirals increased from 74% to 97%. The 90% treatment goal was met in 2014. The percentage of the overall cohort with viral suppression increased from 59% to 91%. The UNAIDS target of a 90% suppression rate among individuals on therapy was achieved in 2013.
By 2017, 88% of individuals were starting antiretroviral treatment with three months of diagnosis with HIV and 58% within one month.
The proportion of individuals entering the cohort with primary or primary/recent HIV infection started falling in July 2012 and January 2013 respectively.
Analysis of the period after 2013, when universal antiretroviral therapy regardless of CD4 cell count was introduced in France, showed that the proportion of individuals taking antiretroviral therapy increased from 90% to 97%. There was a corresponding increase in the proportion of treated people with viral suppression, which rose from 81% to 91%.
The annual number of primary infections fell from 228 in 2013 to 148 in 2017, a 35% decrease, with the number of primary/recent infections falling from 747 to 557, a 25% reduction.
These decreases were seen both in men who have sex with men and in heterosexual men and women.
By 2017, 88% of individuals were starting antiretroviral treatment with three months of diagnosis
“The achievement of the second and third UN targets and the ‘test and treat’ strategy coincided with a dramatic and regular decrease in the numbers of primary HIV infection and primary/recent infection,” comment the authors.
The investigators are confident that the declines in primary and recent infections are due to increases in the proportion of individuals on treatment and virally suppressed, rather than use of pre-exposure prophylaxis (PrEP). This is because, as of 2017, only 6000 people in France were taking PrEP.
“Future epidemiological studies are needed to evaluate the achievement and the impact of the new UNAIDS targets [95-95-95 by 2030], as well as the impact of expanded PrEP use as part of combination prevention strategies to achieve further reductions in the incidence of HIV infection,” they say.
Le Guillou A et al. Reaching the second and third UNAIDS 90-90-90 targets is accompanied by a dramatic reduction in primary HIV infection and in recent HIV infections in a large French nationwide HIV cohort. Clin Infect Dis, online edition: ciz800, https://doi.org/10.1093/cid/ciz800, 2019.