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The undiagnosed HIV epidemic in France and its implications for HIV screening strategies.

ABSTRACT: Describing the undiagnosed HIV-infected population is essential for guiding HIV screening policy, implementing interventions, and resource planning.We used French national HIV surveillance data and a back-calculation approach to estimate the number of undiagnosed HIV-infected individuals in France and the distribution of time since HIV infection among undiagnosed individuals. We also used data on CD4? cell count decline to assess the CD4? cell count distribution among undiagnosed individuals.We estimated that 29,000 [95% confidence interval (CI): 24,200-33,900] individuals were living with undiagnosed HIV infection at the end of 2010. Of these, 28.7% (95% CI: 27.1-30.4) were infected less than a year ago, 16.4% (95% CI: 15.0-17.8) more than 5 years ago, and 59.6% (95% CI: 59.2-59.8) were eligible for antiretroviral treatment (CD4? cell count less than 500 cells/?l) according to the 2010 French guidelines. Men represented 70.0% of the undiagnosed HIV-infected individuals and had lower CD4? cell counts than women. The numbers of undiagnosed infections in MSM, non-French national heterosexuals, and French national heterosexuals were similar (9200, 9300, 10,000, respectively). However, because of differences in group size, undiagnosed HIV prevalence varied significantly between these groups (2.95, 0.36, 0.03%, respectively; P less than 0.001).Our findings suggest that many undiagnosed HIV-infected individuals were eligible for treatment and, thus, lack of HIV diagnosis is a lost chance for them; many more heterosexuals than MSM will need to be tested to find those undiagnosed; and universal screening of men may be cost-effective, especially in the areas most affected by the epidemic, such as the Paris region.

SUBMITTER: Supervie V

PROVIDER: S-EPMC4262966 | biostudies-literature | 2014 Jul

REPOSITORIES: biostudies-literature

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The undiagnosed HIV epidemic in France and its implications for HIV screening strategies.

Supervie Virginie V Ndawinz Jacques D A JD Lodi Sara S Costagliola Dominique D

AIDS (London, England) 20140701 12

<h4>Background</h4>Describing the undiagnosed HIV-infected population is essential for guiding HIV screening policy, implementing interventions, and resource planning.<h4>Methods</h4>We used French national HIV surveillance data and a back-calculation approach to estimate the number of undiagnosed HIV-infected individuals in France and the distribution of time since HIV infection among undiagnosed individuals. We also used data on CD4⁺ cell count decline to assess the CD4⁺ cell count distributio ...[more]

PMID: 24681416

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Project description:BackgroundMore than half of the global population is under strict forms of social distancing. Estimating the expected impact of lockdown and exit strategies is critical to inform decision makers on the management of the COVID-19 health crisis.MethodsWe use a stochastic age-structured transmission model integrating data on age profile and social contacts in Île-de-France to (i) assess the epidemic in the region, (ii) evaluate the impact of lockdown, and (iii) propose possible exit strategies and estimate their effectiveness. The model is calibrated to hospital admission data before lockdown. Interventions are modeled by reconstructing the associated changes in the contact matrices and informed by mobility reductions during lockdown evaluated from mobile phone data. Different types and durations of social distancing are simulated, including progressive and targeted strategies, with large-scale testing.ResultsWe estimate the reproductive number at 3.18 [3.09, 3.24] (95% confidence interval) prior to lockdown and at 0.68 [0.66, 0.69] during lockdown, thanks to an 81% reduction of the average number of contacts. Model predictions capture the disease dynamics during lockdown, showing the epidemic curve reaching ICU system capacity, largely strengthened during the emergency, and slowly decreasing. Results suggest that physical contacts outside households were largely avoided during lockdown. Lifting the lockdown with no exit strategy would lead to a second wave overwhelming the healthcare system, if conditions return to normal. Extensive case finding and isolation are required for social distancing strategies to gradually relax lockdown constraints.ConclusionsAs France experiences the first wave of COVID-19 pandemic in lockdown, intensive forms of social distancing are required in the upcoming months due to the currently low population immunity. Extensive case finding and isolation would allow the partial release of the socio-economic pressure caused by extreme measures, while avoiding healthcare demand exceeding capacity. Response planning needs to urgently prioritize the logistics and capacity for these interventions.

Project description:BackgroundIn France, roughly 40,000 HIV-infected persons are unaware of their HIV infection. Although previous studies have evaluated the cost-effectiveness of routine HIV screening in the United States, differences in both the epidemiology of infection and HIV testing behaviors warrant a setting-specific analysis for France.Methods/principal findingsWe estimated the life expectancy (LE), cost and cost-effectiveness of alternative HIV screening strategies in the French general population and high-risk sub-populations using a computer model of HIV detection and treatment, coupled with French national clinical and economic data. We compared risk-factor-based HIV testing ("current practice") to universal routine, voluntary HIV screening in adults aged 18-69. Screening frequencies ranged from once to annually. Input data included mean age (42 years), undiagnosed HIV prevalence (0.10%), annual HIV incidence (0.01%), test acceptance (79%), linkage to care (75%) and cost/test (€43). We performed sensitivity analyses on HIV prevalence and incidence, cost estimates, and the transmission benefits of ART. "Current practice" produced LEs of 242.82 quality-adjusted life months (QALM) among HIV-infected persons and 268.77 QALM in the general population. Adding a one-time HIV screen increased LE by 0.01 QALM in the general population and increased costs by €50/person, for a cost-effectiveness ratio (CER) of €57,400 per quality-adjusted life year (QALY). More frequent screening in the general population increased survival, costs and CERs. Among injection drug users (prevalence 6.17%; incidence 0.17%/year) and in French Guyana (prevalence 0.41%; incidence 0.35%/year), annual screening compared to every five years produced CERs of €51,200 and €46,500/QALY.Conclusions/significanceOne-time routine HIV screening in France improves survival compared to "current practice" and compares favorably to other screening interventions recommended in Western Europe. In higher-risk groups, more frequent screening is economically justifiable.

Project description:IntroductionTo close gaps in HIV prevention and care, knowledge about locations and populations most affected by HIV is essential. Here, we provide subnational and sub-population estimates of three key HIV epidemiological indicators, which have been unavailable for most settings.MethodsWe used surveillance data on newly diagnosed HIV cases from 2004 to 2014 and back-calculation modelling to estimate in France, at national and subnational levels, by exposure group and country of birth: the numbers of new HIV infections, the times to diagnosis, the numbers of undiagnosed HIV infections. The denominators used for rate calculations at national and subnational levels were based on population size (aged 18 to 64) estimates produced by the French National Institute of Statistics and Economic Studies and the latest national surveys on sexual behaviour and drug use.ResultsWe estimated that, in 2014, national HIV incidence was 0.17‰ (95% confidence intervals (CI): 0.16 to 0.18) or 6607 (95% CI: 6057 to 7196) adults, undiagnosed HIV prevalence was 0.64‰ (95% CI: 0.57 to 0.70) or 24,197 (95% CI: 22,296 to 25,944) adults and median time to diagnosis over the 2011 to 2014 period was 3.3 years (interquartile range: 1.2 to 5.7). Three mainland regions, including the Paris region, out of the 27 French regions accounted for 56% of the total number of new and undiagnosed infections. Incidence and undiagnosed prevalence rates were 2- to 10-fold higher than the national rates in three overseas regions and in the Paris region (p-values < 0.001). Rates of incidence and undiagnosed prevalence were higher than the national rates for the following populations (p-values < 0.001): born-abroad men who have sex with men (MSM) (respectively, 108- and 78-fold), French-born MSM (62- and 44-fold), born-abroad persons who inject drugs (14- and 18-fold), sub-Saharan African-born heterosexuals (women 15- and 15-fold, men 11- and 13-fold). Importantly, affected populations varied from one region to another, and in regions apparently less impacted by HIV, some populations could be as impacted as those living in most impacted regions.ConclusionsIn France, some regions and populations have been most impacted by HIV. Subnational and sub-population estimates of key indicators are not only essential to adapt, design implement and evaluate tailored HIV interventions in France, but also elsewhere where similar heterogeneity is likely to exist.

Project description:BackgroundA target to eliminate HIV transmission in England by 2030 was set in early 2019. This study aimed to estimate trends from 2013 to 2019 in HIV prevalence, particularly the number of people living with undiagnosed HIV, by exposure group, ethnicity, gender, age group, and region. These estimates are essential to monitor progress towards elimination.MethodsA Bayesian synthesis of evidence from multiple surveillance, demographic, and survey datasets relevant to HIV in England was used to estimate trends in the number of people living with HIV, the proportion of people unaware of their HIV infection, and the corresponding prevalence of undiagnosed HIV. All estimates were stratified by exposure group, ethnicity, gender, age group (15-34, 35-44, 45-59, or 60-74 years), region (London, or outside of London) and year (2013-19).FindingsThe total number of people living with HIV aged 15-74 years in England increased from 83 500 (95% credible interval 80 200-89 600) in 2013 to 92 800 (91 000-95 600) in 2019. The proportion diagnosed steadily increased from 86% (80-90%) to 94% (91-95%) during the same time period, corresponding to a halving in the number of undiagnosed infections from 11 600 (8300-17 700) to 5900 (4400-8700) and in undiagnosed prevalence from 0·29 (0·21-0·44) to 0·14 (0·11-0·21) per 1000 population. Similar steep declines were estimated in all subgroups of gay, bisexual, and other men who have sex with men and in most subgroups of Black African heterosexuals. The pace of reduction was less pronounced for heterosexuals in other ethnic groups and people who inject drugs, particularly outside London; however, undiagnosed prevalence in these groups has remained very low.InterpretationThe UNAIDS target of diagnosing 90% of people living with HIV by 2020 was reached by 2016 in England, with the country on track to achieve the new target of 95% diagnosed by 2025. Reductions in transmission and undiagnosed prevalence have corresponded to large scale-up of testing in key populations and early diagnosis and treatment. Additional and intensified prevention measures are required to eliminate transmission of HIV among the communities that have experienced slower declines than other subgroups, despite having very low prevalences of HIV.FundingUK Medical Research Council and Public Health England.

Project description:BackgroundOfficial descriptive data from France showed a strong increase in breast-cancer incidence between 1980 to 2005 without a corresponding change in breast-cancer mortality. This study quantifies the part of incidence increase due to secular changes in risk factor exposure and in overdiagnosis due to organised or opportunistic screening. Overdiagnosis was defined as non progressive tumours diagnosed as cancer at histology or progressive cancer that would remain asymptomatic until time of death for another cause.MethodsComparison between age-matched cohorts from 1980 to 2005. All women residing in France and born 1911-1915, 1926-1930 and 1941-1945 are included. Sources are official data sets and published French reports on screening by mammography, age and time specific breast-cancer incidence and mortality, hormone replacement therapy, alcohol and obesity. Outcome measures include breast-cancer incidence differences adjusted for changes in risk factor distributions between pairs of age-matched cohorts who had experienced different levels of screening intensity.ResultsThere was an 8-fold increase in the number of mammography machines operating in France between 1980 and 2000. Opportunistic and organised screening increased over time. In comparison to age-matched cohorts born 15 years earlier, recent cohorts had adjusted incidence proportion over 11 years that were 76% higher [95% confidence limits (CL) 67%, 85%] for women aged 50 to 64 years and 23% higher [95% CL 15%, 31%] for women aged 65 to 79 years. Given that mortality did not change correspondingly, this increase in adjusted 11 year incidence proportion was considered as an estimate of overdiagnosis.ConclusionsBreast cancer may be overdiagnosed because screening increases diagnosis of slowly progressing non-life threatening cancer and increases misdiagnosis among women without progressive cancer. We suggest that these effects could largely explain the reported "epidemic" of breast cancer in France. Better predictive classification of tumours is needed in order to avoid unnecessary cancer diagnoses and subsequent procedures.

Dataset Information

The undiagnosed HIV epidemic in France and its implications for HIV screening strategies.

Publications

The undiagnosed HIV epidemic in France and its implications for HIV screening strategies.

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