Improving the quality of HIV care for people throughout
the European region will require careful attention to a range of benchmarks of
good-quality care that go beyond the widely cited 'treatment cascade'.
The treatment cascade refers to the proportions of people
who are diagnosed with HIV, linked to care, retained in care, receiving
antiretroviral treatment and who have fully suppressed viral load on treatment.
In Europe, approximately two-thirds of people with HIV have been diagnosed, but it is unclear what proportion have either been
linked to care or retained in care, due to lack of reliable surveillance data
from all countries.
UNAIDS estimates that 25% of people with HIV in the European
region are receiving antiretroviral therapy and that 20% have undetectable
viral load (this includes eastern Europe). In western and northern Europe (this
excludes Spain, Portugal and Italy), the proportion of diagnosed people rises to
75%, while 50% are receiving treatment and 45% have undetectable viral load.
Professor Lundgren commented that the proportion of patients
with undetectable viral load is not the only metric of importance when
measuring the quality of care. The durability of HIV suppression is a key
indicator for benchmarking quality of care, he told the conference.
Whereas 86% of people on antiretroviral therapy in northern Europe have spent at least 90% of their time on treatment with a viral
load below 500 copies/ml, this proportion falls to 67% in southern Europe and 45%
in eastern Europe.
This indicator reveals the extent to which people are
promptly switched from failing regimens, and indicates challenges in retaining,
monitoring and switching patients to new regimens due to lack of resources and to lack of access to resistance testing and
alternative drugs. It also highlights where the risk of transmission of
drug-resistant virus is likely to be highest.
Late presentation will require healthcare providers to
address several challenges, including the need for consistent testing for HIV
in people with indicator diseases, and the need to retain marginalised
patients in care.
“It is unwise public health policy for politicians to
exclude people diagnosed with HIV from care”, said Professor Lundgren.
Variations in access to care exist across the European region – in the United
Kingdom, for example, access to free HIV care was dependent on immigration
status until 2012, while young unemployed people with HIV in Spain report
barriers to obtaining antiretroviral treatment due to public spending cuts. In eastern Europe, people who inject drugs and men who have sex with men are widely
excluded from care due to a lack of services tailored to the needs of these groups.
Addressing the debate regarding earlier treatment, on which
he is an acknowledged sceptic until the randomised START study is completed,
Professor Lundgren said that while a blanket recommendation to put everyone on
treatment is not supported by the evidence, deferring treatment until a CD4
count of 350 is reached may not be appropriate in all circumstances.
Deferral of treatment is only safe if there is good access
to regular CD4 cell counting, he argued, and earlier treatment initiation may
be most appropriate in settings where it may be unsafe to defer treatment due
to lack of CD4 cell counting or poor retention of untreated people in care. The
greater risk in these circumstances may be that deferral of treatment leads to
people becoming late presenters if they cannot be monitored closely.