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Friday 8 February 2019

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The European AIDS Clinical Society’s (EACS) recent meeting on Standard of Care for HIV and Coinfections in Europe was held in Bucharest, Romania. Its aim was to improve standards of HIV care and devise a minimal set of auditable standards that would help standardise and improve HIV care throughout the region. Regional experts shared information on the current European situation to help define a European standard of care, which is currently lacking.

A crisis of linkage and retention in care

Vinay Saldanha at the EACS Standard of Care meeting. Photo by Valentin Boboc.

1.4 million people live with HIV in eastern Europe and central Asia, 75% of them in Russia. HIV diagnoses in the region increased by 60% between 2010 and 2016 and 34,000 people died of AIDS-related conditions last year, Vinay Saldanha, UNAIDS Regional director for Eastern Europe and Central Asia, told the meeting. However, there are signs that new diagnoses may have flattened off, even in Russia.

The HIV crisis in eastern Europe is primarily a crisis of linkage and retention in care, not of testing. Testing rates are actually lower in the European Union (42 HIV tests per 1000 people) than in eastern Europe (166 HIV tests per 1000 people). This is primarily due to a tradition of public-health testing in Russia, with a quarter of its citizens tested last year.

However, the people who need to be tested may be the ones missed – only a quarter of HIV tests were in the key populations at high risk – people who inject drugs and their sexual partners, gay and bisexual men, sex workers and prisoners.

Overall, 73% of people with HIV in eastern Europe know their status. However, only 36% are on treatment and 26% are virally suppressed.

Lowering drug costs

Historically, HIV drugs have been expensive and their procurement inefficient in eastern European countries. There are signs however that some governments have woken up to the scale of the problem, Vinay Saldanha told the meeting.

At a top-level summit of eastern and central European health ministers in Minsk (Belarus) in November 2018, nine out of the 15 countries resolved to claim patent protection status under the TRIPS agreement so they can manufacture and provide generic medications to treat HIV, TB and hepatitis C in advance of patent expiry.

Armenia has led development of a pooled procurement mechanism for smaller countries, using existing international procurement platforms run by UNICEF, UNDP and the Global Fund. In Kazakhstan this led, in 2016, to an 89% reduction in the price of the preferred first-line therapy of tenofovir, emtricitabine and efavirenz from US$956 a year to $109. The price has now fallen further to $83. As a result, the number of people on antiretroviral therapy in the country rose from 6000 to 18,000 in four years.

In Belarus and Russia, direct negotiations with local generics manufacturers have resulted in comparable price reductions. For example, in Belarus, the price of locally manufactured generic tenofovir/emtricitabine pills fell from $37 to $5.60 a month (an 85% reduction).

Far from eliminating hepatitis C

Dr Jerzy Jaroszewicz at the EACS Standard of Care meeting. Photo by Valentin Boboc.

Dr Jerzy Jaroszewicz of the Polish Association for the Study of the Liver outlined issues related to HIV/hepatitis C co-infection. Whereas the World Health Organization (WHO) target is for that by 2030 90% of people with hepatitis C should know their status, this is only the case for a third of people in Europe. And while the WHO target is for 80% of those diagnosed to receive direct-acting antivirals (DAAs) by 2030, last year it was estimated that 13% of those diagnosed received treatment (2.5% of all those with hepatitis C).

The vast majority (93%) of those in the region who have hepatitis C/HIV co-infection are former or current injecting drug users.

In Europe, Iceland is the first example of a country that has implemented a national hepatitis C elimination plan targeted at, though not exclusive to, injecting drug users. In January 2016 the country launched a cohesive, multipronged approach that includes scale‐up of prevention, testing and early treatment of hepatitis C in both hospital and community settings. To implement this, a multidisciplinary public health model of care and co-operation between government, health services, the penitentiary system and community organisations was needed.

Modelling studies show that just making DAAs available is not sufficient to curtail the transmission of hepatitis C in eastern Europe and central Asia. In Belarus, Georgia, Moldova, Kazakhstan and Tajikistan, adding DAAs to current provision would only reduce new hepatitis C infections by 1 to 14%, depending on the country.

In contrast simply providing needle and syringe exchange would reduce infections by 10 to 25% and adding opioid substitution therapy (OST) to that would reduce infections by 45 to 55%. Also providing DAAs to that would only lower infections by a further 5%. Targeted screening programmes would have a much greater impact.

Dr Michel Katzatchkine, UN Special Envoy on HIV in central and eastern Europe, commented: “We’re in a region where 1.9 million people who inject drugs have hepatitis C and 750,000 of those have HIV. One per cent of them are accessing OST, and the average annual allocation of clean syringes is 15 each. This is a health emergency.”

HIV and TB in St Petersburg

Alexander Panteleev at the EACS Standard of Care meeting. Photo by Valentin Boboc.

While the prevalence of TB is not especially high in Russia (ten times lower than that of South Africa or the Philippines) and has fallen by 44% over the past decade, providing good quality care to those with HIV/TB co-infection is challenging. Professor Alexander Panteleev of St Petersburg State Medical University gave a sobering account of care for people with HIV/TB co-infection in the city.

The situation is made especially challenging by the intersection of two factors – an ageing population with HIV who, in the absence of antiretroviral therapy, are now increasingly unwell, and the fact that two-thirds are or were injecting drug users, with all that implies about reaching out to a criminalised, suspicious and sometimes chaotic patient group.

The importance of linkage and retention is shown by the fact that 85% of people with HIV and TB in St Petersburg have known their status for 7 to 10 years, yet are not in care.

Another terrible legacy of lack of care, or rather of intermittent care and loss to follow-up, is the data on multi-drug resistant (MDR-TB). In St Petersburg, the proportion of people with HIV and TB who had MDR-TB rose from about 40% before 2011 to 70% since 2013. Nearly a quarter of people with HIV and MDR-TB live less than a year and half die within three years.

Professor Panteleev described three major challenges to TB/HIV care. The lack of social care for injecting drug users and people with HIV meant they dropped out of whatever systems there were, and they were very hard to find. Secondly, there was a problem with medical staff who were “intolerant to socially-deviant forms of behaviour” and lacked the training to work with active drug users. Thirdly, low levels of education among patients and a pervasive distrust of healthcare workers and treatments meant that people avoided seeking treatment – HIV denialist beliefs are widespread.

He said that peer support should be part of the solution. Russia’s co-infected drug users desperately need the national, regional and local authorities to recognise the value of local NGOs who can support and train peer navigators to assist their fellows on the hard journey back towards health.  

Coming soon: news from CROI 2019

The annual Conference on Retroviruses and Opportunistic Infections (CROI) is being held in Seattle, USA, from 4 to 7 March 2019.

NAM will be reporting on key research presented at the conference, publishing news on aidsmap.com and sending out four summary news bulletins.

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NAM's news reporting services from the 2019 EACS Standard of Care meeting has been supported by the European AIDS Clinical Society (EACS), a grant from Gilead Sciences Europe Ltd., and ViiV Healthcare’s Positive Action Programme.

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