An update on the HIV epidemic in the Netherlands A selection of findings from the SHM Monitoring Report 2017

Transcriptie

1 An update on the HIV epidemic in the Netherlands A selection of findings from the SHM Monitoring Report 2017 Peter Reiss NCHIV November 2017

2 A special thank you to: SHM Ard van Sighem Sima Zaheri Ferdinand Wit Mariska Hillebregt Colette Smit Sonia Boender Catriona Ester Daniela Bezemer Melanie Sormani Special reports on: Amsterdam Cohort Studies Amy Matser Maria Prins Curacao Diederik van de Wetering Gonneke Hermanides Ashley Duits Ard van Sighem Expert clinical and public health advisors Joop Arends Kees Brinkman Suzanne Geerlings Frank Kroon Liesbeth van Leeuwen Jeanine Nellen Kees van Nieuwkoop Eline Op de Coul Jan Prins Clemens Richter Annemarie van Rossum Marc van der Valk Anne Wensing Tom Wolfs 2

3 Acknowledgements Academic Medical Centre of the University of Amsterdam (AMC-UvA): M. van der Valk*, S.E. Geerlings, M.H. Godfried, A. Goorhuis, J.W. Hovius, T.W. Kuijpers, F.J.B. Nellen, D. Pajkrt, T. van der Poll, J.M. Prins, P. Reiss, H.J. Scherpbier, M. van Vugt, W.J. Wiersinga, F.W.M.N. Wit, M. van Duinen, J. van Eden, A.M.H. van Hes, F.J.J. Pijnappel, A.M. Weijsenfeld, S. Jurriaans, N.K.T. Back, H.L. Zaaijer, B. Berkhout, M.T.E. Cornelissen, C.J. Schinkel, K.C. Wolthers. Emma Kinderziekenhuis (AMC-UvA): A. van der Plas, A.M. Weijsenfeld. Admiraal De Ruyter Ziekenhuis, Goes: M. van den Berge, A. Stegeman, S. Baas, L. Hage de Looff, B Wintermans, J Veenemans. Catharina Ziekenhuis, Eindhoven: M.J.H. Pronk*, H.S.M. Ammerlaan, E.S. de Munnik, A.R. Jansz, J. Tjhie, M.C.A. Wegdam, B. Deiman, V. Scharnhorst. DC AMC Hiv Behandelcentrum: A. van Eeden*, M. van der Valk, W. Brokking, M. Groot, L.J.M. Elsenburg, M. Damen, I.S. Kwa. Elisabeth-TweeSteden Ziekenhuis, Tilburg: M.E.E. van Kasteren*, A.E. Brouwer, R. van Erve, B.A.F.M. de Kruijf-van de Wiel, S.Keelan-Pfaf, B. van der Ven, A.G.M. Buiting, P.J. Kabel, D.Versteeg. Erasmus MC, Rotterdam: M.E. van der Ende*, H.I. Bax, E.C.M. van Gorp, J.L. Nouwen, B.J.A. Rijnders, C.A.M. Schurink, A. Verbon, T.E.M.S. de Vries-Sluijs, N.C. de Jong-Peltenburg, N. Bassant, J.E.A. van Beek, M. Vriesde, L.M. van Zonneveld, H.J. van den Berg-Cameron, J. de Groot, M. de Zeeuw-de Man, C.A.B. Boucher, M.P.G Koopmans, J.J.A van Kampen, S.D. Pas. Erasmus MC Sophia, Rotterdam: P.L.A. Fraaij, A.M.C. van Rossum, C.L. Vermont, L.C. van der Knaap, E. Visser. Flevoziekenhuis, Almere: J. Branger*, A. Rijkeboer-Mes, C.J.H.M. Duijf-van de Ven. HagaZiekenhuis, Den Haag: E.F. Schippers*, C. van Nieuwkoop, J.M. van IJperen, J. Geilings, G. van der Hut, N.D. van Burgel. HMC (Haaglanden Medisch Centrum), Den Haag: E.M.S. Leyten*, L.B.S. Gelinck, S. Davids-Veldhuis, A.Y. van Hartingsveld, C. Meerkerk, G.S. Wildenbeest, E. Heikens. Isala, Zwolle: P.H.P. Groeneveld*, J.W. Bouwhuis, A.J.J. Lammers. S. Kraan, A.G.W. van Hulzen, M.S.M. Kruiper, G.L. van der Bliek, P.C.J. Bor, P. Bloembergen, M.J.H.M. Wolfhagen, G.J.H.M. Ruijs. Leids Universitair Medisch Centrum, Leiden: F.P. Kroon*, M.G.J. de Boer, H. Scheper, H. Jolink, A.M. Vollaard, W. Dorama, N. van Holten, E.C.J. Claas, E. Wessels. Maasstad Ziekenhuis, Rotterdam: J.G. den Hollander*, K. Pogany, A. Roukens, M. Kastelijns, J.V. Smit, E. Smit, D. Struik-Kalkman, C. Tearno, T. van Niekerk, O. Pontesilli. Maastricht UMC+, Maastricht: S.H. Lowe*, A.M.L. Oude Lashof, D. Posthouwer, R.P. Ackens, K. Burgers, J. Schippers, B. Weijenberg-Maes, I.H.M. van Loo, T.R.A. Havenith. MC Slotervaart, Amsterdam: J.W. Mulder*, S.M.E. Vrouenraets, F.N. Lauw, M.C. van Broekhuizen, D.J. Vlasblom, P.H.M. Smits. MC Zuiderzee, Lelystad: S. Weijer*, R. El Moussaoui, A.S. Bosma. Medisch Centrum Leeuwarden, Leeuwarden: M.G.A.van Vonderen*, D.P.F. van Houte, L.M. Kampschreur, K. Dijkstra, S. Faber, J Weel. Medisch Spectrum Twente, Enschede: G.J. Kootstra*, C.E. Delsing, M. van der Burg-van de Plas, H. Heins, E. Lucas. Noordwest Ziekenhuisgroep, Alkmaar: W. Kortmann*, G. van Twillert*, R. Renckens, D. Ruiter-Pronk, F.A. van Truijen-Oud, J.W.T. Cohen Stuart, E.P. IJzerman, R. Jansen, W. Rozemeijer W. A. van der Reijden. OLVG, Amsterdam K. Brinkman*, G.E.L. van den Berk, W.L. Blok, P.H.J. Frissen, K.D. Lettinga W.E.M. Schouten, J. Veenstra, C.J. Brouwer, G.F. Geerders, K. Hoeksema, M.J. Kleene, I.B. van der Meché, M. Spelbrink, A.J.M. Toonen, S. Wijnands, D. Kwa, R. Regez. Radboudumc, Nijmegen: R. van Crevel*, M. Keuter, A.J.A.M. van der Ven, H.J.M. ter Hofstede, A.S.M. Dofferhoff, S.S.V. Henriet, M. van de Flier, K. van Aerde, J. Hoogerwerf, M. Albers, K.J.T. Grintjes-Huisman, M. de Haan, M. Marneef, A. Hairwassers, J. Rahamat-Langendoen, F.F. Stelma, D. Burger. Rijnstate, Arnhem: E.H. Gisolf*, R.J. Hassing, M. Claassen, G. ter Beest, P.H.M. van Bentum, N. Langebeek, R. Tiemessen, C.M.A. Swanink. Spaarne Gasthuis, Haarlem: S.F.L. van Lelyveld*, R. Soetekouw, L.M.M. van der Prijt, J. van der Swaluw, N. Bermon, W.A. van der Reijden, R. Jansen, B.L. Herpers, D.Veenendaal. Medisch Centrum Jan van Goyen, Amsterdam: D.W.M. Verhagen, M. van Wijk. Universitair Medisch Centrum Groningen, Groningen: W.F.W. Bierman*, M. Bakker, J. Kleinnijenhuis, E. Kloeze, E.H. Scholvinck, Y. Stienstra, C.L. Vermont, K.R. Wilting, M. Wouthuyzen-Bakker, A. Boonstra, H. de Groot-de Jonge, P.A. van der Meulen, D.A. de Weerd, H.G.M. Niesters, C.C. van Leer-Buter, M. Knoester. Universitair Medisch Centrum Utrecht, Utrecht: A.I.M. Hoepelman*, J.E. Arends, R.E. Barth, A.H.W. Bruns, P.M. Ellerbroek, T. Mudrikova, J.J. Oosterheert, E.M. Schadd, M.W.M. Wassenberg, M.A.D. van Zoelen, K. Aarsman, D.H.M. van Elst-Laurijssen, I. de Kroon, C.S.A.M. van Rooijen, M. van Berkel, R. Schuurman, F. Verduyn-Lunel, A.M.J. Wensing. VUmc, Amsterdam: E.J.G. Peters*, M.A. van Agtmael, M. Bomers, M. Heitmuller, L.M. Laan, C.W. Ang, R. van Houdt, A.M. Pettersson, C.M.J.E. Vandenbroucke-Grauls. Wilhelmina Kinderziekenhuis, UMC Utrecht, Utrecht: L.J. Bont, S.P.M. Geelen, T.F.W. Wolfs, N. Nauta. Sint Elisabeth Hospitaal, Willemstad, Curaçao: J.F. Schattenkerk, F. Muskiet, R. Voigt, D. van de Wetering, I. van der Meer. Coordinating centre: P. Reiss, D.O. Bezemer, A.I. van Sighem, C. Smit, F.W.M.N. Wit, T.S. Boender, S. Zaheri, M. Hillebregt, A. de Jong, D. Bergsma, S. Grivell, A. Jansen, M. Raethke, R. Meijering, T. Rutkens, L. de Groot, M. van den Akker, Y. Bakker, M. Bezemer, E. Claessen, A. El Berkaoui, J. Geerlinks, J. Koops, E. Kruijne, C. Lodewijk, R. van der Meer, L. Munjishvili, F. Paling, B. Peeck, C. Ree, R. Regtop, Y. Ruijs, M. Schoorl, A. Timmerman, E. Tuijn, L. Veenenberg, S. van der Vliet, A. Wisse, E.C. de Witte, T. Woudstra, B. Tuk.

4 A big thank you to colleagues at SHM and at all treatment centres and to all patients who allow us to collect and analyse their data on the course and outcome of their infection 4

5 Topics Epidemic trends in diagnosis and treatment initiation over time Treatment outcome and the continuum of care Initial treatment regimens Ageing and comorbidity, including hepatitis C co-infection Conclusions

6 Annual number of new HIV diagnoses has continued to decline in 2016, but only gradually Around 820 new diagnoses in % in MSM 25% through heterosexual contact 8% through other or unknown mode of acquisition

7 Geographical region of origin of those newly diagnosed with HIV MSM 27% of newly diagnosed persons in 2016 were > 50 yrs: More often the case for Dutch MSM & other Dutch men and women than for those from other regions of origin than the Netherlands Other adult men and women 7

8 Where are people being diagnosed? Data from 2008 onwards 8

9 At time of diagnosis far too many have likely already been infected much longer 43% overall of newly-diagnosed individuals had AIDS and/or CD4 cells < 350/mm 3 when entering care 63% 43% 37% Late presentation even more common in those over 45 when entering care % late presenters >45 yrs <25 yrs MSM 49% 21% Other men 70% 50% Women 57% 23%

10 Early diagnosis needs to be improved Nationwide: slow improvement in MSM, but not in other men or women Of those newly diagnosed in 2016: 26% of MSM 4% of other men 8% of women had a last negative test < 6 months before diagnosis Marked improvement among MSM in Amsterdam? 10

11 Universal rapid start of treatment, regardless of CD4 count, is increasingly the reality Proportion starting cart within 6 months after HIV diagnosis, according to CD4 count at time of diagnosis 2016: 94% with CD4 500 cells/mm 3 started cart within 6 months of diagnosis (81% in 2015)

12 Around 75 percent of patients entering care in 2016 started treatment within 1 month Time between entry into care and initiation of combination antiretroviral therapy (cart) from within days within days within 7-13 days within 1 week Same day

13 Universal rapid treatment initiation fairly uniform across the 26 Netherlands treatment centres Proportion of patients started on cart within 6 months after entering care, by year & treatment centre size > 700 pts pts < 400 pts 13

14 Heading towards epidemic control Number of newly-acquired HIV infections as estimated using ECDC modelling tool is declining 500 (95% CI ) Expanding testing and prevention as options, is the including estimated PrEP, number tailored of people to each community s needs, will be required living to further with undiagnosed improve our HIV capacity for early diagnosis and treatment, and really achieve epidemic control 2,600 (95% CI ) 14

16 Viral suppression rates on cart are high across the 26 Netherlands treatment centres Percentages of treatment-naive patients with a plasma HIV RNA level <400 copies/ml at 6 months (minimum and maximum: 3-9 months) after the start of combination antiretroviral therapy (cart) across all HIV treatment centres. > 700 pts pts < 400 pts 16

17 Increasing proportions of patients on cart are living with higher CD4 counts 750 cells/mm cells/mm 3

18 Continuum of care: persons diagnosed, linked to care, retained in care, on cart, and suppressed 2,600 undiagnosed (95% CI 2,100-3,200) by ,400 undiagnosed (95% CI 1,100-2,000) by 2020

19 S Dissecting the cascade of care further... MSM by region of origin Other men by region of origin Women by region of origin All in care by age 19

20 Care continuum in children who acquired HIV during pregnancy & delivery, or later in childhood By age and route of HIV acquisition 20

22 Shifts in first-line cart regimens TAF/FTC/EVGc ABC/3TC/DTG TDF/FTC/DTG TDF/FTC/EVG/c

23 Durability of first-line regimens has improved Kaplan-Meier estimate of time on initial regimen by calendar year period of initiation (log-rank test p<0.001) Legend: cart=combination antiretroviral therapy. 23

24 Reasons for discontinuing first-line regimen in the first 12 months ( ) Toxicity Simplification/ new drugs available Virologic failure Still on initial regimen 24

26 Increasing age of people in care Median age of people in care = 49 years In 2016: 50+ years:46% 60+ years:16% 26

27 Comorbidity and multimorbidity increasingly prevalent with rise in age Adult population in care in The numbers on top of each bar represent the number of individuals contributing data to that age category. 27

28 Reflected in deaths increasingly being caused by such co-morbidities Absolute numbers of deaths by cause and calendar period since the introduction of cart in 1996 Numbers on top of each bar represent the number of individuals that were at risk during that calendar period 28

29 Treatment for HCV co-infection over time Rapid uptake of (new) DAA combination regimens SVR 12 rate 97% in 672 patients who completed treatment with one of the novel DAA regimens & sufficient follow-up posttreatment sofosbuvir+ledipasvir sofosbuvir+daclatasvir 29

30 HCV treatment cascade for coinfected patients eligible for HCV treatment*, registered by SHM and retained in care as of 1 May 2017 ^ Never treated Ongoing treatment Awaiting SVR Unsuccessfully treated (peg)-ifn +/- BOC or TVR More current DAA Pretreated * Chronic or acute HCV infection without spontaneous clearance of HCV ^2016: n=591

31 Incidence of primary HCV declining in MSM? Reinfection remains a significant concern 31

32 Conclusions Epidemic trends, diagnosis and treatment, the continuum of care, and ART We see a continued, but still only gradual, decline in the annual number of newly diagnosed individuals Late presentation generally still remains far too common Improvements in early diagnosis are possible, as suggested by the data from Amsterdam in MSM More testing and prevention options, including PrEP, tailored to each community s needs, will be needed to achieve more rapid epidemic control The continuum of care is generally looking good, but gaps need to be minded! Immediate treatment after diagnosis, regardless of CD4 count, seems to have been universally adopted Initial ART has shifted further towards integrase inhibitor-based regimens, resulting in rapid viral suppression in the majority of patients

33 Conclusions Ageing, comorbidities, and HCV co-infection More than half of patients over 60 have 1 or 2, and almost 10 percent 3 or more comorbidities, which increasingly affects clinical management and health outcomes Unrestricted access to DAAs against HCV has resulted in continued rapid treatment uptake, high rates of cure, and fewer people remaining in need of effective HCV treatment As a result HCV incidence may be starting to decline, but elimination of HCV infection from the population with HIV in the Netherlands is likely to require additional measures, including optimized screening, prevention and risk counselling

34 For further information Please visit our website ( and read or download the new digital HIV Monitoring Report. Online PDF, with appendix figures and tables included All figures available separately as powerpoint file at Summary and Recommendations on website & in print (see NCHIV bag)