Population-based HIV-1 incidence in France, 2003–08: a modelling analysis

doi:10.1016/S1473-3099(10)70167-5

The Lancet Infectious Diseases

Volume 10, Issue 10, October 2010, Pages 682-687

https://doi.org/10.1016/S1473-3099(10)70167-5 Get rights and content

Summary

Background

Routine national incidence testing with enzyme immunoassay for recent HIV-1 infections (EIA-RI) has been done in France since January, 2003. From the reported number of HIV infections diagnosed as recent, and accounting for testing patterns and under-reporting, we aimed to estimate the incidence of HIV infection in France in 2003–08.

Methods

We analysed reports from the French National Institute for Public Health Surveillance for patients who were newly diagnosed with HIV between January, 2003, and December, 2008. Missing data were imputed with multiple imputation. Patients were classified with non-recent or recent infection on the basis of an EIA-RI test, which was calibrated with serial measurements from HIV seroconverters from the French ANRS-PRIMO cohort. We used an adapted stratified extrapolation approach to calculate the number of new HIV infections in men who have sex with men (MSM), injecting drug users (IDUs), and heterosexual men and women by nationality. Population sizes were obtained from the national census and national behavioural studies.

Findings

After accounting for under-reporting, there were 6480 (95% CI 6190–6780) new diagnoses of HIV infection in France in 2008. We estimate that there were 6940 (6200–7690) new HIV infections in 2008, suggesting an HIV incidence of 17 per 100 000 person-years. In 2008, there were 3550 (3040–4050) new infections in heterosexuals (incidence of 9 per 100 000 person-years), 3320 (2830–3810) in MSM (incidence of 1006 per 100 000 person-years), and 70 (0–190) in IDUs (incidence of 86 per 100 000 person-years). Overall HIV incidence decreased between 2003 and 2008 (p<0·0001), but remained comparatively high and stable in MSM.

Interpretation

In France, HIV transmission disproportionately affects certain risk groups and seems to be out of control in the MSM population. Incidence should be tracked to monitor transmission dynamics in the various population risk groups and to help to target and assess prevention strategies.

Funding

French National Institute for Public Health Surveillance (InVS) and French National Agency for Research on AIDS and Viral Hepatitis (ANRS).

Introduction

The HIV-1 epidemic in France and other European countries has chiefly been monitored by analysis of data for new diagnoses of HIV infection, which are reported by regional or national case surveillance.¹ However, because of the long and variable time from infection to diagnosis, case surveillance of new HIV diagnoses does not show present patterns of virus transmission. In the past 15 years, laboratory-based methods have been developed to estimate incidence of HIV with a cross-sectional approach.2, 3 This method proved applicable with case-based surveillance data.⁴ To monitor the dynamic of HIV infection in France, routine incidence testing with an enzyme immunoassay for recent HIV infections (EIA-RI) has been implemented as part of the national HIV case surveillance since its introduction in 2003. We aimed to estimate HIV incidence in France by use of this serological assay for recent infection.

Section snippets

Procedures

For calibration of the EIA-RI assay, we defined an assay threshold that discriminated recent HIV infection from longstanding infection, and estimated the distribution of time spent in a recently infected state—called the recent-infection-testing algorithm (RITA) duration⁵—from a reference population sample. The EIA-RI test had initially been developed to detect recent HIV infection through an algorithm that combined standardised measures of antibody binding to the immunodominant epitope of gp41

Results

For calibration of EIA-RI, the chosen optical density threshold led to a mean RITA duration of 179·7 days (95% CI 167·2–192·2) and a false recent rate of 0·8% (0–3·1%) in patients without AIDS and 5·6% (2·7–10·8%) in patients with AIDS. The range of possible RITA durations was 25–731 days, with 95% of durations lasting less than 358 days, and 99% less than 480 days.

26760 new diagnoses of HIV infection were reported between Jan 1, 2003, and Dec 31, 2008. With under-reporting (estimated average

Discussion

Overall incidence of HIV infection in France decreased between 2003 and 2008. Our results support previous findings of a disproportionately high number of transmissions among MSM and a very low number of transmissions among IDUs. Because the test for recent infection has been routinely applied since the start of case surveillance in 2003, we were able to calculate trends in incidence of HIV transmission in the most relevant groups of population in France.

With 48% of all new infections and a

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Citation Excerpt :
This trend can also be observed when comparing the data of two nationwide epidemiological studies, with a proportion of late diagnoses of 27.6% between 1996 and 2002 [10] and 19.6% between 2003 and 2011 [11]. This difference between the MSM and other groups may be due to prevention programs specifically targeting MSM as they are known to be at high risk of transmission [16]. This is increasingly underlined in the national recommendations for HIV screening since 2006 [15,17,18], and has been reinforced in the most recent French guidelines mentioning that MSM should be tested every three months in case of risky sexual behaviour.
Health of HIV-infected people relies on early antiretroviral therapy, i.e. early diagnosis. We aimed to determine whether the characteristics at HIV diagnosis in two French medical centres changed over the last 20 years.
All individuals diagnosed with HIV infection in Grenoble University Hospital (N = 814) and Annecy Hospital (N = 246) between 1997 and 2015 were included. We collected age, country of birth, mode of transmission, CD4 T cell count, CD4/CD8 ratio, and HIV viral load.
Among the 1060 patients (mean age 37.4 ± 11 years, 70.2% of men), 42.5% were men having sex with men (MSM); 65.2% were born in France, and 24.4% were born in Africa. Mean CD4 T cell count at diagnosis was 396 ± 288/mm³ and was stable over the study period when considering all patients; when considering the MSM group, a significant increase over time was observed, with a mean increase of 7.3 CD4/mm³ per year (P < 0.001). A higher CD4 count at diagnosis was observed after 2005 (400 ± 289 vs 468 ± 271/mm³, P = 0.005). The proportion of MSM patients with a CD4 count < 200/mm³ at diagnosis was lower after 2005 (14.7% after 2005 and 25.6% before, P = 0.028) This was not observed in heterosexual patients (born in Africa or not).
In the MSM population, CD4 count at diagnosis is higher after 2005, suggesting that screening campaigns have become more efficient. This was not observed in other populations, who should be better targeted in future strategies.
Epidemiological changes of acute/recent human immunodeficiency virus type 1 infection in Barcelona, Spain (1997–2015): a prospective cohort study
2019, Clinical Microbiology and Infection
To describe the epidemiology of acute/recent human immunodeficiency virus (HIV) infection over two decades in Barcelona (Spain).
Prospective, single-centre cohort including all patients with an acute/recent HIV infection (<180 days) since 1997. Patients were stratified into four periods. Phylogenetic analysis was performed to determine clusters of transmission.
A total of 346 consecutive acute/recently infected patients were included. The annual proportion of recent infections among total new HIV diagnoses increased over time from 1% (29 out of 1964) to 8% (112 out of 1474) (p <0.001). Proportion of men who have sex with men (MSM) in the cohort increased from 62% (18 out of 29) to 89% (100 out of 112) (p <0.001). The proportion of migrants showed a non-significant increasing trend (24% (7 of 29) to 40% (45 of 112)) likewise the non-B subtype (0% to 22% (22 of 112)). The mean time from infection to diagnosis was 53.6 days (interquartile range (IQR) 50–57), comparable among all periods. Mean time from infection to treatment decreased over the years from 575 (IQR 467–683) to 471 (IQR 394–549) days (p <0.001) without significant differences between migrants and non-migrants (133 (IQR 71–411) versus 208 (IQR 90–523) days p 0.089). Almost 50% (152 of 311) of recently infected individuals were included in a cluster of transmission, and 92% (137 of 149) of them were MSM.
The MSM population has progressively grown within acutely/recently infected patients in Barcelona, and is frequently involved in transmission clusters. Although the time between diagnosis and treatment has been reduced, the time between infection and diagnosis still needs to be shortened.
Characteristics and health status of homeless women born in France and abroad: Results of Insee–Ined 2012 survey
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Les enquêtes Insee–Ined « sans-domicile » de 2001 et 2012 ont permis de décrire la population sans-domicile bénéficiaire des services d’aide sociale. Au regard du nombre croissant de femmes dans cette population, en majeure partie nées à l’étranger et accompagnées d’enfants, une étude décrivant ces femmes selon le fait d’être née en France ou à l’étranger a été réalisée.
L’étude a porté sur un échantillon de 1470 femmes francophones sans-domicile de l’enquête Insee–Ined de 2012. Les caractéristiques sociodémographiques, les trajectoires de vie, le travail et l’emploi au cours des 12 derniers mois, la santé perçue, la morbidité déclarée, le recours aux soins et la couverture médicale ont été décrits, en comparant les femmes sans-domicile nées à l’étranger et celles nées en France.
Les femmes sans-domicile sont jeunes (âge médian : 34 ans), célibataires (55 %), ne vivent pas en couple (71 %) et sont souvent accompagnées d’enfants (52 %). La grande majorité n’a pas eu d’activité rémunérée les 12 mois précédents (60 %). Les femmes nées en France se distinguent des femmes nées à l’étranger par un hébergement moins précaire, mais par une trajectoire de vie plus difficile, une perception globalement moins favorable de leur état de santé et une fréquence plus élevée de problèmes de santé chroniques. Les femmes sans-domicile nées à l’étranger semblent vivre dans des conditions plus précaires et avoir plus de difficultés d’accès aux aides sociales et à la couverture médicale. Globalement, malgré une bonne couverture médicale, les femmes sans-domicile, quel que soit le lieu de naissance, présentent fréquemment des problèmes de santé déclarés mais non pris en charge.
Cette étude suggère que les femmes sans-domicile sont souvent confrontées à des problèmes de santé chroniques qui ne sont pas pris en charge. Les femmes sans-domicile nées à l’étranger se distinguent par des conditions de vie plus précaires que les femmes nées en France. Bien que plus jeunes, ayant une perception de santé globalement favorable et déclarant moins souvent une addiction, leur état de santé général apparaît aussi fragile que celui des femmes nées en France. Des actions envers les femmes sans-domicile devraient être mises en œuvre pour favoriser leur accès aux soins.
French national surveys among the homeless population in 2001 and 2012 provided a general description of the homeless beneficiaries of medical and social aids. However, given the increasing number of women in this population, mostly born abroad and accompanied by their children, a descriptive study of homeless women according to the fact of being born in France or abroad was conducted.
A probability sample of 1470 French-speaking homeless women was recruited for the Insee–Ined 2012 survey. Socio-demographic characteristics, life trajectories, work and employment over the last 12 months, perceived health, reported morbidity, use of care and medical coverage have been described, comparing homeless women born abroad with those born in France.
Homeless women are young (median age = 34 y.), often single (55%), without a partner (71%) and often accompanied by children (52%). The vast majority (60%) reported no salary during the previous 12 months. Housing conditions were less precarious in women born in France, but these women had a more difficult life history, a more unfavorable perception of their health status, and a higher frequency of chronic health problems. Homeless women born abroad seemed to have more precarious conditions of life and more difficulties to access aids and medical coverage. Overall, despite a relatively good availability of medical insurance, homeless women, regardless of the place of birth, often reported health problems, which were not treated.
This study suggests that homeless women often have to deal with chronic health problems that are not treated. Homeless women born abroad are characterized by more precarious living conditions that women born in France. Although younger, with an overall favorable perception of their health and declaring less often an addiction, their general state of health appears to be as fragile as for women born in France. Actions towards homeless women should be implemented to promote their access to care.
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Fast track — ArticlesPopulation-based HIV-1 incidence in France, 2003–08: a modelling analysis

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Procedures

Results

Discussion

Ann Epidemiol

Lancet

HIV/AIDS surveillance in Europe 2008

New testing strategy to detect early HIV-1 infection for use in incidence estimates and for clinical and prevention purposes

JAMA

Principles and uses of HIV incidence estimation from recent infection testing—a review

Euro Surveill

Estimation of HIV incidence in the United States

JAMA

Final report

Development and validation of an immunoassay for identification of recent human immunodeficiency virus type 1 infections and its use on dried serum spots

J Clin Microbiol

Spontaneous control of viral replication during primary HIV infection: when is “HIV controller” status established?

Clin Infect Dis

Early control of HIV-1 infection in long-term nonprogressors followed since diagnosis in the ANRS SEROCO/HEMOCO cohort

J Acquir Immune Defic Syndr

Four years of surveillance of recent HIV infections at country level, France, mid 2003–2006: experience and perspectives

Euro Surveill

Enquête sur la sexualité en France : pratiques, genre et santé

Prévalence de l'usage problématique de drogues en France—estimations 2006

National population census

Multiple imputation of discrete and continuous data by fully conditional specification

Stat Methods Med Res

Fast track — Articles
Population-based HIV-1 incidence in France, 2003–08: a modelling analysis