Alere HIV Diagnostic Care; Solutions to Fast Track 90-90-90 Value of Earlier Case Findings using Alere™ HIV Combo in a Community Setting Michael Meulbroek Projecte dels NOMS-Hispanosida Alere HIV Diagnostic Care; Solutions to Fast Track 90-90-90 Paris, 25 July 2017

Introduction 2007 UNAIDS Global Campaign “ Know Your Epidemic, Know Your Response”.

Europe 2006 - 2015

The HIV epidemic is concentrated in the cities UNAIDS gap report 2015

Opening of BCN Checkpoint BCN Checkpoint opened in January 2006 A community center for gay men, other men who have sex with men and transgender women Situated in the middle of Barcelona’s gay area Service is free, anonymous and confidential Peer counselors: all are gay and most are HIV+ BCN Checkpoint introduced the use of HIV rapid tests in community centers in Europe in 2006

Introduction of HIV Rapid Test in a non-clinical setting (2006) To reduce high number of persons that doesn’t come back for the result of an HIV test Acceptability test 93.2% important to obtain result in 30 minutes 97.7% positive opinion to offer rapid test in a community center Specific training for counselors Informed consent: Counselor is a peer Positive result needs confirmation

Results of the introduction of HIV Rapid Testing in non-clinical settings

Number of tests and clients in BCN Checkpoint (2006 - 2016) 7,737 5,542 3,837 3,198

Positive results and rate (2006 - 2016) 172 146 132 37

Impact of BCN Checkpoint Source: Actualizació a 06/10/2016. Vigilància epidemiològica de la infecció pel VIH i la SIDA a Catalunya. Ceeiscat. Departament de Salut. Generalitat de Catalunya

Linkage to Care

Need to detect HIV infections earlier New HIV Infections

Early phases of HIV infection

Transmission risk acute infections Blood viral load in acute HIV (n=171) Average fitted curve, with 95% confidence intervals log 10 HIV RNA 8 7 6 5 4 3 2 1 8-10 fold increase risk from peak to day 54 300 200 100 Days from Infection Peak: day 23 Pilcher, et al JID 2004

Challenges to find earlier HIV infections Recommend and promote regular testing in key populations

Campaign for more frequent testing (2014)

Campaign for more frequent testing (2015) Gay men do it often!

Campaign for more frequent testing (2016)

Challenges to find earlier HIV infections Recommend and promote regular testing in key populations Use P24 antigen in usual screening in key populations Alere™ HIV Combo

Detection of P24 antigen before antibodies Acute Seroconversion→Established Das G et al. BMJ 2010;341:bmj.c4583

Test, detect and start treatment Kroon EDMB et al. Journal of the International AIDS Society 2017, 20:21708 http://dx.doi.org/10.7448/IAS.20.1.21708 Published 28 June 2017

Detection of P24 antigen Introduction Alere™ HIV Combo: 25 March 2016 Period: 25 March 2016 – 31 December 2016 Total tests performed: 5,800 Total persons tested: 4,485 Total reactive tests: 113   antibodies P24 and antibodies P24 Total Total reactive tests 106 3 4 113 False positive results 5 1 6 Confirmed positive results 101 107 + 2.9% + 5.9%

Time to start treatment Added value detection of P24 antigen Cases Age Marker Time to hospital Time to start treatment VL (millions) CD4 Nº 1 35 P24 1 day same day > 10 257 Nº 2 46 332 Nº 3 60 2 days 4.60 385 Nº 4 45 P24 and antibodies 16 days 0.57 301 Nº 5 22 12 days 3 days 0.27 144 Nº 6 28 5 days 0.24 238

Results Resource: results BCN Checkpoint 2012-2016

Results Early Detection + Fast Linkage to Care + Treatment Source: Agència de Salur Pública. La Salut a Barcelona 2015. Published: December 2016

Detección infecciones agudas en BCN Checkpoint Late diagnostics Detección infecciones agudas en BCN Checkpoint Alere Pima™ Point-of-Care CD4 test

Summary In Europe the HIV epidemic concentrates mostly in MSM and other key populations and in urban areas. MSM need a specific action plan that includes targeting testing and linkage to care, increase testing frequency and screening for acute infections. Community centers has shown to be effective with the use of POCT in key populations. However, if we want to reduce the gap in the first step of the continuum of care HIV infections should be found in the earliest phases in order to reduce the ongoing transmission chain. The use of Alere™ HIV Combo in BCN Checkpoint permits a general screening to all clients for early HIV infections. Results from 2016 show that at least 2.9% more cases were found where standard antibody tests would have been a missed opportunity. Moreover, cases with only P24 antigen had a significant higher viral load, hence detection in this phase of infection saves 8-10 times more onwards infections and is an important tool for reaching the 90-90-90 goals.

Acknowledgements