Daniel Simões HIV in Europe Portugal Addressing the first 90: How can HIV testing more efficiently reach those in need to promote early diagnosis? Daniel Simões HIV in Europe Portugal

ECDC/EACS Joint Session Addressing the first 90: How can HIV testing more efficiently reach those in need to promote early diagnosis? Daniel Simões HIV in Europe Co-chair Member of the Board @ GAT Global Public Health PhD fellow @ ISPUP EATG member July 23, 2018

Disclosure of interest Represented GAT at World Hepatitis Summit, in 2017 with a travel sponsorship from Abbvie Represented GAT at Abbvie’s Global HCV Advisory Board in 2018 (fee was payed to GAT)

Introductory remarks Much has been done; more is needed. E/CA are not the world – do not forget the rest of the world! We have to link and learn with each other; Strong progress in some parts of the region on the first 90. 90-90-90 is not a magical indicator of success: we need to understand what it means, what it says and what it does not say.

Data availability on the continuum of care 2014 (n=40); 2016 (n=44); 2018 (n=43) Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.

Progress toward achieving the first 90: Target 1: 90% of all PLHIV who know their status (n=39) Estimated # PLHIV (1) % Diagnosed (2) Estimated undiagnosed number Missing Diagnoses per 100.000 (3) Portugal 38959 92% 3234 31,4 Sweden 7718 90% 772 7,6 Greece 14200 89% 1420 13,1 Romania 14000 88% 1680 8,4 Belgium 11774 83% 2001 17,6 Spain 141000 82% 25380 54,6 Croatia 70% 504 11,8 West 86% Centre 83% East 76% 1: Source: European Centre for Disease Prevention and Control. Thematic report: Continuum of HIV care. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2017 progress report. Stockholm: ECDC; 2017 2: Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data. 3: Population estimate source: https://en.wikipedia.org/wiki/List_of_European_countries_by_population Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data. *Latest available data reported, ranging from 2014-2017.

Ticking the boxes Diagnosis has to be a system of responses. It is about giving people choices they are comfortable with to get tested. A series of boxes have to be ticked – with good monitoring: – Indicator conditions, - Pregnant women, - PICT on geographical hotspots, - Community located AND community participated VCT adjusted to your epidemics, - Self testing/Self sampling, - Partner notification and contact tracing – Responses for those out of the box – specific services for specific needs (mind the overlaps – chemsex and HR)

Are new innovative approaches to HIV testing included in national HIV testing guidelines? (n=55) Testing approaches Yes No No response Community-based testing delivered by trained medical staff 28 12 15 Community-based testing delivered by non-medical staff (e.g. trained lay people) 14 26 Home-sampling kits 4 36 Self-testing kits 9 32 Up from 2 in 2017 Source: Dublin Declaration monitoring 2018; validated unpublished data.

Implementation of community-based testing by trained medical staff in Europe and Central Asia, 2018 Implementation of community-based testing by lay providers in Europe and Central Asia, 2018 Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.

Implementation of self-testing in Europe and Central Asia, 2018 Implementation of self-sampling in Europe and Central Asia, 2018 Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.

Keep in mind We need to give people choices (how to test, where to test, who tests); Meaningful participation is crucial! Health is our priority but it is not the priority of many people due to circumstances of life - Social determinants; Integration – other diseases (HCV, HBV, STI, TB), other responses, other stakeholders People are not as square as boxes (most people at least) – We need tailored responses; End repression, stigma and discrimination. Source Portuguese Community Based Screening Network data, 2016-2017 (unpublished data). Source: Portuguese Community Based Screening Network data, 2016-2017 (unpublished data).

An advocacy/protest break #JustSayNo #ChaseTheVirusNotPeople

Some technicalities

Missing data or did not report Late diagnosis, 2016, EU/EEA % persons with CD4 <350 cells/mm3 at HIV diagnosis >50% 30 to <40% <30% Missing data or did not report 40 to <50% EU/EEA Average: 48% Non-visible countries Luxembourg Malta Source: ECDC/WHO (2017). HIV/AIDS Surveillance in Europe 2017– 2016 data

Comparison of the continuum of care for key populations, 2018 Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.

Comparison of the continuum of care for key populations against national continua, 2018 Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.

In sum… End legal and social repression and stigma; Know your epidemics to design your responses; Information and literacy are crucial; Give people choices of where to go where they feel good, and that respond to their needs; Tick the boxes and remember: one size does not fit all; Many things have been tried: look up results and speak to who did them; Involve communities every step of the way! However…

Are sufficient funds available for HIV prevention to decrease the number of new infections in your country? 2018 Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.

Harder, Better, Faster, Stronger Closing remarks (1)2 years to go Harder, Better, Faster, Stronger Daft Punk, 2001

Acknowledgments ECDC Dublin team, especially Teymur Noori Luís Mendão @GATVIH The Community Based Screening Network team in Portugal HIV in Europe team

Thank you!