1. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Factors associated with acute HIV infection diagnosis in MSM ANRS-Opportunity study Karen Champenois, Stéphane Le Vu, Lise Cuzin, Caroline Semaille, Yazdan Yazdanpanah Inserm U738, équipe ATIP-Avenir, Paris, France MOAC0103

2. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Relevance of HIV testing “Whatever … scientifically proven HIV treatment or prevention strategies (PreP / TasP) they will share a common denominator for implementation: the HIV test. They all begin with learning one’s HIV status.” Walensky et al. Plos Med 2011 discussed

3. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Unawareness of HIV infection in France Supervie et al. HIV in Europe Conference 2012, Copenhaguen

4. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Unawareness of HIV infection in France and transmission of HIV Supervie et al. HIV in Europe Conference 2012, Copenhaguen (adapted from Marks et al. AIDS 2006, with French estimated data)

5. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 HIV transmission risk according to the stages of HIV disease and viral load Galvin et al., Nat Rev Microbiol, 2004

6. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Objective To identify factors associated with diagnosis at acute HIV infection stage in MSM in France

7. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Source of data The ANRS – Opportunity study Objective: Identify missed opportunities for HIV testing –within healthcare settings encounters –in patients with newly diagnosed HIV infection HIV diagnosis 3 years 7 Champenois et al. BMC Infect Dis 2013

8. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 ANRS – Opportunity study, methods Study design Cross-sectional study 69 HIV care centers 06/2009 - 10/2010 Administred questionnaire Study population Age ≥18 years Living in France for ≥1 year Newly HIV diagnosed infections (≤6 months of care initiation) HIV diagnosis in France 8 University hospital Non university hospital

9. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 The ANRS – Opportunity study population (n=1,008) New HIV diagnoses Enrolled n=1,008 France 2010* n=6,300 HIV risk group, n (%) Man who have sex with men530 53%40% Migrant from sub-Saharan Africa124 12%30% Injecting drug user 12 1% 1% Others342 34%29% *Cazein et al. BEH 2011

10. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 HIV-infection stage at diagnosis among 530 MSM enrolled in the Opportunity study EIA+ or last neg test >3 mo CD4 cell counts >200/µL no AIDS incomplete western blot or Agp24+ or RNA+ with EIA- or last negative test <3 months EIA+ or last neg test >3 mo CD4 cell counts ≤200/µL or AIDS

11. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Comparison of MSM diagnosed at acute stage vs. chronic stage  Multivariate logistic regression model

12. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Demographic characteristics HIV-infection stage at diagnosisUnivariate analysis Chronic (N=297)Acute (N=111) OR IC95%p Age at diagnosis, years.78 18-29 8529%3532% 1.12 [0.69-1.83] 30-5018061%6659% 1 >50 3211%10 9% 0.85 [0.39-1.83] Educational attainment.05 High school level 9833%2422% 0.60 [0.35-1.04] Post graduate (2 years)14348%5852% 1 Post graduate (>2 years) 5418%2825% 1.28 [0.73-2.22] Marital status.06 In couple 9231%2422% 1 Alone20368%8677% 1.62 [0.96-2.72] Values do not sum to 297 and/or 111 because of missing data

13. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Sexual behaviour HIV-infection stage at diagnosisUnivariate analysis Chronic (N=297)Acute (N=111)ORIC95%p Self defined sexuality.36 Homosexual only23479%9081%1 Bisexual 6020%2119%0.91[0.52-1.58] No definition 3 1% 0NA Number of sexual partners during the 3 previous years.02 <14 partners15051%4641%1 15-29 partners 4816%2119%1.43[0.77-2.63] ≥30 partners 6622%3229%1.58[0.92-2.71] Condom use with casual partners during the 3 previous years.62 Systematically13345%4641%1 Not systematically14649%6155%1.21[0.77-1.90] No casual partners 14 5% 4 4%0.82[0.25-2.64] Values do not sum to 297 and/or 111 because of missing data; NA: not available

14. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Who intiated the test leading to HIV diagnosis? *Others: relatives, friends, NGOs, etc… %

15. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 History of HIV testing No. tests in the 3 previous years / history of testing Variable created to combine the history of HIV testing and the number of test in the 3 years prior to HIV diagnosis:

16. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 History of HIV testing No. tests in the 3 previous years / history of testing Variable created to combine the history of HIV testing and the number of test in the 3 years prior to HIV diagnosis: Tested never or rarely: 0 test lifetime or >3 years ago

17. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 History of HIV testing No. tests in the 3 previous years / history of testing Variable created to combine the history of HIV testing and the number of test in the 3 years prior to HIV diagnosis: Tested never or rarely: 0 test lifetime or >3 years ago Tested occasionally: >1 test 1 to 3 years ago

18. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 History of HIV testing No. tests in the 3 previous years / history of testing Variable created to combine the history of HIV testing and the number of test in the 3 years prior to HIV diagnosis: Tested never or rarely: 0 test lifetime or >3 years ago Tested occasionally: >1 test 1 to 3 years ago Tested regularly: tested ≤1 year and 1-3 tests

19. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 History of HIV testing No. tests in the 3 previous years / history of testing Variable created to combine the history of HIV testing and the number of test in the 3 years prior to HIV diagnosis: Tested never or rarely: 0 test lifetime or >3 years ago Tested occasionally: >1 test 1 to 3 years ago Tested regularly: tested ≤1 year and 1-3 tests Testing very frequently: tested ≤1 year and >3 tests

20. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 History of HIV testing

21. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Factors associated with HIV diagnosis at acute stage (multivariate analysis) n=401aORIC95%p Who initiated the HIV test leading to diagnosis?.0007 The patient himself1 The physician2.50[1.48-4.21] Others*0.39[0.08-1.79] History of HIV testing<.0001 Tested never or rarely1 Tested occasionally1.83[0.86-3.84] Tested regularly5.02[2.27-11.06] Tested very frequently8.34[4.00-17.37] *Others: relatives, friends, NGOs, etc…

22. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Discussion Diagnosis at acute HIV infection stage is associated with HIV–test initiated by healthcare providers –42% of patients diagnosed in acute stage vs. 29% of those diagnosed in chronic stage  Inform and train healthcare providers to Symptoms related to HIV infection HIV testing: systematic offer, regular offer for HIV exposed population Acute infection: HIV RNA measure rather than EIA test Champenois et al. BMC Infect Dis 2013; Yazdanpanah at al. Plos One 2010

23. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Discussion Diagnosis at acute HIV infection stage is associated with History of testing: recent and frequent –Promote different HIV testing strategies Care provider-based HIV testing Community-based VCT Out-reach rapid testing in sex venues … Champenois et al. BMJ Open 2012; Greacen et al. AIDS Care 2012

24. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Discussion Strengths and limitations –Enrollment of 1/5 MSM newly HIV diagnosed in France Results extrapolated to MSM who live in France –Study not designed especially for MSM and had another main objective Sexual behaviour could not be studied in detail

25. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Conclusions 21% of MSM were diagnosed at acute HIV-infection stage How to improve early HIV testing in MSM? Promote HIV–test initiated by healthcare providers –Improve knowledge and training Promote repeated testing in MSM –Recommendations of >1 test / year –Extend HIV-testing offers –Complementarity strategies

26. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Acknowledgments Financial support: ANRS, InVS Healthcare providers and patients who collaborated / participated to the ANRS - Opportunity study

27. www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Estimation of HIV infection incidence in France by transmission group Femmes hétérosexuelles étrangères Hommes hétérosexuels étrangers Femmes hétérosexuelles françaises Hommes hétérosexuels français Usagers de drogues injectables Hommes qui ont des rapports sexuels avec des hommes Années Nombre de nouvelles infections à VIH Ndawinz et al. AIDS 2011; Le Vu et al. Lancet Infect Dis 2010 MSM Incidence 60-fold higher than overall population 31% of the hidden epidemic (~9,000 / 29,000)