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Thematic report HIV continuum of care. Monitoring implementation of the Dublin declaration on partnership to fight HIV-AIDS in Europe and Central Asia 2014.

November 13, 2016


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Since the spectrum of engagement in HIV care was first described in the United States, there has been a growing interest in the HIV continuum of care as a means of monitoring delivery of care for people living with HIV and assessing the extent to which viral suppression is occurring among them. This, in turn, contributes to efforts to further reduce HIV transmission. Although a number of European countries have reported on the HIV continuum of care, attempts to compare and aggregate data across countries have been hampered by different approaches to data collection, a lack of standard definitions for the elements of the continuum and significant gaps in data.

Since 2010, the European Centre for Disease Prevention and Control (ECDC) has been leading a process to monitor the implementation of the 2004 Dublin Declaration concerning the response to HIV in Europe and Central Asia. The process involves up to 55 countries submitting reports every two years. In the 2014 reporting round, a number of questions were included relating to the continuum of care. A total of 48 countries submitted questionnaire responses. As part of the data validation process, ECDC followed up on the data submitted by countries in the European Union and European Economic Area (EU/EEA). This resulted in some further data submission and clarification by reporting countries.

Figures were available on at least one element of the care continuum in responses from 40 countries (73%). Countries were better able to report on the number of people diagnosed with HIV and the number on antiretroviral therapy (ART) than other categories. Most countries reported population-based data, although a few reported data from cohort studies. There was wide variation in how continuum elements were defined, particularly regarding ‘linked to’ and ‘retained in’ care.

Using a definition proposed in the literature of a breakpoint in the continuum as a drop between elements of ≥19%, the most common breakpoint (78% of countries with data) related to diagnosing people with HIV. Breakpoints were also fairly common for linking those diagnosed to care (41% of countries with data) and getting those retained in care onto treatment (48%). Few countries reported breakpoints for retaining people in care or ensuring that those on ART were virally suppressed. The HIV continuum of care could be useful to the countries of Europe and Central Asia in monitoring both provision of care and treatment for people living with HIV and the effects that such treatment may have on the further transmission of HIV. For example, analysis of a country’s continuum of care can reveal which breakpoints are particularly important in that country.

The data can also be used to assess the extent to which countries are meeting the 90–90–90 targets proposed by the Joint UN Programme on HIV/AIDS (UNAIDS). Figures show how challenging it will be to meet these targets, with only one country currently meeting the criteria. There is also wide variation in the extent to which countries in Europe and Central Asia are ensuring that people living with HIV are virally suppressed. In general, countries in the western parts of the region are achieving higher levels of viral suppression than those in eastern parts.

Cross-country comparisons, while difficult because of data issues, reveal very large differences between countries in different parts of the region. These are very difficult to explain in terms of methodological variation alone. A four-point continuum may be more feasible and relevant to the region for monitoring purposes than the current six-point continuum. Data reporting is likely to increase if ECDC introduces a system of regular country reporting on these elements. To do this, it may be helpful to use shared, standard definitions as there are currently wide variations in how terms are defined and how data are collected.

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