On the occasion of World AIDS Day on 1is December, UNAIDS published an encouraging annual report on the state of the pandemic: 2023 is a very positive year with the lowest point of new HIV infections since the late 1980s. And some 31 million people have received antiretroviral therapy (ARV) in 2023, which helped reduce the number of AIDS-related deaths to its lowest level since 2004. Despite this, the agency UN alert: “the world is not on track to eliminate AIDS as a public health threat by 2030”. Last year, 9.3 million people living with HIV did not receive ARVs and 1.3 million new infections were reported.
In France, screening is a weak point in the fight against HIV. To remedy this, since 2016 HIV self-tests (ATVIH) have been available in pharmacies, as well as in certain associations since the Covid-19 pandemic. On January 1, 2022, the HIVTest system was also introduced, allowing you to be tested in medical biology laboratories without a prescription and with full coverage by Health Insurance. In its weekly bulletin of November 26, Public Health France (SPF) reports the effect of these two devices on the evolution of the use of screening and the profile of users.
HIVTest is popular among men and 40-59 year olds
Despite a slow ramp-up, the deployment of the HIVTest system is accelerating across the country: the share of tests without a prescription increases from 5% of total tests reimbursed in 2022 to almost 15% in 2023. Prescription or not, just over 251,000 tests were reimbursed in 2022, a figure multiplied in 2023 to nearly 841,500.
According to the demographic analysis of users, 25-39 year olds are tested the most but rather on prescription: they account for only 12% of HIVTests. Conversely, the system is popular with 40-59 year olds whose share in HIVTest is 36.6% and those over 60 who go from 16% in 2022 to 25% in 2023. If women have more use of HIVTest (and HIV testing in general), it is men who favor this system the most compared to prescription tests.
Thus, HIVTest appears to recruit a population initially less affected by pre-existing screening offers. “Even if one of the objectives of the HIVTest system is to extend screening to populations who were previously far from testing”the SPF study invites us to get closer to the recommendations of the High Authority of Health (frequency adapted to the risk).
Laboratories play a central role in the promotion and deployment of HIVTest
The analysis by region shows territorial disparities, a heterogeneity which highlights the central role played by laboratories in the promotion and deployment of HIVTest. Indeed, in the regions where the promotion of the system by the laboratories seemed most active (for example a systematic offer of HIV screening), the offer made it possible to recruit a population which had previously escaped screening.
The self-test finds its audience among men less accustomed to screening
Sold at around 65,000 units per year in France, HIV self-tests were used by 14.3% of men between 2022 and 2023, 4% during their last test, within a panel of 10,500 men. Not representative of the population, this sample nevertheless highlights how the different screening methods can be used.
The factors associated with greater use of ATVIH are: a level of education equivalent to the baccalaureate or lower (adjusted odds ratio ORa = 1.32), the existence of financial difficulties (ORa = 1.26), the use regular use of gay dating apps (ORa=1.5), not being regularly followed by a doctor (ORa=1.5) and having several HIV tests per year (ORa=1.8). This result contrasts with what is observed for the overall use of HIV testing, which is less reported by men with low education. However, the investigation cannot identify the causes.
The results of this survey confirm the potential of ATVIH in the infection eradication strategy and its appeal for populations less in contact with the health system. For SPF, “access to self-tests is an integral part of access to the healthcare system and their provision must be considered as an element of public health action aimed at diversifying access to screening to reduce the number of people unaware of their serological status ».
The majority of patients at the AIDS stage have not been screened or treated
The estimated number of AIDS cases in France decreased from 2012 (around 1,200 cases) until 2020 (around 750), then stabilized around 800 cases per year. Between 2012 and 2023, 62% of AIDS diagnoses were made in people unaware of their HIV status and 18% in people who knew their HIV status but had not received antiretrovirals. For the remaining 20%, diagnosed and treated, the cause could be explained by the circumstances in which the treatment was taken: type, methods of taking it, duration, compliance, interruptions, possible resistance, etc.
More than two thirds (69%) of people who developed AIDS between 2012 and 2023 were cisgender men and the proportion of people over 49 increased over the period. The vast majority (82%) of AIDS cases among those aged 15 and over were diagnosed with less than 200 CD4/mm3. Between 2012 and 2023, 84% of diagnoses were declared with a pathology indicative of isolated AIDS, notably pulmonary pneumocystosis (PCP, 27%). For the 16% with multiple pathologies, the proportion increased from 2016 (11%) to 2021 (21%), the most frequent association being PCP and esophageal candidiasis (14%).
The occurrence of the AIDS stage mainly in people who were unaware of their HIV status underlines the importance of improving screening in the fight against AIDS. In addition, AIDS diagnoses in people who know their HIV status but are not treated show that strengthening the link to care remains necessary.
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