Dominique Van Beckhoven

BACKGROUND: With improvements in test sensitivity and testing frequency, more people in Europe are diagnosed during the HIV acute/seroconversion phase, when their CD4 ⁺ T-cell count can be temporarily low. AIM: We piloted a revised definition of late HIV diagnosis for surveillance which considers laboratory markers, evidence of HIV test negativity in the past year and clinical evidence of recent HIV acquisition, to better distinguish between people diagnosed late and those diagnosed during the acute/seroconversion phase. METHODS: We collected pseudonymised HIV diagnosis records for 2022 and 2023 from nine European countries (Belgium, Czechia, Denmark, Germany, Greece, Italy, the Netherlands, Portugal and Sweden). We applied the revised definition to reclassify those with evidence of recently acquired HIV as 'not late' and calculated the corresponding correction factor by country and demographic group. Individuals with a previous diagnosis were excluded from the analysis. RESULTS: Among 10,220 individuals with a CD4 ⁺ T-cell count at diagnosis, 56% (5,689/10,220) had a CD4 ⁺ T-cell count < 350 cells/µL or an AIDS-defining event at diagnosis. Applying the revised definition reduced the late diagnosis proportion from 56% to 50%, a correction factor of 9% (535/5,689). The correction factor ranged between 3% and 25% across countries and was higher for younger ages and for gay, bisexual and other men who have sex with men, compared with other groups. CONCLUSIONS: Without reclassification, late HIV diagnosis proportions are overestimated. We provide recommendations and validity considerations for countries intending to use the revised definition.

Introduction: In border regions like the EuRegio Meuse‐Rhine (EMR), mobility does not stop at the border. HIV risk may therefore not only be determined by within‐country factors but also by between‐country differences. We explored between‐country differences in HIV indicators in the EMR using two complementary data‐driven approaches. Methods: First, we used 2019–2021 surveillance data from the German Robert Koch Institute, the Belgian Health Institute Sciensano and the Dutch HIV Monitoring Foundation to report on the EMR‐specific 95‐95‐95 goals. Second, we used the cross‐sectional EMIS‐2017 survey, including (trans)men who have sex with men (MSM), to report on determinants of HIV testing in the EMR. We employed multilevel multinomial regression modelling to identify sociodemographic factors associated with recent (n = 1335/2669) tested recently, 26% tested not‐recently ( n = 693) and 24% ( n = 641) never tested for HIV; with 8% of HIV‐testing variance explained by between‐country differences. Non‐recent and never‐testing were both associated with socio‐demographic factors, suggesting that some key populations (e.g., with transgender identity) and lack of resources determined differences in HIV testing. Conclusion: Targeted approaches to address regional and socio‐demographic differences are urgently needed, especially to tackle HIV‐testing barriers and reach individuals undiagnosed.

The international spread of HIV-1 sub-subtype A6 raises concerns due to its association with contraindications for long-acting injectable formulations of cabotegravir (LA-CAB) and rilpivirine (LA-RPV). This study investigated its increasing proportion in Belgium, assessing transmission dynamics and potential migration links. Additionally, genotypic drug resistance in the Belgian HIV-1 sub-subtype A6 population were analyzed and four automatic subtyping tools were compared. A dataset of 4764 HIV-1 protease and reverse transcriptase (RT) sequences from newly diagnosed, treatment-naïve individuals in Belgium (2013–2022) was analyzed. A combination of phylogenetic analysis and online subtyping tools identified 136 sub-subtype A6 sequences. The increase in the proportion of HIV-1 sub-subtype A6 observed in Belgium since 2020 reflects changing transmission patterns, especially among Belgium-born men having sex with men, and cannot be solely linked to the recent influx of Ukrainian migrants. Of these sub-subtype A6 sequences, less than 10% showed LA-CAB + LA-RPV resistance, mainly due to E138A within RT. HIVdb and ANRS reliably assessed resistance in this therapy-naïve cohort, and HIVdb, COMET, and SmartGene^® produced concordant subtyping results. While algorithm choice has little impact at low resistance prevalence, further research is necessary and HIVdb and ANRS remain more suitable for ongoing clinical and research use.

Introduction: This study provides a comprehensive overview of HIV care by combining cross‐sectional and longitudinal continuum of care (CoC) analyses.Methods: Using national surveillance data 2014–2022, a five‐stage cross‐sectional CoC was calculated among people living with HIV (incl. undiagnosed): diagnosed, linked to care, retained in care, on antiretroviral therapy (ART) and virally suppressed. For the longitudinal CoC, cumulative incidences (CI) were calculated for each transition.Results: The study included 26 191 people living with HIV. By the end of 2022, an estimated 18 302 persons were living with HIV in Belgium. Of these, 92.1% were diagnosed, 90.9% linked to care, 89.2% retained in care, 87.9% on ART and 85.6% virally suppressed. One‐year post‐infection diagnosis rates were 38% (2014–2016), 33% (2017–2019) and 31% (2020–2022), with differences disappearing after correction for immigration timing. Time from diagnosis to care entry remained stable at 82% within 3 months. Time to ART initiation and to viral load suppression reduced substantially, with 3‐month CIs rising from 69% and 71%, respectively (2014–2016), to 91% and 77% (2020–2022). Transitions between all stages of care were the fastest among Belgian men who have sex with men. People who inject drugs had the lowest CI for care entry and viral suppression. Cumulative incidences of ART initiation increased substantially for all key populations, exceeding 90% within 3 months in 2020–2022, except for non‐Belgian heterosexuals (87%).Conclusion: A steady improvement in the CoC places Belgium close to the joint united nations programme on HIV/AIDS 95‐95‐95 targets, although populations like people who inject drugs and migrants still face significant barriers to care. Timely diagnosis by supporting existing and innovative testing strategies should be prioritized.

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Background: To gain insight into the impact of the COVID-19 pandemic and containment measures on the HIV epidemic and services, this study aims to describe HIV trends in 2020 and compare them with previous years.Methods: Belgian national HIV surveillance data 2017–2020 were analysed for trends in HIV testing, HIV diagnoses, VL measurements, ART uptake and PrEP purchase. Descriptive statistics from 2020 are compared to annual averages from 2017 to 2019 (proportional difference, %).Results: In 2020, 725 HIV infections were diagnosed in Belgium (− 21.5% compared to 2019). The decline was most pronounced during the first lockdown in April–May but also present in July–December. The number of HIV tests performed decreased by 17.6% in 2020, particularly in March–May and October–December (− 57.5% in April and -25.4% in November 2020 compared to monthly 2017–19 numbers). Diagnosis of acute HIV infections decreased by 47.1% in 2020 (n = 27) compared to 2019 (n = 51). Late HIV diagnoses decreased by 24.7% (95% CI [− 40.7%; -9.7%]) in 2020 compared to 2019. Of patients in care in 2019, 11.8% interrupted HIV care in 2020 compared to 9.1% yearly in the 3 previous years. The number of HIV patients with VL monitoring per month dropped in March–May 2020, whilst proportions of VL suppression and ART coverage remained above 86% and 98.5% respectively in 2020. PrEP purchases, number of purchasers and starters dropped during April–May 2020 (respectively − 45.7%, − 47.4%, − 77.9% in April compared to February 2020).Conclusions: The significant decrease in HIV diagnoses in Belgium in 2020 coincided with the COVID-19 pandemic and following containment measures, particularly in April–May during the first lockdown. A slowdown of HIV transmission due to reduced HIV risk exposure is suggested by the halving in diagnosis of acute HIV infections in March-December 2020 compared to the previous year, and the adaptive decrease in PrEP use and PrEP initiation from April onwards. Despite a slight increase in HIV care interruptions, the indicators of quality of HIV care remained stable. Access to prevention, testing and care for all people living with HIV and at risk of acquiring HIV is a priority during and after times of pandemic.

Introduction: In recent years, HIV testing frequency has increased, resulting in more people being diagnosed during seroconversion with a temporarily low CD4 count. Using the current consensus definition of late HIV presentation ('presenting for care with a CD4 count < 350 cells/μL or an AIDS‐defining event, regardless of CD4 count') these individuals would be incorrectly assigned as being diagnosed late.Methods: In spring 2022, a European expert group convened to revise the current late HIV presentation consensus definition. A survey on data availability to apply this revised definition was sent to nominated European focal points responsible for HIV surveillance (n = 53).Results: Experts agreed that the updated definition should refer to late HIV diagnosis rather than presentation and include the following addition: People with evidence of recent infection should be reclassified as 'not late', with evidence of recent infection considered hierarchically. The individual must have: (i) laboratory evidence of recent infection; (ii) a last negative HIV test within 12 months of diagnosis; or (iii) clinical evidence of acute infection. People with evidence of being previously diagnosed abroad should be excluded. A total of 18 countries responded to the survey; 83% reported capturing CD4 count and/or AIDS at diagnosis through national surveillance, 67% captured last negative test and/or previous HIV diagnosis, 61% captured seroconversion illness at diagnosis and 28% captured incident antibody results.Conclusions: Accurate data on late diagnosis are important to describe the effects of testing programmes. Reclassification of individuals with recent infection will help to better identify populations most at risk of poor HIV outcomes and areas for intervention.