The Current Situation of the HIV Epidemic in France An ANRS Report Reviews the 2013 – 2018 Period
The "Indicators" group working within ANRS Coordinated Action 47 has prepared a report giving an overview of HIV infection in France between the years 2013 and 2018. This report, which is based on the various data derived from surveillance systems, surveys and modelling, was published on July 8, 2020 on the ANRS website.
Although the HIV epidemic has been on the decline in France since 2018, this trend differs between regions and populations. The epidemic was concentrated in Île-de-France (40% of new diagnoses in 2018) and in two populations: men who have sex with men (MSM) (41.6% of new diagnoses) and populations born abroad, particularly heterosexuals born in sub-Saharan Africa (32.5%). Heterosexual women and men born in France accounted for 14.2% of new diagnoses in 2018.
The authors highlight the still-too-slow progress in recent years and the need for powerful, proactive action to halt HIV transmission by 2030.
New diagnoses, which are subject to mandatory reporting, constitute the central indicator for monitoring the evolution of HIV infection. They are the result of trends in the incidence of infection, the combined effects of testing, treatment and prevention, and also demographic changes, particularly international migration. It is these processes that the "Indicators" group within Coordinated Action 47 "Dynamics and Control of HIV and Hepatitis Epidemics" at ANRS have analyzed simultaneously in order to understand the trends observed in new diagnoses by group and by region.
An uneven downward trend across regions...
After a few years of relative stability, the number of new diagnoses in 2018 decreased by 7% in comparison with 2017 (6,155 versus 6,583).
The national trends were accentuated in Île-de-France (40% of new diagnoses in 2018), while Nouvelle-Aquitaine and Auvergne-Rhône-Alpes – two major regions reporting the national metropolitan situation outside of Île-de-France – presented stable indicators of new diagnoses.
... and population groups
Between 2013 and 2018, for people born in France, incidence estimates that reflect the "actual" epidemic, i.e. when new infections occur, were on the decline among MSM and heterosexual men, and were stable among women. These trends were marked in Île-de-France and even more so in Paris.
According to the authors of the report, "increased testing began to reduce the number of undiagnosed HIV-positive MSM and within the heterosexual population born in France."
For heterosexual populations born abroad (for the most part in sub-Saharan Africa), the situation improved for men, but remained a concern for women. Following an increase between 2013 and 2016, new diagnoses among women were stable between 2016 and 2018, but the estimated incidence was on the increase. This was also the case for foreign-born MSM.
Interpreting changes in incidence is more complex for foreign-born populations, "because of the failure to disentangle what is due to the size of recent migration flows, the contexts of exposure prior to migration and on the journey to Europe, and what is due to increasingly difficult living conditions after arrival", the authors of the report say.
Progress in all areas of combination prevention remains insufficient
Combination prevention, which includes testing, antiretroviral treatment for people living with HIV, condom use and pre-exposure prophylaxis (PrEP), is the current paradigm in the fight against HIV. Positive developments were observed for all of these components between 2013 and 2018.
The preventive effect of treatment through control of viral load is fully effective when those diagnosed have entered a care route and are receiving treatment, with very small differences between populations and regions.
Testing is the key to entering such a treatment cascade. Serological testing increased from 11 to 14% in all regions over the period, with the number of tests performed increasing from 5.2 to 5.8 million. In 2018, the rate of positive results was on the decline nationally and in Île-de-France but remained stable elsewhere. HIV testing activity at the centers for free information, testing and diagnosis (CeGIDDs) was stable over the three last years (322,000 tests in 2018). Similarly, community-based testing using rapid HIV tests (TROD), deployed among high-risk groups where they live and meet, was stable. In 2018, approximately 65,000 such tests were conducted, with high rates of positive results. The density and diversity of the testing offered were higher in Île-de-France than in the rest of the country.
Sales of self-tests changed little between 2016 and 2018 (74,000 tests sold in 2018), then picked up again in 2019 with the launch of a cheaper product (79,500 tests sold in 2019).
The researchers consider that "in all the groups, the time from infection to diagnosis was still too long. Several thousand people are living with an unknown and potentially transmissible infection. However, with the exception of foreign-born MSM and women born in sub-Saharan Africa, their numbers were declining in all of the other groups, but not fast enough to rapidly reduce the undiagnosed infected population."
PrEP, an effective measure to be deployed more widely
According to the report, testing can only increase moderately, even when measures and recommendations to expand and repeat testing are diversified. That is why protection against contracting HIV must remain high across all measures and improve for PrEP.
Among the MSM population, while condom use with casual partners decreased in recent years, the level of protection increased with PrEP. This has had a very marked effect, particularly in Paris where it was deployed among MSM earlier, notably under the impetus of the ANRS IPERGAY trial (read below) and the establishment of the ANRS Prévenir cohort (read below). Access has improved thanks to the participation of the CeGIDDs. The renewal – and soon the possibility to initiate – prescriptions in the community medicine setting is also expected to contribute to this. The more marked acceleration in the deployment of PrEP since the second half of 2018, particularly outside Île-de-France, is expected to impact data on the epidemic in 2019 and 2020.
There are still very few heterosexual PrEP users. Those who need it could benefit if promotion – hitherto non-existent – were to be undertaken.
Acting locally and in context: the keys to success by 2030
The authors of the report conclude that "accelerating the decline of the epidemic in the various groups must be supported by a more proactive choice within local and context-specific programs. The overall performance of combination prevention (effective access to testing, treatment and PrEP) will be critical to achieving control of the epidemic". The objective of halting HIV transmission by 2030 remains valid provided that programs resume after the COVID-19 crisis and innovate.
The Director of the ANRS, Prof. François Dabis, praised the work of the AC47 "Indicators" group: "We needed a summary of this nature to serve as a progress report and guide for future research. It is the role of the ANRS to contribute to analyzing and contextualizing the indicators of the HIV epidemic and, ultimately, provide solid arguments to perfect the combination prevention mechanisms. This report shows that by combining all available data, the evolution of the epidemic can now be measured. If we give ourselves the means to do so, we can seriously envisage bringing it under lasting control by 2030. And our course will not be changed by the current health crisis."
The ANRS IPERGAY trial studied PrEP on demand at the time of sexual risk exposure and was conducted in France and Canada in 400 HIV-negative MSM. From 2012 to 2014, its first phase was conducted under double-blind conditions: half of the group took an oral tablet containing two antiretroviral drugs (TDF/FTC combination) at the time of sexual intercourse, the other half a placebo. On-demand PrEP was shown to reduce the risk of HIV infection by 86%. The second phase, during which the volunteers all received PrEP, started as soon as the initial results were published at the end of 2014 and ended in June 2016. It showed a 97% relative reduction in the incidence of HIV.
The ANRS Prévenir cohort, initiated in May 2017, is a continuation of the ANRS IPERGAY trial. More than 3,000 HIV-negative volunteers at high risk of HIV infection have been recruited in Île-de-France. Prevention based on daily PrEP or on demand is offered to them.
For more information
Épidémiologie de l’infection VIH en France – 2013-2018. Tendance et contribution de la prévention combinée (dépistage, traitement antirétroviral des PVVIH, prévention par le préservatif et la PrEP)
ANRS, Coordinated Action "Dynamics and Control of HIV and Hepatitis Epidemics", President: Dominique Costagliola.
Françoise Cazein, Florence Lot, Nathalie Lydié, Annie Velter (Santé publique France), Lise Marty, Virginie Supervie, Dominique Costagliola (IPLESP, Inserm), Rosemary Dray-Spira (Epi-Phare, Ansm-Cnam), Valérie Féron, Isabelle Grémy (ORS Île-de-France, Institut Paris Région), Frédéric Goyet (ARS Île-de-France), France Lert, Véronique Doré (ANRS).
President of Coordinated Action 47
Séverine Ciancia and Cécile Pinault