HIV Combination Prevention Associated with Sharp Drop in Diagnoses

A combination of HIV prevention methods—including pre-exposure prophylaxis (PrEP), early HIV diagnosis through frequent testing and timely antiretroviral therapy for treatment as prevention – was associated with a sharp drop in HIV transmission among gay, bisexual and other men who have sex with men, a new study found.

The study, published in HIV Medicine, evaluated HIV prevention measures at 56 Dean Street, which is a part of Chelsea and Westminster Hospital NHS Foundation Trust in London.

“We witnessed an 80% reduction in the number of HIV diagnoses between 2012 and 2017, following the introduction of a number of HIV prevention measures (PrEP introduction, early HIV diagnosis through frequent and facilitated access to HIV testing and timely ART used as treatment-as-prevention) were key to the success of this model,” lead author Nicolo Girometti, MRCP, DipHIV, a consultant in HIV medicine at 56 Dean Street, Chelsea and Westminster NHS Foundation Trust, told Contagion.

56 Dean Street began offering care related to sexually transmitted infections and HIV in March 2009. In February, 2014, a second location, Dean Street Express, opened to manage asymptomatic patients, starting with a focus on screening, with routine ART initiation added in 2016 and PrEP added in October 2017.

“We were humbled to see how the introduction of rapid ART start allowed on one hand to reduce drastically the time to viral suppression (from a median of 520 days to 79 days in 6 years) and on the other hand to see a high uptake of rapid ART initiation with consistent levels of retention in care,” Girometti said

The average number of HIV tests performed at Dean Street increased from 4,732 per quarter in 2012 to 10,362 per quarter in 2017, with the sharpest increase coming when Dean Street Express opened. In 2017, 43 percent of patients were tested for HIV more than once a year, up from 25% in 2012, and the number of patients who tested at least 3 times a year rose from 957 to 4,553.

“The increase in HIV testing was permitted only through the adoption of a flexible model based on a strategic location of the clinic, a policy of openness and engagement with the local community in the attempt of attracting high-risk populations and the setup of free services offering rapid testing with a rapid turnaround,” Girometti said.

A total of 2111 patients were diagnosed with HIV during the 6-year study period, with 31 cases reported in the last quarter of 2017, down from a peak of 128 cases diagnosed in the first quarter of 2015. The median number of days between diagnosis and ART initiation was 7 days in 2017, down from 317 days in 2012.

The study authors noted that the clinic’s location in the heart of the London gay scene, engagement with the local community and social media campaigns contributed to the success of the program.

Research is ongoing to improve HIV prevention and care. In 2018, 56 Dean Street initiated a case-note review to discuss risk reduction and began offering opt-out PrEP initiation for high-risk patients, according to an article in The Lancet. Efforts to increase the accessibility of PrEP at 56 Dean Street have previously been associated with decreases in HIV infections.

“We intend to monitor the trend of HIV infections following the wider introduction of PrEP which started happening in 2018 and will try to establish the impact of SARS-CoV-2 pandemic in testing rates and ultimately HIV diagnoses,” Girometti said.

The Dean Street Express model has drawn attention in the past, including at the Centers for Disease Control and Prevention 2016 STD Prevention Conference.