HSE Position on Antiretrovial Therapy for all people living with HIV

The HSE have released a document laying out the HSE’s position on the use of antiretroviral therapy (including TasP) for HIV infected people attending HIV services in Ireland. In it the HSE recommends that all HIV infected individuals attending HIV services in Ireland are offered antiretroviral therapy as soon as possible and are informed of the benefits of antiretroviral therapy in reducing HIV infectiousness (TasP) and improving personal health.

The overarching vision of Ireland’s first sexual health strategy, launched in October 2015, was to improve sexual health and wellbeing and reduce negative sexual health outcomes. With respect to HIV, action was called to reduce the number of new infections and ensure the health and wellbeing of those living with HIV. These requirements were reflected in two of the priority actions in the strategy, specifically:

“Assessing, developing and implementing guidance on (STI and) HIV testing in various settings to improve access and ease of testing and to include guidance on home based testing and the use of point of care HIV testing.”

“Develop and implement guidance to support the appropriate use of antiretroviral therapy in HIV prevention.”

Antiretroviral therapy can be used for HIV prevention by treating those with established infection, known as Treatment as Prevention (TasP); through administration to those at risk of infection (Pre exposure prophylaxis, PrEP); or administration to those who may have been exposed to infection (Post exposure prophylaxis, PEP). National guidelines for the use of PEP have been in place since 20122 . There are no national guidelines for the use of TasP and PrEP. In Ireland, in accordance with the Infectious Diseases Regulations, there is no charge to an individual for the treatment of HIV.3 4

Current HIV care and practice in Ireland

In Ireland, HIV care is currently provided in nine hospital settings. Adult care is provided in Cork (Cork University Hospital), Dublin (Beaumont Hospital, Mater Misericordiae University Hospital, St. James’s Hospital, St. Vincent’s University Hospital), Galway (Galway University Hospital) and Limerick (Limerick University Hospital). Paediatric HIV care is provided in Dublin at Temple St. University Hospital and Our Lady’s Children’s Hospital. In 2010, a national study of six adult HIV outpatient services found that of 3202 patients accessing care, 80% were on antiretroviral therapy of whom 87% had evidence of virological control (HIV-RNA levels /=90%.16 17 . In June 2016 a cross-sectional study of healthcare professionals involved in the provision of HIV and STI care in Ireland was undertaken. Respondents prescribing antiretroviral therapy indicated that on average 90% (range 70-100) of their HIV patients were in receipt of antiretroviral therapy. Furthermore, 95% of respondents agreed that Ireland should adopt a policy of offering antiretroviral therapy to all HIV-infected individuals and 92% of respondents indicated they agreed (19%) or strongly agreed (72%) with the statement “In general, I recommend antiretroviral therapy for HIV- 09/08/2017 HSE Sexual Health & Crisis Pregnancy Programme Page 3 of 7 infected patients irrespective of CD4 count” and 86% reported that they “always” or “often” recommended initiation of antiretroviral therapy in HIV-infected patients with CD4+ >500 cells/mm.18 This suggests that, in Ireland, of HIV infected individuals engaged in care, the UNAIDS target of “90% in receipt of sustained antiretroviral therapy” has been reached and in many instances exceeded.

Implementation and Monitoring

Information from the HSE suggests that the target of 90% in receipt of antiretroviral therapy for those attending services has already been met within existing services. Therefore this recommendation does not require a formal implementation plan. A patient information leaflet outlining this recommendation is in development. In order to monitor this recommendation an audit of clinical services will be undertaken in 2017. Further monitoring and audit will be guided by the initial audit findings with a view to annual assessment. This will serve to fulfill Ireland’s obligation to report on the national response to the HIV epidemic to the European Centre for Disease Prevention and Control (ECDC) via the “Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia” and to the UN General Assembly via UNAIDS/WHO.

The first audit round will address the following:

• Number attending HIV services over the reporting time
• Number and proportion of those who attended over the reporting period on antiretroviral therapy

Number and proportion of those on antiretroviral therapy over the reporting period virologically suppressed (at <200 copies/ml and <40 copies/ml).