The HIV treatment and care cascade in Italy: successes and disparities

Objectives: In 2013, we conducted a retrospective cross-sectional study to assess the characteristics of people living with HIV in 12 Infectious Diseases Clinics (IDC) and to estimate the HIV cascade. Methods: Among the 173 IDC existing in Italy, we selected 12 Clinics through a stratified sampling by geographical area, population density, gender, age, nationality and mode of transmission. We asked every IDC to report demographic, clinical, immunological and virological characteristics of people diagnosed with HIV that had at least one care visit during 2013. Results: In 2013, there were 10,160 HIV persons who had at least one visit in one of the 12 IDC. The majority were males (71.0%), Italians (85.3%), aged between 25-49 years (59.0%); 41.1% were heterosexuals, 27.3% men who have sex with men (MSM) and 23.7% injecting drug users. In the sample, 16.6% of people were in care before in another IDC and among these 34.8% for more than ten years and 6.9% were cured in a foreign country. Moreover, 82.9% had ≥350 CD4 cells/µL, 24.6% had had in the past an AIDS diagnosis [Pneumocystis carinii pneumonia (32.4%), toxoplasmosis (11.5%), candidiasis (10.1%)] and 91.7% were receiving ART. In the latter group, 18.7% were receiving first line ART regimen. Twenty-eight percent were co-infected with HCV, 8.3% with HBV, 12.7% had had syphilis. Overall, 10,118 (99.6%, 95%CI: 98.1-1.00) were linked to care; among these 9,201 (90.9%, 95% CI: 83.6-98.3) were retained in care; among these 8,523 (92.6%, 95%CI: 86.6-98.6) were on ART and among these 7,282 (87.0%, 95%CI: 84.7-89.3) had the viral load suppressed. Factors significantly associated with each step of HIV cascade were: being female (OR=5.3 [95%CI 2.3-12.2]) for not being in care were; age 25-49 years (OR=1.34 [95%CI 1.04-1.74]) for not being retained in care; age 25-49 (OR=1.72 [95%CI 1.23-2.41]), age ≥60 years (OR=1.47 [95%CI 1.03 -2.09]), have been linked to care after 2012 (OR=2.35 [95%CI 1.8-2.9]) for not being in ART; age 25-49 years (OR=1.42 [95%CI 1.10-1.84]), being migrants (OR=1.39 [95%CI 1.16-1.66]), being heterosexual (OR=1.42 [95%CI 1.19-1.69]), have been linked to care after 2012 (OR=1.87 [95%CI 1.53-2.27]) for not having viral suppression. Conclusion: In Italy, the vast majority of people diagnosed with HIV are linked to care and are receiving antiretroviral therapy. The proportion of people on care and on ART observed in our study is higher to that reported in other Western European countries (UK 88.0% and 85.0%; France 92% and 80%; The Netherlands 93% and 87%, respectively). Significant disparities were observed for some steps of the cascade, particularly young people, migrants, heterosexuals, and people linked to care recently. Finally, the high observed proportion of people with viral load suppressed must be deeply evaluated.