The “Joint Action on integrating prevention, testing and link to care strategies across HIV, Viral Hepatitis, TB & STIs in Europe” (INTEGRATE) has the overall objective to increase Integrated early diagnosis and linkage to prevention and care of HIV, viral hepatitis, TB and STIs in EU Member States by 2020.
A number of tools have been developed to reduce transmission, optimize early diagnosis and linkage to care for one or more of these four diseases. INTEGRATE will map relevant existing tools for cross-linking. A peer-review process will identify which of these tools are complimentary or redundant for other disease(s), and which could be adapted or require further innovation.
HIV, viral hepatitis, TB and STIs are cross-borders public health threats of concern to Europe that affect vulnerable populations disproportionately and require personalised interventions. As multiple dimensional approaches are required to reduce the public health burden, the most optimal profile of approaches that provide additive effects (and that are reasonably cost-effective) should be identified and implemented broadly.
INTEGRATE provides a platform to disseminate and exchange best practice among Member States and facilitate discussions on innovations and emerging issues within the four diseases. In this respect, INTEGRATE is a shared European effort that extends beyond the partners and can create important synergies across European stakeholders, projects and initiatives.
INTEGRATE supports the implementation of the Commission Communication on ‘Combating HIV/AIDS in the European Union and neighboring countries’ and the ‘Action Plan on HIV/AIDS in the EU and neighboring countries’ by ensuring better preparedness across the EU and by identifying innovative evidence-based testing and prevention tools to reduce new cases of HIV, viral hepatitis, TB and STIs in priority groups.
Summary of context:
HIV, viral hepatitis B and C, sexually transmitted infections (STIs) and active and latent tuberculosis (TB) infection are major public health concerns in Europe. Despite progress in prevention methods and uptake of treatment, there are continued challenges in terms of controlling and preventing further transmission of these diseases and in ensuring that people who are infected are diagnosed early and enter the care system. Further, there is a high prevalence of co-infection due to overlaps in key populations and/or common modes of transmission which underlines the need to combine efforts throughout the continuum of care.
Disease areas of interest:
INTEGRATE will mainly focus on HIV, viral hepatitis and STIs, which share modes of transmission and to a lesser extent address TB which is a different disease in terms of risk of acquisition.
HIV is still highly prevalent in Europe with a cumulative number of 810.000 people diagnosed with HIV in the EU/EEA in 2015 and a substantial number of people living with HIV who remain undiagnosed (estimated at 15% of people living with HIV in 2015). In 2015, 29.747 new HIV infections were diagnosed and the rate of new infections has not declined significantly over the last decade despite important advances in biomedical and behavioural HIV prevention strategies. Furthermore, almost half (47%) of all people newly diagnosed are presenting at a late stage of infection. These data indicate that despite important progress in both prevention (including treatment as prevention) and testing, there is still a need to strengthen efforts across Europe to reduce transmission and ensure timely diagnosis. A set of fast-track actions and regional targets to reverse the HIV epidemic in Europe and end the epidemic as a public health threat by 2030 has been established and require renewed political commitment to urgently put in place innovative responses to HIV.
An estimated 4.7 million and 5.6 million are living with chronic hepatitis B (HBV) and hepatitis C (HCV), respectively in the EU/EEA. Among those already diagnosed, many are not linked to healthcare services that can provide comprehensive care. Consequently, a large proportion of the chronically infected enter care only after they have developed liver-disease-related clinical symptoms. Effective and well tolerated treatments for both HBV and HCV infection have greatly improved the possibility of successful treatment and (in the case of HCV) cure, especially if diagnosed early in the course of infection. In most European countries however, it remains unknown to what extent testing policies and strategies succeed in identifying the undiagnosed population over the course of their disease. Also, the extent to which diagnosed patients are linked to and retained in care is unknown.
Among the five sexually transmitted infections (STIs) under EU surveillance , chlamydia is the most common in EU/EEA with 384.555 cases reported in 2013. The majority are reported among young people (between 15 and 24 years of age) and among women. Gonorrhoea rates have been increasing, with 52.995 cases reported in 2013. It is three times more prevalent among men than women. A total of 22.237 syphilis cases were reported in 2013 and five times more often in men than in women, with increasing trends reported by most countries between 2008 and 2013. In 2013, 64 cases of congenital syphilis were reported in nine countries; thirteen countries reported zero cases. Over the last decade several countries in the EU/EEA region, have seen an increase in the incidence of sexually transmitted infections including gonorrhoea, syphilis and chlamydia among specific groups such as MSM . ECDC concludes that, there is evidence that services to prevent, diagnose and treat infections are not being delivered at the appropriate scale to impact on transmission patterns.
Active and latent tuberculosis infection (TB), although a treatable and preventable disea
Step 1: Review process
In the first phase, INTEGRATE’s activities will take point of departure in already available tools focusing on implementation of testing and linkage to care for HIV, hepatitis, TB and STIs. An important first step will therefore be a mapping of existing implementation tools, partly drawing on data sources and work already conducted by ECDC and EMCDDA, other EU agencies and EU networks to build upon the results obtained by the ‘Quality Action’ initiative and ensure synergies with previous and ongoing initiatives. The review process will be supervised by the coordinator and WP leads to ensure synergies between the areas overlapping different WPs. The mapping process has the following elements.
Mapping of existing platforms and analysis of the type of content, audience and use. The analysis will be based on a matrix developed by WP2 lead and with inputs from all lead partners and has two main outcomes:
Identification of thematic materials to complement specific reviews
Decision on use/linkage with existing platforms
Mapping of material/tools for implementation/introduction of testing and linkage to care (WP2 and 5):
Focus on introducing testing in health care settings (WP4 and 5)
Good practices of data collection of testing and linkage to care activities (done for HEPCARE EUROPE, HIV in HiE, HIV-COBATEST and Euro HIVEdat projects. HA-REACT, E-DETECT, HEPCARE and ESTICOM outcomes will be taken into account) (WP6)
Specific training materials of health care and community staff in testing and linkage to care (WP8)
Review of home/self-testing/sampling evidence and measures for linkage to care (WP5)
Mapping of prevention tools/activities will focus on
Mapping of good practices in partner notification and linkage to care
New technologies used for combination prevention
Mapping of policies in support of implementation of above and barriers
Indicator condition guided HIV testing and improving testing for viral hepatitis in health care settings
Supporting adequate linkage to care of self-testers
Integration of monitoring of testing and linkage to care data into national M&E and surveillance systems, including data from CBVCT, GPs and home/self-testing
Novel secondary prevention strategies including partner notification
A peer review based assessment will be conducted of the strengths and weaknesses of the identified materials with regards to their potential for adaptation/innovation and transferability to cover other diseases areas and/or priority groups.
JA partners will examine the existing tools relating to HIV, hepatitis, TB and STI testing and linkage to care in addition to any combination effort. INTEGRATE will systemically review the materials and identify strengths and successes from each. In addition, all current materials will be examined to detect the feasibility for any of the tools to be adapted to other disease areas or a combination of diseases, as well as the aspects of replication and transferability to other countries to ensure the EU dimension of the tools. Not all tools or guidelines will be applicable to other diseases, but the aim is to employ the most effective components to the tools developed by the INTEGRATE Joint Action. Then follows a development process where a number of tools are adapted to other disease areas.
Step 2: Implementation and piloting
The next phase of the project will be the development and implementation of activities under each WP theme and piloting of tools developed to support increased and improved linkage to care activities.
A number of countries participating as partners in the Joint Action have been thoroughly chosen for the activities and pilots taking into consideration geographical distribution, partner profile and country needs and resources. Based on information from ECDC and EMCDDA completed with input from INTEGRATE partners and overview of country, epidemics and challenges were listed and analysed. Criteria for s
INTEGRATE was launched on 19 September 2017 in Brussels followed by the first Partnership Forum meeting the day after, which was opened by Mr. Vytenis Andriukaitis the EC Commissioner for Health and Food Safety.
During the first year (Sep 2017 – Aug 2018) INTEGRATE has achieved the following main activities per WP:
WP1 – Coordination
As part of setting up the administrative and coordination structure of INTEGRATE Joint Action the Advisory Board, Partnership Forum and Steering Committee was set up and has guided and made quality control of the work, milestones and deliverables during the first year. The Steering Committee has met twice at Face2Face meeting and have telephone meetings every second month.
The coordinator has developed guiding documents such as the Consortium Agreement, Workplan and FAQ documents together with templates and guides for the technical and financial reporting. 3 Financial TCs have been held with the financial officers in the partner organisations and regular internal cost-follow up has been used to follow the implementation of the JA and assist and guide the partners with financial reporting.
Continuous collaboration with ECDC, EMCDDA, WHO Regional office for Europe, WHO HQ and relevant other EU funded projects and Joint Actions such as HAREACT, HEPCARE, E-DETECT TB and other European initiatives within HIV, viral hepatitis, TB and STIs.
WP2 - Dissemination
Visual identity and a comprehensive communication and dissemination package has been developed consisting of: logo, website, social media profiles, JA leaflet and INTEGRATE templates (power point and documents). All outputs have been reviewed and approved by the Steering Committee.
A detailed dissemination plan was developed with input from all WP Leads reflecting all WPs and key messages.
As part of the analysis of existing knowledge platforms and initiatives relevant for INTEGRATE an online matrix structure (incl. guide on how to use) was developed. The matrix has been used by the different WPs to enter their review findings and mapping activities (WP5 and WP7)
WP3 – Monitoring and Evaluation
The evaluation plan has been developed with input from the Coordinator and Steering Committee.
M&E tools have been developed (RAG reporting, partner survey and interview topic guide). The yearly partner evaluation survey was conducted in August (100% respond rate from partners) together with 8 interviews with the WP Lead and Co-Lead Partners.
TOR developed for the external mid-term and final evaluation and the tender is expected to be published in the fall of 2018.
WP4 – Policy development and sustainability
Previous sustainability plans were reviewed (UNAIDS, WHO, OECD, ECDC, OptTEST etc.) To make recommendations for the future implementation of the pilots in the pilot countries, country profiles were developed to assess the country context and identify key stakeholders. Pilot partners performed semi-structured interviews with their relevant national stakeholders and a desk review was performed by WP LP. In total 28 stakeholders were interviewed from the 12 pilot countries. A stakeholder consultation report was developed.
Patient experience Survey
Findings from the stakeholder consultation have informed the development of the draft questionnaires for HIV and Hepatitis C. The questionnaires are in late draft format and the survey protocol is finalized. A baseline survey has been conducted among the pilot partners to identify the key aspects of recruitment for the patient survey. The protocol will shortly be submitted to local ethics committees for approval.
WP 5 – Integrating testing and linkage to care
Telephone meetings have been conducted with all pilot partners to discuss and plan the proposed pilot activities. Discussions were taken forward at the Face2Face meeting and pilot plans were reviewed and adjusted based on the possibilities in the specific partner organisations. 6 partners have
INTEGRATE is still in an early phase of its implementation and the impact of main outputs will be described in the reporting after year 2 and 3. However, once the outputs and findings from INTEGRATE are being produced they will on an on-going basis be available on the website www.integrateja.eu
The main target groups of INTEGRATE are:
• Public health authorities and policy-makers involved in HIV, viral hepatitis, TB and STI testing and linkage to care prevention.
• Staff of civil society organisations working in the field of HIV, viral hepatitis, TB and STI with the key groups at increased risk mainly MSM, PWID, Sex workers and migrants.
• Health care professionals, including general practitioners of primary care services as well as health care staff of public and private institution
Through close engagement with the target groups in the respective JA partner member states, INTEGRATE is through the pilot activities and sustainability plans working towards wider implementation and dissemination of the findings and outputs which is expected to happen in year 2 and 3.
However, the year 1 internal evaluation has shown that there are examples where INTEGRATE has already made an impact on integrating testing and care, by building links between organisations in different disease areas and running a successful pilot of European Spring Testing Week for hepatitis and HIV.
INTEGRATE is after the first year still in an early phase of its implementation, so achieved outcomes compared to expected outcomes will be described in year 2 interim report and final report.
The dissemination activities during the reporting period included:
• The release of the Project Web site (November 2018)
• The active presence of the project in popular social media platforms (i.e. Twitter, Facebook, LinkedIn)
• The release of the project brochure and newsletter
• The dissemination of INTEGRATE material and announcements in the EU Health Policy Platform
• The organization and conduction of the INTEGRATE Satellite session, which was held on July 25, 2018, in conjunction with AIDS 2018, in Amsterdam, the Netherlands
• INTEGRATE has been presented at 15 international conferences/meetings/events during the first year.
Further, the internal evaluation from year 1 showed that many of the JA partners had promoted the JA internally within their organisation, with 82% (23/28) of partners and 86% (6/7) advisory group members having done so through many channels including giving presentations to colleagues, sharing leaflets and newsletters, disseminating information via email lists, and posting information on their website or social media pages. A presentation to the Ministry of Health was also reported by two participants.
The internal evaluation of INTEGRATE year 1 was conducted in August 2018 by WP3 lead partners PHE (UK) and IPMN (Romania) focusing on process, progress, and implementation of the joint action in the first year. Data was collected through semi-structured interviews, progress (RAG) reporting and an online survey, synthesised and analysed using a mixed-methods approach. Thirty-eight responses were received: 29 from partner organisations (100%) (of whom 11 were pilot sites and 11 were work package LP/co-LP) and 9 advisory board members.
Overall, the progress and implementation of INTEGRATE is on track, with a little variation between the work packages, and INTEGRATE has met partners’ expectations as much as can be expected in the first year. The project infrastructure and collaboration that was built in the first year will be vital to the success of the joint action in the next two years. There is a need to ensure INTEGRATE continues to build momentum into its second year, as more substantive elements of work get underway, and that partners increasingly take ownership of their work and that no partners are left behind