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Standardized variables are collected at each outpatient visit, or hospital admission for an HIV-related clinical event or a new treatment prescription, or at least every 6 months. Reported cases are adjusted for delay in reporting, under-reporting, and missing data. To estimate the distribution of times from infection to diagnosis, we used data from the HIV surveillance system and statistical modelling.

The method has been described elsewhere. For the purpose of this study, we report here the estimated distribution of times from infection to diagnosis for individuals who were newly infected with HIV in ; estimated distributions for individuals infected in previous or subsequent years were similar results not shown. Individuals who entered care and did not initiate treatment, and individuals who initiated treatment and did not achieve viral suppression were censored at the time of last known contact.

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From these data, we obtained nonparametric estimates of the cumulative distribution functions accounting for censoring. We then used the 4 estimated distributions and the inversion method to generate 10, random values for each time interval. Mean, median, and interquartile range were calculated for each time interval. To estimate the number of individuals living with undiagnosed HIV, we used estimates of HIV incidence and distribution of times from infection to diagnosis, obtained as aforementioned. The method and results have been described elsewhere. Two thousand bootstrap estimates were obtained.

A fraction of these individuals were aware of their HIV infection for several months, whereas others just discovered their HIV status. To estimate the number of HIV-infected individuals in care in , we used data from the general social insurance scheme. In , the number of individuals affiliated to the general social insurance scheme who had active ALD status for HIV was 96, Statistical comparisons between HIV exposure groups were carried out with the nonparametric Kruskal—Wallis test.

Among these, The prevalence of HIV in the general population was 0. Among the , individuals living with HIV, Among individuals diagnosed with HIV, IDUs had the highest percentages at every stage of the care continuum, followed by French-national heterosexual women and MSM with intermediate percentages, and then by French-national heterosexual men and non-French national heterosexuals with the lowest percentages.

The overall median time from infection to reaching viral suppression was 6. It comprised 4 steps: a median time of 3. Once on cART, the median time to reaching viral suppression was around 0. Ensuring early universal access to cART and viral suppression is critical to achieve maximum individual and public health benefits of cART. In this study, we evaluated both the cascade and the timing of HIV care in a specific setting, and we revealed 2 major findings that could likely be extrapolated to other settings.

High coverage of cART and viral suppression can coexist with large gap between time of HIV infection and time of viral suppression. Evaluating patient flow-time through the continuum of HIV care is key to identifying what kind of actions is required to accelerate access to cART and viral suppression. Findings at the group level show that there is no straightforward relationship between the rates of viral suppression and the time to reach viral suppression.

IDUs had the longest median time intervals 9.


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These paradoxical results at first sight can be easily reconciled by considering the different nature of the 2 metrics used to describe access to cART and viral suppression. Indeed, the time from HIV infection to viral suppression measures the pace of access to HIV care and treatment in the recent past, whereas the coverage of cART and viral suppression is an aggregate measure of what happened in terms of HIV transmission, access to care and treatment, retention in care, and survival rates since the beginning of the HIV epidemic. In this group, HIV transmission has substantially decreased over time due to needle program exchange, from several thousand new infections per year in the s to around per year in the mids.

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Nevertheless, IDUs infected in recent years have long time intervals between infection and viral suppression according to our estimates of the timing of care. All these show that the coverage of cART and viral suppression is determined by many factors, including changes in the intensity of the HIV epidemic over time, and thus does not necessarily reflect gaps in recent access to care and treatment. Hence the cascade of care, while useful to assess the percentage of HIV-infected individuals at risk of HIV transmission, might not be the right tool to determine what kind of actions are required to accelerate access to cART and viral suppression, and thus to decrease the percentage of individuals at risk of HIV transmission.

As for estimates of the timing of HIV care , it provides information to identify recent gaps in the care continuum which delays access to cART and viral suppression. In France, we found that the time lost in achieving viral suppression was mainly due to delays in HIV testing overall median of 3.

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Once in care, times to move from one stage to the next remained short less than 5 months in median , except for MSM and French-national heterosexual women for which the median time from care entry to cART initiation was 10 and 7 months, respectively. Time to initiate cART is however expected to have decreased after , because the cART eligibility threshold was lowered to cells per cubic millimeter in October and to universal treatment in Our study has some limitations. The number of undiagnosed HIV-infected individuals and the distribution of times from infection to diagnosis cannot be directly observed and were estimated using back-calculation modelling, 24 similar to recent studies in the US and England.

In addition, once in care, HIV-infected individuals may drop in and out of care, go on and off treatment, and undetectable viral loads can bounce back. Our time estimates account for drops in and out of care and treatment discontinuation that occurred before treatment initiation or before viral suppression, but not for those that occurred after. Furthermore, we did account for viral rebound after achieving viral suppression.

However, it should be noted that, in France, drops in and out of care, treatment discontinuation, and treatment failures remain limited. Indeed, according to data from the national social security scheme, only 6. The coverage of cART and viral suppression and the time to reach viral suppression may have changed since However, this does not invalidate our 2 major findings. To the best of our knowledge, no study has reported estimates of times from HIV infection to viral suppression, and how these times were affected by the flow-time in between steps of the care continuum.

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However, large gaps between time of HIV infection and time of viral suppression are likely to exist in other settings. Indeed, in high-income settings, the mean time from infection to diagnosis was estimated to be 5.

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In addition, the mean time from diagnosis to viral suppression in 14 US jurisdictions was between 1. Alerts on laboratory reports and the application of bioinformatics to electronic health records may also be useful for identifying familial hypercholesterolaemia in community settings. Effective detection, diagnosis, and codification of familial hypercholesterolaemia are essential for the development of registries.

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Your Name: optional. The travails and discoveries of her path ultimately bring her to the Cascade, and a great deal further. Her adventures lead to dramatic changes in her mental perspective and her spiritual state, and an explosive and transcendent culmination. What genre is it? Beyond the Cascade is literary commercial fiction, with threads of magical realism, adventure, science and self-discovery.


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What kind of readers will it appeal to? Spiritually oriented, strong minded women; readers curious about minds, and the limits of language and thought itself; readers who like a good adventure story with a touch of magical realism; dreamers and lucid sleepers who slip out of the world at night. Richard Bach. It touches, as well, on the nature of thought beyond language and where the outer boundaries of such thought may be. Tell us a bit about yourself. Born in New York, went to sea young, have worked as a miner, a diver, a deckhand and a captain, a pastor, a systems engineer and a writer.

I have written dry technical stuff for thirty years, as well as novels, essays, poems and doggerel of various kinds.