The evolving HIV epidemic in Ontario: Epidemiologic update ... Update Remis Dec 200… · • HIV...

The evolving HIV epidemic The evolving HIV epidemic in Ontario: in Ontario:

Epidemiologic update Epidemiologic update and policy implicationsand policy implications

Robert S. Remis MD, MPH, FRCPCRobert S. Remis MD, MPH, FRCPCOntario HIV Epidemiologic Monitoring Unit Ontario HIV Epidemiologic Monitoring Unit

Department of Public Health Sciences, University of TorontoDepartment of Public Health Sciences, University of Toronto

HIV Rounds, Toronto General Hospital, HIV Rounds, Toronto General Hospital, December 11, 2006December 11, 2006

Dr. Robert S. RemisPublic Health Sciences, University of Toronto

BackgroundBackground

•• HIV epidemic in Ontario remains unstable and dynamicHIV epidemic in Ontario remains unstable and dynamic

•• Critical to monitor trends in HIV transmission (incidence) Critical to monitor trends in HIV transmission (incidence) to evaluate effectiveness of prevention and burden of to evaluate effectiveness of prevention and burden of HIV infection (prevalence) to quantify the need for health HIV infection (prevalence) to quantify the need for health care and support services care and support services


Organization of presentationOrganization of presentation

•• Brief review of Ontario HIV and AIDS dataBrief review of Ontario HIV and AIDS data•• Ontario HIV model 2004Ontario HIV model 2004•• Focus on emerging situationsFocus on emerging situations

•• MSM, IDU, HIVMSM, IDU, HIV--endemic and other heterosexualendemic and other heterosexual•• Implications for HIV/AIDS policyImplications for HIV/AIDS policy


Number of new HIV diagnoses* by sexNumber of new HIV diagnoses* by sexand proportion female, 1985and proportion female, 1985--20052005

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Year

Num

ber H

IV d

iagn

oses

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Prop

ortio

n fe

mal

e (%

)

MalesFemales% female

* Adjusted for unknown sex


New HIV diagnoses* among males (22,736)New HIV diagnoses* among males (22,736)Ontario, 1985Ontario, 1985--20052005

6.1%

1.2%

4.1%6.5%

0.9%

4.8%

1.3%0.3%0.6%

74.2% MSMMSM-IDUIDUClotting factorTransfusionHIV-endemicHR heteroLR heteroMTCOther

* Adjusted for unknown sex, region and exposure category


New HIV diagnoses* among females (3,725)New HIV diagnoses* among females (3,725)Ontario, 1985Ontario, 1985--20052005

2.1%

5.3%

0.9%

38.7%

17.0%

2.2%

17.7%

16.1% IDUClotting factorTransfusionHIV-endemicHR heteroLR heteroMTCOther

* Adjusted for unknown sex, region and exposure category


Reported AIDS cases*, Ontario, 1981Reported AIDS cases*, Ontario, 1981--20052005

0

100

200

300

400

500

600

700

800

<198

419

8419

8519

8619

8719

8819

8919

9019

9119

9219

9319

9419

9519

9619

9719

9819

9920

0020

0120

0220

0320

0420

05

Year of diagnosis

Num

ber o

f rep

orte

d ca

ses

* Adjusted for unknown exposure category


Reported AIDS cases* among MSM Reported AIDS cases* among MSM Ontario, 1981Ontario, 1981--20052005

0

100

200

300

400

500

600

<198

419

8419

8519

8619

8719

8819

8919

9019

9119

9219

9319

9419

9519

9619

9719

9819

9920

0020

0120

0220

0320

0420

05

Year of diagnosis

Num

ber o

f rep

orte

d ca

ses



Reported AIDS cases* for other exposure Reported AIDS cases* for other exposure categories, Ontario, 1981categories, Ontario, 1981--20052005

0

10

20

30

40

50

60

70

80

<198

419

8419

8519

8619

8719

8819

8919

9019

9119

9219

9319

9419

9519

9619

9719

9819

9920

0020

0120

0220

0320

0420

05

Year of diagnosis

Num

ber o

f rep

orte

d ca

ses

MSM-IDUIDUHIV-endemicHeterosexualBlood



Modeled HIV prevalence and number diagnosed Modeled HIV prevalence and number diagnosed by exposure category, Ontario, 2004by exposure category, Ontario, 2004

HIV Proportion HIV Proportionprevalence Ontario diagnosed diagnosed

MSM 14,927 61.6% 10,602 71.0%MSM-IDU 653 2.7% 438 67.1%IDU 1,768 7.3% 1,428 80.8%Endemic 3,356 13.8% 1,678 50.0%Hetero 3,367 13.9% 1,586 47.1%Clotting 149 0.6% 149 100.0%Transfusion 30 0.1% 30 100.0%

24,251 100.0% 15,909 65.6%


Modeled HIV incidence among MSMModeled HIV incidence among MSMOntario, 1977Ontario, 1977--20042004

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Year

Ann

ual i

ncid

ence

rate

0

200

400

600

800

1000

1200

1400

1600

1800

Num

ber o

f new

infe

ctio

ns

Incidence rateIncidence number


Modeled HIV prevalence among MSM Modeled HIV prevalence among MSM Ontario, 1977Ontario, 1977--20042004

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Year

Prop

ortio

n H

IV in

fect

ed

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

Num

ber o

f HIV

-infe

cted

men

Prevalence %Prevalence number


Modeled MSM number, HIV prevalence and Modeled MSM number, HIV prevalence and incidence by health region, Ontario, 2004incidence by health region, Ontario, 2004

Health region(aggregated)

ProportionMSM

NumberMSM

Number HIV

Prevalence HIV

Annual HIVincidence

(No.)

5.5%5.5%

3.4%3.4%

0.8%0.8%

2.0%2.0%

19.6%19.6% 610610

100100

160160

14.2%14.2%

10.3%10.3%

87087016.3%16.3%

10,650 10,650

1,5001,500

2,7502,750

14,90014,900

54,30854,308

10,58610,586

26,62126,621

91,51591,515

Annual HIVincidence

(%)

TorontoToronto 1.4%1.4%

OttawaOttawa 1.1%1.1%

Rest of OntarioRest of Ontario 0.67%0.67%

Ontario, totalOntario, total 1.1%1.1%


MSM: Epidemiologic highlightsMSM: Epidemiologic highlights

• 14,900 infected, of whom 71% diagnosed• New HIV diagnoses in 2005 up 54% over 2000• HIV prevalence 16.3%: Toronto 19.6%, Ottawa 14.2%

and other 10.3%• HIV prevalence up 28.7% 1999 to 2004, annual 5.2% • 866 new HIV infections in 2004 • HIV incidence 1.1%: Toronto 1.4%, Ottawa 1.1% and

other 0.67%


Modeled HIV incidence among IDUModeled HIV incidence among IDUOntario, 1977Ontario, 1977--20042004

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Year

Ann

ual i

ncid

ence

rate

0

50

100

150

200

250

Num

ber o

f new

infe

ctio

ns

Incidence rateIncidence number


Modeled HIV prevalence among IDUModeled HIV prevalence among IDUOntario, 1977Ontario, 1977--20042004

0.0%

0.5%1.0%

1.5%2.0%

2.5%

3.0%3.5%

4.0%4.5%

5.0%

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Year

prop

ortio

n H

IV in

fect

ed

0

200400

600800

1000

12001400

16001800

2000

Num

ber o

f HIV

-infe

cted

IDU

sPrevalence %Prevalence number


Modeled IDU number, HIV prevalence and Modeled IDU number, HIV prevalence and incidence by health region, Ontario, 2004incidence by health region, Ontario, 2004


ProportionIDU

NumberIDU

Number HIV

Prevalence HIV

Annual HIVincidence

(No.)

0.60%0.60%

0.40%0.40%

0.20%0.20%

0.30%0.30%

3.4%3.4% 2525

2525

3030

13.8%13.8%

4.3%4.3%

80804.8%4.8%

540 540

460460

770770

1,7701,770

15,88815,888

3,3403,340

17,84817,848

37,07637,076

Annual HIVincidence

(%)






IDU: Epidemiologic highlightsIDU: Epidemiologic highlights

• 1,800 HIV-infected, of whom 81% diagnosed• New HIV diagnoses in 2005 up 17% over 2000• HIV prevalence 4.8%: Ottawa 13.8%, Toronto 3.4% and

other 4.3%• HIV prevalence up 9% from 1999 to 2004, annual 1.8%• 80 new HIV infections in 2004 • HIV incidence 0.23%: Toronto 0.16%, Ottawa 0.87%

and other 0.18%


Modeled HIV incidence among persons from Modeled HIV incidence among persons from HIVHIV--endemic regions, Ontario, 1977endemic regions, Ontario, 1977--20042004

0

50

100

150

200

250

300

350

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Year

Num

ber o

f new

infe

ctio

ns


Modeled HIV prevalence among personsModeled HIV prevalence among personsfrom HIVfrom HIV--endemic regions, Ontario, 1977endemic regions, Ontario, 1977--20042004

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

0.60%

0.70%

0.80%

0.90%

.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..

Year

Prop

ortio

n HI

V-in

fect

ed

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Num

ber H

IV-in

fect

ed



Modeled population and HIV prevalence among Modeled population and HIV prevalence among persons born in HIVpersons born in HIV--endemic countries, by endemic countries, by health region, Ontario, 2004health region, Ontario, 2004


ProportionEndemic

NumberEndemic

Number HIV

Prevalence HIV

Annual HIVincidence

(No.)

11.4%11.4%

2.9%2.9%

0.50%0.50%

3.0%3.0%

0.67%0.67% 220220

6060

6060

2.2%2.2%

1.6%1.6%

3403400.90%0.90%

2,080 2,080

540540

730730

3,3503,350

301,872301,872

24,21524,215

44,62044,620

370,707370,707

Annual HIVincidence

(%)






HIVHIV--endemic: Epidemiologic highlightsendemic: Epidemiologic highlights

• 3,400 HIV infected, of whom 50% diagnosed• New HIV diagnoses in 2005 up 34% over 2000• HIV prevalence 0.90%: Toronto 0.67%, Ottawa 2.2%

and other 1.6%• HIV prevalence up 82% from 1999 to 2004, annual 13%• 330 new HIV infections in 2004

•includes imported and acquired in Canada• HIV incidence 0.09%: Toronto 0.07%, Ottawa 0.25% and

other 0.14%


Modeled HIV incidence among persons at Modeled HIV incidence among persons at heterosexual risk, Ontario, 1977heterosexual risk, Ontario, 1977--20042004

0

50

100

150

200

250

300

350

400

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Year

Num

ber o

f new

infe

ctio

ns


Modeled HIV prevalence among persons at Modeled HIV prevalence among persons at heterosexual risk, Ontario, 1977heterosexual risk, Ontario, 1977--20042004

0.00%

0.05%

0.10%

0.15%

0.20%

0.25%

0.30%

0.35%

0.40%

. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Year

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Num

ber H

IV-in

fect

ed p

erso

ns



Modeled population and HIV prevalence among Modeled population and HIV prevalence among persons at heterosexual risk, by health region persons at heterosexual risk, by health region Ontario, 2004Ontario, 2004


Proportionhetero at

risk

Numberhetero at

risk

Number HIV

Prevalence HIV

Annual HIV

incidence (No.)

7.7%7.7%

7.7%7.7%

7.7%7.7%

7.7%7.7%

0.80%0.80% 200200

5050

130130

0.69%0.69%

0.19%0.19%

3803800.35%0.35%

1,610 1,610

440440

1,3201,320

3,3703,370

200,700200,700

64,10664,106

690,471690,471

955,366955,366

Annual HIVincidence

(%)



Rest of Rest of OntarioOntario

0.02%0.02%



Heterosexual: Epidemiologic highlightsHeterosexual: Epidemiologic highlights

• 3,370 HIV-infected, of whom47% diagnosed• New HIV diagnoses up 34% over 2000• HIV prevalence 0.35%: Toronto 0.80%, Ottawa 0.69%,

and other 0.19%• HIV prevalence up 79% from 1999 to 2004, annual 12%• 370 new HIV infections in 2004 • HIV incidence 0.04%: Toronto 0.10%, Ottawa 0.08% and

other 0.02%


Number of new HIV diagnoses by sex Number of new HIV diagnoses by sex Ontario, 2000Ontario, 2000--2006 (first2006 (first--half)half)

0

100

200

300

400

500

600

700

800

2000-1 2000-2 2001-1 2001-2 2002-1 2002-2 2003-1 2003-2 2004-1 2004-2 2005-1 2005-2 2006-1

Num

ber o

f cas

es

MalesFemalesBoth sexes


Number of new HIV diagnoses by exposure Number of new HIV diagnoses by exposure category, Ontario, 2000category, Ontario, 2000--2006 (first2006 (first--half)half)

0

50

100

150

200

250

300

350

400

2000-1 2000-2 2001-1 2001-2 2002-1 2002-2 2003-1 2003-2 2004-1 2004-2 2005-1 2005-2 2006-1

Num

ber o

f cas

es

MSMHIV-endemicLR heteroHR heteroMSM-IDUIDU


Number of new HIV diagnoses by exposure Number of new HIV diagnoses by exposure category, Toronto, 2000category, Toronto, 2000--2006 (1st half)2006 (1st half)

0

50

100

150

200

250

2000-1 2000-2 2001-1 2001-2 2002-1 2002-2 2003-1 2003-2 2004-1 2004-2 2005-1 2005-2 2006-1

Num

ber o

f cas

es

MSM HIV-endemicLR hetero HR heteroMSM-IDU IDU


Number of new HIV diagnoses by exposure Number of new HIV diagnoses by exposure category, Ottawa, 2000category, Ottawa, 2000--2006 (1st half)2006 (1st half)

0

10

20

30

40

50

2000-1 2000-2 2001-1 2001-2 2002-1 2002-2 2003-1 2003-2 2004-1 2004-2 2005-1 2005-2 2006-1

Num

ber o

f cas

es

MSMHIV-endemicLR heteroHR heteroMSM-IDUIDU


LimitationsLimitations

•• Populations at risk (especially MSM, IDU) not well Populations at risk (especially MSM, IDU) not well characterized (size, behavioural patterns, regional variations)characterized (size, behavioural patterns, regional variations)

•• Adjustments for HIV diagnoses, AIDS cases and HIVAdjustments for HIV diagnoses, AIDS cases and HIV--related related mortality subject to uncertaintymortality subject to uncertainty

•• Limited data on HIV incidence and available data biasedLimited data on HIV incidence and available data biased•• Taken into account in HIV modelTaken into account in HIV model

•• Despite challenges, with triangulation, obtain plausible Despite challenges, with triangulation, obtain plausible estimates for HIV incidence and prevalenceestimates for HIV incidence and prevalence


Conclusions (1)Conclusions (1)

•• HIV epidemic in Ontario is not yet under controlHIV epidemic in Ontario is not yet under control•• Good news:Good news:

••AIDS incidence and mortality decreasingAIDS incidence and mortality decreasing••HIV infection among IDUs relatively stableHIV infection among IDUs relatively stable

•• However . . . . . However . . . . . •• Overall, HIV prevalence increased by 37% (17,700 to 24,300)Overall, HIV prevalence increased by 37% (17,700 to 24,300)


Conclusions (2)Conclusions (2)

•• HIV prevalence increased markedly in HIVHIV prevalence increased markedly in HIV--endemic and endemic and other heterosexual exposure categories other heterosexual exposure categories

•• HIV incidence among MSM doubled since 1996HIV incidence among MSM doubled since 1996•• Increase among others infected heterosexually requires Increase among others infected heterosexually requires

further elucidationfurther elucidation


Policy perspectives: Policy perspectives: Prevention for persons at riskPrevention for persons at risk

•• Preventive interventions need to be systematically Preventive interventions need to be systematically reviewed and either reinforced or reoriented reviewed and either reinforced or reoriented

•• Subset of population continue high risk behaviours and Subset of population continue high risk behaviours and drive HIV epidemicdrive HIV epidemic

•• Many likely want and need help to reduce riskMany likely want and need help to reduce risk•• Current programs do not systematically reach these Current programs do not systematically reach these

personspersons


Policy perspectives: Policy perspectives: Prevention for persons at riskPrevention for persons at risk

•• Many interventions have been proven effective Many interventions have been proven effective ((““evidenceevidence--basedbased””) but are not generally available) but are not generally available

•• Need pilot programs and scaleNeed pilot programs and scale--up to achieve up to achieve adequate and appropriate impactadequate and appropriate impact

•• Need network for comprehensive identification Need network for comprehensive identification and referral and referral

•• Interventions must be evaluatedInterventions must be evaluated•• Need more research +++Need more research +++


Policy perspectives: HIVPolicy perspectives: HIV--endemicendemic

•• Stigma, fear, discrimination, fear and denial are important Stigma, fear, discrimination, fear and denial are important factors requiring longfactors requiring long--term interventionterm intervention

•• Referral and personalised intervention for newly arrived Referral and personalised intervention for newly arrived HIVHIV--infected immigrants?infected immigrants?

•• Prevention guidelines need to be disseminated and Prevention guidelines need to be disseminated and programs developed, funded and implementedprograms developed, funded and implemented


Policy perspectives: Policy perspectives: Prevention for positivesPrevention for positives

•• Reducing HIV transmission must include HIVReducing HIV transmission must include HIV--infected infected persons persons

•• Most are responsible and care about partners and Most are responsible and care about partners and communitycommunity

•• Current programs do not systematically reach these Current programs do not systematically reach these personspersons

•• Interventions for HIVInterventions for HIV--positive persons are effectivepositive persons are effective•• Need to pilot and systematically disseminate interventionsNeed to pilot and systematically disseminate interventions•• Involve healthInvolve health--care providers to collaborate and refercare providers to collaborate and refer


Policy perspectives: Policy perspectives: Undiagnosed HIVUndiagnosed HIV--infected personsinfected persons

•• Need to diagnose undiagnosed HIV infectionsNeed to diagnose undiagnosed HIV infections•• Rationale: Evidence for decreased HIV transmissionRationale: Evidence for decreased HIV transmission•• Comprised of three distinct groupsComprised of three distinct groups

•• Infected since last HIVInfected since last HIV--negative test (negative test (““pipeline casespipeline cases””))•• Perception of low or no risk: no needPerception of low or no risk: no need•• Perception of high risk: resistant Perception of high risk: resistant


Policy perspectives: Policy perspectives: Undiagnosed HIVUndiagnosed HIV--infected personsinfected persons

•• Implementation:Implementation:••Target highTarget high--risk populationsrisk populations••Systematic testing during appropriate opportunities Systematic testing during appropriate opportunities ••Routine testing in regions where HIV prevalence >0.1%Routine testing in regions where HIV prevalence >0.1%


AcknowledgementsAcknowledgements

•• Frank McGee, Coordinator, AIDS Bureau, Frank McGee, Coordinator, AIDS Bureau, Ontario Ontario Ministry of Health and Long Term Care (MOHLTC)Ministry of Health and Long Term Care (MOHLTC)

•• Juan Liu, University of TorontoJuan Liu, University of Toronto•• Maraki Maraki FikreFikre Merid, University of TorontoMerid, University of Toronto•• Carol Swantee, HIV Laboratory, MOHLTCCarol Swantee, HIV Laboratory, MOHLTC•• Lorraine Schiedel, Public Health Branch, Lorraine Schiedel, Public Health Branch, MOHLTCMOHLTC•• Ontario HIV Treatment Network (OHTN) and Health Ontario HIV Treatment Network (OHTN) and Health

Canada for funding Laboratory Enhancement StudyCanada for funding Laboratory Enhancement Study

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