Epidemiologic Update on the HIV Epidemic in Ontario

instructional media centre, Laboratories Branch - 2000

Epidemiologic Epidemiologic Update on the Update on the HIV Epidemic in HIV Epidemic in

OntarioOntarioTheThe SituationSituation inin thethe YearYear 20002000

Robert S. Remis, MD, MPH, FRCPCRobert S. Remis, MD, MPH, FRCPCDepartment of Public Health Sciences Department of Public Health Sciences

University of TorontoUniversity of Toronto


BackgroundBackground•HIV epidemic in Ontario is unstable and dynamicHIV epidemic in Ontario is unstable and dynamic•Monitoring trends in HIV transmission (incidence) and Monitoring trends in HIV transmission (incidence) and burden of HIV infection (prevalence) is critical to burden of HIV infection (prevalence) is critical to evaluate effectiveness of primary prevention and project evaluate effectiveness of primary prevention and project the need for health and support services the need for health and support services

•Available data is biased and incomplete but Available data is biased and incomplete but triangulation allows obtaining plausible estimates for triangulation allows obtaining plausible estimates for HIV incidence and prevalenceHIV incidence and prevalence

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


Organization of presentationOrganization of presentation•Describe the databases and the methodologies used Describe the databases and the methodologies used •Overview of HIV epidemic in OntarioOverview of HIV epidemic in Ontario•Focus on emerging situationsFocus on emerging situations

•MSMMSM•IDUIDU•Persons from HIV-endemic countriesPersons from HIV-endemic countries•Mother-infant transmissionMother-infant transmission



Methods: Data sourcesMethods: Data sources•HIV diagnoses: First-time diagnoses at HIV Laboratory HIV diagnoses: First-time diagnoses at HIV Laboratory adjusted for unknown risk factors and previous HIV adjusted for unknown risk factors and previous HIV testing using data from Laboratory Enhancement Studytesting using data from Laboratory Enhancement Study

•AIDS incidence: Cases diagnosed to December 1999 AIDS incidence: Cases diagnosed to December 1999 and and reported by October 2000;reported by October 2000;

•HIV-related mortality: Deaths to end 1997 adjusted for HIV-related mortality: Deaths to end 1997 adjusted for underascertainmentunderascertainment

•HIV-infected mothers and infants: HIV-infected mothers and infants: Data reported to Data reported to CPARG CPARG and analyzed by period of HIV diagnosis, infection and analyzed by period of HIV diagnosis, infection status of status of infant and mother’s exposure category infant and mother’s exposure category



Methods: Data analysisMethods: Data analysis•HIV modelHIV model

• HIV infection: incidence, cumulative incidence and HIV infection: incidence, cumulative incidence and prevalenceprevalence

• HIV diagnosis: incidence, cumulative incidence and HIV diagnosis: incidence, cumulative incidence and prevalenceprevalence

• AIDS: incidence, cumulative incidence and prevalenceAIDS: incidence, cumulative incidence and prevalence• HIV-related mortality: incidence and cumulative HIV-related mortality: incidence and cumulative

incidenceincidence• Model values adjusted to fit available data on HIV Model values adjusted to fit available data on HIV

diagnoses, reported AIDS cases and AIDS deaths and diagnoses, reported AIDS cases and AIDS deaths and results from results from back-calculationsback-calculations



Methods: Data analysisMethods: Data analysis•HIV incidence from repeat testers HIV incidence from repeat testers

• Results linked within HIV Laboratory database using name, Results linked within HIV Laboratory database using name, sex, date of birth, previous test history to identify repeat sex, date of birth, previous test history to identify repeat testerstesters

• HIV incidence calculated by exposure category, age and HIV incidence calculated by exposure category, age and health region using method of Kitayaporn health region using method of Kitayaporn

•HIV incidence from detuned assayHIV incidence from detuned assay• HIV-positive sera tested using Abbott EIA assay rendered HIV-positive sera tested using Abbott EIA assay rendered

less sensitive to detect recent HIV infection (< 129 days)less sensitive to detect recent HIV infection (< 129 days)• HIV incidence = # discordant sera / (# tested x 129/365)HIV incidence = # discordant sera / (# tested x 129/365)



Number of first-time HIV diagnoses by Number of first-time HIV diagnoses by sexsexand proportion female, and proportion female, 1985–19991985–1999

0

200

400

600

800

1000

1200

1400

1600

1800

2000

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Year

HIV

inc

ide

nc

e p

er

10

0 P

Y

0

5

10

15

20

25

Pro

po

rtio

n f

em

ale

(%

)

MalesFemales% female



First-time HIV-positive diagnoses among First-time HIV-positive diagnoses among males, n=17,878, HIV Laboratory, 1985–males, n=17,878, HIV Laboratory, 1985–19991999

2.8%4.7%2.1%

6.5%1.4%4.3%

0.8%0.6%

0.2%

76.7% MSMMSM-IDUIDUClotting factorTransfusionHIV-endemicHR heteroLR heteroPerinatalOther



First-time HIV-positive diagnoses among First-time HIV-positive diagnoses among females n=2,464,females n=2,464, HIV Laboratory, 1985–HIV Laboratory, 1985–19991999

4.4%6.8%2.4%

21.1%

17.0% 0.5%

18.6%

29.1% IDU

Clotting factor

Transfusion

HIV-endemic

HR hetero

LR hetero

Perinatal

Other



Reported AIDS cases among MSM, Reported AIDS cases among MSM, Ontario, 1981–1999Ontario, 1981–1999

0

100

200

300

400

500

600

<198

419

8419

8519

8619

8719

8819

8919

9019

9119

9219

9319

9419

9519

9619

9719

9819

99

Year of diagnosis

Nu

mb

er

of

rep

ort

ed

ca

se

s

MSM



Reported AIDS cases by exposure Reported AIDS cases by exposure category, Ontario, 1981–1999category, Ontario, 1981–1999

0

10

20

30

40

50

60

70

80

Year of diagnosis

Num

ber

of

repo

rted

cas

es

MSM-IDUIDUHIV-endemicHeterosexualBlood



HIV incidence among MSM repeat HIV incidence among MSM repeat testers, testers, with 95% CLs, 1992-99 with 95% CLs, 1992-99 (28,103 PY)(28,103 PY)

1.48 1.41.21

10.86

1.18 1.18

2.56

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

1992 1993 1994 1995 1996 1997 1998 1999Year

Sero

conve

rsio

ns

per

100

PY

Source: Polaris Seroconversion Study


HIV incidence among MSM repeat HIV incidence among MSM repeat testerstestersby age group, 1992-99by age group, 1992-99

0.0

1.0

2.0

3.0

4.0

5.0

6.0

1992 1993 1994 1995 1996 1997 1998 1999

Year

Sero

conve

rsio

ns

per

100

PY

20-29 (7078 PY)30-39 (11350 PY)40-49 (5792 PY)50+ (3019 PY)



HIV incidence among MSM repeat HIV incidence among MSM repeat testers testers by health region, 1992-99by health region, 1992-99

0.0

1.0

2.0

3.0

4.0

5.0

6.0

1992 1993 1994 1995 1996 1997 1998 1999Year

Sero

conve

rsio

ns

per

100 P

Y

Toronto (17380 PY)Ottawa (2977 PY)Other (6976 PY)



HIV incidence from detuned assay HIV incidence from detuned assay among MSM by health region, among MSM by health region, October 1999–June 2000October 1999–June 2000

4.8

0.4

1.1

2.7

0.0

1.0

2.0

3.0

4.0

5.0

HIV

inci

dence

per

100 P

Y

Metro Toronto Ottawa-Carleton Other Ontario

Source: Laboratory Enhancement Study


HIV incidence from detuned assay HIV incidence from detuned assay among among MSM by age group, MSM by age group, October 1999–June October 1999–June 20002000

0.0

1.0

2.0

3.0

4.0

5.0

6.0

15-24 25-29 30-34 35-39 40-44 45-49 50+Age group (years)

Inci

dence

den

sity

(/1

00 p

-y)



Modeled HIV incidence among MSMModeled HIV incidence among MSMOntario, 1977–1999Ontario, 1977–1999

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Year

An

nu

al i

nc

ide

nc

e r

ate

0

200

400

600

800

1000

1200

1400

1600

1800

Nu

mb

er

of

ne

w in

fec

tio

ns

Incidence rate

Incidence number



Modeled HIV prevalence among Modeled HIV prevalence among MSM MSM Ontario, 1977–1999Ontario, 1977–1999

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Year

Pro

po

rtio

n H

IV in

fec

ted

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

Nu

mb

er

of

HIV

-in

fec

ted

me

n

Prevalence %

Prevalence number



Modeled MSM population at risk, HIV Modeled MSM population at risk, HIV prevalence prevalence and incidence by health region, Ontario, 1999and incidence by health region, Ontario, 1999

Health region(aggregated)

PrevalenceMSM

NumberMSM

PrevalenceHIV

NumberHIV

Annual HIVincidence

(%)

Annual HIVincidence

(No.)

Metro Toronto 6.0% 58,000 15% 8,500 1.5% 720

Ottawa-Carleton 3.0% 8,700 11% 900 0.5% 40

Rest of Ontario 1.4% 43,600 7% 3,200 0.5% 220

Ontario, total 2.5% 110,300 11% 12,600 1.0% 970




HIV incidence among IDU repeat HIV incidence among IDU repeat testers with 95% CLs, 1992-99 testers with 95% CLs, 1992-99 (26,271 PY)(26,271 PY)

0.57

0.44

0.64

0.360.26 0.25

0.4

0.74

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1992 1993 1994 1995 1996 1997 1998 1999Year

Sero

conve

rsio

ns

per

100 P

Y



HIV incidence among IDU repeat HIV incidence among IDU repeat testers testers by health region, 1992-99by health region, 1992-99

0.0

1.0

2.0

3.0

4.0

5.0

1992 1993 1994 1995 1996 1997 1998 1999Year

Se

roc

on

ve

rsio

ns

pe

r 1

00

PY

Toronto (7099 PY)

Ottawa (1952 PY)

North (2468 PY)

Other (13895 PY)


HIV Incidence from detuned assay HIV Incidence from detuned assay among IDU by health region, among IDU by health region, October October 1999–June 20001999–June 2000

0.71

1.57

0.39

0.58

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

HIV

inci

dence

per

100 P

Y




Modeled HIV incidence among IDUsModeled HIV incidence among IDUsOntario, 1977–1999Ontario, 1977–1999

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Year

An

nu

al i

nc

ide

nc

e r

ate

0

50

100

150

200

250

Nu

mb

er

of

ne

w in

fec

tio

ns

Incidence rate

Incidence number



Modeled HIV prevalence among Modeled HIV prevalence among IDUsIDUsOntario, 1977–1999Ontario, 1977–1999

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Year

Pro

po

rtio

n H

IV in

fec

ted

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Nu

mb

er

of

HIV

-in

fec

ted

IDU

s

Prevalence %

Prevalence number



Modeled IDU population at risk, HIV prevalence Modeled IDU population at risk, HIV prevalence

and incidence by health region (aggregated), and incidence by health region (aggregated), Ontario, December 1999Ontario, December 1999


PrevalenceIDU

NumberIDU

PrevalenceHIV

NumberHIV

Annual HIVincidence

(%)

Annual HIVincidence

(No.)

Metro Toronto 0.6% 14,700 5.5% 800 0.7% 90

Ottawa-Carleton 0.5% 3,400 14.5% 500 1.7% 50

Rest of Ontario 0.2% 19,800 2.8% 550 0.5% 90

Ontario, total 0.3% 37,900 4.9% 1,850 0.6% 230




HIV incidence from detuned assay HIV incidence from detuned assay among among MSM-IDU by health region,MSM-IDU by health region, October 1999–October 1999–June 2000June 2000

15.4

26.2

0

6.2

0

5

10

15

20

25

30

HIV

inci

dence

per

100 P

Y



Modeled HIV prevalence among MSM-Modeled HIV prevalence among MSM-IDU IDU by health region,by health region, 19991999

550

50

200

0

100

200

300

400

500

600

Num

ber

of

HIV

-infe

cted p

ers

ons

Metro Toronto Ottawa-Carleton Ontario other



Modeled HIV incidence among Modeled HIV incidence among persons from HIV-endemic regionspersons from HIV-endemic regions, , Ontario, 1977–1999Ontario, 1977–1999

0.00%

0.01%

0.02%

0.03%

0.04%

0.05%

0.06%

0.07%

0.08%

0.09%

0.10%

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Year

An

nu

al i

nc

ide

nc

e r

ate

0

50

100

150

200

250

300

350

400

Nu

mb

er

of

ne

w in

fec

tio

ns

Incidence rate

Incidence number



Modeled HIV prevalence among Modeled HIV prevalence among personspersonsfrom HIV-endemic regionsfrom HIV-endemic regions, , Ontario, Ontario, 1977–19991977–1999

0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

0.8%

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999Year

Pro

po

rtio

n H

IV in

fec

ted

0

500

1000

1500

2000

2500

3000

Nu

mb

er

HIV

-in

fec

ted

pe

rso

ns

Prevalance %

Prevalance number



Modeled persons born in HIV-endemic Modeled persons born in HIV-endemic countries, countries, HIV prevalence and incidence by health regionHIV prevalence and incidence by health regionOntario, 1999Ontario, 1999


Proportionpopulation Number

HIVprevalence

(%)HIV

number

Annual HIVincidence

(%)

Annual HIVincidencenumber

Metro Toronto 11.2% 286,700 0.7% 2,020 0.10% 270

Ottawa-Carleton 2.9% 22,000 1.3% 280 0.16% 40

Rest of Ontario 0.5% 41,300 0.8% 310 0.10% 40

Ontario, total 3.0% 350,000 0.7% 2,610 0.10% 350




HIV incidence among high risk HIV incidence among high risk versusversuslow risk heterosexual repeat testerslow risk heterosexual repeat testers

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.16

0.18

1992 1993 1994 1995 1996 1997 1998 1999Year

Sero

conve

rsio

ns

per

100 P

Y

High risk (25758 PY)Low risk (174074 PY)


Modeled HIV prevalence among Modeled HIV prevalence among heterosexuals heterosexuals by health region and sex,by health region and sex, 19991999

400

450

100 100

400

500

0

50

100

150

200

250

300

350

400

450

500

Num

ber

of

HIV

-infe

cted p

ers

ons

Metro Toronto Ottawa-Carleton Ontario other

Male

Female



Proportion of HIV-infected infants by Proportion of HIV-infected infants by period period of birth and exposure category of of birth and exposure category of mother mother Ontario, 1984–1999Ontario, 1984–1999

0

10

20

30

40

50

60

70

80

90

Pro

po

rtio

n o

f k

no

wn

e

xp

os

ure

ca

teg

ory

(%

)

1984-87 1988-89 1990-91 1992-93 1994-95 1996-97 1998-99

Period of birth

IDU HIV-endemicHeterosexual Transfusion

Source: Dr Susan King, CPARG


Number of HIV-positive mothers by Number of HIV-positive mothers by antiretroviral prophylaxis and HIV status antiretroviral prophylaxis and HIV status

of infant, Ontario, of infant, Ontario, July 1994-December July 1994-December 19991999

HIV status of infantAntiretroviralprophylaxis? Infected

Notinfected Unknown Total

No 31 20 4 55

Yes 3 91 13 107

Total 34 111 17 162

Source: Dr Susan King, CPARG


HIV testing among pregnant women HIV testing among pregnant women receiving prenatal care, Ontarioreceiving prenatal care, Ontario, January , January 1999 to June 20001999 to June 2000

0

10

20

30

40

50

60

Month of first prenatal specimen

Propo

rtio

n H

IV t

este

d (%

)

PrenatalDiagnosticAny



LimitationsLimitations

•Populations at risk (especially MSM, IDU) are not well Populations at risk (especially MSM, IDU) are not well characterized (e.g. size, regional variations)characterized (e.g. size, regional variations)

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

•Data on HIV incidence is limited and biased (likely Data on HIV incidence is limited and biased (likely overestimates); overestimates);

•However, these have been taken into account in HIV However, these have been taken into account in HIV modelmodel



ConclusionsConclusions

•HIV epidemic in Ontario is not yet under controlHIV epidemic in Ontario is not yet under control•Good news: AIDS incidence and mortality have decreasedGood news: AIDS incidence and mortality have decreased•However . . . . . However . . . . . •Overall, HIV prevalence increased by 22% (16,480 to 20,050) Overall, HIV prevalence increased by 22% (16,480 to 20,050) and annual incidence by 50% (1,200 to 1,790) since 1996 and annual incidence by 50% (1,200 to 1,790) since 1996

• Increase in incidence among MSM: 80% (540 to 970)Increase in incidence among MSM: 80% (540 to 970)•MSM: preventive intervention efforts need to be MSM: preventive intervention efforts need to be systematically reviewed, reassessed and reinforced systematically reviewed, reassessed and reinforced

•HIV-endemic: prevention objectives and guidelines need to be HIV-endemic: prevention objectives and guidelines need to be developed and programs conceived, funded and implementeddeveloped and programs conceived, funded and implemented

•Mother-infant: invest in education of physicians and women Mother-infant: invest in education of physicians and women



ConclusionsConclusions

•Limitations in available data limit precision of Limitations in available data limit precision of HIV incidence estimates; good studies are lacking HIV incidence estimates; good studies are lacking •Cohort studies among MSM and IDU would be Cohort studies among MSM and IDU would be invaluable invaluable

•HIV prevalence studies with correlates of infectionHIV prevalence studies with correlates of infection•Prevention research: An idea whose time has come?Prevention research: An idea whose time has come?



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

•Carol Major and Carol Swantee, HIV Laboratory, MOHLTC Carol Major and Carol Swantee, HIV Laboratory, MOHLTC •Liviana Calzavara, Ann Burchell and Polaris coinvestigators Liviana Calzavara, Ann Burchell and Polaris coinvestigators •Elaine P. Whittingham, University of TorontoElaine P. Whittingham, University of Toronto•Susan King, Hospital for Sick Children Susan King, Hospital for Sick Children •Evelyn Wallace and Lorraine Schiedel, Public Health Branch, Evelyn Wallace and Lorraine Schiedel, Public Health Branch, MOHLTCMOHLTC

•Ontario HIV Treatment Network (OHTN) Ontario HIV Treatment Network (OHTN) •Instructional Media Centre, Instructional Media Centre, Laboratory Services,Laboratory Services, MOHLTCMOHLTC

Epidemiologic Update on the HIV Epidemic in Ontario

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