HIV Diagnosis and the Cascade of Care in Ontario Abigail Kroch, Ph.D. M.P.H. Director of the Applied Epidemiology Unit Ontario HIV Treatment Network June 2017

What is the Ontario HIV Epidemiology and Surveillance Initiative (OHESI)? A new collaboration What do we hope to achieve? Better access to timely, relevant and comprehensive information about the epidemiology of HIV in Ontario Disseminate this information more widely to the stakeholders who need to know it

Lab Testing Data Person decides to get an HIV test Health care provider completes a lab form (known as a test requisition) Specimen is collected and sent to Public Health Ontario Laboratory If the result is HIV positive: Result reported back to health care provider to give result to the person, and to local public health unit Result is shared with the Laboratory Enhancement Program (LEP), which sends a data collection form to the health care provider

Changes to the Test Requisition in 2017 Simplified Exposure Categories Expanded Reasons for Testing Expanded sex/gender categories to include M-F and F-M transgender.

Cascade of care, testing and diagnosis Diagnostic Testing (Public Health Ontario Laboratory data)

Number of HIV tests, total, Ontario, 2000-2015 Key points There was a large increase in the number of tests between 2000 and 2006, which stabilized in the late 2000s. Since 2010, there has been a slight but steady increase in number of tests. Limitations Tests conducted prenatally are not included. OHESI is a collaboration between the AIDS Bureau of the Ontario Ministry of Health and Long-Term Care, Public Health Ontario, Public Health Agency of Canada, and the Ontario HIV Treatment Network (OHTN). The main objective of OHESI is to understand, monitor and translate the epidemiology of HIV in the province of Ontario. Data provided to Ontario HIV Epidemiology and Surveillance Initiative (OHESI) by Public Health Ontario Laboratory. Does not include prenatal tests. www.ohesi.ca

Positivity rate, total and by sex, Ontario, 2000-2015 Key points The positivity rate has steadily decreased overall and for both sexes since 2000 The positivity rate has consistently been higher for males compared to females. Limitations Tests conducted prenatally are not included. HIV test positivity rates can be helpful by indicating which populations of individuals testing for HIV have a higher level of HIV risk. However, positivity rates should be interpreted with caution as they are influenced by both changes in HIV incidence as well as changes in the number and types of people getting tested and it is difficult to disentangle these two effects. OHESI is a collaboration between the AIDS Bureau of the Ontario Ministry of Health and Long-Term Care, Public Health Ontario, Public Health Agency of Canada, and the Ontario HIV Treatment Network (OHTN). The main objective of OHESI is to understand, monitor and translate the epidemiology of HIV in the province of Ontario. Data provided to Ontario HIV Epidemiology and Surveillance Initiative (OHESI) by Public Health Ontario Laboratory. Does not include prenatal tests. Positivity rate is the proportion of tests with HIV-positive results. www.ohesi.ca

HIV Positivity rate by exposure category, Ontario, 2014-2015 Data provided to OHESI by PHOL

Number of tests and HIV Positivity rate by age and sex, Ontario, 2013-2015 Data provided to OHESI by PHOL

New HIV diagnoses, total, Ontario, 2007-2016 Key points The number of new HIV diagnoses has generally decreased over the past decade. There has been a slight increasing trend since 2013. This increase does not necessarily mean that HIV infections are increasing, and may partly be due to increased HIV testing during this time. There were 842 new HIV diagnoses in 2015, which was slightly higher than the 828 diagnoses in 2014. The number of diagnoses in 2015 was still lower than most years over the past decade. Data provided to Ontario HIV Epidemiology and Surveillance Initiative (OHESI) by Public Health Ontario Laboratory. www.ohesi.ca

New HIV diagnoses by sex, Ontario, 2007-2016 Key Points There was a slight increase in male diagnoses from 2014 (655) to 2015. The percent female diagnoses have generally decreased over the past decade Data provided to Ontario HIV Epidemiology and Surveillance Initiative (OHESI) by Public Health Ontario Laboratory. www.ohesi.ca

New HIV diagnoses by age and sex, Ontario, 2016 Key Points There was a slight increase in male diagnoses from 2014 (655) to 2015. The percent female diagnoses have generally decreased over the past decade Data provided to Ontario HIV Epidemiology and Surveillance Initiative (OHESI) by Public Health Ontario Laboratory. www.ohesi.ca

New HIV diagnoses by Health Region, Ontario, 2016 Key Points There was a slight increase in male diagnoses from 2014 (655) to 2015. The percent female diagnoses have generally decreased over the past decade Data provided to Ontario HIV Epidemiology and Surveillance Initiative (OHESI) by Public Health Ontario Laboratory. www.ohesi.ca

Ontario’s HIV Prevention, Engagement, and Care Cascade Diagnostic and Viral Load Testing (Public Health Ontario Laboratory data)

Cascade indicators Ontario cascade steps defined based on review of the literature, OHESI Technical Working Group decisions, and expert consultation We calculated the number of individuals each year meeting the cascade indicator definitions The denominator used to calculate the proportion of individuals in each stage per year varied by cascade stage Each indicator has a “Main” estimate, representing our best estimate for the cohort Where applicable, also calculated “Upper” and “Lower” estimates based on a sensitivity analysis of our assumptions

Number of people with diagnosed HIV living in Ontario, 2000-2015 17,423 16,111 Data provided to OHESI by the Public Health Ontario Laboratory

Proportion of diagnosed PLWH who are in care, Ontario, 2000-2015 Data provided to OHESI by the Public Health Ontario Laboratory

Proportion of diagnosed PLWH who are on treatment, Ontario, 2000-2015 82.0% 69.9% Data provided to OHESI by the Public Health Ontario Laboratory -- Poster #: EPHP1.03 – CAHR April 2017

Proportion of diagnosed PLWH on treatment who are virally suppressed, Ontario, 2000-2015 95.1% 90.9% Data provided to OHESI by the Public Health Ontario Laboratory – CAHR Poster #: EPHP1.03 – CAHR April 2017

Time from diagnosis to viral load suppression, Ontario, 2000-2013 Data provided to OHESI by PHOL

Proportion of diagnosed PLWH engaged in the HIV cascade, Ontario, 2000-2015 Data provided to OHESI by PHOL

UNAIDS 90-90-90 Targets Source: www.avert.org If all UNAIDS targets are met, this would mean… 90% of all people living with HIV are diagnosed 81% of all people living with HIV are on treatment 73% of all people living with HIV are virally suppressed

Where is Ontario with the 90-90-90? 81% 66% 62% Data provided to OHESI by the Public Health Ontario Laboratory – CAHR April 2017

Take-Home Messages Most comprehensive province-wide estimates of the HIV cascade for Ontario Engagement in Ontario’s HIV cascade has improved over time Reflects success of care and treatment initiatives, availability of improved antiretroviral treatment regimens, and guideline changes A full understanding of how close Ontario is to the combined 90-90-90 target (all PLWH  90% diagnosed, 81% on ART, and 73% virally suppressed) requires a reliable estimate of the First 90

Improving Ontario’s cascade Generate estimates by age, sex, population and region Link to administrative health record databases at ICES to better account for migration and death Develop Ontario models for HIV incidence, prevalence and undiagnosed infection Improve missing data through modelling and improved data quality

Acknowledgements OHESI partners Technical working group Public Health Ontario (PHO) AIDS Bureau, Ministry of Health and Long-Term Care Public Health Agency of Canada (PHAC) Ontario HIV Treatment Network (OHTN) Technical working group Juan Liu (PHO Laboratory) Ashleigh Sullivan (PHO Laboratory) Lucia Light (OTHN) Beth Rachlis (OHTN) James Wilton (OHTN) Claudia Rank (PHAC) Steering Committee Champions Committee

For more information or to register for updates, please visit www For more information or to register for updates, please visit www.ohesi.ca akroch@ohtn.on.ca