1. The HIV epidemic in Ontario: An epidemiologic update Robert S. Remis, MD, MPH, FRCPC, Department of Public Health Sciences, University of Toronto Presentation to the: Ontario Advisory Committee on HIV/ AIDS Toronto, January 12, 2004

2. instructional media centre, Laboratories Branch - 2000 Background HIV epidemic in Ontario is unstable and dynamic HIV epidemic in Ontario is unstable and dynamic Monitoring trends in HIV transmission (incidence) and burden of HIV infection (prevalence) is critical to evaluate effectiveness of primary prevention and project the need for health and support services Monitoring trends in HIV transmission (incidence) and burden of HIV infection (prevalence) is critical to evaluate effectiveness of primary prevention and project the need for health and support services Available data is biased and incomplete but triangulation allows obtaining plausible estimates for HIV incidence and prevalence Available data is biased and incomplete but triangulation allows obtaining plausible estimates for HIV incidence and prevalence Dr. Robert S. Remis Public Health Sciences, University of Toronto

3. instructional media centre, Laboratories Branch - 2000 Organization of presentation Describe the databases and the methodologies used Describe the databases and the methodologies used Overview of HIV epidemic in Ontario Overview of HIV epidemic in Ontario Focus on emerging situations Focus on emerging situations MSM MSM IDU IDU Persons from HIV-endemic countries Persons from HIV-endemic countries Others infected by heterosexual contact Others infected by heterosexual contact Dr. Robert S. Remis Public Health Sciences, University of Toronto

4. instructional media centre, Laboratories Branch - 2000 Methods: Data sources HIV diagnoses: First-time diagnoses at HIV Laboratory adjusted for unknown risk factors and previous HIV testing using data from Laboratory Enhancement Study HIV diagnoses: First-time diagnoses at HIV Laboratory adjusted for unknown risk factors and previous HIV testing using data from Laboratory Enhancement Study AIDS incidence: Cases diagnosed to December 2002 and reported by May 2003; AIDS incidence: Cases diagnosed to December 2002 and reported by May 2003; HIV-related mortality: Deaths to end 1999 adjusted for underascertainment HIV-related mortality: Deaths to end 1999 adjusted for underascertainment HIV-infected mothers and infants: Data reported to CPARG and analyzed by period of HIV diagnosis, infection status of infant and mother’s exposure category HIV-infected mothers and infants: Data reported to CPARG and analyzed by period of HIV diagnosis, infection status of infant and mother’s exposure category Dr. Robert S. Remis Public Health Sciences, University of Toronto

5. instructional media centre, Laboratories Branch - 2000 Methods: Data analysis HIV model HIV model HIV infection: incidence, cumulative incidence and prevalence HIV infection: incidence, cumulative incidence and prevalence HIV diagnosis: incidence, cumulative incidence and prevalence HIV diagnosis: incidence, cumulative incidence and prevalence AIDS: incidence, cumulative incidence and prevalence AIDS: incidence, cumulative incidence and prevalence HIV-related mortality: incidence and cumulative incidence HIV-related mortality: incidence and cumulative incidence Model values adjusted to fit available data on HIV diagnoses, reported AIDS cases and AIDS deaths and results from back-calculations Model values adjusted to fit available data on HIV diagnoses, reported AIDS cases and AIDS deaths and results from back-calculations Dr. Robert S. Remis Public Health Sciences, University of Toronto

6. instructional media centre, Laboratories Branch - 2000 Methods: Data analysis HIV incidence from repeat testers HIV incidence from repeat testers Results linked within HIV Laboratory database using name, sex, date of birth, previous test history to identify repeat testers Results linked within HIV Laboratory database using name, sex, date of birth, previous test history to identify repeat testers HIV incidence calculated by exposure category, age and health region using method of Kitayaporn HIV incidence calculated by exposure category, age and health region using method of Kitayaporn HIV incidence from detuned assay HIV incidence from detuned assay HIV-positive sera tested using diagnostic EIA assay rendered less sensitive to detect recent HIV infection (< 129 days) HIV-positive sera tested using diagnostic EIA assay rendered 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) Dr. Robert S. Remis Public Health Sciences, University of Toronto

7. instructional media centre, Laboratories Branch - 2000 Number of first-time HIV diagnoses by sex and proportion female, 1985–2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

8. instructional media centre, Laboratories Branch - 2000 First-time HIV-positive diagnoses among males (n=20,465), Ontario, 1985–2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

9. instructional media centre, Laboratories Branch - 2000 First-time HIV-positive diagnoses among females (n=2,464), Ontario, 1985–2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

10. instructional media centre, Laboratories Branch - 2000 Reported AIDS cases among MSM, Ontario, 1981–2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

11. instructional media centre, Laboratories Branch - 2000 Reported AIDS cases by exposure category, Ontario, 1981–2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

12. instructional media centre, Laboratories Branch - 2000 HIV incidence among MSM repeat testers, with 95% CLs, 1992-2001 (30,881 PY) Source: Polaris Seroconversion Study

13. instructional media centre, Laboratories Branch - 2000 HIV incidence among MSM repeat testers by age group, 1992-99 Source: Polaris Seroconversion Study

14. instructional media centre, Laboratories Branch - 2000 HIV incidence from detuned assay among MSM by health region, Oct 1999 – Dec 2002 Source: Laboratory Enhancement Study

15. instructional media centre, Laboratories Branch - 2000 HIV incidence from detuned assay among MSM by region, Oct 1999 – Dec 2002 Source: Laboratory Enhancement Study

16. instructional media centre, Laboratories Branch - 2000 Modeled HIV incidence among MSM Ontario, 1977–2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

17. instructional media centre, Laboratories Branch - 2000 Modeled HIV prevalence among MSM Ontario, 1977– 2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

18. instructional media centre, Laboratories Branch - 2000 Modeled MSM population at risk, HIV prevalence and incidence by health region, Ontario, 2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

19. instructional media centre, Laboratories Branch - 2000 HIV incidence from detuned assay among IDU by health region, Oct 1999 – Dec 2002 Source: Laboratory Enhancement Study

20. instructional media centre, Laboratories Branch - 2000 HIV incidence from detuned assay among IDU by region, Oct 1999 – Dec 2002 Source: Laboratory Enhancement Study

21. instructional media centre, Laboratories Branch - 2000 Modeled HIV incidence among IDUs Ontario, 1977–2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

22. instructional media centre, Laboratories Branch - 2000 Modeled HIV prevalence among IDUs Ontario, 1977–2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

23. instructional media centre, Laboratories Branch - 2000 IDU population, HIV prevalence and incidence by health region, Ontario, December 2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

24. instructional media centre, Laboratories Branch - 2000 Modeled HIV incidence among persons from HIV-endemic regions, Ontario, 1977–2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

25. instructional media centre, Laboratories Branch - 2000 Modeled HIV prevalence among persons from HIV-endemic regions, Ontario, 1977–2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

26. instructional media centre, Laboratories Branch - 2000 Modeled population and HIV prevalence among persons born in HIV-endemic countries, by health region, Ontario, 2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

27. instructional media centre, Laboratories Branch - 2000 Modeled HIV prevalence among other persons infected heterosexually, Ontario, 1977–2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

28. instructional media centre, Laboratories Branch - 2000 Modeled HIV prevalence and number diagnosed by exposure category, Ontario, 2002 Dr. Robert S. Remis Public Health Sciences, University of Toronto

29. instructional media centre, Laboratories Branch - 2000 Limitations Populations at risk (especially MSM, IDU) not well characterized (e.g. size, regional variations) Populations at risk (especially MSM, IDU) not well characterized (e.g. size, regional variations) Adjustments for HIV diagnoses, AIDS cases and HIV-related mortality subject to uncertainty Adjustments for HIV diagnoses, AIDS cases and HIV-related mortality subject to uncertainty Data on HIV incidence is limited and biased Data on HIV incidence is limited and biased However, these have been taken into account in HIV model However, these have been taken into account in HIV model Dr. Robert S. Remis Public Health Sciences, University of Toronto

30. instructional media centre, Laboratories Branch - 2000 Conclusions HIV epidemic in Ontario is not yet under control HIV epidemic in Ontario is not yet under control Good news: AIDS incidence and mortality decreasing Good news: AIDS incidence and mortality decreasing However..... However..... Overall, HIV prevalence increased by 36% (16,300 to 22,100) Overall, HIV prevalence increased by 36% (16,300 to 22,100) Increase in HIV incidence among MSM: 45% (600 to 880) Increase in HIV incidence among MSM: 45% (600 to 880) MSM: Preventive intervention efforts need to be systematically reviewed and reinforced MSM: Preventive intervention efforts need to be systematically reviewed and reinforced Dr. Robert S. Remis Public Health Sciences, University of Toronto

31. instructional media centre, Laboratories Branch - 2000 Conclusions Persons infected by heterosexual contact increasing in both exposure categories Persons infected by heterosexual contact increasing in both exposure categories HIV-endemic: prevention objectives and guidelines need to be developed and programs conceived, funded and implemented HIV-endemic: prevention objectives and guidelines need to be developed and programs conceived, funded and implemented Increase among others infected heterosexually requires validation and elucidation Increase among others infected heterosexually requires validation and elucidation Dr. Robert S. Remis Public Health Sciences, University of Toronto

32. instructional media centre, Laboratories Branch - 2000 Acknowledgements Frank McGee, Coordinator, AIDS Bureau, Ontario Ministry of Health and Long Term Care (MOHLTC) Frank McGee, Coordinator, AIDS Bureau, Ontario Ministry of Health and Long Term Care (MOHLTC) Carol Swantee, HIV Laboratory, MOHLTC Carol Swantee, HIV Laboratory, MOHLTC Liviana Calzavara, Ann Burchell and Polaris coinvestigators Liviana Calzavara, Ann Burchell and Polaris coinvestigators Maraki Fikre Merid, University of Toronto Maraki Fikre Merid, University of Toronto Lorraine Schiedel, Public Health Branch, MOHLTC Lorraine Schiedel, Public Health Branch, MOHLTC Ontario HIV Treatment Network (OHTN) and Health Canada for funding Laboratory Enhancement Study Ontario HIV Treatment Network (OHTN) and Health Canada for funding Laboratory Enhancement Study