1. 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

2. 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

3. 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

4. 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.

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

6. 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.

7. 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.

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

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

10. 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 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 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.

11. 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.

12. 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.

13. 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.

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

15. 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

16. 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

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

18. 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

19. 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

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

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

22. UNAIDS Targets
Source:
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

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

24. 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 target (all PLWH  90% diagnosed, 81% on ART, and 73% virally suppressed) requires a reliable estimate of the First 90

25. 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

26. 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

27. For more information or to register for updates, please visit www
For more information or to register for updates, please visit