1. Community viral load and newly reported HIV infections in Switzerland Matthias Egger Professor of Epidemiology & Public Health Institute of Social and Preventive Medicine (ISPM) University of Bern CH-3012 Bern, Switzerland egger@ispm.unibe.ch IAS Satellite, Rome, 17 July 2011

2. Introduction Individual level  Strong dose-response relation between viral load (VL) and HIV transmission in heterosexual discordant couples in Rakai, Uganda. 1 Population level  Median VL associated with HIV incidence in injecting drug users (IDU) in Vancouver, Canada. 2  Total community VL (CVL), based on most recent value, associated with new HIV-infections in San Francisco, USA. 3 1. Quinn et al. N Engl J Med 2000; 2. Wood et al. BMJ 2009; 3. Das et al. PLoS One 2010. 2

3. Swiss HIV Cohort Study  Nation-wide study of HIV-infected adults  >17,000 patients enrolled since 1988, 30% women  ~70% of all patients with advanced diseases enrolled, ~50% of all HIV-infected patients enrolled 3

4. Swiss HIV Cohort Study  Nation-wide study of HIV-infected adults  >17,000 patients enrolled since 1988, 30% women  ~70% of all patients with advanced diseases enrolled, ~50% of all HIV-infected patients enrolled  Main transmission groups represented 4

5. Swiss HIV Cohort Study  Nation-wide study of HIV-infected adults  >17,000 patients enrolled since 1988, 30% women  ~70% of all patients with advanced diseases enrolled, ~50% of all HIV-infected patients enrolled  Main transmission groups represented  85% on treatment in 2010 5

6. Methods 1. HIV transmission potential in SHCS calculated using three approaches:  Total community VL based on all VL values  Infectivity based on a saturation curve. 1  Linear association between VL and infectivity. 2 2. Poisson model for association between number of new HIV diagnoses (national surveillance data from Swiss Federal Office of Public Health, SFOPH) and CVL in the year before 1. Fraser C, et al. Proc Natl Acad Sci USA 2007. 2. Wilson DP, et al. Lancet 2008; 6

7. Imputation of VL Taffé and May. Stat Med 2008. HET – heterosexuals, MSM – men who have sex with men; IDU – injection drug users 7

8. Viral load in the SHCS 8 HIV-RNA New HIV infections (FOPH) <500 copies >500 copies

9. Predictions from Poisson model by transmission group (CVL) HET – heterosexual contacs, MSM – men who have sex with men; IDU – injection drug users 9

10. Strengths and limitations Strengths  Inclusion of annual VL back to time of HIV infection  Examination of CVL and HIV diagnoses in different risk groups  Comparison of different measures of HIV transmission potential Limitations  SHCS includes only ~50% of HIV+ persons  Increased transmission potential at very high VL in acute HIV infection ignored  Transmission between risk groups ignored 10

11. Conclusions  First national level study to show association between CVL and new HIV diagnoses  CVL in the SHCS is a simple measure to estimate the transmission potential and predict new diagnoses, particularly in MSM and IDU  In Switzerland people infected through HET are a more heterogeneous group than MSM and IDUs, which may explain the less accurate predictions in these groups  Further research, including pilot studies, are needed to better understand the feasibility and likely population effects of TasP in Switzerland 11

12. Acknowledgments  F. Schöni-Affolter  N Low, ISPM Bern  C Althaus, ISPM Bern  O Keiser, ISPM Bern  M Gebhardt, SFOPH  J Ambrosioni, HUG, GE  B Hirschel, HUG, GE  P Vernazza, SG  HJ Furrer, Bern  D Vuichard, Basel  R Weber, Zürich 12