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The ageing HIV population in
Scotland:adults and children
Lesley A WallaceHealth Protection Scotland
SHIVAG, Dunfermline, 26th June 2015
HIV infection in Scotland
• Outline: Adults• HIV landscape • HIV diagnoses• Treatment & Care• Late diagnoses
• Combined with age information
• Data on paediatric infection
HIV Landscape: Scotland 2014 Estimates
Annual Annual Death & Chronically New transmissions (MSM) Exported Infection Infected & Imported Infection
(High Prev. ountries)
?100 – 120 6450 ~350
Diagnosed Undiagnosed 4900 (76%) 1550 (24%)
In Specialist Care Not in Specialist Care 4100 (84%) 800 (16%) Treated Untreated 3650 (89%) 450 (11%)
Optimal Response* Suboptimal Response 3500 (96%) 150 (4%)
*Cases recording HIV viral load of 400 copies/ml or less at latest attendance
34% >50
33% >50
35% >50
HIV infected persons by transmission category and year of
report, Scotland, 1981-2014
Data source: HIV diagnoses database, Health Protection Scotland
0
50
100
150
200
250
300
350
400
450
500
Nu
mb
er
Year
MSM
Heterosexual
PWID
Other/not known
Total
Reports of HIV infection – age at diagnosis, 2005-2014
• Most diagnoses in 25-49 age group
• Small increase in proportion of those aged 50+
0
20
40
60
80
100
120
140
160
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Nu
mb
er
Year
15-24 25-34 35-49 50+
Current ages of HIV cohort living in Scotland
0
200
400
600
800
1000
1200
1400
1600
1800
2000
<20 20-29 30-39 40-49 50-59 60-69 >70
Nu
mb
er
Age group
• 36% of cohort aged 40-49• 1.6% over 70 – this includes those >80• 34% of cohort >50 years• People living with HIV in Scotland for >30 years
Current ages of HIV cohort in Scotland by transmission category
Data: HIV positive individuals alive and not known to have left Scotland at 31st December 2014
0
250
500
750
1000
1250
1500
1750
2000
2250
Women Men Heterosexual women
Heterosexual men
PWID women PWID men MSM
Num
ber
Exposure category
15-24 25-34
35-44 45+
Reports of heterosexually acquired HIV infection, Scotland, 2000-2014
0
20
40
60
80
100
120
140
160
180
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Nu
mb
er
Year
Non-UK nationals infected outwith the UK Non-UK nationals infected within the UK
UK Nationals infected within the UK UK Nationals infected outwith the UK
50% attending services are >45years, of this group:• 58% infected UK & 42% sub-Saharan Africa• 59% White UK/Ireland ethnicity & 32% Black African• 54% men
HIV reports among people who inject drugs (PWID), Scotland 1984-2014
2015 Cluster in Glasgow: 17 cases
• similar strain of virus
• Evidence of recent infection
• Many homeless
• Epidemiological links between cases
• Public health action
70% attending services are >45years
HIV: Evidence of transmission• Testing of new ‘first time’ reports in Scotland• Recency of infection
– Avidity test results– Acquired infection within past 3-4m
MSM Other All
2012 17% 0% 11%
2013 21% 6% 14%
2014 30% 15% 21%
Most recent infections in MSM are aged 25-34y
HIV diagnoses, AIDS registrations and deaths and individuals undergoing CD4 monitoring by year of report/death in
Scotland, 1992-2014
Deaths data 2011-2014: 102 of 145 (70%) are aged >45
- 1ry cause for all ages: 35% HIV related and15% malignancies
- 32% with AIDS registration at some time
0
500
1000
1500
2000
2500
3000
3500
4000
4500
0
50
100
150
200
250
300
350
400
450
500
Nu
mb
er
un
derg
oin
g H
IV m
on
ito
rin
g
Nu
mb
er
Year
HIV diagnoses AIDS registrations Deaths
AIDS deaths CD4 Persons monitored
Combination therapy available 1996
HIV Landscape: Scotland 2014 Estimates
Annual Annual Death & Chronically New transmissions (MSM) Exported Infection Infected & Imported Infection
(High Prev. ountries)
?100 – 120 6450 ~350
Diagnosed Undiagnosed 4900 (76%) 1550 (24%)
In Specialist Care Not in Specialist Care 4100 (84%) 800 (16%) Treated Untreated 3650 (89%) 450 (11%)
Optimal Response* Suboptimal Response 3500 (96%) 150 (4%)
*Cases recording a “managable” HIV viral load of 400 copies/ml or less at latest attendance
34% >50
33% >50
35% >50
Number predicted to be receiving HIV treatment and care,Scotland,2020
S. Corson et al, BASHH, Glasgow 2015
Model predicts: - 40% increase in those in care - 50% increase in those receiving treatment
START – Scotland perspective
• 1539 individuals attending for the first time AND starting treatment for the first time between 2000 -2011
• CD4 count up to 90 days before first recorded treatment– 19% started treatment CD4 >350
• Outcome: proportion of deaths– 6.6% in those treated at CD4 <350– 3.7% in those treated at CD4 >350
CD4 count pre
treatmentNumber
Number of deaths
Proportion (%)
<200 739 70 9.5
201-350 503 12 2.4
350-500 192 8 4.2
>500 105 3 2.9
HIV - late diagnosis
• Late diagnosis: CD4 count <350*
* CD4 cell count <350 within 30 days of earliest positive HIV diagnosis , excludes those known to be previously infected
0
10
20
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Pro
po
rtio
n (
%)
Year
% 201-350
% <200
0
10
20
30
40
50
60
70
80
90
100
2012 2013 2014 2012 2013 2014
Pro
port
ion
%
Year
<30 years 31-50 years >50 years
Heterosexual MSM
• Age comparisons: no evidence that more late diagnoses are made in older people
HIV infection among children•126 paediatric HIV infections notified to HPS
•73 males and 53 females • 58% UK born • 39% Black African ethnicity• Transmission routes:
96
22
6 2
Mother-to-child transmission
Blood factor treatment
Blood/tissue transfer
Other/undetermined
Data source: Laboratory reports of newly diagnosed HIV positive individuals aged > 18m and *NSHPC- National Study of HIV in Pregnancy and Childhood
UK*: ~2570• 84% MTCT• 40% UK born•15% died
HIV diagnoses among children by year of report and transmission category,
Scotland, 1982-2014
Data source: Integrated HIV & AIDS Diagnoses Surveillance System
0
1
2
3
4
5
6
7
8
9
10
11
12
1982 1984 1986 1989 1991 1994 1998 2001 2003 2005 2007 2009 2011 2013
Num
ber
Year
Blood/Tissue transfer Blood factor treatment Mother to child Other/Unknown
HIV antibody test available
Antenatal screening
HIV diagnoses among children by ethnicity and year of
report,Scotland, 1982-2014
Data source: Integrated HIV & AIDS Diagnoses Surveillance System
0
2
4
6
8
10
12
14
16
1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
Num
ber
Year
Black-African Mixed White-Scottish
White-Other White-Other British Other/Unk
Antenatal screening
Outcomes among paediatric HIV diagnoses
• Of 126 paediatric diagnoses:
• 29 (23%) have died
• median survival 5years (range 0-20years)
• 21 (72%) of these registered as having AIDS
• Of 97 HIV infected children alive at end 2014• 43 attending for treatment and care• 30 are <15 years• 18 lost to follow up• 6 left ScotlandData source: Integrated HIV & AIDS Diagnoses Surveillance System
Access to specialist care and therapy
• Of 43 paediatric HIV infections now attending for treatment and care:
- aged 16-46years (median 24y) - 93% (40) on antiviral therapy
- 93% (37) achieved viral suppression - 67% UK born - 26% Black African
UK*: 1037 in treatment and care • 48% UK born• 79% Black African• 97% Mother to child transmission
• 84% on ART (11% naive and 5% off ART)* CHIPS data to end March 2014
Summary• Estimated 6450 living with HIV in Scotland
– 4900 diagnosed
• Ongoing HIV transmission
• Late diagnosis
• High proportion of cohort accessing specialist care and responding to treatment
• Diagnosis of HIV among children in Scotland is rare event - mostly imported infection
• Ageing cohort – further analyses?– use morbidity data?– survival analyses?
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