Epidemiologic overview of HIV/AIDS in Ontario and Toronto: 2004 update Robert S. Remis MD, MPH, FRCPC, Maraki Fikre Merid BSc Ontario HIV Epidemiologic

instructional media centre, Laboratories Branch - 2000

Epidemiologic Epidemiologic overview overview

of HIV/AIDS in Ontario of HIV/AIDS in Ontario and Toronto: 2004 and Toronto: 2004

updateupdate Robert S. Remis MD, MPH, FRCPC, Maraki Fikre Merid BScRobert S. Remis MD, MPH, FRCPC, Maraki Fikre Merid BSc

Ontario HIV Epidemiologic Monitoring Unit Ontario HIV Epidemiologic Monitoring Unit

Department of Public Health Sciences, University of TorontoDepartment of Public Health Sciences, University of Toronto

Current HIV/AIDS Trends in TorontoCurrent HIV/AIDS Trends in TorontoToronto Public HealthToronto Public Health

Toronto, January 6, 2005Toronto, January 6, 2005


BackgroundBackground

•The HIV epidemic in Ontario, including Toronto, is The HIV epidemic in Ontario, including Toronto, is unstable and dynamicunstable and dynamic

•Critical to monitor trends in HIV transmission Critical to monitor trends in HIV transmission (incidence) and burden of HIV infection (incidence) and burden of HIV infection (prevalence) to evaluate effectiveness of (prevalence) to evaluate effectiveness of prevention and assess the need for health and prevention and assess the need for health and support services support services

Dr. Robert S. RemisPublic Health Sciences, University of Toronto


Organization of presentationOrganization of presentation

•Brief review of Ontario and Toronto HIV dataBrief review of Ontario and Toronto HIV data•Ontario HIV model 2003Ontario HIV model 2003•Focus on evolving situations with respect to:Focus on evolving situations with respect to:

• MSMMSM• IDUIDU• HIV-endemic HIV-endemic • Other heterosexualOther heterosexual



Number of first-time HIV diagnoses by Number of first-time HIV diagnoses by

sex and proportion female, 1985–2003sex and proportion female, 1985–2003

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Year

Nu

mb

er

HIV

dia

gn

os

es

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Pro

po

rtio

n f

em

ale

(%

)

MalesFemales% female



First-time HIV-positive diagnoses First-time HIV-positive diagnoses amongamongmales (n=21,325), Ontario, 1985–2003males (n=21,325), Ontario, 1985–2003

4.2% 1.3%

4.6%6.6%

1.0%

3.5%

0.8%0.8%

0.3%

76.8% MSMMSM-IDUIDUClotting factorTransfusionHIV-endemicHR heteroLR heteroPerinatalOther



First-time HIV-positive diagnoses First-time HIV-positive diagnoses among females (n=3,409), Ontario, among females (n=3,409), Ontario, 1985–20031985–2003

4.8%5.3%1.1%

32.9%

17.6%1.9%

16.4%

20.0%

IDU

Clotting factor

Transfusion

HIV-endemic

HR hetero

LR hetero

Perinatal

Other



Number of first-time HIV diagnoses Number of first-time HIV diagnoses MSM, Toronto, 1999–2004MSM, Toronto, 1999–2004

0

100

200

300

400

500

1999 2000 2001 2002 2003 2004

Nu

mb

er

of

ca

se

s


Number of first-time HIV Number of first-time HIV diagnoses for selected diagnoses for selected exposure categories, exposure categories, Toronto, 1999–2004Toronto, 1999–2004

0

50

100

150

200

1999 2000 2001 2002 2003 2004

Nu

mb

er

of

ca

se

s

HIV-endemicLR heteroHR heteroMSM-IDUIDU


HIV incidence from detuned assay among HIV incidence from detuned assay among MSM, Ontario, October 1999 – December MSM, Ontario, October 1999 – December 20032003

0.0

0.5

1.0

1.5

2.0

2.5

3.0

1999 2000 2001 2002 2003

Inc

ide

nc

e d

en

sit

y (

/10

0 p

-y)

ID measuredID adjusted

Source: Laboratory Enhancement Study


HIV incidence from detuned assay among HIV incidence from detuned assay among MSM, Toronto, October 1999 – December MSM, Toronto, October 1999 – December 20032003

0.0

0.5

1.0

1.5

2.0

2.5

3.0

1999 2000 2001 2002 2003

Inc

ide

nc

e d

en

sit

y (

/10

0 p

-y)




HIV incidence from detuned assay among HIV incidence from detuned assay among MSM, Ottawa, October 1999 – December MSM, Ottawa, October 1999 – December 20032003

0.0

0.5

1.0

1.5

2.0

2.5

3.0

1999 2000 2001 2002 2003

Inc

ide

nc

e d

en

sit

y (

/10

0 p

-y)




HIV incidence from detuned assay among HIV incidence from detuned assay among MSM, other regions, October 1999 – MSM, other regions, October 1999 – December 2003December 2003

0.0

0.5

1.0

1.5

2.0

1999 2000 2001 2002 2003

Inc

ide

nc

e d

en

sit

y (

/10

0 p

-y)




HIV incidence from detuned assay HIV incidence from detuned assay among among IDU, Ontario, October 1999 – December IDU, Ontario, October 1999 – December 20032003

0.0

0.2

0.4

0.6

0.8

1.0

1999 2000 2001 2002 2003

Inc

ide

nc

e d

en

sit

y (

/10

0 p

-y)




HIV incidence from detuned assay HIV incidence from detuned assay among IDU, Toronto, October 1999 – among IDU, Toronto, October 1999 – December 2003December 2003

0.0

0.1

0.2

0.3

0.4

0.5

1999 2000 2001 2002 2003

Inc

ide

nc

e d

en

sit

y (

/10

0 p

-y)




HIV incidence from detuned assay HIV incidence from detuned assay among IDU, Ottawa, October 1999 – among IDU, Ottawa, October 1999 – December 2003December 2003

0.0

0.2

0.4

0.6

0.8

1.0

1999 2000 2001 2002 2003

Inc

ide

nc

e d

en

sit

y (

/10

0 p

-y)




HIV incidence from detuned assay HIV incidence from detuned assay among IDU, other regions, October 1999 among IDU, other regions, October 1999 – December 2003– December 2003

0.0

0.2

0.4

0.6

0.8

1.0

1999 2000 2001 2002 2003

Inc

ide

nc

e d

en

sit

y (

/10

0 p

-y)




Modeled HIV prevalence and Modeled HIV prevalence and diagnoses diagnoses by exposure category, Ontario, by exposure category, Ontario, 20032003


HIV Proportion HIV Proportionprevalence Ontario diagnosed diagnosed

MSM 14,370 61.0% 9,887 68.8%MSM-IDU 703 3.0% 408 58.0%IDU 1,959 8.3% 1,313 67.0%Endemic 3,011 12.8% 1,431 47.5%Hetero 3,311 14.1% 1,672 50.5%Clotting 156 0.7% 156 100.0%Transfusion 52 0.2% 48 92.3%

23,563 100.0% 14,916 63.3%


Modeled HIV infections by Modeled HIV infections by exposure category and health exposure category and health region, both sexes, Ontario, region, both sexes, Ontario, 20032003


MSM MSM IDU IDU Endemic Hetero Total

Toronto 10,000 360 610 1,900 1,560 14,540 Ottawa 1,450 120 590 580 510 3,280 Other 2,920 220 760 530 1,245 5,740

Ontario 14,370 700 1,960 3,010 3,315 23,560 Toronto % 70% 51% 31% 63% 47% 62%

%Toronto 69% 2% 4% 13% 11% 100%


Modeled HIV infections by Modeled HIV infections by exposure category and health exposure category and health region, males,region, males,Ontario, 2003Ontario, 2003


MSM MSM-IDU IDU Endemic Hetero Total

Toronto 10,000 360 400 1,230 760 12,845 Ottawa 1,450 120 400 390 250 2,635 Other 2,920 220 530 350 525 4,605

Ontario 14,370 700 1,330 1,970 1,535 20,085 Toronto % 70% 51% 30% 62% 50% 64%

%Toronto 78% 3% 3% 10% 6% 100%


Modeled HIV infections by Modeled HIV infections by exposure category and health exposure category and health region, females,region, females,Ontario, 2003Ontario, 2003


IDU Endemic Hetero Total

Toronto 210 670 800 1,695 Ottawa 190 190 260 645 Other 230 180 720 1,135

Ontario 630 1,040 1,780 3,475 Toronto % 33% 64% 45% 49%

%Toronto 12% 40% 47% 100%


Modeled HIV prevalence among MSM Modeled HIV prevalence among MSM Ontario, 1977–2003Ontario, 1977–2003

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003

Year

Pro

po

rtio

n H

IV in

fec

ted

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

Nu

mb

er

of

HIV

-in

fec

ted

me

n

Prevalence %

Prevalence number



MSM: Epidemiologic overviewMSM: Epidemiologic overview

•14,370 HIV-infected (61% of Ontario infections), 69% 14,370 HIV-infected (61% of Ontario infections), 69% diagnoseddiagnosed

•New HIV diagnoses 2004 up 54% over 2001, especially in New HIV diagnoses 2004 up 54% over 2001, especially in Toronto and Central West regionsToronto and Central West regions

•HIV prevalence 15% (Toronto 19%, Ottawa 18%, other HIV prevalence 15% (Toronto 19%, Ottawa 18%, other 8%)8%)

•1998-2003 prevalence up 29% (annual 5%)1998-2003 prevalence up 29% (annual 5%)•690 new infections in 2003 690 new infections in 2003 •HIV incidence 0.9% (Toronto 1.1%, Ottawa 1.5%, other HIV incidence 0.9% (Toronto 1.1%, Ottawa 1.5%, other 0.3%)0.3%)



Modeled HIV prevalence among IDUsModeled HIV prevalence among IDUsOntario, 1977–2003Ontario, 1977–2003

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003

Year

Pro

po

rtio

n H

IV in

fec

ted

0

500

1,000

1,500

2,000

2,500

Nu

mb

er

of

HIV

-in

fec

ted

IDU

sPrevalence %

Prevalence number



IDU: Epidemiologic overviewIDU: Epidemiologic overview

•1,960 HIV-infected (8% of Ontario infections), 67% 1,960 HIV-infected (8% of Ontario infections), 67% diagnoseddiagnosed

•New HIV diagnoses stable overall past five years, New HIV diagnoses stable overall past five years, though increase in 2004 in Southwest and Northern though increase in 2004 in Southwest and Northern regionsregions

•HIV prevalence 5% (Ottawa 15%, elsewhere 4%)HIV prevalence 5% (Ottawa 15%, elsewhere 4%)•1998-2003 prevalence up 8% (annual 1.5%)1998-2003 prevalence up 8% (annual 1.5%)•80 new infections in 2003; HIV incidence 0.2%80 new infections in 2003; HIV incidence 0.2%•Relatively reassuringRelatively reassuring



Modeled HIV prevalence persons Modeled HIV prevalence persons from HIV-endemic regions, Ontario, from HIV-endemic regions, Ontario, 1977–20031977–2003

0

500

1,000

1,500

2,000

2,500

3,000

3,500

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003Year



HIV-endemic: Epidemiologic HIV-endemic: Epidemiologic overviewoverview

•3,310 HIV-infected (13% of Ontario infections); 48% 3,310 HIV-infected (13% of Ontario infections); 48% diagnosed diagnosed

•HIV prevalence 0.8%HIV prevalence 0.8%•Most HIV-infected persons in Toronto (75%) and Most HIV-infected persons in Toronto (75%) and Ottawa (15%)Ottawa (15%)

•1998-2003 prevalence up 86% (annual 13%)1998-2003 prevalence up 86% (annual 13%)•New HIV diagnoses increased 1999 (160) to 2002 New HIV diagnoses increased 1999 (160) to 2002 (280) then decreased somewhat (230 in 2004)(280) then decreased somewhat (230 in 2004)

•330 new HIV infections in 2003 (imported & Canada)330 new HIV infections in 2003 (imported & Canada)



Modeled HIV prevalence other personsModeled HIV prevalence other personsinfected heterosexually, Ontario, 1977–infected heterosexually, Ontario, 1977–20032003

0.0%

0.1%

0.1%

0.2%

0.2%

0.3%

0.3%

0.4%

0.4%

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003Year

0

500

1,000

1,500

2,000

2,500

3,000

3,500

Nu

mb

er

HIV

-in

fec

ted

pe

rso

ns

Prevalence %

Prevalence number



HeterosexualHeterosexual: Epidemiologic : Epidemiologic overviewoverview

•3,310 HIV-infected (14% of Ontario infections), 3,310 HIV-infected (14% of Ontario infections), 48% diagnosed48% diagnosed

•1998-2003 HIV prevalence up 64% (annual 10%)1998-2003 HIV prevalence up 64% (annual 10%)•2000 to 2004, HIV diagnoses increased 70%; 2000 to 2004, HIV diagnoses increased 70%; increased in most regions but especially Central increased in most regions but especially Central West (+202%), Southwest (+160%) and Toronto West (+202%), Southwest (+160%) and Toronto (+74%) (+74%)

•320 new HIV infections in 2003320 new HIV infections in 2003



Summary of findings, TorontoSummary of findings, Toronto

•MSM: still most important group; though HIV MSM: still most important group; though HIV incidence from detuned assay appeared stable, incidence from detuned assay appeared stable, HIV diagnoses increased 58% since 2001HIV diagnoses increased 58% since 2001

• IDU: stable HIV prevalence, low HIV incidenceIDU: stable HIV prevalence, low HIV incidence•HIV-endemic: now 2nd most important group, HIV-endemic: now 2nd most important group, 13% of infected persons13% of infected persons

•Heterosexual: fastest growing group by far; ~69% Heterosexual: fastest growing group by far; ~69% increase in prevalence 1998-2003 (five years)increase in prevalence 1998-2003 (five years)



LimitationsLimitations

•Populations at risk not well characterized Populations at risk not well characterized •Adjustments for HIV diagnoses, AIDS cases and HIV-Adjustments for HIV diagnoses, AIDS cases and HIV-related mortality subject to uncertaintyrelated mortality subject to uncertainty

•Data on HIV incidence limited and biasedData on HIV incidence limited and biased•Despite challenges, triangulation allows obtaining Despite challenges, triangulation allows obtaining plausible estimates for HIV incidence and prevalenceplausible estimates for HIV incidence and prevalence



ConclusionsConclusions

•Good news: AIDS incidence and mortality Good news: AIDS incidence and mortality decreasing and situation reassuring among IDUsdecreasing and situation reassuring among IDUs

•Overall, HIV epidemic in Ontario unstableOverall, HIV epidemic in Ontario unstable•HIV prevalence up 36% past 5 years (17,400 to HIV prevalence up 36% past 5 years (17,400 to 23,600)23,600)

•Concerning in MSM, HIV-endemic and Concerning in MSM, HIV-endemic and heterosexual heterosexual

•Sustained HIV transmission in these groupsSustained HIV transmission in these groups



AcknowledgementsAcknowledgements

•Frank McGee, AIDS Bureau, Frank McGee, AIDS Bureau, Ontario Ministry of Ontario Ministry of Health and Long Term Care (MOHLTC)Health and Long Term Care (MOHLTC)

•Carol Swantee, HIV Laboratory, MOHLTC Carol Swantee, HIV Laboratory, MOHLTC • Jane Njihia, FSO, PHAC / MOHLTCJane Njihia, FSO, PHAC / MOHLTC•Lorraine Schiedel, Public Health Branch, Lorraine Schiedel, Public Health Branch, MOHLTCMOHLTC •Ontario HIV Treatment Network (OHTN) and Ontario HIV Treatment Network (OHTN) and Health Canada for funding Laboratory Health Canada for funding Laboratory Enhancement StudyEnhancement Study

Documents

Epidemiologic overview of HIV/AIDS in Ontario and Toronto: 2004 update Robert S. Remis MD, MPH, FRCPC, Maraki Fikre Merid BSc Ontario HIV Epidemiologic