Robert S. Remis, Maraki Fikre Merid Ontario HIV Epidemiologic Monitoring Unit

Epidemiologic trends inEpidemiologic trends inHIV infection among men who HIV infection among men who have sex with men in Ontario: have sex with men in Ontario:

The situation in 2004The situation in 2004

Robert S. Remis, Maraki Fikre MeridRobert S. Remis, Maraki Fikre Merid

Ontario HIV Epidemiologic Monitoring UnitOntario HIV Epidemiologic Monitoring Unit

Department of Public Health SciencesDepartment of Public Health Sciences

University of TorontoUniversity of Toronto

Gay Men’s HIV Prevention Working GroupGay Men’s HIV Prevention Working Group

Toronto, Ontario, November 18, 2004Toronto, Ontario, November 18, 2004

MOHLTC, Laboratories Branch, IMC – 2001

BackgroundBackground

• MSM seriously affected by HIV epidemic MSM seriously affected by HIV epidemic since the beginning (late 1970s)since the beginning (late 1970s)

• Many developments have influenced Many developments have influenced trends in the epidemic since then:trends in the epidemic since then:

Education, information and preventionEducation, information and preventionIdentification of HIV in 1984Identification of HIV in 1984HIV test developed late 1985HIV test developed late 1985Antiretroviral drugs, 1987-95Antiretroviral drugs, 1987-95HAART 1996-HAART 1996-


ObjectiveObjective

• To examine trends in incidence and To examine trends in incidence and prevalence of HIV infection among MSM prevalence of HIV infection among MSM in Ontarioin Ontario


Methods: Data sourcesMethods: Data sources

• HIV diagnostic data HIV diagnostic data • Laboratory Enhancement Study Laboratory Enhancement Study • Detuned assayDetuned assay• Repeat testersRepeat testers• Reported AIDS casesReported AIDS cases• HIV-related mortalityHIV-related mortality


Methods: Data analysisMethods: Data analysis

• HIV model: Incidence and prevalence ofHIV model: Incidence and prevalence of• HIV infectionHIV infection• HIV diagnosesHIV diagnoses• AIDSAIDS• HIV-related mortalityHIV-related mortality

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


Reported AIDS cases by Reported AIDS cases by exposure category and exposure category and sex,1981-2003sex,1981-2003

Males Females TotalNo. % No. % No. %

MSM 5,258 78.3% 0 0.0% 5,258 72.6%MSM-IDU 299 4.5% 0 0.0% 299 4.1%IDU 258 3.8% 78 14.8% 336 4.6%HIV-endemic 260 3.9% 156 29.6% 416 5.7%Heterosexual 414 6.2% 204 38.7% 618 8.5%Clotting factor 100 1.5% 10 1.9% 110 1.5%Transfusion 94 1.4% 49 9.3% 143 2.0%Perinatal 26 0.4% 29 5.5% 55 0.8%Occupational 6 0.1% 1 0.2% 7 0.1%NIR 248 24 272Total 6,963 100.0% 551 100.0% 7,514 100.0%

* Proportion EC known = 96.4%


Reported AIDS cases for selected Reported AIDS cases for selected exposure categories, 1981-2003exposure categories, 1981-2003

0

100

200

300

400

500

600

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Year of AIDS diagnosis

Nu

mb

er

of

ca

se

s (

ad

jus

ted

)

MSM

MSM-IDU

Other known


First-time HIV diagnoses (adjusted) for First-time HIV diagnoses (adjusted) for selected exposure categories,1985-selected exposure categories,1985-20032003

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

Year of HIV diagnosis

Nu

mb

er

of

ne

w d

iag

no

se

s (

ad

jus

ted

)

MSM

MSM-IDU

Other exp


HIV diagnoses (adjusted) by exposure HIV diagnoses (adjusted) by exposure category and gender, Ontario 1985-category and gender, Ontario 1985-20032003

Males Females Total

MSM 16,382 76.8% 0 0.0% 16,382 66.2%MSM-IDU 973 4.6% 0 0.0% 973 3.9%IDU 1,410 6.6% 600 17.6% 2,010 8.1%Clotting factor 271 1.3% 37 1.1% 307 1.2%Transfusion 212 1.0% 182 5.3% 394 1.6%HIV-endemic 901 4.2% 1,120 32.9% 2,021 8.2%HR hetero 180 0.8% 683 20.0% 863 3.5%LR hetero 755 3.5% 559 16.4% 1,314 5.3%Perinatal2 175 0.8% 164 4.8% 339 1.4%Other 67 0.3% 64 1.9% 131 0.5%Total 21,325 100.0% 3,409 100.0% 24,734 100.0%


First-time HIV diagnoses among MSM First-time HIV diagnoses among MSM by health region, 1985-2003by health region, 1985-2003

Number Proportion RateToronto 12,293 75.0% 1,028.6Ottawa 1,238 7.6% 339.3Southwest 1,162 7.1% 158.8Eastern, other 232 1.4% 59.9Central West 668 4.1% 63.9Northern 179 1.1% 39.5Central East, other 608 3.7% 47.0

Total 16,382 100.0% 299.5


Number first-time HIV diagnoses, MSM Number first-time HIV diagnoses, MSM selected health regions, 1999–2004selected health regions, 1999–2004

0

20

40

60

80

100

1999 2000 2001 2002 2003 2004

Nu

mb

er

of

ca

se

s

NorthernOttawaEasternC EastC WestSouthwest


Number first-time HIV diagnoses, Number 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

Toronto


HIV incidence among MSM repeat testers, HIV incidence among MSM repeat testers,

with 95% CLs, 1992-2002 (37,711 PY)with 95% CLs, 1992-2002 (37,711 PY)

0.75

0.94 0.88

1.13

0.870.97

1.5

0.0

0.5

1.0

1.5

2.0

2.5

1996 1997 1998 1999 2000 2001 2002

Year

Ser

oco

nve

rsio

ns

per

100

PY

Source: Polaris Seroconversion Study


Measured and adjusted HIV incidence, Measured and adjusted HIV incidence, MSM by health region,1999 – 2003MSM by health region,1999 – 2003

1.94

2.28

1.71

2.01

0.670.78

1.51

1.77

0.0

1.0

2.0

3.0

HIV

inci

den

ce p

er 1

00 P

Y

Toronto Ottawa Other Ontario

Source: Laboratory Enhancement Study


Measured and adjusted HIV Measured and adjusted HIV incidence,MSM, Ontario, 1999 – incidence,MSM, Ontario, 1999 – 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



Measured and adjusted HIV Measured and adjusted HIV incidence MSM, Toronto, 1999 – incidence MSM, Toronto, 1999 – 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)




Measured and adjusted HIV Measured and adjusted HIV incidence MSM, Ottawa, 1999 – incidence MSM, Ottawa, 1999 – 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)




Measured and adjusted HIV Measured and adjusted HIV incidence, MSM, Ontario, 1999 – 2003incidence, MSM, Ontario, 1999 – 2003

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)




Modeled HIV prevalence by Modeled HIV prevalence by exposure category, Ontario,exposure category, Ontario,December 2003December 2003

Proportion Number ProportionHIV diagnosed HIV Ontario

prevalence living undiagnosed undiagnosed

MSM 14,370 68.9% 4,278 51.9%MSM-IDU 703 58.1% 262 3.2%IDU 1,959 67.0% 644 7.8%Endemic 3,011 47.5% 1,481 18.0%Hetero 3,311 50.5% 1,557 18.9%Clotting 156 99.5% 3 0.0%Transfusion 41 77.0% 10 0.1%

23,552 63.3% 8,236 100.0%


Modeled HIV incidence among MSMModeled HIV incidence among MSMOntario, 1977–2003Ontario, 1977–2003

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

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

An

nu

al i

nc

ide

nc

e r

ate

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

Nu

mb

er

of

ne

w in

fec

tio

ns

Incidence rate

Incidence number



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

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003Year

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



ConclusionsConclusions

• Gay men in Ontario continue to be severely Gay men in Ontario continue to be severely affected by the HIV epidemicaffected by the HIV epidemic

• Remains most important groupRemains most important group• 14,400 MSM HIV-infected14,400 MSM HIV-infected• HIV prevalence: ~16% (varies regionally, 10-HIV prevalence: ~16% (varies regionally, 10-

20%)20%)• Past 5 years, Increase in MSM living with HIV Past 5 years, Increase in MSM living with HIV

infection 29%, 5.4% annuallyinfection 29%, 5.4% annually• HIV incidence (i.e. new infections) not HIV incidence (i.e. new infections) not

decreasing; increasing in Ottawadecreasing; increasing in Ottawa



• Trends in risk behaviour elsewhere are Trends in risk behaviour elsewhere are consistent with trend in HIV incidenceconsistent with trend in HIV incidence

• Reasons for persisting high incidence unclear: Reasons for persisting high incidence unclear: treatment optimism? safe-sex fatigue?treatment optimism? safe-sex fatigue?



• Observed increase in new HIV Observed increase in new HIV diagnoses in 2003 of particular diagnoses in 2003 of particular concernconcern

• May be due to: May be due to: • increased HIV testingincreased HIV testing

oror• increased HIV incidenceincreased HIV incidence



• Likely due, at least in part, to increased Likely due, at least in part, to increased HIV incidence since:HIV incidence since:• increase in HIV+ tests > increase in increase in HIV+ tests > increase in

teststests• proportion identified as seroconverters proportion identified as seroconverters

by linked tests or serologic evidence is by linked tests or serologic evidence is stablestable

• incidence in repeat testers increasingincidence in repeat testers increasing• data from elsewhere and syphilis data from elsewhere and syphilis

epidemic evidence for increased risky epidemic evidence for increased risky sexual behavioursexual behaviour


AcknowledgementsAcknowledgements

AIDS Bureau, AIDS Bureau, Ontario Ministry of Health and Long-Term Ontario Ministry of Health and Long-Term CareCare

• Frank McGee, coordinatorFrank McGee, coordinator• HIV Laboratory, Central Public Health LaboratoryHIV Laboratory, Central Public Health Laboratory

• Carol Swantee, diagnostic dataCarol Swantee, diagnostic data• Keyi Wu, programmingKeyi Wu, programming• Jane NjihiaJane Njihia

• Laboratory Enhancement StudyLaboratory Enhancement Study• Chris Archibald, CIDPC, Health CanadaChris Archibald, CIDPC, Health Canada• Ontario HIV Treatment NetworkOntario HIV Treatment Network

Documents

Robert S. Remis, Maraki Fikre Merid Ontario HIV Epidemiologic Monitoring Unit