HIV/Hepatitis co-infection situation in BALTIC COUNTRIES

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1 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV HIV/Hepatitis co-infection situation in BALTIC COUNTRIES Prof. Dr. SAULIUS ČAPLINSKAS Director, Centre for Communicable Diseases and AIDS Vilnius Lithuania

Date from Latvia: Riga East University Hospital clinic Infectology Centre of Latvia Inga Ažiņa, MD, Ph.D.Head of HIV/AIDS Out-patient Department Velga Ķūse, MD, Deputy Chief Physician Anastasija Šangirejeva, MD, Head of HIV/AIDS In-patient Department Prof.

2 Date from Latvia: Riga East University Hospital clinic Infectology Centre of Latvia Inga Ažiņa, MD, Ph.D.Head of HIV/AIDS Out-patient Department Velga Ķūse, MD, Deputy Chief Physician Anastasija Šangirejeva, MD, Head of HIV/AIDS In-patient Department Prof. Baiba Rozentāle, Chief doctor of Infectology Centre of Latvia Date from Estonia: Kristi Rüütel, MD, PhD Scientific secretary/senior researcher National Institute for Health Development, Tallinn Kerstin Kase Department of Infectious DiseasesWest Tallinn Central Hospital Tallinn Date from Lithuania: Prof. Ligita Jančorienė, Vilnius University, Vilnius University Hospital Santaros klinikos, Centre of Infectious DiseasesVilnius Lithuania; and

3 BALTIC COUNTRIES

4 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV HIV Cumulative cases diagnosed (end 2016) BALTIC COUNTRIES Prevalence per population (in 2016) Annual Incidence (in 2016) Estonia Latvia Lithuania

5 Newly diagnosed cases per population Overview of new HIV and AIDS cases in the Baltic countries Cumulative cases per per population Latvia new HIV cases Latvia new AIDS cases Estonia new HIV cases Estonia new AIDS cases Lithuania new HIV cases Lithuania new AIDS cases Latvia Cumulitive HIV cases Latvia Cumulitive AIDS cases Estonia Cumulitive HIV cases Estonia Cumulitive AIDS cases Lithuania Cumulitive HIV cases Lithuania Cumulitive AIDS cases

6 Newly diagnosed cases per population Overview of new HIV and AIDS cases in the Baltic countries Cumulative cases per per population Latvia new HIV cases Latvia new AIDS cases Estonia new HIV cases Estonia new AIDS cases Lithuania new HIV cases Lithuania new AIDS cases Latvia Cumulitive HIV cases Latvia Cumulitive AIDS cases Estonia Cumulitive HIV cases Estonia Cumulitive AIDS cases Lithuania Cumulitive HIV cases Lithuania Cumulitive AIDS cases

7 Newly diagnosed cases per population Overview of new HIV and AIDS cases in the Baltic countries Cumulative cases per per population Latvia new HIV cases Latvia new AIDS cases Estonia new HIV cases Estonia new AIDS cases Lithuania new HIV cases Lithuania new AIDS cases Latvia Cumulitive HIV cases Latvia Cumulitive AIDS cases Estonia Cumulitive HIV cases Estonia Cumulitive AIDS cases Lithuania Cumulitive HIV cases Lithuania Cumulitive AIDS cases

8 Newly diagnosed cases per population Overview of new HIV and AIDS cases in the Baltic countries Cumulative cases of diagnosed HIV cases, end 2016 N = N = N = Cumulative cases per per population Latvia new HIV cases Latvia new AIDS cases Estonia new HIV cases Estonia new AIDS cases Lithuania new HIV cases Lithuania new AIDS cases Latvia Cumulitive HIV cases Latvia Cumulitive AIDS cases Estonia Cumulitive HIV cases Estonia Cumulitive AIDS cases Lithuania Cumulitive HIV cases Lithuania Cumulitive AIDS cases

9 Newly diagnosed cases per population Overview of new HIV and AIDS cases in the Baltic countries 2016 Prevalence per population Cumulative cases per per population Latvia new HIV cases Latvia new AIDS cases Estonia new HIV cases Estonia new AIDS cases Lithuania new HIV cases Lithuania new AIDS cases Latvia Cumulitive HIV cases Latvia Cumulitive AIDS cases Estonia Cumulitive HIV cases Estonia Cumulitive AIDS cases Lithuania Cumulitive HIV cases Lithuania Cumulitive AIDS cases

10 Newly diagnosed cases per population Overview of new HIV and AIDS cases in the Baltic countries UNAIDS 2016 estimated number (total) Coud be around 7900 No data 6600 ( ) 2900 ( ) Cumulative cases per per population Latvia new HIV cases Latvia new AIDS cases Estonia new HIV cases Estonia new AIDS cases Lithuania new HIV cases Lithuania new AIDS cases Latvia Cumulitive HIV cases Latvia Cumulitive AIDS cases Estonia Cumulitive HIV cases Estonia Cumulitive AIDS cases Lithuania Cumulitive HIV cases Lithuania Cumulitive AIDS cases

11 HIV incidence in Estonia, Latvia and Lithuania, (new cases per population) N= N= N= Estonia Latvia Lithuania

12 Incidence of acute VHB and VHC in Lithuania, (cases per population) Prof. Saulius Čaplinskas, MD, PhD

13 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV HBV BALTIC COUNTRIES HCV Prevalence Incidence Prevalence Icidence Estonia Acute 0.6 Acute 1.1 Latvia 2,3 % HBsAg pos.* Acute 4.3 Chronic 18.0** 2% * (HCV RNS -1,7% anti-hcv-2,4%) Lithuania Acute 1.12 Acute 0.56 *The Centre for Disease Prevention and Control of Latvia.The Prevalence of Viral Hepatitis C in Latvia: A Population-Based Study; medicina.lsmuni.lt/med/1110/ e.pdf **The Centre for Disease Prevention and Control of Latvia.

14 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV BALTIC COUNTRIES Co-infected HIV/HBV HIV/HCV Estonia Prevalence Incidence Prevalence Incidence High prevalence among PWID Latvia About 634 cases * About 2435 cases * Lithuania 5% ** 39% ** ** Among new HIV treated patients Source: * Infectology Centre of Latvia; ** Center For Communicable Diseases And AIDS (CCDA), 2016

15 HIV and hepatitis co-infection prevalence among PWID in Estonia in 2016 HCV Ab prevalence in different regions ranges from 61% to 90%; HBsAg prevalence from 4% to 22% 98% of those who were HIV-positive, were also HCV-Ab positive. Vice versa: 80% among those HCV-Ab positive, were also HIV positive. So co-infection is very common (but it s just HCV Ab positivity) Data from Kristi Rüütel

16 HIV and hepatitis co-infection prevalence among sex workers in three regions in Estonia in % were HCV-Ab positive 13% were HIV-positive Out of those who were HIV-positive, ¾ were also HCVpositive Data from Kristi Rüütel

17 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV BALTIC COUNTRIES HIV Prevalence of Different Subtype/Genotype in Country Estonia Latvia Lithuania A = 25,29%, B = 31,03%, Other = 43,68% * Source: * National Public Health Surveillance Laboratory

18 Molecular epidemiology of HIV infection in Lithuania, % 18% 27% 49% 5% 95% 1% 3% 14% 82% A B CRF03_AB Other Hetero MSM Prof. Saulius Čaplinskas, MD, PhD IVDU

19 Molecular epidemiology of HIV infection in Lithuania, % Prevalence of HIV-1 subtypes in Lithuania, % 27% 49% 5% 95% 1% 3% 14% 40.2 All % A B CRF03_AB Other mixes with B Other (C, D, F, G, K and mixes with them) Hetero MSM Prof. Saulius Čaplinskas, MD, PhD IVDU

36.4 18% 27% 5.4 24.8 30.2 Tested repeatedly 49% 5% 47.1 3.

20 Molecular epidemiology of HIV infection in Lithuania, % Prevalence of HIV-1 subtypes in Lithuania, % 27% Tested repeatedly 49% 5% % Tested for the first time 1% 3% 14% 40.2 All % A B CRF03_AB Other mixes with B Other (C, D, F, G, K and mixes with them) Hetero MSM Prof. Saulius Čaplinskas, MD, PhD IVDU

21 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV BALTIC COUNTRIES HCV Prevalence of Different Subtype/Genotype in Country Estonia Latvia Lithuania 1a = 7%, 1b = 72%, 1 unndifferentiated = 21%, 2 = 4%, 3 = 32%, 4 = 0,7% 1= 63.8%, 2= 3.6%, 3= 31.9%, 4= 0.7% 1 = 65% (90 % 1b), 2 = 8,7% (80% 2a/c), 3 = 26,3% (80 % 3a) Liakina V, Valantinas J. Med Sci Monit, 2012 Mar:18(3):PH28-35

22 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV BALTIC COUNTRIES HIV Estonia Latvia Lithuania Main Risk factors for Transmission (among new diagnosed HIV cases in 2016) IVDU = 14%, Hetero = 49%, MSM = 4%, UNK = 33% (in 2016) Proper transmission data for all routes only since 2010 ** IVDU = 17%, Hetero = 38%, MSM = 7%, UNK = 37%, MTCT = 1% (in 2016) IVDU = 44.6 %, Hetero = 35.6%, MSM = 18.4%, MTCT = 1.4% ** IVDU = 39%, Hetero = 30%, MSM = 12%, UNK = 18%, MTCT = 0.5% (in 2016) IVDU = 60%, Hetero = 22%, MSM = 8%, UNK = 10%, MTCT = 0.2% ** ** Among all HIV cases ( )

23 Main risk factors for HIV transmission in % 60% in Latvia 70% 60% in Lithuania 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% -10% IVDU Hetero MSM UNK MTCT 0% IVDU Hetero MSM UNK MTCT

24 Main Risk factors for HIV Transmission among new cases in 2016 (%)

25 Main Risk factors for HIV Transmission - among new cases in 2016 (%) (Total 6) (Total 72) (Total 48)

26 New HIV cases by transmission mode in Lithuania (%) Total No: 2744 IDUs 59.9% MSM Hetero Sex IDUs From 2013 SEX

27 HIV cases by mode of transmission in Lithuania % 0.5% 9.8% 8.4% 12.1% 18.2 % 21.8% 30.4% 59.8% 38.8% Prof. Saulius Čaplinskas, MD, PhD

28 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV BALTIC COUNTRIES HBV Estonia Latvia Lithuania Main Risk factors for Transmission Hetero=11%, IVDU=11%, Needlestick exposure=11%, UNK=55% (2012, ECDC) IVDU=33.3%, Sex. (not specified)=22.7% (2012, ECDC) IVDU = 6,3%, Hetero = 15,6%, UNK = 75%, OTHER = 3% * UNK=84.4 %, Hetero= 9.4 %, IVDU= 6.3 % (new acute HBV cases, 2015) * Acute infection, Center For Communicable Diseases and AIDS (CCDA), 2016

29 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV BALTIC COUNTRIES HCV Estonia Latvia Lithuania Main Risk factors for Transmission IVDU=21%, Hetero=13% (2012, ECDC) IVDU=29%, Sexual transmission (not specified)=25%, Nosocomial= 22% (2012, ECDC) IVDU = 19%, UNK = 81% * UNK =95.7 %, IVDU = 4.3 % (new acute HCV cases, 2015) * Acute infection, Center For Communicable Diseases and AIDS (CCDA), 2016

30 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV HIV Estonia Latvia * Lithuania BALTIC COUNTRIES Antiviral Treatment Currently Available All 1st line regimens: 2 NRTI + NNRTI ( ABC/3TC or TDF/FTC + EFV) 2nd line : 2NRTI + II (ABC/3TC or FTC/TDF + RTG or DTG) 2 NRTI + PI/r ( ABC/3TC or FTC/TDF + DRV/c or ATV +RTV or LPV/r 1st line reg.: NNRTI EFV 1 (35 % all new HIV treated patients in 2016 ***) PI/r-ALL (56,6 % all new HIV treated patients in 2016 **) Source: * Clinical guidlines for HIV diagnostics, Treatment and Prophylaxis ( Latvia, 2014). ***According MoH Order ; ** Center For Communicable Diseases And AIDS (CCDA), 2016

31 ARV in Lithuania Drugs No of patients % Abacavirum et Lamivudinum Lopinavirum et Ritonavirum Lopinavirum et Ritanovirum (child) 1 Efavirenzum Zidovudinum et Lamivudinum Darunavir et Cobicistat Darunavir Ritonavir Raltegravirum 28 4 Dolutegravirum 28 4 Total: 689 High % of ART being composed of abacavir, lopinavir/ritonavir and zidovudine

32 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV BALTIC COUNTRIES HBV Antiviral Treatment Currently Available Estonia Latvia TDF, 3TC, alpha Interferon Lithuania Lamuvudin, PegIFN alfa 2a, Entecavir, Tenofovir* (*on the basis of individual request for Lithuanian Sick Funds)

33 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV BALTIC COUNTRIES HCV Antiviral Treatment Currently Available Estonia Latvia Lithuania Acute: Interferonum alfa Chronic: PegIFN alfa 2a and alfa 2b +/- RBV) till December 2016; Simeprevir (till December 2016); Viekirax (Ombitasvir/Paritaprevir/ritonavir) + Exviera (Dasabuvir); Zepatier (Grazoprevir/Elbasvir) PegIFN alfa 2a and alfa 2b +/- RVB (GT1 GT3; treatment naïve or experienced) Viekirax (Ombitasvir/Paritaprevir/ritonavir) + Exviera (Dasabuvir); Zepatier (Grazoprevir/Elbasvir) (GT1, treatment naïve or experienced, F-2 and more)

34 Chronic hepatitis C treatment in Lithuania: GT1 ( F2) week: PEG-IFN alfa + RBV GT1 ( F3): 12 week: Ombitasvir/Paritaprevir/Ritonavir + Dasabuvir (3D therapy) GT2 24 week: PEG-IFN alfa + RBV GT3: week. PEG-IFN alfa + RBV Chronic hepatitis C treatment in Lithuania from GT1 ( F1) week: PEG-IFN alfa + RBV GT1 ( F2): 12 week: Ombitasvir/Paritaprevir/Ritonavir + Dasabuvir (3D therapy) Data from prof. Ligita Jančorienė

35 Chronic hepatitis C treatment in Lithuania from GT1 ( F1) week: PEG-IFN alfa + RBV GT1b ( F2): 8-12 week: Ombitasvir/Paritaprevir/Ritonavir + Dasabuvir (3D therapy) GT1a (F2-F3): 12 week: Ombitasvir/Paritaprevir/Ritonavir + Dasabuvir (3D therapy) + RBV GT1a (F4) 24 week: Ombitasvir/Paritaprevir/Ritonavir + Dasabuvir (3D therapy) + RBV GT2 24 week: PEG-IFN alfa + RBV GT3: week. PEG-IFN alfa + RBV GT1b ( F2): 12 week: Grazoprevir/Elbasvir GT1a ( F2): 12 week, if baseline HCV-RNA IU/ml: Grazoprevir/Elbasvir GT1a ( F2): 16 week, if baseline HCV-RNA > IU/ml: Grazoprevir/Elbasvir GT4 ( F2): 12 week, if baseline HCV-RNA IU/ml: Grazoprevir/Elbasvir GT4 ( F2): 16 week, if baseline HCV-RNA > IU/ml: Grazoprevir/Elbasvir Data from prof. Ligita Jančorienė

36 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV HIV Estonia Percent of Patients on HAART From 9492 ever diagnosed 5354 in care (3863 on ART) (582 started ART in 2016) BALTIC COUNTRIES Percent of patient suppressed (<50) 414 (11%) were not virally suppressed Number Dying of AIDS (in 2016) 43 (41 AIDS cases in 2016) Latvia 1702 ( 32%) ND 75 (928 cumulative) Lithuania 754 * 72 % ** 23 * (HIV death: 406 total; 44 - in 2016) Source: * Center For Communicable Diseases And AIDS (CCDA), 2016 ** Vilnius University Hospital Santaros Klinikos (Treated 29 % HIV patients in 2016, viral suppressed <75), 2016

37 Continuum of HIV care Lithuanian HIV cascade (up to 01/01/2016) 100%. 90%. 75% 81.7%.. 90%. 77% UNAIDS target 90% Regional average 90% 29.8% 88% 81.9% N = 3100 N = 2535 N = 2173 N = 647 N = 530

38 Continuum of HIV care Lithuanian HIV cascade (up to 01/01/2016) 100%. 90%. 75% 81.7%.. 90%. 77% UNAIDS target 90% Regional average 90% 29.8% 88% 81.9% N = 3100 N = 2535 N = 2173 N = 647 N = 530

39 Continuum of HIV care Lithuanian HIV cascade (up to 01/01/2016) 100%. 90%.. 75% N = % UNAIDS target 90% Regional average 90% 29.8% 88% 81.9% N = 3100 N = 2535 N = 2173 N = 647 N = 530

40 Continuum of HIV care Lithuanian HIV cascade (up to 01/01/2016) 100%. 90%. 75% 81.7%.. 90%. 77% UNAIDS target 90% Regional average 29.8% 81.9% N = 3100 N = 2535 N = 2173 N = 647 N = 530

41 Continuum of HIV care Lithuanian HIV cascade (up to 01/01/2016) 100%. 90%. 75% 81.7%.. 90%. 77% UNAIDS target 90% Regional average 29.8% 81.9% N = 3100 N = 2535 N = 2173 N = 647 N = 530

42 Continuum of HIV care Lithuanian HIV cascade (up to 01/01/2016) 100%. 90%. 75% 81.7%.. 90%. 77% UNAIDS target 90% Regional average 90% 29.8% 88% 81.9% N = 3100 N = 2535 N = 2173 N = 647 N = 530

43 Continuum of HIV care Lithuanian HIV cascade (up to 01/01/2016) 100%. 90%. 75% 81.7%.. 90%. 77% UNAIDS target 90% Regional average 90% 29.8% 88% 81.9% N = 3100 N = 2535 N = 2173 N = 647 N = 530

45 Year ART start ART end of the year ART in Lithuania Discontinued ART New HIV cases total IDU% total IDU% Total IDU% M 11 N 1 Vt M 12 N 1 Vt 1 K 3 Sn M 29 N 5 Iš 2 K 1 Vt 1 Sn 2 Bpp M 34 N 4 Iš 4 K M 51 N 5 Iš 3 K 1 Sn M 61 N 9 Iš 1 Sn 1 Bpp Reasons for discontinuation of ART : M died N do not turn up Sn by own choice Iš left Every year, the number of individuals receiving ART is increasing Vt drug toxicity Bpp after finishing perinatal prophylaxis K imprisoned

46 The Estonian HIV Cohort Study: E-HIV Source: Design and structure of the Estonian HIV Cohort Study (E-HIV) / Pilleriin Soodla, Heli Rajasaar, Radko Avi et al // Infectious Diseases, 2015; Early Online: 1 8.

47 3rd Central and Eastern European Meeting on Viral Hepatitis and Co-infection with HIV BALTIC COUNTRIES HBV HCV Estonia Percent of Patients on Therapy Of Those Treated Percent of Patients Suppressed Number Dying of Cirrhosis/ Hepatoma Latvia ND ND ND Lithuania No of patients 264 * Estonia Latvia 70% (874 patients started treatment in 2016) ** Lithuania No of patients 809 * Source: * National Health Insurance Fund under the Ministry of Health, 2016; **The Centre for Disease Prevention and Control of Latvia

Epidemiology of HIV in the Baltic countries

2016 Population: Epidemiology of HIV in the Baltic countries 1.3 mln. 1.9 mln. 2.8 mln. Prof. SAULIUS ČAPLINSKAS MD, PhD Director, Centre for Communicable Diseases and AIDS under the Ministry of Health,