The evolution of HIV/AIDS Epidemic in Romania 31 December 2013

Transcription

1 The evolution of HIV/AIDS Epidemic in Romania 31 December 2013

2 The data is collected from the HIV/AIDS confirmation charts, sent by the nine Regional Centers for Evaluation and Monitoring of HIV/AIDS Data and further processed and elaborated by Compartment for Monitoring and Evaluation of HIV/AIDS data in Romania, in National Institute for Infectious Diseases Prof. Dr. Matei Bals

3 Romania December 2013: PLWHA ( cumulative total, since 1985). High rate of HIV incidence in children who were infected in the 1980s in Romania The maximum number of these patients recorded at the beginning of the 1990s ; >90%: sub-type F1. During the same period, HIV incidence rate among the adult population was low, with a slight increase afterwards due to unprotected heterosexual contact, the main route of transmission for the last decade. Currently, Romania has a large number of survivors in the age group, who belong to the cohort (>6000). A large number of PLWHA who receive specific ARV therapy in relation to the total number of infected persons (>8000 December 31, 2012 out of 9800 in active surveillance at1 December 2013). Source: Surveillance Report: HIV/AIDS Surveillance in Europe ECDC Stockholm Source: Compartment for Monitoring and Evaluation of HIV/AIDS Data in Romania INBI Prof.Dr.M.Balş

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6 HIV subtype: F predominance, unique in Europe cohort children: homogenous F1 subtype of HIV Thomson and Najera, JID, 2007; Stanojevic et al. AIDS Rev 2011;

7 Phylogenetic analysis of HIV-1 subtype F1 isolates F= <1% HIV infections worldwide: Africa & South America Romanian F1 subtype: closely related to Angolan subtype distantly related to S America F1 F1 origin: Congo (DRC), around the late 1950s Guimaraes & al Retrovirology 2009

8 Ministry of Health National Institute for Infectious Diseases Prof. Dr. Matei Bals Compartment for Monitoring and Evaluation of HIV/AIDS Infection in Romania General Data at 31 December 2013 TOTAL HIV/AIDS (CUMULATIVE ) OF WHICH: HIV/AIDS cases in children (0-14 years at date of diagnosis ) HIV/AIDS cases in adults (> 14 years at date of diagnosis) Total no. of AIDS deaths ( ) Out of records HIV/AIDS children + adults 621 Number of patients living with HIV/AIDS Total AIDS (Cumulative ) AIDS cases in children (0-14 years at date of diagnosis) AIDS cases in adults (> 14 years at date of diagnosis) Total HIV (Cumulative ) HIV cases in children (0-14 years at date of diagnosis) HIV cases in adults (> 14 years at date of diagnosis) New HIV/AIDS cases, diagnosed in New HIV cases 472 New AIDS cases 325 HIV/AIDS related deaths, confirmed by medical charts in

9 Distribution of ages Age at date of diagnosis Cumulative total Distribution by age of PLWHA

10 Kaplan-Meyer survival curve % of persons who deceased, survived, on average >50 months: 15% of persons who deceased survived, on average around 100 month; 10% of persons who deceased survived, on average, 100 months. Limitations: we excluded the periods with no treatment, ART schemes, duration of treatment. Average period of survival= 43,4 months (C.I.95% 42,1-44,6) Median period of survival for men=42,2 months (C.I.95% 40,6-43,8) Median period of survival for women=45,4 months (C.I.95% 43-47,2)

11 New HIV/AIDS Cases 1 JANUARY 31 DECEMBER 2013

12 Distribution of new HIV/AIDS cases by counties LEGEND CHILDREN (0-14 yrs) ADULTS (> 14 yrs)

13 Distribution of new HIV/AIDS cases by sex, 2013

14 Distribution of new HIV/AIDS cases by age group and sex, 2013

15 Distribution of new HIV/AIDS cases by route of transmission in children, Vertical Male female

16 Distribution of new HIV/AIDS cases by routes of transmission in adults, 2013

17 Tendencies in routes of transmission Romania Route of transmission 31 December December December December December December December 2013 Vertical 8 (2%) 7 (1%) 20 (4%) 25 (5%) 21 (3%) 21 (2,6%) 21 (2,64%) MSM IDU 14 (3%) 40 (8%) 44 (9%) 60 (11) 95 (13%) 89 (10,8%) 4 (1%) 3 (1%) 7 (1,4%) 14 (3%) 131 (18%) MSM/IDU 1 (<0,5%) 5 (1%) Heterosexual 352 (79%) 397 (76) 383 (77%) 399 (75%) 440 (61%) Unknown 67 (15%) 71 (14%) 43 (8,6%) 32 (6%) 28 (4%) 252 (30,6%) 6 (1%) 414 (50%) 39 (5%) 88 (11,04%) 233 (29,23%) 5 (0,63%) 435 (54,58%) 15 (1,88%) Total

18 Tendencies in the routes of transmission Romania Heterosexual IDUs

19 New HIV/AIDS cases (January-December 2013) through i.v. drug use, by age groups Age group Male Female Total yrs yrs yrs yrs yrs yrs Total

20 New cases of HIV/AIDS infection through i.v. drug use, by age groups, recorded in % 6% 2% 7% 15% 30% 29% yrs yrs yrs yrs yrs yrs. 50

21 Drugs used by HIV patients, diagnosed in 2013

22 Drugs declared by HIV/IDU patients, diagnosed in % 10% 3% 69% Heroine Heroine/Ethnobotanicals/Cocaine Heroine/Ethnobotanicals Ethnobotanicals

23 New HIV/AIDS cases (January-December 2013) through i.v. drug use, by counties County Male Female Total Arad 1 1 Argeş 1 1 Bucureşti Braşov 1 1 Brăila 1 1 Buzau 1 1 Constanţa 3 3 Giurgiu 1 1 Gorj 1 1 Hunedoara 1 1 Ialomita 4 4 Ilfov Mureş 1 1 Neamţ 2 2 Olt 1 1 Prahova Timiş 3 3 Tulcea 1 1 Vâlcea 2 2 Total

24 HBV, HCV, STDs in new HIV/AIDS cases through i.v. drug use Tested for Positive % AgHBs 3 1,24% VHC % AgHBs + VHC 29 12,03% STDs 34 14,10%

25 HIV/TB Co-infection in HIV/IDUs, diagnosed in 2013

26 I.V. drug users diagnosed HIV+ in 2013, previously tested before the current HIV positive test Year of previous testing No. of patients Total 53

27 New HIV/AIDS cases registered in the National Data Base: vs. New HIV/AIDS cases in IDUs registered in the National Data Base: Year Criterion Number of HIV cases TOTAL of which IDUs TOTAL of which IDUs TOTAL of which IDUs TOTAL of which IDUs TOTAL of which IDUs Number of AIDS cases Total number of HIV/AIDS cases

28 HIV prevalence in IDUs under treatment HIV/HCV Prevalence in IDUs under treatment HCV prevalence in IDUs under treatment Source: The evolution of the HIV/AIDS outbreak among IDUs in Romania. Andrei Botescu- Romanian National Antidrug Agency

29 HIV testing in IDUs performed by the Public Health Directions Year Negative tests Positive tests TOTAL % positive tests % % % % % % %

30 CD4 values in new HIV/AIDS cases at adults Total no. of cases: 776

31 CD4 values in new cases diagnosed in adults Male Female Total no. of cases: 550 Total no. of cases: 226

32 CD4 values in new HIV/AIDS cases at adults Total no. of new cases: 776

33 CD4 values in new HIV/AIDS cases at adults Male Female Total no. of cases: 550 Total no. of cases : 226

34 CD4 values in i.v. drug users vs. HIV/AIDS patients with different routes of transmission, 2013 IDUs Patients with different routes of HIV transmission

35 CD4 values in IDUs diagnosed with HIV/AIDS in 2013

36 CD4 values in IDUs vs. patients with different routes of HIV transmission, diagnosed in 2013 IDU Patients with different routes of transmission

37 CD4 values in IDUs diagnosed with HIV/AIDS in 2013

38 Viral load (VL) values for 2013 Total no. of cases in adults: 776 2% 3% 11% 11% 56% 6% 11% < > Under assessment Not assessed Sursa: Compartimentul pentru Monitorizarea şi Evaluarea Infecţiei HIV/SIDA în România INBI Prof.Dr.M.Balş

39 Viral load values in new cases at adults, diagnosed in 2013 Male Female Total no. of assessed cases: 174 Total no. of assessed cases: 89

40 Evolution of HIV/AIDS infection in Romania

41 AIDS incidence in adults and children ( ) Children 2013: 0,28/ Adults 2013: 1,74/

42 Distribution of AIDS cases by sex at 31 December 2013 (cumulative total )

43 Age groups and sex distribution of AIDS cases at 31 December 2013 (cumulative total )

44 Probable route of transmission in children with AIDS (0-14 years at date of diagnosis) 31 December 2013 (cumulative total ) *Persons who received blood transfusions at the end of the 1980s and beginning of 1990s. **Persons with repeated and/or parenteral treatments and admissions at the end 1980s and beginning of 1990s

45 Probable routes of transmission in adults diagnosed with AIDS (>14 years at date of diagnoses) at 31 December 2013 (cumulative total ) * Persons who received blood transfusions at the end of the 1980s and beginning of 1990s.

46 Distribution of AIDS cases in women, by age groups and year of diagnosis, between

47 HIV incidence in adults and children, ( ) Children 2013: 0,37/ Adults 2013: 2,54/

48 Distribution of HIV cases by sex at 31 December 2013 (cumulative total )

49 Distribution of HIV cases by sex and age groups (at date of diagnosis) at 31 December 2013 (cumulative total)

50 Probable route of transmission in children with HIV (0-14 years at date of diagnosis) at 31 December 2013 (cumulative total) *Persons who received blood transfusions at the end of the 1980s and beginning of 1990s. **Persons with repeated and/or parenteral treatments and admissions at the end 1980s and beginning of 1990s

51 Probable route of transmission in adults with HIV (>14 years at date of diagnosis) at 31 December 2013 (cumulative total) * Persons who received blood transfusions at the end of the 1980s and beginning of 1990s

52 Distribution of HIV cases in women, by year of dagnosis and age groups ( )

53 Distribution of PLWHA by age group and sex at 31 December 2013 (cumulative total ) Age group Male SEX Female TOTAL < 1 year yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs yrs and > TOTAL

54 HBV, HCV and HBC+HCV infections in children HIV

55 HBV, HCV and HBC+HCV infections in HIV+ adults No. cases Year of diagn. 0 '85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 13 VHB VHC VHB+VHC

56 AIDS defining illnesses 2013

57 Distribution of deaths cases by years

58 Mean period of survival (months) of PLWA, between BI-therapy Triple therapy

59 Mother to child transmission in Romania

60 HIV/AIDS in children with mother to child transmission

61 HIV/AIDS acquired through vertical transmission by age groups

62 Children 0-14 years: number of therapeutic regimens, prior to the current one: 31 December 2013

63 ARV schemes in children- 31 December 2013

64 Viral load in children under antiretroviral treatment

65 MTCT prophylaxis in pregnant women Total no. pregnant women Prophylaxis No prophylaxis

66 Prophylaxis of mother to child transmission in children to HIV positive mothers Year Number of newborns Number of prophylaxis

67 HIV testing 2013

68 *Data are sent by County Public Health Authorities HIV testing* in risk groups 2013 Risk groups Negative tests Positive tests TOTAL %positive STI ,71 TBC ,81 Maternity testing ,45 Pregnant women ,10 Health professionals ,00 Persons with hemodialysis ,00 Persons with transfusions ,00 Prenuptial check-up ,00 IDU ,75 Inmates ,47 MSM ,04 SWs ,86 HIV contacts ,24 Sailors ,02 Drivers ,17 Work abroad > 6 months ,58 Stay abroad > 6 months ,00 On request ,99 Occasional ,19 TOTAL ,74

69 HIV testing in pregnant women*, by age groups 2013 Age group Negative tests Positive tests TOTAL years years years years years years > 40 years Unspecified age TOTAL *Data are sent by County Public Health Authorities

70 HIV testing in pregnant women by age groups 2013

71 Total testing HIV testing in pregnant women Total testing Year

72 HIV testing in blood donors Year

73 HIV testing in STI patients Total tests Positive tests Year '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 Total tests Positive tests Total tests Positive tests

74 HIV testing in TB patients Total tests Positive tests 2000 Year 0 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 ' Total tests Positive tests

75 HIV testing in HIV contacts Total tests Positive tests Year 0 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 0 Total tests Positive tests

76 Source: Compartment for Monitoring and Evaluation of HIV/AIDS Infection in Romania INBI Prof.Dr.M.Balş HIV testing on request Year

77 Challenges

78 Challenges of HIV/AIDS management in Romania Impact of therapeutic fatigue on adherence to antiretroviral therapy. Advanced stage of diseases+ virologic and immunologic failure. Multiple associated diseases that require specific treatment and antiretroviral treatment. Management: ART in TB/HIV co-infection ART în HIV, HBV/HCV co-infection New HIV-IDU cases (78% HC co-infection, 12% HBV-HCV coinfection, 14% STDs in 2013) Source: Compartment for Monitoring and Evaluation of HIV/AIDS Infection in Romania INBI Prof.Dr.M.Balş

79 *National HIV/AIDS Strategy Challenges of HIV/AIDS management in Romania Most WLHA are long term survivors, infected at the end of the 1980s: Multiple therapeutic regimens- impact on ART resistance. ~50% of couples are serodiscordant (>50% women are HIV+). In this context, during the last few years the rate of MTCT has maintained a low value- <5%, due to the National Prevention Program of Mother to Child Transmission, established in In 2013 the rate represented 2,64% of the new reported cases. Further efforts are made to keep MTCT rate at low values.

80 Challenges of HIV/AIDS management in Romania During the last few years the main route of transmission has been heterosexual contact (unprotected)> in ,58% of the new cases. IDU/HIV increased: from 3% in 2010 to 329,23% in MSM/HIV has the same value: 11% of the new cases in The largest number of newly diagnosed cases has been recorded for the age group, 35% of these being late presenters. Increase in the number PLWHA whose state requires specialized medical care. Source: Compartment for Monitoring and Evaluation of HIV/AIDS Infection in Romania INBI Prof.Dr.M.Balş

81 Challenges: 2013 PLWHA MTCT ART Use IDUs Young by age, old by treatment Therapeutic fatigue Young mothers, multi- experienced in ART Mothers with unknown HIV status- tested and treated for HIV Treatment as prevention Legal drugs Source : A. Streinu-Cercel. cnlas.ro: Specific Challenges of the Hiv Epidemic in Romania. EACS 2013.

82 cohort The largest cohort in Europe age group. It represents ~half of the HIV+ population in Romania Share by sexes: 1:1 F1 subtype: approximatively 100 % Long term survivors (~6000 survivors) Multiple ART regimens (10-15!) Salvage therapy ARV toxicity therapeutic fatigue They have/want children: problemes vertical transmission Long term teratogenic effects of ART Sourse: A. Streinu-Cercel. cnlas.ro: Specific Challenges of the Hiv Epidemic in Romania. EACS 2013.

83 New cases: Late presenters: heterosexual persons, F1 subtype Real time presenters: MSM&IDUs (primary HIV infection!): MSMs: high level of education voluntary and pro-active IDUs: socially integrated tested by the healthcare professionals in the system Transmitted resistance: low levels in all groups <10% (4.6%) An important problem: children to mothers who inject drugs, which represents a risk of HIV+HCV+HBV co-infections! Source : A. Streinu-Cercel. cnlas.ro: Specific Challenges of the Hiv Epidemic in Romania. EACS 2013.

84 HIV/AIDS infection in the world 2012

85 General data on HIV/AIDS in the world December 2012 Source: UNAIDS Global Report Epidemiology September 2013 Total 35,3 million (32,2 38,8 million) PLWHA Persons infected with HIV in 2012 Adults Women Children < 15 years Total Adults 32,1 million (29,1 35,3 million) 17,7 million (16,4 19,3 million) 3,3 million (3,0 3,7 million) 2,3 million (1,9 3,7 million) 2,0 million (1,7 2,4 million) Children < 15 years ( ) AIDS deaths in 2012 Total Adults 1,6 million(1,4 1,9 million) 1,4 million (1,2 1,7 million) Children < 15 ani ( )

86 million Source: UNAIDS Global Report Epidemiology September 2013 Estimates on the numbers of PLWHA

87 Source: UNAIDS Global Report Epidemiology September 2013 Global estimates for adults and children December 2012 PLWH: 35,3 million (32,2 38,8 million) New cases of HIV cases in ,3 million (1,9 3,7 million) Deaths caused by AIDS in ,6 million (1,4 1,9 million)

88 Estimates on the number of living children and adults with HIV infection at the end of 2012 Source: UNAIDS Global Report Epidemiology September 2013

89 Estimates on the number of adults and children infected with HIV in 2012 Suource: UNAIDS Global Report Epidemiology September 2013

90 Estimates on the number of deaths caused by AIDS (adults and children) in 2012 Source: UNAIDS Global Report Epidemiology September 2013

91 Source: UNAIDS Global Report Epidemiology September 2013 Approximately 6300 persons have been infected with HIV, daily in 2012 Over 95% come from poor and developing countries. Almost 400 are children, with ages <15 years. Almost 5500 are persons between years, of whom: ~47% are women ~39% are between years

92 Source: UNAIDS Global Report Epidemiology September 2013 Global estimates on HIV and AIDS at the end of 2012 Children (<15 years) Children LWHA 3,3 million (3,1 3,8 million) Newly infected children in ( ) Deaths caused by AIDS in ( )

93 Source: UNAIDS Global Report Epidemiology September 2013 Statistical data by regions December 2012

94 HIV/AIDS estimates within the WHO Region (53 countries) Reported cases of HIV/AIDS (cumulative total): AIDS cases: AIDS deaths: HIV infection: Source: HIV surveillance Report 2012

95 Characteristics of HIV cases, diagnosed in the WHO European Region, by geographical areas WHO European Region West Centre East EU/EEA Countries Reporting countries/number 51/53 23/23 15/15 13/15 30/31 Number of HIV cases Rate/ population 7,8 6,6 1,9 22 5,8 % of cases: age group 10,3% 9,8% 15,4% 10,1% 10,6% Men/women ratio 2,1 3,1 4,5 1,4 3,2 Route of transmission Heterosexual 45,6% 35,3% 24,6% 60,2% 33,8% MSM 22,8% 41,7% 26,3% 1,2% 40,4% IV Drugs 17,8% 5,1% 7,4% 33,6% 6,1% Unknown 12,3% 17% 36,9% 3,2% 18,7% No data: Liechtenstein, Rusisa şand Uzbekistan; Countries that did not report age groups and routes of transmission are excluded *includes persons(12%) coming from Sub-Saharan African Countries; Source: HIV/AIDS surveillance Report 2012

96 Case definition: CDC&ECDC Stockholm This section contains the case definitions* for Acquired Immunodeficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV) Infection *Source: Commission Decision of 28/IV/2008 amending Decision 2002/253/EC laying down case definitions for reporting communicable diseases to the Community network under Decision No 2119/98/EC of the European Parliament and of the Council Clinical Criteria (AIDS) Any person who has any of the clinical conditions as defined in the European AIDS case definition for: Adults and adolescents > 13 years [1] Children < 13 years of age [2] Laboratory Criteria (HIV) Adults, adolescents and children aged = 18 months At least one of the following three: Positive result of a HIV screening antibody test or a combined screening test (HIV antibody and HIV p24 antigen) confirmed by a more specific antibody test (e.g. Western blot) Positive result of 2 EIA antibody test confirmed by a positive result of a further EIA test Positive results on two separate specimens from at least one of the following three: Detection of HIV nucleic acid (HIV-RNA, HIV-DNA) Demonstration of HIV by HIV p24 antigen test, including neutralisation assay Isolation of HIV

97 Children aged <18 months Positive results on two separate specimens (excluding cord blood) from at least one of the following three: Isolation of HIV Detection of HIV nucleic acid (HIV-RNA, HIV-DNA) Demonstration of HIV by HIV p24 antigen test, including neutralisation assay in a child =1 month of age Epidemiological Criteria NA Case Classification A. Possible case NA B. Probable case NA C. Confirmed case HIV infection Any person meeting the laboratory criteria for HIV infection AIDS Any person meeting the clinical criteria for AIDS and the laboratory criteria for HIV infection

98 Definitions Incidence = number of new cases x /population, registered at 1 July Prevalence = number of new and old cases x /population registered at 1 July Child = individual entering the 0-14 age group, according to CDC definition ( ). Adult = individual over 15 years, according to CDC definition ( ).

99 *Sources Revised surveillance Case Definition for HIV Infection Among Adults, Adolescents, and Children Aged < 18 Month sand for HIV Infection and AIDS Among Children Aged 18 Months to <13 years--- CDC, United States, Commission Decision of 28/IV/2008 amending Decision 2002/253/Ec laying down case definitions for reporting communicable diseases to the Community network under Decision no 2119/98/EC of the European Parliament and Council Who case definitions of HIV for surveillance and Revised clinical staging and immunological Classification of HIV-related disease in adults and Children (World Health Organization 2007)

100 Manager: Prof.Dr. Adrian Streinu-Cercel Head of Infectious Diseases UMF Carol Davila President of National Committee to Fight AIDS& Infectious Diseases Committee Coordinator: Coordinator Adults Programme: CoordInator Children Programme: Mariana Mărdărescu MD PhD Lecturer Dr.Elisabeta Otilia Benea Dr. Sorin Petrea Statistical data operators : PC Operators: Epidemiology: As.med. Marieta Iancu Daniela Viţelaru Sanda Vintilă Dr. Ionel Iosif