Comprehensive Epi Update: HIV, AIDS and STI Mark Gilbert, MD

Transcription

1 Comprehensive Epi Update: HIV, AIDS and STI Mark Gilbert, MD February 2014

2 Objectives Recognize importance of disease syndemics To review current provincial trends: HIV AIDS Infectious syphilis Chlamydia Gonorrhea Hepatitis B, C after lunch!

3 Disease Syndemics SOCIAL AND STRUCTURAL FACTORS BEHAVIOUR BIOLOGY FACTORS PROMOTING VULNERABILITY FACTORS PROMOTING RESILIENCY INTERMEDIATE CONDITIONS e.g.,mental Health, Substance Use RISK BEHAVIOUR Sex Substance use HIV STI HBV, HCV CORE GROUPS Populations Individuals

4 Not quite there yet Nieves-Rivera, I. A Model for Planning and Monitoring Infectious Disease Syndemics in San Francisco.

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6 1. HIV trends

7 HIV Cascade of Care BC, 2011 Today focusing on left side of cascade of care: prevention, testing, diagnosis Detailed quarterly reports on components of the cascade of care for BC and each Health Authority available at: Nosyk B et al. The cascade of HIV care in British Columbia, Canada, : a population-based retrospective cohort study. Lancet, October 2013.

8 Interpreting trends in New HIV diagnoses All people in BC who have received a new HIV diagnosis Excludes people with a previous positive result (inside/outside BC) Does not represent true incidence Diagnosis can be made years after infection occurs Doesn t include undiagnosed infections Based on data elicited by public health nurse or testing provider from person with a new diagnosis Influenced by changes in testing behaviour

9 HIV Incidence and Prevalence: Comparison of BC and Canada Estimates provided by the Public Health Agency of Canada

10 New HIV diagnoses, BC, New HIV diagnosis rate per 100, HIV Reportable BC Rate Canadian Rate : 238 new HIV diagnoses 5.2 per 100,000 BCCDC Surveillance Data; *2012 Canadian rate not yet available

11 New HIV diagnoses: Health Authority, New HIV diagnosis rate per 100, Interior Fraser Vancouver Coastal Vancouver Island Northern BC BCCDC Surveillance Data

12 New HIV diagnoses: Gender, BC, New HIV diagnosis rate per 100, : 10 Males 209 cases Females 29 cases BCCDC Surveillance Data (NB: 5 cases transgender/gender unknown during this time period)

13 Prenatal HIV Screening Total number prenatal HIV tests New HIV diagnoses by prenatal test Two infants diagnosed with HIV BCCDC Surveillance Data; Oak Tree Data; BC Public Health Microbiology Reference Laboratory data

14 New HIV diagnoses: Age distribution, 2012 New HIV diagnosis rate per 100, Rate - Female Rate - Male yrs yrs yrs yrs yrs 60+ yrs BCCDC Surveillance Data

15 New HIV diagnoses: Caucasian Ethnicity, % 90% 80% 70% 60% 50% 40% 30% 20% 10% Percent of new HIV diagnoses - FEMALE 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Percent of new HIV diagnoses - MALE 0% % BCCDC Surveillance Data

16 New HIV diagnoses: Ethnicity, Percent of new HIV diagnoses - FEMALE 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% Percent of new HIV diagnoses - MALE 0% % Aboriginal Asian South Asian Hispanic Black BCCDC Surveillance Data (other/unknown ethnicity excluded)

17 New HIV diagnoses: First Nations People, Rate per 100, Female Male Total

18 Stage of Infection at Diagnosis CIHR Team in the Study of Acute HIV Infection in Gay Men

19 New HIV diagnoses: Acute HIV infection at diagnosis, BC, Percent of new HIV diagnoses 50% 45% 40% 35% 30% 25% Documentation of acute HIV infection Up to 6-8 weeks after HIV infection Period of high viral load Identified on the basis of a characteristic pattern of HIV laboratory test results 20% 15% 10% 5% 0% BCCDC Surveillance Data (data for acute HIV available 2006 onwards)

20 Stage of HIV Infection at Diagnosis, ACUTE Acute infection or prior negative test within 3 months ADVANCED First recorded CD4+ < 200, or AIDS Case report within one year HIV Monitoring Quarterly Report for British Columbia, Fourth Quarter 2013

21 Time since last negative HIV test, BC, Exposure Group Heterosexual (Identified Risk) Heterosexual (No Identified Risk) % with Previous Negative Test Inter-test interval (ITI) (months) % with ITI < 12 months 42.4% % 34.9% % PWID 72.7% % MSM 59.6% % Gilbert et al. Time since last negative HIV test among men who have sex with men and people who use injection drugs in British Columbia, CJPH (in press)

22 Time since last negative HIV test, BC,

23 Annual HIV Incidence and Prevalence, BC, 2011 New HIV infections People living with HIV 3% 3% 1% 23% 19% 43% 16% 54% 31% 3% MSM MSM-IDU 3% IDU Heterosexual (non-endemic) Heterosexual (endemic) Other Estimates provided by the Public Health Agency of Canada.

24 New HIV diagnoses: Exposure Group, BC, Percent of new HIV diagnoses MSM IDU HET Other NIR/UNK BCCDC Surveillance Data; MSM=Men who have sex with men, IDU = people who use injection drugs, HET = heterosexual contact, NIR/Unk = no identified risk/unknown

25 New HIV diagnoses: MSM by birth cohort, BC, Number of new HIV diagnoses BCCDC Surveillance Data

26 New HIV diagnoses: MSM by age group, BC, Number of new HIV diagnoses 100% 90% yrs yrs yrs yrs yrs 60+ yrs 80% 70% 60% 50% 40% 30% 20% 10% 0% BCCDC Surveillance Data

27 New HIV diagnoses: MSM by Ethnicity, Percent of new HIV diagnoses - Caucasian Percent of new HIV diagnoses 100% 50% 90% 45% 80% 40% 70% 35% 60% 30% 50% 25% 40% 20% 30% 15% 20% 10% 10% 5% 0% % Caucasian Aboriginal Asian South Asian Hispanic Black Other*/UNK BCCDC Surveillance Data

28 MSM PHO report, Sex Now: Condom Use, BC, 2010 Condom Use with Anal Sex on Casual Dates past 12 months, by birth cohort, BC, Sex Now 2010.

29 MSM PHO report, Sex Now: Behavioural trends, BC, Risk sex = Unprotected anal sex with unknown status partner; by postal code aggregated region, BC, Sex Now 2011.

30 MSM PHO Report, Sex Now: Relationship between risk sex and risk perception by birth cohort, BC, 2011 Relationship between Risk Sex (UAI with unknown status partner) and perceived risk by birth cohort, BC, Sex Now 2011.

31 MSM PHO Report, BCCFE: Stage of infection at diagnosis & population viral load, BC, Data provided by BC Centre for Excellence in HIV/AIDS.

32 MSM PHO Report, Sex Now: HIV Test in past year, by region, BC, HIV test in past 12 months by postal code aggregated region, BC, Sex Now 2011.

33 New HIV diagnoses: PWID by Gender, Number of new HIV diagnoses Diagnoses - Female Diagnoses - Male BCCDC Surveillance Data

34 New HIV diagnoses: PWID by Gender, Number of new HIV diagnoses yrs yrs yrs yrs yrs 60+ yrs BCCDC Surveillance Data

35 New HIV diagnoses: PWID by Ethnicity, % 90% 80% 70% 60% 50% 40% 30% 20% 10% Percent of new HIV diagnoses 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% Percent of new HIV diagnoses 0% % Caucasian Aboriginal Asian South Asian Hispanic Black Other*/UNK BCCDC Surveillance Data

36 New HIV diagnoses: Heterosexual Contact by Gender, BC, Number of new HIV diagnoses Diagnoses - Female Diagnoses - Male BCCDC Surveillance Data

37 New HIV diagnoses: Heterosexual Contact by Ethnicity, Percent of new HIV diagnoses Percent of new HIV diagnoses 100% 50% 90% 45% 80% 40% 70% 35% 60% 30% 50% 25% 40% 20% 30% 15% 20% 10% 10% 5% 0% % Caucasian Aboriginal Asian South Asian Hispanic Black Other*/UNK BCCDC Surveillance Data

38 New HIV diagnoses: Heterosexual Contact by Identified Risk, BC, Number of new HIV diagnoses HET-IR HET-NIR BCCDC Surveillance Data; HET = Heterosexual Contact, IR = Identified Risk (e.g., Sex partner HIV+, born/resided in endemic country), NIR = No Identified Risk

39 Immigration of Individuals with HIV, BC, HIV diagnoses made on immigration medical exams (IME) Country Unspecified Endemic Countries Non-Endemic Countries BCCDC Surveillance Data

40 2013 trends? (Preliminary numbers) 35 New HIV diagnosis rate per 100,000 BC Rate HIV Reportable * 2013 numbers are preliminary. 2013: 280 new HIV diagnoses BCCDC Surveillance Data

41 Reasons for increase? Conducted preliminary review of new HIV diagnoses Jan-Sept 2014 and compared to previous years Suggested increase is related primarily to increased testing and detection of HIV cases at a later stage of infection Routine offer of HIV testing in hospitals, testing of partners Decrease in number of cases diagnosed with acute HIV infection, which suggests incidence may not be increasing At a provincial level cannot rule out increase in diagnoses in groups such as MSM (for example, related to increase in syphilis) Will be repeating the analysis once HIV case numbers for 2013 are final

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43 2. AIDS

44 Interpreting trends in AIDS cases Reports of HIV positive individuals who have a first report of an AIDS defining illness Information collected by clinicians or as recorded in clinical information systems passive reporting Likely under-estimates total number of cases Importance as a measure of the HIV epidemic much lower in 2014 than in the pre-antiretroviral era due to success of treatment

45 AIDS Case reports, BC, Rate per 100,000 population BC Rate Canadian Rate 2011: 70 cases BCCDC Surveillance Data

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47 3. Infectious Syphilis

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49 Interpreting trends in syphilis cases Cases are people diagnosed with Infectious Syphilis: Primary syphilis (one month after diagnosis) Secondary syphilis (two months after diagnosis) Early Latent syphilis (< 1 year after diagnosis) We also monitor trends in Non-Infectious Syphilis or serious complications if untreated Neurosyphilis is most common (and can manifest during infectious syphilis)

50 Infectious syphilis cases: By Sex, BC, * 2013 numbers are preliminary Number of syphliis cases 2013: 558 cases BCCDC Surveillance Data

51 Maternal and Congentital Syphilis, BC, * 2013 numbers are preliminary BCCDC Surveillance Data

52 Infectious syphilis cases: Provincial and Health Authority Rate, * 2013 numbers are preliminary BCCDC Surveillance Data

53 Infectious syphilis cases: By Exposure Group, BC, * 2013 numbers are preliminary Number of cases BCCDC Surveillance Data

54 Infectious Syphilis cases, Vancouver, MSM Toronto, Males Seattle, MSM New York City, Males

55 Infectious syphilis cases, MSM: By Stage of Infection, BC, * 2013 numbers are preliminary Number of cases Percent of cases BCCDC Surveillance Data

56 Infectious syphilis cases, MSM: By Age Group, BC, * 2013 numbers are preliminary Number of cases Percent of cases BCCDC Surveillance Data

57 Infectious syphilis cases, MSM: Percent that are HIV Positive, BC, * 2013 numbers are preliminary; left: number of cases, right: percent of cases BCCDC Surveillance Data

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59 4. Chlamydia & Gonorrhea trends

60 Interpreting trends in Chlamydia & Gonorrhea All cases have a positive test result Information is collected on a form sent to the diagnosing health care provider or completed by public health nurses on follow-up Most common reported diseases in BC, large number per year Have good quality information about sex, age, residence Poor information on exposure group or ethnicity

61 Genital Chlamydia cases, BC, * * 2013 BC rate is preliminary Rate per 100, : 12,166 cases 261 per 100,000 BCCDC Surveillance Data

62 Genital Chlamydia cases by HA, Rate per 100,000 BCCDC Surveillance Data

63 Genital Chlamydia cases by gender, Rate per 100,000 BCCDC Surveillance Data

64 Lymphogranuloma venereum, BC, Number of cases BCCDC Surveillance Data

65 Genital Gonorrhea cases, BC, * * 2013 BC rate is preliminary Rate per 100, : 1,682 new cases 36 per 100,000 BCCDC Surveillance Data

66 Genital Gonorrhea cases by HA, BC, Rate per 100,000 BCCDC Surveillance Data

67 Genital Gonorrhea cases by gender, BC, Rate per 100,000 BCCDC Surveillance Data

68 Percentage of tested N. gonorrhoeae isolates with elevated MIC to Cefixime, BC Public Health Microbiology Reference Laboratory Data

69 Cases of women aged yrs with a hospital discharge related to PID or EP, Rate per 100,000 Discharge Abstract Database, Ministry of Health

70 Thanks and Questions To stay up to date: Annual surveillance reports posted to Trend updates on blog at Length of presentation After Lunch Before Lunch Chance of falling asleep