HIV Endgame II: Stopping the Syndemics that Drive HIV

Sean B. Rourke, Ph.D., FCAHS Scientific and Executive Director, OHTN Professor of Psychiatry, University of Toronto Director, CIHR Centre for REACH 2.0 in HIV/AIDS Director, CIHR Collaborative Centre for CBR in HIV HIV Endgame II: Stopping the Syndemics that Drive HIV November 21-22, 2016, King Edward Hotel, Toronto

First OHTN Conference on Syndemics Lived Experience Research Evidence The Best Care Practice Knowledge/ Judgement

New Optimism in the HIV Sector

Ontario s HIV Strategy to 2026 Goals: 1. Improve the health and well-being of populations most affected by HIV 2. Promote sexual health and prevent new HIV, STI and hepatitis C infections 3. Diagnose HIV infections early and engage people in timely care 4. Improve health, longevity and quality of life for people living with HIV 5. Ensure the quality, consistency and effectiveness of all provincially funded HIV programs and services

HIV Treatment: Critical to ending the AIDS epidemic and making HIV transmissions rare

The Applied Epidemiology Unit: Strategic, Monitoring and Evaluation of HIV Epidemic in Ontario 1,400 1,200 1,000 800 1,104 1,013 1,080 969 994 986 861 798 828 842 600 400 200 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

HIV Treatment: Critical to ending the AIDS epidemic and making HIV transmissions rare

Ontario s Prevention, Engagement and Care Cascade

How close is Ontario to Meeting the Targets?

Change in the Care Cascade, 2000-2015 Cascade Summary, Ontario, 2000-2015 100% 90% Percent of diagnosed people living with HIV 80% 70% 60% 50% 40% 30% 20% 10% 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 In care On treatment Suppressed Data provided by the Public Health Ontario Laboratory. In Care = 1 VL test. On Treatment = Documented on treatment on last VL or treatment documentation missing but supressed on last VL. Supressed = VL< 200 copies/ml on last VL test

Towards an integrated primary and secondary HIV prevention continuum: Critical to making HIV transmissions rare Tim Horn and colleagues (2016) J Int AIDS Society

Key Syndemic Drivers of HIV in Ontario: Depression, alcohol and drug use, smoking OHTN Cohort Study data there are significant health and social factors that need attention: 28% experience depression 50 Syndemic risk factors count 37% have hazardous alcohol use 40% smoke tobacco (compared to 14% of general population) 20% use recreational drugs (excluding marijuana) % 40 30 20 10 31 32 23 14 0 0 1 2 3

Syndemic Drivers of HIV in Ontario Other OHTN Cohort Study Syndemic Drivers: 57% live on <$20,000/year 25% experienced history of trauma (sexual abuse as a child by someone close to them) 38% experienced intimate partner violence (of those, 50% were sexually abused and 89% were emotionally abused)

Syndemic Drivers of HIV in Ontario CIHR Funded Positive Spaces Healthy Places: 50% Housing instability Overall, those who were unstably housed had: more substance use, higher levels of stress, higher rates of depression, and lower CD4 counts and viral loads Indigenous participants in our study were more likely to live in unstable housing, have a history of homelessness, experience housing discrimination and have a history of incarceration

Impact of Syndemics on Risk and Health Outcomes Brennan et al (2012) Higher syndemic index Mustanski et al (2007) increased sexual risk behaviour, self-reported HIV infection, and social marginalization Increasing # of psychosocial health problems higher rate of unprotected anal intercourse and HIV infection among young MSM Friedman et al (2015) Higher syndemic count higher viral load and lower ART adherence in HIV+ MSM Rourke et al (2016) Higher # of syndemic factors declining levels of HIV care engagement and poorer HIV treatment outcomes

Impact of Syndemics 100 No risk factor One risk factor Two risk factors Three or more risk factors 95 90 85 % 80 75 70 65 60 55 50 In continuous care On ARV treatment On ART with suppressed VL On ART with undetectable VL

Number of syndemic risk factors and HIV treatment outcomes No. of syndemic In continuous care On ART risk factors Unadjusted estimate Adjusted estimate a Unadjusted estimate Adjusted estimate b 0 1.00 1.00 1.00 1.00 1 0.99 (0.97, 1.00) 0.99 (0.98, 1.00) 0.99 (0.98, 1.00) 0.99 (0.98, 1.00) 2 0.96 (0.94, 0.97) 0.97 (0.95, 0.98) 0.97 (0.96, 0.99) 0.99 (0.97, 1.00) 3 0.95 (0.93, 0.96) 0.96 (0.94, 0.98) 0.91 (0.88, 0.93) 0.94 (0.91, 0.96) Note: Data reported are ratio of proportions (ROP) and 95% confidence intervals a N=4,089; PY= 13,364; Adjusted for age, gender, race/ethnicity, immigrant status, relationship status, history of IDU, region of Ontario, time since HIV diagnosis, years since ARV initiation, calendar year, and clinic. Analyses restricted to participants in care and completed a questionnaire in that year. b N=4,009; PY= 13,228. Adjusted for age, gender, race/ethnicity, immigrant status, relationship status, history of IDU, region of Ontario, time since HIV diagnosis, calendar year, and clinic. Analyses restricted to participants in care, completed a questionnaire in that year, with non-missing prescription medication data, and non-missing VL results

Number of syndemic risk factors and HIV treatment outcomes: No. of syndemic risk factors On ART with suppressed VL Unadjusted estimate Adjusted estimate c On ART with undetectable VL Unadjusted estimate Adjusted estimate c 0 1.00 1.00 1.00 1.00 1 1.00 (0.98, 1.01) 1.00 (0.99, 1.01) 0.98 (0.97, 1.00) 0.99 (0.97, 1.00) 2 0.96 (0.95, 0.98) 0.98 (0.96, 0.99) 0.94 (0.93, 0.96) 0.96 (0.94, 0.98) 3 0.91 (0.88, 0.93) 0.93 (0.91, 0.96) 0.89 (0.86, 0.92) 0.92 (0.89, 0.95) Note: Data reported are ratio of proportions (ROP) and 95% confidence intervals c N=3,768; PY= 12,057; Adjusted for age, gender, race/ethnicity, immigrant status, relationship status, history of IDU, region of Ontario, years since ARV initiation, ARV regimen, calendar year, and clinic. Analyses restricted to participants in care, completed a questionnaire in that year, with non-missing prescription medication data, and non-missing VL results.

Impact of childhood adversity: With each past experience there is stepwise increase in current severity depression 25 20 Mean CES-D score 15 10 5 0 0 1 2 3 4 5 Number of childhood adversities p<0.001

Impact of childhood adversity on mental health-related quality of life (QOL) Physical health QOL Mental health related QOL 60 p<0.001 60 p<0.001 SF-36 PCS score (mean) 50 40 30 20 10 SF-36 MCS score (mean) 50 40 30 20 10 0 0 1 2 3 4 5 0 0 1 2 3 4 5 Number of Childhood adversities Number of Childhood adversities

Health Opportunities for Ontarians Living with HIV Despite these health/social challenges, many people living with and at risk of HIV demonstrate remarkable resilience How can we build on those strengths to stop the syndemics that drive HIV?

The OHTN gratefully acknowledges the core funding from the MOHLTC AIDS Bureau and the support we received from our sponsors for our HIV Endgame conference series:

Sean B. Rourke, Ph.D., FCAHS Scientific and Executive Director, OHTN Professor of Psychiatry, University of Toronto Director, CIHR Centre for REACH 2.0 in HIV/AIDS Director, CIHR Collaborative Centre for CBR in HIV Thank you!