Comprehensive Epi Update: HIV, AIDS and STI Mark Gilbert, MD February 2014
Objectives Recognize importance of disease syndemics To review current provincial trends: HIV AIDS Infectious syphilis Chlamydia Gonorrhea Hepatitis B, C after lunch!
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
Not quite there yet Nieves-Rivera, I. A Model for Planning and Monitoring Infectious Disease Syndemics in San Francisco. http://www.cdc.gov/nchhstp/programintegration/docs/sf-trip-pcsi-presentation.pdf
1. HIV trends
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: www.cfenet.ubc.ca/stop-hivaids Nosyk B et al. The cascade of HIV care in British Columbia, Canada, 1996-2011: a population-based retrospective cohort study. Lancet, October 2013.
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
HIV Incidence and Prevalence: Comparison of BC and Canada Estimates provided by the Public Health Agency of Canada
New HIV diagnoses, BC, 1986-2012 New HIV diagnosis rate per 100,000 35 HIV Reportable 30 25 20 BC Rate Canadian Rate 15 10 5 0 1986 1991 1996 2001 2006 2011 2012: 238 new HIV diagnoses 5.2 per 100,000 BCCDC Surveillance Data; *2012 Canadian rate not yet available
New HIV diagnoses: Health Authority, 2003-12 New HIV diagnosis rate per 100,000 25 20 15 10 5 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Interior Fraser Vancouver Coastal Vancouver Island Northern BC BCCDC Surveillance Data
New HIV diagnoses: Gender, BC, 2003-12 New HIV diagnosis rate per 100,000 25 20 15 2012: 10 Males 209 cases 5 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Females 29 cases BCCDC Surveillance Data (NB: 5 cases transgender/gender unknown during this time period)
Prenatal HIV Screening Total number prenatal HIV tests 50000 45000 40000 New HIV diagnoses by prenatal test 12 10 35000 30000 25000 20000 15000 10000 5000 0 Two infants diagnosed with HIV 2003 2005 2007 2009 2011 8 6 4 2 0 BCCDC Surveillance Data; Oak Tree Data; BC Public Health Microbiology Reference Laboratory data
New HIV diagnoses: Age distribution, 2012 New HIV diagnosis rate per 100,000 25 Rate - Female Rate - Male 20 15 10 5 0 15-19 yrs 20-24 yrs 25-29 yrs 30-39 yrs 40-59 yrs 60+ yrs BCCDC Surveillance Data
New HIV diagnoses: Caucasian Ethnicity, 2003-12 100% 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% 2003 2005 2007 2009 2011 0% 2003 2005 2007 2009 2011 BCCDC Surveillance Data
New HIV diagnoses: Ethnicity, 2003-12 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% 2003 2005 2007 2009 2011 0% 2003 2005 2007 2009 2011 Aboriginal Asian South Asian Hispanic Black BCCDC Surveillance Data (other/unknown ethnicity excluded)
New HIV diagnoses: First Nations People, 2003-12 Rate per 100,000 70 60 Female Male Total 50 40 30 20 10 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Stage of Infection at Diagnosis CIHR Team in the Study of Acute HIV Infection in Gay Men
New HIV diagnoses: Acute HIV infection at diagnosis, BC, 2003-2012 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% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 BCCDC Surveillance Data (data for acute HIV available 2006 onwards)
Stage of HIV Infection at Diagnosis, 2010-2012 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
Time since last negative HIV test, BC, 2006-2011 Exposure Group Heterosexual (Identified Risk) Heterosexual (No Identified Risk) % with Previous Negative Test Inter-test interval (ITI) (months) % with ITI < 12 months 42.4% 32 25.6% 34.9% 33 17.6% PWID 72.7% 21 33.1% MSM 59.6% 15 41.2% 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, 2006-2011 CJPH (in press)
Time since last negative HIV test, BC, 2006-2011
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.
New HIV diagnoses: Exposure Group, BC, 2003-2012 Percent of new HIV diagnoses 220 200 180 160 140 120 100 80 60 40 20 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 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
New HIV diagnoses: MSM by birth cohort, BC, 2003-2012 Number of new HIV diagnoses 100 90 1920-39 1940-49 1950-59 1960-69 1970-79 1980-89 1990-99 80 70 60 50 40 30 20 10 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 BCCDC Surveillance Data
New HIV diagnoses: MSM by age group, BC, 2003-2012 Number of new HIV diagnoses 100% 90% 15-19 yrs 20-24 yrs 25-29 yrs 30-39 yrs 40-59 yrs 60+ yrs 80% 70% 60% 50% 40% 30% 20% 10% 0% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 BCCDC Surveillance Data
New HIV diagnoses: MSM by Ethnicity, 2003-2012 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% 2003 2005 2007 2009 2011 0% 2003 2005 2007 2009 2011 Caucasian Aboriginal Asian South Asian Hispanic Black Other*/UNK BCCDC Surveillance Data
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.
MSM PHO report, Sex Now: Behavioural trends, BC, 2007-2011 55 Risk sex = Unprotected anal sex with unknown status partner; by postal code aggregated region, BC, Sex Now 2011.
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.
MSM PHO Report, BCCFE: Stage of infection at diagnosis & population viral load, BC, 1996-2011 Data provided by BC Centre for Excellence in HIV/AIDS.
MSM PHO Report, Sex Now: HIV Test in past year, by region, BC, 2011 67 HIV test in past 12 months by postal code aggregated region, BC, Sex Now 2011.
New HIV diagnoses: PWID by Gender, 2003-2012 Number of new HIV diagnoses 100 90 80 70 60 50 40 30 20 10 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Diagnoses - Female Diagnoses - Male BCCDC Surveillance Data
New HIV diagnoses: PWID by Gender, 2003-12 Number of new HIV diagnoses 100 90 15-19 yrs 20-24 yrs 25-29 yrs 30-39 yrs 40-59 yrs 60+ yrs 80 70 60 50 40 30 20 10 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 BCCDC Surveillance Data
New HIV diagnoses: PWID by Ethnicity, 2003-12 100% 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% 2003 2005 2007 2009 2011 0% 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Caucasian Aboriginal Asian South Asian Hispanic Black Other*/UNK BCCDC Surveillance Data
New HIV diagnoses: Heterosexual Contact by Gender, BC, 2002-2011 Number of new HIV diagnoses 80 70 Diagnoses - Female Diagnoses - Male 60 50 40 30 20 10 0 2003 2005 2007 2009 2011 BCCDC Surveillance Data
New HIV diagnoses: Heterosexual Contact by Ethnicity, 2003-12 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% 2003 2005 2007 2009 2011 0% 2003 2005 2007 2009 2011 Caucasian Aboriginal Asian South Asian Hispanic Black Other*/UNK BCCDC Surveillance Data
New HIV diagnoses: Heterosexual Contact by Identified Risk, BC, 2002-2011 Number of new HIV diagnoses 80 70 HET-IR HET-NIR 60 50 40 30 20 10 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 BCCDC Surveillance Data; HET = Heterosexual Contact, IR = Identified Risk (e.g., Sex partner HIV+, born/resided in endemic country), NIR = No Identified Risk
Immigration of Individuals with HIV, BC, 2005-2012 HIV diagnoses made on immigration medical exams (IME) 60 50 40 30 20 10 0 2005 2006 2007 2008 2009 2010 2011 2012 Country Unspecified Endemic Countries Non-Endemic Countries BCCDC Surveillance Data
2013 trends? (Preliminary numbers) 35 New HIV diagnosis rate per 100,000 BC Rate HIV Reportable 30 25 20 15 10 5 0 1986 1991 1996 2001 2006 2011 * 2013 numbers are preliminary. 2013: 280 new HIV diagnoses BCCDC Surveillance Data
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
2. AIDS
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
AIDS Case reports, BC, 1983-2011 Rate per 100,000 population 11 10 9 8 7 6 5 4 3 2 1 BC Rate Canadian Rate 2011: 70 cases 0 1983 1988 1993 1998 2003 2008 BCCDC Surveillance Data
3. Infectious Syphilis
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)
Infectious syphilis cases: By Sex, BC, 2003-13 * 2013 numbers are preliminary Number of syphliis cases 2013: 558 cases BCCDC Surveillance Data
Maternal and Congentital Syphilis, BC, 2003-13 * 2013 numbers are preliminary BCCDC Surveillance Data
Infectious syphilis cases: Provincial and Health Authority Rate, 2003-13 * 2013 numbers are preliminary BCCDC Surveillance Data
Infectious syphilis cases: By Exposure Group, BC, 2003-13 * 2013 numbers are preliminary Number of cases BCCDC Surveillance Data
Infectious Syphilis cases, 1994-2012 Vancouver, MSM Toronto, Males Seattle, MSM New York City, Males
Infectious syphilis cases, MSM: By Stage of Infection, BC, 2004-13 * 2013 numbers are preliminary Number of cases Percent of cases BCCDC Surveillance Data
Infectious syphilis cases, MSM: By Age Group, BC, 2004-13 * 2013 numbers are preliminary Number of cases Percent of cases BCCDC Surveillance Data
Infectious syphilis cases, MSM: Percent that are HIV Positive, BC, 2004-13 * 2013 numbers are preliminary; left: number of cases, right: percent of cases BCCDC Surveillance Data
4. Chlamydia & Gonorrhea trends
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
Genital Chlamydia cases, BC, 1991-2013* * 2013 BC rate is preliminary Rate per 100,000 2013: 12,166 cases 261 per 100,000 BCCDC Surveillance Data
Genital Chlamydia cases by HA, 2003-2012 Rate per 100,000 BCCDC Surveillance Data
Genital Chlamydia cases by gender, 2003-2012 Rate per 100,000 BCCDC Surveillance Data
Lymphogranuloma venereum, BC, 2004-2012 Number of cases BCCDC Surveillance Data
Genital Gonorrhea cases, BC, 1991-2013* * 2013 BC rate is preliminary Rate per 100,000 2013: 1,682 new cases 36 per 100,000 BCCDC Surveillance Data
Genital Gonorrhea cases by HA, BC, 2003-2012 Rate per 100,000 BCCDC Surveillance Data
Genital Gonorrhea cases by gender, BC, 2003-2012 Rate per 100,000 BCCDC Surveillance Data
Percentage of tested N. gonorrhoeae isolates with elevated MIC to Cefixime, 2006-2012 BC Public Health Microbiology Reference Laboratory Data
Cases of women aged 15-44 yrs with a hospital discharge related to PID or EP, 1993-2011 Rate per 100,000 Discharge Abstract Database, Ministry of Health
Thanks and Questions To stay up to date: Annual surveillance reports posted to http://www.bccdc.ca/util/about/annreport/default.htm Trend updates on blog at http://smartsexresource.com mark.gilbert@bccdc.ca @mpjgilbert Length of presentation After Lunch Before Lunch Chance of falling asleep