Trends in High Risk Sexual Behaviour Among Homosexual Men

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					HIV infection among persons in
Ontario infected through
heterosexual contact
   Robert S. Remis, Maraki Fikre Merid

   Ontario HIV Epidemiologic Monitoring Unit
   Department of Public Health Sciences
   University of Toronto

   Heterosexual HIV Transmission Meeting
   November 17, 2004
    Methods: Data sources


           • AIDS cases in Ontario diagnosed 1981-
             2003 and reported to April 2004
             obtained from Public Health Branch,
             MOHLTC
           • HIV diagnoses obtained from the HIV
             Laboratory diagnosed1985-2003




MOHLTC, Laboratories Branch, IMC – 2001
        Methods: Data analysis


           • AIDS: Number and proportion of reported
             AIDS cases heterosexually acquired by
             health region and year of diagnosis, 1981-
             2003
           • HIV diagnoses: Number and proportion of
             HIV diagnoses (adjusted) heterosexually
             acquired by health region and year of
             diagnosis, 1985-2003


MOHLTC, Laboratories Branch, IMC – 2001
        Methods: Data analysis


     • HIV model: incidence and prevalence of
       • HIV infection
       • First-time HIV diagnoses
       • AIDS
       • HIV-related mortality




MOHLTC, Laboratories Branch, IMC – 2001
HIV diagnoses (adjusted) by exposure
category and gender, Ontario 1985-2003

                                          Males   Females          Total

               MSM             16,382 76.8%             0   0.0%     16,382 66.2%
               MSM-IDU            973   4.6%            0   0.0%        973   3.9%
               IDU              1,410   6.6%          600 17.6%       2,010   8.1%
               Clotting factor    271   1.3%           37   1.1%        307   1.2%
               Transfusion        212   1.0%          182   5.3%        394   1.6%
               HIV-endemic        901   4.2%        1,120 32.9%       2,021   8.2%
               HR hetero          180   0.8%          683 20.0%         863   3.5%
               LR hetero          755   3.5%          559 16.4%       1,314   5.3%
               Perinatal2         175   0.8%          164   4.8%        339   1.4%
               Other               67   0.3%           64   1.9%        131   0.5%
               Total           21,325 100.0%        3,409 100.0%     24,734 100.0%


MOHLTC, Laboratories Branch, IMC – 2001
     HIV diagnoses (adjusted) among
     heterosexuals by health region,
     Ontario, 1985-2003

          HR hetero                               LR hetero             Both hetero            Total diagnoses
                 n            % Col %      Row           n % Col % Row         n % Col % Row                       %
Northern        30             3.5%        6.2%          43 3.3%   8.9%       74    3.4% 15.1%             486  2.0%
Ottawa         101            11.7%        3.6%        145 11.0%   5.1%      246 11.3%    8.7%           2,818 11.4%
Eastern         32             3.7%        5.0%          35 2.6%   5.3%       67    3.1% 10.3%             651  2.6%
Toronto        388            44.9%        2.4%        789 60.0%   4.8%    1,176 54.0%    7.2%          16,424 66.4%
C East          93            10.8%        8.2%        103  7.8%   9.0%      196    9.0% 17.2%           1,142  4.6%
C West          98            11.3%        6.9%        106  8.1%   7.5%      203    9.3% 14.4%           1,416  5.7%
Southwest      122            14.1%        6.8%          94 7.2%   5.2%      216    9.9% 12.0%           1,796  7.3%

Ontario                864 100.0%          3.5%      1,314 100.0%   5.3%    2,179 100.0%   8.8%        24,734 100.0%




 MOHLTC, Laboratories Branch, IMC – 2001
 Proportion HR and LR heterosexual
 among HIV diagnoses, 1985-2003

                                    20%
                                    18%
                                                        HR hetero
                                    16%
                                                        LR hetero
                                    14%                 Both hetero
                     Proportion %




                                    12%
                                    10%
                                    8%
                                    6%                                                                                 H
                                    4%
                                    2%
                                    0%
                                          1985
                                                 1986
                                                        1987
                                                               1988
                                                                      1989
                                                                             1990
                                                                                    1991
                                                                                           1992
                                                                                                  1993
                                                                                                         1994
                                                                                                                1995
                                                                                                                       1996
                                                                                                                              1997
                                                                                                                                     1998
                                                                                                                                            1999
                                                                                                                                                   2000
                                                                                                                                                          2001
                                                                                                                                                                 2002
                                                                                                                                                                        2003
                                                                                     Year of HIV diagnosis




MOHLTC, Laboratories Branch, IMC – 2001
    Proportion heterosexual among HIV
    diagnoses by sex, 1985-2003

                      45%
                            Male
                      40%
                            Female
                      35%
                            Both sexes
                      30%
       Proportion %




                      25%
                      20%
                      15%
                      10%
                      5%
                      0%
                         85
                         86

                         87

                         88

                         89
                         90

                         91
                         92

                         93
                         94

                         95
                         96

                         97
                         98

                         99
                         00

                         01

                         02

                         03
                       19
                       19

                       19

                       19

                       19
                       19

                       19
                       19

                       19
                       19

                       19
                       19

                       19
                       19

                       19
                       20

                       20

                       20

                       20
                                          Year of HIV diagnosis




MOHLTC, Laboratories Branch, IMC – 2001
Reported AIDS cases by exposure
category and sex,1981-2003

                               Males        Females                       Total
                                 No.      %     No.     %                   No.      %
               MSM             5,258 78.3%        0  0.0%                 5,258  72.6%
               MSM-IDU           299   4.5%       0  0.0%                   299   4.1%
               IDU               258   3.8%      78 14.8%                   336   4.6%
               HIV-endemic       260   3.9%    156 29.6%                    416   5.7%
               Heterosexual      414   6.2%    204 38.7%                    618   8.5%
               Clotting factor   100   1.5%      10  1.9%                   110   1.5%
               Transfusion        94   1.4%      49  9.3%                   143   2.0%
               Perinatal          26   0.4%      29  5.5%                    55   0.8%
               Occupational        6   0.1%       1  0.2%                     7   0.1%
               NIR               248             24                         272
               Total           6,963 100.0%    551 100.0%                 7,514 100.0%

                                          * Proportion EC known = 96.4%


MOHLTC, Laboratories Branch, IMC – 2001
    Reported AIDS cases among
    heterosexual cases by health region,
    Ontario, 1981-2003

                                            n   % Col    % Row All AIDS cases        %
              Northern                    24     3.9%    11.9%            202     2.7%
                Ottawa                     36    5.8%     5.8%             620    8.3%
         Eastern, other                    15    2.4%     7.3%             206    2.7%
               Toronto                    269   43.5%     5.9%           4,558   60.7%
          Central East                    128   20.7%    18.8%             680    9.0%
          Central West                     81   13.1%    12.3%             657    8.7%
            Southwest                      65   10.5%    11.0%             591    7.9%

                          Total           618   100.0%    8.2%          7,514    100.0%




MOHLTC, Laboratories Branch, IMC – 2001
       Proportion annual reported AIDS
       cases among heterosexual cases by
       sex,1981-2003

                                    25%
                                            Ma les        Fema les      Both sexes
                                    20%
                     Proportion %




                                    15%


                                    10%


                                    5%


                                    0%
                                       81

                                              83

                                                     85

                                                            87

                                                                   89

                                                                          91

                                                                                 93

                                                                                        95

                                                                                               97

                                                                                                      99

                                                                                                             01

                                                                                                                    03
                                     19

                                            19

                                                   19

                                                          19

                                                                 19

                                                                        19

                                                                               19

                                                                                      19

                                                                                             19

                                                                                                    19

                                                                                                           20

                                                                                                                  20
                                                                     Year of AIDS diagnosis



MOHLTC, Laboratories Branch, IMC – 2001
       Modeled HIV prevalence by
       exposure category, in Ontario,
       December 2003

                                              Male            Female            Both sexes
                                          Number         %    Number      %        Number
                         MSM                14,370   71.6%          -               14,370
                     MSM-IDU                   703    3.5%          -                   703
                           IDU               1,331    6.6%        628   18.2%         1,959
                     Endemic                 1,971    9.8%      1,041   30.2%         3,011
                       Hetero                1,535    7.7%      1,743   50.5%         3,311
                      Clotting                 148    0.7%          5    0.1%           156
                  Transfusion                    6    0.0%         35    1.0%            41

                                Total       20,063   100.0%     3,452 100.0%        23,552



MOHLTC, Laboratories Branch, IMC – 2001
          Modeled HIV prevalence among
          heterosexual cases by sex,1977-2003

                              3,500

                              3,000
                                               Ma les        Fema les            Both sexes
                              2,500
               Proportion %




                              2,000

                              1,500

                              1,000

                               500

                                 0
                                  77

                                         79

                                                81

                                                       83

                                                              85

                                                                     87

                                                                            89

                                                                                   91

                                                                                          93

                                                                                                 95

                                                                                                        97

                                                                                                               99

                                                                                                                      01

                                                                                                                             03
                                19

                                       19

                                              19

                                                     19

                                                            19

                                                                   19

                                                                          19

                                                                                 19

                                                                                        19

                                                                                               19

                                                                                                      19

                                                                                                             19

                                                                                                                    20

                                                                                                                           20
                                                                     Year of HIV infection



MOHLTC, Laboratories Branch, IMC – 2001
    Modeled HIV prevalence by
    exposure category, in Ontario,
    December 2003

                                                     Proportion       Number     Proportion
                                                 HIV diagnosed           HIV        Ontario
                                          prevalence      living undiagnosed   undiagnosed

         MSM                                  14,370     68.9%         4,278         51.9%
         MSM-IDU                                 703     58.1%           262          3.2%
         IDU                                  1,959      67.0%           644          7.8%
         Endemic                               3,011     47.5%         1,481         18.0%
         Hetero                                3,311     50.5%         1,557         18.9%
         Clotting                                156     99.5%             3          0.0%
         Transfusion                              41     77.0%            10          0.1%
                                              23,552     63.3%         8,236        100.0%




MOHLTC, Laboratories Branch, IMC – 2001
    Conclusions

     • Females important: Proportion heterosexual 36%
       for HIV and 39% for AIDS cases among females
       (compared to 5% and 6% for males)
     • Observed increase over time for both first-time
       HIV diagnoses (mostly LR) and AIDS cases
       among persons infected heterosexually
     • Cases mostly in Toronto and Ottawa




MOHLTC, Laboratories Branch, IMC – 2001
Conclusions
 • Estimated number of HIV infected persons
   infected heterosexually
    • 3,311 or 14% of Ontario (n=23,552)
       • 1,535 among males (or 8% of total)
       • 1,743 among females (or 51%)

 • Overall, persons infected heterosexually
   increased 1.64 over five years (1998 to
   2003), annual increase of 10.4%


MOHLTC, Laboratories Branch, IMC – 2001
Next steps


  • Study under way to understand increase
    and patterns of HIV infection among cases
    in Ontario heterosexually acquired




MOHLTC, Laboratories Branch, IMC – 2001
    Objectives


       • Validate heterosexual cases and NIR

       • Determine context and factors involved in
         heterosexual HIV acquisition and likely
         source of HIV infection (risk factors of
         sexual partner if any)




MOHLTC, Laboratories Branch, IMC – 2001
    Study design

       • PHU selection: Toronto and Ottawa based
         on reported number of HIV heterosexual
         cases
       • All HIV cases reported from July 1 ,2004 to
         June 30, 2005 and
       • random selection of NIR cases (1:2 for
         Ottawa and 1:10 for Toronto)




MOHLTC, Laboratories Branch, IMC – 2001
    Study design

       • Subject recruitment
          • Cases referred by PHU nurse or through
            physician contact and meeting criteria for
            inclusion

       • Data collection
         • Face-to-face interviews using
           standardized questionnaire
         • Data sent to OHEMU for analysis

MOHLTC, Laboratories Branch, IMC – 2001
    Timeline of study

       • Ethics approval
          • Obtained from Toronto PHU
          • Awaiting U of T and Ottawa PHU

       • Retrospective data extraction for cases
         from July 1, 2004 to study commencement




MOHLTC, Laboratories Branch, IMC – 2001
     Acknowledgements

           • Ontario Ministry of Health and Long-Term Care
              • Frank McGee, coordinator, AIDS Bureau
              • Lorraine Schiedel, Public Health Division
           • HIV Laboratory, Central Public Health Laboratory
              • Carol Swantee, diagnostic data
              • Keyi Wu, programming




MOHLTC, Laboratories Branch, IMC – 2001

				
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