1. 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

2. MOHLTC, Laboratories Branch, IMC – 2001 Methods: Data sources AIDS cases in Ontario diagnosed 1981- 2003 and reported to April 2004 obtained from Public Health Branch, MOHLTCAIDS cases in Ontario diagnosed 1981- 2003 and reported to April 2004 obtained from Public Health Branch, MOHLTC HIV diagnoses obtained from the HIV Laboratory diagnosed1985-2003HIV diagnoses obtained from the HIV Laboratory diagnosed1985-2003

3. 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- 2003AIDS: 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, 1985-2003HIV diagnoses: Number and proportion of HIV diagnoses (adjusted) heterosexually acquired by health region and year of diagnosis, 1985-2003

4. MOHLTC, Laboratories Branch, IMC – 2001 Methods: Data analysis HIV model: incidence and prevalence ofHIV model: incidence and prevalence of HIV infectionHIV infection First-time HIV diagnosesFirst-time HIV diagnoses AIDSAIDS HIV-related mortalityHIV-related mortality

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

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

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

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

9. MOHLTC, Laboratories Branch, IMC – 2001 Reported AIDS cases by exposure category and sex,1981-2003 * Proportion EC known = 96.4%

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

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

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

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

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

15. 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)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 heterosexuallyObserved increase over time for both first-time HIV diagnoses (mostly LR) and AIDS cases among persons infected heterosexually Cases mostly in Toronto and OttawaCases mostly in Toronto and Ottawa

16. MOHLTC, Laboratories Branch, IMC – 2001 Conclusions Estimated number of HIV infected persons infected heterosexuallyEstimated number of HIV infected persons infected heterosexually 3,311 or 14% of Ontario (n=23,552)3,311 or 14% of Ontario (n=23,552) 1,535 among males (or 8% of total)1,535 among males (or 8% of total) 1,743 among females (or 51%)1,743 among females (or 51%) Overall, persons infected heterosexually increased 1.64 over five years (1998 to 2003), annual increase of 10.4%Overall, persons infected heterosexually increased 1.64 over five years (1998 to 2003), annual increase of 10.4%

17. MOHLTC, Laboratories Branch, IMC – 2001 Next steps Study under way to understand increase and patterns of HIV infection among cases in Ontario heterosexually acquiredStudy under way to understand increase and patterns of HIV infection among cases in Ontario heterosexually acquired

18. MOHLTC, Laboratories Branch, IMC – 2001 Objectives Validate heterosexual cases and NIRValidate 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)Determine context and factors involved in heterosexual HIV acquisition and likely source of HIV infection (risk factors of sexual partner if any)

19. MOHLTC, Laboratories Branch, IMC – 2001 Study design PHU selection: Toronto and Ottawa based on reported number of HIV heterosexual casesPHU selection: Toronto and Ottawa based on reported number of HIV heterosexual cases All HIV cases reported from July 1,2004 to June 30, 2005 andAll 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)random selection of NIR cases (1:2 for Ottawa and 1:10 for Toronto)

20. MOHLTC, Laboratories Branch, IMC – 2001 Study design Subject recruitmentSubject recruitment Cases referred by PHU nurse or through physician contact and meeting criteria for inclusionCases referred by PHU nurse or through physician contact and meeting criteria for inclusion Data collectionData collection Face-to-face interviews using standardized questionnaireFace-to-face interviews using standardized questionnaire Data sent to OHEMU for analysisData sent to OHEMU for analysis

21. MOHLTC, Laboratories Branch, IMC – 2001 Timeline of study Ethics approvalEthics approval Obtained from Toronto PHUObtained from Toronto PHU Awaiting U of T and Ottawa PHUAwaiting U of T and Ottawa PHU Retrospective data extraction for cases from July 1, 2004 to study commencementRetrospective data extraction for cases from July 1, 2004 to study commencement

22. MOHLTC, Laboratories Branch, IMC – 2001 Acknowledgements Ontario Ministry of Health and Long-Term Care Ontario Ministry of Health and Long-Term Care Frank McGee, coordinator, AIDS Bureau Frank McGee, coordinator, AIDS Bureau Lorraine Schiedel, Public Health Division Lorraine Schiedel, Public Health Division HIV Laboratory, Central Public Health Laboratory HIV Laboratory, Central Public Health Laboratory Carol Swantee, diagnostic data Carol Swantee, diagnostic data Keyi Wu, programming Keyi Wu, programming