1. University
of Athens
Organisation
Against Drugs
Trends in HIV-1 incidence during an outbreak among injecting drug users in Athens, Greece: Results of a sero-behavioral survey (ARISTOTLE program)
Sypsa V1, Nikolopoulos G2, Paraskevis D1, Katsoulidou A1, Kantzanou M1, Psichogiou M3, Pharris A4, Wiessing L5, Donoghoe M6, Friedman S7, Des Jarlais DC8, Malliori M3, Hatzakis A1
1National Retrovirus Reference Center, Medical School, University of Athens, Athens, Greece, 2IAS/NIDA Fellow, Hellenic Center for Diseases Control and Prevention, Athens, Greece, 3Medical School, University of Athens, Athens, Greece, 4European Centre for Disease Prevention and Control, Stockholm, Sweden, 5European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal, 6World Health Organization- Regional Office for Europe, 7National Development and Research Institutes, New York, USA, 8Beth Israel Medical Center, New York, USA

2. Newly diagnosed cases of HIV-1 infections reported in Greece, 2000-2011
Surveillance data from the Hellenic Centre for Diseases Control and Prevention

3. ARISTOTLE programme Primary Aims
To screen for anti-HIV PWID in Athens Metropolitan Area.
To provide the WHO/ UNODC/ UNAIDS and EMCDDA/ECDC prevention, treatment and care package.
To contribute to the decrease of HIV-1 incidence among PWID .
Eligibility criteria for participants
Persons who:
Have injected drugs in the past 12 months
Live in the area of Athens
≥18 years old

4. ARISTOTLE programme Sampling method: Respondent Driven Sampling (RDS)
carried out in 5 rounds during
August 2012-December 2013
HIV testing and interviews
anti-HIV-1/2 (AxSYM HIV-1/2 gO, Abbott), confirmation by Western Blot (MP Diagnostics). Limiting Antigen Avidity Assay (LAg Sedia™ HIV-1 LAg-Avidity EIA) was used to identify recent infections
The questionnaire of the National HIV Behavioral Surveillance System (NHBS)-IDU3 was used as the basis for the core questionnaire

5. At the end of the process:
Description of the process
Participant arrives at ARISTOTLE site
If valid coupon: Eligibility screening
If eligible:
Consent process
If consent obtained:
Interview & blood sample collection for HIV testing
Approximately 3 days later:
HIV test result
Payment of secondary incentive(s) including payment for collecting HIV test result
For HIV (+) participants: Referral to ARV treatment - Priority referral to OST
At the end of the process:
Payment of primary incentive
3 coupons are provided
Syringes-leaflets are provided
Sypsa et al. Am J Public Health, 2014
Hatzakis et al, poster THPE103

6. The 5 rounds of ARISTOTLE
Time period
Number of participants A
Aug Oct2012
1,415 B
Dec Mar2013
1,444 C
Mar Jun2013
1,434 D
Jun Sep2012
1,413 E
Sep Dec2013
1,407
During these 5 rounds :
7,110 questionnaires and blood samples were obtained
3,320 unique persons participated to the programme

7. HIV prevalence per round: crude and weighted estimates

8. Incidence of HIV infection

9. Incidence estimation during ARISTOTLE using data from repeat blood testing
All participants with at least 2 samples who tested anti- HIV(-) in their 1st sample were included (N=1521)
Events: 45 seroconversions
Incidence rate (95% CI): 4.48 (3.34, 5.60) /100pyrs

10. Incidence rate estimate
Time interval
Events
Time at risk
(yrs)
Incidence
(/100 pyrs)
95% CI
Aug-Dec2012 14
180
7.76
(4.60, 13.4)
Dec2012-Apr2013 18
306
5.88
(3.70, 9.33)
Apr-Aug2013 10
344
2.91
(1.57, 5.41)
Aug-Dec2013 3
175
1.71
(0.55, 5.31)
78% decrease
Using Lag testing  81% decrease in incidence from round A to round E

11. Estimating HIV incidence before Aristotle (2011-Aug2012)
An SI model was fit on the HIV prevalence estimates during Jun2011-Aug2012 to estimate incidence
S: Susceptible PWID - I: Infected PWID
b: rate at which susceptible PWID enter the population
m: death rate - q: rate at which they cease to inject drugs
βΙ/Ν: force of infection q b m
βΙ/Ν S I

12. Estimating HIV incidence before Aristotle (2011-Aug2012)
We used prevalence estimates over time from the Greek national treatment monitoring centre (Greek Reitox Focal Point) and Aristotle:
1.72% June 2010
10.2% Dec 2011
19.5% in Oct 2012

13. 88% lower than that projected by the model
Force of infection
17.4
88% lower than that projected by the model

14. Transmission of resistance
EMCDDA
Early Warning
Origin of a new strain
New outbreak
Potential role of migrants
Transmission pattern identified
Ecological association with economic crisis
Potential founders
Unique
CRF sequence
identified
Indication of
spill over
Transmission of resistance
September-
October 2011
May 2011
August 2013
October 2010
July 2011
January 2013
BOOST OF NSP & OST
ARISTOTLE

15. Is it possible to separate out the effect of ARISTOTLE from that of other concurrent interventions during the outbreak, i.e. opioid substitution treatment (OST) and needle and syringes programmes (NSP) ?

16. % of ARISTOTLE participants reporting being currently on OST
Test for trend:p<0.001
OST coverage still suboptimal despite the increase observed during ARISTOTLE

17. % reporting having received free syringes through prevention activities in the last month
During ARISTOTLE, there was no scale-up of
needle and syringes programs

18. Discussion HIV incidence was estimated to decrease by 78%-88%.
The coverage of OST increased during the period ARISTOTLE was implemented whereas no scale-up was observed in NSP coverage
The coverage of opioid substitution treatment (OST) and needle and syringes program (NSP) was suboptimal during ARISTOTLE

19. Discussion Explaining the impact of ARISTOTLE
During ARISTOTLE: adoption of safer injecting practices by participants (and safer sexual practices among HIV(+) PWID)
(posters WEPE212 & MOPE133)
ARISTOTLE was a peer-driven intervention - HIV testing was coupled with repeated interviews and a number of services were provided to PWID along with monetary incentives
ARISTOTLE may have functioned as an “induction” type of network intervention that stimulates peer-to-peer interaction to create cascades in information/behavioral diffusion (Valente et al, Science 2012)

20. Funding
Implemented under NSRF (Operational Programme "Human Resources Development" , Priority Axis 14-Attika, Central Macedonia, Western Macedonia) and co-funded by European Social Fund and national resources.
(MIS )
NGO Positive Voice
TRIP: Preventing HIV Transmission by Recently-Infected Drug Users (NIDA Grant 1DP1DA034989))
NGO PRAKSIS
Hellenic Scientific Society for the study of AIDS and STDs
Additional funding and support