1. Laboratories Branch, MOHLTC, IMC – 2001 The epidemiology of HIV infection among persons from HIV-endemic countries in Ontario Robert S. Remis MD Department of Public Health Sciences University of Toronto Community Forum organized under the auspices of the HIV Endemic Task Force November 3, 2001 – Toronto, Ontario

2. Laboratories Branch, MOHLTC, IMC – 2001 Acknowledgments Elaine Whittingham, Department of Public Health Sciences, University of Toronto Frank McGee, AIDS Bureau, Ontario Ministry of Health and Long-Term Care (OMHLTC) Carol Major, HIV Laboratory, OMHLTC Dr. Evelyn Wallace, Public Health Branch, OMHLTC Vital Statistics Division, Registrar-General of Ontario Dr. Susan King, Hospital for Sick Children HIV Endemic Task Force

3. Laboratories Branch, MOHLTC, IMC – 2001 Background Anecdotal reports, especially from the Hospital for Sick Children, Toronto Growing community concern Limited research and few specific data available Formation of HIV Endemic Task Force

4. Laboratories Branch, MOHLTC, IMC – 2001 Definition: HIV-Endemic 1.High prevalence of HIV infection in the general population (generally greater than 0.8% but may attain 20% or higher); 2.and 3.Heterosexual contact the most important mode of transmission;

5. Laboratories Branch, MOHLTC, IMC – 2001 Study mandate Describe population born in HIV-endemic countries stratified by region of residence and country of origin Characterize incidence and prevalence of HIV infection among persons from HIV-endemic countries

6. Laboratories Branch, MOHLTC, IMC – 2001 Methods Two stages Estimate population by gender, region of residence and country of birth (‘demographic model’ based on immigration, births, deaths, and census estimates), Estimate prevalence of HIV infection Spreadsheet model Multiple data sources Derive estimates which best ‘fit’ the observed data Limitations of modeling approach

7. Laboratories Branch, MOHLTC, IMC – 2001 Methods: Data sources Population Vital Statistics, Registrar General and Statistics Canada HIV diagnostic data HIV Laboratory: HIV-positive diagnoses from 1985 to 1998 Reported AIDS casesAIDS Surveillance Program, Public Health Branch: cases reported from 1981 to 1998 HIV mortalityVital Statistics, Registrar General Deaths with codes 042, 043, 044 Mother-infant HIV Canadian Pediatric AIDS Research Group Ontario region

8. Laboratories Branch, MOHLTC, IMC – 2001 Methods: Selection of countries Category 1: Modeled individually Category 2: Modeled regionally Category 3: Not modeled CaribbeanCategory 1 6 Category 2 8 (1) Category 315 AfricaCategory 1 7 Category 2 17 (4) Category 3 20

9. Laboratories Branch, MOHLTC, IMC – 2001 Results: Population “Census” populationCaribbean 256,000 African 94,000 Total350,000 However, modeled population is Caribbean 371,000 and African 120,000 for a total of 491,000 (includes second generation) Toronto:Caribbean (86%) and African (76%); overall 84% Ottawa:6% overall, but 74% of Haitians and 29% of Somalians

10. Laboratories Branch, MOHLTC, IMC – 2001 Results: Descriptive 1 HIVAdjusted HIV diagnoses: 1,350 AIDS258 cases (4.0%) among 6,502 AIDS cases reported in Ontario but 9%, 12% and 17% of cases in 1996, 1997 and 1998, respectively 61% of cases from Caribbean Substantial number (151) MSM-endemic cases not evident in classification using hierarchy Male:female ratios high for Caribbean cases (7.9) compared to Africa (2.5)

11. Laboratories Branch, MOHLTC, IMC – 2001 Results: Descriptive 2 Deaths311 HIV-related deaths 67% residents of Toronto 73% Caribbean Mother-infant HIV transmission 116 HIV-positive mother-infant pairs 62 HIV-infected infants 58% of infants overall but 70% in recent years 63% cared for in Toronto 76% among mothers from Africa

12. Laboratories Branch, MOHLTC, IMC – 2001 Results: HIV model Model fit well for most countries HIV-infected persons, 1998 Caribbean 1,491 African 855 Total 2,346 HIV prevalence Caribbean 0.5% (0.4% - 3.8%) Africa 0.9% (0.6% - 4.5%)

13. Laboratories Branch, MOHLTC, IMC – 2001 Results: HIV model (cont’d) Caribbean: Four countries account for 87% of infections Jamaica544 (36%) Guyana311 (21%) Trinidad295 (20%) Haiti142 (10%) Africa: Five countries account for 72% of infections Ethiopia158 (19%) Somalia138 (16%) South Africa133 (16%) Uganda 96 (11%) Kenya 91 (11%)

14. Laboratories Branch, MOHLTC, IMC – 2001 Results: HIV model (cont’d) Substantial HIV transmission in Canada, representing 30-45% of HIV infections Male: female ratios indicate importance of MSM-endemic, especially from Caribbean Marked increase in recent years, mostly since 1990 (especially for Africans) HIV prevalence in 1990Caribbean370 (1998/1990 = 4.0) African150 (1998/1990 = 5.7) Total520 (1998/1990 = 4.5) Annual increase of about 250 HIV infections, or about 12% in latest year

15. Laboratories Branch, MOHLTC, IMC – 2001 Modeled HIV prevalence among persons born in sub-Saharan Africa or Caribbean, Ontario 1981-98

16. Laboratories Branch, MOHLTC, IMC – 2001 Interpretation Estimates are based on modeling Therefore, estimates are not precise but represent plausible range Also, data used often had to be adjusted, adding additional uncertainty Level of uncertainty not known exactly, but probably about 30%

17. Laboratories Branch, MOHLTC, IMC – 2001 Interpretation: Comparison with other groups Low compared to primarily affected groups Compared to other heterosexual persons in Ontario, 20-fold higher for persons from Caribbean 40-fold higher for persons from sub-Saharan Africa HIV prevalenceHIV number Proportion infections Endemic MSM IDU Other hetero ~0.7% 10-15% 5-10% ~0.02% 2,600 12,800 2,000 2,400 12% 61% 9% 11%

18. Laboratories Branch, MOHLTC, IMC – 2001 Interpretation: Comparison with other groups Comparison of HIV infection rates MSM 1:8 IDU 1:15 Endemic 1:140 Other heterosexual 1:4,400

19. Laboratories Branch, MOHLTC, IMC – 2001 Summary of findings Modeling exercise produced plausible estimates of 2,350 HIV-infected persons Caribbean 1,500; sub-Saharan Africa 850 HIV infection among persons from HIV-endemic countries is: Lower than in persons living in country of origin Lower than MSM and IDU Higher than other heterosexual persons in Ontario Number of HIV infections increasing substantially year over year Estimates must be considered hypothesis: Actual studies required to confirm findings