HIV Endgame II: Stopping the Syndemics that Drive HIVNovember 21-22, 2016, King Edward Hotel, Toronto

Sean B. Rourke, Ph.D., FCAHSScientific and Executive Director, OHTNProfessor of Psychiatry, University of TorontoDirector, CIHR Centre for REACH 2.0 in HIV/AIDSDirector, CIHR Collaborative Centre for CBR in HIV

First OHTN Conference on Syndemics

ResearchEvidenceResearchEvidence

PracticeKnowledge/Judgement

PracticeKnowledge/Judgement

LivedExperience

The Best Care

New Optimism in the HIV Sector

Ontario’s HIV Strategy to 2026

Goals:1. Improve the health and well-being of populations most affected by HIV2. Promote sexual health and prevent new HIV, STI and hepatitis C

infections3. Diagnose HIV infections early and engage people in timely care4. Improve health, longevity and quality of life for people living with HIV5. Ensure the quality, consistency and effectiveness of all provincially

funded HIV programs and services

HIV Treatment: Critical to ending the AIDS epidemic and making HIV transmissions rare

The Applied Epidemiology Unit: Strategic, Monitoring and Evaluation of HIV Epidemic in Ontario

1,1041,013

1,080

969 994 986

861798 828 842

0

200

400

600

800

1,000

1,200

1,400

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

HIV Treatment: Critical to ending the AIDS epidemic and making HIV transmissions rare

Ontario’s Prevention, Engagement and Care Cascade

How close is Ontario to Meeting the Targets?

Change in the Care Cascade, 2000-2015

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

In care On treatment Suppressed

Percent of diagnosedpeople living with HIV

Data provided by the Public Health Ontario Laboratory. In Care = ≥1 VL test. On Treatment = Documented on treatment on last VL or treatment documentation missing but supressed on last VL. Supressed = VL< 200 copies/ml on last VL test

Cascade Summary, Ontario, 2000-2015

Towards an integrated primary and secondary HIV prevention continuum: Critical to making HIV transmissions rare

Tim Horn and colleagues (2016) J Int AIDS Society

Key Syndemic Drivers of HIV in Ontario:Depression, alcohol and drug use, smoking

OHTN Cohort Study data – there are significant health and social factors that need attention:

28% experience depression

37% have hazardous alcohol use

40% smoke tobacco (compared to 14% ofgeneral population)

20% use recreational drugs (excluding marijuana)

31 32

23

14

0

10

20

30

40

50

0 1 2 ≥ 3

%

Syndemic risk factors count

Syndemic Drivers of HIV in Ontario

Other OHTN Cohort Study Syndemic Drivers:57% live on <$20,000/year

25% experienced history of trauma (sexual abuse as a child by someone close to them)

38% experienced intimate partner violence (of those, 50% were sexually abused and 89% were emotionally abused)

Syndemic Drivers of HIV in Ontario

CIHR Funded Positive Spaces Healthy Places:50% Housing instability

Overall, those who were unstably housed had:

• more substance use, higher levels of stress, higher rates of depression, and lower CD4 counts and viral loads

Indigenous participants in our study– were more likely to live in unstable housing, have a history of homelessness, experience housing discrimination and have a history of incarceration

Impact of Syndemics on Risk and Health Outcomes

Brennan et al (2012) Higher syndemic index increased sexual risk behaviour, self-reported HIV infection,

and social marginalization

Mustanski et al (2007) Increasing # of psychosocial health problems higher rate of unprotected anal intercourse

and HIV infection among young MSM

Friedman et al (2015) Higher syndemic count higher viral load and lower ART adherence in HIV+ MSM

Rourke et al (2016) Higher # of syndemic factors declining levels of HIV care engagement and poorer HIV

treatment outcomes

Impact of Syndemics

50

55

60

65

70

75

80

85

90

95

100

In continuous care

On ARVtreatment

On ART withsuppressed VL

On ART withundetectable VL

%

No risk factor One risk factor Two risk factors Three or more risk factors

Number of syndemic risk factors and HIV treatment outcomes

No. ofsyndemic

risk factors

In continuous care On ART

Unadjusted estimate

Adjustedestimate a

Unadjusted estimate

Adjusted estimate b

0 1.00 1.00 1.00 1.001 0.99 (0.97, 1.00) 0.99 (0.98, 1.00) 0.99 (0.98, 1.00) 0.99 (0.98, 1.00)2 0.96 (0.94, 0.97) 0.97 (0.95, 0.98) 0.97 (0.96, 0.99) 0.99 (0.97, 1.00)

≥3 0.95 (0.93, 0.96) 0.96 (0.94, 0.98) 0.91 (0.88, 0.93) 0.94 (0.91, 0.96)

Note: Data reported are ratio of proportions (ROP) and 95% confidence intervals

a N=4,089; PY= 13,364; Adjusted for age, gender, race/ethnicity, immigrant status, relationship status, history of IDU, region of Ontario, time since HIV diagnosis, years since ARV initiation, calendar year, and clinic. Analyses restricted to participants in care and completed a questionnaire in that year.

b N=4,009; PY= 13,228. Adjusted for age, gender, race/ethnicity, immigrant status, relationship status, history of IDU, region of Ontario, time since HIV diagnosis, calendar year, and clinic. Analyses restricted to participants in care, completed a questionnaire in that year, with non-missing prescription medication data, and non-missing VL results

No. ofsyndemic

risk factors

On ART with suppressed VL On ART with undetectable VL

Unadjusted estimate

Adjusted estimate c

Unadjusted estimate

Adjusted estimate c

0 1.00 1.00 1.00 1.00

1 1.00 (0.98, 1.01) 1.00 (0.99, 1.01) 0.98 (0.97, 1.00) 0.99 (0.97, 1.00)

2 0.96 (0.95, 0.98) 0.98 (0.96, 0.99) 0.94 (0.93, 0.96) 0.96 (0.94, 0.98)

≥3 0.91 (0.88, 0.93) 0.93 (0.91, 0.96) 0.89 (0.86, 0.92) 0.92 (0.89, 0.95)

Note: Data reported are ratio of proportions (ROP) and 95% confidence intervals

c N=3,768; PY= 12,057; Adjusted for age, gender, race/ethnicity, immigrant status, relationship status, history of IDU, region of Ontario, years since ARV initiation, ARV regimen, calendar year, and clinic. Analyses restricted to participants in care, completed a questionnaire in that year, with non-missing prescription medication data, and non-missing VL results.

Number of syndemic risk factors and HIV treatment outcomes:

Impact of childhood adversity: With each past experience there is stepwise increase in current severity depression

0

5

10

15

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25

0 1 2 3 4 ≥5

Mea

n C

ES-D

sco

re

Number of childhood adversities p<0.001

0

10

20

30

40

50

60

0 1 2 3 4 ≥5

SF-3

6 PC

S s

core

(mea

n)

Number of Childhood adversities

p<0.001

0

10

20

30

40

50

60

0 1 2 3 4 ≥5

SF-3

6 M

CS

sco

re (m

ean)

Number of Childhood adversities

p<0.001

Physical health QOL Mental health related QOL

Impact of childhood adversityon mental health-related quality of life (QOL)

Health Opportunities forOntarians Living with HIV

Despite these health/social challenges, many people living with and at risk of HIV demonstrate remarkable resilience

How can we build on those strengthsto stop the syndemics that drive HIV?

The OHTN gratefully acknowledges the core funding from the MOHLTC AIDS Bureau

and the support we received from our sponsors for our HIV Endgame conference series:

Thank you!

Sean B. Rourke, Ph.D., FCAHSScientific and Executive Director, OHTNProfessor of Psychiatry, University of TorontoDirector, CIHR Centre for REACH 2.0 in HIV/AIDSDirector, CIHR Collaborative Centre for CBR in HIV