Abigail Kroch, of The OHTN, opens the HIV Endgame 3: Breakthrough Initiatives conference, sets the stage for the two-day conference, and highlights key HIV epidemiology data in Ontario.
The HIV Endgame logo appears on screen. Text reads: Setting the Stage HIV in Ontario. Abigail Kroch, PhD M.P.H. Director of Data and Applied Science Impact Ontario HIV Treatment Network. Abigail Kroch stands in front of a dais and presents a PowerPoint document. The PowerPoint document occupies the right 3/4 of the screen.
Abigail Kroch: It’s great to see all the friendly faces here today. And grateful to recognize many of you, but not all. I should say on behalf of the OHTN, thank you for the thank yous. We really appreciate it, and you’re welcome. But really we thank you because it’s the people in this room that inspire us to do this work. That challenge us. They bring their passion, their knowledge and their expertise. And working with all of you is what makes this job rewarding. And to know that we have made a difference in Ontario.
We will continue to make a difference. And we will see that conferences like this one will allow us to synergize our efforts to have even more impact for people in the community, and people living with HIV. So thank you all here today.
So I’m going to just show some data slides because that’s what I do, but just to put us all on the same page, to say like where are we looking at the epidemic? So I was asked to kind of highlight a few things that I thought were key, and some of those things are related to things that will happen at the conference, but there will be other things as well. I should disclose that I’m an OHTN employee.
So to understand the HIV epidemic in Ontario we have to think about the unique geography we have in Ontario. We have disproportionate burdens and new diagnoses that I’m gonna describe. We have structural barriers to HIV care and other health outcomes, and we have a complex landscape of social factors that drive health outcomes. So thinking about the social determinants and health equity, that’s something that really grounds the way that I think about my work.
So just in summary, to know that Toronto is not only the largest city, but it not only has a disproportionate burden of new cases, but also a higher rate for new infections. So when we think about Toronto as the epicentre of the epidemic, it’s not just because there are more people here, there is also a greater burden here in Toronto. But that doesn’t exclude the disproportionate burden for other outcomes in other parts of Ontario.
In particular when we look in northern communities and see lower HIV care outcomes. So I’m just highlighting some of the work that I’ve done with the Ontario HIV Epidemiology and Surveillance initiative. Some of my colleagues, I noticed from public health Ontario in the room, they house this data, they analyze this data, we work together very closely, that collaboration includes the AIDS Bureau who helped direct us, and make sure that our work informs policies and programs. We also work collaboratively with the public health agency of Canada, that helps us set the national context, but here just looking at the number of new diagnoses between 2016 and 2017, you can see those highest numbers in Toronto and a slightly greater number in 2017 than 2016.
And then when we look at this map, and this is from a great new report we have out online. I always encourage people to go and check out the OHESI website and sign up for our mailing list to get the hottest information off the press, but these maps show public health units and you can see that darker red is a higher rate. So when we think about rates, are the number of new diagnoses based on the population size.
So that the last slide was looking at the numbers. Here we see the highest rates. With the highest in Toronto, followed by Middlesex, London, and Ottawa. Also the highest number of people living with HIV. So when we think about HIV we think about new infections, but we also think about the healthcare system and the people who need care and treatment. So the number of people living with HIV we estimated in 2015 to be over 8,000 living in Toronto, with the next highest location being Ottawa.
When we look at the care cascade, and I’m just showing one outcome here, the percent of people who are diagnosed with HIV who are experiencing viral suppression. Those lighter areas are the areas that have lower viral suppression, so it’s very noticeable that although there are fewer people, which means that the data has more statistical variability. We see consistently in northern health units that their patients are experiencing lower viral suppression, and of course these are for people for whom we have information. If they’ve never gone in for a viral load test, then we have no idea what their outcomes are. So when we look at disproportionate burdens and new diagnosis, it remains the case that men who have sex with men have the most common exposure category. And we call those exposure categories, instead of modes of transmission because we don’t actually know what happens in people’s private lives or what they choose to do, but when people come in for a test they say I’m a mand and I’ve had sex with men in the past, and so we consider that an exposure of HIV, which is the likely mode of transmission of HIV.
Women still comprise 20 percent of the new diagnosis and actually around the same for people living with HIV. I think of particular importance is that African and Caribbean and black communities experience a disproportionate burden of new diagnosis. And that the recent increases, so when I showed you those numbers before and you saw that Toronto went slightly up those may be driven by out of province diagnosis, and I suggest you look at James Wilton’s presentation.
So here we’re just looking at the percent of new diagnoses by exposure category, and you can see MSM men who have sex with men in 2017, over 57 percent of new diagnoses were among men who have sex with men. And when we look at exposure categories these are mutually exclusive. So men who have sex with men who also use injection drugs, in 2017 were 3 percent new diagnoses. And this is where that information is known, which we collect on both the requisition form and follow-up information.
So here we’re looking at the disproportionate burden and new diagnosis by race ethnicity. And you can see that in the darker orange is the percent for new diagnoses, and this is where race is known, and then the lighter orange is for Ontario population. So although Ontario is 68 percent white, 46 percent of our new diagnoses are among white individuals. And when you look at black people, 26 percent of our new diagnoses were among black people, but only five percent of the Ontario population is black in the 2016 Ontario census. So we know we have many challenges to overcome, to ensure that people receive optimal health care, and optimal health.
The UN aids ninety ninety ninety targets are one way of assessing this. So in Ontario, we estimate that around 86 percent of people are who are living with HIV are diagnosed with HIV. Of those people treatment, and of those who are on antiretroviral treatment, 94 percent are people are virally suppressed. So what this means is that we get people tested, we get them diagnosed we get them on treatment, they have good outcomes and they can maintain viral suppression. But those challenges really are upstream in the pathway to ensure that we have timely diagnosis, and that we have timely access to antiretrovirals. So we know there are structural barriers, and a lot of these are going to be discussed today.
And this is a biased summary of some bullets of some of the presentations you’ll see but people in Ontario have challenges paying for the medications, in part due to our system of drug coverage. We know there are gaps in comprehensive services, including social and mental health services, that the clinic resources differ across the province, and that those may also be related to the differences and outcomes that we see, and you know every time we present the 90-90-90, we talk about the 10-10-10.
So who are the people that are falling out of these cracks through that process? And not only seeing that we have good viral suppression of those who are on ART, but we are doing everything we can to pull people into care and services who are falling out along the pathway, and that there are issues around access and medications, but also geographic cultural and social barriers that we should address. So there’s a complex landscape of social factors and HIV is no different than any other health outcome when we think about the social determinants of health and health inequity.
So a lot of the challenges that we have are the same challenges that other disciplines face but making sure that people are housed, have food. You can’t worry about your HIV meds when you don’t have food to eat. When we look at the factors associated with lower engagement in the OHTN cohort study we found that being younger, women and men who do not have sex with men, indigenous persons, people have lower income, people without drug coverage, people who lacked social support, mental health concerns, substance and alcohol use, those were all barriers to people being able to reach a suppressed viral load, and ultimately optimal health.
So some of the key issues that we’re gonna be thinking about are: How do we access prevention services? In particular PrEP across the province? We have some new data, and I think we’ll have some presentations on this as well in a poster about how PrEP is being rolled out across Ontario, and where some of the barriers lie for people. And thinking about the people living with HIV having experienced greater levels of violence and trauma, and how does that inform how we treat and care for them.
And there will be some sessions on that today. And then as people age, really thinking about HIV and ageing, and how multiple comorbidities and polypharmacy make it a real challenge, not just for the patient for managing their own self-care, but for physicians and other service providers, to know how to care. So what does all this mean?
I present numbers all day long and people often ask me, Now what? And I think the “Now what?” is today. Today is the “Now what”. So we know, what do we do next. So putting this knowledge into action, planning provincially but with local ideas and local context. Every time I present people want more data. And that’s a challenge for us, but it’s also an inspiration because that’s what we want. We want to give you the information that you need to do your job better. And preventing and treating across the epidemic, the past, the president, and the future. Those disproportionate burdens that we see, mean that our future epidemic may not look like our past epidemic.
So we need to be thinking about not just the who’s been and who’s acquired HIV in the past, but what’s gonna happen in the future, and how do we treat those people? Ensuring that our services are well designed and accessible to the people who need them most, and targeting those services based on the diversity of patient needs in Ontario.
I’d like to thank all of you for listening to me today, and for the opportunity needs to speak to you and have a great conference.
[Applause, fade to black.]
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