Trends in HIV-1 incidence during an outbreak among injecting drug users in Athens, Greece: Results of a sero-behavioral survey (ARISTOTLE program) Sypsa V 1 , Nikolopoulos G 2 , Paraskevis D 1 , Katsoulidou A 1 , Kantzanou M 1 , Psichogiou M 3 , Pharris A 4 , Wiessing L 5 , Donoghoe M 6 , Friedman S 7 , Des Jarlais DC 8 , Malliori M 3 , Hatzakis A 1 1 National Retrovirus Reference Center, Medical School, University of Athens, Athens, Greece, 2 IAS/NIDA Fellow, Hellenic Center for Diseases Control and Prevention, Athens, Greece, 3 Medical School, University of Athens, Athens, Greece, 4 European Centre for Disease Prevention and Univers ity of Athens Organisati on Against Drugs
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Trends in HIV-1 incidence during an outbreak among injecting drug users in Athens, Greece: Results of a sero-behavioral survey (ARISTOTLE program)
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
University of
Athens
Organisation Against Drugs
Newly diagnosed cases of HIV-1 infections reported in Greece, 2000-2011
Cases of HIV-1 infection reported in IDUsTotal number of cases of HIV-1 infection reported in Greece
Surveillance data from the Hellenic Centre for Diseases Control and Prevention
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
ARISTOTLE programme
Sampling method: Respondent Driven Sampling (RDS) carried out in 5 rounds duringAugust 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
Participant arrives at
ARISTOTLE site
If valid coupon: Eligibility screening
If eligible: Consent process
If consent obtained: Interview & blood sample collection for HIV testing
At the end of the process:• Payment of primary
incentive • 3 coupons are provided• Syringes-leaflets are
provided
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
Description of the process
Sypsa et al. Am J Public Health, 2014Hatzakis et al, poster THPE103
The 5 rounds of ARISTOTLE
1533
681469 374 263
0
400
800
1200
1600
2000
In 1 round In 2 rounds In 3 rounds In 4 rounds All 5 rounds
Number of rounds they have participated
Num
ber of
per
sons
1787 PWID participated in multiple rounds
Round Time period Number of participants
A Aug2012 - Oct2012
1,415
B Dec2012 - Mar2013
1,444
C Mar2013 - Jun2013 1,434
D Jun2013 - Sep2012 1,413
E Sep2013 - Dec2013
1,407During these 5 rounds :7,110 questionnaires and
blood samples were obtained
3,320 unique persons participated to the programme
HIV prevalence per round:crude and weighted estimates
19.5%
16.5%17.3%
15.5%14.5%14.1%
12.0%13.5%
16.5%16.2%
0%
5%
10%
15%
20%
25%
A B C D E
RDS round
% a
nti-H
IV-1
(+)
Crude Weighted for RDS
Incidence of HIV infection
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
Using Lag testing 81% decrease in incidence from round A to round E
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
qβΙ/Ν
S
m
I
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
Estimating HIV incidence before Aristotle (2011-Aug2012)
Boost NSP/OST Aristotle
0
.02
.04
.06
.08
.1
.12
.14
.16
.18
.2
Fo
rce
of in
fect
ion
Jun10Aug10
Oct10Dec10
Feb11Apr11
Jun11Aug11
Oct11Dec11
Feb12Apr12
Jun12Aug12
Oct12Dec12
Feb13Apr13
Jun13Aug13
Oct13Dec13
TIME
Incidence from SI model (accounting for boost of NSP/OST)Projected incidence from SI modelIncidence estimates ARISTOTLE (midpoint of 4-month periods)
Force of infection
17.4
88% lower than that projected
by the model
0 0 0 2 2 2 14 2 2 1
16
2428
2327 29
18
26 26 27
44
26
35
23
34
26
42
116
86
77
2117
24
55
21
14 13
2419
2520 20 20
10 10 8 8 10
0
12 10
0
20
40
60
80
100
120
140
160
Nu
mb
er
of
new
ly d
iag
no
sed
cases i
n I
DU
s
rep
ort
ed
per
mo
nth
2010 2011 2012 2013 2014
Unique CRF sequence identified
• Origin of a new strain
• New outbreak• Potential role of
migrants• Transmission
pattern identified
• Ecological association with economic crisis
• Potential founders
Indication of spill over
EMCDDA Early Warning
October 2010
May 2011September-
October 2011
July 2011 January 2013
Transmission of resistance
August 2013
BOOST OF NSP & OST
ARISTOTLE
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) ?
% of ARISTOTLE participants reporting being currently on OST
OST coverage still suboptimal despite the increase observed during ARISTOTLE
11.5%
17.6%
22.7%25.2%
23.0%
0%
5%
10%
15%
20%
25%
30%
A B C D ERound
Test for trend:p<0.001
62.1%56.4%
61.8% 63.2%
49.3%
0%
20%
40%
60%
80%
100%
A B C D E
%
No syringes 1-10 syringes 11-20 syringes 21+ syringes
% reporting having received free syringes through prevention activities in the last month
During ARISTOTLE, there was no scale-up of needle and syringes programs
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
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)
Funding
Implemented under NSRF 2007-2013 (Operational
Programme "Human Resources Development" 2007-2013, Priority Axis 14-Attika, Central Macedonia,
Western Macedonia) and co-funded by European Social Fund
and national resources.(MIS 365008)
NGO PRAKSIS
Hellenic Scientific Society for the study of AIDS and STDs
Additional funding and support
NGO Positive Voice
TRIP: Preventing HIV Transmission by Recently-Infected Drug Users (NIDA Grant 1DP1DA034989))