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University of Athens

Trends in HIV-1 incidence during an outbreak among injecting drug users in Athens, Greece: Results of a sero-behavioral survey (ARISTOTLE program).

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University of Athens

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  1. 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 Organisation Against Drugs University of Athens

  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 (LAgSedia™ 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. Participant arrives at ARISTOTLE site Description of the process 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 During these 5 rounds: • 7,110questionnaires 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 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 PWIDenter the population m: death rate - q: rate at which they cease to inject drugs βΙ/Ν: force of infection q q βΙ/Ν b S I m m

  12. 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)

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

  14. 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 2010 2011 2012 2013 2014

  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 OST coverage still suboptimal despite the increase observed during ARISTOTLE Test for trend:p<0.001

  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. 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) Funding • 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

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