Contribution of molecular virology to the understanding of the madagascan hiv epidemic
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Contribution of Molecular Virology to the Understanding of the Madagascan HIV Epidemic. F Lamontagne (1), G Lurton (1), S Andriantsimietry (2), ML Chaix (3), M Randria (4), J Nely (4), CB Ramamonjisoa (4), JS Lalao (4),

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Contribution of Molecular Virology to the Understanding of the Madagascan HIV Epidemic

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Contribution of MolecularVirology to the Understanding of the Madagascan HIV Epidemic

F Lamontagne (1), G Lurton (1), S Andriantsimietry (2), ML Chaix (3),

M Randria (4), J Nely (4), CB Ramamonjisoa (4), JS Lalao (4),

H Rahasana (4), F Huber (1), L Pizarro (1), RL Razanakolona (2),

C Rouzioux (3)

  • SOLTHIS NGO, Paris, France

  • National ReferenceLaboratory of HIV/STI, Antananarivo, Madagascar

  • APHP, Necker Hospital, Paris, France

  • BefelatananaTeachingHospital, Antananarivo, Madagascar 5. Diana RegionalHospital, Antsiranana, Madagascar 6. MahabiboHealth Center, Majunga, Madagascar 7. MenabeRegionalHospital, Morondava, Madagascar 8. Toamasina RegionalHospital, Madagascar


The paradoxes of madagascanepidemic

  • Numerousrisk factor for HIV transmission in general population (sexualbehavior, condom use, STI rate…)

  • Low HIV prevalence(0.2%,UNAIDS 2010)

  • None mostatrisk population clearlyidentified (exceptrecently MSM)

  • Concentratedepidemicsuspected

  • Intensive national VCT program

  • <10% of expected HIV population diagnosed

  • Many viral subtypes in previousstudies


Objective

  • Betterunderstanding of thisepidemic

  • Strategy:

    • Use of virological data

    • Confrontation with:

      • Socio-bevavioral profile

      • Place of residence


Method

Antsiranana (Diana)

Main ART sites

Majunga (Boeny)

Toamasina (Atsinana)

Morondava (Menabe)

Antananarivo (Analamanga)

Toliara

(Atsimoandrefana)


Method

HIV infected patients attending ART clinics

Antsiranana (Diana)

Main ART sites

Blood samplessystematicallycollected

Majunga (Boeny)

Jan/Apr 2008  86

Toamasina (Atsinana)

Morondava (Menabe)

Antananarivo (Analamanga)

Toliara

(Atsimoandrefana)


Method

HIV infected patients attending ART clinics

Antsiranana (Diana)

Main ART sites

Blood samplessystematicallycollected

Majunga (Boeny)

Jan/Apr 2008  86

Toamasina (Atsinana)

Aug/Sept 2010  74

Viral load

DR test (genotype)

Viral subtype

Phylogeneticanalysis

Morondava (Menabe)

Antananarivo (Analamanga)

Place of residence

Behavioralcharacteristics (MSM, sexworker, potential clients of sexworkers, migrant or partner of migrant)

Toliara

(Atsimoandrefana)


HIV diversity

  • N=160 subjects

  • N=118 with viral load>500 cp/ml

10 subtypes


Drug resistance

High level of HIVDR

  • N=160 subjects / N=118 with VL>500 cp/ml

  • N=35 viruseswith major HIV drugresistance (DR) mutations

p<0.001

79%

Poster A-403-0050-03391

High Level of Transmitted HIV Drug Resistance Caused by a Viral Cluster: The Singular Case of Madagascar


  • Distribution of viral subtypesby regions

Diana

1 A1, 16 B, 10 C, 3 CRF02, 1 CRF06, 6 non determined (ND)

Boeny

3 B, 16 C, 1 CRF06, 2 CRF15, 3 ND

Atsinana

2 B, 1 C, 1 D, 3 ND

Menabe

Analamanga

p<0.01

13 A1, 1 B, 1 C, 2 ND

5 A1, 1 A2, 8 B, 7 C, 1 F, 1 G, 2 CRF02, 6 ND

p<0.001


  • Behavioral profile

p<0.001

p<0.001

*sailors, miners, military staff, commercial drivers…


Multiple CorrespondenceAnalysis


Hierarchicalclustering

1

2

3

Others viruses

B viruses

A1 viruses


Multiple CorrespondenceAnalysis & Hierarchicalclustering

Others viruses

B viruses

A1 viruses


Relevant characteristics: B viruses

Phylogenetic tree

of subtype B viruses(N=17, 2008)

  • High HIVDR level (80%)

  • Frequency:

    • in Diana region (43%)

    • Among MSM (52%)

Poster A-403-0050-03391

High Level of Transmitted HIV Drug Resistance Caused by a Viral Cluster: The Singular Case of Madagascar

  • DR major mutations

  • 215 D

  • 215D+210W

  • Autres/Absence

98

96

96

B Ref

B Ref

B Ref

B Ref

B Ref


Relevant characteristics: A1 viruses

  • Absence of main behavioralrisksfactors for HIV (0%)

  • Mainlylocalized in Menaberegion (68%)

  • Geolocalization of PLWH fromMenabeRegion

Tarred road

Damagedtarred road

Track (non passable in rainyseason)

Residence of PLWH (proportional size)

Miandrivazo

Belo/Tsiribina

Morondava

Mahabo

Administrative centers

Manja


Conclusions

  • Confrontation of virologic and socio-behavioral data provided a new lighting

  • Madagascan epidemic appears composed by several sub-epidemics:

    • Of different origins (as shown by their viral subtypes)

    • With specific characteristics

  • This deeper understanding could help policy makers:

    • To develop more targeted testing and prevention programs

    • To adapt their treatment strategy

“know your virus,”

+

“know your epidemic,

know your response”


  • Acknowledgements


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