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

University of

Athens

Organisation Against Drugs

Newly diagnosed cases of HIV-1 infections reported in Greece, 2000-2011

18 15 17 11 11 19 16 9 9 14 16

492

406 397434 442

565 573517

653604 610

266

968

0

100

200

300

400

500

600

700

800

900

1000

1100

1200

1300

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Year

Nu

mb

er

of

ne

wly

dia

gn

os

ed

ca

se

s

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

Incidence rate (95% CI): 4.48 (3.34, 5.60) /100pyrs

Incidence rate estimate

Time interval Events

Time at risk(yrs)

Incidence (/100 pyrs)

95% CI

Aug-Dec2012 14 180 7.76 (4.60, 13.4)

Dec2012-Apr2013

18 306 5.88 (3.70, 9.33)

Apr-Aug2013 10 344 2.91 (1.57, 5.41)

Aug-Dec2013 3 175 1.71 (0.55, 5.31)

78% decrease

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

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ly d

iag

no

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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))