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HIV diagnoses in Ontario: Refinements to surveillance data in the 2018 reports

Summary

  • OHESI continues to refine and update the methods we use to improve our understanding of HIV transmission in Ontario.
  • Reporting on new HIV diagnoses in Ontario is important to 1) understand local transmission in Ontario and 2) best inform policy and planning services that can be tailored to all people living with HIV.
  • In an effort to better understand trends in HIV diagnoses, we report two diagnosis definitions:
    • “New HIV diagnoses” consist of all new diagnoses including 1) first-time diagnoses as well as 2) people with previous evidence of HIV – that is, people who already knew their status at the time of their first positive nominal diagnostic test in Ontario
    • “First-time diagnoses” removes people with previous evidence of HIV, including a documented previous HIV diagnosis outside of Ontario and/or viral load test history within Ontario.
  • People who know their HIV-positive status may be retested later on and not all of these repeated tests can be linked to their prior test results. A test cannot be linked to previous result when:
    • Their first positive test was done outside Ontario.
    • Their first positive test in Ontario was coded or anonymous.
    • o They have changed their name or OHIP number.
  • In 2018, there were 1,003 new HIV diagnoses in Ontario. As a result of removing diagnoses with previous evidence of HIV, there were 738 first-time HIV diagnoses in 2018.

What’s new in the 2018 HIV diagnosis surveillance data?

A more accurate picture of people diagnosed or entering care for HIV in Ontario and people who are learning their HIV diagnosis for the first time.

New HIV diagnoses in Ontario

We report on new HIV diagnoses in Ontario to inform policy and planning services that can be tailored to all people living with HIV. New HIV diagnoses include all HIV-positive diagnoses in Ontario. A new HIV diagnosis is not the same as a new infection. Most people living with HIV are not diagnosed in the same year they became infected with the virus.

The new HIV diagnosis definition includes 1) first-time diagnoses and 2) people who have previous evidence of HIV. Individuals with previous evidence of HIV either 1) had an HIV-positive diagnosis outside of Ontario and later retested in Ontario (as recorded on the test history section of the laboratory enhancement program (LEP) case report form or the test requisition form), or 2) had a history of viral load testing in Ontario (without a recorded and linked prior confirmatory diagnostic test in Ontario).

Recent trends in new HIV diagnoses could be due to changes in testing programs, local HIV transmission and/or migration.

First-time HIV diagnoses in Ontario

First-time diagnoses are new HIV diagnoses with no previous evidence of HIV. We look at this number to better understand which diagnoses are likely due to local transmission in Ontario and, therefore, what populations might be at most risk and benefit most from prevention activities. We report on first-time diagnoses separately to better understand local transmission.

First-time diagnoses exclude anyone with a previous positive diagnostic test as indicated on the LEP form, regardless of the location of the previous positive test (inside or outside of Ontario). It also uses linked viral load testing history in Ontario as evidence of being in care for HIV and so excludes 1) anyone with a history of viral load testing in Ontario of more than 30 days before a first diagnostic positive test and 2) anyone with viral load testing in Ontario within 30 days (including same day) with a viral load <200 copies/mL.

Both the new HIV diagnoses and first-time HIV diagnoses definitions include individuals who reside in another province but test HIV-positive in Ontario. Both definitions exclude duplicates – that is, a diagnosis with a documented history of a previous HIV diagnosis within Ontario. Duplicates can be recognized by lab records or the test history section of the LEP/HIV test requisition form indicating a previous positive in Ontario.

Why do some new diagnoses have previous evidence of HIV (PEH)?

HIV diagnoses with previous evidence of HIV include both 1) people who may be new to the province who already knew their HIV-positive status and have a confirmatory HIV test in Ontario and 2) people who may have been infected in Ontario and have been living and receiving care in the province but have no prior linked confirmatory diagnostic test in Ontario. Excluding these individuals better reflects who is testing to learn their status and, therefore, which people might be at greater risk of HIV transmission in Ontario today.

People move to Ontario

People who move to Ontario from another province or country and already know their HIV-positive status can be retested when they arrive in the province. Some reasons for retesting could include immigration, insurance, entering care. This information is most often captured in their testing history when they retest in Ontario. These individuals were initially diagnosed (and likely infected) outside of Ontario. We refer to these new diagnoses as ‘out-of-province’ and they are counted as new diagnoses with PEH.

People have previous viral load testing history in Ontario

Some people have a linked history of viral load testing in Ontario before having a positive nominal diagnostic test in Ontario. These people already received care for HIV in Ontario. Possible reasons a person may not have a linked diagnostic test prior to having viral load testing include (but are not limited to):

  1. A diagnostic test was ordered for someone who had been in care and knew they were living with HIV (e.g., by a new clinic or new clinician)
    • Their first diagnostic test in Ontario was done as an anonymous or coded test (and therefore unlinked) or for some other reason it was not possible to link their historical diagnostic test with their viral load results.
    • They had a nominal diagnostic test but had a name or OHIP number change, so their first diagnostic and viral load tests couldn’t be linked.
    • They were diagnosed outside of Ontario and a diagnostic test was not ordered when they initially entered care in Ontario.
  2. A viral load test was ordered for someone who did not know their HIV status and subsequently had a diagnostic test.

What are the trends in new HIV diagnoses and first-time HIV diagnoses in Ontario?

The number of new diagnoses and the number of first-time HIV diagnoses in Ontario between 2009 and 2018 are shown in the figure below.

Figure 1. The number of new HIV diagnoses and first-time HIV diagnoses, Ontario, 2009 to 2018

There were 1,003 new HIV diagnoses in Ontario in 2018. After excluding diagnoses with previous evidence of HIV, there were 738 first-time HIV diagnoses in Ontario in 2018. The number of new HIV diagnoses in Ontario was lowest in 2013 and has increased each year from 2013 to 2018. Over that time period, there was a larger increase in the number of diagnoses with previous evidence of HIV. First-time diagnoses have been relatively stable since 2013.

Considerations about our definitions and surveillance data

  • Excluding previous positive diagnoses in Ontario (duplicates) is only possible when previous HIV-positive tests can be linked. Reasons for unlinked data include an individual having one (or more) anonymous or coded HIV tests prior to their nominal test. Another reason could be because the ‘testing history’ section on the LEP form is either missing or not filled out correctly. Approximately 50% of new diagnoses have both the LEP forms returned and the test history section complete.
  • When an individual has a history of viral load testing, they may have already received a diagnostic test in Ontario that could not be linked to their viral load tests. That first diagnostic test could have been anonymous, coded, or unable to be linked for some other reason. When this person is included because they’ve received a new diagnostic test, they may be counted twice in the data, at the time of their first diagnosis and their new diagnostic test. These individuals are counted as a new diagnosis but removed as a first-time diagnosis.

What is surveillance data and what does it tell us?

  • Public health surveillance collects, analyzes, and disseminates health-related data to help monitor, provide information to, and improve the health of populations.
  • Information from surveillance data can be used to monitor the burden of a disease and detect changes over time (trends and outbreaks), and help inform and guide prevention and intervention programs.
  • Surveillance data can give insight into which populations are at risk for HIV, including demographic information, risk factors, and clinical factors of people newly diagnosed.
  • The Ontario HIV Epidemiology and Surveillance Initiative (OHESI), a collaboration between Public Health Ontario, the Ontario HIV Treatment Network, the Ontario Ministry of Health and Public Health Agency of Canada, is dedicated to providing the most accurate HIV surveillance data for Ontario.
  • By refining the HIV diagnosis definition, OHESI aims to report the best estimate of the actual number of first-time HIV-positive diagnoses in Ontario, as well as improve our interpretation of local transmission and trends over time.

Getting an HIV test in Ontario

  • Data on new HIV diagnoses come from the laboratory at Public Health Ontario (PHO), which conducts all HIV diagnostic testing requested by health care providers in Ontario.
  • When someone gets an HIV test in Ontario, the health care provider ordering the test (e.g. a physician or HIV counsellor) fills out a form that is sent to PHO. This form, known as an HIV test requisition, collects information on the individual being tested, including their sex, age and HIV risk factors. As of 2018, the HIV test requisition form also collects data on race/ethnicity, country of birth, transgender identity and expands answer options in the ‘reason for testing’ and ‘previous test information’ sections.
  • If the result of the HIV test is positive, the Laboratory Enhancement Program (LEP) sends a second form to the provider who ordered the test to collect more information or information that may have been missed on the first form. Since 2009, the LEP form has collected information on race/ethnicity, country of birth, and test history (data not historically collected on the HIV test requisition).
  • The test history question on the LEP form asks if the individual who tested HIV-positive had ever had a previous positive HIV test and, if so, if this previous positive test was performed in Ontario or out of province.
  • Information reported on the HIV test requisition and the LEP form is used to refine the new HIV diagnoses definitions.

Factsheet

HIV testing and diagnosis in Ontario, 2018

In this factsheet, OHESI reports on the trends of HIV testing and diagnoses in Ontario over the past decade, with an emphasis on new diagnoses in 2018.

Download factsheet

Diagnostics de VIH en Ontario : améliorations apportées aux données de surveillance dans les rapports de 2018

Sommaire

  • L’Initiative ontarienne d’épidémiologie et de surveillance du VIH (OHESI) continue d’affiner et de mettre à jour les méthodes qu’elle utilise pour améliorer la compréhension de la transmission du VIH en Ontario.
  • Les rapports de déclaration des nouveaux diagnostics de VIH en Ontario sont importants pour (1) comprendre la transmission locale en Ontario et (2) éclairer le mieux possible les politiques et la planification de services adaptables pour toutes les personnes vivant avec le VIH.
  • Afin de mieux saisir les tendances dans les diagnostics de VIH, nous faisons état de deux définitions de diagnostics :
    • Les « nouveaux diagnostics de VIH », qui comprennent tous les nouveaux diagnostics, incluant (1) les premiers diagnostics ainsi que (2) les personnes qui avaient déjà des indications de VIH (c’est-à-dire qui connaissaient leur séropositivité au moment de leur premier test diagnostique nominatif en Ontario).
    • Les « premiers diagnostics », une définition qui exclut les personnes qui avaient déjà des indications de VIH, y compris des diagnostics antérieurs documentés hors Ontario, et/ou des antécédents de test de charge virale en Ontario.
  • Des personnes qui connaissent leur séropositivité au VIH peuvent être de nouveau dépistées, ultérieurement, et ces tests répétés peuvent ne pas être tous reliés aux résultats antérieurs. Il n’est pas possible de relier un test à un résultat antérieur lorsque :
    • Le premier dépistage ayant livré un résultat positif a été effectué hors de l’Ontario.
    • Le premier dépistage ayant livré un résultat positif était codé (non nominatif) ou anonyme.
    • La personne a changé de nom ou de numéro de carte Santé (OHIP).
  • En 2018, il y a eu 1 003 nouveaux diagnostics de VIH en Ontario. Comme conséquence de la distinction avec les cas de diagnostics pour lesquels il existait déjà des indications de VIH, nous savons qu’il y a eu 738 premiers diagnostics de VIH en 2018.

Quoi de neuf dans les données sur la surveillance des diagnostics de VIH en 2018?

Un portrait plus précis des personnes diagnostiquées ou amorçant des soins pour le VIH en Ontario et des personnes qui apprennent pour la première fois leur diagnostic de VIH.

Nouveaux diagnostics de VIH en Ontario

Nous faisons état des nouveaux diagnostics de VIH en Ontario afin d’éclairer le mieux possible les politiques et la planification de services adaptables pour toutes les personnes vivant avec le VIH. Les diagnostics de VIH incluent tous les diagnostics positifs pour le VIH en Ontario. Un nouveau diagnostic n’est pas la même chose qu’une nouvelle infection. La plupart des personnes qui vivent avec le VIH ne sont pas diagnostiquées l’année même où elles ont contracté l’infection.

La définition de nouveau diagnostic de VIH inclut : (1) les premiers diagnostics ainsi que (2) les personnes qui avaient déjà des indications de VIH. Les personnes ayant des indications antérieures de VIH avaient soit (1) reçu un diagnostic positif pour le VIH hors de l’Ontario puis elles ont été testées plus tard en Ontario (tel que mentionné dans la section des antécédents de dépistage du rapport de cas du Laboratory Enhancement Program (LEP) [Programme de bonification des données de laboratoire] ou dans le formulaire de demande de test); soit (2) des antécédents de test de charge virale du VIH en Ontario (sans pour autant avoir passé en Ontario un test relié et déclaré de confirmation diagnostique).

Les récentes tendances des nouveaux diagnostics de VIH pourraient être attribuables à des changements aux programmes de dépistage, à la transmission locale du VIH et/ou à la migration.

Premiers diagnostics de VIH en Ontario

Les premiers diagnostics sont de nouveaux diagnostics de VIH dépourvus d’indication antérieure de VIH. Nous utilisons ce nombre pour mieux comprendre quels diagnostics sont probablement dus à la transmission locale du VIH en Ontario – et par conséquent quelles populations pourraient être les plus à risque et bénéficier le plus des activités de prévention. Nous faisons état des premiers diagnostics de façon séparée afin de mieux comprendre la transmission locale.

Les premiers diagnostics excluent toute personne qui a reçu un diagnostic antérieur comme indiqué dans le formulaire du LEP, quel que soit le lieu d’origine du test positif antérieur (en Ontario ou ailleurs). En tenant compte également des antécédents reliés de test de la charge virale en Ontario en tant que preuve de l’obtention de soins pour le VIH, nous excluons également de ce nombre (1) toute personne ayant des antécédents de test de la charge virale en Ontario remontant à plus de 30 jours avant le test positif du premier diagnostic; et (2) toute personne obtenant un test de charge virale dans une période de 30 jours (y compris le jour même) et dont la charge virale est de <200 copies/ml.

Les deux définitions, nouveaux diagnostics de VIH et premiers diagnostics de VIH, incluent des personnes d’autres provinces qui reçoivent un résultat positif au dépistage du VIH en Ontario. Les deux définitions excluent les doublons – c’est-à-dire les diagnostics pour lesquels il existe un antécédent documenté d’un diagnostic antérieur de VIH en Ontario. Les doublons peuvent être repérés dans les dossiers de laboratoire ou la section des antécédents de dépistage dans le formulaire du LEP ou de demande de test indiquant la réception d’un résultat positif antérieur en Ontario.

Pourquoi certains nouveaux diagnostics s’accompagnent-ils d’une indication antérieure de VIH (IAV)?

Les diagnostics de VIH comportant des indications antérieures de VIH incluent (1) des personnes qui pourraient être nouvellement arrivées dans la province, qui connaissaient déjà leur séropositivité au VIH et qui font un test de confirmation du VIH en Ontario et (2) des personnes qui ont pu contracter le VIH en Ontario et qui vivent dans la province et y reçoivent des soins, mais sans avoir pour autant passé de test relié de confirmation diagnostique en Ontario. L’exclusion de ces cas indique plus clairement quelles personnes se font dépister pour découvrir leur statut VIH et, par conséquent, quelles personnes pourraient être plus à risque de contracter le VIH en Ontario aujourd’hui.

Des personnes déménagent en Ontario

Des personnes qui déménagent en Ontario en provenance d’une autre province ou d’un autre pays et qui connaissent déjà leur séropositivité au VIH peuvent être dépistées de nouveau pour le VIH à leur arrivée dans la province. Certaines des raisons de ce dépistage additionnel peuvent avoir trait à l’immigration, aux assurances et à l’entrée dans les soins. La plupart du temps, cette information est incluse dans la description des antécédents de dépistage de la personne, lorsqu’elle refait le dépistage en Ontario. Ces personnes ont été initialement diagnostiquées (et probablement infectées) hors de l’Ontario. Nous appelons ces nouveaux diagnostics « hors province » et ils sont comptés comme de nouveaux diagnostics comportant des IAV.

Des personnes ont des antécédents de test antérieur de la charge virale en Ontario

Certaines personnes ont un dossier relié d’antécédents de test de la charge virale en Ontario avant de recevoir un résultat positif à un test diagnostique nominatif en Ontario. Ces personnes ont déjà reçu des soins pour le VIH en Ontario. Les raisons pouvant expliquer qu’une personne n’a pas passé de test diagnostique relié avant de passer des tests de charge virale incluent les suivantes (et d’autres) :

  1. Un test diagnostique a été commandé pour une personne recevant des soins et connaissant déjà sa séropositivité (p. ex., par une nouvelle clinique ou un nouveau médecin)
    • Son premier test diagnostique en Ontario avait été fait en mode anonyme ou codé [non nominatif] et n’avait donc pas été relié – ou pour une autre raison il n’avait pas été possible de relier son test diagnostique antérieur et ses résultats de mesure de la charge virale.
    • Elle avait reçu un test diagnostique nominatif, mais a changé de nom ou de numéro de carte Santé (OHIP) depuis ce temps, donc son premier diagnostic et ses tests de charge virale n’ont pas pu être reliés.
    • Elle a été diagnostiquée en Ontario mais n’a pas passé de test diagnostique lorsqu’elle a amorcé des soins en Ontario.
  2. Un test de la charge virale a été commandé pour une personne alors qu’elle n’était pas au courant de son statut VIH positif et elle a passé ultérieurement un test diagnostique.

Quelles tendances s’observent dans les nouveaux diagnostics et les premiers diagnostics en Ontario?

Le nombre de nouveaux diagnostics et le nombre de premiers diagnostics de VIH en Ontario entre 2009 et 2018 sont illustrés dans la figure ci-dessous.

Figure 1. Nombre de nouveaux diagnostics de VIH et de premiers diagnostics de VIH, Ontario, de 2009 à 2018

En 2018, les nouveaux diagnostics de VIH en Ontario ont été au nombre de 1 003. Après l’exclusion des diagnostics comportant des indications antérieures de VIH, le nombre de cas de premier diagnostic de VIH en Ontario en 2018 est de 738. Le nombre de nouveaux diagnostics de VIH en Ontario a été à son plus bas en 2013 et a augmenté chaque année de 2013 à 2018. Pendant cette période, il y a eu une augmentation plus importante du nombre de diagnostics comportant des indications antérieures de VIH. Le nombre de premiers diagnostics est demeuré relativement stable depuis 2013.

Considérations relatives à nos définitions et données de surveillance

  • L’exclusion des diagnostics positifs antérieurs en Ontario (les doublons) n’est possible que si les tests antérieurs dont le résultat avait été positif peuvent être reliés. Les causes de données non reliées incluent la situation où un individu passe un test anonyme ou codé, avant son dépistage nominatif. Une autre raison possible peut être que la section « antécédents de test » dans le formulaire du LEP est absente ou n’a pas été remplie adéquatement. Le formulaire du LEP est reçu avec sa section sur les antécédents de test dûment remplie dans approximativement 50 % des nouveaux diagnostics effectués.
  • Lorsqu’un individu a des antécédents de test de la charge virale, il se peut qu’il ait déjà passé un test diagnostique en Ontario qui n’a pu être relié à ses tests de la charge virale. Ce premier test diagnostique a pu être anonyme, codé, ou impossible à relier pour d’autres raisons. Lorsque cet individu est inclus, parce qu’il a passé un nouveau test diagnostique, il se peut qu’il ait été compté deux fois dans les données – soit au moment de son diagnostic antérieur et de son nouveau dépistage. Ces individus sont comptés comme étant de nouveaux diagnostics, mais sont exclus du nombre de premiers diagnostics.

Que sont les données de surveillance et que nous indiquent-elles?

  • Les initiatives de surveillance de santé publique collectent, analysent et disséminent des données relatives à la santé pour aider au suivi de la santé des populations, pour fournir de l’information à celles-ci et pour contribuer à améliorer leur santé.
  • L’information issue de ces données peut servir à surveiller le fardeau relatif à une maladie, à déceler des changements au fil du temps (tendances et flambées de transmission) et à éclairer et orienter les programmes de prévention et d’intervention.
  • Les données de surveillance peuvent permettre de mieux cerner quelles populations sont à risque pour le VIH, y compris les caractéristiques démographiques, facteurs de risque et facteurs cliniques des personnes nouvellement diagnostiquées.
  • L’Initiative ontarienne d’épidémiologie et de surveillance du VIH (OHESI) – une collaboration entre Santé publique Ontario, le Réseau ontarien de traitement du VIH, le ministère de la Santé de l’Ontario et l’Agence de la santé publique du Canada – s’efforce de fournir les données de surveillance les plus précises possible, pour l’Ontario.
  • En affinant la définition des diagnostics de VIH, l’OHESI vise à estimer le mieux possible le nombre réel de personnes diagnostiquées du VIH pour la première fois, en Ontario, et à améliorer notre interprétation de la transmission locale et des tendances dans le temps.

Se faire dépister pour le VIH en Ontario

  • Les données sur les nouveaux diagnostics de VIH viennent du laboratoire de Santé publique Ontario (SPO), qui effectue tous les tests diagnostiques pour le VIH demandés par des fournisseur(-euse)s de soins de santé de l’Ontario.
  • Lorsqu’une personne se fait dépister pour le VIH en Ontario, le ou la professionnel-le des soins de santé (p. ex., un médecin ou un-e conseiller(-ère) en VIH) qui demande le test remplit un formulaire qui est envoyé à SPO. Ce formulaire, aussi appelé réquisition de dépistage du VIH, consigne de l’information sur l’individu concerné, y compris son sexe, son âge et ses facteurs de risque pour le VIH. Depuis 2018, le formulaire de réquisition de dépistage du VIH collecte également des données sur la race/origine ethnique, le pays de naissance et l’identité transgenre, en plus d’élargir les options de réponses aux questions « raison du dépistage » et « information de dépistage antérieur ».
  • Si le résultat du dépistage du VIH est positif, le Laboratory Enhancement Program (LEP) transmet un deuxième formulaire à l’intervenant-e qui a demandé le test, de manière à collecter plus d’informations ou à demander des informations qui auraient été omises dans le premier formulaire. Depuis 2009, le formulaire du LEP collecte de l’information sur la race/origine ethnique, le pays de naissance et les antécédents de dépistage (des renseignements qui n’étaient jusqu’ici pas collectés dans le formulaire de réquisition de dépistage).
  • La question sur les antécédents de dépistage, dans le formulaire du LEP, demande si l’individu dont le dépistage est positif a reçu antérieurement un résultat positif à un dépistage du VIH et, le cas échéant, si ce dépistage positif antérieur avait été effectué en Ontario ou à l’extérieur.
  • L’information déclarée dans le formulaire de réquisition de dépistage du VIH et dans le formulaire du LEP est utilisée pour affiner les définitions de « nouveaux diagnostics ».

Feuillet d’information

Dépistage et diagnostic du VIH en 2018

Dans le feuillet d’information sur le dépistage et le diagnostic du VIH en 2018, l’OHESI fait état des tendances du dépistage et du diagnostic du VIH en Ontario au cours de la dernière décennie, avec un point de mire sur les nouveaux diagnostics en 2018.

Lire le feuillet d’information

OHESI shares OHTN report on HIV pre-exposure prophylaxis (PrEP) use in Ontario

OHESI would like to share a newly released report by The Ontario HIV Treatment Network (OHTN) titled “HIV pre-exposure prophylaxis in Ontario”.

View report

HIV pre-exposure prophylaxis (PrEP) is the use of daily antiretroviral medications by HIV-negative individuals to reduce their risk of HIV infection. PrEP is a highly effective HIV-risk reduction strategy and a critical part of a comprehensive approach to HIV prevention. It is important to monitor PrEP uptake to provide information to improve access and identify implementation gaps. However, Ontario does not currently have a provincial-level monitoring system for PrEP. To fill this gap, the OHTN is using pharmacy data on PrEP prescriptions to summarize PrEP uptake in Ontario between 2015 to 2018.

This report contains projected provincial-level estimates based on PrEP medication dispensation data from more than 2,000 pharmacies across Ontario. The estimated number, percent or rate of PrEP users is described overall, by sex, age, prescriber specialty, payment type and by region between July 2015 to June 2018. The estimated number of physicians prescribing PrEP by prescriber’s region between March 2018 to February 2019 is also described.

Key findings of the report include:

  • By mid-2018, approximately 3,000 people were on PrEP in Ontario: an 8-fold increase from mid-2015 (estimated 374 PrEP users).
  • Between mid-2015 and mid-2018, the vast majority (97%) of PrEP users were male.
  • While males in the 30-39 age category consistently made up the greatest proportion of PrEP users, the greatest relative increase in male PrEP users between 2015 to 2018 was in the 19-29 age category.
  • In the middle of 2018, the majority of estimated PrEP users were prescribed PrEP by family and general practitioners (68%), followed by infectious disease (14%), and internal medicine (5%) physicians.
  • While approximately 77% of PrEP users used private insurance to cover the cost of the medications in mid-2018, the proportion of PrEP users using public coverage increased between 2015 and 2018as more public coverage became available.
  • By mid-2018, almost 60% of the estimated PrEP users were dispensed PrEP from a pharmacy in the Toronto core region but between 2015 to 2018 the relative increases were greatest in regions outside Toronto core.
  • Over 700 physicians prescribed PrEP at least once between March 2018 and February 2019, over 40% of whom were located in the Toronto core region.

OHESI releases new report on HIV testing in Ontario 2017

The Ontario HIV Epidemiology and Surveillance Initiative (OHESI) is pleased to announce the release of a new report titled “HIV testing in Ontario, 2017”.

View report

Reporting on HIV testing data in Ontario is critical to measuring our success in the HIV prevention, engagement and care cascade. A robust testing program ensures that high risk individuals receive regular HIV tests and that people who are living with HIV can learn their status and be linked to care. HIV testing is also an important gateway to services for people who are HIV-negative to be linked to prevention services. Trends in HIV testing can be useful for measuring the success of HIV testing initiatives.

In the 2017 HIV Testing Report, OHESI describes the trends in HIV testing in Ontario over the past decade (2008-2017), with a focus on HIV tests in 2017. The report includes analyses broken down by type of test (nominal, coded, and anonymous), sex, age, HIV exposure category, and geographic location (health regions), as well as information specific to rapid/point-of-care (POC) and prenatal HIV testing. Metrics described in the report include the number and percent of HIV tests, rates of HIV tests per 1,000 people, and HIV test positivity rates (i.e. the percent of HIV diagnostic tests with a confirmed HIV-positive result), among other analyses. For more information on HIV diagnoses in Ontario, please see the OHESI new report on HIV diagnoses in Ontario, 2017

Some of the key findings of the report:

  • In 2017, there were 574,035 HIV tests in Ontario – equivalent to an HIV testing rate of 40.4 tests per 1,000 people.
  • While the number of tests conducted remained relatively stable between 2008 and 2013, it increased by 29.9% between 2013 and 2017. The HIV testing rate per 1,000 people also increased by 24.1% during this time.
  • In 2017, the vast majority of HIV tests (95.9%) – including POC tests – were nominal and the remainder were coded (1.6%) or anonymous (2.5%).
  • In recent years, the number and rate of HIV tests were similar among males and females. In 2017, 50.1% of people tested were males and 49.9% were females. For the first time in 2017, the number of HIV tests among males was greater than the number of HIV tests among females.
  • Between 2013 to 2017, the rate of HIV tests per 1,000 people was consistently highest in the 25 to 29 age category and increased for all age groups over time. Over this time period, the HIV testing rate per 1,000 people increased for all age groups by an average of 25%.
  • Between 2013 and 2017, the percent of HIV tests in males attributed to men who have sex with men (MSM) increased from 23.7% to 30.9%.
  • In 2017, the HIV testing rate per 1,000 people was highest in Toronto (68) followed by Ottawa (46). The number of HIV tests and the HIV testing rate increased between 2016 and 2017 in all health regions.
  • Between 2013 and 2017, the number of point-of-care (POC) tests decreased by 31.7% from 29,362 to 20,068 through more targeted testing to priority populations, while the POC test positivity rate increased from 0.47% to 0.59%.
  • Between 2013 and 2017, the estimated number of prenatal HIV tests was stable and the estimated proportion of women receiving prenatal laboratory testing who had an HIV test increased from 97.3% to 97.8%.

The information in this report can also be found in the Data and figures section of the OHESI website.

Stay tuned for future reports from OHESI!

OHESI releases new report on HIV diagnoses in Ontario 2017

The Ontario HIV Epidemiology and Surveillance Initiative (OHESI) is pleased to announce the release of a new report titled “New HIV diagnoses in Ontario, 2017”.

View Report 

This report describes, updates and expands on the trends in HIV diagnoses in Ontario over the past decade (2008-2017) with a focus on new HIV diagnoses in 2017. It presents analyses by sex, age, race/ethnicity, geographic location and priority populations (i.e. subgroups of Ontarians who experience a higher risk of HIV).

This report is the first to use data from the Laboratory Enhancement Program (LEP) to better understand trends in new HIV diagnoses in Ontario. This new information allowed us to:

  • reduce double counting by removing HIV diagnoses with a documented history of a previous HIV-positive test result within Ontario
  • Identify HIV diagnoses with a documented history of a previous HIV-positive test result outside of Ontario (‘out-of-province’ diagnoses). These individuals were initially diagnosed (and likely infected) outside of the province, and then moved to Ontario and were tested again. To help target prevention programs, it is important to exclude these diagnoses for some analyses. At the same time, it is important to report on all new HIV diagnoses so the health system can plan services for all people living with HIV in the province.

 

A few key findings of the report include:

  • The number of new HIV diagnoses has increased each year since 2014. In 2017, there were a total of 916 new HIV diagnoses. When ‘out-of-province’ diagnoses were removed, there were 797 new HIV diagnoses.
  • Gay, bisexual and other men who have sex with men still account for the largest proportion of HIV diagnoses while women account for approximately 1 of 5 new HIV diagnoses.
  • Between 2012 to 2017, the proportion of new HIV diagnoses has decreased among White men and increased among Black men while, over the same period, the proportion of new diagnoses has increased among White women and decreased among Black women.
  • Toronto has the highest number and rate of new HIV diagnoses in Ontario, almost twice the rate of the next highest health region (Ottawa).

 

Stay tuned for the 2017 HIV Testing Report, coming soon!

 

OHESI releases Women & HIV in Ontario factsheet

We are excited to announce the release of a factsheet about women and HIV in Ontario. This factsheet was developed in collaboration with the Women & HIV/AIDS Initiative (WHAI), the Ontario HIV Epidemiology and Surveillance Initiative (OHESI), and the OHTN Cohort Study (OCS). The purpose of this factsheet is to highlight which women are most at risk for HIV and the service needs and challenges for women living with HIV in Ontario.

Download Women & HIV in Ontario factsheet.

The intent of the fact sheet is not to be exhaustive, but to provide an overview of the key issues we must address to end the HIV epidemic for women in Ontario. The information is gathered from multiple sources, including surveillance data, communicated research findings, published literature, and conference proceedings. We included the most recent and rigorous data available to draw attention to specific issues.

We hope this factsheet helps support the development and implementation of services and policies that meet the needs and priorities of women living with or at risk of HIV.

For more information on WHAI or to contact a WHAI coordinator, visit WHAI.ca
For more information on the OHTN Cohort Study (OCS), visit ohtncohortstudy.ca

OHESI releases new factsheet to mark World AIDS Day 2018

World AIDS Day provides an opportunity to remember those who lost their lives to HIV/AIDS, educate people about the impacts and prevention of HIV infection, celebrate our accomplishments, and support those in the continued fight against the pandemic. Today we release a new OHESI factsheet to commemorate World AIDS Day.

Download 2017 Testing and Diagnosis factsheet.

Over the course of the Ontario epidemic, HIV infections have declined and outcomes have improved, but new infections persist. Our continued effort is necessary to reduce the number of people affected by HIV and the disproportionate burden experienced by those at greatest risk (priority populations). The Ontario HIV Epidemiology and Surveillance Initiative (OHESI) plays a critical role by providing information that informs effective policies and programs in Ontario.

This factsheet includes an update for 2017 testing and diagnosis data. In summary, HIV testing in Ontario continues to increase with testing rates similar for males and females. There were 916 new diagnoses in Ontario; these diagnoses include a number of individuals originally diagnosed (and who likely became infected) elsewhere and later moved to Ontario and tested again. Excluding those previously diagnosed out of province, there were 797 new diagnoses. Regional breakdowns and breakdowns for males and females, by age and priority population, are included on the factsheet.

World AIDS Day brings us together to remember those who have passed on, to share knowledge, and to support the response to HIV/AIDS. We support this event with reinvigorated optimism and a strategy for the future.

Please join the OHESI mailing list to have access to the most up to date information on HIV/AIDS in Ontario.

OHESI releases new report presenting HIV indicators by public health unit

OHESI is pleased to announce the release of a new technical report: HIV in Ontario by public health unit: Testing, new diagnoses and care cascade.

Download the report on “HIV in Ontario by public health unit.”

Timely, relevant HIV epidemiological data are critical for public health units (PHUs) to monitor their local HIV epidemic, and to plan and evaluate local health promotion and prevention programs. PHU-level data is not only important for the health units themselves, but also for AIDS Service Organizations and other community-based organizations whose catchment areas may be better represented by these smaller geographic boundaries.

This newly released report is the first OHESI knowledge product to present HIV indicators at the PHU level. The data included in the report span the breadth of the HIV prevention, engagement and care cascade and include testing and diagnosis, as well as later care cascade indicators (i.e., the percent of diagnosed individuals who are in care, on antiretroviral treatment and virally suppressed). These indicators were derived from databases at the laboratory at Public Health Ontario.

A few key findings of the report include:

  • Diagnoses were distributed unevenly across Ontario and there were relatively small numbers in most PHUs. Between 2013 and 2017, the cumulative number of diagnoses ranged from 2,220 in Toronto to zero in Huron County, and there were fewer than 25 cumulative diagnoses in 21 PHUs.
  • Toronto and Middlesex-London had the highest diagnosis and positivity rates, followed by Ottawa, Hamilton and Windsor-Essex (not necessarily in that order).
  • While test rates were generally similar by sex in each PHU, diagnosis rates were higher for males than females in almost all PHUs. The overall diagnosis rate was four times higher for males than females.
  • PHUs with the largest numbers of diagnosed people living with HIV (for example, Toronto, Ottawa, Peel, Hamilton, Middlesex-London) generally ranked in the middle to lower end in terms of the measures of engagement in the HIV care cascade (i.e., the percent who were in care, on antiretroviral treatment or virally suppressed).

We hope you find the data in this report useful. Moving forward, OHESI aims to produce similar reports in the future.

OHESI releases factsheet summarizing Ontario’s HIV care cascade

This new knowledge exchange product is OHESI’s first factsheet and summarizes data from two previously published OHESI technical reports titled ‘HIV care cascade in Ontario‘ and ‘HIV care cascade in Ontario by sex, age and health region‘. These cascade data include the number of people who are living with diagnosed HIV in Ontario and the percent who are in care, on antiretroviral treatment and virally suppressed. Click here to check out the factsheet.

Stay tuned for additional reports and factsheets that include testing and diagnosis data up to 2017.

Refining HIV surveillance on new HIV diagnoses in Ontario

Summary

  • In Ontario, the number of new HIV diagnoses has increased in recent years. Challenges to interpreting diagnosis trends include:
    • The double-counting of individuals diagnosed through anonymous testing (duplicate diagnoses).
    • The inclusion of people who were diagnosed outside of the province and later moved to Ontario and tested again (‘out-of-province’ diagnoses).
  • In recent analyses led by OHESI, removing duplicates decreased the number of diagnoses in 2017 from 935 to 916. Also removing ‘out-of-province’ diagnoses further reduced this number to 797.
  • These analyses also suggest that the overall increase in new diagnoses between 2016 and 2017 was the result of an increase in ‘out-of-province’ diagnoses, rather than an increase in new HIV transmissions in the province.

Surveillance data on new HIV diagnoses are often used by front-line service providers and policy makers to inform their work. Information collected on diagnoses, such as sociodemographics and HIV risk factors, is commonly used to:

  • guide the planning and delivery of appropriate HIV care.
  • inform HIV prevention initiatives and evaluate their success (as new diagnoses are often used as an indirect way of measuring new infections).

This blog post describes the challenges of using Ontario surveillance data for the above purposes, OHESI’s recent work in refining these data and the impact of these refinements on recent trends.

Information collected during HIV testing in Ontario

Before discussing refinements to HIV surveillance, it is important to understand the HIV testing process and how information on newly diagnosed individuals is collected in Ontario.

When a person is tested for HIV in the province, the health care provider ordering the test fills out an HIV test requisition form. This form collects information on the person tested, including sex, date/year of birth, HIV risk factors and either the person’s name (nominal testing) or an anonymous code (anonymous testing).

When a person tests positive for HIV, Public Health Ontario sends a second form – the Laboratory Enhancement Program (LEP) questionnaire – to the health care provider who ordered the initial test. The purpose of this second form is to supplement the HIV test requisition and provide a more comprehensive understanding of who is being diagnosed with HIV in Ontario. Data collected on the LEP form includes some of the same information documented on the requisition form, as well as other information, such as race/ethnicity, country of birth and HIV testing history.[1]

Double-counting of diagnoses

In Ontario, a new diagnosis is defined as an individual’s first HIV-positive test result in the province. This means that if a person receives more than one HIV-positive test in Ontario (see Box below), only the first test is counted as a new diagnosis in order to avoid double-counting. Duplicate diagnoses are identified and removed when test information is entered into the laboratory surveillance databases at Public Health Ontario.

Why might a second HIV diagnostic test be conducted?

There are several possible reasons. For example, some physicians order an HIV test to confirm an individual’s diagnosis when the person first enters care.

Anonymous testing provides an important option for people concerned about privacy; however, it complicates the accurate collection of surveillance information and can result in an individual being counted twice in the data. With anonymous testing, duplicate diagnoses are difficult to identify due to the lack of identifying information collected on the person tested. For example, someone who initially received an HIV-positive diagnosis through anonymous testing, and later had a nominal HIV test when entering care, may be counted twice as a new diagnosis.[2] Individuals who receive more than one anonymous HIV-positive test may also be counted twice.

When people are double-counted, the number of new diagnoses included in Ontario surveillance reports is higher than the actual number of diagnoses.

‘Out-of-province’ diagnoses

Interpretation of diagnosis trends is also complicated by individuals who were initially diagnosed outside of Ontario and then moved to the province and tested for HIV again (for example, as part of the immigration process or when entering care). These ‘out-of-province’ diagnoses are counted as a new diagnosis in Ontario and their inclusion means that trends can be influenced by migration patterns to the province, in addition to other factors. This makes it difficult to interpret trends. For example, an increase in new diagnoses could be due to more HIV transmissions occurring in Ontario, more HIV-diagnosed individuals moving to and being re-tested in Ontario, or a combination of both.

Refining Ontario’s HIV surveillance data

OHESI (a collaboration between Public Health Ontario and the Ontario HIV Treatment Network, AIDS Bureau of the Ontario Ministry of Health and Long-Term Care, and Public Health Agency of Canada) is dedicated to providing the best possible provincial surveillance numbers for Ontario. By refining the new diagnosis data, we may be able to better estimate the actual number of people who receive a first time HIV-positive diagnosis in Ontario, as well as improve our ability to interpret trends.

Recently, OHESI conducted new analyses to determine how information collected on HIV testing history (on the LEP form) could help improve these data. This LEP-based information includes when and where an individual has previously tested positive for HIV.[3]

In these new analyses:

  • diagnoses with history of a previous HIV-positive test result within Ontario were removed in order to reduce double-counting (as these diagnoses are duplicates and would have already been counted as a new diagnosis with their first positive test in Ontario).
  • individuals with history of a previous HIV-positive test result outside of Ontario (‘out-of-province diagnoses) were removed in order to better assess trends in new HIV infections that occurred in the province (as these individuals were most likely infected with HIV outside of Ontario).

Note: Diagnoses with history of a previous HIV-positive test result are referred to as ‘previous positives’ in the remainder of this post.

What is the impact of removing previous positives?

Trends in the number of new diagnoses in Ontario between 2008 and 2017 are shown in the figure below, along with the impact of excluding previous positives.

 

Line graph showing new diagnoses with previous positives removed (over time)

The top line displays the trend in new diagnoses when the LEP is not used to remove any previous positives. This line shows a decrease in diagnoses in the earlier part of the past decade, followed by an increase between 2013 and 2017.

When the LEP form is used to address double-counting and remove duplicate diagnoses with history of a previous positive test result within Ontario (the middle line), the trend is identical but there are an average of 22 fewer diagnoses each year.

When ‘out-of-province’ diagnoses are also removed (the bottom line), the difference is more noticeable. In this scenario, the trend is identical until 2016 and then – instead of continuing to increase – the number of new diagnoses in Ontario decreases to 797 in 2017.

Taken together, these data suggest that the increase in new diagnoses between 2016 and 2017 (as observed in the top and middle lines) was the result of an increase in ‘out-of-province’ diagnoses, rather than an increase in new HIV transmissions in the province. Further, these data suggest that the number of new HIV infections occurring in Ontario in recent years may be closer to 800 than 900, and possibly lower (information on HIV testing history is missing for about half of diagnoses each year).[4]

Implications

Moving forward, OHESI will use information collected on HIV testing history to refine Ontario diagnosis data.

Future OHESI knowledge exchange products will exclude diagnoses with history of a previous positive within Ontario to reduce double-counting. Importantly, OHESI will continue to include ‘out-of-province’ diagnoses to provide an accurate picture of how many people and who require HIV care in the province. However, in separate tables and figures, OHESI will also exclude ‘out-of-province’ diagnoses in order to better understand trends in new HIV infections and guide HIV prevention priorities.

We hope these refinements will enhance the usefulness of surveillance data for people working in HIV.

Footnotes

  1. Race/ethnicity, country of birth and HIV testing history were added to the HIV test requisition in 2018.
  2. In Ontario, an average of 115 people are diagnosed with HIV through anonymous testing each year. However, it is unclear how many of these individuals also receive an additional anonymous and/or nominal HIV-positive diagnostic test and are double-counted.
  3. Information on HIV testing history has been collected on the LEP since the questionnaire was introduced in 1999, but is not available for every diagnosis. Approximately 50% of new HIV diagnoses have both 1) an LEP questionnaire returned, and 2) the HIV testing history section of the questionnaire completed.
  4. Additional caution is needed when using new HIV diagnoses as an indirect measure for new HIV infections. This is because many people are not diagnosed in the year they become infected with HIV. OHESI is currently working with mathematical modelers to better estimate the number of new HIV infections.