Specific challenges in key

population in Romania and in

Central and Eastern Europe

Prof. Adrian Streinu-Cercel MD, PhD, HC

National Institute for Infectious Diseases “Prof. Dr. Matei Balș”,

Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

30-31 January 2019, Bucharest

Disclosures

Carol Davila University of Medicine and Pharmacy, Bucharest, Romania

National Institute for Infectious Diseases “Prof. Dr. Matei Balș”, Romania

No relevant conflicts of interest to declare

in relation to this presentation

Romania – 20 million people

Prevalence Annual Incidence

Comments

HIV1 0.07% 0.002%

725 new cases per year on average during 2007-2017:

• 2007-2010 (538 cases/year) • 2011-2017 (850 cases/year)

HBV 5.6%2 0.001%3 National vaccination: 21-fold

decrease in incidence vs. 1995

HCV 1.9%4 0.0003%3 -

Co-infected HIV/HBV 19.9%5 0.3%1 43.4% in the “Romanian cohort”6

Co-infected HIV/HCV 1.8%6 0.2%1 86.8% of IDUs 1Calculated based on: www.cnlas.ro. Data current through 30 Jun 2017; 2Constantinescu I, et al, Hepat Mon. 2014;14(10): e22072; 3Romanian National Institute for Public Health 2015. http://www.cnscbt.ro/index.php/rapoarte-anuale/; 4RO 19.02 project; 5Juganariu G et al, Rev Med Chir Soc Med Nat Iasi. 2014;118(2):339-45; 6Ruță SM et al, MedGenMed. 2005; 7(1): 68.

Romania

Prevalence of Different Subtype/Genotype in Country

HIV Subtype

Distribution:

Historically: F1 = 95%

New cases: F1 = 77%1, B = 6.3%2, C and A = 16.7% CRF14_BG = 20.3% in IDUs3

1Stanojevic M et al, AIDS Rev. 2012;14(1):28-36 2Paraschiv S et al, Infect Genet Evol. 2012;12(5):1052-7 3Niculescu I, et al. AIDS Res Hum Retroviruses. 2015; 31(5): 488–495. 5Ruță S, et al. J Infect Dev Ctries. 2016 May 31;10(5):523-7

HIV1

Historically: • Epidemiologic accident = 68.9%, • Unknown = 17.4%, • IDU = 0.1%, • Hetero = 0.1%

New cases: • Hetero = 64.5%, • IDU = 15.5%, • MSM = 18%, • MTCT = 0.7%

Romania Main Way of Transmission

1Calculated based on: www.cnlas.ro. Data current through 30 Jun 2017 2Romanian National Institute for Public Health 2015. http://www.cnscbt.ro/index.php/rapoarte-anuale/

HIV1

Historically: • Epidemiologic accident = 68.9%, • Unknown = 17.4%, • IDU = 0.1%, • Hetero = 0.1%

New cases: • Hetero = 64.5%, • IDU = 15.5%, • MSM = 18%, • MTCT = 0.7%

Romania Main Way of Transmission

1Calculated based on: www.cnlas.ro. Data current through 30 Jun 2017 2Romanian National Institute for Public Health 2015. http://www.cnscbt.ro/index.php/rapoarte-anuale/

HIV/AIDS

• It is a book of “Good Clinical Practice”

30-31 January 2019, Bucharest

We started in 1985 with …

• Nothing

• A lot of questions

• A lack of answers

• With empty hands

30-31 January 2019, Bucharest

But …

• With the desire to do something

30-31 January 2019, Bucharest

Challenges During the Time

• Lack of testing

• Lack of therapy

• Low acceptance of diagnosis

• Tender love & care

• Social stigma

• Clinical international trials for the new molecules

30-31 January 2019, Bucharest

Thomson and Najera, JID, 2007; Stanojevic et al. AIDS Rev 2011; www.cnlas.ro

“1987-1990 cohort” children: homogenous F1 subtype of HIV

HIV subtype F predominance,

unique in Europe

Long term survivors – yesterday’s children, today’s parents

No of cases No of cases

Age at diagnosis – cumulative total

1985 - 2010 Current age in 2019

June 2010, HIV/AIDS Monitoring and Evaluation Department of the National AIDS Commission for Romania – “Matei Bals” National Institute of Infectious Diseases

Epidemiology/trends in the WHO European Region 2017 and in Romania 2018

Percentage of new diagnoses in the 19-24 age

group, by EU/EEA countries, 2017

Distribution of PLWHA from the Romanian cohort, by age groups 2018

Source: Compartment for Monitoring and Evaluation of HIV/AIDS Data in Romania– INBI “Prof.Dr.M.Balş”

Sursa: Compartimentul pentru Monitorizarea si Evaluarea Infectiei HIV/SIDA in Romania – INBI Matei Bals 15

Young by age…

…old by treatment

• Antiretrovirals timeline

• Adolescence

• Awareness

• Pediatric to adult transition

• Starting their own family

358 children born during 2006-2012

Number of cases: 1005 Sample: general population

Gender Age

46,5 y.o.

Average

Residence area Educational level

A Streinu-Cercel et all,BMC Infectious Diseases 2016, Volume 16 Suppl 3 DOI 10.1186 s12879-016-1480-8

Knowledge, attitudes and practices of the general population regarding HIV/AIDS, HBV&HCV

Disease awareness How can HCV/HBV be transmitted?

96,1% of respondents heard

about hepatitis B

96,5% of respondents heard

about hepatitis C

97% of respondents heard

about HIV

A Streinu-Cercel et all,BMC Infectious Diseases 2016, Volume 16 Suppl 3 DOI 10.1186 s12879-016-1480-8

Number of cases: 1005/200 Sample: general population/IDUs

Have you ever went through screening for ?

37,4% of respondents

were screened

for hepatitis B/C

85% of respondents

were screened for

hepatitis B/C

HIV Hepatitis

B/C

17,7% of respondents

were screened

for HIV

83% of respondents

were screened

for HIV Number of cases: 1005/200

Sample: general population/IDUs A Streinu-Cercel et all,BMC Infectious Diseases 2016, Volume 16 Suppl 3 DOI 10.1186 s12879-016-1480-8

Estimates UNAIDS Romania 2018

ROMANIASELECTED TRENDS

AIDS Deaths Number of people living with HIV

New HIV Infections Percent of people living with HIV receiving ART

0

100

200

300

400

500

600

700

800

2000 2002 2004 2006 2008 2010 2012 2014 2016

AIDS Deaths

Lower and upperlimits

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

2000 2002 2004 2006 2008 2010 2012 2014 2016

Number of peopleliving with HIV

Lower and upperlimits

0

10

20

30

40

50

60

70

80

2000 2002 2004 2006 2008 2010 2012 2014 2016

Percent of peopleliving with HIV

receiving ART

Lower and upperlimits

0

100

200

300

400

500

600

700

800

900

1,000

2000 2002 2004 2006 2008 2010 2012 2014 2016

New HIV infections

Lower and upperlimits

Sursa: UNAIDS Estimates for Romania 2018

Characteristics of HIV infection cases diagnosed in the WHO European Region in 2017, by geographical areas

* No data received from Germany, Russian Federation, Turkmenistan, Uzbekistan. All data presented were reported to ECDC/WHO through the European Surveillance System (TESSy), except for data for the Russian Federation which were obtained through publicly available national sources [1]. Russian data are included in the numbers in parentheses for the European Region and the East. ** EU/EEA rate is adjusted for reporting delay (Annex 6), the corresponding estimated number of new diagnoses adjusted for reporting delay is (xx xxx/to be updated later).

WHO European Region West Centre East EU/EEA countries

Reporting countries/no. of reporting countries* 49/53 (51/53) 22/23 15/15 12/15 (13/15) 30/31

Number of HIV infection cases 55 018 (159 420) 22 354 6 205 26 459 (130 861) 25 353

Rate per 100.000 population** 8,3 (20,0) 6,4 3,2 23,6 (51,1) 5,8

% of cases:

15-24 age group 9,3% 11,0% 13,7% 6,9% 11,1%

Percentage age 50+ years 16,1% 20,7% 13,1% 13,0% 19,3%

Men/women ration 2,2 2,9 5,8 1,6 3,1

Percentage new diagnoses CD4<350 cells/mm3 53,1% 48,0% 52.5% 57.2% 48,6% Way of transmssion

Heterosexual (men) 25,3% 16,7% 19,4% 33,9% 16,6%

Heterosexual (women) 24,1% 17,5% 7,3% 33,7% 16,5%

MSM 21,2% 39,7% 28,4% 3,9% 38,2%

I.V. drugs 13,0% 2,7% 2,7% 24,1% 3,7%

MTCT 0,7% 0,5% 0,6% 0,9% 0,5%

Unknown 15,4% 22,5% 41,2% 3,4% 24,2%

HCV hotspots ● <2% ● 2-7%

● >=8%

Source: INBIMB 2016

Positive HCV tests

• 3.3% positive anti-HCV tests

• 60.7% of the positive tests had negative HCV-RNA

• 9 counties in Romania were “HCV-free”

3% 3%

5%

6%

8%

0%

10%

4% 4%

5%

0%

10%

7%

1%

4%

1%

2%

7% 5%

7%

3%

2%

4%

0%

3%

0%

3% 3%

0%

7%

9%

0% 0%

7%

12%

6%

4% 3%

1%

3%

0% 0% 0%

3%

6%

9%

12%

15%

Alba Bihor Brăila Călărași Dâmbovița Gorj Iași Mureș Satu Mare Teleorman Vâlcea

=> 1.9%

Source: INBIMB 2016

Progress toward achieving the 1st 90: 90% of all PLHIV who know their status (n=39)

Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data. Latest available data reported, ranging from 2014-2017.

Target reached Above regional average Below regional average

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Global target 90%

Overall percentage 80%

88%

How Math Can Trick You…

• Depends what you compare

How Epidemiology Can Save You…

• Depends of innitial pool of infected individuals

Decreasing estimated time from infection to diagnosis in the EU/EEA

Source: van Sighem, Eurosurveillance, 2017

Median time from infection to diagnosis is

2.9 years

@ECDC_HIVAIDS

Comparison of treatment coverage with year that guidelines on immediate treatment initiation were introduced

89% 86%

68%

0

2

4

6

8

10

12

14

16

18

Introduced by 2014 Introduced by 2016 Introduced by 2018

National treatment policy guidelines

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% diagnosed receiving treatment Number of countries

Source: ECDC. Dublin Declaration monitoring 2018; validated unpublished data.

“Early adopters of progressive policies and interventions have better outcomes.” Romania - 2001

No further comments your honor !

30-31 January 2019, Bucharest

BUT

30-31 January 2019, Bucharest

Proposed healthcare strategy steps

• Actively promote and implement Early Detection as the foundation for a medically successful treatment and a cost-consciousness approach • Testing/Screening campaign: Randomized screening in general population

(rapid tests) combined with at risk population testing

• Ensure Access, Best-in-Class Treatment, Universality and Equity • Improve access to treatment

• Ensure equitable access and prevent discrimination

• Revise Medical Guidelines

• Revise the collaboration frame between all stakeholders (GPs, specialists, HA, NGO)

• Include Health-Economics in treatment paradigm

Proposed healthcare strategy steps

• Reduction in transmission of the disease through raising awareness

• Ensure public recognition of chronic viral hepatitis with B, C, HIV viruses as an urgent public

health issue by establishing a National Awareness Program on Viral Hepatitis B, C and HIV

transmission routes

• Raise awareness of hepatitis B, C and HIV transmission risks and improve knowledge and skills

for sustaining preventive practices

• Make Hepatitis B, C and HIV a 100% preventable disease with the implementation of the

National Prevention Plan.

• Access the National Registry for viral Hepatitis, HIV, TB, STD… (Surveillance Program)

• Prevention of Biomedical Transmission (Nosocomial)

• Prevention of Mother-to-Child Transmission

• Prevention in PWID

• Prevention in Service Providers

• Prevention in tattooing, piercing, and nail care business

30-31 January 2019, Bucharest

Women and key populations

face even more difficulties

HIV and Aging