AIDS 2008 - HIV and Coinfections Satellite Summary Report

“Strengthening global policy cooperation amongst high resource/low HIV/AIDS prevalence countries, to improve the domestic response to HIV/AIDS and co-infections.”

Satellite Session of the XVII International AIDS Conference

Mexico City, Mexico - August 6, 2008

Table of Contents

• List of Acronyms
• Executive Summary
• Background and Context
• Similarities and Differences Across Participating Jurisdictions
• Highlights of Country Presentations
• Summary and Conclusions
• Annexes
  • Annex A: Agenda – Welcome - Panelists
    Annex B: Discussion Paper
    

List of Acronyms

Executive Summary

With a view to strengthening global policy cooperation amongst high resource/low HIV/AIDS prevalence countries to improve the domestic response to HIV/AIDS, sexually transmitted infections, blood-borne infections and tuberculosis co-infection, Canada (Public Health Agency of Canada) and the United States Centers for Disease Control and Prevention hosted an HIV/AIDS and Co-Infections Satellite Session during the XVII International AIDS Conference, Mexico City, Mexico, August 6, 2008.

Participating panelists included representatives of four countries: United Kingdom, Germany, United States and Canada (see Appendix A for a complete list of participants).

Objectives of the Satellite Session

The one-day Satellite Session had several objectives:

• to advance policy and program linkages aimed at strengthening policy working relationships
• to increase the collective effectiveness of governments to address domestic responses to HIV/AIDS and co-infections
• to engage in dialogue examining the opportunity to establish an international policy network for high resource/low HIV/AIDS prevalence countries

Results

Overall, participants in the HIV/AIDS and Co-Infections Satellite Session considered the session to be highly successful in meetings its objectives. In addition, speakers were reported to have been encouraged by the productive dialogue and described the exchange of information as an opportunity to understand the different experiences of their colleagues in other high resource/low HIV/AIDS prevalence countries with respect to HIV and co-infection strategic activities.

At the same time, many participants identified that the session was only the beginning of a longer term discussion that was urgently needed to explore concrete activities in surveillance standards, benchmarking best practices, and for establishing an international policy network on HIV and co-infections. 

Country Overviews

The United Kingdom is focusing its efforts on targeted prevention interventions, particularly early screening initiatives, earlier testing campaigns and improving on surveillance and monitoring tools. The U.K. acknowledges the commonalities in risk behaviours and infection rates with respect to HIV+ and co-infections. The U.K. is developing new testing guidelines which are expected to be released for the fall of 2008 and is currently investigating structural models through which to increase effectiveness and reach of health services to populations in need.

The United States is focusing on the integration of prevention measures across HIV, tuberculosis, sexually transmitted infections (STIs) and infectious diseases. Training for service providers and targeted interventions for African-American and men who have sex with men (MSM) populations are the immediate focus. The U.S. also acknowledges that a broader view of the epidemic is needed—to include socioeconomic factors as part of monitoring and assessment strategies that will contribute to comprehensive programs and effective programs. Targeted responses will be reinforced to meet the pressing priorities of its key populations and will include emphasis on partnerships and collaboration to reach long-term goals. The U.S. is currently planning a program review to develop a strategic long-term plan (to 2020); efforts will include identifying measurable indicators.

Germany is looking to legislative reform to improve its ability to gather and monitor data across the spectrum of HIV+ and STIs. It is expected that an improved evidence base will advance system practices, as well as leading to a standard and comprehensive level of services and care across the country. Partnership opportunities could be explored in which to further the country response.

Canada supports a comprehensive, integrated approach to HIV/AIDS and co-infections.  Investments are currently geared to testing and counseling strategies, integrated prevention interventions, surveillance and research initiatives to build the evidence base and forming targeted responses to meet the needs of key populations.

Opportunities

Discussions led to the identification of four key steps that would improve collaboration and information sharing across developed countries:

1. Enhance surveillance practices: To develop standards, indicator lists, etc., with respect to co-infections so that collected information can increase the knowledge across audiences (HIV, TB, STI programs), results can become more meaningful, lessons learned can be adopted across strategies and relevance is heightened.
2. Report and synthesize experiences: To share information more regularly in order to inform each country’s strategic developments. Given that there are overlapping epidemics, lessons, best practices and challenges faced by other countries can serve to inform action in any jurisdiction.
3. Investigate structural changes: To reduce barriers to effective prevention, diagnosis, treatment, care and support services for all populations; consider opportunities to reduce duplication and; where it makes sense, to integrate programs and services. Increased policy coordination within and across jurisdictions can be supported through open sharing of information and concrete collaborative efforts (i.e., technical exchange, partnerships, co-investments). 
4. Conduct research to improve diagnosis and treatment of co-infections: Participants highlighted HIV and TB co-infection as a key priority throughout the conference, particularly for developing countries and sub-populations in developed countries. Heightened risk and corresponding urgency was noted due to increased evidence of TB drug resistant strains and complications due to dual infections. Investment in research, new innovative treatments, and new and improved diagnostic tools were highlighted as essential activities to further action in this area. An extension of the research for HIV and other sexually transmitted and blood-borne infections (STBBIs) would be equally beneficial in developing the evidence base to formulate effective responses.

Next Steps

Participants highlighted a short-term requirement and longer term follow-up to address the opportunities they identified. In the short-term, participants called for the preparation and dissemination of a report on the Satellite Session discussion as the basis for expanding the dialogue within the participating countries and to encourage others to participate. Canada offered to take the lead on a summary report that would be provided to all panelists for validation of content.

Longer term efforts to establish an international policy network on HIV and co-infections were agreed upon. Efforts would focus on: 

• building a more formal mechanism to create an environment for systematic and effective dialogue;
• widening the existing network with the goal of engaging other appropriate stakeholders, other high resource/low HIV/AIDS prevalence countries such as, but not limited to, Sweden, France and Australia; 
• conducting a scan of the various approaches taken by high resource/low HIV/AIDS prevalence countries to assessing the issues, needs, challenges and opportunities for collaboration;
• continuing dialogue on priority issues and promoting an environment of open sharing to gain insight into the underlying factors that are similar/different across jurisdictions and what lessons can be shared to enhance progress across the jurisdictions;
• reinforcing HIV and co-infections issues and activity—those now underway and those needed—by taking advantage of existing global fora to meet and promote ideas, knowledge and action.

Background and Context

Many governments face similar challenges with respect to domestic responses to HIV/AIDS, sexually transmitted infections (STIs), other blood-borne infections and tuberculosis (TB), including policy and program challenges which may not fall within the parameters of current global discussions.

Based on common experience and interest across a number of countries, the Public Health Agency of Canada and United States Centers for Disease Control and Prevention pursued the opportunity of the AIDS 2008 conference to support dialogue among the governments of high resource/low HIV/AIDS prevalence countries. In particular, they sought to share experiences, lessons learned and strategic orientations of domestic responses to HIV/AIDS and co-infections.

A Satellite abstract was accepted as part of the XVII International AIDS Conference (AIDS 2008). Four primary speakers each representing a different high resource/low HIV/AIDS prevalence country (the U.S., Germany, the U.K., Canada) outlined their country HIV/AIDS epidemiology, key policy and program priorities, key activities/strategies, outcomes and lessons learned focusing on:

• policy and programming implications and priorities—including the development of integrated initiatives to promote the prevention and control of HIV, STIs, viral hepatitis and TB
• models of collaboration—designed to address multiple infections/co-infection, common risk populations, and/or common risk behaviours

Participants identified a number of common threads, opportunities and priority areas for action. The panel dialogue included members of the audience. An overarching priority was identified: to increase collaboration and efficiencies by determining best practices, strategic frameworks and models that could be adapted to meet country-specific circumstances and responses.

Participating countries also agreed that continuing and expanding the dialogue with other high resource/low HIV/AIDS prevalence countries was an important area for action, and identified possible mechanisms and approaches for such expansion.

Similarities and Differences Across Participating Jurisdictions

This section summarizes key points made during the presentations, emphasizing challenges, similarities and differences across participating countries, and opportunities for further action. Questions from the audience and highlights of panel responses wrap up this section.

Challenges

Although incidence rates have stabilized over the past six years, a consistent number of new infections are identified year after year. Populations appear to be engaging in high-risk behaviours—for example, use of the internet and saunas to “hook up” with strangers. At the same time, there are signs of complacency in terms of prevention programs. Current prevention programs must strive to recognize and integrate the changing behaviours that have an impact on transmission, and to obtain credible information and data on these behaviours on which to realign HIV/AIDS responses.

Accessing hard-to-reach populations continues to slow progress in achieving HIV/AIDS goals and commitments. Despite targeted efforts, participating countries have estimated that 24%–30% of their HIV/AIDS population is unaware that they are infected (known as the HIV “undiagnosed”). The ability to work with the high-risk populations (i.e., people who use injection drugs (IDU), men who have sex with men (MSM), sex workers as well as concentrated epidemics in the population (such as people of African descent)) continues to present challenges in both prevention and treatment efforts.

There is limited research concerning the behavioural aspects of the epidemic. There is increasing evidence to support the use of a determinants of health approach. By considering socioeconomic influences, opportunities for multisectoral action may be identified. The approach is also seen as a way to broaden knowledge about influences on risk behaviours, risk conditions (such as poverty), access to services, as well as influences on a population’s vulnerability and resiliency to infection.

In considering ways of moving forward, participants recognized that integration of HIV and co-infection programs will take time, investment and a change at the health practice level. Other important shifts were identified as necessary to mitigating HIV/AIDS and co-infections:

• Leadership and accountability across partnership models will be needed to effect integration.
• Capacity needs of the service providers will need to be considered in order to equip the front-lines with the training, tools and processes to move towards increased quality and effectiveness of program delivery.
• Direct training support and policy tools (such as guidelines, protocols) will need to be developed in order to achieve positive change in the system.

Similarities

All countries face a similar epidemiology of HIV/AIDS in terms of prevalence and incidence rates over three decades, seeing numbers rise in the mid-80s, dropping in the mid-90s and leveling in the 2000s. 

The rate of HIV infection appears to have declined in certain populations, but is increasing primarily in MSM, but also through heterosexual transmission—particularly among women and people of African descent. In terms of age, those with the highest rates of infection are older, within the 30- to 50-year-old range, primarily through MSM transmission. All four countries have adopted a population-specific approach with responses that meet the needs of these populations which may vary according to culture, risk behaviours, risk conditions and vulnerability.

All participating countries identified that their populations are engaging in more risk behaviours. Current prevention and treatment services do not appear to be effective, nor is the reach to populations at risk—as evidenced by the consistent identification of new infections from year to year. Solutions put forward for supporting better prevention and treatment interventions included the need re-invigorate prevention. Such a shift would see including behavioural science within the scope of evidence-based research, thereby enabling monitoring of longer term behavioural patterns of marginalized and “vulnerable” groups. Reinvigoration efforts would also include evaluation of the effectiveness of prevention programs and the inclusion of populations at risk in the process of identifying solutions.

There have been increased rates of HIV+ and sexually transmitted and blood-borne infections (STBBIs) across all countries, the most common being HIV+ and TB, HIV+ and syphilis, and HIV+ hepatitis C. This suggests that comprehensive surveillance and monitoring techniques may be able to use sexual disease reports to serve as early indication of infection. 

All jurisdictions are experiencing inconsistencies in the provision of adequate and high quality services. Opportunities for partnerships and collaborative work on this front exist and must be explored to strengthen the health system, to break down the “silos” in health practice as well as across sectors, and to share accountability for an improved response.

All presenters supported a response approach that strived for greater integration and collaboration of HIV and co-infections. Such a strategy could make optimal use of limited resources by pooling efforts where it makes sense, and by sharing information and data across sectors to form a sound basis for developing higher quality and effective responses. Other cross-jurisdictional opportunities were identified—to enhance surveillance practices, disseminate evidence across programs, address common risk behaviours and conditions, and pool resources accordingly. 

It was equally clear to participants that health systems may “resist” integration, in particular, where disease-specific program interventions have traditionally gained funding support through association with a specific disease response. Funding for integrated responses may be perceived to be unsustainable or even unattainable. Political leadership is needed to ensure public health responses continue to be comprehensive, evidence-based, long-term, of high quality, effective, and serving the needs of the population. 

Differences

Across participating countries, populations most at risk for HIV infection and demonstrating highest rates of co-infection, incidence and prevalence varied:

• United Kingdom—TB and HIV+ is prominent in heterosexual migrants, primarily of Black African descent; however, hepatitis C is also of concern in IDU and MSM.
• Germany—syphilis rates have risen three-fold since 2000, mainly in the MSM group of 30–40 years of age.
• United States—African-Americans represent 45% of the HIV+ population and the MSM risk group represents 53% of HIV+. An estimated 150,000 HIV+ are infected with hepatitis C—50% of HIV+.
• Canada—TB rates in Aboriginal communities are estimated to be three times higher than in the general population, as are Aboriginal rates of HIV+. MSM consist of 51% of the affected HIV+ population.

The U.K. approach includes the commissioning of specific services to organizations that can deliver to the needs of the particular community. The U.K. is currently developing a strategy for broadening and solidifying the health system response in efforts to bridge the gap between acute care and community-based care. Canada adopts a multi-jurisdictional approach, governed by legislation, in which it can provide health care services to its populations. Germany and the U.S. also have multi-jurisdictional strategies in place. Each considers the specific needs of the local populations and provides free access to health care services, although what services are free, available and who administers them may differ.

The developed countries have varying models of partnership designed to effectively deliver prevention, treatment, care and support services to targeted populations.  Structural differences and partnership models span a variety of stakeholder groups, including health care practitioners, community-based actors (health, science, social and cultural interventions), the research and academia community, as well as private sector care.

Health insurance coverage for basic services appears to be approached differently across countries. Some services are free, centralized and governed by legislation or policy tools.  The approach also varies with respect to public and/or private health care models. More information is required in order to accurately assess the impact on the response to HIV/AIDS and co-infections.

Opportunities

Discussions supported the formation of an international policy network on HIV/AIDS and co-infections among high resource/low HIV/AIDS prevalence countries. The policy network would serve as a formal mechanism to facilitate ongoing dialogue and strategic action as well as a mechanism to expand the dialogue to other countries such as Australia, Sweden, France and others.

Opportunities were also seen with respect to setting standards in key areas of epidemiology, surveillance, monitoring and evaluation practices. Standards would help achieve common language and comparable data to enrich each other’s strategies and approaches. Investing in socioeconomic and behavioural research was also seen as an opportunity to support the evidence base by capturing risk behaviour data, patterns and conditions to give context to increased vulnerability and resiliency to transmission and infection.

Exchange programs were also identified as an opportunity to build technical capacity by enabling countries to gain insight into the structural measures and approaches designed to increase the effectiveness of programs in other jurisdictions.

Finally, accountability and leadership were seen as requisite to breaking down the silos that exist within health systems and across sectors that contribute to health outcomes for citizens. Results achieved through strategies to HIV and co-infections put in place by different countries can inform other jurisdictions through reports on progress, lessons learned and opportunities to advance the response to HIV and co-infections.

Panel Dialogue and Audience Qs & As

Members of the audience were encouraged to participate in the dialogue with panel members. Questions put forward for discussion with panel members included:

In response, panelists reinforced a number of points from their presentations, and referred to particular assessments that contributed to the development of their country’s strategic directions:

• Best practices need to be reported and shared. In recommendations and guidelines, issues from across jurisdictions should be reflected and integrated where and when appropriate.
• Standards for surveillance and monitoring models must be developed and shared.
• Results of surveillance, as well as models of integration must be shared in order to inform policy orientations and program development across jurisdictions.
• At the local level, flexibility and the adoption of practices that reflect community needs must be encouraged and supported.
• Prevention interventions must be designed “from the bottom up.” This approach involves front-line health providers in discussions and recommended approaches.
• Ownership and leadership must be embraced by each involved “silo,” with each recognizing and actively demonstrating that integration is valued and valuable. To inspire positive change, structural barriers need to be broken down, enabling ready sharing of information, integrated service delivery and eliminating duplication where possible. The challenge will be to get the “practice” to change its approach, while remaining appropriate and effective.

Among the opportunities panelists identified for advancing the dialogue and network among high resource/low HIV/AIDS prevalence countries was the use of such groups as the ANISI group on surveillance. ANISI meets regularly to review best practices and results, and to discuss challenges related to the surveillance approach adopted for public health interventions. They also discuss approaches to infectious diseases (including TB, HIV and STIs). Groups like ANISI also embrace scientific discussions; their approach could be used as a model for an international policy network for HIV and co-infections. 

Other forward-looking closing remarks encompassed a range of related issues, such as:

• Broadened engagement can build on existing networks and groups that meet regularly. Opportunities may exist to build HIV and co-infections within (or parallel to) the program, continuing to focus discussions on policy and program needs.
• Cost savings and efficiencies can be gained by using existing fora, such as conferences, and each can express their continued leadership by using every opportunity to advance discussions.
• Ongoing support for the issue of HIV and co-infections could be supported by building into the AIDS Conference a permanent track or theme on integration.

Highlights of Country Presentations

Each of the four countries participating in the Satellite Session provided an overview of approaches and activities underway in their respective jurisdictions, as well as an overview of the epidemiology of HIV/AIDS and co-infections, the challenges they face and strategic directions underway or being considered.

Dr. Kevin Fenton, Centers for Disease Control and Prevention, United States

The U.S. has applied new mathematical models to assess incidence and prevalence data. Use of new models revealed that the U.S. may have underestimated rates by 40% (i.e., 50,000 versus 40,000 new infections in 2006). The new assessment tool employed a stratified extrapolation approach that is based on surveillance information, standard HIV testing models and new HIV testing technology—it also has the ability to distinguish recent from long-standing infections. Known as the Serological Testing Algorithm for Recent HIV Seroconversion (STARHS) approach, the method was applied to a sample of newly HIV diagnosed individuals across the U.S. (22 states) in 2006 and allowed for a retrospective view of the evolution of HIV incidence since 1977,  incorporating AIDS, HIV and HIV testing data from routine surveillance.

Overview of Epidemiology in the U.S.

HIV/AIDS

• total number of people infected with HIV: 1,039,000–1,185,000
• 56,300 (95% CI 48,200–64,500) new HIV infections: men 73%, women 27%
• number of people unaware of their HIV infection status: 252,000–312,000 (24%–27% of those infected)
• cumulative AIDS deaths: 565,000, with 14,000+ in 2006
• AIDS diagnosis within one year of HIV diagnosis (for 33 states): 38%

Co-infections

• estimated 300,000 STI cases are co-infected with HIV:~22% of those with HIV
• estimated 150,000 HIV+ are co-infected with hepatitis C: 50%–90%
• studies showed an HIV-TB rate decline over time

• infection “syndemics” are occurring mostly in male African-Americans
• TB and co-infection rates exacerbate disparities in health status and general socioeconomic status
• common social, behavioural and economic characteristics are found and drive increased risk in these “syndemic” populations (including poverty, homophobia, homelessness, racism)

Challenges

• There is continued need for prevention measures—25% of the population is still unaware of their HIV status (i.e., they are undiagnosed).
• The number of new infections among at-risk groups is increasing—MSM remain at high risk.
• Some sub-populations bear the heaviest burden—specifically, African-Americans and Hispanics.
• There is limited access to effective prevention and growing concern that the lack of available and effective treatments is generating complacency about HIV risk.
• Stigma and discrimination continue to present barriers for progress.
• Responses need to consider the social and behavioural patterns that surround HIV infection, such as substance use patterns (e.g., methedrine), social engagement (internet “hooking up”).
• There are known disparities in services—for example, in centres where vaccines for sexually transmitted diseases and hepatitis B are being administered, there is no HIV treatment/assessment. The situation is the same in HIV centres.

Strategic Directions

The CDC supports a comprehensive national HIV plan that is culturally relevant and targets risk communities based on evidence and the needs of these communities.

The CDC acknowledges that the best public health approach would be to:

• adopt the “syndemics”
• take a holistic view of the issues
• focus on science-based responses that are comprehensive
• further promote high quality in services

Responses also need to expand access to effective programs (e.g., HIV testing) and engage in research on innovative prevention interventions. 

The CDC will focus on implementing structural, program and policy activities in support of their strategic direction—comprehensive science and program integration. Key activities in the response include the development of national guidelines (e.g., administrative, data collection), improvements to surveillance methods and the provision of training with respect to best practices. The CDC renewed its commitment to assist the mobilization of communities in the response, and will engage in partnerships and increased collaboration, where feasible. The CDC will also undertake a review of its HIV prevention portfolio (by an independent panel of national experts) with the goal of developing a strategic road map for HIV prevention to 2020, including measurable objectives.

Dr. Osamah Hamouda, Robert Koch Institute, Germany

With a population of 82 million, Germany is a federated state represented by 16 states of autonomic governance. Federal laws exist but health care is delivered mostly through private practice (and includes hospital referrals). The country offers a central health insurance scheme, paid for by the state, which includes coverage for the homeless.

Germany has observed a similar epidemiology of HIV/AIDS as the U.S. in terms of prevalence/incidence over three decades—seeing numbers rise in the mid-80s, drop in the mid-90s and level in the 2000s. There has also been a rise of recent new infections of HIV and STIs.

Overview of Epidemiology in Germany

HIV/AIDS

• 3,000 new HIV infections: 30% among MSM

Co-infections

• syphilis rates have risen three-fold since 2000, mainly in the MSM group of 30- to 40-year-olds (identified through sentinel studies for HIV and syphilis)
• it is estimated that 25% of those infected with HIV are unaware of their infection, as is the case for TB and STIs
• 50% of MSM are infected with HIV

Challenges

• Germany has recognized that people are living longer with HIV/AIDS. Under the “equal access” health care scheme, consideration must be given to the long-term health care costs and service delivery requirements for those with compromised health to uphold the national universal access to care.
• There is a lack of information for the general public on HIV/AIDS and STIs.
• In Germany, STIs are not yet regarded as a public health issue. Moreover, there is dis-investment in sexual health prevention at the local level. There are discrepancies in the access to state-provided diagnosis across STIs—where voluntary testing is available it is at a cost, in some cases. Although nominal, costs may serve as a disincentive for testing.
• Training remains an issue across the country—physicians are not trained to use the tools necessary for prevention, diagnosis and treatment (i.e., what questions to ask, what to administer, etc.).
• Privacy/confidentiality and access to cross-information remain challenges. For example, TB testing results are required (by legislation) to be publicly reported and must be logged by the individual’s name and made available through easy sharing of data sets. HIV testing does not include the name of individuals, therefore rendering it difficult to identify co-infections.
• For the Robert Koch Institute specifically, a key challenge is to partner with others to influence program development.

Strategic Directions

Germany’s general approach aims to improve prevention interventions through improved screening practices and information through the provision of widespread standardized training. 

Germany will also focus on surveillance activities, by improving methods to generate high quality data sets that can be readily shared across practices. As well, Germany plans to make legislative changes regarding the transfer of data required to provide appropriate and effective prevention, treatment, care and support to those with HIV/AIDS and co-infections.

Dr. Valerie Delpech, Health Protection Agency, HIV and STI Department, United Kingdom 

The U.K. has also observed a similar epidemiology of HIV/AIDS as the U.S. and Germany in terms of prevalence/incidence over three decades, seeing numbers rise in the mid-80s, drop in the mid-90s and level in the 2000s. There has been a recent rise in the number of new infections of HIV and STIs in the U.K., particularly in MSM HIV+, heterosexual HIV transmission, hepatitis C virus and syphilis. In the European Union, the U.K. has one of the highest rates of new diagnosis for HIV and infectious diseases in Europe, driven by migration and infections among MSM.

There is widespread access to free health care in the U.K., through the National Health Service. Prevention services are “out-sourced,” providing distinct prevention programs that aim to meet the needs of the communities they serve: genito urinary medicine (GUM-STI) clinics, HIV clinics, TB clinics, drug dependence units and antenatal clinics. These clinics offer HIV and STI testing and treatment services. 

Overview of Epidemiology in the U.K.

HIV/AIDS

• 7,000 HIV+ per year (estimated at 6,840 in 2007)
• new diagnoses of HIV+ are highest in heterosexual transmission (56%), and are  particularly high among those of Black African ethnicity
• new diagnoses of HIV+ are second highest among MSM (38%), and are particularly high among those of white ethnicity, where 84% of this mode of HIV infection was occurring in the U.K.
• HIV+ infection as a marker of country of origin could prove to be valuable information as the HIV+ rates appear to be linked with migratory patterns and with such issues as: late diagnosis, reduced access to testing and treatment, and prevalence rates in the U.K. among Black African populations of both MSM and heterosexuals

Co-infections

• an estimated 250,000 people are infected with acute STIs
• rates of TB and hepatitis C are very high, with approximately 7,000 of each diagnosed annually
• hepatitis C prevalence rates reached 250,000 in 2006: 73,000 were HIV+ and 85% of hepatitis C+ were found in the IDU risk group
• with respect to TB and HIV+, the highest incidence occurs in heterosexual migrants, primarily of Black African descent, at disproportionately high rates compared to the general population; the death rate is also 10 times higher in this population 
• TB is the most important cause of AIDS in migrant populations: although TB and HIV+ co-infection represented 5.7% of TB co-infections in 2003, TB and HIV+ co-infection contributed to one third of the new TB cases over a five-year period
• MSM HIV+ compose the majority of STI co-infections: within the MSM HIV+ co-infections, hepatitis C is predominant (99%), lymphogranuloma venererum (LGV) (75%), syphilis (34%) and gonorrhea (28%)
• enhanced surveillance models identified that MSM syphilis HIV positivity was directly related to being non-white, born outside of the U.K., behavioural risks (e.g., by “hooking up” in public saunas, through the internet), and is most prevalent in the age group 40 to 49 years

Challenges

• There are discrepancies in the manner in which testing across infectious diseases is being carried out. For example, persons with TB+ were not routinely tested for HIV even though the highest risk of co-infections in the U.K. is TB and HIV+. In addition, 18.5% of co-infection TB cases are not reported on the national TB database, making it difficult to provide appropriate clinical care.
• Data are needed to improve knowledge of how common co-infections are—including across what categories of infection, in which sub-populations—and what risk factors contribute to higher transmission exposure.
• Recent change towards a practice-based approach is aimed to facilitate patient pathways and promote closer working relationships between acute care and community-based services. However, commissioning this “specialist” care and support may prove to be challenging to deliver local services given changes in personnel and population configuration. 
• Surveillance efforts are being enhanced to look beyond the traditional disease focus to a more “at-risk population” focus. Standardizing tools and methods across the health care system and the inclusion of behavioural information will be needed to inform an appropriate response.
• Integration of health services is necessary to improve early diagnosis, screening, testing, treatment and continued care across STIs and HIV. Recent efforts have increased screening and testing for HIV and STIs up to 80% in GUM clinics, HIV testing up to 85% in antenatal clinics, and routine HIV testing in TB clinics.

Strategic Directions

The U.K. has implemented strategies and policies since 2002 to address HIV and co-infections and continues to further implement them through the development of guidelines, outbreak responses and health promotion activities at the local level. Strategies include a review of the National Sexual Health Strategy as well as specific TB, STI and hepatitis C strategies and action plans (developed in 2002, 2003 and 2006, respectively).

In July 2008, the U.K. released a plan for modernizing its public health service plan, including how it will commission to deliver health services across the country. The plan aims to prioritize sexual health as a key public health issue, calling for leadership at national, regional and local levels, and for a focus on accountability and evidence-based interventions. The U.K. is improving surveillance methods for HIV co-infections, through a multi-layered approach including data linking, surveillance schemes (through a system called SOPHID) and enhanced reporting systems (including behavioural data). The U.K. is also focusing on prevention interventions, particularly screening initiatives, earlier testing campaigns and improvements to surveillance and monitoring tools. New testing guidelines are expected to be released in the fall of 2008.

The U.K. acknowledges that there is a need for future collaboration across high resource countries in order to learn from each other’s strategies, issues, results and models used (i.e., surveillance, monitoring, evaluation) through a mechanism such as the international policy network on HIV/AIDS and co-infections.

Dr. Howard Njoo, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada

Canada is a country of 36 million people, widely dispersed across 10 provinces and three northern territories. Public health and access to services are provided through provincial service control, however national law provides for universal access. Reporting and surveillance data across the country varies, which has an impact on capturing an accurate picture of HIV and co-infection rates for Canada. Issues remain with regard to equitable service delivery and access, particularly in rural and northern regions where approximately 20% of the population resides.

Canada has also observed a similar epidemiology of HIV/AIDS as the U.S., Germany and the U.K. in terms of prevalence/incidence over three decades, seeing numbers rise in the mid-80s, drop in the mid-90s and level in the 2000s. HIV affects eight key populations in Canada including MSM, women, youth, Aboriginal peoples, IDU, prisoners, persons living with HIV and AIDS (PHA), and people from countries where HIV is endemic (primarily those of African and Caribbean descent). There has also been a rise of recent new infections of HIV and STIs, particularly HIV+ and TB in Aboriginal populations, HIV heterosexual transmission in women, HIV+ in MSM and people with hepatitis C.

Overview of Epidemiology in Canada

HIV/AIDS 

• 2,300–4,500 new HIV+ infections in 2005: primarily among MSM (51%), heterosexuals (38%) and IDU (17%)
• 58,000 people estimated to have HIV/AIDS 2005, with 27% undiagnosed
• Aboriginal communities are disproportionately affected by HIV/AIDS, with rates three times higher than other sub-populations
• transmission rates for women heterosexuals are on the rise

Co-infections

• chlamydia is the most prevalent bacterial STI in Canada—its rate increased by 77% from 1997 to 2006: two thirds of those infected are female; youth aged 15–24 years account for 64% of cases (as of 2006)
• syphilis rates increased 1,050% from 1997 to 2006: primarily in males over 30 years (74%); rates of HIV co-infection are high
• in 2006 there were 250,000 hepatitis C cases in Canada: hepatitis C/HIV+ co-infections are high (14.5%); in 2006, 11,000 cases were attributed to contaminated blood and IDU use in youth; rates are four to five times higher in Aboriginal communities
• there were 1,619 cases of TB in Canada in 2006: TB/AIDS co-infections represent 5.8% of AIDS infections, with co-infection more likely in persons born outside of Canada, in Aboriginal persons and IDU

Challenges

1. Canada’s geography presents challenges in delivering services to remote locations—areas where a large percentage of the Aboriginal communities are located. Although the majority (80%) of Canada’s population lives in urban centres and progress is being made with respect to service delivery in these areas, access to comprehensive prevention, diagnosis, treatment, care and support services in rural areas continues to be affected.
2. Service delivery is through the provinces—variances in reporting tools and data collection methods, as well as challenges in sharing health data across jurisdictions, continue to affect the analysis and assessment of HIV and STBBI rates across the country. HIV and co-infection status are not routinely collected or reported; comprehensive reporting standards and tools are called for.
3. Hepatitis C and HIV+ is currently one of the most clinically relevant co-morbidities in the HIV population. TB is harder to diagnose and progresses faster in HIV+. Care for people with co-infections further complicates prevention and treatment regimes, requiring expertise across several disciplines; however, co-infections can be treated successfully, particularly with early diagnosis and treatment. Tools and approaches to support this are required.

Strategic Directions

Canada recognizes that mitigation of the HIV/AIDS epidemic and STI incidence can be achieved through the provision of integrated and comprehensive prevention, diagnosis, treatment, care and support. Canada’s strategic orientation also reflects a holistic view of intervention—by taking action on the determinants of health (i.e., poverty, education, homelessness), service providers can collectively address public health issues such as HIV, STIs and TB. This approach also acknowledges the specific population and regional epidemics, and supports the development of innovative evidence-based responses to meet the needs of those populations.

Canada is investing in second generation (enhanced) surveillance systems to study trends in HIV and STBBI prevalence, associated risk behaviours and conditions among key populations. Specialized laboratory services also support surveillance, quality assurance testing and molecular epidemiology services. Observing STI incidence can also serve to identify risky sexual behaviours in populations. Broader strategies can be informed by this assessment of epidemiology, risk behaviours, risk conditions and risk populations. 

Canada invests in numerous strategic partnerships, committees, and advisory and policy fora to facilitate coordination, engage leadership and improve stakeholder engagement in policy and program development. This includes dialogue and collaborative action across jurisdictions and sectors to formulate high quality and effective responses to HIV and co-infections. Primary interventions include: increased screening rates; testing and counseling guidelines; integrated service delivery combining testing, treatment and referrals in one location for HIV, STIs, hepatitis C and TB; prevention programs that recognize vulnerabilities and resilience to co-infections; and anti-stigma and discrimination measures.

Summary and Conclusions

Dr. Miguel Gomez of the U.S. Department of Health and Human Services closed the session with summary remarks that reinforce the importance of the participating high resource/low HIV/AIDS prevalence countries to continue the discussions initiated in the session.

Dr. Gomez reiterated that lessons and best practices are available to share, with many results expected to be available in the near term given the current state and variety of activity with respect to the integration of HIV and co-infection responses across the participating countries. 

Jurisdictions are adopting approaches that are compatible with their health care systems―for example, that make use of existing services and health care providers, and that are consistent with priority needs. Approaches also reflect how structures are in put in place—whether they are legislative, political, governance and/or resource based (funding, expertise, centres, etc.). Although approaches vary, the concept fundamental to program integration for HIV and co-infections is shared—each developed country acknowledges the benefits and challenges of moving towards a more integrated approach to the response. Integration provides for comprehensive and high quality services to address the realities of the diseases and the needs of the population.

Concrete actions in the areas of surveillance, program design, partnership models and investment in research can be pursued and enriched by collaboration across jurisdictions, by sharing expertise and knowledge, lessons learned and best practices. Increasing policy coordination within jurisdictions as well as globally should be supported through open sharing of information and concrete collaborative efforts.

The AIDS 2008 Conference provided an opportunity to gather and to discuss approaches to integrating responses to HIV/AIDS and co-infections—clearly a priority issue for many countries. Discussion, action and results can contribute to the global dialogue to improve the response to HIV and co-infections around the world. An extension of the dialogue to other high resource/low HIV/AIDS prevalence countries was favoured by participants as a mechanism for expanding the network to include expertise and capacity of other developed countries. Taking action to establish an international policy network that would reinforce collaboration on program and policy actions to meet the needs of developed countries was identified as an important next step by all participants.

The group identified other important guidance for moving forward, including the importance of reflecting issues from across jurisdictions, to the extent possible, in recommendations and guidelines. In addition, best practices, results of surveillance and models of integration must be shared in order to inform policy and program development across jurisdictions. Local level issues were also highlighted, including the need for supporting flexibility and the adoption of practices that reflect community needs, as well as the value of designing prevention interventions “from the bottom up”—an approach that involves front-line health providers in discussions and recommended approaches.

Participants also identified the need for ownership and leadership to be embraced by each involved “silo,” with each recognizing and actively demonstrating that integration is valued and valuable. They recognized that positive change can only be inspired when structural barriers are eliminated, and also that encouraging those involved in policy and programming to change their approach (to one of integration), while remaining effective, will be challenging.

Panelists pointed to the ANISI group as a possible model for an international policy network for HIV and co-infections. More generally, they supported the use of existing conferences and bodies that meet regularly to take advantage of every opportunity to advance discussions, while minimizing costs. Panelists also supported building into the AIDS Conference agenda a permanent theme of integration.