Molecular surveillance reveals a recent outbreak of HIV-1 subtype C - - PowerPoint PPT Presentation

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Molecular surveillance reveals a recent outbreak of HIV-1 subtype C - - PowerPoint PPT Presentation

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Molecular surveillance reveals a recent outbreak of HIV-1 subtype C infections among people who inject drugs (PWID) in Munich, Germany Norbert Bannert 05.05.2018 Arevir-Meeting 05.05.18 Arevir-Meeting 2 Spread of HIV Subtype A Variant FSU

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Molecular surveillance reveals a recent

  • utbreak of HIV-1 subtype C infections

among people who inject drugs (PWID) in Munich, Germany

Norbert Bannert 05.05.2018 Arevir-Meeting

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05.05.18 Arevir-Meeting 2

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Thomson et al. 2015

05.05.18 Arevir-Meeting 3

Spread of HIV Subtype A Variant FSU (AFSU) in the Countries of the Former Soviet Union

HIV-1 AFSU arrives in Odessa 1980 1990 2000 2010 2020 HIV-1 AFSU is introduced into PWIDs in Odessa 2002: 200,000 cases1

1Bobkova et al. 2013 2Estimate based on Beyrer et al. 2017

1999: 30,000 cases (ca. 93%)1 2017: 800,000 AFSU cases in Russia (ca. 70% of cases)2

  • 40-50% of new HIV-1 infections are in PWIDs (in 2007: 83%)
  • 70% of the infections are caused by HIV-1 subtype AFSU

HIV Outbreak

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05.05.18 Arevir-Meeting 4

  • 5 HIV Infections in 2003-2014 in Austin IN
  • Sharp increase in new HIV diagnoses beginning in December 2014 in PWIDs

Scott County, Indiana, USA 2014-2015 HIV-1 Outbreak

Austin, IN

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05.05.18 5

Scott County, Indiana, USA 2014-2015 HIV-1 Outbreak

  • Indiana law made it illegal to possess

a syringe without a prescription

  • Sharing of needles was common

(up to 6 partners)

  • 142/181 cases injected Oxomorphone
  • 4-6 daily injections
  • 95% were HCV coinfected
  • Gov. Mike Pence at a news

conference in Indianapolis on March 26, 2015. Mr. Pence declared a public health emergency in response to the H.I.V. epidemic in Scott County and put aside his own views in order to allow a program to distribute clean needles to drug

  • users. Credit Michael/NYtimes.com

Conroy/Associated Press Arevir-Meeting

Rights by Clay Duda

Peters et al. NEJM 2017

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Acquisition of Samples for the Molecular Surveillance

  • f New HIV Diagnoses in Germany
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09.04.18 Virologisches Seminar 7

Analysis of the statutory notification data from the southern German state of Bavaria shows a significant increase in new HIV-1 diagnoses in PWID in 2016.

12 DSS 29 DSS

Increase of Reported New HIV-1 Diagnoses in PWIDs in Bavaria in 2016

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Subtyping Reveals a High Subtype C Prevalence in the Bavarian PWID Cases in 2015/2016

2015 2016

3/12 (25%)

2015

Germany (2013-2016)

2013/2014

14/29 (48%)

2016

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  • HIV-1 subtyping of samples from Bavaria and phylogenetic analysis

reveals that the increase is driven by a cluster of subtype C infections.

Maximum Likelihood Tree of several hundred subtype C sequences. 17 of the Bavarian PWID cases diagnosed between March 2015 and December 2016 (shown in blue) are part of a larger transmission cluster (red box).

Phylogeny of Subtype C Infections

23/24 cases were diagnosed in Munich and 1/24 in Augsburg

Munich subtype C outbreak

0.02
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(9)

(4) (3)

(3)

(1) (1)

(2)

(1)

Stadelheimer Str. 12, 81549 München Justizvollzugsanstalt München

Location of Cases in Munich

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  • Four sequences are long-standing (time between infection and diagnosis longer

than 5 months).

  • Only two new infection belonging to this cluster were reported from Bavaria (both

from Munich) in the first six months of 2017 (Outbreak stabilization).

Diagnosis Dates of the Outbreak Cases

Number of Cases Month of Diagnosis

recent long standing 05.05.18 Arevir-Meeting 11

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Characteristics of the Individuals Associated with the Transmission Cluster of HIV-1 Subtype C Infections in Bavaria

Age: 26-51, Ø=36

Anti-HCV (n=23)

*self-reporting n.d.: not done

05.05.18 Arevir-Meeting 12 Gender (n=26) Risk group (n=26)

Case # Sex* Transmission group* Country of origin* Country of infection* anti-HCV HCV-RNA

1 Male PWID Eastern Europe Germany n.d. n.d. 2 Male PWID Germany Germany + + 3 Male PWID Western Europe Germany

  • 4

Male PWID Germany Germany +

  • 5

Male PWID Germany Germany +

  • 6

Male PWID Germany Germany + + 7 Male PWID Eastern Europe Germany + + 8 Male PWID Germany Germany + + 9 Male PWID Germany Germany + + 10 Male HET Germany Germany + + 11 Male MSM Germany Germany + + 12 Female PWID Germany Germany + + 13 Female PWID Germany Germany + + 14 Male PWID Germany Germany + + 15 Male PWID Germany Germany

  • n.d.

16 Female HET Germany Germany + + 17 Male PWID Germany Germany + + 18 Male PWID Germany Germany + + 19 Male HET Germany Germany + + 20 Not reported Not reported Not reported Not reported + n.d. 21 Male Not reported Germany Not reported + + 22 Male PWID Not reported Germany + + 23 Female HET Germany Germany +

  • 24

Male PWID Germany Germany n.d. n.d. 25 Male PWID Germany Germany n.d. n.d. 26 Female PWID Germany Germany + +

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Recent Outbreaks among PWIDs

Stadt/Region Jahr Infektionen Stabilisierung Droge Athen 2011-2012 256 2015 Kokain Tel Aviv 2012-2013 40 2014 Hagigat Scott County 2014-2015 181 2015 Oxymorphone Dublin 2014-2015 38 2015 Snow blow Luxemburg 2014-2015 67 ? Kokain Glasgow 2015 100 ? München 2015-2016 26 2017 ?

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SLIDE 14 https://www.zauberpilzblog.net

New Psychoactive Substances (NPS)

Hundreds of substances; main chemical classes:

  • Synthetic Cannabinoids
  • Synthetic Cathinones
  • Phenethylamines
  • Tryptamines
  • Piperazines
  • Pharmacological effects unexplored
  • Strong addiction effect
  • Cheap and easy to buy (Internet)
  • Many were legal (legal highs) until 11/2016
  • Frequent intravenous injection common

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  • NPS associated increase in the frequency of intravenous injections
  • Common intravenous consumption of NPS in groups

Is there an association of the Munich outbreak cases with injection of new psychoactive substances (NPS)?

Risk Faktors for HIV Infection of PWID Consuming New Psychoactive Substances (NPS)

Arevir-Meeting

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  • Prof. Dr. rer. nat. Dipl.-Chem. Volker Auwärter

+ Christina Grumann (PhD) Institut für Rechtsmedizin Forensische Toxikologie

In 5 of 10 DSS a-PVP was identified (a-PVP: α-Pyrrolidinopentiophenone)

Evidence of an Association of the Munich Outbreak with a-PVP

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  • We have identified a recent local outbreak of HIV-1 subtype C infections among PWIDs

in Munich with at least 26 cases (21 cases in 2016).

  • Health authorities in Bavaria were informed in June 2017.
  • The molecular surveillance of new HIV-diagnoses reported from Bavaria has been

instantly intensified, but only two new case belonging to the outbreak cluster were identified in the first 6 month of 2017.

  • We have found strong evidence for an association of the Munich outbreak cases with

needle sharing and frequent injection of a-PVP, a new psychoactive substance (synthetic cathinone).

  • The recent sub-epidemics in Europe show that HIV-surveillance of vulnerable groups,

especially PWIDs, is an important public health issue. Despite current prevention measures, HIV-outbreaks can occur and need to be identified early to allow an adequate response.

  • The statutory reporting system in Germany (IfSG) together with the established RKI

program “Molecular Surveillance of newly diagnosed HIV-infections (MolSurv_HIV)” is suited for an early detection and analysis of such regional HIV outbreaks.

Summary and Conclusions

Arevir-Meeting

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Diagnostic labs Kirsten Hanke Andrea Hauser Patrycja Machnowska Stefan Fiedler Karolin Meixenberger Britta Altmann Barbara Gunsenheimer-Bartmeyer Alexandra Hofmann Viviane Bremer Uli Marcus Ruth Zimmermann

Acknowledgments

Volker Auwärter Christina Grumann Oliver Ratmann

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08.02.16 EUPHEM 19

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Contact tracing networks (Scott County outbreak)

Main measures to put an HIV outbreak among PWIDs on hold

  • Needle and syringe exchange programs (NSP)
  • Opioid substitution treatment programs (OST)
  • Frequent HIV-testing and assignment of cases to clusters
  • Linkage to care and treatment (e.g. HIV-treatment as prevention)
  • Seek-test-treat programs (including contact network analysis)
  • Condom provision
  • Intensified community outreach counseling
  • Raising of general awareness for the HIV sub-epidemics
  • Effective collaboration across multiple sectors (community, local

health authorities, federal health authorities, drug counselling services, HIV counselling services and others

How to Address HIV-Outbreaks Among At-Risk-Populations?

Need for rapid detection of sub-epidemics

  • Timely and comprehensive reporting of new diagnoses
  • Immediate analysis with regional resolution
  • Almost real-time phylogenetic analysis of new diagnoses

Respondent-driven sampling (Athens outbreak, ARISTOTLE)

HIV+ HIV-

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