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Contribution of Molecular Virology to the Understanding of the Madagascan HIV Epidemic

Contribution of Molecular Virology to the Understanding of the Madagascan HIV Epidemic. F Lamontagne (1), G Lurton (1), S Andriantsimietry (2), ML Chaix (3), M Randria (4), J Nely (4), CB Ramamonjisoa (4), JS Lalao (4),

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Contribution of Molecular Virology to the Understanding of the Madagascan HIV Epidemic

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  1. Contribution of MolecularVirology to the Understanding of the Madagascan HIV Epidemic F Lamontagne (1), G Lurton (1), S Andriantsimietry (2), ML Chaix (3), M Randria (4), J Nely (4), CB Ramamonjisoa (4), JS Lalao (4), H Rahasana (4), F Huber (1), L Pizarro (1), RL Razanakolona (2), C Rouzioux (3) • SOLTHIS NGO, Paris, France • National ReferenceLaboratory of HIV/STI, Antananarivo, Madagascar • APHP, Necker Hospital, Paris, France • BefelatananaTeachingHospital, Antananarivo, Madagascar 5. Diana RegionalHospital, Antsiranana, Madagascar 6. MahabiboHealth Center, Majunga, Madagascar 7. MenabeRegionalHospital, Morondava, Madagascar 8. Toamasina RegionalHospital, Madagascar

  2. The paradoxes of madagascanepidemic • Numerousrisk factor for HIV transmission in general population (sexualbehavior, condom use, STI rate…) • Low HIV prevalence(0.2%,UNAIDS 2010) • None mostatrisk population clearlyidentified (exceptrecently MSM) • Concentratedepidemicsuspected • Intensive national VCT program • <10% of expected HIV population diagnosed • Many viral subtypes in previousstudies

  3. Objective • Betterunderstanding of thisepidemic • Strategy: • Use of virological data • Confrontation with: • Socio-bevavioral profile • Place of residence

  4. Method Antsiranana (Diana) Main ART sites Majunga (Boeny) Toamasina (Atsinana) Morondava (Menabe) Antananarivo (Analamanga) Toliara (Atsimoandrefana)

  5. Method HIV infected patients attending ART clinics Antsiranana (Diana) Main ART sites Blood samplessystematicallycollected Majunga (Boeny) Jan/Apr 2008  86 Toamasina (Atsinana) Morondava (Menabe) Antananarivo (Analamanga) Toliara (Atsimoandrefana)

  6. Method HIV infected patients attending ART clinics Antsiranana (Diana) Main ART sites Blood samplessystematicallycollected Majunga (Boeny) Jan/Apr 2008  86 Toamasina (Atsinana) Aug/Sept 2010  74 Viral load DR test (genotype) Viral subtype Phylogeneticanalysis Morondava (Menabe) Antananarivo (Analamanga) Place of residence Behavioralcharacteristics (MSM, sexworker, potential clients of sexworkers, migrant or partner of migrant) Toliara (Atsimoandrefana)

  7. HIV diversity • N=160 subjects • N=118 with viral load>500 cp/ml 10 subtypes

  8. Drug resistance High level of HIVDR • N=160 subjects / N=118 with VL>500 cp/ml • N=35 viruseswith major HIV drugresistance (DR) mutations p<0.001 79% Poster A-403-0050-03391 High Level of Transmitted HIV Drug Resistance Caused by a Viral Cluster: The Singular Case of Madagascar

  9. Distribution of viral subtypesby regions Diana 1 A1, 16 B, 10 C, 3 CRF02, 1 CRF06, 6 non determined (ND) Boeny 3 B, 16 C, 1 CRF06, 2 CRF15, 3 ND Atsinana 2 B, 1 C, 1 D, 3 ND Menabe Analamanga p<0.01 13 A1, 1 B, 1 C, 2 ND 5 A1, 1 A2, 8 B, 7 C, 1 F, 1 G, 2 CRF02, 6 ND p<0.001

  10. Behavioral profile p<0.001 p<0.001 *sailors, miners, military staff, commercial drivers…

  11. Multiple CorrespondenceAnalysis

  12. Hierarchicalclustering 1 2 3 Others viruses B viruses A1 viruses

  13. Multiple CorrespondenceAnalysis & Hierarchicalclustering Others viruses B viruses A1 viruses

  14. Relevant characteristics: B viruses Phylogenetic tree of subtype B viruses(N=17, 2008) • High HIVDR level (80%) • Frequency: • in Diana region (43%) • Among MSM (52%) Poster A-403-0050-03391 High Level of Transmitted HIV Drug Resistance Caused by a Viral Cluster: The Singular Case of Madagascar • DR major mutations • 215 D • 215D+210W • Autres/Absence 98 96 96 B Ref B Ref B Ref B Ref B Ref

  15. Relevant characteristics: A1 viruses • Absence of main behavioralrisksfactors for HIV (0%) • Mainlylocalized in Menaberegion (68%) • Geolocalization of PLWH fromMenabeRegion Tarred road Damagedtarred road Track (non passable in rainyseason) Residence of PLWH (proportional size) Miandrivazo Belo/Tsiribina Morondava Mahabo Administrative centers Manja

  16. Conclusions • Confrontation of virologic and socio-behavioral data provided a new lighting • Madagascan epidemic appears composed by several sub-epidemics: • Of different origins (as shown by their viral subtypes) • With specific characteristics • This deeper understanding could help policy makers: • To develop more targeted testing and prevention programs • To adapt their treatment strategy “know your virus,” + “know your epidemic, know your response”

  17. Acknowledgements

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