The occurrence, frequency, distribution and determinants of HIV and AIDS are described for Maltese residents. Up to 30 June 1996, 38 notifications of AIDS were received by the Public Health Department (36 in males), 35 died. The overall mean survival between notification date and death was calculated using data for 28 reported cases as 216.71 days. Mean age at notification was 30.5 years (range: 2 to 48; median 31). Occurrence in males was highest for homosexuals/bisexuals (52.8%), followed by recipients of contaminated blood products (30.6 %) and heterosexual contact (5.6%). The two females acquired HIV through mother-to-child transmission (abroad) and heterosexual intercourse respectively. Mode of transmission was unrecognised in 7.9% of cases. Epidemiological data on AIDS cases usually reflects the situation of HIV transmission some twelve to fifteen years previously. Sero-surveillance studies are now indicated to clarify the actual prevalence of HIV infection.peer-reviewe

Amato-Gauci, Andrew J.

Vella, K.A.

English

OAR@UM

17 Maltese Medical Journal, 1996; 8 (2): 17-20 All rights reserved Epidemiology of AIDS in Malta K A Vella*, A J Amato-Gaucj* Abstract: The occurrence, frequency, distribution and determinants of HIV and AIDS are described for Maltese residents. Up to 30 June 1996,38 notifications of AIDS were received by the Public Health Department (36 in males), 35 died. The overall mean survival between notification date and death was calculated using data for 28 reported cases as 216.71 days. Mean age at notification was 30.5 years (range: 2 to 48; median 31). Occurrence in males was highest for homosexuals/bisexuals (52.8 %), followed by recipients of contaminated blood products (30.6 %) and heterosexual contact (5.6%). The two females acquired HIV through mother-to-child transmission (abroad) and heterosexual intercourse respectively. Mode of transmission was unrecognised in 7.9% of cases. Epidemiological data on AIDS cases usually reflects the situation of HIV transmission some twelve to fifteen years previously. Sero-surveillance studies are now indicated to clarify the actual prevalence of HIV infection. "Department of Public Health, Yalletta Correspondence: 	 Or K A Vella, Disease Surveillance Branch, Public Health Department, 15 Merchants Street. Valletta CMR 02 Keywords: 	 epidemiology, AIDS, HIV, Malta, surveillance, distribution, transmission categories This article is bosed Oil 0 I'al'er read ot the Third Ma/tese Medical School COIl/ereIlCe, 29th NOl'elll/Jer - 21ld Decelllber 1995. AIDS in Malta, the region and the world 7 According to published estimates, 27.1.) million people 6 world-wide were infected with HIV from the beginning of the pandemic until mid-11.)1.)6. Of these, 14,9 million 5 were men (58 GIr)) and 10,5 million were women (42 o/c)), c: (J) 0The majority of HlV infections - 26 million (1.)3 %) - '+=, 4 have occurred in developing countries, This figure is '" 0 ;;::: '+=,expected to climb to a total of sOl11e 40 million by the 0 3 end of the century I, Z 2In Europe, every day, 200 persons are new Iy infected with HIV and 70 persons are diagnosed with AIDS. By 131 March 191.)6, a cumulative total of 168,111 AIDS cases including 6,297 paediatric cases had been reported oin the WHO European region 2. 	 <0 ,... 00 .,.0 	 LD ~ 00 00 00 '"00 '" '" In The Global Programme on AIDS in the European 	 '" '" '" '" '" '" '" '" " >'" '" '" '" '" '" '" '" :-Qc; Region' report for 1994 and 1995, Malta ranked 20th 	 E ;; iD"highest amongst 	the 50 WHO Member States with a '" '" cumulative AIDS incidence of 8,3 per 100.000 YearpopUlation (at end 1994), The cumulative incidence at end June 1996 was up to 9.8 per 100,000 population, Fig, 1 - Notifications of AIDS, Malta, up to 30 June 1996. The number of notifications of AIDS in Maltese Source: Disease Surveillance Branch, Public Health Department residents over the last decade is graphically represented (Figure I), (A Maltese resident is any person residing in Also, several homosexual men voluntarily presented Malta for a period of six months or longer), themselves for testing and were also found to be positive for HIV, Transmission of HIV amongst the local History homosexual community was later confirmed, Homosexual intercourse is still the predominant risk As far as can be established, the Human behaviour Cor infection seen in Maltese AIDS patients Immunodeficiency Virus (HIV) was first introduced into today, Malta in 1984 in Abbott Anti-Haemophilic Factor (the The first documented case of AIDS in Malta came to exact date however remains uncertain), and in a few the attention of the Superintendent of Public Health in returned HIV positive homosexual men, previously 1985, In December 1986, a National Advisory domiciled and almost cenainly infected abroad, Committee on AIDS was established, By this time five As soon as the ELISA test became cOIllmercially cases 01' AIDS had already been reported and it was available in June 1985, all Maltese persons with estimated that there were about 25 HIV poslti ve persons coagulation disorders were offered the HIV test. All amongst the resident population of the Island, these patients tested positive for HIV, A National Educational Campaign organised by the I 18 K A Vella, A J Health Education Unit of the Department of Health in conjunction with the National Advisory Committee on AIDS was established. This included the publication of an information booklet, leaflets and posters , articles in the press, radio interviews, television advertisements, an answering machine information service, seminars and workshops for school teachers, as well as talks to schoolchildren 3. The WHOjCDC AIDS surveillance case definition 4 was formally adopted in January 1988 and a c ircular to this effect sent to all doctors 5.6 . Table I gives the list (revised 1987 4 and 1993 7,X) of the AIDS Indicator Diseases for Notification purposes . Table 1 - AIDS indicator diseases for notification purposes A. Opportunistic infections • Bacterial infections, multiple or recurrent in a child under 13 years of age • Candidiasis of bronchi, trachea or lungs, oesophageal • Coccidioidomycosis disseminated or extrapulmonary • Cryptococcosis ex trapulmonary • Cryptosporidiosis intestinal with diarrhoea (> I month's duration) • Cytomegalovirus disease (other than liver, spleen or nodes) in a patient> I month old, CMV re tinitis (with loss of vision) • Herpes simplex chronic ulcer(s) (> I month's duration); or bronchitis, pneumoni tis or oesophagitis in a patient >1 month old • Histoplasmosis disseminated or extrapulmonary • Isosporiasis intestinal with diarrhoea (> I month's duration) • Mycobacterium aviurn complex or M. kansasii disseminated or extrapulmonary • Mycobacterium tuberculosis any site (pulmonary or extrapulmonary) • Mycobacterium , other species, di sseminated or extrapulmonary • Pneumocystis carinii pneumonia • Pneumonia, (recurrent) • Salmonella septicaemia, (recurrent) • Toxoplasmosis, (brain) B. Other diseases • Cervical cancer, invasive • HIV related Encephalopathy • Kaposi's sarcoma • Lymphoid interstitial pneumonia in a child under 13 years of age • Lymphoma, Burkitt's, immunoblastic, primary of brain • Wasting syndrome due to HIV Amato-Gauci This definition was further revised for surveillance in children in 1995 <) Transmission of HIV is not known to have occurred locally amongst injecting drug users . One Maltese homosexual male who tested positive also had a past history of injec ting drug use (lDU) abroad . It is unlikely that this case was infected through local sharing in IDU. A total of some 800 atlendees have been screened through the Detoxification Unit, St. Luke's Hospital : no Maltese res idents have tested positi ve for HI V. but several foreigners and their partners who attend the Detox Unit test positive each year 10. AIDS surveillance Voluntary HIV testing is confidential. This makes discrimination between separate and repeat testing by the same individual difficult to determine although the medical practitioner requesting the test is usually contacted to try to eliminate duplication of data. Routine screening for HIV is carried out on all blood and organ donations. This IS not considered as surveillance, but rather as quality control to safeguard recipients. Information in this regard is only available as unlinked, anonymous aggregate data. Although all diagnostic HIV tests are processed at one site (Virology Laboratory, St. Luke's Hospital), use of data gleaned from these records offer limited scope in epidemiology. The info1111ation given on the request forms is limited. and often if}complete (unpublished data, Virology Unit , St. Luke's Hospital). Notifications of AIDS in Malta In a small population such as ours, the level of notification of AIDS may be assumed to be more or less complete, given that the nature and se verity of the illness sooner or later necess itates access to the centralised secondary referral centres. The mean survival in days from notification till certified death was calculated using all available data for 28 local residents. The mean survival was 216.71 days (range: I to 1064 ; median:87.5 ; S.D: 301.81). Data on the 4 cases notified at death was excluded for the purpose of this calculation. However , the value for the mean remains low as in many cases practitioners are reluctant to notify, often for reasons of confidentiality in such a small community. This creates an artificially short lag between time of initial diagnosis and time of notification. Patients are known to be seeking treatment overseas and therefore these fail to be included in the local statistics. Figure 2 shows the survival curve for 31 notified cases of AIDS in Maltese residents (for whom data is complete) for the period 1986 to June 1996. Present situation From the first case reported in 1985 up to end of June 1996, a total of 78 Maltese residents are known to ha ve been infected with HIV (an average of 6.2 new cases of HIV infection recorded each year). Another 26 cases of HIV infection occurring amongst persons of other or unknown nationality have been recorded locally. These 19 Epidemiology of AIDS in Malta Day ~ <log !lca.l e ) Fig . 2 - Survival for 31 notified AIDS cases, Malta 1986-June 1996. Source: Disease Surveillance Branch,Public Health Department. are not in9luded in the figures presented. Of the 78 HIV positive persons, 38 (36 males) are known to have been diagnosed with AIDS according to the WHO/CDC AIDS defining criteria. The reported AIDS defining conditions in Maltese patients are shown in Table 2. Table 2 - Reported AIDS Defining Conditions, Malta, up to 30 June 1996 Opportunistic infection 27 Kaposi's Sarcoma 3 Opportunistic infection + 2 Kaposi's Sarcoma Lymphoma 2 HIY encephalopathy 4 By the 30 June 1996, 35 persons with AIDS (34 males) died. Five of these persons died in the first half of 1996; which is the highest rate for annual deaths so far. Figure 3 depicts the distribution of persons with HTV by age group and gender. HIV positivity is documented for 68 males and 8 females (gender unknown for 2 additional cases). The age-range of HIV positive persons is known for 65 of the 78. The most commonly represented age bracket is 30-39 years, the age range for females being 1 to 39 years; that for males I-50 years. 60·69 40-49 U> 30·39 >­26-29 c. :> 0 20-24 \5 ., 16-19 0 <{ '3"4 ~ • Female 10_12 11 Male <10 10 16 20 No. of Individuals Fig. 3 - Persons with HIV by age group and gender, Malta, up to June 1996. Source: Disease Surveillance Branch,Public Health Department. Transmission The likely mode of transmission is known for 63 of the 78 cases of HIV - Figure 4. Males HTV positivity in males remains highest amongst homosexuals/ bisexuals (31 cases); followed by recipients of contaminated blood products (22 cases) and heterosexual contacts (4 cases). One other case occurred in a homosexual male who also had a past history of injecting drug abuse abroad. Females Four of the 8 reported HIV positive females are likely to have been infected through heterosexU<11 contact and one through blood products administered abroad . Mother-to-child transmission occurred in one baby delivered abroad to a Maltese woman. The mode of transmission could not be ascertained for the other 2 cases. Homo-/bi­sexual males 42% sexual Hetero­sexual 9% Homo'/bi. ­+ idu labroad) 1% Products ~ 19% 28 % Mother.to. child labroad) 1% Fig. 4 - Modes of transmission for persons with HIV, Malta (till June 1996). Source: Disease Surveillance Branch, Public Health Department What about the future? The dynamics of infection in Malta are still unclear and behavioural studies are needed to support interventions to prevent further spread or the epidemic. Studies of prevalent knowledge, attitudes and behaviour concerning HIV / AIDS, including information on average age at first sexual intercourse, number of sexual partners , 'safer' sexual practices (including condom use) will be essential for rational, targeted prevention campaigns. Trends in Europe J J (Figure 5) clearly show a slow and steady increase in those infected through heterosexual contact, with women becoming especially vulnerable. The main risk behaviour of concern however is now injecting drug use, especially in Southern Europe 12. If Malta follows these trends, preventive programmes should primarily address injecting drug use, where particularly rapid spread is known to occur. These should include both Demand Red uction and Harm Reduction Strategies (e.g. needle exchange programmes) . A second priority should be targeting prevention of sexual transmission (especially amongst young people) through 'safer' sexual practices. 'Safer sex' emphasises a more responsible attitude to sex i.e. mutual monogamy with a non-infected partner, avoiding multiple sexual partners or casual or anonymous sex and consistent use of condoms with all partners. l K A Vella, A J Amato-Gauci20 References I. 	 Final report. The Status and Trends of the Global HIV/j AIDS Pandemic. July 5-6, 1996. XI International. .. 100%'''~ Conference on AIDS. Vancouver July 7-12 , 1996. 2. 	 European centre for the Epidemiological Monitoring of• .:::-: '" '" _c. ....~ 80% . '. . " ,. 70% Q) g' ~ 60% 50% fl 1 1\.\ ~ 40% p., 30% 20% 10% 0% 1-1-1-',-1-1-1-1-1~ ~ ~ ~ ~ ~ ~ m ~ ~ ~ ~ Year of diagnosis • Homo/Bisexual a Intravenous Drug • Homo/Bisexual + males Users IOU D Transfusion fillII Heterosexual. nu Other/Undet . reCIpients Fig. 5 - Adult/Adolescent AIDS cases by transmission group (%) and year of diagnosis (adjusted for reporting delays) WHO European region 31.12.95; N= 154437. Source: WHO / EC AIDS Centre Saint Maurice - France AIDS. HIV/ AIDS Surveillance in Europe, Quarterly Report 1996: no 49: 7. 3. 	 Galea G. AIDS in Malta: An Overview. Health Education Unit, Department of Health, Malta 1989. 4. 	 World Health Organization. 1987 revision of CDC/WHO case definition for AIDS. Weekly Epidemiological Record, 1988: 63:1-7. 5. 	 Department of Health. Malta. DH File 645/88/Vol I. AIDS Surveillance. DH Circular No 66/88: 14 April 1988. 6. 	 Department of Health. Malta. DH File 645/88/Vol I. AIDS Surveillance. DH Circular No 90/88; 25 May 1988. 7. 	 Ancelle-Park R. Expanded European AIDS case definition. Lancet, 1993: 341 :441. 8. 	 European centre for the epidemiological monit oring of AIDS. 1993 revision of the European AIDS surveillance case definition. AIDS Surveillance in Europe, Quarterly Report 1993: no 37: 23-28. 9. 	 European centre for the epidemiological monitoring of AIDS. European case definition for AIDS surveillance in children - revision 1995. HIV/AIDS Surveillance in Europe, Quarterly Report 1995: no 48: 46-53. 10. 	 Falzon D. Prevention of Hepatitis C - A Policy for Malta. 1995. 11. 	 European centre for the epidemiological monitoring of AIDS. WHO-EC Collaborating Centre on AIDS, Saint­Maurice. France. AIDS Surveillance in the European Region at 31 December 1995. 12. 	 Quinn TC. HIV series. Global burden of the HIV pandemic. Lancet 1996: 348:99-106. The copyright of this article belongs to the Editorial Board of the Malta Medical Journal. The Malta Medical Journal’s rights in respect of this work are as defined by the Copyright Act (Chapter 415) of the Laws of Malta or as modified by any successive legislation. Users may access this full-text article and can make use of the information contained in accordance with the Copyright Act provided that the author must be properly acknowledged.  Further distribution or reproduction in any format is prohibited without the prior permission of the copyright holder. This article has been reproduced with the authorization of the editor of the Malta Medical Journal (Ref. No 000001)  

Adult/Adolescent AIDS cases by transmission group (%) and year of diagnosis (adjusted for reporting delays)

AIDS in Malta: An Overview. Health Education Unit, Department of Health,

European centre for the epidemiological monit oring of AIDS.

European centre for the epidemiological monitoring of AIDS.

European centre for the epidemiological monitoring of AIDS. European case definition for AIDS surveillance in children - revision

Expanded European AIDS case definition.

Prevention of Hepatitis C - A Policy for

revision of CDC/WHO case definition for AIDS. Weekly Epidemiological Record,

Epidemiology of AIDS in Malta

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Epidemiology of AIDS in Malta

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