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!Molecular!Epidemiology!of!HIV!in!!San!
Diego!and!Tijuana!
Tracking!HIV!
Sanjay!Mehta!MD!
Assistant!Professor!
February!2015!
How!Does!an!InternaGonal!Border!
Affect!the!Spread!of!InfecGous!
Diseases!
www.globecartoon.com!
Ebola!and!Air!Travel!
• An!esGmated!2.8!travelers!with!Ebola!board!an!
internaGonal!plane!each!month!
Bogoch,!Lancet!Jan!2015!
www.darrinbell.com!
SARS:!The!Metropole!Hotel!
US!Central!Intelligence!Agency!
San!DiegoTTijuana!Border!
San!Diego!County!
!pop!3.1!million!
San!Diego!City!
!pop!1.3!million!
Tijuana!
! !pop!1.3!million!
San!DiegoTTijuana!Border!
• Worlds!busiest!
land!border!
• Over!50!million!
border!crossings!
each!year!
CityTdata.com!
Inthedf.com!
San!Diego!Tijuana!Border!
• How!likely!is!this!going!to!stop!the!spread!of!infecGous!
diseases!across!the!border?!
Lest!We!Forget!
faculty.catawba.edu!
2009!H1N1!Influenza!Epidemic!
• From!a!small!town!in!
Veracruz,!Mexico!the!
2009!H1N1!epidemic!
spread!into!Imperial!and!
San!Diego!counGes!first!
in!the!US.!
Scienceblog.com!
Cameron!et!al!JIDC!2009!
Dengue!
• 14!confirmed!
cases!of!Dengue!
in!Baja!California!
• A.!aegypG!found!at!
32nd!st!Naval!StaGon!
and!in!a!home!in!
Chula!Vista!
Aedes%aegyp*%has!arrived!!
• Transmits!Dengue,! !
Chikungunya!and!
Yellow!Fever!
HIV!in!Mexico!
• In!1980s,!most!HIV!cases!in!
Mexico!were!in!individuals!who!
previously!lived!in!the!US.!
• By!1991,!44.3%!of!cases!were!in!
previous!US!residents.!
• In!2000!the!rate!dropped!to!
~12%,!but!was!higher!in!rural!
areas,!with!over!20%!of!HIV!
cases!in!Michoacán!and!
Zacatecas!acquired!in!the!US.!
MagisTRodriguez!JAIDS!2004!
! Strathdee!et!al!!JAMA!2008!
MigraGon!to!US!
Zacatecas!
Michoacán!
QuesGons!
1) Can!we!demonstrate!that!San!Diego!and!Tijuana!
HIV!epidemics!are!connected?!
2) Is!there!direcGonality!to!viral!migraGon!across!the!
border?!
3) What!risk!factors!are!driving!the!border!HIV!
epidemic?!
!
Molecular!Epidemiology!
Using!the!relaGonships!between!viral!sequence!data!
sampled!from!infected!individuals!to!characterize!the!
spread!of!HIV!!
1) AACTGATCGC
2) AACAGATCGC
HIV!Diversity!
Low!fidelity! High!fidelity!
HSV!
HIV!
HCV! HIV!
Duffy,!Shackleton,!Holmes!2008!
HIV!Diversity!
• Results!in!a!unique!HIV!sequence!for!each!infected!
individual!
• This!unique!sequence!signature!conGnues!to!evolve!
over!Gme!(~1%/yr!for!HIVT1!pol)!
• This!can!be!used!to!
• Study%intra1individual%viral%spread%
• Study%inter1individual%viral%spread%
• Study%epidemics%in%*me%and%space%
The!HIV!Diaspora!
From!Tebit!and!Arts!Lancet!ID,!2011!
Establishing!RelaGonships!
Phylogenetic Trees Network Maps
B!
Network(
Understanding(HIV(Transmission(Networks(
A B C A(Sexual(Network:!Real(World(Network(
• Dashed!lines!indicate!sexual!contact!
D E F
An(HIV(Transmission(Network:(What(we(see(
A C
• Solid!lines!indicate!very!similar!viruses!
• Red!circles!indicate!HIV!infected!persons!
D F • Other!individuals!are!HIV!negaGve!so!don’t!appear!
I
An(Transmission(Network:(Limita?ons(of(our(
A
knowledge(
C
• Dates!of!infecGon!are!used!to!assign!direcGon!of!
transmission!
H D F • New!HIV!infected!persons!already!in!care!appear!
• Other!potenGal!“sources”!of!HIV!transmission!
J! K! idenGfied!
G
• What!we!don’t!see!remains!missing!
Courtesy!of!Susan!Liple!
Why!use!Network!Analysis!!
• PhylogeneGc!analysis!cannot!esGmate!the!direcGon!of!
transmission!with!certainty.!
• Similar!strains!may!be!found!in!many!more!than!two!individuals,!
especially!if!they!are!part!of!the!same!transmission!network.!
• A!network!map!beper!represents!similariGes!between!
sequences! ?
D
? E
A B C F
G
H
23! 11/07/14!
Courtesy!of!Susan!Liple!
Terminology!–!PhylogeneGc!Trees!
Trees!allow!us!to!
1) infer!characterisGcs! Node!
about!ancestors!!
2) Beper!understand!
the!role!of!Gme!
(Tips)
Time!or!GeneGc!Difference!!!
San!Diego!–!Tijuana!Molecular!Epidemiology!
Project!
CollaboraGng!Projects!Across!the!
Border!Region!
• Tijuana!
• Persons!who!inject!drugs!(PWID)!!T!Proyecto!El!Cuete!
• Female!sex!workers!(FSW)!and!Clients!!T!Mujer!Segura,!Mujer!Mas!
Segura,!Proyecto!Parejas,!Hombre!Seguro,!!Amigos!
• Truck!Drivers!–!Crossing!Borders!–!Proyecto!Mapa!
• Community!HIV!clinic!–!CAPACITS!clinic!Tfuture!
• Prenatal!HIV!clinic!–!IMPAACT!T!future!
• MSM!in!Tijuana!Tfuture!
• San!Diego!
• MSM!T!Primary!InfecGon!Research!ConsorGum!!
• PWID!T!STAHR!study!and!STAHR!II!study!
• MSM,!Heterosexuals!TSouth!Bay!Primary!InfecGon!Surveillance!
• MSM,!PWID,!Heterosexuals!–!CHARTER!cohort!T!future!
• MSM,!PWID,!Heterosexuals!T!CNICS!Cohort!T!future!
!
San!Diego!–!Tijuana!Molecular!
Epidemiology!Project!
• Projects!used!various!sampling!methods!
– Respondent!Driven!Sampling!
– Convenience!Sampling!
– VenueTbased!Sampling!
– Targeted!Sampling!
San!Diego!–!Tijuana!Molecular!
Epidemiology!Project!
• Data!collecGon!!
– HIVT1!pol!genotype!(sequence!data)!
– SocioTdemographic!data!(Age,!Sex,!Race,!etc…)!
– Clinical!data!(HIV!VL,!CD4,!STI!infecGon,!etc…)!
– !Risk!Factor!Data!(IDU,!sexual!RF,!etc…!
!
!!!!!TT!Geographic!Data!
San!DiegoTTijuana!Molecular!
Epidemiology!Study!
• 1111!HIV!sequences!were!collected!from!the!
collaboraGng!studies!(including!263!
background!sequences)!
• 4!sequences!were!removed!due!to!lab!
contaminaGon!or!duplicaGon!
• The!remaining!1107!sequences!included!!
– 76!from!subjects!residing!in!Tijuana!
– 768!from!subjects!residing!in!San!Diego!
– 263!background!sequences!from!San!Diego!
Clustering!
• Using!a!network!approach,!we!inferred!the!presence!
of!transmission!clusters!by!inferring!linkages!when!
two!sequences!were!≤!1.5%!different!
• We!idenGfied!164!transmission!clusters!(2T33!
individuals)!
• 17!included!sequences!from!Tijuana,!and!5!included!
sequences!from!both!Tijuana!and!San!Diego!
Data!VisualizaGon!
hpp://Gcino.ucsd.edu/avantgarde/dev_hua/
demo2.html!
!
!
hpp://54.69.246.216/avant_data/
circle_packing!
Clustering!
• 8!Clusters!made!up!of!predominantly!PWID!
– InteresGngly,!bisexual!individuals!were!significantly!more!common!in!
these!clusters!than!others!
• 16!Clusters!were!made!up!predominantly!of!heterosexuals!
– All!of!these!that!had!3!or!more!individuals!were!predominantly!made!
up!of!females!
• 89!clusters!were!made!up!predominantly!of!MSM!
Map(of(the(Observed(San(Diego(–(Tijuana(Transmission(Network(
Tijuana!Clusters!
• 17!clusters!indenGfied!in!subjects!residing!in!
Tijuana!
– Predominantly!involved!sex!workers!and!injecGon!drug!
users!
– In!6!individuals!who!seroconverted!over!the!course!of!the!
study,!4!were!linked!to!another!individual!
– In!two!idenGfied!epidemiologically!linked!pairs!who!
seroconverted!over!the!course!of!!the!study,!only!one!was!
geneGcally!linked!
San!DiegoTTijuana!CrossTBorder!
Clusters!
CrossTBorder!Clusters!
• 5!idenGfied!clusters!including!sequences!from!
San!Diego!and!Tijuana!
– Significantly!higher!proporGon!of!
• Females!(p=0.02)!
• Heterosexuals!(p=0.0003)!
– Consistent!with!our!sampling!
• Suggests!the!heterosexualTPWID!HIV!epidemic!
in!Tijuana!is!linked!to!the!San!Diego!MSM!HIV!
epidemic!
CrossTborder!Clusters!
– 3/5!clusters!included!PWID!and!heterosexuals!in!Tijuana,!
and!MSM!in!US!(i.e.!bridging!of!risk!groups!across!the!
border)!
PWID
MSM
Heterosexuals
(sex workers)
Bridging!PopulaGons!
• Very!important!in!the!Southeast!Asian!epidemic!
Is!there!direcGonality!to!viral!migraGon?!
Faria!et!al,!Science!2014!
MigraGon!Across!the!San!DiegoTTijuana!Border!
Region!
TransiGon!from! !1)San!Diego!to!Tijuana!(Blue!to!Red)!
! ! ! ! !2)!Tijuana!to!San!Diego!(Red!to!Blue)!
How!Much!Viral!MigraGon!
0.25
From SD toTJ
From TJ to SD
Total
0.2
Probability!
0.15
Density
0.1
5E-2
0
-10 0 10 20 30 40 50 60
Viral Movement Counts
Increasing Amount !
When!did!Viral!MigraGon!Occur!
Timing!of!Viral!MigraGon!between!San!Diego!and!Tijuana!
US!is!sGll!exporGng!HIV!to!Mexico!
• What!is!the!role!of!deportaGon!
– In!Tijuana!
• HIV!prevalence!of!deportees!esGmated!1.23%!
• 77%!of!male!HIV!+!IDUs!are!deportees!
• Deportees!report!feeling!that!IDU!and!
transacGonal!sex!more!acceptable!in!their!new!
environment!
– 8!deportees!involved!in!transmission!clusters!
• 4!likely!acquired!infecGon!in!TJ!
• Other!4!deported!with!HIV?!
Pinedo!et!al.!2014!
Ojeda,!et!al!2011!
What!risk!factors!are!driving!the!border!HIV!
epidemic?!!
A!Focus!of!the!nonTMSM!Epidemic!in!San!Diego!
lies!just!across!the!Border!
Conclusions!based!on!our!Sample!
• The!San!Diego!and!Tijuana!epidemics!are!connected!
bridging!risk!groups!across!the!border!
• There!is!evidence!of!biTdirecGonal!viral!migraGon!
across!the!border!
– 1990s!–!More!migraGon!from!SD!to!TJ!
– 2000s!–!More!migraGon!from!TJ!to!SD!
• The!demographics!of!the!border!epidemic!likely!
differs!from!that!of!the!overall!San!Diego!epidemic!
Does the disparity in resources between
Mexico and the US affect HIV prevention
efforts in the border region?!
Treatment!as!PrevenGon!
• Test!and!Treat!
strategies!rely!on!
frequent!tesGng!of!
high!risk!individuals!
and!early!treatment!!
Viral!IntroducGons!can!Help!Sustain!an!Epidemic!
Grabowski,!PloSMed!2015!
One!Epidemic!
Which!country!
has!universal!
access!to!HIV!
For!prevenGon!of!new!infecGons,!we!need!aggressive!screening!
for!HIV!infecGon!on!both!sides!of!the!border,!followed!by!linkage!
to!care.!!
Acknowledgements!
UCSD SDPIRC and CFAR
UCSD GPH
Susan Little
Doug Richman Steffanie Strathdee
Tom Patterson
Davey Smith Kimberly Brouwer
Christy Anderson Rich Garfein
Gina Osorio Maria Rangel
Karole Ignacio Karla Wagner
Lab! Alicia Vera
Millenka Vargas
Deyna Arellano
GIS Daniela Abramovitz
Hayden Lowenstein
Bioinformatics Team
Lorri Freitas
Antoine Chaillon
Funding(Sources( Ben Murrell
Sergei L Kosakovsky Pond
Konrad Scheffler
Joel Wertheim
Jason Young