Transcript of Vincent Wong, MSc Dr. Charlene Brown, MD MPH Global Health Mini-U HIV Testing and Counseling...
- Slide 1
- Vincent Wong, MSc Dr. Charlene Brown, MD MPH Global Health
Mini-U HIV Testing and Counseling Roundtable Discussion
- Slide 2
- HIV Testing and Counseling Context and History Minimum
standards 5Cs etc. Testing technologies Programmatic Approaches
Issues (Quality, Linkage to care, etc) New directions
(self-testing, etc) Where weve been and where were going
- Slide 3
- Access to HIV Testing is Increasing +33% growth in 4 years 21
million more tests Source: WHO Global Reporting 2014, WHO Global
Reporting 2014
- Slide 4
- Nearly Half of All PLHIV Aware of Status ~16 million in 2013
Source: UNAIDS, Gap Report 2014 PLHIV aware of HIV status 35
million Weve come a long way
- Slide 5
- Estimated Percentage of PLHIV Know Their Status in Top 30
Countries* in 2014 Estimated awareness of status among PLHIV varies
significantly, but for 2/3s of countries it is within the 40%-60%
range. * By size of the epidemic Sources: Courtesy of CHAI, UNAIDS
Aidsinfo; DHS StatcompilerUNAIDS AidsinfoDHS Statcompiler Likely
Aware Likely Unaware Total: ~35 million South Africa Nigeria India
Uganda Malawi Zimbabwe Kenya Tanzania Zambia Average PLHIV aware =
~48% Remaining Countries Grouped by Region 3.2 M 6.3 M
- Slide 6
- Source: DHS data (Staveig, 2013; WHO 2014 progress report)
Percentage of men ages 15-49 yrs ever tested for HIV & received
results of most recent test Percentage of women ages 15-49 yrs ever
tested for HIV & received results of most recent test Trends in
Reported Uptake of HIV Testing in Sub- Saharan Africa Malawi
Zimbabwe Mozambique Congo Ghana Nigeria Ghana
- Slide 7
- Evolution of HTC Approaches 2015 1985 2005 1995 1985 Clinical
diagnostic testing; Blood donors 1990 VCT sites, e.g. AIC Uganda
1999 Social marketing, e.g. New Start 2013 Community-based HTC
(WHO) 2007 PITC (WHO) HIV self-testing? 2000 Campaigns
- Slide 8
- Evolution of HIV Diagnostics 2015 1985 2005 1995 2015
Smartphone testing 1985 1st HIV Antibody test licensed 1988 Rapid
test (WHO eval) Numerous RTDs developed 1999 EIAs for Ag/Ab
detection 2001 Rapid test, oral fluid 2008 Rapid HIV test for Ag/Ab
detection 2010 HIV / syphilis multiplex rapid test 2012 Self-test
approved by US FDA
- Slide 9
- Slide 10
- Source: 1. Shanks PLoS One 2013; 2. Klarkowski PLoS One 2009;
WHO 2015 forthcoming Studies (N=44) Identified in a Literature
Review, Reporting Factors Related to Misclassification #% Improper
practices around supplies 19 43% Clerical / technical errors 14 32%
Incorrect / suboptimal testing strategy 13 30% User error 11 25%
Weak positive 9 20% Cross-reactivity 7 16% HTC Quality /
Misclassification Reports of misclassification range from 2.6% to
10.3% 1,2 Implications: For public health Undermines credibility of
health system Emotional & legal False positive Unnecessary life
long ART False negative Ongoing transmission risk to partners &
infants
- Slide 11
- Slide 12
- 12 SCMS HRDT Product Diversity (2007-2013)
- Slide 13
- Health Service Utilization Model, from Ulett et al. The
therapeutic implications of timely linkage and early retention in
HIV care. AIDS Patient Care STDs. 2009: 23(1)41-49.
- Slide 14
- Determinants of Linkage & Retention Psycho-social factors
Structural factors Health care delivery factors Related to
knowledge, beliefs and motivations within a given social context
(herbal medicine, lack of disclosure, stigma) Qualities of health
care delivery at the point of contact with the patients (waiting
time, conflict with staff, coordination of care) Underlying
economic conditions of daily life (accessibility of care,
transportation, work responsibilities, food insecurity) NEED ELVINS
PERMISSION TO USE
- Slide 15
- Source: UNAIDS Graphic of Recent DHS Data, 2012
- Slide 16
- EXTRA SLIDESET for DISCUSSION
- Slide 17
- Where we are with HTC? Where are the gaps? HTC approaches
Concerns and issues Next steps Overview Toward the UNAIDS 90-90- 90
Right people? Right places? The good, the bad, and the ugly
Quality, prioritisation For programmes and research
- Slide 18
- Source: Frits van Griensven, 2014 Thailand Treatment Linked /
Retained in Care Linked / Retained in HTC & Prevention HTC at
Core of Prevention and Care Cascades
- Slide 19
- Nearly Half of All PLHIV Aware of Status ~16 million in 2013
Source: UNAIDS, Gap Report 2014 PLHIV aware of HIV status 35
million Weve come a long way
- Slide 20
- Estimated Percentage of PLHIV Know Their Status in Top 30
Countries* in 2014 Estimated awareness of status among PLHIV varies
significantly, but for 2/3s of countries it is within the 40%-60%
range. * By size of the epidemic Sources: Courtesy of CHAI, UNAIDS
Aidsinfo; DHS StatcompilerUNAIDS AidsinfoDHS Statcompiler Likely
Aware Likely Unaware Total: ~35 million South Africa Nigeria India
Uganda Malawi Zimbabwe Kenya Tanzania Zambia Average PLHIV aware =
~48% Remaining Countries Grouped by Region 3.2 M 6.3 M
- Slide 21
- Access to HIV Testing is Increasing +33% growth in 4 years 21
million more tests Source: WHO Global Reporting 2014, WHO Global
Reporting 2014
- Slide 22
- Countries HTC Scale-up and Diagnosis of PLHIV of Over Time
Averaged evolution over time for the percent identification of
PLHIV, Top 30 countries* by burden On current trajectory,
projection suggests, it will take ~25 years for countries to
identify 90% of PLHIV * By size of the epidemic Source: CHAI Input
data via UNAIDS Aidsinfo; DHS Statcompiler projections via CHAI
NMOT modelingUNAIDS AidsinfoDHS Statcompiler Slow start: Initial
VCT efforts (Voluntary Testing) Steep increase: Ramping up the
number of facilities and introduction of Provider-Initiated testing
Decelerated increase: High hanging fruits are more difficult to
reach via traditional strategies
- Slide 23
- Evolution of HTC Approaches 2015 1985 2005 1995 1985 Clinical
diagnostic testing; Blood donors 1990 VCT sites, e.g. AIC Uganda
1999 Social marketing, e.g. New Start 2013 Community-based HTC
(WHO) 2007 PITC (WHO) HIV self-testing? 2000 Campaigns
- Slide 24
- Evolution of HIV Diagnostics 2015 1985 2005 1995 2015
Smartphone testing 1985 1st HIV Antibody test licensed 1988 Rapid
test (WHO eval) Numerous RTDs developed 1999 EIAs for Ag/Ab
detection 2001 Rapid test, oral fluid 2008 Rapid HIV test for Ag/Ab
detection 2010 HIV / syphilis multiplex rapid test 2012 Self-test
approved by US FDA
- Slide 25
- Where we are with HTC? Where are the gaps? HTC approaches
Concerns and issues Next steps Overview Toward the UNAIDS 90-90- 90
Right people? Right places? The good, the bad, and the ugly
Quality, prioritisation For programmes and research
- Slide 26
- Source: DHS data (Staveig, 2013; WHO 2014 progress report)
Percentage of men ages 15-49 yrs ever tested for HIV & received
results of most recent test Percentage of women ages 15-49 yrs ever
tested for HIV & received results of most recent test Trends in
Reported Uptake of HIV Testing in Sub- Saharan Africa Malawi
Zimbabwe Mozambique Congo Ghana Nigeria Ghana
- Slide 27
- Make Up Approximately 63% of Those Tested in 2013 Much testing
in ANC, even in low and concentrated epidemics Women Source: WHO
global reporting 2014 AFROSEARO EMROAMRO WPRO EURO
- Slide 28
- Source UNAIDS, 2014; UN Human Development Report 2014
Percentage of Pregnant Women Tested for HIV in Africa ANC Coverage
90-100% 60-89% 0-58% In 2013, 54% of pregnant women in low- &
middle-income countries did not receive HTC.
- Slide 29
- Cohabiting relationships are common
- Positivity Rate Facilities Home based Campaigns KP outreach
Index partner ? Community Based HTC Unit Cost But cost
effectiveness may be acceptable especially for KP Linkage to Care
Highly variable and problematic ?? Earlier Diagnosis 11 studies
(3190 participants) CD4 >350 cells- pooled 59%. Missing
Populations Men Key Populations Young women (not pregnant) Highly
Acceptable Home based 82% (#18) Index partner 93% (#6)
Mobile/outreach 93% (#9) Workplace 59% (#4) Source : Suthar 2914;
WHO 2014
- Slide 35
- Malawi National HTC programme outputs 2008- 14 Source: Ade
Fakoya GFATM 2015
- Slide 36
- High uptake of those reached Low positivity rate cf background
prevalence Lower than hoped access by men Poor linkage to care
Source: Labhardt et al 2014. PLoS Med; UN Development Report 2014;
AIDSinfo 2013 prevalence Home-based vs. Mobile HTC in Lesotho Not
always what we expect
- Slide 37
- Source: Unpublished literature review based on 88 country
studies, 2007-2013 Average HIV Prevalence in Key Population Surveys
and General Population Key Populations are Disproportionally
Affected by HIV in All Regions
- Slide 38
- Source: Mathews R et al forthcoming, WHO forthcoming 2015;
*Data not shown Uptake, Positivity and Linkage from Community-
based HTC PWID and Transgender People, 16 studies, mean and range
HTC Uptake (n= 4 TG; n=4 PWID) Positivity Rate (n=8 TG; n=7 PWID)
Linkage (n=1 TG; n=5 PWID) Transgender People Who Inject Drugs
Studies primarily mobile or venue-based approaches. Generally good
uptake, lower than expected positivity rates, and suboptimal
linkage Highest uptake of mobile HTC, but with lower positivity
rate, compared to venue-based or peer- recruitment*
- Slide 39
- Already happening in many settings, (formally & informally)
March 2014 Supplement to ARV Guidelines & UNAIDS technical
update Individual performs a HIV test and interprets his or her
results Many models, priorities and policy issues, and evidence
gaps WHO Evidence Map of HIVST (www.hivst.org) HIV Self-Testing
(HIVST)
- Slide 40
- Generally acceptable Studies mostly among MSM in high- income
settings Desire HIVST over-the-counter & via Internet Report
they would link to care (80- 100%) More research on other KP groups
& in resource-limited settings needed! Source: Figueroa et al.
forthcoming, WHO 2015 ModerateLow High Acceptability of HIVST Among
Key Populations
- Slide 41
- Implementation-research partnership tackling market barriers
by: Demonstrating approaches in multiple sites, models, & among
populations Normalising HIVST in Southern Africa Providing evidence
for scale-up Developing WHO Guidelines Influencing policy change
Enabling the regulatory environment Encouraging market entry of
low-cost HIVST products Countries Malawi South Africa Zambia
Zimbabwe STAR Project Catalyzing HIVST in southern Africa
- Slide 42
- Source: Jhpiego/CDC/PEPFAR program in support of the Ministry
of Health of Mozambiques HIV prevention efforts HTC for Men and
Linkage to VMMC Mozambique: Tracking VMMC Referrals from Home-based
HTC
- Slide 43
- Where we are with HTC? Where are the gaps? HTC approaches
Concerns and issues Next steps Overview Toward the UNAIDS 90-90- 90
Right people? Right places? The good, the bad, and the ugly
Quality, prioritisation For programmes and research
- Slide 44
- Source: 1. Shanks PLoS One 2013; 2. Klarkowski PLoS One 2009;
WHO 2015 forthcoming Studies (N=44) Identified in a Literature
Review, Reporting Factors Related to Misclassification #% Improper
practices around supplies 19 43% Clerical / technical errors 14 32%
Incorrect / suboptimal testing strategy 13 30% User error 11 25%
Weak positive 9 20% Cross-reactivity 7 16% #1. HTC Quality /
Misclassification Reports of misclassification range from 2.6% to
10.3% 1,2 Implications: For public health Undermines credibility of
health system Emotional & legal False positive Unnecessary life
long ART False negative Ongoing transmission risk to partners &
infants
- Slide 45
- Sources: Flynn et al forthcoming, WHO information note - 22
October 2014
http://www.who.int/hiv/pub/vct/retest-newly-diagnosed-plhiv-
full/en/ #2. Poor Choice of HIV Testing Strategies National Testing
Policies in Line with WHO Recommendations, 49 Countries Review of
national HTC guidelines - Poor uptake of WHO recommended testing
strategies Important to: Implement QA, sufficient training, SOPs,
& strategies to reduce workload/stress; Ensure use of WHO
testing strategy, correct algorithm, re-testing +ves before ART
initiation; Improve inventory management & reducing stock-outs
Adapt instructions, e.g. job aides to improve interpretation of
weak positives. WHO reminds national programmes to retest all newly
diagnosed people with HIV
- Slide 46
- Source: Flynn et al forthcoming #3. Legitimise Lay Provider HTC
WHO considering recommendation for lay provider rapid HIV testing,
July 2015 Country policies, trained lay providers can perform HTC
tasks Total Policies, 49 Countries WHO African Region, 25
Countries
- Slide 47
- Concerned complex testing algorithms may lead to errors
Proposed policy for community-based sites A single rapid diagnostic
test in community- based HIV testing Not a definitive test result
Emphasis on HIV diagnosis at health facility (start at A1) Triage
prioritize HTC where care most needed Community based tester to
focus on linkage for re-test and clinical assessment HIV Test for
Triage An Alternative Community-based HTC Approach A0 + Perform HIV
test for triage A0 Perform HIV test for triage A0 A0 report HIV-
Recommend repeat testing as needed A0 report HIV- Recommend repeat
testing as needed Link to HIV testing for diagnosis, care &
treatment
- Slide 48
- #4. Rationalising Testing Strategic use of PITC in low and
concentrated epidemics Where to stop testing and re-prioritize
Focusing on diagnosing the undiagnosed, underserved & those
with ongoing risk Strategies to reach men Overcome reluctance to
provide partner testing /index partner testing Legitimize lay
provider/peer testing for outreach, esp. for KP Couples and Partner
Testing Generalized epidemics - offer to all Low and Conc epidemics
- offer to partners of +ves Effective Focused PITC Generalized
epidemics PITC in every health contact Low and Conc epidemics PITC
in select services (TB, STI, Key pops) Community Approaches
Generalized epidemics - outreach for key pops, consider door to
door, workplace, schools augmented by campaigns Low and Conc
epidemics - outreach to key pops
- Slide 49
- Where we are with HTC? Where are the gaps? HTC approaches
Concerns and issues Next steps Overview Toward the UNAIDS 90-90- 90
Right people? Right places? The good, the bad, and the ugly
Quality, prioritisation For programmes and research
- Slide 50
- Forthcoming WHO Consolidated Guidelines on HTC July 2015 Next
Steps: Programmes Rationalising Approaches How & where to focus
HTC approaches Quality Issues Immediate issues: WHO information
note WHO Quality Handbook Long term issue: Quantifying, the
magnitude, identifying cause & mitigating misdiagnosis Task
Sharing Lay HTC Providers Test for triage