HIV Counseling & Testing to Prevent HIV and Increase ... · PDF fileIndividual Focus...
Transcript of HIV Counseling & Testing to Prevent HIV and Increase ... · PDF fileIndividual Focus...
HIV Counseling & Testing to Prevent HIV and Increase Access to Prevention, Treatment and Care
ART For Prevention Meeting, GenevaNov 2009
Michael Sweat, PhD – The Medical University of South Carolina
Evolving Themes in HIV TestingScreening tool (protection of blood supply) Preventative
Lab-based Rapid
Fixed Clinic Mobile
Individual Couple
Individual Focus Community Focus
Highly Standardized Flexible (PITC)
Preventative Route to Treatment & Care
What is the Evidence for Behavior Change from HIV VCT in Developing
Countries?
Supported by The National Institute of Mental Health(Grant: R01 MH071204 )
Number of Partners
Unprotected Sex
Odds: 1.22, p=NS
Odds: 1.69, p<.001
Challenges of Assessing VCTRigor of Many Studies is Weak
Lack of randomization to control groupUnmatched baseline characteristics
Non-random selection of participantsHigh attrition
Testing and counseling are linkedHard to assess the independent benefit of each
Conducting a cohort study on VCT with HIV incidence as outcome is challengingAssessment (HIV testing) confounds the intervention effect
HIV testing is needed for the assessment, but is also the interventionAssessment for HIV incidence contaminates the control group
Only 1 RCT in Developing Country
•VCT vs. Health Education
•VCT Associated With:
•Individuals: Significant Reduction in Unprotected Sex with Non-Primary Partners
•Couples: Significant reduction in unprotected sex with enrollment partners
•No significant difference in sexual risk with non-enrollment partners
This research was supported by AIDSCAP/FHI under funding from USAID contract number
USAID/HRN-5972-C-00-4001-00, and by WHO.
VCT was also Very Cost Effective
Cost per HIV Infection Averted:$249 Kenya
$346 Tanzania
This research was supported by NIMH grant 5R29MH57217, AIDSCAP/FHI under funding from USAID contract number USAID/HRN-
5972-C-00-4001-00, and by WHO.
Lessons Learned from First RCTThere are significant post test support needs
Ignoring these is a lost opportunity in prevention
Those who seek VCT in Clinics are Highly MotivatedOpportunity costs and stigma drives away many peopleThere are limits to standard clinic-based VCT in reaching large numbers of clients
The more you test in a community the larger the demand for testing
There are community-level dynamics at play in a testing programPrograms need to adapt to community changes over time
Trust in confidentiality is essentialClients value the counseling
Major Challenge in HIV EpidemicsHIV spreads through communities faster than community members realize the problem
Few visual cues to epidemicStigma and discrimination drive people to keep infection secretBiased beliefs that HIV affects “the other”
Thus, we felt there was a need to test an intervention that will:
De-stigmatize HIV and normalize HIV testingEnhance disclosure of HIV infection status
Harmonize perceptions of the scope of epidemic with realityGet large proportion of community to know HIV infection status
Take advantage of community-dynamicsCapitalize on prevention opportunities of post-test needs
NIMH Project AcceptHPTN 043
Impact of Community-Based Provision of VCT
Collaborators on NIMH Project Accept:HPTN 043
Principal InvestigatorsSoweto, South Africa – Thomas Coates / Glenda Gray
Tanzania – Michael Sweat / Jessie Mbwambo
Thailand – David Celentano / Suwat Chariyalertsak
Vulindlela, South Africa – Thomas Coates / Linda Richter
Zimbabwe – Steve Morin / Alfred Chingono
NIMH Cooperative Agreement Project Officer – Chris Gordon
Institutions
•Charles University, Prague•Chris Hani Baragwanath Hospital, Soweto•Family Health International•Fred Hutchinson Cancer Research Center•Human Sciences Research Council, Durban•International Center for Research on Women•The Johns Hopkins University•Muhimbili University, Tanzania•National Institute of Mental Health
•Research Institute for Health Sciences, Chiang Mai•The Medical University of South Carolina•University of California Los Angeles •University of California San Francisco•University of Kwa Zulu Natal•University of North Carolina•University of Witwatersrand, Johannesburg•University of Zimbabwe
Uptake is Much Higher with Community-Based VCTProportion of Community Members Receiving VCT Age 16-32
54%
Interventions TestedComparing two approaches to VCT:
Standard VCT (SVCT)Clinic-based
Community-based VCT (CBVCT)1. Community preparation, outreach, mobilization2. Mobile VCT3. Post-test support services
stigma reduction skills training, coping effectiveness training, ongoing counseling
4. Ongoing data feedback and field adjustments
DesignBaseline Survey – Probability-Based Sample of Community Members
Community Randomization
2.5 Years of Intervention
Post-Test Assessment (Assessment is at Community Level)
Behavioral SurveyBiologic Assays to Estimate HIV Incidence
BED
Avidity Index
PCR to Detect HIV
CD4 (to eliminate advanced HIV cases)
Qualitative Cohort
Cost-Effectiveness
Study SitesTanzania: Kisarawe District, Very Rural
5 community pairs – SVCT provided by project
Thailand: Hill Tribe Areas near Chiang Mai7 community pairs – SVCT from Available Clinics
South Africa: Vulindlela, Kwa Zulu Natal, Rural4 community pairs – SVCT from Available Clinics
South Africa: Soweto, Urban4 community pairs - SVCT from Available Clinics
Zimbabwe: Mutoko, Very Rural 4 community pairs – SVCT provided by project
Setting up CBVCT (Tanzania)
Vulindlela, South Africa
Rural Settings (Tanzania)
Venues – Go where the people go…Don’t hide the service
Aggressive Community Mobilization
The Ultimate Boom Box
Draw Crowds, Create Interest, Make Outreach Culturally Relevant – Don’t Hide!
Trends in CBVCT & SVCT Testing Uptake
Trends in CBVCT Testing Uptake
Uptake is Much Higher with Community-Based VCTProportion of Community Members Receiving VCT Age 16-32
We Have Reached a Relatively Young Group of Clients
There has been gender equity in uptake for CBVCT
There is variation in HIV Prevalence Across Sites
It has been challenging to recruit couples
How are CBVCT and SVCT Clients Different?
Focus on Tanzania, Zimbabwe, & ThailandLocations where we have detailed utilization data from both CBVCT & SVCT venues
P<0.001
VCT Clients from SVCT Communities Are Younger(Except for Zimbabwe)
We are likely testing people in CBVCT areas who would not normally test at a clinic
Testing as a Couple is More Common for SVCT (and very common in Thailand)Couples may be more concerned about confidentiality. We are exploring this in qualitative cohort.
Having Previously Been Tested for HIV is More Common in CBVCT Communities (Except for Tanzania)
Testing at SVCT venues is not as convenient. Motivation with initial test may be higher than repeat test.
A Much Higher Proportion of People from SVCT Communities Test Positive for HIVPeople with reason to believe they are HIV-infected are more motivated to overcome barriers
However: We Test More HIV-Infected
People From CBVCT Communities
Higher HIV Prevalence in SVCT:Trend Towards Diminishing HIV Prevalence in CBVCT
Very Low Recent HIV Prevalence
Declining HIV Prevalence
Higher HIV Prevalence in SVCT:Trend Towards Diminishing HIV Prevalence in CBVCT
Repeat Testing Grows Over Time Proportion previously tested by Project Accept
Implications
Community-Based VCT reaches many more people than Clinic Based VCT.
With Community-Based VCT:More HIV-infected clients are tested than in clinic-based VCT
Provides a pathway for treatment & careMobilizes community to demand services
In many of our sites treatment came as result of VCT availability
There are higher rates of regular retesting for HIVPeople who would not normally seek VCT will test for HIV
Implications
The Complete Package is EssentialMobilization, Quality Services with Counseling, Posttest Support, Local Access, Constantly Revising Program Based on Data
These have a significant impact on enhanced uptake of HIV testing
The Big Question – Stay Tuned
Will large scale community-based VCT significantly reduce HIV incidence?
Anticipate results to be available within next two yearsJust now beginning to conduct Post Intervention AssessmentLarge numbers & specialized HIV assays will take at least a year to process by the Core HPTN Lab at Hopkins
Thank you!