Jackie Ndirangu, Wendee Wechsberg, William Zule,Tracy Kline, Irene Doherty & Charlie van der Horst

International AIDS Conference

Melbourne, July 20, 2014

Methods for Increasing Access and ARV Retention among Sex Workers and

Drug-using Women in Pretoria, South Africa: Structural and Individual

Determinants

Thank you to all the women in the study and for the dedicated women’s Health CoOp Plus (WHC+)

staff who have made this happen

Funded by RODA032061

Forerunner: Women’s Health CoOp (WHC) -Pretoria*

R01AA014488

*Listed in USAID’s “Multiple Gender Strategies to Improve HIV and AIDS Interventions: A compendium of Programs in Africa”

Research Aim/Outcomes

Seek, test, treat and retain for Vulnerable womenR01 DA032061

To test whether adding WHC to standard Treat, Test, and Retain (TTR) practices results in more HIV-positive AOD-using women getting medical evaluations (e.g., CD4, viral load), starting treatment, staying in treatment and in greater reductions in risk behaviors (e.g., AOD use, condom use, victimization) among all women—positive or negative

.

Randomized Zones & Distance

Outreach targeted High-Risk Target Areas (HRTA) and other hotspots in Pretoria

The whole of Pretoria was divided into 14 Zones that were later paired and randomized into 7 (zones) clusters

WHC+ Team:Mapping each day’s work to be efficient with time and petrol

Vulnerable women have basic needs

Shower, donated clothes, toiletries and donated food available

Sample Characteristics by Intervention (N=561) preliminary

Standard

n=274

Women’s

n=287

Age 29.4 (7.2) 30.0 (8.1)

Main sex partner* 99% 98%

Unemployed 83% 87%

Education

None to Primary 9% 9%

Secondary 22% 15%

Tertiary 64% 71%

Diploma + 5% 5%

Ever given birth 76% 76%

* Also have multiple partners

Biologicals at Intake by Intervention (preliminary)

Standard

n=274

Women’s

n=287

HIV confirmed (p=0.006) 61% 49%

Confirmed Pregnancy 4% 5%

Alcohol 16% 14%

Benzodiazepines 3% 2%

Cocaine (p<0.0001) 10% 23%

Methamphetamine 1% 1%

Opiates (p<0.0001) 11% 29%

Marijuana (p=0.0007) 28% 42%

**Not testing for glue/inhalants.

Biologicals at Intake by Sex Worker (preliminary)

Ever Sex Work

n=236

No Sex Work

n=325

HIV confirmed (p<0.0001) 68% 46%

Confirmed Pregnancy (p=0.003)

2% 7%

Alcohol 11% 17%

Benzodiazepines 3% 2%

Cocaine (p=0.0003) 23% 12%

Methamphetamine 2% 1%

Opiates (p=0.008) 26% 17%

Marijuana (p=0.0006) 44% 30%

Lack of Knowledge of HIV Status

Although 89% of the total sample had been previously tested for HIV at least once, 35% of those testing HIV positive were new diagnoses

Among sex workers, HIV prevalence was very high, however, 73% of those infected reported being previously informed of status

Among the non-sex workers infected with HIV, 55% reported being previously informed of their status

Referrals for ARV

Those aware of HIV+ status, 43% (n=86) reported ever taken ARV treatment

We have referred 197 women for further HIV evaluation and care

At 6 months follow-up, 68 women are currently taking ARVs, and of those 24 have reported to have recently started taking or re-initiated ARV treatment

Referrals for Substance Abuse Treatment

We have actively referred 52 women in the intervention group for drug rehabilitation services

19% (10/52) have followed through with the referral. However, only 4 have completed  rehab; the others having defaulted on their rehab treatment

What are the challenges to this strategy Seek, Test, Treat, Retain (STTR) In Pretoria?

Reaching high risk women and sex workers through outreach across Pretoria takes time and is costly

Recent cleaning up of the city from drug-users and sex workers

Transient cohort

Health system is not fully in sync

Stigmatization of vulnerable populations

Barriers reported to obtaining and adhering to ARVs

Structural Barriers

Poor clinic linkages

Nearest clinic does not provide ARV/Inconsistent access to medication

Transportation costs to clinic

No identification card or locator information

Food Insecurity

Homelessness and poverty

No safe place to store ARVs

Missed staging/ initiation appointment

Low levels of social support

Barriers reported to obtaining and adhering to ARVs

Individual barriers

Took when pregnant but stopped after pregnancy

Missed staging appointment/did not attend ARV initiation classes

Did not see the need/ not ready to start

Fear of ARV side effects especially when concurrently taking TB medication

Fear of commitment to ARV daily dose/ missing doses

Non disclosure of HIV status to family and partners

Denial/disbelief/unclear results

Preference of traditional medicine

AOD Use/Arrests

Case Management Barriers

Tracking challenges; lack of cell phones or charged cell phones and distance from the field site

Lack of rehab centers with pro bono slots

Lack of adherence to substance abuse treatment once allocated slots

Poor treatment in clinics

Lack of a proper medical referral system

Trying to change behavior in resistant environment

Solutions: Problem Solving

Reducing stigmatization and facilitating ART initiation by creating relationships with local clinics

Educating participants and denouncing myths about HIV/AIDS and ARVs

Monthly case management to remind women of personal health goals including checking on ART initiation and adherence.

Staff support and debriefing

Actively working with the Community Advisory Board

Solutions: Lessons Learned

Accompanying the women for clinical staging and initiation

Acquiring a point-of-care CD4 testing machine

Keeping ARVs at the clinic site for self-medication

Seeking more food donations

Striving to find substance abuse rehabilitation centres willing to admit the participants, pro bono

Conducting intakes in the rural and brothel areas

Current FU rate 84% at 6 MFU; 88% at 12 MFU

Next Steps..

Open a Halfway House in Pretoria (waiting on submitted proposal)

Accelerate access to Point-of Care (POC) HIV diagnostics in HCT programs

Engage groups that are responsible for reaching at-risk vulnerable women in strategic planning activities

Identify gaps in service delivery and develop plans for reducing social and structural barriers to treatment

Implement above processes in combination with behavioral interventions in order to achieve maximum impact