Achieving Impact:Focusing on Key Populations

Masami FujitaHIV-TB Team Leader, WHO Cambodia

GF SEA Regional Workshop, 16-18 June 2014, Phnom Penh, Cambodia

“Cascade” conceptual framework

(Source: PEPFAR, 2013)

WHO Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key

Populations

Consolidation of interventions along the continuum of care (prevention, diagnosis, treatment and general care)

Consolidation of health sector interventions across ;• Men who have sex with men, • People in prisons and closed settings, • People who inject drugs, • Sex workers, • Transgender people, with a focus on transgender women

Consolidation of new with existing guidance

Consolidation Components

Key Interventions (What to do?)HTC, Prevention, Treatment & care, Critical enablers, 'Essential' packages for specific KP

Service delivery & implementation (How to do it?)Service delivery, Community approaches, Case examples

Decision making, planning, M&E (How to decide?)Assessing the local situation, Decision making and planning,Framework for key population specific M&E, Key data sources

Epidemiological Targeting

• HIV positivity among KP in outreach testing very low• Overlapping risk in the region well documented• HIV spreads quickly among PWID, likely thru

overlapping sex work networks• Nearly all HIV prevention benefit may come from

reaching minority of sex workers with highest number of clients (AIDS 2014)

Targeting KP at Higher Risk

At risk + At increased risk ++ At highest risk +++

Sex workers SW with >7 clients/week

Injecting plus many sexual partners (paid

and non-paid) and/or very high

vulnerability

Men having sex with men

Male sex workers, MSM with many

partnersTransgender

womenTG with many

partners (paid and non-paid)

People who use drugs PWID

(Source: NCHADS, MOH Cambodia, 2014)

Approaches to identify/reach KP at higher risk

• Mapping• Outreach network• Engage brokers• Internet/SMS• Partner notification, tracing and testing• In-depth exploration with dedicated peers • Use HIV/STI case reporting data• “Multi-disciplinary rapid response team”

HTC Strategies in Low-level & Concentrated Epidemics

Facility-based Community-based

Clinical settings

Other facilities

ANC TB STI

Stand alone VCT Drop-in centers OST services Prisons; rehab centers

Outreach to KP

Home-based index

1. Expand and diversify testing options and settings

2. Simplify testing Not only by health staff but also by CBO staff (peers) Using rapid tests at point of services, finger prick/ mouth swabs

3. Repeat testing and combine with other tests At least annually if high risk behavior HIV/syphilis

4. Partner notification, tracing and testing including couple HTC

5. Increase demand: internet for MSM

6. Improve linkage to care and treatment:

7. Respect privacy, confidentiality and non discrimination

2009

2011

HTC Strategies in Low-level & Concentrated Epidemics

HTC Strategies in Low-level & Concentrated Epidemics

100%

78%

32%28%

n.a n.a 0

50 000

100 000

150 000

200 000

250 000

300 000

Est. number ofPLHIV

PLHIV diagnosedand reported

PLHIV in care(pre-ART+ART)

PLHIV currentlyreceiving ART

No. receiving VL VL suppressed

Too many people are lost to care after diagnosis

Cascade of HIV diagnosis to care, Vietnam, 2012

Sources: Estimated number of people living with HIV: UNAIDS 2013. WHO-UNAIDS National AIDS Programme Managers Meeting, Beijing, Feb 2013

Data from Treat ASIA cohorts: Cambodia, China, India, Indonesia, Malaysia, Philippines, Taiwan, Thailand, Vietnam

Globally, in low- and middle-income settings, 1 in 4 patients started ART at CD4<100 in 2010

In Asia, 1 in 3 patients started ART at CD4<100* in 2010

Still too many people start ART late

Cambodia Indonesia Malaysia Thailand Vietnam China

Populations SD couples

IDU (West Java)

a) MSM (Kualalumpur, Sungai Buloh)

b) IDU

MSM (Bangkok, Ubonratchathani, Lampang, Mahasarakam, etc)

a) SD couples (Dien Bien, Can Tho)

b) IDU

a) Seek, Test, Treat, Retain (Guangxi)

b) MSM (12 cities)

Test & Treat Partner testing, early ART

Irrespective of CD4TDF-based

a) Cascade analysisb) In planning

Irrespective of CD4TDF-based

Irrespective of CD4, TDF-based

Irrespective of CD4TDF-based

Enrolment Partner notification, tracing and testing from ART clinic

Internet, peer outreach

a)+b) Internet peer outreach b) OST

Internet, peer outreach

Enrolment at clinic (couples at HTC; monitor linkage to care)

VCT, ART clinics

Progress 2014 In planning a) 2013-14b) In planning

2012-2014 1st enrolment 3/2013; >100 HIV+ partners in SD relationship started ARTb) Planning

a) 2013-2015b) 2011-2015

Treatment as Prevention

Confirm& enroll inPre-ART

ARTPreART

TB

PW

KPs

STI Finger Prick

Case Management

Coordinator (CMC)

PMTCT, TB/HIV

Treatment as Prevention

Partner Tracing and Testing

CMP CMP CMP CMP

Civil Society Organizations (Community-based Prevention, Care and Support)

Integrated Active Case Management to Maximize Retentionlinking prevention and care for KPs

CMP: Case Management Provider

(Source: NCHADS, MOH Cambodia, 2013)

Information Must be Accessible to Provide Appropriate Care

Information Must be Protected to Prevent Harm to the Patient

Considerations and Guidance for Countries Adopting National Health Identifiers

– Types of data (identifiable, anonymized, pseudo-anonymized)– Organization and procedures– Collection of personally identifiable data– Storage of confidential data– Use of data – Dissemination of information – Disposal of information

Unique Identifier Critical to Monitor Coverage and Track Individuals across HIV Cascades

Achieving Impact by Addressing “Cascade” Bottleneck

(Source: PEPFAR, 2013)

Acknowledgement

Mean Chhi Vun Wing-Sie ChengLy Penh Sun Lori ThorellOuk Vichea Amala ReddyMarie-Odile Emond Nicole DelaneyYing-Ru Lo Amaya Maw-NaingYu Dongbao Razia Narayan PendseZhao Pengfei Gottfried HirnschallMark Landry Richard Steen Masaya Kato Tea PhaulyEng Dany