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!