One year outcomes following availability of HIV self-testing in Blantyre, Malawi

Transcription

1 Uptake, accuracy, Health impact One year outcomes following availability of HIV self-testing in Blantyre, Malawi Couples & social harms Linkage into care Health economics Choko et al PLoS Med 2011; 2015; PLoS One 2016 Mavedzenge, Baggaley, Corbett Clin Infect Dis 2013 Kumwenda et al AIDS Care and Behaviour 2014 MacPherson et al JAMA Oral presentations at CROI

2 Conflict of interest All authors declare no conflict of interest

3 Why self-testing for HIV? HIV care and prevention goals unlikely to be reached through standard HTS Demand barriers Confidentiality & quality concerns Embarrassment being seen Direct and opportunity costs Few opportunities outside of facilities o Men, adolescents, low risk, poor, testing with partner Supply barriers Time consuming & labour intensive Error prone without training and proficiency testing Not acceptable from someone you know o Community-based distribution: costly and top-down Mavedzenge, Corbett WHO 2011; Choko et al PLoSMed 2011; Napierala-Mavedzenge, Baggaley, Corbett CID 2013

4 Research question Can sufficiently high uptake of HIV-testing be achieved through facility-based services? or does the addition of community-based services have a lasting impact on the prevalence of undiagnosed or untreated HIV?

5 Secondary outcome (s) Prevalence of HIV infection in adults (measured through post-intervention survey after 2.5 years) Undiagnosed (no previous positive HIV test) Not being treated (with any of ART, cotrimoxazole or IPT) Confirmatory testing for HIV viraemia

6 Whole study area: North-West Blantyre 1/3rd of Blantyre City Adult - population 114,450 - HIV prevalence 19% gen pop, 73% TB pts - TB CNR ~800 per 100,000 p.a. N LIKHUBULA CHILOMONI NDIRANDE

7 Randomisation + trial arms Cluster size: ~1200 adults 1. All 28 clusters: Facility testing clusters (yellow): Fac + HIVST CHILOMONI Community counsellor Cluster rep LIKHUBULA NDIRANDE

8 Uptake Amongst All Residents Malawi Since Self-testing Made Available 100% Women Men 75% 50% 25% 0% Age Group (years) Months

9 Uptake Amongst All Residents Malawi Since Self-testing Made Available 100% Women Men 75% 50% 25% 0% Age Group (years) Months

10 Uptake Amongst All Residents Malawi Since Self-testing Made Available 76% in months % 75% Women Men 50% 25% 0% Age Group (years) Months

11 Uptake Amongst All Residents Malawi Since Self-testing Made Available Highest uptake among adolescents 100% Year 1 Year 2 Women Men 76% in months % 74% in months % first-time testers 50% ~90% returned kits with self-completed questionnaire 25% 0% Months Age Group (years)

12 Accuracy and safety indicators Accuracy estimates QA sample on 1649 participants Agreement: 99.4% (98.9, 99.7) Sensitivity: 93.6% ( %) Specificity: 99.9% ( %) Safety Being forced to test Reported by 3% (287/10,007) But 94% still recommend to friends and family No suicides or homicide attributed to HIVST One unrelated suicide? Four unrelated murders No actively reported genderbased violence Kumwenda et al AIDS Care and Behaviour 2014

13 Linkage into care Within acceptable range Current estimate range: 42-56% 42% presenting with self-referral card with CD4 Up to 56% adjusted for already known HIV+ in care? May have linked but missed by our system 3-fold increase in linkage if assessed and initiated at home MacPherson et al JAMA 2014

14 Undiagnosed / untreated HIV (Prevalence survey: ; N = 6466) No previous positive HIV test or not on ART, cotrimoxazole or IPT 24% significant reduction at cluster level (C = 3334; I = 3132) No difference in population viral load >1500 copies/ml RR: 0.94 (0.74; 1.19) Prop. of adults with undiagnosed / untreated HIV Facility testing (47.7% of all HIV+) RR: 0.76 (0.64, 0.90) Facility testing + HIVST (35.7% of all HIV+)

15 Conclusions HIVST achieved the first 90 at population level and was Empowering Popular Scalable Cost-saving (potentially) Acceptable to men Acceptable accuracy More work to understand and address linkage to care? Linkage to prevention e.g. VMMC Coercion and GBV need to be anticipated, but other major harms rare

16 Acknowledgements London School of Hygiene & Tropical Medicine Liz Corbett; Fern Terris-Prestholt; Aurelia Lepine; Katherine Fielding MLW Rob Heyderman; Nicola Desmond; Moses Kumwenda Warwick Nigel Stallard, Hendy Maheswaran Liverpool School of Tropical Medicine Caroline O Leary, John Spallford Ministry of Health HIV unit Blantyre District Health Office, Blantyre