Enrollment of high risk men in Africa

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1 Enrollment of high risk men in Africa Susan Allen MD MPH Professor, Department of Pathology and Laboratory Medicine Emory University Rwanda Zambia HIV Research Group

2 Africa Population 950 million by Region 167,198, ,147,982 97,931, ,149, ,027,622

3 Population density

4 Background sub-saharan Africa 2015 population 950 million including 475 million men 9.2% aged 15-19==43.7 million youth (avg age first sex 16 (south)-18 (east)) 7.8% aged % aged % aged % aged million 112 million 3.2% aged sexually active married/cohabiting 2.6% aged avg age at marriage % aged

5 HIV prevalence ages > <1

6 High risk groups and characteristics Pre-marital youth age 16-24: low prevalence Migrant labor: 10% of African men, concentrated areas Military: mobile during maneuvers and deployment, tend to marry soon after enlisting Workforce (factories, security firms etc): reluctant if employer can access confidential information (real or perceived concern), tend to marry soon after employment MSM: socially stigmatized, illegal in some countries STI clinic visitors: easy to identify and recruit Clients of FSW: easy to identify but difficult to recruit HIV- men with HIV+ spouses: easy to identify and recruit

7 Other variables to consider Generalizability of findings in one group to anotherexample MSM and heterosexual men, with or without STI. Urban vs. rural - prevalence, logistics, culture Multi-lingual areas vs. monolingual Clade type Penile-vaginal vs. penile-rectal exposure Repeated exposure to one infected person vs. exposure to many partners and viruses Transmitted ARV resistance

8 Some data from IAVI network Figure 1. Map of the collaborating research centers of the IAVI Africa HIV Prevention Partnership. Kamali A, Price MA, Lakhi S, Karita E, Inambao M, et al. (2015) Creating an African HIV Clinical Research and Prevention Trials Network: HIV Prevalence, Incidence and Transmission. PLoS ONE 10(1): e doi: /journal.pone

9 Work with MSM is feasible Figure 1 Identifying At-Risk Populations in Kenya and South Africa: HIV Incidence in Cohorts of Men Who Report Sex With Men, Sex Workers, and Youth Price, Matthew A.; Rida, Wasima; Mwangome, Mary; Mutua, Gaudensia; Middelkoop, Keren; Roux, Surita; Okuku, Haile S.; Bekker, Linda-Gail; Anzala, Omu; Ngugi, Elizabeth; Stevens, Gwynn; Chetty, Paramesh; Amornkul, Pauli N.; Sanders, Eduard J. JAIDS Journal of Acquired Immune Deficiency Syndromes. 59(2): , February 1, doi: /QAI.0b013e31823d8693 FIGURE 1. Screening, enrollment, and analysis cohorts by CRC. Copyright 2015 JAIDS Journal of Acquired Immune Deficiency Syndromes. Published by Lippincott Williams & Wilkins. 9

10 Incidence data in IAVI cohorts of men M-F+ not on ARV N PY Incidence 95% CI Kigali Rwanda Lusaka Zambia Ndola Zambia Masaka Uganda MSM Kilifi Kenya Nairobi Kenya Rustenberg RSA Fishing community Masaka Uganda Masaka+Entebbe Uganda

11 Impact of enrollment in cohort study on HIV incidence M-F+ not on ARV 0-3 mo > 3 mo p value Kigali Rwanda <0.001 Lusaka Zambia MSM Kilifi Kenya <0.001 Impact of enrollment on incidence not significant: M-F+ in Ndola, Masaka, Entebbe; MSM in Nairobi; men in fishing community

12 Services offered to research and trial cohorts will reduce incidence Cohort effect (aka impact of intervention) due to prevention services which must be provided in any study or trial Benchmark is Locally achievable standard of care Must by definition include VCT and may also include In low resource settings (>=60% reduction in incidence) Male circumcision STI screening and treatment Joint testing with spouse/steady partner (CVCT) In high resource settings TasP for HIV+ partner in M-F+ couples PreP (vaginal microbicide, contraception)

13 How do we define locally achievable standard of care? Per capita income (PPP*), and expenditure on health Country PPP Per capita health Botswana $ 17,596 $ 384 South Africa $ 11,750 $ 645 Kenya $ 1,885 $ 45 Zambia $ 1,842 $ 96 Tanzania $ 1,670 $ 41 Rwanda $ 1,592 $ 66 Uganda $ 1,460 $ 44 Mozambique $ 1,263 $ 37 High resource Low resource *Per capita income adjusted for cost of living = purchasing power parity or PPP PPP conomic-statistics/economicindicators/ Per capita health or/sh.xpd.pcap

14 Useful benchmarks Cost per participant relative to per capita expenditure on health Cost per HIV infection averted relative to PPP In low resource settings (>=60% reduction in incidence) Male circumcision STI screening and treatment Joint testing with spouse/steady partner (CVCT) In high resource settings (variable reduction retention, adherence) TasP for HIV+ partner in M-F+ couples PreP (vaginal microbicide, contraception) Thanks to Ambassador Gordon Streeb, Emory Professor of Development Economics

15 Cost of preventing one HIV infection with CVCT in Zambia $392

16 CVCT Technical Assistance Provided COUNTRY YEAR OF SUPPORT LOCATION TYPE OF SUPPORT Botswana , Botswana, Zambia China 2010 China, Zambia TA visit,cvct and CVCT promotion ToT TA visit, CVCT ToT for MSM, Pilot study of CVCT for MSM DRC 2012 Rwanda TA visit on, CVCT implementation Ethiopia 2010,2011 Ethiopia, Zambia. Rwanda TA visit on, CVCT implementation Ghana 2011 Ghana, Zambia TA visit, Study tour, CVCT Training Guyana 2011 Rwanda TA visit on CVCT implementation Kenya 2010,2014 Kenya, Rwanda TA visit, management of sero-discordant couples Ivory Coast 2014 Ivory Coast Curriculum adaptation, CVCT ToT Malawi 2009,2011 Malawi, Zambia TA visit, CVCT training Mozambique 2009,2010 Mozambique, Zambia Meeting on CVCT strategic planning Namibia 2014 Namibia, Zambia Needs assessment, TA visit, CVCT and CVCT promotion ToT Nigeria 2012 Nigeria, Review of PEPFAR HCT program Rwanda Rwanda South Africa 2009,2011, 2014 South Africa, Zambia,Rwanda Nationwide CVCT implantation, follow-up of discordant couples and develop M&E tools TA visit, CVCT and CVCT promotion ToT, CVCT program managers training Swaziland 2010,2011 Swaziland Nationwide CVCT implantation, CVCT ToT Tanzania 2009,2010,2011 Tanzania, Zambia TA visit, Develop CVCT training manual, CVCT training Thailand 2011 Thailand CVCT for MSM Uganda 2011,2013 Uganda, Rwanda TA visit, CVCT and CVCT promotion ToT 16 U.S.A 2009 Zambia Adopt RZHRG CVCT strategize for MSM

17

18 Cost of preventing one HIV infection with CVCT in ART clinic $666

19 Costs of TasP or PreP Most cost-effective in discordant couples rather than blanket treatment since many HIV+ adults have HIV+ partners and TasP will not prevent new infections in this group Hypothetical example with conservative assumptions: incidence after CVCT 7%/year Reduce from 7% to 0% would need to treat 100 couples to prevent 7 infections Annual cost of ART $750/year 100 x $750 /7 =$10,700 per infection averted for one year Close to PPP for South Africa or Botswana 7 x PPP for other countries

20

21 Many thanks and welcome to Rwanda!

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