Chiang Mai University/Johns Hopkins University HIV/AIDS Research on VCT

Transcription

1 Chiang Mai University/Johns Hopkins University HIV/AIDS Research on VCT David Celentano, Professor of Epidemiology May 26, 2005

2 Scope of the CMU/JHU Collaborative HIV/AIDS Research Agenda HIV/AIDS research includes: Basic epidemiology Behavioral interventions HIV/AIDS treatment as HIV prevention Drug treatment and harm reduction as HIV prevention Health and human rights Microbicide development HIV vaccine evaluations Populations include: Community residents HIV discordant couples Ethnic minority populations Drug users Health services patients

3 Scope of the CMU/JHU Collaborative HIV/AIDS Research Agenda Research approaches include: Individual randomized controlled trials Couples randomized controlled trials Social networks randomized controlled trials Community randomized controlled trials

4 Background Thailand has had an extensive epidemic of HIV/AIDS since In national HIV surveillance, IDUs have had the highest prevalence among those surveyed from1989 to the present Efficacy of HIV VCT to reduce HIV risk behaviors is widely accepted. VCT is widely available and accessible in Northern Thailand Factors associated with VCT uptake and estimates of HIV incidence after VCT among IDUs in the region are unknown

5 Study Population Male IDU Patients at Northern Drug Dependence Treatment Center (NDTC) admitted for detoxification of Heroin, Opium or Methamphetamine 976 men met eligibility criteria and 891 (91%) agreed to participate in the study 825 men completed (84% of eligible) the study process Study period: February 1, 1999, to January 31, 2001 NDTC, located in Chiang Mai Province, provides drug dependence treatment for drug users in 17 northern provinces

6 Methods of Study Voluntary informed consent was obtained Assessments were conducted by trained interviewers using a standard questionnaire on demographics sexual practices and history of STD drug use history History of VCT and knowledge of HIV HIV serology -- ELISA, GPA and Western Blot (for confirmation)

7 Results 36% (298/825) of the IDUs reported having had VCT prior to enrollment in the study 44% (131/298) were tested two or more times 52% (155/298) sought first VCT to learn their HIV sero-status 58% (172/298) had their first VCT at a government facility

8 Knowledge of Prior VCT results and HIV Serostatus (determined by the project) Had prior VCT N HIV+ (%) No (26.8) Yes (33.2) Knowledge of last test results Negative (27.8) Positive (95.4) Did not know 39 12(30.8) Note: Over all 87% (259/298) reported that they knew the result of their prior test.

9 History of VCT by Demographic Factors N % Prior VCT O.R. (95% C.I.)* Ethnicity Hill tribes Thai (1.8, 3.3) Age Group < (0.8, 2.9) (0.5, 1.9) > (0.5, 2.2) Education No education Primary (1.4, 3.4) > Secondary (2.5, 5.9)

10 History of VCT and Sexual Exposures Marital status N %Prior VCT O.R. (95% C.I.)* Married Single (0.8, 1.6) Other** (0.8, 1.6) Number of sex partners None or one Two to three (1.3, 4.9) More than three (2.1, 6.3) Had sex with CSW Never Ever (1.0, 1.9)

11 History of VCT by HIV Risk Behaviors N %Prior VCT O.R. (95% C.I.)* Had sex with Male Never Ever (1.1, 3.6) Sex for money Never Ever (1.1,7.4) Needle sharing Never Ever (0.9, 1.7) * 95% confidence interval

12 Adjusted Odds Ratio* for Prior VCT Characteristics Reference OR (95%CIs) Ethnicity: Thai Hilltribe 1.3 (0.9, 2.0) Education: No education Primary school 1.8 (1.0, 3.0) Secondary or higher 2.7 (1.5, 4.7) # of sex partners: two or three None or one 2.3 (1.1, 4.6) more than (1.6, 5.6) Had sex with CSW 0.8 (0.6, 1.2) Had sex with male 1.1 (0.6, 2.2) Sex for money 1.8 (0.6, 5.3) *Logistic regression

13 Estimated HIV incidence after prior VCT HIV incidence /100person years < > 3 Over all Time last having VCT (year) HIV Incidence 95% CIs

14 Conclusions Substantial proportion of the IDU (36%) in the region received VCT Most IDU sought VCT wanted to learn their HIV sero-status History of VCT was associated with sexual risk behaviors but not needle sharing, the main mode of HIV transmission among IDU; this is supported by the estimated HIV incidence after prior VCT

15 Implications Harm reduction education for IDU and drug users, particularly issues on injection and HIV transmission, is urgently needed in the region. HIV counseling at VCT sites in Thailand must emphasize injecting drug risk for HIV infection

16 Design of the VCT Efficacy Study Multicenter randomized trial: Three sites: Kenya, Tanzania & Trinidad Randomized to receive (VCT) or Health Information(HI) Traced and interviewed at 6 & 12 months Cross-over at 6 months so that the original HI group now had access to VCT

17 Sample Size 586 Couples 85% retained at 1st follow-up 76% retained at 2nd follow-up 3120 Individuals 1563 to VCT; 1557 to HI 1534 Men; 1586 Women 82% retained at 1st follow-up 70% retained at 2nd follow-up

18 Men and Women Assigned to VCT Reduced Unprotected Sex With Non-Primary Partners, But HI Reduced After VCT P<.01 P< Baseline 1st Fup 2nd Fup 5 0 Men VCT Women VCT

19 Couples Assigned to VCT At Baseline Reduced Unprotected Sex With Enrolment Partners, But HI Reduced As Much After VCT P<.02 Baseline 1st Fup 2nd Fup VCT HI

20 HIV VCT is Cost-Effective Delivery = $26.65 in Kenya/$28.93 in Tz Averted HIV Infections: 1100 in Kenya; >800 in Tanzania $250,000 to $300,000 for 10,000 clients DALY = $12.77 in Kenya/$17.78 in Tz Childhood immunization = $12-17/DALY Increased prevalence to 45%

21 Conclusions People wanted VCT, did not have access to it before the study, and did take advantage of the study to get tested Most of the HI group got tested at the 6 month follow-up VCT reduces risk behavior Greater risk reduction in HIV+ persons VCT is cost-effective Should be promoted widely

22 Project Accept A collaboration in Thailand of the MoPH, CMU and JHU Purpose: Make HIV voluntary counseling and testing (VCT) easy to access, increase volume in order to reduce HIV incidence and stigma and discrimination at the village level Community randomized trial of 7 pairs of villages (size of about 10,000 each) half given standard VCT services, half get mobile, community-based VCT services Residents about half Thai, half ethnic minorities

23 Study Sites GO to a region by clicking on the map T T Z S K

24 Rationale Theory-based, pragmatic and sustainable ( no tech, no cost) approach to community-level change Tailored to cultural reality of each country and sensitive to gender-based issues Approach: (1) establish change in community norms and behaviors that lead to HIV transmission; support early adopters; (2) ensure all have needed information and skills to maintain change; and (3) establish support systems to promote effective coping for those diagnosed with HIV

25 Thailand Study Sites Myanmar Mae-ai Fang Chai-pra-karn Chiang-dao Mae-tang Praow THAILAND CHIANGMAI Muang district

26

27 VCT services Standard Clinic-based VCT: strengthen district hospital services to meet current best practice Mobile Community-based VCT: rapid testing following pre-test counseling; intensive counseling, with option for repeat counseling; referral (on-site) to post-test support (disclosure, coping, support, stigma/discrimination)

28

29 Project Accept study overview Baseline study conducted with 3000 residents in 14 project villages (Jan Apr 2005) Intervention applied for 2.5 years (Aug 05 Jan 08) Follow-up study conducted with 7000 residents in the 14 villages (Mar Dec 08) Study endpoint: Comparison of HIV incidence in the two types of communities; also, comparison of HIV stigma and discrimination at the community level