IAS 2013: 7 th IAS Conference on HIV Pathogenesis, Treatment and Prevention

1. IAS 2013: 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention Track D: Operational and Implementation Research

2. Track D Rapporteur Team • Elvin Geng (UCSF) • Thomas Odeny (Kenya Medical Research Institute and University of Washington) • Nancy Czaicki (UC Berkeley) • Sathish Kumar (SAATHII)

3. Track D: Implementation Science and Operational Research Stakeholders (government, NGO’s, civil society) Real-world Practice Evidence Health Delivery Organizations(clinics, hospitals, etc) Individuals (patients, health workers, community)

4. Updates on the “Gap”WHO Global Update on HIV Treatment • 2013 WHO Update on Treatment (Weiler, SUSA02) • 68% adult ART coverage (range 30%-90%) • 70% retention at 3 year • 65% PMTCT coverage (13%-95%) • 34% coverage for children • WHO Consolidated Guidelines 2013 (SUSA03) • Testing • Adherence • Integration • Decentralization • Task shifting

5. 2013 IAS Track D Overview: Major Themes • Important scientific presentations • Adult Treatment Cascade: Linkage and Retention • Voluntary Male Medical Circumcision • Prevention of Mother to Child Transmission • Innovative Delivery Strategies • Point of Care Diagnostics • Quality of Care • Much more important data at IAS 2013 not captured in this summary!

6. Linkage and Retention: Connecting the Dots (MOAD01) • Linkage after home based testing in South Africa (R. Naik) • Cohort study of 492 patients in Umzimkhulu • 62% linked to care within 3 months • Younger age, alcohol and negative beleifs / denial predicted failure to link • Linkage after inpatient provider initiatied testing (Dalsone Kwarisiima) • Patients in Kampala - 70% located by phone after PITC • Among 500 contact - linkage was 91% • Single marital status and younger age associated with non-linkage

7. Linkage and Retention: Connecting the Dotswith Social Support (MOAD01) • Malawi “teen clubs” (Agarwal) • Weekends meetings with fun activities, adherence support, health education • 192 participants had 3-fold lower rate of loss to follow up than 750 not in the club • Self help groups in Mozambique (Pestilli) • In remote and rural Cabo Delgado • 140 patients in self help groups vs. 778 not in groups had lower loss to follow up (1 vs. 14%)

8. Linkage and Retention: Connecting the Dots with mHealth(WELBD02) • Text messages to improve retention (D. Joseph-Davey) • Three clinics in Maputo, Mozambique Province (two urban, one rural) • Randomized to SMS reminder before upcoming appointent • 1,106 interviewed and (69%) 830 patients enrolled but 31% excluded mostly becuase of lacked phone or illiterate • Outcome: Loss-to-follow-up • All patients difference not signficant • Urban patients (RR=0.56, 0.319-0.969) • Newly urban patients (RR=0.30, 0.105-0.866)

9. Accumulated risk among urban patients Linkage and Retention: Connecting the Dots with mHealth (Joseph Davey, WELBD02) Urban, recent ART initiated (< 3 months)

10. Circumcision: Getting it Done (MOPDD01) • Quality during scale-up (Reich) • Evaluation during rapid 15 to 40 VMMC sites from 2011 to 2012 in South Africa • Used WHO instrument for assessing quality • Mean score decreased from 1.68, to 1.51 and then to 1.36 • Outcomes among the lost after surgery (Grund) • In Nyanza • 70% were lost after surgical circumcision • 86% of the lost were located at home • The adverse event rate was 7.5% in those who did not come vs. 3.3% who did

11. PMTCT: Advancing the Cascade and Option B+ (WELBD01) • Monitoring outcomes of B+ in Malawi (late breaker, Tenthani) • Cohort of 28,428 women using B+ • 17% of all Option B+ patients were LTF six months after ART initiation. • 37% of sites had less than 10% LTF • 33% of the sites had LTF >20% • LTF was higher in urban, larger sites with EMRS, in sites operated by the Ministry of Health, and in central hospitals.

12. PMTCT Advancing the Cascade: Identifying Bottlenecks in Early Infant Diagnosis (MOAD02) (Tiam et al) Foothills Highlands Lowlands

13. PMTCT: Advancing the Cascade (MAOD02) • Food Insecurity and PMCTC (McCoy) • Rural Zimbabwe probability sample of 8,662 women • 2,841 (32.8%) were food insecure and 1518 (17.5%) had hunger. • 94.7% of women attended antenatal care • Food insecure women with hunger were 42% more likely to never have attended ANC compared with food secure women

14. PMTCT: Advancing the Cascade with Integration (MAOD02) • Integrating HIV care into ANC (Cohen) • Kisumu, Kenya • Cluster-randomized 16 ANC sites: Co-located HIV care vs. referral to HIV care among pregnant women newly testing + for HIV • 1,172 women randomized • Integrated arm had increased HAART initiation (HR = 2.74) and adherence to ARV’s (OR = 4.05) • No significant difference in MTCT, maternal health outcomes, or HIV-free survival of babies

15. PMTCT: SMS Messages to Advance the Cascade • Randomized trial of SMS messages to 388 pregnant women in Kisumu, Kenya (Odeny) • Content developed by the patients themselves

16. Delivery Strategies: Testing and Community Norms (TUSS01) • Project Accept: community randomized trail in Thailand, South Africa, Tanzania and Zimbabwe • Multi-sector community mobilization, mobile VCT, post testing support • Increase in HIV testing in intervention communities by 25% overall and 45% among men • Multiple sexual partners among HIV positive men lower by 29% (p = 0.0006) • Subgroup of In women 25-34, HIV incidence declined (RR=0.7, 0.5-0.9)

17. Delivery Strategies: Leveraging Social Networks to Test Key Populations (TUAD01) • Testing strategies to reach key populations of MSM in Nigeria (Adebajo) • 2009-2012 in 3 states

18. Delivery Strategies: HIV Testing using Performance Based Financing (TUSY02) • 24 facilities Rwanda (Bautista-Arredondo) • Randomly selected facilities received 1 dollar for each HIV test done (goes to clinic) in intervention • Control sites received the same amount of money unlinked to performance • Quantity and quality both used to assess reimbursement • Intervention led to increased testing in the community by 11%

19. Delivery Strategies: Hybrid Models (TUAD01) • TASO in Eastern Uganda • Community drug distribution points model • 1,302 (38%) were facility based and 2,155(64%) were community based • Loss to follow-up was four times higher in the facility arm (17% vs. 4%, p< 0.0001). • Fewer deaths were reported in the CDDP arm (4% vs. 6%, p=0.008)

20. Quality of Care: More than the Cascade (WEPDD01) Using QI methodology to improve care in Uganda (Mutesasira) CQI training & team formation Integrated clinical mentoring and QI coaching Orientation on indicator definitions and reporting tools Quarterly mentorship & QI coaching

21. Track D: Summary • There is no single cascade: know your cascade, know your implementation “gaps” • Understand common barriers across the cascade • Circumcision and PMTCT –progress but barriers remain • Public health must meet patients half-way • Innovative Delivery Strategies • Mobile testing, community drug distribution points, social “capital,” mHealth • Quality • Growth of quality improvement movement as well as performance based financing

22. Implementation Science: the Way Forward • Progress is being made, but gaps remain • Invest in implementation science to find generalizable strategies to close these gap • Interdisciplinary teams • Industrial engineering, marketing, sociology, economics, anthropology, etc. • Innovative research designs • Hybrids design to understand effectiveness and implementation • Adaptive interventions, modular designs • Build on existing knowledge about real world change • Behavioral economics, PRECEED, CFIR and others • Diffusion of innovations: Identify the core, understand adaptable periphery, evaluate comparative effectiveness and scale up • Foster implementer – researcher partnerships: ensure “practice based evidence” and pragmatic research

23. Thank you! • Assistant Rapporteurs • Sathish Kumar • Nancy Czaicki • Thomas Odeny • Track D Chairs • Nancy Padian • SoumyaSwaminathan • Conference organizers and chairs • All participants!