Benjamin Bearnot, MD Candidate CAPRISA Fulbright-Fogarty Fellow

1. Impact of antiretroviral therapy on HIV-positive status disclosure in rural KwaZulu-Natal, South Africa Benjamin Bearnot, MD Candidate CAPRISA Fulbright-Fogarty Fellow XIX International AIDS ConferenceWashington D.C., July 24, 2012 On behalf of Lise Werner, Ayesha Kharsany, Silvia Maarschalk,SalimAbdoolKarim, Janet Frohlich,QuarraishaAbdoolKarim, and the CAPRISA 060 study team

2. Background • Sero-discordant partnerships major driver of the sexual spread of HIV • HPTN052 highlighted benefits of treatment initiation in the HIV+ partner in sero-discordant couples • Knowledge of HIV status is key • Southern Africa at epicenter of the HIV pandemic, yet knowledge of HIV status remains low; HPTN043 data • Disclosure to family members and close contacts associated with safer sexual behaviors, greater social support, improved ART adherence

3. Vulindlela, South Africa • Rural KZN, 150km west of Durban • CAPRISA research facility since 2002 • High levels of poverty and unemployment • 2010 HIV prevalence in pregnant women: • 40% (95% CI: 35.2-44.8%) • Particularly high burden in young women: • 20-24yo, 9.2 infections /100py (95% CI: 5.2-14.9)

4. Purpose of the Study • To assess the impact of antiretroviral therapy (ART) on HIV status disclosure in a recently established ARV treatment and care program in rural KwaZulu-Natal, South Africa

5. Methods • Prospective cohort study conducted in Vulindlela, KwaZulu-Natal • HIV+ adults on ART or in care in the CAPRISA AIDS Treatment Program between 2006 and 2009 were eligible for enrollment • Disclosure of HIV status was not a prerequisite for care or treatment • Data about disclosure behaviors were collected at two time points, using a structured interviewer-administered questionnaire: • At enrollment & 3-12 months post-enrollment

6. Results • 687 HIV+ individuals were enrolled; 73.3% female • median age 32 (IQR 28-38) • Majority of participants unemployed, single, with some secondary schooling • 8.6% reported to be married or with stable partner • 273 (39.7%) in care but not eligible for ART, 81% female • Median CD4+ 346 cells/μL, IQR 254-476 • 414 participants (60.3%) on ART, 68% female • Median days on ART: 54 • Median CD4+ 138 cells/μL, IQR 86-199

7. Disclosure Patterns - Overall • Disclosure rates >80% in ART and non-ART groups • Participants on ART more likely to have disclosed than non-ART participants • 99% versus 83.3%; p<0.001 • Disclosure occurred soon after HIV diagnosis, most often to a family member • ART median days to disclosure: 1 • Non-ART median days to disclosure: 0

8. Disclosure to Sexual Partners – By ART Status and Gender • Disclosure rates to sexual partners low in both ART and non-ART groups • Overall 29.4%; ART 31.6% and non-ART 26.0% • Partner disclosure less common among females compared to males • 23.7% versus 45.1%; p<0.001 • Low rates of further partner disclosure persisted at a median 4.4 months post-enrollment • Females 9.9% versus Males 19.2%; p=0.003

9. And among those with long-term partners? • Of 59 participants who reported that they were either married or had a stable sex partner: • 50.9% reported that they had disclosed their HIV-positive status to their partner • Male > Female; 80.0% versus 40.9%; p=0.009

10. Additional temporal trends Probability of non-disclosure

11. Conclusions • Overall, high rates of HIV disclosure early after diagnosis • Low rates of disclosure to sexual partners • especially among females participants • & even if participants are in stable partnerships • Probability of status disclosure increased among those testing positive more recently • Implications for scale-up of test and treat initiatives

12. Acknowledgements Benjamin Bearnot was supported by the National Institutes of Health Office of the Director, Fogarty International Center, Office of AIDS Research, National Cancer Center, National Eye Institute, National Heart, Blood, and Lung Institute, National Institute of Dental and Craniofacial Research, National Institute On Drug Abuse, National Institute of Mental Health, National Institute of Allergy and Infectious Diseases, and National Institutes of Health Office of Women’s Health and Research through the Fogarty International Clinical Research Scholars and Fellows Program at Vanderbilt University (R24 TW007988) and the American Relief and Recovery Act. CAPRISA was established as part of the Comprehensive International Program of Research on AIDS (CIPRA) and supported by the National Institute of Allergy and infectious Disease (NIAID), National Institutes of Health (NIH) and the US Department of Health and Human Services (DHHS) (grant# 1 U19 AI51794). The US President's Emergency Plan for AIDS Relief (PEPfAR) Strategic Information grant for supporting the HIV counseling and testing programme. This study was supported through the CARE- South Africa and the Centres for Disease Control and Prevention supplemental agreement #S1307.

13. Thank you!

15. Background continued • When scaling up HCT, an increasing number of infected individuals will become aware of their status and be faced with disclosure decisions • Disclosure is associated with consequent safer sexual behavior and greater social support (HPTN 043, RSA Data) • Decreased unsafe sex among disclosed sero-concordant and sero-discordant partners (Mlambo and Peltzer, 2011) • Greater disclosure to family members and close personal contacts correspond to higher rates of ARV adherence (SMART Couples Study, NYC)

16. Cohort Characteristics

17. Disclosure by ART status and gender

18. Additional temporal trends Logrank = 0.006

19. Overall Days to Disclosure in Cohort

20. Broader Context • Consistent with findings from Vulindlela in HPTN043 Project Accept • Participants who disclosed more likely to report always or more frequently using condoms, reducing number of sexual partners, and becoming monogamous • Risk of HIV transmission in sero-discordant partnershipsis a major driver of the spread of HIV/AIDS in Sub-Saharan Africa • Given advances in biomedical HIV prevention research, uninfected individuals might access HIV counseling, testing, and prevention strategies after becoming aware of their partner’s HIV positive status.