Jackie Ndirangu, Wendee Wechsberg, William Zule,

1. Methods for Increasing Access and ARV Retention among Sex Workers and Drug-using Women in Pretoria, South Africa: Structural and Individual Determinants Jackie Ndirangu, Wendee Wechsberg, William Zule, Tracy Kline, Irene Doherty & Charlie van der Horst International AIDS Conference Melbourne, July 20, 2014

2. Thank you to all the women in the study and for the dedicated women’s Health CoOp Plus (WHC+) staff who have made this happen Funded by RODA032061

3. Forerunner: Women’s Health CoOp (WHC) -Pretoria*R01AA014488 *Listed in USAID’s “Multiple Gender Strategies to Improve HIV and AIDS Interventions: A compendium of Programs in Africa”

4. Research Aim/Outcomes Seek, test, treat and retain for Vulnerable women R01 DA032061 • To test whether adding WHC to standard Treat, Test, and Retain (TTR) practices results in more HIV-positive AOD-using women getting medical evaluations (e.g., CD4, viral load), starting treatment, staying in treatment and in greater reductions in risk behaviors (e.g., AOD use, condom use, victimization) among all women—positive or negative .

6. Randomized Zones & Distance • Outreach targeted High-Risk Target Areas (HRTA) and other hotspots in Pretoria • The whole of Pretoria was divided into 14 Zones that were later paired and randomized into 7 (zones) clusters

7. WHC+ Team: Mapping each day’s work to be efficient with time and petrol

8. Vulnerable women have basic needs Shower, donated clothes, toiletries and donated food available

9. Sample Characteristics by Intervention (N=561) preliminary * Also have multiple partners

10. Biologicals at Intake by Intervention (preliminary) **Not testing for glue/inhalants.

11. Biologicals at Intake by Sex Worker (preliminary)

12. Lack of Knowledge of HIV Status • Although 89% of the total sample had been previously tested for HIV at least once, 35% of those testing HIV positive were new diagnoses • Among sex workers, HIV prevalence was very high, however, 73% of those infected reported being previously informed of status • Among the non-sex workers infected with HIV, 55% reported being previously informed of their status

13. Referrals for ARV • Those aware of HIV+ status, 43% (n=86) reported ever taken ARV treatment • We have referred 197 women for further HIV evaluation and care • At 6 months follow-up, 68 women are currently taking ARVs, and of those 24 have reported to have recently started taking or re-initiated ARV treatment

14. Referrals for Substance Abuse Treatment • We have actively referred 52 women in the intervention group for drug rehabilitation services • 19% (10/52) have followed through with the referral. However, only 4 have completed  rehab; the others having defaulted on their rehab treatment

15. What are the challenges to this strategy Seek, Test, Treat, Retain (STTR)In Pretoria? • Reaching high risk women and sex workers through outreach across Pretoria takes time and is costly • Recent cleaning up of the city from drug-users and sex workers • Transient cohort • Health system is not fully in sync • Stigmatization of vulnerable populations

16. Barriers reported to obtaining and adhering to ARVs Structural Barriers • Poor clinic linkages • Nearest clinic does not provide ARV/Inconsistent access to medication • Transportation costs to clinic • No identification card or locator information • Food Insecurity • Homelessness and poverty • No safe place to store ARVs • Missed staging/ initiation appointment • Low levels of social support

17. Barriers reported to obtaining and adhering to ARVs Individual barriers • Took when pregnant but stopped after pregnancy • Missed staging appointment/did not attend ARV initiation classes • Did not see the need/ not ready to start • Fear of ARV side effects especially when concurrently taking TB medication • Fear of commitment to ARV daily dose/ missing doses • Non disclosure of HIV status to family and partners • Denial/disbelief/unclear results • Preference of traditional medicine • AOD Use/Arrests

18. Case Management Barriers • Tracking challenges; lack of cell phones or charged cell phones and distance from the field site • Lack of rehab centers with pro bono slots • Lack of adherence to substance abuse treatment once allocated slots • Poor treatment in clinics • Lack of a proper medical referral system • Trying to change behavior in resistant environment

19. Solutions: Problem Solving • Reducing stigmatization and facilitating ART initiation by creating relationships with local clinics • Educating participants and denouncing myths about HIV/AIDS and ARVs • Monthly case management to remind women of personal health goals including checking on ART initiation and adherence. • Staff support and debriefing • Actively working with the Community Advisory Board

20. Solutions: Lessons Learned • Accompanying the women for clinical staging and initiation • Acquiring a point-of-care CD4 testing machine • Keeping ARVs at the clinic site for self-medication • Seeking more food donations • Striving to find substance abuse rehabilitation centres willing to admit the participants, pro bono • Conducting intakes in the rural and brothel areas • Current FU rate 84% at 6 MFU; 88% at 12 MFU

21. Next Steps.. • Open a Halfway House in Pretoria (waiting on submitted proposal) • Accelerate access to Point-of Care (POC) HIV diagnostics in HCT programs • Engage groups that are responsible for reaching at-risk vulnerable women in strategic planning activities • Identify gaps in service delivery and develop plans for reducing social and structural barriers to treatment • Implement above processes in combination with behavioral interventions in order to achieve maximum impact