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K Vasarhelyi, S Kok, JSG Montaner, AR Rutherford, R Barrios, K McPherson, M Thumath, L Tran, A Nathoo, R Gustafson

Role of Routine HIV Testing in Concentrated Epidemics Operations Research for Optimizing the HIV Testing Program in an Urban Canadian Setting. K Vasarhelyi, S Kok, JSG Montaner, AR Rutherford, R Barrios, K McPherson, M Thumath, L Tran, A Nathoo, R Gustafson .

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K Vasarhelyi, S Kok, JSG Montaner, AR Rutherford, R Barrios, K McPherson, M Thumath, L Tran, A Nathoo, R Gustafson

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  1. Role of Routine HIV Testing in Concentrated Epidemics Operations Research for Optimizing the HIV Testing Program in an Urban Canadian Setting K Vasarhelyi, S Kok, JSG Montaner, AR Rutherford, R Barrios, K McPherson, M Thumath, L Tran, A Nathoo, R Gustafson

  2. Collaboration of Academic and Public Health Partners • BC Centre for Excellence in HIV/AIDS • Vancouver Coastal Health • Providence Health Care • The IRMACS Centre A poster for the Vancouver Coastal Health / Providence Health Care social marketing campaign promoting routine HIV testing The IRMACS Centre The BC Centre for Excellence in HIV/AIDS & Providence Health Care

  3. BACKGROUND

  4. Stakeholder’s Questions • Should we do it? Can routine voluntary HIV testing make a useful contribution to controlling the HIV epidemic in Vancouver? • How can we do it? What is the best way to integrate routine voluntary HIV testing into the current testing program?

  5. The HIV Epidemic in Vancouver • Concentrated epidemic • MSM, IDU, sex workers1 • HIV prevalence ~12 / 10002 • >200 new diagnoses / year in past 10 years3 • <150 new diagnoses in 20123 • HIV testing traditionally risk-based • No routine testing guidelines in Canada MSM – men who have sex with men; IDU – injection drug user McInnes et al., 2009, Harm Reduction Journal BC Centre for Disease Control (Vancouver’s population 600,000) / Vancouver Coastal Health

  6. What is the optimal mix of testing methods for Vancouver? Routine Testing Generalized epidemics Lower yield Lower cost/test Risk-based Testing Concentrated epidemics Higher yield Higher cost/test

  7. What is the optimal mix of testing methods for Vancouver? Routine Testing Generalized epidemics Lower yield Lower cost/test Risk-based Testing Concentrated epidemics Higher yield Higher cost/test COST YIELD

  8. What is the optimal mix of testing methods for Vancouver? Objectives • Minimize morbidity • Minimize mortality • Minimize HIV incidence

  9. What is the optimal mix of testing methods for Vancouver? Objective • Minimize morbidity • Minimize mortality • Minimize HIV incidence

  10. Operations Research and Optimization • Find best intervention to meet objective • Intervention is resource allocation • Optimal distribution of newresources • Optimal realignment of existingresources

  11. MODEL

  12. Model Development Step 1 Qualitative Model for Cascade of Care Step 2 Qualitative Model for HIV Testing Program Step 3 Combine Step 4 System Dynamics / HIV Transmission Simulation Model of Cascade of Care with Detailed HIV Testing Program

  13. Model Development Step 1 Qualitative Model for Cascade of Care Step 2 Qualitative Model for HIV Testing Program General Population MSM Other Key Populations (IDU, Sex workers) Step 3 Combine Step 4 System Dynamics / HIV Transmission Simulation Model of Cascade of Care with Detailed HIV Testing Program

  14. Qualitative Model of the Cascade of Care Decisions and activities in the HIV care continuumdefined through consultations with system experts

  15. Qualitative Model of the Cascade of Care Decisions and activities in the HIV care continuumdefined through consultations with system experts RETENTION IN CARE DIAGNOSIS LINKAGE TO CARE

  16. Qualitative Model of the HIV Testing Program Vancouver Coastal Health for STOP HIV/AIDS Project, Vancouver, Canada (2013)

  17. Qualitative Model of the HIV Testing Program Routine Testing in HOSPITALS Vancouver Coastal Health for STOP HIV/AIDS Project, Vancouver, Canada (2013)

  18. HIV Testing Resources • No $ estimate available • Cost of 1 Risk-Based Test > Cost of 1 Routine Test • Considered 1:1 to 9:1 cost ratios + Cost Ratio Number of Tests / Month Total HIV Testing Resources

  19. RESULTS

  20. Question 1Is routine testing effective in reducing HIV incidence in Vancouver? • SIMULATON SCENARIO • Increase total testing budget by 50%. • Invest all new resources in one program: • Risk-based testing or • Routine testing in high-prevalence settings or • Routine testing in hospitals • Compare 5-year cumulative incidence.

  21. Relative effectiveness of testing programsin reducing 5-year cumulative HIV incidence Risk-based Testing Up to 83 infections averted in 5 years Routine Testing in High-Prevalence Settings Up to 274 infections averted in 5 years Routine Testing in Hospitals Up to 104 infections averted in 5 years

  22. Question 2How many infections would be averted by increasing routine testing in hospitals and improving engagement in treatment? SIMULATION SCENARIO Increase total testing budget by 50%. Invest all new resources in routine testing in hospitals. Increase immediate treatment initiation after linkage to care from 38% to 75%and reduce loss to follow-up from 26% to 10%. Compare 5-year cumulative incidence.

  23. Increasing routine testing in hospitals and improving engagement in treatment

  24. Question 3How many infections would be averted by realigning existing resources between risk-based and routine testing in hospitals? SIMULATION SCENARIO Keep total testing budget the same. Realign existing resources between risk-based testing and routine testing in hospitals in 5% increments. Compare 5-year cumulative incidence.

  25. Optimal resource allocation to risk-based testing and routine testing in hospitals to minimize HIV incidence

  26. Optimal resource allocation to risk-based testing and routine testing in hospitals to minimize HIV incidence

  27. CONCLUSIONS

  28. Conclusions • Routine HIV testing in Vancouver is likely to be averting infections, especially in high-prevalence settings. In general routine testing may play an important role in controlling concentrated HIV epidemics. • Optimizing across the cascade of care could avert additional infections. • Realigning existing resources may improve efficiency of the testing program.

  29. Conclusions • Next steps include • Morbidity and mortality as optimization objectives • Developing other parts of the model of cascade • Operations research and optimization provide powerful methods to inform implementation of WHO guidelines on early treatment initiation.

  30. Collaborators & Sponsors BC Centre for Excellence in HIV/AIDS Silvia Guillemi Guillaume Colley Susan Shurgold Benita Yip Vancouver Coastal Health & Providence Health Care Kendra McPherson Meaghan Thumath Lynn Tran Reka Gustafson Afshan Nathoo Allison Macbeth Chris Buchner Val Munroe Jat Sandhu Ellen Demlow Tim Chu Scott Harrison IRMACS Pam Borghardt Peter Borwein Brian Corrie Felix Breden Kelly Gardner Alexa van der Waall BC Centre for Disease Control Mark Gilbert Travis Salway Hottes Gina Ogilvie University of Zurich Lukas Ahrenberg

  31. Buffer Slide • This slide can be lost!

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