Acknowledgements/Disclosure

1. Oral testing, multimedia pre-test counseling and telephonic post-test counseling amongst Indian truck drivers and men who have sex with men Schneider, Snyder, Kumar, Liao, Lakshmi, Reddy, Muppudi, Oruganti, YeldandiThe University of ChicagoXVIII International AIDS ConferenceJuly 22, 2010

2. Acknowledgements/Disclosure • This work was supported by the American Foundation for AIDS Research (amFAR), the University of Chicago Section of Infectious Diseases and Global Health, and the College of the University of Chicago • OraSure provided oral testing kits. • Special thanks to Quoc Pham and Doug Michaels for coordinating • Thanks to Darpan, Mithrudu, and Gati organizations • None of the funders or providers of test kits were involved with the project design, analysis or interpretation of the results.

3. Outline • HIV Epidemic in India • Truck drivers (TD) • Men who have sex with men (MSM) • VCT Challenges • Oral testing and phone counseling • Methods • Results • Conclusions

4. Epidemic in India • Third largest population of people living with HIV (PLHIV) in the world, around 2.27 million PLHIV • High risk states • Andra Pradesh • High risk groups, bridge groups • MSM, TD HIV Estimation in India 2007 HIV Sentinel Surveillance

5. Men Who Have Sex with Men (MSM) • Often don’t identify as homosexual, diverse identities and behaviors • Andra Pradesh (AP): HIV prevalence 17.04% HIV Sentinel Surveillance and HIV Estimation in India, 2007; National Behavioral Surveillance Survey: MSM & IDU, 2006

6. Truck Drivers (TD) • Prevalence: 2.51% nationwide • Bridge population between: • Geographic areas • FSW and wives Summary report: Behavioural Surveillance Survey in Healthy Highways Project, India, 2001 HIV Sentinel Surveillance and HIV Estimation in India, 2007

7. Possible Voluntary Counseling and Testing (VCT) Challenges • MSM stigmatization • TDs can’t regularly access clinics • Clients may not pick up results • Not rapid, point-of-care testing • Hard to specifically target high risk populations, causing inefficiency

8. Andhra Pradesh • Largest population of PLHIV • Highest prevalence due to sexual transmission Steinbeck, NEJM, 2008

9. Recruitment • 600 total participants • 300 TDs from parking lots • 300 MSM from cruising spots and drop-in centers

10. Methods • Informed consent • Multimedia pre-test counseling • HIV Testing • Self sampling: OraQuick • Dry blood spots: 3 ELISAs and PCR confirmation • Counselor administered interview • Telephonic post test counseling, connection to confirmatory testing and government centers

11. Multimedia • What is HIV? • How is it transmitted? • How can you prevent HIV? • Why get tested? • What is OraQuick? How do you use it? • What are the next steps for a preliminary positive?

12. OraQuick 1) 2) 3) 1. AsiaOne Health 2. Center for Disease Control

13. Oral Testing Benefits • Rapid, less invasive • Advantages in community non-clinical settings Pai, PLoS One, 2007

14. Testing Algorithm All consenting MSM and TD n=600 Oral test positive n=81 Oral test negative n=519 ELISA confirmation positive n=78 ELISA confirmation negative or equivocal n=2 Insufficient ELISA sample n=2 ELISA confirmation positive or equivocal n=11 ELISA confirmation negative n=506 Insufficient ELISA sample n=1 PCR negative n=2 PCR positive n=1 PCR negative n=10 Final result positive n=79 Final result negative n=508 Final result equivocal n=13

15. Telephonic Post-Test Counseling • Initial oral test result provided to both positives and negatives by phone • Try to call them, they have counselor’s number • Convenient, increased feelings of anonymity • If oral test positive: • Counseled that test is preliminary positive • Connected to confirmatory testing at government center or at SHARE-India affiliated clinic (free) • Contacted subsequently if oral results false

16. Demographics • Age: • Median age=26, range 18-56 • Education • 34% no school or only primary, 50% some high school, 14.5% more than high school • Marital Status • 34% of MSM ever married • 55% of TD ever married

17. HIV Prevalence HIV Sentinel Surveillance and HIV Estimation in India, 2007

18. Method Satisfaction • 97.3% were satisfied with multimedia pre-test counseling • 50.4% said face-to-face counseling is the best method • 98.6% would recommend the oral testing method to friends • 99.7% rate the phone method of counseling as good

19. OraQuick Accuracy • Sensitivity: .987 [0.922, 0.999], those with HIV who test positive • Specificity: .996 [0.984, 0.999] those without HIV who test negative • 13 equivocal results not included

20. Multimedia Completion • Multimedia successfully completed in 72.7% of cases. • Potential reasons for not starting or completing: • Problems with equipment or power cuts • Area not safe for equipment • Participant found it boring • Police activity, particularly among MSM

21. Phone Counseling Completion • 70.7% completed post-test counseling • Slightly higher rates for positives • Reasons for no post-test counseling • Phone number changed • Client never answered phone • Option to call in available for all participants

22. Connection to Treatment • Ofthose who tested positive, 1/3 had a confirmed visit to a government center • Median CD4 count: 520

23. Challenges and Limitations • Difficult field environment: privacy • Saturation with testing programs • Issues between community based organizations • Poor follow-up for clients without cell phones

24. Conclusions • High prevalence of HIV infection and significant risk for bridging • Initial field testing indicates Oraquick is feasible and accurate • High acceptability of multimedia pre-test counseling and telephonic post-test counseling • High prevalence makes this a potentially efficient screening method for VCTCs