ias 2013: 7 th ias conference on hiv pathogenesis, treatment and prevention

www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013

IAS 2013: 7th IAS Conference on HIV

Pathogenesis, Treatment and Prevention

Track D: Operational and Implementation Research


Track D Rapporteur Team

• Elvin Geng (UCSF)• Thomas Odeny (Kenya Medical Research

Institute and University of Washington)• Nancy Czaicki (UC Berkeley)• Sathish Kumar (SAATHII)


Track D: Implementation Science and Operational Research

Evidence Real-worldPractice

Stakeholders (government, NGO’s, civil society)

Health Delivery Organizations (clinics, hospitals, etc)

Individuals (patients, health workers, community)


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


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!


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


Linkage and Retention: Connecting the Dots with 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%)


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)


Urban, recent ART initiated (< 3 months)

Accumulated risk among urban patients

Linkage and Retention: Connecting the Dots with mHealth

(Joseph Davey, WELBD02)


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


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.


PMTCT Advancing the Cascade: Identifying Bottlenecks in Early Infant Diagnosis (MOAD02)

Result to caregiver- infant ART

Health Facility -result to caregiver

District lab -result to health facility

Central lab -result to district lab

District lab -central lab

Specimen-district lab

0 5 10 15 20 25 30 35 40

Number of DaysHighlands LowlandsFoothills

(Tiam et al)


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


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


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


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)

•


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 Strategy Numbers testedOpinion leaders refer to facility-based testing 1,988 (6.3%)

Opinion leaders refer to mobile testing 14,726 (46.6%)

Opinion leaders and peers test 14,895 (47.1%)


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%


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)


Quality of Care: More than the Cascade (WEPDD01)

Apr-Jun '11

Jul-Sep '11

Oct-Dec '11

Jan-Mar '12

Apr-Jun '12

Jul-Sep '12

0

10

20

30

40

50

60

70

80

25

4252 51

55

68

Aggregated TB treatment completion rates; 16 project-supported hospitals

% T

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treat

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CQI training & team formation

Quarterly mentorship

& QI coaching

Orientation on indicator

definitions and reporting tools

Integrated clinical

mentoring and QI coaching

Using QI methodology to improve care in Uganda (Mutesasira)


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


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


Thank you!

• Assistant Rapporteurs– Sathish Kumar– Nancy Czaicki– Thomas Odeny

• Track D Chairs– Nancy Padian – Soumya Swaminathan

• Conference organizers and chairs

• All participants!

ias 2013: 7 th ias conference on hiv pathogenesis, treatment and prevention

Documents

treatment update

implementation gap

treatment weiler

preventiontrack d

ias conference

implementation research

orgkuala lumpur

critical gap