Treatment Eligibility among Men Testing HIV-Positive in Voluntary Medical Male Circumcision (VMMC) at Two Clinics In Lesotho Authors: Virgile Kikaya, Kelly Curran, Mathabang Mokoena, Letsie Mosilinyane

Lesotho Context Population: 1.8 million (census 2006) 23.8% urban vs. 76.2% rural Capital: Maseru Geography: Low lands and highlands (poor accessibility) Migrant mine workers with TB cannot be resent and therefore will hide their diseases

Lesotho HIV Epidemic >360,000 people living with HIV HIV prevalence: 23% Over 25,000 new HIV infections annually, stable HIV prevalence among pregnant women is 24.3% TB/HIV co-infection is 74% HIV prevalence among sex workers, men having sex with men and injection drug users is unknown; prisoners–31%; factory workers–42.7% New infections occur mostly within stable relationships (multiple concurrent partnerships)

HIV Prevalence among Men 15–49, 2004 and 2009 Revised for clarity

Lesotho HIV Response Only about 42% of women and 24% of men know their HIV status 59% adult antiretroviral therapy (ART) coverage (initiation eligibility: CD4 <500) 72% retained after first year of ART initiation 74% of patients on ART had a CD4 count less than 250 at the time of initiation -Is first bullet the estimated % of HIV POSITIVE women and men that know they are infected, or the % of all that know their status whether positive or negative? -Do you have estimates of adult ART coverage by sex? -Do you have retention estimates by sex?

ART Coverage, 2000–2012 (adults) If time is an issue, consider deleting this slide, since info presented on Slide #5 The point being that 40% of infected people are estimated to be eligible but not on ART equating to ~60,000 people, in the context of ~90,000 people eligible on ART already

Lesotho HIV Epidemic: Status of the Response: HIV Treatment and CD4 Suggest deleting. This slide gets into the nuance of how ART has restored immune status of patients, the point being that gradually immune status has been restored with increasing number/ proportion of infected people with CD4 count > 250. Where are the numbers of people with CD4 350-500 and > 500? Are they just too small in number to be reflected?

VMMC Program in Lesotho Modeled impact: 1 HIV infection averted for every 5 males circumcised Package of services: HIV testing and counseling, sexually transmitted infection screening and treatment, condom provision, health education, and linkage to HIV care and treatment Health facility-based (hospitals/health centers): Improved potential for continuum of care, including HIV-positive clients Services free of charge to clients

VMMC Key Results, 2012–2015 100,000+ reached with VMMC service package ~80% tested for HIV: Overall 6% HIV positivity 20% HIV-positive at VMMC adults-only clinic: Similar to positivity rates in women in antenatal care settings (19%) Higher than positivity rates in voluntary counseling and testing settings (15%) All HIV-positive VMMC clients referred for HIV care Demonstrated potential: support of 90-90-90 treatment goals in men To capture the important info from the next slide, I pulled forward HIV-positivity rates from ANC (labeled “PMTCT” on slide #10) and VCT (labeled “HTC” on slide #10). Need for you to review and verify accuracy.

Contribution of VMMC to 90-90-90 Goals I would delete this slide. It’s really busy, though I understand it is intended to reflect the relative contribution of VMMC to care/treatment goals. However, the 4% is not congruent with the 6% stated in prior slide. Also, if general population is 8%, then it appears the VMMC program is reaching lower risk males. This is because of the age distribution, of course, but you would need to get into that explanation. The stronger example is the

Role of VMMC in Testing, Diagnosing and Linking 80% testing among VMMC clients vs. 24% among men in general population VMMC brings men to health facilities for HIV testing, many for the first time in their lives Previous published research on care and treatment linkages: Findings All VMMC clients who tested positive for HIV and who received a CD4 count on the day of diagnosis were initiated on ART. Provision of VMMC within an integrated service delivery setting such as a district hospital has contributed to the increase in HIV testing among men in Lesotho. Study findings serve as a foundation for further analysis of the potential of VMMC services as an entry point to care and treatment for HIV-positive men in other hospital settings. Investing in Pima CD4 devices at integrated VMMC clinics will also likely increase male enrollment in care and treatment services. Kikaya V, et al. Voluntary Medical Male Circumcision Programs Can Address Low HIV Testing and Counseling Usage and ART Enrollment among Young Men: Lessons from Lesotho. PLOS ONE 2014. In the “Previous work on Linkages”, suggest summarizing your findings from the article (what was learned about point of care CD4 testing, about linkage mechanisms, about staff willingness and competency?)

Objective of Current Review Assess contribution of VMMC in increasing enrollment of HIV-positive males: Number of VMMC clients testing HIV-positive: Number ART-eligible among newly diagnosed “Increasing enrollment” in what? In HIV care and treatment?

Methods Two VMMC sites provided point of care CD4 in 2014 Program data analyzed: New diagnosis vs. previously diagnosed Percentage treatment-eligible (CD4 <500) by age Mean CD4

Results Total of 6,124 VMMC clients 5,398 tested for HIV (88%) 276/5,398 (5.1%) newly HIV diagnosed: 133/276 (48.2%) received same-day CD4: 107/133 (80.5%) eligible for ART; 60% initiated ART within 30 days 143/276 not CD4 tested due to reagent stock-out

Results (cont.) ART eligibility by age (CD4 <500 among newly diagnosed): 10–19 years: 80% 20–29 years: 70% 30+ years: 91% Mean CD4 count: All ages: 359 [50; 900] 20–29 years: 399 [50; 896] 30+ years: 311 [64; 900] Please clarify statistical test for mean. Are the standard deviations?

CD4 Count Distribution (among newly diagnosed) Need labels for X and Y axes

Discussion HIV testing highly acceptable among VMMC clients, vs. low awareness of HIV status in adult population, especially men HIV positivity and new diagnosis rates increased with client age Over 80% of newly HIV diagnosed receiving same-day CD4 eligible for ART initiation (CD4 <500) High ART eligibility found across all age groups More than 20% with a CD4 count <200 Further analysis and statistical tests are warranted to confirm the trend

Discussion (cont.) Expanded, reliable point-of-care CD4 testing warranted Novel linkage and initiation strategies warranted to ensure VMMC platform leveraged to virally suppressing men Examples of HIV care alternatives at Jhpiego-supported clinics: HIV care/treatment at the same (private) clinic as circumcision, although HIV care is not a free service Referral to specialized ART center in Maseru (where HIV services free) Referral to public facility (where HIV services free)

Conclusion In the hyper-endemic context of Lesotho with low awareness of HIV status across the general population, HIV testing via VMMC platform is a critical component of HIV response: Virally suppress HIV-positive men for health and onward transmission Protect HIV-negative men from HIV by circumcision VMMC an opportunity to provide “male-friendly” services, including first-time HIV testing for many Given very low HIV diagnosis rates and CD4 counts at time of diagnosis, piloting point of care CD4 with “test and treat” at VMMC sites suggested: Maximize preventive benefits of VMMC vis-à-vis viral suppression Minimize loss to follow-up risk in referral process

This review was made possible by the generous support of the American people through the U.S. Agency for International Development, under the terms of the Cooperative Agreement AID-674-A-15—000005. The contents are the responsibility of Jhpiego, and do not necessarily reflect the views of the U.S. Agency for International Development or the United States Government.

An HIV-free generation is possible in Lesotho, it begins with us… Thank you An HIV-free generation is possible in Lesotho, it begins with us… Kea leboha