Parastu Kasaie Johns Hopkins University Modeling the integration of health services for HIV and other health conditions in Kenya, Nigeria, and India Parastu Kasaie Johns Hopkins University

Background - Kenya The joint fourth largest HIV epidemic in the world, with 1.6 million PLHIV Compared to South Africa: Lower HIV prevalence in adults (5.4% vs. 18.9%) Higher proportion of undiagnosed HIV (30% vs. 13%) Increasing burden on non-communicable diseases (NCDs), accounting for 27% of all deaths and over 50% of hospital admissions Attributed to late diagnosis and poor treatment outcomes 56% of people have never had their blood pressure measured 22% of those with increased blood pressure or hypertension are taking treatment Opportunities for integration of HIV screening/treatment services with hypertension and diabetes

Methods - Kenya Model: Spectrum package by Avenir Health Baseline: Maintaining fixed ART coverage over the next decade (2018 – 2028) Intervention Modeling a joint community-outreach campaign for HIV and NCDs screening, based on Project SEARCH Targeting a geographically distinct area of Kenya comprising 10% of the population on an annual basis 90% of eligible adults aged 15 years or older would be successfully screened for HIV, diabetes and hypertension Treatment uptake following diagnosis: 81% for HIV, 23% hypertension and 45% diabetes Outcomes: Reduction in HIV incidence and mortality, Improvement to diagnosis and treatment for hypertension and diabetes Spectrum is a suit of easy to use policy models providing policy makers with analytical tools to support decision making.

Projected effects of HIV & NCD integration on HIV outcomes Baseline: Gradual reduction in HIV incidence over the next decade (by 13%) Intervention: Modeling gradual increase in ART coverage (up to 78% in 2028) Results: 44% reduction in HIV incidence (~216,000 new infections & ~244,000 deaths averted) Marginal improvements to HIV prevalence (1.4% reduction by 2028) Baseline: Gradual reduction in HIV incidence over the next decade (by 13%) Intervention: Gradual increase in HIV diagnosis and ART coverage (up to 78% in 2028) Results: 44% reduction in HIV incidence (~216,000 new infections and ~244,000 AIDS deaths averted) SA with 40% ART initiation projects a 23% reduction in HIV incidence Marginal improvements to HIV prevalence (1.4% reduction by 2028) – an aging population

Projected effects of HIV & NCD integration on NCD outcomes Immediate impact on cascade of care Treatment communities: Increasing treatment from 10% to 47% for diabetes and from 8% to 27% for hypertension in first year Overall: Identifying ~686,000 individuals with untreated diabetes and 7.5 million individuals with untreated hypertension by 2028

Background - Nigeria The second largest HIV epidemic in the world, with 3.2 million PLHIV Compared to Kenya and South Africa: Lower coverage of PMTCT (30% vs. 80-95%) Resulting in ~75,000 new infant HIV infections annually Low coverage of contraception methods for limiting or spacing births 15% of Nigerian women age 15-49 use contraceptives Average birth rate of 6.5 per women 16% of married women with unmet need for contraceptives Opportunities for integration of HIV services with reproductive health services for women in Nigeria

Methods - Nigeria Model: Spectrum’s demproj, AIM/GOALs, and FamPlan modules Baseline: Maintaining fixed PMTCT (26%) and contraceptive (15%) coverage over the next decade (2018 – 2028) Interventions Family planning: Increasing contraceptive coverage to 31% by 2023 and maintaining through 2028 PMTCT: Increasing PMTCT option B+ coverage to 90% (UNIAIDS & PEPFAR targets) by 2023 and maintaining through 2028 Outcomes: Reduction in HIV incidence, HIV diagnosis in infants, unwanted pregnancies and maternal and infant morbidity and mortality

Projected effects of HIV & family planning services integration Baseline increase in number of women of reproductive age by 37% over next decade (growing need for family planning) Impact: 15.5% reduction in fertility rate (from 6.5 to 5.49) Averting more than 8 million cumulative unintended pregnancies Growing need for family planning: Baseline increase in number of women of reproductive age by 37% over next decade Fam plan intervention: 15.5% reduction in fertility rate (from 6.5 to 5.49), averting more than 8million cumulative unintended pregnancies PMTCT: reduction in infant HIV by 56%, averting ~ 237,000 vertical HIV transmissions FamPlan and PMTCT: 12% reduction in HIV incidence at a national level, averting ~300,000 new HIV infections, 3.5% reduction in prevalence

Projected effects of HIV & reproductive health services integration Impact of PMTCT: Reduction in infants’ HIV infection by 56% (averting ~237,000 vertical HIV transmissions) Impact of joint programs at a national level: 12% reduction in HIV incidence (averting ~300,000 HIV infections) 3.5% reduction in HIV prevalence

Background - India The third largest HIV epidemic in the world, with 2 million PLHIV Concentrated epidemic among female sex workers (FSW), men who have sex with men (MSM) and people who inject drugs (PWID) A reported HIV prevalence of 2.2% among FSW in 2016 Significant geographical variation: HIV prevalence of 17.9% in Maharashtra and 13.1% in Manipur among FSW in 2013 Similar trends for prevalence of other STIs 3.1% to 51.0% syphilis prevalence among FSW 2.5% to 28.0% syphilis prevalence among MSM and transgender people Opportunities for integration of HIV/STI services for MSM and FSW in India

Methods – India Model: Spectrum package Baseline: Maintaining fixed ART coverage among FSW and MSM over the next decade (2018 – 2028) Interventions Modeling a joint community-outreach campaign for HIV/Syphilis among MSM and FSW over 5 years (2018 – 2023), based on Avahan programme Assuming 60% coverage form MSM and 90% for FSW Assuming 81% ART initiation among those diagnosed with HIV (a 54% and 81% reduction in unmet need for ART among MSM and FSW) PrEP: Modeling low (10%) and high (30%) coverage, with 50% adherence Outcomes: Reduction in HIV incidence and mortality, increase in syphilis diagnosis and treatment

Projected effects of HIV & Syphilis services integration Intervention: Gradual increase in coverage of ART (43% to 73% among MSM, 29% to 81% among FSW) Impact among MSM: Reduction in HIV incidence by 34% (~43,000 new infections, and 59,000 AIDS deaths averted) Impact among FSW: Marginal impact on HIV incidence but substantial impact on mortality (81% reduction, ~6,200 AIDS deaths averted) PrEP: Averting 6,800 to 20,000 additional infections compared to ART scale-up alone Syphilis: Intervention projected to diagnose and treat more than 510 000 cases of syphilis in FSWs (5·8% prevalence) and MSM (3·5% prevalence) in 2018 alone Baseline: A national level syphilis prevalence of 5.8% for FSW and 3.% for MSM Intervention: gradual increase in coverage of ART (43% to 73% among MSM, 29% to 81% among FSW) Reduction in HIV incidence by 34% among MSM (~43,000 new infections, and 59,000 deaths) Marginal impact on HIV incidence among FSW (1.6% reduction) – but substantial impact on mortality (81% reduction – 6,200 deaths averted) National level: a 7% reduction in incidence, averting 51,000 new infections and 81,000 deaths. SA with lower ART initiation (40%): impact was roughly halved PrEP::: low vs. high coverage averting 6.8K to 20K infections compared to ART scale-up alone Diagnosing more than 510,000 syphilis cases

Summary Integration is not a one-size-fit-all approach As currently envisioned, we anticipate that “optimistic but realistic” integration of HIV services with other healthcare delivery systems can: Substantially reduce HIV incidence in the population targeted by integration Marginally reduce HIV incidence, but will have only minimal impact on HIV prevalence in the country as a whole Despite not reducing HIV prevalence on a large scale, integration – if done well – still likely has the potential to offer economic benefits (Brian Wier) These results may overestimate the achievable scale of integration efforts (immediate scale-up to large proportions of the population) but also do not account for the substantial benefits that may be realized in health sectors other than HIV (e.g., NCD) Should be designed with care to setting-specific factors and the context of HIV epidemic in the underlying population Treated with care, not a ready to use guideline for implementing these interventions but rather a promise of impact

Acknowledgements Avenir Health International AIDS Society Johns Hopkins University Chris Beyrer David Dowdy Brian Weir Shannon Seopaul Avenir Health John Stover Yu Teng Johns Hopkins Center For AIDS Research (JHU-CFAR)