From 90-90-90 toward HIV Elimination with Boosted-Integrated Active HIV Case Management (B-IACM) in Cambodia Dr. Penh Sun LY, Director, NCHADS Presented by Sopheap SENG, Deputy Director, LINKAGES Cambodia Good morning friends and colleagues! On behalf of Dr Ly Penh​ Sun, Director of Cambodia’s National Center for HIV/AIDS, Dermatology and STD, or NCHADS, who could not be with us today, I am so happy and excited to present to you the Boosted-integrated active HIV case management or B-IACM and its role in helping Cambodia move toward HIV elimination.

Cambodia’s Epidemic Curve Source: Estimated from AEM & Spectrum, 2016 3,709 TOTAL infections found (2017) 2,085 deaths (2017) 523 NEW infections (2017) In 2000: epidemic control 400 300 Cambodia is aiming and is ON TRACK to reach 90:90:90 by 2020 and elimination of HIV as a public health problem (defined by NCHADS as <300 new infections a year) by 2025.

National HIV Impact Cascade (Adult And Pediatric), End Of Dec 2017 Denominator is estimated PLHIV In July 2017, Cambodia was recognized by UNAIDS as being one of 7 countries to have reached their overall 90/90/90 goals. This slide shows the national cascade and our progress towards 90/90/90 goals using the method use by WHO and NCHADS. In 2017, the estimation of people living with HIV (PLHIV) was 68,244. Of these, 87% knew their status; and, 99% of those knowing their status were on ART while 78% have viral load suppressed. Source: Estimated PLHIV based on AEM estimates, adjusted to include children by ratio of current pediatric children enrolled in care by province. Results was from NCHADS Pre ART and ART report, and lab VL register by Sep 2017 Introduction #AIDS2018 | @AIDS_conference | www.aids2018.org

The Current HIV Status In Cambodia Adult population ages 15-49 AEM 2016 0.6% 2.3% 3.2% 5.9% 5.7% 15.2% MSM IBBS EWs IBBS TG IBBS PWUD IBBS PWID IBBS However, HIV prevalence from several IBBS among KPs were 3.2% of Female Entertainment Workers or EWs; 2.3% Men who have sex with men or MSM; 5.9% of Transgender Women or TG; 5.7% of people who use drugs or PWUD and for those injecting drugs or PWID 15.2%. Prevalence is high among some KP sub-groups such as Freelance EWs where around 13% are HIV positive. So, how is Cambodia doing on reaching the 90-90-90 targets? 2014 2016 2017

Boosted Integrated Active HIV Case Management (B-IACM) B-IACM focuses on identifying and reaching all infections, intensifying efforts to ensure cases are brought into the HIV cascade to receive immediate treatment (Test and Treat); retaining all PLHIV on treatment to become stable through viral load suppression. The Boosted Integrated HIV Case Management (B-IACM) was initiated in 2014 and implementing in 35 Operational Districts (OD) in 12 Provinces where have high HIV prevalence. This B-IACM pay attention to KPs to ensure we reach unreached KPs, fill the gap of lost from reactive to confirm and from confirm to enrolment, getting them tested and into care, and retaining those that are HIV+ on treatment to become stable through viral load suppression.

Management of B-IACM Through the Group of Champions Under B-IACM, The GOC is composed of a core group of people who manage and oversee the B-IACM process. The GoC member included government’s HIV and STI Program, health care providers, government and NGO ART clinic representative, Community Based Organization, … etc. Additional GOC members can be included as necessary contingent on their respective involvement in the operational district as part of the HIV care cascade. The GOC manages B-IACM in the OD with regular review of the HIV care cascade data to identify issues and find appropriate local solutions for improvement. How B-IACM Implemented - Identify all PLHIVs who are still unaware of their status or lost to follow-up - Trace and propose HTC to all partner(s) of newly detected HIV cases - Referral of all reactive cases from community-based organization/health facility to VCCT for confirmation - Enrol all confirmed HIV infections in ART and actively follow-up individuals to ensure no cases are lost. - Follow-up all patients on ART ensuring that ARV adherence is carefully monitored helping identify and resolve problems of adherence. - Implement and monitor routine Viral Load (VL) testing for all patients on ART - Monitor the HIV cascade outcomes

Current Coverage of the B-IACM 12 Provinces (35 operational districts)

Achievements—HIV Cascade From Jan. 2014 to Dec. 2017 In Nine Provinces 262 88% Achievements in B-IACM Coverage areas include 6,747 reactive cases referred from community and health facilities, 88% came to confirmatory test and 5660 confirmed positive, 262 confirmed negative, among those, 4,621 were enrolled in ART while 478 were lost to follow up.

HIV+ By Population Type from Jan-June 2018 in 26 sites, 9 provinces The HIV+ by client type for 6 months (Jan-June 2018) in 26 operational districts in 9 Provinces, total 1117. 65% is general population while around 20% are KPs.

ART Enrollment and Cost per Individual Enrolled on ART Source: HIV Innovate and Evaluation Project 2017

Lessons Learnt B-IACM improved the case detection rate and PLHIV were retained in HIV care through strong coordination between all partners. The direct financial support to contract case management assistants who could commit full time to B-IACM was important for day-to-day implementation. Financial support to monthly and quarterly Group of Champion meetings was also critically important to ensure that all activities were conducted appropriately. Decrease in the average number of days between confirmation of HIV status and enrolment into ART. The evaluation of B-IACM by the HIV Innovate and Evaluate project in 2017 showed that - B-IACM improved the case detection rate and PLHIV retained in HIV care through a strong coordination between all partners. - The direct financial support to contract CMAs to commit full-time for B-IACM was important to ensure the day-to-day implementation of B-IACM activities. - Financial support to monthly and quarterly GoC meeting was also critically important to ensure all activities were conducted appropriately. - Decreased in the average number of days between HIV status confirmation and enrolment into ART.

For more information, contact Dr For more information, contact Dr. Penh Sun Ly, Director, National Center for HIV/AIDS, Dermatology and STD (NCHADS), penhsun@nchads.org HIV/AIDS guidelines, SOPs, reports of Cambodia program, please log in to: www.nchads.org Thank you for your attention! For more information, please contact Dr. Penh Sun LY, Director, National Center for HIV/AIDS, Dermatology and STD (NCHADS). If you would like to access the HIV/AIDS guidelines, SoPs, reports of Cambodia program, please log in to www.nchads.org   Thank you for your attention!