Peter Godfrey-Faussett for Charlotte Watts Interim report on behavioural studies and HIV model for ProTEST Peter Godfrey-Faussett for Charlotte Watts ProTEST Meeting, Durban February 2003

Strategies to control TB and HIV STI control IEC Lifeskills Condoms VCT Microbicides Peer educators  HIV transmission DOTS intensive case-finding reduce diagnostic delays improve adherence  TB transmission Isoniazid preventive therapy  TB reactivation

Decreased Risk Behaviours: VCT Efficacy Group RCT in Kenya, Tanzania and Trinidad Voluntary HIV -1 Counselling and Testing Efficacy Group, 2000 3120 individuals and 586 couples randomly assigned to VCT or basic health information At 6 month FU, HI offered VCT, VCT offered retesting, STIs dx’d and tx’d Behavioural questionnaires at baseline, 6 months and 12 months

Decreased Risk Behaviours: VCT Efficacy Group Unprotected intercourse down 35% in men with VCT cf 13% with health education (HE) In women, VCT: 39%, HE: 17% in HIV+>HIV-, couples with at least 1 HIV+>uninfected couples Couples reduced unprotected intercourse with enrolment partners but not with non-enrolment partners

Voluntary HIV Counselling and Testing: Cost-Effectiveness Cost per HIV infection averted: $249 in Kenya and $346 in Tanzania Sweat M, 2000 Cost per DALY saved: $12.77-$17.78 if lower infectivity: $28.87-$45.73 Peer education of CSWs ($0.35-$0.52) Improved STI management ($9.45) ARVs in pregnancy ($10.51) Jha P, 2001

Protest behavioural study and epidemiological modelling Update on progress and baseline data Charlotte Watts Health Policy Unit Department of Public Health and Policy LSHTM

Components to study Behavioural survey – clients attending urban VCT services in Lilongwe and Lusaka (one site in each city) Epidemiological modelling of impact on HIV & TB HIV estimates use VCT behavioural data from each site TB projections build on model estimates of VCT impact on HIV incidence Link with economic analysis to estimate cost per HIV infection averted and cost per DALY saved

Behavioural study design Collect behavioural data from HIV+/HIV- men and women before and after VCT Interview 1,400 clients from MACRO, Lilongwe attending VCT services Follow-up with HIV+/HIV- male and female clients 6 months later Control population new clients attending VCT services during follow-up phase of study

Steps in behavioural study - Malawi Drafting and pre-testing of male and female questionnaire Building of interview buildings at MACRO Development of accompanying materials Selection and training of interviewers Piloting of questionnaire in Lilongwe Final revision / development of data entry screens Base-line interviews (Jan – April 2002) Follow-up & control interviews (6 months) (July - Dec 2002) Data entry and cleaning (ongoing) Analysis using SPSS (ongoing)

Baseline survey – preliminary results Interviews conducted Jan – April 2002 Low levels of refusal 1408 interviews completed and analysed 73% male (1028), 27% female (380)

Patterns of sexual behaviour - men Casual partner past 6 months Have steady partner 43% Male VCT 30% No other partners last 6 mths 57% 67% Single / sexually active Casual partner past 6 months 69% 3% No partners past 6 mths 31% Never had sex

Patterns of sexual behaviour - women Casual partner past 6 months Have steady partner 7% Women VCT 35% No other partners last 6 mths 93% 59% Single / sexually active Casual partner past 6 months 64% 6% No partners past 6 mths 36% Never had sex

Reported number non-regular sexual partners in past 6 months

Over-view baseline results Analysis preliminary Majority of VCT clients aged 15 – 24 with at least primary level education Approximately 2/3 male and female VCT clients are single 1/3 of VCT clients have a regular / steady partner 43% partnered men report casual partners in past 6 months 7% partnered women report casual partners in past 6 months 1/3 single VCT clients do not report having a sexual partner in the past 6 months Large variation in the numbers of casual sexual partners reported – with single men having the greatest number of partners in the last 6 months Results on reported condom use not presented – preliminary analysis suggests low levels of use Late analysis will merge survey data with data on HIV infection status of clients

Follow-up & control surveys Malawi Designed to ensure that interviews with HIV+ve / HIV-ve males and females obtained Requests to return, incentives and follow-up used to identify people for follow-up Target for follow-up interviews: All HIV+ve men and women interviewed All HIV-ve women interviewed 1/4 of HIV-ve men (other men interviewed using a short questionnaire) 938 interviewed in follow-up – 509 with full questionnaire (71% of targeted follow-up group) 770 control interviews completed

Key features of HIV modelling Deterministic, epidemiological model to consider transmission between VCT client and different sexual partners Population of VCT clients will be stratified by characteristics of sexual behaviour, HIV infection status, condom use For each sub-category model the impact of behaviour change on patterns of HIV transmission Model includes role of high viraemia, role of one STI in facilitating HIV transmission, and dynamic of HIV and STI transmission over time Focus of analysis to explore short term impact on HIV transmission (6 month and 2 year projections) Impact estimates will depend on assumptions about HIV and STD prevalence among different types of sexual partners of VCT clients

transmission over time Format of HIV impact model to be used with each strata of VCT clients Sexual partners VCT clients (male / female) Steady HIV+ HIV & STD transmission over time Short term / occasional HIV- Commercial

Progress with epidemiological modelling Review of existing behavioural data from Malawi Drafting of outline for epidemiological model(s) Programming of beta version of model(s) Analysis of baseline sexual behavioural data Revision of model to reflect patterns of sexual behaviour seen / level of complexity Analysis of follow-up & control sexual behaviour data – identification of main forms of behaviour change Finalisation of alpha version of model to incorporate forms of behaviour change documented Modelling of VCT impact on HIV incidence (comparing with and without VCT) Estimation of associated impact on TB infection

Next steps - Malawi January – March 2003 Analysis of baseline data and revision of model March – May 2003 Analysis of control and follow-up data Comparisons between before and after data, control and intervention data Revision of model and estimation of VCT impact on HIV Use of data on impact on HIV incidence to estimate associated TB cases averted

Next steps - Zambia and South Africa Review Zambian budget and timeframe based on Malawi experience South Africa is also planning to undertake behavioural study Tools developed collaboratively by Malawi and South Africa Possible location under discussion Awaiting funding to commence