Achieving Impact: Focusing on Key Populations Masami Fujita HIV-TB Team Leader, WHO Cambodia GF SEA Regional Workshop, June 2014, Phnom Penh, Cambodia

“Cascade” conceptual framework (Source: PEPFAR, 2013)

WHO Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations Consolidation of interventions along the continuum of care (prevention, diagnosis, treatment and general care) Consolidation of health sector interventions across ; Men who have sex with men, People in prisons and closed settings, People who inject drugs, Sex workers, Transgender people, with a focus on transgender women Consolidation of new with existing guidance

Consolidation Components Key Interventions (What to do?) HTC, Prevention, Treatment & care, Critical enablers, 'Essential' packages for specific KP Service delivery & implementation (How to do it?) Service delivery, Community approaches, Case examples Decision making, planning, M&E (How to decide?) Assessing the local situation, Decision making and planning, Framework for key population specific M&E, Key data sources

Epidemiological Targeting HIV positivity among KP in outreach testing very low Overlapping risk in the region well documented HIV spreads quickly among PWID, likely thru overlapping sex work networks Nearly all HIV prevention benefit may come from reaching minority of sex workers with highest number of clients (AIDS 2014)

Targeting KP at Higher Risk At risk +At increased risk ++At highest risk +++ Sex workers SW with >7 clients/week Injecting plus many sexual partners (paid and non-paid) and/or very high vulnerability Men having sex with men Male sex workers, MSM with many partners Transgender women TG with many partners (paid and non-paid) People who use drugs PWID (Source: NCHADS, MOH Cambodia, 2014)

Approaches to identify/reach KP at higher risk Mapping Outreach network Engage brokers Internet/SMS Partner notification, tracing and testing In-depth exploration with dedicated peers Use HIV/STI case reporting data “Multi-disciplinary rapid response team”

HTC Strategies in Low-level & Concentrated Epidemics Facility-basedCommunity-based Clinical settings Other facilities ANCTBSTI Stand alone VCTDrop-in centersOST servicesPrisons; rehab centers Outreach to KP Home-based index 1. Expand and diversify testing options and settings

2. Simplify testing  Not only by health staff but also by CBO staff (peers)  Using rapid tests at point of services, finger prick/ mouth swabs 3. Repeat testing and combine with other tests  At least annually if high risk behavior  HIV/syphilis 4. Partner notification, tracing and testing including couple HTC 5. Increase demand: internet for MSM 6. Improve linkage to care and treatment: 7. Respect privacy, confidentiality and non discrimination HTC Strategies in Low-level & Concentrated Epidemics

Too many people are lost to care after diagnosis Cascade of HIV diagnosis to care, Vietnam, 2012 Sources: Estimated number of people living with HIV: UNAIDS WHO-UNAIDS National AIDS Programme Managers Meeting, Beijing, Feb 2013

Data from Treat ASIA cohorts: Cambodia, China, India, Indonesia, Malaysia, Philippines, Taiwan, Thailand, Vietnam Globally, in low- and middle-income settings, 1 in 4 patients started ART at CD4<100 in 2010 In Asia, 1 in 3 patients started ART at CD4<100* in 2010 Still too many people start ART late

CambodiaIndonesiaMalaysiaThailandVietnamChina PopulationsSD couples IDU (West Java) a) MSM (Kualalumpur, Sungai Buloh) b) IDU MSM ( Bangkok, Ubonratchathani, Lampang, Mahasarakam, etc) a) SD couples (Dien Bien, Can Tho) b) IDU a) Seek, Test, Treat, Retain (Guangxi) b) MSM (12 cities) Test & TreatPartner testing, early ART Irrespectiv e of CD4 TDF-based a) Cascade analysis b) In planning Irrespective of CD4 TDF-based Irrespective of CD4, TDF- based Irrespective of CD4 TDF-based EnrolmentPartner notification, tracing and testing from ART clinic Internet, peer outreach a)+b) Internet peer outreach b) OST Internet, peer outreach Enrolment at clinic (couples at HTC; monitor linkage to care) VCT, ART clinics Progress 2014In planning a) b) In planning st enrolment 3/2013; >100 HIV+ partners in SD relationship started ART b) Planning a) b) Treatment as Prevention

Confirm & enroll in Pre-ART ART PreART TB PW KPs STI Finger Prick    Case Management Coordinator (CMC ) PMTCT, TB/HIV Treatment as Prevention Partner Tracing and Testing CMP Civil Society Organizations (Community-based Prevention, Care and Support) Integrated Active Case Management to Maximize Retention linking prevention and care for KPs CMP: Case Management Provider (Source: NCHADS, MOH Cambodia, 2013)

Information Must be Accessible to Provide Appropriate Care Information Must be Protected to Prevent Harm to the Patient Considerations and Guidance for Countries Adopting National Health Identifiers –Types of data (identifiable, anonymized, pseudo-anonymized) –Organization and procedures –Collection of personally identifiable data –Storage of confidential data –Use of data –Dissemination of information –Disposal of information Unique Identifier Critical to Monitor Coverage and Track Individuals across HIV Cascades

Achieving Impact by Addressing “Cascade” Bottleneck (Source: PEPFAR, 2013)

Acknowledgement Mean Chhi VunWing-Sie Cheng Ly Penh SunLori Thorell Ouk VicheaAmala Reddy Marie-Odile EmondNicole Delaney Ying-Ru LoAmaya Maw-Naing Yu DongbaoRazia Narayan Pendse Zhao PengfeiGottfried Hirnschall Mark LandryRichard Steen Masaya Kato Tea Phauly Eng Dany