Kuala Lumpur, Malaysia, 30 June - 3 July 2013 IAS 2013: 7 th IAS Conference on HIV Pathogenesis, Treatment and Prevention Track D: Operational and Implementation Research

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Track D Rapporteur Team Elvin Geng (UCSF) Thomas Odeny (Kenya Medical Research Institute and University of Washington) Nancy Czaicki (UC Berkeley) Sathish Kumar (SAATHII)

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Track D: Implementation Science and Operational Research Evidence Real-world Practice Stakeholders (government, NGO’s, civil society) Health Delivery Organizations (clinics, hospitals, etc) Individuals (patients, health workers, community)

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Updates on the “Gap” WHO Global Update on HIV Treatment 2013 WHO Update on Treatment (Weiler, SUSA02) – 68% adult ART coverage (range 30%-90%) – 70% retention at 3 year – 65% PMTCT coverage (13%-95%) – 34% coverage for children WHO Consolidated Guidelines 2013 (SUSA03) – Testing – Adherence – Integration – Decentralization – Task shifting

Kuala Lumpur, Malaysia, 30 June - 3 July IAS Track D Overview: Major Themes Important scientific presentations – Adult Treatment Cascade: Linkage and Retention – Voluntary Male Medical Circumcision – Prevention of Mother to Child Transmission – Innovative Delivery Strategies – Point of Care Diagnostics – Quality of Care Much more important data at IAS 2013 not captured in this summary!

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Linkage and Retention: Connecting the Dots (MOAD01) Linkage after home based testing in South Africa (R. Naik) – Cohort study of 492 patients in Umzimkhulu – 62% linked to care within 3 months – Younger age, alcohol and negative beleifs / denial predicted failure to link Linkage after inpatient provider initiatied testing (Dalsone Kwarisiima) – Patients in Kampala - 70% located by phone after PITC – Among 500 contact - linkage was 91% – Single marital status and younger age associated with non- linkage

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Linkage and Retention: Connecting the Dots with Social Support (MOAD01) Malawi “teen clubs” (Agarwal) – Weekends meetings with fun activities, adherence support, health education – 192 participants had 3-fold lower rate of loss to follow up than 750 not in the club Self help groups in Mozambique (Pestilli) – In remote and rural Cabo Delgado – 140 patients in self help groups vs. 778 not in groups had lower loss to follow up (1 vs. 14%)

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Linkage and Retention: Connecting the Dots with mHealth (WELBD02) Text messages to improve retention (D. Joseph-Davey) – Three clinics in Maputo, Mozambique Province (two urban, one rural) – Randomized to SMS reminder before upcoming appointent – 1,106 interviewed and (69%) 830 patients enrolled but 31% excluded mostly becuase of lacked phone or illiterate Outcome: Loss-to-follow-up – All patients difference not signficant – Urban patients (RR=0.56, ) – Newly urban patients (RR=0.30, )

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Urban, recent ART initiated (< 3 months) Accumulated risk among urban patients Linkage and Retention: Connecting the Dots with mHealth (Joseph Davey, WELBD02)

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Circumcision: Getting it Done (MOPDD01) Quality during scale-up (Reich) – Evaluation during rapid 15 to 40 VMMC sites from 2011 to 2012 in South Africa – Used WHO instrument for assessing quality – Mean score decreased from 1.68, to 1.51 and then to 1.36 Outcomes among the lost after surgery (Grund) – In Nyanza – 70% were lost after surgical circumcision – 86% of the lost were located at home – The adverse event rate was 7.5% in those who did not come vs. 3.3% who did

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 PMTCT: Advancing the Cascade and Option B+ (WELBD01) Monitoring outcomes of B+ in Malawi (late breaker, Tenthani) Cohort of 28,428 women using B+ – 17% of all Option B+ patients were LTF six months after ART initiation. – 37% of sites had less than 10% LTF – 33% of the sites had LTF >20% – LTF was higher in urban, larger sites with EMRS, in sites operated by the Ministry of Health, and in central hospitals.

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 PMTCT Advancing the Cascade: Identifying Bottlenecks in Early Infant Diagnosis (MOAD02) Highlands Lowlands Foothills (Tiam et al)

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 PMTCT: Advancing the Cascade (MAOD02) Food Insecurity and PMCTC (McCoy) – Rural Zimbabwe probability sample of 8,662 women – 2,841 (32.8%) were food insecure and 1518 (17.5%) had hunger. – 94.7% of women attended antenatal care – Food insecure women with hunger were 42% more likely to never have attended ANC compared with food secure women

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 PMTCT: Advancing the Cascade with Integration (MAOD02) Integrating HIV care into ANC (Cohen) – Kisumu, Kenya – Cluster-randomized 16 ANC sites: Co-located HIV care vs. referral to HIV care among pregnant women newly testing + for HIV – 1,172 women randomized – Integrated arm had increased HAART initiation (HR = 2.74) and adherence to ARV’s (OR = 4.05) – No significant difference in MTCT, maternal health outcomes, or HIV-free survival of babies

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 PMTCT: SMS Messages to Advance the Cascade Randomized trial of SMS messages to 388 pregnant women in Kisumu, Kenya (Odeny) Content developed by the patients themselves

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Delivery Strategies: Testing and Community Norms (TUSS01) Project Accept: community randomized trail in Thailand, South Africa, Tanzania and Zimbabwe Multi-sector community mobilization, mobile VCT, post testing support Increase in HIV testing in intervention communities by 25% overall and 45% among men Multiple sexual partners among HIV positive men lower by 29% (p = ) Subgroup of In women 25-34, HIV incidence declined (RR=0.7, )

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Delivery Strategies: Leveraging Social Networks to Test Key Populations (TUAD01) Testing strategies to reach key populations of MSM in Nigeria (Adebajo) in 3 states StrategyNumbers tested Opinion leaders refer to facility-based testing 1,988 (6.3%) Opinion leaders refer to mobile testing14,726 (46.6%) Opinion leaders and peers test14,895 (47.1%)

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Delivery Strategies: HIV Testing using Performance Based Financing (TUSY02) 24 facilities Rwanda (Bautista-Arredondo) Randomly selected facilities received 1 dollar for each HIV test done (goes to clinic) in intervention Control sites received the same amount of money unlinked to performance Quantity and quality both used to assess reimbursement Intervention led to increased testing in the community by 11%

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Delivery Strategies: Hybrid Models (TUAD01) TASO in Eastern Uganda Community drug distribution points model 1,302 (38%) were facility based and 2,155(64%) were community based Loss to follow-up was four times higher in the facility arm (17% vs. 4%, p< ). Fewer deaths were reported in the CDDP arm (4% vs. 6%, p=0.008)

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Quality of Care: More than the Cascade (WEPDD01) CQI training & team formation Quarterly mentorship & QI coaching Orientation on indicator definitions and reporting tools Integrated clinical mentoring and QI coaching Using QI methodology to improve care in Uganda (Mutesasira)

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Track D: Summary There is no single cascade: know your cascade, know your implementation “gaps” – Understand common barriers across the cascade Circumcision and PMTCT –progress but barriers remain – Public health must meet patients half-way Innovative Delivery Strategies – Mobile testing, community drug distribution points, social “capital,” mHealth Quality – Growth of quality improvement movement as well as performance based financing

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Implementation Science: the Way Forward Progress is being made, but gaps remain Invest in implementation science to find generalizable strategies to close these gap Interdisciplinary teams – Industrial engineering, marketing, sociology, economics, anthropology, etc. Innovative research designs – Hybrids design to understand effectiveness and implementation – Adaptive interventions, modular designs Build on existing knowledge about real world change – Behavioral economics, PRECEED, CFIR and others – Diffusion of innovations: Identify the core, understand adaptable periphery, evaluate comparative effectiveness and scale up Foster implementer – researcher partnerships: ensure “practice based evidence” and pragmatic research

Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Thank you! Assistant Rapporteurs – Sathish Kumar – Nancy Czaicki – Thomas Odeny Track D Chairs – Nancy Padian – Soumya Swaminathan Conference organizers and chairs All participants!