Maximising the use of VCT data for programs' planning and evaluation; experience from developing longitudinal studies of FSWs in Bali LUH PUTU LILA WULANDARI PANDE PUTU JANURAGA Presented in Satellite Session, Local to Large: Utilising Locally Available Data to Evaluate Programs and Answer Research Questions. AIDS th International AIDS Conference. 22 July 2014 School of Public Health, Udayana University, Bali, Indonesia

HIV epidemic in Bali Bali Province has been one of the more heavily affected Epidemic is at concentrated level with HIV prevalence among general population 0.68% FSWs is among the groups that highly affected Epidemic among this group is not only a local problem ◦The majority of FSWs are migrant workers ◦The mobility nature of FSWs and their clients

Surveillance of HIV in Bali, Indonesia Effective and efficient surveillance system is crucial to supports prevention programs: ◦For monitoring the impact of epidemic ◦For predicting the future course of epidemic ◦For planning ◦For monitoring the impact of intervention program Population based surveys among high risk groups have become the primary source of data for tracking trends in the HIV epidemic in Bali, and results have been made available on a regular basis in provincial and national

Population based surveys to monitor HIV epidemics among FSWs in Bali IBBS, MOH of Indonesia, 2007 and 2011, direct (brothel based) FSWs in Denpasar Sero-surveys, Bali Health Office, , direct (brothel based) and indirect (non-brothel based) FSWs Behavioral surveys, Yayasan Kerti Praja (YKP), direct FSWs, 2007, 2009, 2012 and 2013

HIV prevalence among FSWs in Denpasar, Bali

Population based surveys provide more representative point prevalence estimates However in Bali context ◦Expensive, logistically complex. ◦Methodological problems such as inconsistencies in the sampling technique, sample numbers and sites over time, and incomplete recording of individual information about survey participants ◦Lack of incorporation of additional information on behavioural factors to ensure that the surveillance system is in the best position to support prevention activities.

Details of analysis of population based surveys of high risk groups in Bali could be found in an article of International journal of STD & AIDS 2013, 24:

It is time now to also look at another potential source of surveillance data

VCT data in Bali Multiple VCT providers: ◦Hospitals based (12 centres) ◦Health centres/Puskesmas based (23 centres) ◦NGO clinics based (4 centres) Different approaches: ◦Outreaches: health centres and NGO clinics ◦Referrals: hospitals Growing databases

Growing databases Number of FSWs underwent VCT at Amertha clinic

Multi centres (VCT clinics with the majority of clients are FSWs) VCTs: 2 D FSWs: 2,200 Sero-surveys: yes VCT: 1 D FSWs: 500 Sero-surveys: irregular VCTs: 2 D FSWs: 150 Sero-surveys: no VCT: 1 DFSWs: 280 Sero-surveys: irregular

Contribution to the surveillance data in Bali Up to now contributing very little to the surveillance of HIV Bali ◦Self selection bias, users will differ between sites and even over time within sites ◦Context-specific: data collected in a Puskesmas or NGO clinics VCT centre will be different from those collected in a testing centre attached to a hospital ◦Lack of VCT data sets with individual client data from all key VCT providers, poor overall reporting 'culture'. ◦Lack of multi-sites comparisons of VCT and survey data including trends from multiple surveys

The potential of VCT data for surveillance purposes among high risk groups including FSWs Since 2007, the majority of VCT clinics have followed National Guidelines on VCT data collection forms, analysis and reporting The scale up of ARV treatment among FSWs in Bali has significant implications for surveillance of HIV-AIDS Have the potential as sources for longitudinal community studies Since the data is in a multi-site manner, the results may have far reaching implications for surveillance and estimates

In Bali context and particularly to the HIV epidemic among FSWs … Does VCT data have potential for supplemental HIV surveillance? Does VCT data have potential for HIV prevalence trends? Can prevalence trends among VCT centres be used to approximate HIV incidence trends, with the introduction of ART policy and program? Can others data (behavioural) collected from VCT centres be used to inform planning and evaluation?

Dr. Wulan…

Context: This project showcase the use of VCT data to supplement the other HIV surveillance We used the VCT database available at private clinic in Bali mainly serve female sex workers (YKP) This clinic has been providing VCT services for FSWs since 2000, however dataset were available since 2006 Until 2013, there have been more than 14,000 VCT sessions conducted in this clinics, at least 9,000 of them were among FSWs

Context : VCT testing at the this clinic uses a combination of three rapid HIV tests, the same method used for the serosurveillance Almost all of clients who came to this clinics were came from areas where the sample of serosurvey were selected. The number of clients participated in the VCT testing far outnumber the number of sample of survey. Large amount of data collected is consistently collected over time at the same site

HIV proportion among FSW from VCT data in Bali

HIV proportion among FSW from VCT data in Denpasar

HIV proportion among FSW who came at the first time from VCT data

HIV proportion among FSW who engaged in the sex work for less than 12 months

HIV proportion among FSW who came to the VCT clinic without HIV symptoms

HIV positivity among direct FSWs in Denpasar, Bali

HIV positivity among indirect FSWs in Denpasar, Bali

Our study demonstrates that routinely collected data from a large VCT clinic can provide a robust source of data over time on FSWs, to supplement serosurvey data ◦Although the point HIV prevalence estimates using VCT data as described in this study are lower than those estimated from serosurveillance data, this VCT data paralled the trend of HIV infection among sex workers ◦The VCT data also confirmed the lower rate of HIV infection among indirect sex workers compared with direct sex workers which is also found in serosurvey data

VCT data is provides more comprehensive sociodemographic and behavioural data from the same individual seeking HIV testing which is useful when interpreting the time trend of HIV epidemic

Acknowledgement ◦YKP Clinic ◦Bali Health Office ◦Kirby Institute ◦DFAT