Community-Level Secondary (Behavioral) Outcomes of NIMH Project Accept (HPTN 043) David D Celentano for the Project Accept Study Team IAS July 2013 Kuala Lumpur, Malaysia

HIV testing history = % participants reporting HIV testing in the prior 12 months Social norms regarding HIV testing = assessed with multiple items on prevailing community attitudes towards testing Sexual risk = self-reported of number of unprotected acts averaged over prior 6 months; Number of sexual partners Negative life-events = reports of partnership break-up, discrimination, estrangement, neglect or violence Secondary Trial Outcomes

Discussion of HIV = proportion reports in prior 6 months Disclosure of HIV status HIV stigma = mean of 28 validated stigma items Secondary Trial Outcomes

We hypothesized that in CBVCT communities, mobilization and modeling would lead to: –Increased rates of HIV testing –Increased discussion about HIV testing –Improved social norms regarding testing –Through more common discussion about HIV –Disclosure of HIV status to partners –Reduced sexual risks associated with VCT and post-test support services –All of which would lead to reduced HIV stigma at the community level These would then result in reduced HIV incidence Secondary Trial Outcome Hypotheses

Baseline assessment of 14,657 randomly selected community residents ages Post-intervention assessment of 56,683 randomly selected community residents ages who provided biological samples and short behavioral questionnaire; Subset of 14,364 participants completed a detailed behavioral assessment Response rates of 85% at baseline, 93% post-intervention long version, and 85% short survey and blood draw. Refusals < 5%, with no difference by arm Secondary Trial Outcome Assessment and Methods

Overall increase in HIV testing in intervention communities by 25% (95%CI = 12%-39%, p=0003) HIV testing increased by 45% among men (95%CI= ; p<0.0001) 15% among women (95%CI= ; p=0.0134). –Many women had been tested in antenatal clinics but the increase was still significant HIV testing uptake

There has been gender equity in uptake for CBVCT

We reached a relatively young group of clients

Proportion of the Population Using Mobile VCT CountryCBVCTSVCTRatio South Africa--Soweto17%1%14.8 South Africa--Vulindlela20%1%16.8 Zimbabwe25%8%3.07 Tanzania21%7%2.93 Thailand35%1%35.0

Testing Uptake: 12 Months Effect a 95% CIp-value All sites – Thailand – 1.16 Zimbabwe – 1.13 Tanzania – 1.09 Vulindlela – 1.18 Soweto – 1.15 SVCT-BSVCT-PCBVCT-BCBVCT-PRatioP-Value Overall 16%26%14%32% Thailand17%15%17%24%1.56 Zimbabwe7%26%3%32%1.20 Tanzania15%32%16%37%1.13 Vulindlela20%35%19%40%1.14 Soweto33%37%31%41%1.10

Number of sexual partners reported by HIV positive individuals lower by 8% (95% CI: 1% - 15%, p = 0.03) Number of sexual partners among HIV positive men lower by 18% (95% CI = 5% to 28%, p =.009) Reductions in number of sexual partners

CBVCT resulted in more favorable social norms in intervention communities Improved by 6% (95% CI= 03 – 09, p = ) Social Norms

Multiple sexual partners among HIV infected persons reduced by 30% (95% CI: 0.54 – 0.92, p = 0.01) Multiple sexual partners among HIV positive men lower by 29% (95% CI: 0.57 to 0.89, p =.0006) Reductions in Multiple Sexual Partners

No increase in negative life events in intervention communities –No increase in violence towards women, break-up of marriage or sexual relationships, neglect by family, discrimination) The Intervention was Safe

Stigma Reduction No effect on stigma reduction as a secondary endpoint Scale values on stigma measure low at baseline, little room to decline People reluctant to report they stigmatize, even though such stigma may exist

Modest reductions in incidence, except in older women where incidence reduced by a third Created more favorable social norms Effectively engaged men in HIV testing Reduced behavioral risk among HIV+ men Conclusions

HIV testing is the first and essential in the cascade for community- level virologic suppression A generation free of HIV necessitates widespread (and repeated) HIV testing, especially among men Conclusions

Principal Investigators –Soweto, South Africa: Thomas Coates / Glenda Gray –Tanzania: Michael Sweat / Jessie Mbwambo –Thailand: David Celentano / Suwat Chariyalertsak –Vulindlela, South Africa: Thomas Coates / Linda Richter / Heidi van Rooyen –Zimbabwe: Steve Morin / Alfred Chingono NIMH Cooperative Agreement Project Officer: Chris Gordon Core Lab: Susan Eshleman/Estelle Piwowar-Manning Statistical Core: Michal Kulich, Deborah Donnell Collaborators: NIMH Project Accept (HPTN 043)

We thank the communities that partnered with us in conducting this research, and all study participants for their contributions. We also thank study staff and volunteers at all participating institutions for their work and dedication. Acknowledgements