1. High HIV-1 viral loads seen in commercial sex workers enrolled in a community-based comprehensive HIV/AIDS clinic in Nigeria Christopher Akolo, MD, MSc, FWACP Institute of Human Virology - Nigeria ICASA 2011 Dec. 4 - 8, 2011

2. Overview of the Institute of Human Virology, Nigeria (IHVN) IHVN was established in 2004 as a Local Organization affiliated with University of Maryland, Baltimore (now fully indigenous with over 98% Nigerian staff). A PEPFAR implementing partner, provides comprehensive HIV/AIDS services, including ART to over 68,000 through the AIDS Care and Treatment in Nigeria (ACTION) Program.

3. IHVN’s 139 Sites in Nigeria and 6 Training Centers (Sept. 2011)

4. ACTION Totals March 2005 – December 2010 778,607 Counseled and Screened with Rapid Test and Referred to care (including MARPS).778,607 Counseled and Screened with Rapid Test and Referred to care (including MARPS). 621,512 women screened for prevention of mother to child transmission. 621,512 women screened for prevention of mother to child transmission. 171,699 receive basic care and support. 171,699 receive basic care and support. 111,907 Received ARV therapy including 6,197 children. 111,907 Received ARV therapy including 6,197 children. 23,063 HIV Positive Treated for TB. 23,063 HIV Positive Treated for TB.

5. 2007 Integrated biological & behavioral survey in Nigeria shows Concrete evidence of FSW, MSM, IDU groups in Nigeria more highly affected by HIV

6. Background: The MARPs Epidemic in Nigeria Nigeria’s 4.1% HIV-1 prevalence rate masks concentrated epidemics in most-at-risk populations (MARPs). – High HIV-1 prevalence rates and regional variation 1,2 37.4% HIV+ brothel-based female sex-workers (FSW) – 49% in FCT As a result, MARPS represent 3.5% of the population but account for 38% of new HIV infections. Majority of MARPS are not linked or retained in long- term HIV care and treatment. 1 FMOH. IBBS 2008 2 CRH 2009

7. IHVN’s Integrated Program for CSWs Building on longstanding HCT and HIV prevention service partnerships with ANAWIM Home, IHVN created a community-based comprehensive mobile clinic (CBCMC) for CSWs in Abuja. Services are co-locate to increase uptake (HCT, care and treatment). Incorporate flexibility in provision of services (i.e. time of day, location) to promote utilization.

8. Services Available at the CBCMC HCT with same day results Prevention services including education, condom provision and partner testing Basic care and support services Enrollment into care (including HIV-ve clients) Regular community outreaches TSS orientation Establishment of Support Groups STI syndromic management Mobile laboratory assessment including CD4 count and VL

9. Framework These CBMCs are being fully integrated into IHVN’s hub-spoke and cluster network of care and treatment sites. Mobile clinical team (multidisciplinary) – Consisting of physician, nurse, pharmacist, adherence counselor, network coordinator and documentation clerk from hub provide weekly services Mobile laboratory team – Same day sample collection, processing and analysis for diagnosis and treatment monitoring

10. Comprehensive Primary Care and HIV services All CSW clients are enrolled in the clinic irrespective of their HIV status. All receive comprehensive primary health care HIV-positive individuals undergo treatment preparation that includes: – disclosure support – treatment buddy identification – adherence counseling – home visits – started on recommended first-line regimens

11. Public Health Evaluation Pilot demonstration project – Prospective cohort design – Data entry conducted by ANAWIM staff, mentored and supervised by IHVN program staff – Review and analysis of routinely collected program data Tools – Nigerian FMOH Patient Monitoring and Management (PMM) forms – HIV Counseling and Testing Client Intake Form

12. Results: HCT and Enrollment among CSW (March-Oct. 2011) ParameterNumber (%)Comments Total HCT177 Includes male partners, children and repeat HCT (CSW)158 (89) 1 tested HIV+ after initially testing - HIV +74 (47) HIV -84 (53) Total Enrolled133 (84) HIV+ Enrolled62 (84) Some clients were lost in the first week of the program HIV- Enrolled71 (85) Enrolled HIV+ with previous HCT 38 (61) Mean age of CSW: 28.6 years (15-56)

13. Of the 62 HIV-positives enrolled.. 33 self-reported ART naïve clients Median CD4 count: – 378 (121-771) cells/ul Median viral load: – 4.94 log10 (2.95-6.57) copies/ml – 85,216.50 (892-474,937.95) copies/ml WHO stage: – 1 (90.5%) – 2 (9.5%)

14. Other Results/Screenings *Symptoms include vaginal discharge and genital sores

15. Of the 29 self-reported ART experienced clients Commenced ART at traditional clinics Median CD4 count: – 351 (94-1025) cells/mm 3 Median HIV viral load: – 400 (20-326,911) c/ml – 2.60 log10 (1.30-5.51) c/ml Those with undetectable (<400 c/ml) viral load at enrollment: – 21 (72.0%)

16. Conclusions: Prevention Implications High rates of unrecognized and untreated HIV-1 seen in this population (“treatment as prevention”). Population likely a significant driver of new infections due to increased transmission risk from: – High viral load – Transactional sex – Multiple sexual partners – STIs. When linked to care, over 70% of CSWs are achieving undetectable viral load.

17. Way Forward More efforts needed to link and retain the CSWs in long-term care and treatment. Explore possibilities for targeted combination prevention strategies including provision of ART to all CSWs and other MARPS irrespective of CD4 count and clinical status. Possibility of “test and treat” strategy.

18. Acknowledgements Etiebet, Mary-Ann 1, Akolo, Christopher 1, Iwu, Emilia 1, Chang, Harry 1, Blattner, Micheal 2, Selo-Ojeme, Jane 3, Etafo, Felicitas 3, Yusuf, Oche 2, Abdulkadir, Binta 2, Abdullahi, Abubakar 2, Charurat, Manhattan 1, Dakum, Patrick 2, Blattner, William 1 1 Institute of Human Virology, University of Maryland School of Medicine, Baltimore, United States, 2 Institute of Human Virology, Nigeria, Abuja, Nigeria, 3 The Poorest of the Poor Rehabilitation centre (ANAWIM Home), Gwagwalada, Nigeria Staff and volunteers at ANAWIM Home and IHVN

19. Thank You