1. Community-Based Voluntary Counseling and Testing in Rural South Africa Shenoi SV, Moll AP, Madi J, Guddera V, Madondo T, Turner D, Brooks RP, Kyriakides T, Andrews L, Friedland G. 22 July 2016

2. Community-based VCT Extending services beyond health facilities Community events Home-based services Reach people where they are Diagnosis earlier in the course of disease (ie. at higher CD4 counts) Asymptomatic Not yet on ART Sweat, Lancet ID, 2011 Van Rooyen, JAIDS, 2013 Barnabas, Lancet, 2014

3. Tugela Ferry, Rural South Africa 180,000 traditional Zulu people 31% HIV antenatal prevalence 1074/100,000 TB incidence Extreme poverty – high unemployment (85%) – no electricity (70%) – no access to clean water (70%) Served by 350 bed district hospital 16 primary care clinics Philanjalo NGO Tugela Ferry

5. CBVCT / TB integration Community-Based VCT integrated with TB screening In partnership with local Department of Health Team of nurses, HIV counselors, field health workers HIV testing with phlebotomy for CD4 cell count TB symptom screen with sputum collection Linkage to care and evaluation of clinical outcomes Congregate community sites: Municipality eventsPension pay points PrisonsTaxi ranks Home based care events Secondary schools

7. Feasibility, Acceptability, & Yield 880 community events Screened 13,975 HIV testing 11,963 (86%) HIV-positive 1430 (10.2%) Phlebotomy for CD4 performed 803 (56%) Median CD4 429 (IQR 275-586) -583 Flow diagram of Community-based Voluntary Counseling and Testing March 2010 – Jan 2016 Self-identified as HIV+ 775

8. 11,963 (85%) accepted HIV testing Median age: 41 (IQR 23-56) 15-24yo: 2858 (24%) 1221 (43%) men 4569 (38.2%) reported first time HIV testing 1,430 (10.4%) HIV positive Median age: 38 (IQR 30-48) 15-24yo: 169 (12%) 775 (54%) self identified as HIV+

9. HIV Positive Individuals by Community Site Congregate Site Number Tested Number HIV+ % HIV+ by Site NNS Secondary schools 35361.759 Pension pay points 26962629.710 Home based care events 31533079.710 Municipality events 55835399.710 Health fairs 5057214.27 Taxi ranks 149420914.07 Prisons 1913518.35.5

10. HIV Positive Individuals Identified by Community Site (n=1430)

11. HIV Positive Individuals by Gender and Community Site (n=1430) n=331n=1099

12. HIV Positive Individuals by Age Group and Community Site (n=1430) n=169n=391 n=534 n=323

13. VariableUnadjusted p-valueAdjusted p-value Socio-economic demographics Young Age0.0010.0001 Female Gender0.020.0001 Marital Status0.88 Electricity0.23 Community Site<.00010.0015 Health History Previous HIV testing<.0001 Contact with a TB patient (12 mo)0.0001 History of TB treatment<.00010.0001 Recurrent pneumonia<.0001 History of shingles<.00010.0001 History of oral thrush<.0001 Current Symptoms Lymph nodes<.00010.0001 Diarrhea > 2 weeks<.0001 Cough > 2 weeks0.006 Night sweats0.04 Weight loss <.00010.03

14. Conclusions Community-based ICF is an effective strategy for improving early case detection of HIV Identifies HIV positive individuals at an earlier stage of disease though many in this sample were not asymptomatic Utilizing a variety of congregate community settings is essential to reach a variety of demographic groups including high risk young people 42% of HIV positive 15-24yo women were found at municipality events 30% of HIV positive 15-24yo men were found at taxi ranks Community-based HIV testing with CD4 count services may remove obstacles to HIV care Identification of HIV positive, ART eligibility and need for further risk stratification Informs urgency of referral to HIV care May facilitate ART initiation

15. Acknowledgements Tugela Ferry-Yale Research Team Madi J Madondo T Guddera V Chonco N Fuse C Majola T Majola Z Mvelase H Khanyile N Mvelase H Malembe N Sibiya K Myende H Makhaya K Gerald Friedland Ralph Brooks Laurie Andrews Anthony Moll Rick Altice Tassos Kyriakides Francois Eksteen Jennifer Gilbert Alison Galvani David Paltiel Funders NIAID/NIH USAID Gilead Foundation PEPFAR US CDC Fogarty Yale School of Public Health CIRA Patterson Foundation Health Systems Trust Irene Diamond Foundation Doris Duke Foundation

16. Sheela.Shenoi@yale.edu