1. #AIDS2016 | @AIDS_conference Intervention Outcomes of the Bukoba Tanzania Combination Prevention Evaluation: Duncan MacKellar 1, Haruka Maruyama 2, Rachel Weber 3, Oscar Ernest 2, Sarah Porter 1, Joshua Gikaro 2, Geofrey Alexander 2, Gerald Kundi 2, Johnita Byrd 4, Kokuhumbya Kazaura 5, Deogratias Mbilinyi 5 Fernando Morales 2, Jessica Justman 6, Robert Josiah 7 1 CDC, Atlanta, Georgia, USA; 2 ICAP, Dar es Salaam, Tanzania; 3 CTS Global, Inc., assigned to CDC, Dar es Salaam, Tanzania; 4 ICF International, Atlanta, Georgia; 5 CDC, Dar es Salaam, Tanzania; 6 ICAP, New York, New York, USA; 7 National AIDS Control Program, Dar es Salaam, Tanzania. Promising HIV Testing & Linkage-to-care Methods to Achieve 90-90-90* *This research has been supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention under the terms of Cooperative Agreement #5U2GPS001998. The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of CDC.

2. #AIDS2016 | @AIDS_conference Bukoba Combination Prevention Evaluation Location Bukoba Municipality, capital of Kagera Region, bordering Lake Victoria Est. Population (2015): ~143,000 Collaborators ICAP; Tanzania MOHSW & TACAIDS; CDC Primary Goal Achieve >80% ART coverage among eligible adult residents (CD4<500), ages 18-49, after a 2.5 year, community-wide combination-prevention intervention Design Single community, pre-post, program evaluation 2

3. #AIDS2016 | @AIDS_conference Program Evaluation Design Intervention Baseline Endline Nov 2013 – Aug 2014 Cross-sectional Household survey (residents 18-49 yrs) Cross-sectional Household survey (residents 18-49 yrs) Assess HIV Prevalence % previously HIV diagnosed (diagnostic coverage) % HIV-positive on ART, of eligible (ART coverage) 6 mos. Intrv. Newly diagnosed, HIV-positive cohort (residents 18-49 yrs) Newly diagnosed, HIV-positive cohort (residents 18-49 yrs) Assess Enrollment in HIV care among residents newly diagnosed at home (cross-section survey) and at 3 health-care facilities within 6 months of standard referral

4. #AIDS2016 | @AIDS_conference Program Evaluation Design Intervention Baseline Endline Nov 2013 – Aug 2014 Oct 2014 – Mar 2017 CP Intervention Cross-sectional household survey (residents 18-49 yrs) Cross-sectional household survey (residents 18-49 yrs) 6 mos. Intrv. Newly diagnosed, HIV-positive cohort (residents 18-49 yrs) Newly diagnosed, HIV-positive cohort (residents 18-49 yrs) HTC (PITC/CBHTC) Linkage Case Management (LCM) ART-care Mop-up & Defaulter Tracing PMTCT (B+) VMMC

5. #AIDS2016 | @AIDS_conference Program Evaluation Design Intervention Baseline Endline Nov 2013 – Aug 2014 Oct 2014 – Mar 2017 May 2017 – Dec 2017 CP Intervention HTC (PITC/CBHTC) Linkage Case Management (LCM) ART-care Mop-up & Defaulter Tracing PMTCT (B+) VMMC Cross-sectional household survey (residents 18-49 yrs) Cross-sectional household survey (residents 18-49 yrs) 6 mos. Intrv. Newly diagnosed, HIV-positive cohort (residents 18-49 yrs) Newly diagnosed, HIV-positive cohort (residents 18-49 yrs)

6. #AIDS2016 | @AIDS_conference Baseline Findings (Nov 2013 – Aug 2014) Population-based, cross-sectional household survey (n=4,799) 9.1% HIV prevalence 38% of 436 HIV-positive participants were previously diagnosed 21% of 261 HIV-positive participants with CD4<500 were on ART Diagnostic and ART coverage estimates were applied to census to establish intervention targets. Newly diagnosed, HIV-positive cohort study (n=288) Within 6 months of standard referral: 31% of 191 persons diagnosed at home enrolled in HIV care 82% of 97 persons diagnosed at 3 medical facilities enrolled in HIV care

7. #AIDS2016 | @AIDS_conference Program Evaluation Design Intervention Baseline Endline Nov 2013 – Aug 2014 Oct 2014 – Mar 2017 CP Intervention HTC (PITC/CBHTC) Linkage Case Management (LCM) ART-care Mop-up & Defaulter Tracing PMTCT (B+) VMMC Cross-sectional household survey (residents 18-49 yrs) Cross-sectional household survey (residents 18-49 yrs) 6 mos. Intrv. Newly diagnosed, HIV-positive cohort (residents 18-49 yrs) Newly diagnosed, HIV-positive cohort (residents 18-49 yrs)

8. #AIDS2016 | @AIDS_conference Intervention Goals & Targets (Residents 18-49 years) Population Goals Increase HIV diagnostic coverage from 38% to >90% Increase early enrollment in HIV care from 31%/82% to >90% Increase ART coverage (CD4 80% HTC Targets Newly diagnose >3,450 residents 18-49 yrs (1350 males, 2100 females) Conduct: >90,000 tests LCM Targets Enroll in HIV care >3,700 newly and previously diagnosed, out-of-care residents 18-49 yrs Initiate >2,000 new patients 18-49 yrs on ART (CD4<500) HTC and linkage-case management programs were developed to help achieve these goals and targets.

9. #AIDS2016 | @AIDS_conference BCPE INTERVENTIONS: HTC & LINKAGE CASE MANAGEMENT

10. #AIDS2016 | @AIDS_conference Enhanced HTC Provider-Initiated HTC (Poster: WEPEC150, O. Ernest, et al.) Goal: achieve near 100% HTC coverage in 11 facility out-patient department (OPD) and maternal child health (MCH) clinics All patients provided group-pre-test counseling, screened on need for HTC, and referred for testing unless recently tested (< 3 months) or in HIV care At least two lay counselors and one nurse counselor added per facility (only nurses could perform rapid HIV tests at the time of this program). 10

11. #AIDS2016 | @AIDS_conference Enhanced HTC Community-Based HTC (CBHTC) Conducted in all 14 wards: 7 rural, 6 urban, 1 mixed Support of community leaders, and HTC promotion and mobilization Venue-based HTC near businesses and at community events, targeting men Home-based HTC offered to all encountered residents 7 field teams of ~4 lay counselors and 1 nurse counselor 11

12. #AIDS2016 | @AIDS_conference Linkage Case Management Program Participants provided with a package of services that are: – Recommended by WHO, CDC, and IAPAC – Delivered by HIV-positive, peer counselors (lay counselors) LCM services initiated at the point of HIV diagnosis and last for up to 90 days Integrated within 11 facilities and 7 community-based HTC teams Poster: TUPEB044, J Gikaro et al.

13. Peer-delivered LCM Program (Poster: TUPEB044)

14. #AIDS2016 | @AIDS_conference HTC AND LINKAGE PROGRAM: OUTCOMES

15. #AIDS2016 | @AIDS_conference HTC Outcomes Oct 2014 – March 2016 Provider-initiated HTC (Poster: WEPEC150, O. Ernest, et al.) 54,550 tests (34% among males) – 4.6 times more tests than prior 18 months (n=11,984) 2,829 (5.2%) HIV-positive – 5.7 times more HIV-positive tests than prior 18 months (n=494)

16. #AIDS2016 | @AIDS_conference HTC Outcomes Oct 2014 – March 2016 Community-based HTC 31,638 tests (50% among males), 791 (2.5%) HIV+ HBHTC: 26,782 home visits, 23,873 tests (46% among males), 2.3% HIV+ VBHTC: 31 multi-day events, 7,765 tests (64% among males), 3.1% HIV+

17. #AIDS2016 | @AIDS_conference HTC Outcomes Oct 2014 – March 2016 Facility & Community HTC 86,188 tests (females: 51,551; males: 34,637) 3,620 (4.2%) HIV-positive – 3,292 (91%) LCM eligible (HIV+, out-of-care >90 days) LCM Eligible 2,856 (87%) newly HIV diagnosed – 2,740 ages 15-49 years (1,744 females, 996 males) Target: 3450 new HIV diagnoses 18-49 years of age (2100 females, 1350 males) Status: 79% reached (females, 83%; males, 74%) Target: 3450 new HIV diagnoses 18-49 years of age (2100 females, 1350 males) Status: 79% reached (females, 83%; males, 74%)

18. #AIDS2016 | @AIDS_conference LCM Consent & Case Status Oct 2014 – March 2016 LCM Consent (n=3,292 eligible) Year 1 (Oct 2014 – Sept 2015): 86% (2035/2365) Year 2 (Oct 2015 – Mar 2016): 94% (874/927) 88% (2909/3292) Case Status (n=2909) 2517 (87%) closed and compiled for M&E 392 cases still being managed Outcomes reported on 2517 closed cases

19. #AIDS2016 | @AIDS_conference CTC Registration (<3 Months of Consent) Oct 2014 – March 2016 Closed LCM Cases (n=2517) –91% registered at HIV CTC (medical chart opened) 93% of 987 men 90% of 1530 women 85% of 503 clients aged 15-24 years 92% of 1,727 clients aged 25-49 years 81% of 404 clients diagnosed in community settings (vs. baseline: 31%) 93% of 2,113 clients diagnosed in facility settings (vs. baseline: 82%) 90% of 1528 clients 1 st year (Oct 2014-Sep 2015) 93% of 989 clients 2 nd year (Oct 2015-Mar 2016) Target: 90% enroll in HIV care < 3 months of consent Status: Met overall, including for men and women, but not for 15-24 year olds and clients diagnosed in community. Target: 90% enroll in HIV care < 3 months of consent Status: Met overall, including for men and women, but not for 15-24 year olds and clients diagnosed in community.

20. #AIDS2016 | @AIDS_conference Clinical Outcomes (<3 months of Consent) Oct 2014 – March 2016 Closed LCM Cases (n=2517) – 86% (2167/2517) had baseline CD4 test result in medical chart 51% ART eligible by CD4 – 50% (1260/2517) initiated on ART 1074 ART initiated 15-49 years of age – Dec 2015, ART-eligibility changed from CD4<350 to CD4<500 Target: 2,000 new patients 18-49 years on ART Status: 54% (1074/2000) of target reached through HTC/LCM pgms Target: 2,000 new patients 18-49 years on ART Status: 54% (1074/2000) of target reached through HTC/LCM pgms Intervention Baseline Endline Nov 2013 – Aug 2014 Oct 2014 – Mar 2017 May 2017 – Dec 2017 CP Intervention

21. #AIDS2016 | @AIDS_conference Next Steps Intervention Baseline Endline Nov 2013 – Aug 2014 Oct 2014 – Mar 2017 May 2017 – Dec 2017 CP Intervention Cross-sectional household survey (residents 18-49 yrs) Cross-sectional household survey (residents 18-49 yrs) HTC (PITC/CBHTC) Linkage Case Management (LCM) ART-care Mop-up & Defaulter Tracing PMTCT (B+) VMMC

22. #AIDS2016 | @AIDS_conference Conclusions HTC models effective (and in settings where task shifting is permitted, most likely at modest cost) – PITC yielded large majority of new HIV diagnoses – VBHTC effective in accessing and testing men Peer-delivered, linkage-case management is well accepted > 90% enrollment in HIV care <3 months achieved for many sub-groups – Relative to baseline evaluation, superior than standard referral Need to improve delivery of linkage services and enrollment for clients: – Aged 15-24 years, diagnosed in community settings Target of >2,000 new ART patients should be reached by end of intervention period 31 March 2017 Bukoba Combination Prevention Evaluation HTC/LCM models are promising methods that might help programs achieve 90-90-90

23. #AIDS2016 | @AIDS_conference Acknowledgements ICAP Geoffrey Alexander Oscar Ernest Joshua Gikaro Jessica Justman Gerald Kundi Caitlin Madevu-Matson Haruka Maruyama Fernando Morales Omari Msumi Tara Ornstein Neena Philip Tanzania MOHSW & TACAIDS Robert Josiah (MOHSW) Subilaga Kaganda (TACAIDS) CDC Tanzania Kokuhumbya Kazaura Eva Matiko Deogratius Mblinyi Michelle Roland Rachel Weber CDC Atlanta Irene Benech Johnita Byrd Haddi Cham Duncan MacKellar Jan Moore Susan Nkengasong Sherri Pals Bharat Parekh Sarah Porter

24. Asante!