1. Cutting Across Prevention Program Boundaries with VMMC HIV Testing & Counseling (HTC): opportunities for and engagement of testing services Jason Reed, MD, MPH U.S. Centers for Disease Control & Prevention 16 th ICASA, Addis Ababa, Ethiopia December 2011

2. Outline HTC in VMMC programs as opportunities for HIV case identification among men Couples counseling and testing by VMMC programs HTC venues as referral sources for VMMC HTC efficiencies and innovations – request for assistance

3. VMMC for Case Identification Benefits of VMMC scale-up, as per the DMPPT model (3.34 million infections averted resulting from 80% scale-up in 5 years 1 ), did not account for added benefits of diagnosing/treating men via VMMC To realize promise of treatment as prevention, more men must first test for HIV (and engage in treatment) Women more likely to have tested for HIV due to ANC; men a difficult population to reach

4. HIV Testing Rates in Men % Never HIV Tested - MenReference Botswana 90.9%BAIS 2011 Ethiopia 94.5%DHS 2005 Kenya 57.7%DHS 2008-09 Lesotho 60.7%DHS 2009 Malawi 47.5%DHS 2010 Mozambique 80.9%AIS 2009 Namibia 65.7%DHS 2006-07 Rwanda 78.1%DHS 2005 South Africa Not AvailDHS 2003 Swaziland 81.4%DHS 2006-07 Tanzania 70.8%AIS 2007-08 Uganda 87.5%AIS 2004-05 Zambia 78.1%DHS 2007 Zimbabwe 80.6%DHS 2005-06

5. VMMC for HIV Case Identification VMMC programs provide a unique opportunity to HIV test & counsel men – Botswana VMMC Program HTC Uptake: 97% 2 – PSI Swaziland VMMC Program HTC Uptake: 81% 3 – Kenya VMMC Program HTC Uptake: 31% (VCT) → 83% (PITC) 4 – Society for Family Health (SA) HTC Uptake: 30% (VCT) → 96% (PITC) 5 Need for evaluation to determine best practices for and rates of successful linkage to care

6. VMMC for HIV Case Identification VMMC programs progressively targeting older men; higher HIV prevalence anticipated among older clients Example of age distribution and HIV status, ICAP Tanzania Lake Victoria Island VMMC Campaigns 6 % of VMMC Clients% HIV Positive >14 years31%1.7% 15-25 years40%5.7% 26+ years29%17.2%

7. Couples Counseling & Testing VMMC programs increase access to HIV testing overall, including for women Unique opportunity to engage couples in counseling and testing together; more work is needed to increase the number of women accompanying men to VMMC Discordant couples may especially benefit from HTC and VMMC where the man is negative and the woman is positive – While the efficacy of ART as prevention and VMMC are known scientifically, the real-world effectiveness of both in combination is not known but is likely exceptionally high in discordant couples (M-; F+)

8. HTC Venues as Referral Sources All providers of HIV testing should provide VMMC information and actively refer HIV-negative men to VMMC, including hospitals and clinics instituting PITC STD clinics and other providers reaching high-risk men with HTC are especially valuable referral partners due to immediacy of need among clients VCT centers may have high referral success rates as male clients may exhibit greater self efficacy to protect their health PMTCT programs should offer VMMC information and encourage women to refer partners for services ART providers, as they may encourage female patients to refer HIV-negative male partners

9. HTC Innovation & Efficiency (Needed) As VMMC clinical efficiencies increase with innovation and technological advancements, HTC timing and logistics become the bottleneck PITC and VCT programs with experience in efficient and effective service delivery models needed to inform VMMC programs Novel approaches to HTC (campaigns, home- based testing, outreach HTC services) provide unique opportunities for combining HTC and VMMC services

10. Conclusion/Summary VMMC programs provide opportunity to test potentially millions of men for HIV that might otherwise forego awareness of HIV status Millions of men may be newly diagnosed with HIV as a result of VMMC programs Enrolling newly diagnosed men in care & treatment may further, greatly reduce HIV incidence among women and increase the impact of VMMC programs on the HIV epidemic All HTC providers (VCT, PITC) should be leveraged as sources of VMMC clients and make active referrals

11. Acknowledgments CDC HIV Testing & Counseling Team PEPFAR VMMC Technical Working Group Jhpiego & PSI WHO/IRDO/Tanzania MOH

12. References 1)Njeuhmeli E, PLoS, 2011 2)Curran K/Jhpiego, personal communication 3)Hatzold K/PSI, personal communication 4)Mwandi Z, PLoS, 2011 5)Nhlapo C, In abstracts: 16 th ICASA, 2011 6)Mwinyi A, In abstracts: 16 th ICASA, 2011

13. Thank you! Jason Reed jreed1@cdc.gov

14. CountrySurveyYear Sample size Percentage men ever tested Percentage men never tested Percentage men tested in the last 12 monthsWeb linkIndicator/page/table TotalMen (15-49 y/o) BotswanaBAIS20014,2671,4139.1%90.9% 1 N/A http://hivdata.measuredhs.com/survey s/survey_ind_data.cfm?survey_id=402 &survey_ind_id=3198&ind_id=98Indicator 5.1.1 2 Ethiopia DHS200520,1035,4645.5%94.5%2.3% http://www.measuredhs.com/pubs/pdf /FR179/FR179[23June2011].pdfp. 197 (Table 13.9.2) Kenya DHS2008-200911,9093,25842.3%57.7%22.8% http://www.measuredhs.com/pubs/pdf /FR229/FR229.pdfp. 192 (Table 13.9.2) LesothoDHS200910,9413,00839.3%60.7%24.0% http://www.measuredhs.com/pubs/pdf /FR241/FR241.pdf p. 182 (Table 12.10.2) Malawi DHS201030,1956,81852.5%47.5%31.3% http://www.measuredhs.com/pubs/pdf /FR247/FR247.pdfp. 210 (Table 15.1.2) MozambiqueAIS200911,2124,16819.1%80.9%8.9% http://www.measuredhs.com/what- we-do/survey/survey-display-322.cfmp. 135 (Table 9.1.2) NamibiaDHS2006-200713,7193,91534.3%65.7% 1 N/A http://hivdata.measuredhs.com/survey s/survey_ind_data.cfm?survey_id=482 &survey_ind_id=8017&ind_id=98Indicator 5.1.1 2 Rwanda DHS200516,1414,41321.8%78.1%11.0% http://www.measuredhs.com/pubs/pdf /FR183/00FrontMatter00.pdfp. 207 (Table 14.9.2) South AfricaDHS200310,5192,780N/A 22.5% http://www.measuredhs.com/publicati ons/publication-FR206-DHS-Final- Reports.cfmp. 95 (Table 5.6) SwazilandDHS2006-20079,1434,15618.6%81.4%8.9% http://www.measuredhs.com/pubs/pdf /FR202/FR202.pdf p. 199 (Table 13.11.2) Tanzania AIS2007-200816,3186,97529.2%70.8%18.9% http://www.measuredhs.com/pubs/pdf /AIS6/AIS6_05_14_09.pdfp. 84 (Table 7.5.2) Uganda AIS2004-200519,6568,01012.5%87.5% 1 3.8% http://www.measuredhs.com/pubs/pdf /AIS2/AIS2.pdfp. 70 (Table 6.7) ZambiaDHS200713,6465,99521.9%78.1%11.7% http://www.measuredhs.com/pubs/pdf /FR211/FR211[revised-05-12-2009].pdf p. 205 (Table 13.10.2) ZimbabweDHS2005-200616,0826,86318.6%80.6%6.7% http://www.measuredhs.com/pubs/pdf /FR186/FR186.pdf p. 202 (Table 13.10.2) 1 Survey report did not include this number. Calculated by substracting "percentage men ever tested" from 100%. 2 Indicator 5.1.1: Population ever receiving an HIV test.

15. Rakai Uganda Discordant Couples Study Gray, AIDS, 2000