1. Peter Godfrey-Faussett for Charlotte Watts
Interim report on behavioural studies and HIV model for ProTEST
Peter Godfrey-Faussett for Charlotte Watts
ProTEST Meeting, Durban February 2003

2. Strategies to control TB and HIV
STI control
IEC Lifeskills
Condoms VCT
Microbicides
Peer educators
 HIV transmission
DOTS
intensive case-finding
reduce diagnostic delays
improve adherence
 TB transmission
Isoniazid
preventive
therapy
 TB reactivation

3. Decreased Risk Behaviours: VCT Efficacy Group
RCT in Kenya, Tanzania and Trinidad Voluntary HIV -1 Counselling and Testing Efficacy Group, 2000
3120 individuals and 586 couples randomly assigned to VCT or basic health information
At 6 month FU, HI offered VCT, VCT offered retesting, STIs dx’d and tx’d
Behavioural questionnaires at baseline, 6 months and 12 months

4. Decreased Risk Behaviours: VCT Efficacy Group
Unprotected intercourse down 35% in men with VCT cf 13% with health education (HE)
In women, VCT: 39%, HE: 17%
in HIV+>HIV-, couples with at least 1 HIV+>uninfected couples
Couples reduced unprotected intercourse with enrolment partners but not with non-enrolment partners

5. Voluntary HIV Counselling and Testing: Cost-Effectiveness
Cost per HIV infection averted: $249 in Kenya and $346 in Tanzania Sweat M, 2000
Cost per DALY saved:
$12.77-$17.78
if lower infectivity: $28.87-$45.73
Peer education of CSWs ($0.35-$0.52)
Improved STI management ($9.45)
ARVs in pregnancy ($10.51) Jha P, 2001

6. Protest behavioural study and epidemiological modelling Update on progress and baseline data Charlotte Watts Health Policy Unit Department of Public Health and Policy LSHTM

7. Components to study
Behavioural survey – clients attending urban VCT services in Lilongwe and Lusaka (one site in each city)
Epidemiological modelling of impact on HIV & TB
HIV estimates use VCT behavioural data from each site
TB projections build on model estimates of VCT impact on HIV incidence
Link with economic analysis to estimate cost per HIV infection averted and cost per DALY saved

8. Behavioural study design
Collect behavioural data from HIV+/HIV- men and women before and after VCT
Interview 1,400 clients from MACRO, Lilongwe attending VCT services
Follow-up with HIV+/HIV- male and female clients 6 months later
Control population new clients attending VCT services during follow-up phase of study

9. Steps in behavioural study - Malawi
Drafting and pre-testing of male and female questionnaire
Building of interview buildings at MACRO
Development of accompanying materials
Selection and training of interviewers
Piloting of questionnaire in Lilongwe
Final revision / development of data entry screens
Base-line interviews (Jan – April 2002)
Follow-up & control interviews (6 months) (July - Dec 2002)
Data entry and cleaning (ongoing)
Analysis using SPSS (ongoing)

10. Baseline survey – preliminary results
Interviews conducted Jan – April 2002
Low levels of refusal
1408 interviews completed and analysed
73% male (1028), 27% female (380)

11. Patterns of sexual behaviour - men
Casual partner past
6 months
Have
steady
partner
43%
Male
VCT
30%
No other
partners
last 6 mths
57%
67%
Single /
sexually
active
Casual partner past
6 months
69% 3% No
partners
past 6 mths
31%
Never had sex

12. Patterns of sexual behaviour - women
Casual partner past
6 months
Have
steady
partner 7%
Women
VCT
35%
No other
partners
last 6 mths
93%
59%
Single /
sexually
active
Casual partner past
6 months
64% 6% No
partners
past 6 mths
36%
Never had sex

13. Reported number non-regular sexual partners in past 6 months

14. Over-view baseline results
Analysis preliminary
Majority of VCT clients aged 15 – 24 with at least primary level education
Approximately 2/3 male and female VCT clients are single
1/3 of VCT clients have a regular / steady partner
43% partnered men report casual partners in past 6 months
7% partnered women report casual partners in past 6 months
1/3 single VCT clients do not report having a sexual partner in the past 6 months
Large variation in the numbers of casual sexual partners reported – with single men having the greatest number of partners in the last 6 months
Results on reported condom use not presented – preliminary analysis suggests low levels of use
Late analysis will merge survey data with data on HIV infection status of clients

15. Follow-up & control surveys Malawi
Designed to ensure that interviews with HIV+ve / HIV-ve males and females obtained
Requests to return, incentives and follow-up used to identify people for follow-up
Target for follow-up interviews:
All HIV+ve men and women interviewed
All HIV-ve women interviewed
1/4 of HIV-ve men (other men interviewed using a short questionnaire)
938 interviewed in follow-up – 509 with full questionnaire (71% of targeted follow-up group)
770 control interviews completed

16. Key features of HIV modelling
Deterministic, epidemiological model to consider transmission between VCT client and different sexual partners
Population of VCT clients will be stratified by characteristics of sexual behaviour, HIV infection status, condom use
For each sub-category model the impact of behaviour change on patterns of HIV transmission
Model includes role of high viraemia, role of one STI in facilitating HIV transmission, and dynamic of HIV and STI transmission over time
Focus of analysis to explore short term impact on HIV transmission (6 month and 2 year projections)
Impact estimates will depend on assumptions about HIV and STD prevalence among different types of sexual partners of VCT clients

17. transmission over time
Format of HIV impact model to be used with each strata of VCT clients
Sexual partners
VCT clients
(male / female)
Steady
HIV+
HIV & STD
transmission over time
Short term
/ occasional
HIV-
Commercial

18. Progress with epidemiological modelling
Review of existing behavioural data from Malawi
Drafting of outline for epidemiological model(s)
Programming of beta version of model(s)
Analysis of baseline sexual behavioural data
Revision of model to reflect patterns of sexual behaviour seen / level of complexity
Analysis of follow-up & control sexual behaviour data – identification of main forms of behaviour change
Finalisation of alpha version of model to incorporate forms of behaviour change documented
Modelling of VCT impact on HIV incidence (comparing with and without VCT)
Estimation of associated impact on TB infection

19. Next steps - Malawi January – March 2003
Analysis of baseline data and revision of model
March – May 2003
Analysis of control and follow-up data
Comparisons between before and after data, control and intervention data
Revision of model and estimation of VCT impact on HIV
Use of data on impact on HIV incidence to estimate associated TB cases averted

20. Next steps - Zambia and South Africa
Review Zambian budget and timeframe based on Malawi experience
South Africa is also planning to undertake behavioural study
Tools developed collaboratively by Malawi and South Africa
Possible location under discussion
Awaiting funding to commence