1. Evaluating the Effects of Three HIV Testing and Counseling Strategies on Uptake of HTC among Male Key Populations S. Adebajo, J. Njab, G. Eluwa, A. Oginni, F. Ukwuije, B. Ahonsi 2013 IAS Conference, Malaysia

2. Background Situated in the west of Africa Most populous in Africa (>160 m); 10 th in the world The second largest global HIV burden next to South Africa. Mixed epidemic HIV prevalence in GP = 3.6% (F=4.0%; M=3.2%); 4.1% among pregnant women 3m people living with HIV.

3. Introduction Most-at-risk populations (MARPs) make up ~1% of the Nigerian Population MARPs + sex partners account for a disproportionately high burden (38%) of HIV infections Between 2007 – 2010, prevalence of HIV: 13.5% to 17.2% among MSM ( 27.5%) 37.4% to 27.4% among BB FSWs ( 26.7%) 30.2% - 21.1% among NBB FSWs ( 30.1%) 5.6% - 4.2% among IDUs ( 25.0%)

4. Despite elevated risks of HIV infection: M-MARPs are less likely to access HCT and other prevention services because they engage in behaviours that are criminalized have poor health seeking behaviours stigmatizing behaviours of Health Care Providers lack of relevant and appropriate services to meet the needs of MARPs internalized homophobia Critically lacking were: Targeted, innovative, relevant prevention strategies Limited evidence of the effects of community/peer led strategies on HTC uptake.

5. Provides clinic and community- based interventions harnessing partnerships with CBOs, private and public health sectors to avert new infections among male MARPs

6. Objective We analysed the effects of three different community peer-based strategies on uptake of HTC among M-MARPs

7. Methods Three HCT strategies were implemented over different periods between 2009 and 2012 Strategy 1 (S1) => Static facility-based clinics with M-MARPs Peer Educators - Key Opinion Leaders (KOLs) referring their peers. Strategy 2 (S2) => KOLs referring their peers to nearby mobile HCT teams. Strategy 3 (S3) => KOLs mobilizing their peers and conducting HCT.

8. Methods Data were obtained from structured pre- coded HTC client intake forms administered by MARP-friendly counselors. Uptake of HTC was measured as the number of persons tested, counseled, who received their results. Segmented linear regression was used to assess the effects of different strategies on uptake of HTC

9. Results A total of 31,609 M-MARPs received HTC S1 = 1,988 (6.3%) S2 = 14,726 (46.6%) S3 = 14,895 (47.1%)

10. Socio-demographic characteristics of Clients Reached S1 S2 S3 Age 16-18 years 4.3 (85) 4.2 (612)3.40 (505) 19 - 25 years37.8 (741)28.4 (4,159)33.7 (5004) >=26 years57.9 (1135)67.4 (9874)28.2 (9337) Median Age (yrs)28 (22-36)30.0 (24-40) 28 (24-34) Marital status Single71.7 (1410)49.5 (7186)59.3 (8747) Married/cohabiting25.0 (491)50.0 (7272)39.8 (5872) Separated/divorced 3.3 (65) 0.5 (68) 0.9 (140) Occupation Student26.2 (422)27.9 (4028)18.2 (2,647) Employed72.0 (1158)61.1 (8833)77.3 (11,230) Unemployed 1.7 (28)11.1 (1600) 4.5 (646) First time testers87.9 (1646)84.3 (12079)90.1 (13313) HIV+ Clients 9.1 (177) 3.3 (480)12.7 (1853)

11. HIV Prevalence by Key Variables across Strategies S1 (%) S2 (%) S3 (%) Age 16-18 years 7.3 1.98.4 19 - 25 years12.4 3.912.1 >=26 years 6.5 3.113.2 Marital status Single11.4 4.310.7 Married/cohabiting 3.1 2.115.2 Separated/divorced 1.5 024.3 Target Population MSM19.511.219.0 PWUD 1.7 1.411.0 First time testers 8.2 2.913.2 Repeat Testers 3.6 4.2 8.4

12. Effects of Different Strategies on Uptake of HTC Strategy 1 vs Strategy 2 Independent VariablesCoefficientStandard errorp value Constant β 0 -36.35275.330.896 Secular trend β* 1 14.0424.150.566 Change in level β* 2 271.57436.610.539 Change in trend β* 3 53.0753.920.334 Strategy 2 vs Strategy 3 Independent VariablesCoefficientStandard errorp value Constant β 0 501.98776.210.528 Secular trend β* 1 67.11105.470.534 Change in level β* 2 -3068.241266.960.029 Change in trend β* 3 821.97260.640.007 β 0 - baseline level of the HTC uptake at time 0; β* 1 - estimates increase in HTC uptake independent of intervention β* 2 estimates immediate impact of change in intervention on HTC β* 3 reflects change in growth rate in HTC uptake, after intervention. Cost of HTC/client - S1 = $40.7; S2=$8.6; S3=$5.9

13. Conclusion & Recommendations First study to evaluate the effects of community peer-based strategies among MARPs in Nigeria Training lay M-MARPs as HTC counselors and testers is a feasible strategy for increasing uptake of HTC among male MARPs. This strategy yielded a high number of first-time M- MARPS testers and a high proportion of undiagnosed HIV+ clients. Given that men have a poor health seeking behavior, effective evidence based strategies are needed to increase uptake of HTC among M-MARPs Nigeria’s National Prevention Plan needs to align to WHO’s goal of universal access and promote annual testing for all MARPs in Nigeria.

14. Acknowledgements Participants who despite the hostile and homophobic environment disclosed their sexual identities accessed HTC testing. CDC, Atlanta and Nigeria for funding the MHNN project. All our project partners, CBOs, NGOs, Health care providers and MHNN staff.

15. Thank You