1. Centers for Disease Control and Prevention Global AIDS Program Prevention Interventions for People Living with HIV: 5 HIV Prevention Steps and Tools for Implementation Pamela Bachanas, PhD Washington, DC August, 2008

2. Prevention for People Living with HIV Scale up of care and treatment programs in SSA have been an extraordinary success – 2.5 million people on ARVs However, in 2007 alone, 2.5 million people were newly infected with HIV, most of whom will eventually need ARVs Effective and efficient HIV prevention interventions are critically needed

3. Prevention for People Living with HIV Traditional focus of prevention efforts have been on preventing acquisition among HIV- individuals To have a significant impact on slowing the spread of the epidemic, prevention efforts must also be directed toward individuals living with HIV who can transmit the virus

4. HIV prevalence, Kenya, 2006 HIV negative, 94% HIV positive, 6% Only HIV+ individuals can transmit HIV ►Focusing on ~1.3m HIV-infected people rather than ~21.6m uninfected people is an efficient, targeted prevention approach

5. HIV Prevention in Care and Treatment Due to increasing availability of HIV treatment, many HIV+ persons are accessing health care settings and clinics, providing an opportunity to reach a large number of infected persons with prevention messages and interventions Health care providers in HIV clinic settings meet with patients regularly and can deliver consistent, targeted prevention messages and strategies during routine visits Providers are considered authority figures and trusted sources of health information

6. HIV Prevention in Care and Treatment For any disease, preventive information on infection control is regarded as quality standard of care Health care providers can also address biomedical prevention strategies, such as reproductive health and STI management Given clinic burden and complexity of patients’ needs, many patients need more in-depth counseling on prevention issues (e.g. disclosure, alcohol use). Incorporating counselors (including PLWHA) into clinic settings is essential for a comprehensive prevention program

7. Prevention for People Living with HIV Multiple approaches to prevention are needed; integration of prevention into care and treatment settings is critical Integrating prevention services into care and treatment can be overwhelming and can require a great deal of effort and resources However, we can’t afford not to do it

8. ART Need in Namibia Assuming Immediate End to Transmission

9. ART Need in Namibia Assuming Ongoing Transmission

10. Prevention for People Living with HIV The question isn’t can we do prevention in care and treatment… The question is how do we do prevention in care and treatment… –What are the specific interventions –How can they be implemented most efficiently (task shifting, etc,)

11. Step 1 – Give prevention recommendations to every patient at every visit

12. Critical Need for Prevention Interventions with PLWHA Vast majority of PLWHA are married in Kenya (70%), Malawi (82%), & Uganda (57%) [DHS & AIS data] Rates of partner testing among PLWHA very low Rates of disclosure of serostatus to partner(s) low and challenging Condom use in stable relationships very low

13. HIV status of spouses of HIV-infected persons in Kenya, DHS, 2003 ►In Kenya, 50% of married HIV+ persons (450,000) have an HIV-negative spouse HIV DISCORDANT: One partner positive, one partner negative: 50% CONCORDANT POSITIVE: Both partners HIV-infected: 50%

14. Nature of Incident Infection, Uganda Sero-behavioral Survey, 2004-5 Note: among 79 couples

15. CONDOM USE IN REGULAR PARTNERSHIPS

16. Discordant Couple Interventions: Couple Counseling and Testing 963 discordant couples in Lusaka (Allen et al., 2003) 53 discordant couples in Kigali (Allen et al., 1992) 149 discordant couples in Kinshasa (Kamenga et al., 1991) Self-reported condom use increased from 3% to 80% after 1 year Self-reported condom use increased from 4% to 57% after 1 year Self-reported condom use increased from <5% to 77% after 1 year

17. Step 1 – Give prevention recommendations to every patient at every visit Providers and counselors must assess whether each patient’s partner has been tested; test or refer to counselor for testing Provider- and/or counselor-assisted disclosure Counselor who can conduct rapid testing available in clinic and community settings Children of HIV+ moms tested

18. Step 1 – Give prevention recommendations to every patient at every visit Discordant couples identified and counseled –Positive partners linked to care and treatment –Negative partners counseled on prevention practices to stay negative (condoms!) Provider delivers brief messages on patient self- protection & partner protection –Consequences of unprotected sex Provider assesses patient for alcohol use that affects adherence or risky behavior –Refer drinkers to counselor

19. HIV Acquisition among Male Partners of HIV + Female Partners By Circumcision Status In Rakai Female viral load Quinn et al; NEJM 2000; 342:921-9

20. Step 2 – Assess adherence to ARVs Provide adherence support or refer to counselor for support

21. Step 3 – STI Management Integrated into HIV Clinics

22. STI Management Integrated into HIV Care In HIV+ individuals, STIs have been shown to increase genital HIV shedding, increasing likelihood of HIV transmission. STIs have been associated with increased genital HIV shedding in persons on ARVs with suppressed plasma viral loads. Genital ulcer disease has the strongest association with HIV transmission; high rates of HIV/HSV co-infection. Urethritis, vaginitis, and bacterial vaginosis have also been associated with transmission and acqusition.

23. STI Management Integrated into HIV Care Assess for signs and symptoms of STIs at every visit and treat as indicated Treating STIs in HIV+ persons is important for care, as STIs can be more severe and more difficult to treat in immunocompromised individuals Treating STIs in HIV+ persons is important for prevention; may reduce chances of transmission of HIV Treating partners of patients with STIs may reduce reinfection and stop the spread of the STI

24. Step 4 - Family Planning Services and Safer Pregnancy Counseling in Care and Treatment (through Wrap-Around Programs)

25. Family Planning Many women on ARVs resume sexual activity and have unintended pregnancies (Bunnell et al., 2006) Preventing unintended pregnancy in HIV+ women who do not want children can avert the need for and costs associated with (Sweat et al., 2004) –PMTCT –care for HIV+ children –support for orphans Other HIV+ women on treatment desire children (Nakayiwa et al., 2006); they require counseling on safe timing of pregnancy and referrals to PMTCT

26. Unmet need for family planning among HIV-infected women (Bunnell, 2007) KenyaMalawiUganda Last pregnancy unplanned/unwanted 54%40%49% HIV-infected women who do not want more children 41%50% - Unmet need for contraception among those who do not want more children 64% 79% -

27. Step 4 – Assess pregnancy status & intentions Inquire about pregnancy status/intentions every visit Through wrap-around funding: Provide basic contraceptives in HIV clinic (pills, injectables) and refer to FP for other contraceptives Provide basic counseling on safer conception, pregnancy, and delivery for HIV+ women desiring pregnancy in the HIV care and treatment setting

28. Step 5 – Give patient condoms at every visit!!

29. Lay Counselors in Care and Treatment Clinics

30. Lay Counselors Given clinic burden and complexity of patients’ needs, many patients need more in-depth counseling on prevention issues than providers can manage Task shifting some responsibilities to lay counselors may be a cost-effective and supportive way to meet clinic and patient needs for services Training lay counselors to expand and reinforce prevention messages delivered by providers and to provide more in-depth counseling on specific prevention issues is critical for prevention efforts

31. HIV Prevention for People Living with HIV/AIDS: An Intervention Toolkit for HIV Care and Treatment Settings Overhead 5-10

32. The 5 HIV Prevention Steps Intervention 1-day Provider Training –Sensitizes providers to their critical role in influencing patients’ risk behaviors –Teaches them skills for delivering behavioral prevention messages –Provides overview and rationale for biomedical interventions –Allows providers to practice delivering prevention messages to patients

33. Family Planning and Safer Pregnancy Counseling 2 day provider training Trains providers to integrate FP services into routine care and treatment of HIV+ women and partners of male patients Pills, injectables Safer pregnancy counseling Flip chart for health care providers – technical resource

34. Management of Sexually Transmitted Infections in People Living with HIV/AIDS 2 day provider training Management of STIs in PLWHA as part of routine care –Assessment questions, exams, syndromic management Partner management

35. HIV Prevention and Adherence Counseling for PLWHA 2 week training on prevention and adherence counseling for lay counselors (many of whom are PLWHA) 2 week training on counseling and testing for lay counselors (where permitted by national guidelines Flip chart for group education on prevention and adherence topics Individual counseling guide

36. Prevention for People Living with HIV in Care and Treatment Settings Kenya Namibia Nigeria Haiti Ethiopia Tanzania Rwanda Cote d’ Ivoire Botswana South Africa (?)

37. Prevention for PLWHA PMTCT/ ANC Primary Care CCC Family Planning Integrating HIV Prevention into Clinic Settings TB Male Circumcision Testing and counseling

38. Prevention for PLWHA Community counseling centers Community Health Workers VCT PLWHA support networks Integrating HIV Prevention into Community Settings FBO services Home-based Care

39. Thank you!

40. Discussion Questions How can Track 1 partners assist MOH and USG in developing and scaling up national programs? How can Track 1 partners strengthen role as technical leaders and TA providers in this area? How can efforts be coordinated to reduce duplication of program development and increase implementation efforts? What are challenges and barriers to implementation and scale-up?