1. Providing Treatment, Restoring Hope Secondary Prevention as part of HIV Clinical Care Martine Etienne, MPH, DrPH University of Maryland School of Medicine TRACK 1 Meeting HRSA August 12, 2008

2. Slide 2 How do we do it? Comprehensive Treatment Preparation Intensive Home and Community based Support

3. Slide 3 Treatment Preparation Comprehensive treatment education incorporated into initial preparation of patient for care and treatment Included topics  Benefits of delaying sexual experiences among HIV+/- youth, men and women  Benefits of abstinence  Inform on the benefits of condom use at sexual encounters

4. Slide 4 Secondary HIV Prevention  Support reduction of unintended pregnancy and MTCT  Mandatory disclosure of HIV status to partners  Testing partners (and children/family) of HIV+ patients  Discuss the benefits of reduction of number of sex partners

5. Slide 5  Identify discordant couples and continue educational counseling on prevention  Discussion of diagnosis and treatment of STIs in HIV+ persons and their partners  Discuss and encourage reduction of alcohol use and other high risk behaviors

6. Slide 6 Disclosure Condom Use Sexual Partners Alcohol Use Pregnancy STIs AIDSRelief 2006, 2007 Patient Level Outcomes Targeted Indicators

7. Slide 7 Quality Assurance/Improvement Data: Kenya and Zambia 2007 N=1962 Patients starting ART 9-15 months prior randomly selected for cross-sectional analysis. Patients active in program received matched adherence survey and viral load measurement.

8. Providing Treatment, Restoring Hope N=1962 Median age=37

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10. Slide 10 n=1281 n=130 N=1411

11. Slide 11 n% Spouse61343.2 Parent60042.3 Children46833.0 Siblings/relatives57340.4 Friends42530.0 Church/Temple22716.0 Traditional Healer40.3 Community volunteer30521.5 Support groups39127.6 Neighbors17912.6 Counselors36625.8 Others986.9 Not disclosed191.3 Disclosure

12. Slide 12 Reasonsn% Stigma223.0 Fear for abandonment91.2 Fear of violence or abuse121.6 Feeling guilty or responsible60.8 No one whom you trust111.5 Don’t feel like it is necessary131.8 Other60.8 Reasons for not disclose

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14. Slide 14 n=434 n=267 n=253 N=954

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16. Slide 16 n=634 n=683n=42 N=1359

17. Slide 17 n=805 n=75

18. Slide 18 n=848 n=55 n=63 N=966

19. Slide 19 n=1258 n=498 n=294 N=2050

20. Slide 20 Sexually Transmitted Infection (STI) Active at the time of ARV start (%) New since ARV start (%) Genital Ulcerative Disease 2.5 n=39 1.7 n=37 Urethritis/ Cervicitis 1.3 n=20 1.1 n=23 PID0.6 n=9.0 0.8 n=18

21. Slide 21 n=1296 n=28 N=1324 98% 2% NeverOnce or more Medical Quality Assurance and Improvement AIDSRelief, 2007 Frequency of illicit drug use in the past month

22. Slide 22 Case # 9 – St Mary’s Hospital, Lacor # 392 16 yo adolescent female

23. Slide 23 Pre-ART HX No previous ART exposure OIs prior to ART – Diarrhea and wasting, Genital ulcerative disease Baseline CD4 – 37 c/mm3 (11/2004) ARV start date – 12/22/04 14 month duration of therapy Start 12/22/04: TDF/3TC/EFV (current)

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25. Slide 25 OIs since ART start Herpes Simplex Genital Ulcerative Disease Tonsillitis Anal sores Perianal warts

26. Slide 26 Adherence Patient had treatment preparation, home visits and DOT Dispensing frequency – Monthly No subjective history of missed doses in the past 6 months No history of missed refills in past 6 months No history of missed appointments in past 6 months

27. Slide 27 Viral Load? >750,000 copies/ml

28. Slide 28 Why? Poor adherence to safe sexual practices is been closely linked to poor adherence to ARVs.

29. Slide 29 What is major concern in this case? This patient is at high risk for spreading resistance virus Is secondary prevention counseling alone going to have any effect on this patient’s behavior?

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31. Slide 31 Our goal Using community adherence programs as a vital therapeutic intervention Engaging everyone in prevention Promoting prevention at every patient encounter