Transcript Document

Program
Promoting HIV/AIDS Evidencebased Decision Making
Naomi Rutenberg, PhD
Program Director, Horizons,
Population Council
Horizons Structure and
Organization
 Global HIV/AIDS operations research
program
 10 years, August 1997 – July 2007
 Funded by USAID: Office of HIV/AIDS,
Bureaus and Missions
 25 professional staff in DC, Kenya, Ghana,
South Africa, India, and Thailand
Horizons Partners
International Center for Research on
Women
PATH
Tulane University
International HIV/AIDS Alliance
Johns Hopkins
Family Health International
Objectives
 Identify problems in HIV/AIDS programs
 Field test and evaluate program approaches
to treatment, prevention, care and support
 Disseminate research findings to program
managers and policy makers
 Promote utilization of findings for program
improvement
Horizons Approach
 Field based, program-oriented research
 Focus on program solutions under the control of
managers
 Research to guide program design/ implementation
 Collaborate with NGOs, community groups,
universities, FBOs, government
 Responsive to national HIV/AIDS needs
 Rapid review and implementation
 Examine cost of interventions
Guiding OR Questions
 WHAT is the program problem?
 WHICH interventions work best?
 WHY do they work?
 WHERE do they work best?
 WHO do they affect?
 WHAT do they cost?
 HOW do they impact on HIV/AIDS?
Types of OR Studies
 Diagnostic: Identify program problems
 Intervention: Seek program solutions
 Evaluative: Measure program impact
 Cost: Determine cost of impact
Current HIV/AIDS Focus Areas
Treatment, Prevention, Care
 Increase ARV coverage and adherence
 Reduce stigma and discrimination
 Change behavior using ABC approach
 Involve private sector
 Prevent mother to child transmission
 Provide care and support to orphans and PLHA
 Assess cost and effectiveness of interventions
 Scale-up successful pilot programs
18 Studies
1. Prevention of mother-to-child transmission of HIV
(PMTCT), 9 studies. Naomi Rutenberg, Carolyn Baek
2. Adherence to antiretroviral therapy, 4 studies.
Avina Sarna, Susan Cherop-Kaai, Philip Guest
3. Changing gender norms among young men,
2 studies. Julie Pulerwitz, Ravi Verma
4. Health needs of men who have sex with men,
3 studies. Placide Tapsoba, Amadou Moreau, Harriet
Birungi, Scott Geibel, Andy Fisher
Why these four areas?
• Large gaps in our knowledge that prevent us
from developing evidence based programs
• New technology with ARVs but little real world
experience delivering the technology
• Important relationship between gender norms
and health risks but how to measure this
concept and develop operational programs
• Health and risk behavior of MSM a neglected
topic in Africa
Outline
• Why is topic important to HIV/AIDS
• Focus of Horizons research
• Selected findings
• Impact of research and scale-up
1. PMTCT Programs
• 630,000 children worldwide infected in 2003
• 490,000 children died of AIDS-related causes in
2003
• Short course AZT (1997) and Nevirapine (1999)
trials showed that nearly 50% of infant infections
could be prevented cheaply
• Opportunity to integrate PMTCT into ANC/MCH
platform
Infection Rates
RATE WITH NO INTERVENTION
35-40%
RATES WITH INTERVENTION
• Antiretroviral drugs + extended breastfeeding 15-25%
• Antiretroviral drugs + short breastfeeding
10-15%
• Antiretroviral drugs + no breastfeeding
9%
• Antiretroviral drugs + no breastfeeding +
1-2%
cesarean delivery
If You Build It, Will They Come?
•
Multi-site studies to measure use-effectiveness in
Kenya and Zambia
•
Strengthening infant feeding practices in Ndola, Zambia
•
Evaluation of UN Pilot PMTCT Programs in 11 countries
What is the real world “use-effectiveness” of a package
of PMTCT services for prevention of vertical
transmission?
PMTCT Utilization and Infections
Averted in Zambia: Targets and Practice
Infections averted
Used ARVs
HIV+
Got results
HIV test
Pre-test counseled
9
29
53
58
164
182
134
729
226
810
406
900
1000
1000
Sought antenatal care
Target
0
200
400
600
Urban health center, Zambia
800
1000
Why the “cascade”?
• Demand
– Do not want to know HIV status
» Fear, no cure, depression
– No intervention for mother
– Concern about stigma
– Lack of male and community support
– Difficulty in implementing infant feeding options
• Supply
– Human resources and capacity
– Lack of basic ANC and HIV services
Strengthening Health
Systems and Scale-up
• PMTCT needs assessment methodology developed
• Patient counseling procedures improved
• Supplies and equipment needs identified
• Patient and program monitoring systems developed
• University-government partnership formed
• Curriculum for training health workers developed for
Kenya study adopted in other countries
• Kenya study basis for national scale-up
2nd Generation PMTCT Studies
• Adherence to PMTCT ARVs in Botswana
• Evaluation of peer psychosocial support in South
Africa
• Community based PMTCT in Nairobi, Kenya
• Pilot of postnatal services for HIV+ women and
infants in Swaziland
• Linking PMTCT to ARV care for HIV+ women in
India
2. ARV Adherence
• High levels of adherence to ARVs (≥ 95%)
required for treatment to be successful
• Low levels of adherence may increase chances
of resistant strains rendering the drug
treatment ineffective
Focus of Kenya ARV
Adherence Research
• Randomized controlled two-arm study
DAART
»Twice weekly follow-up at clinic for first 24 weeks
»Routine monthly follow-up for next 24 weeks
Non-DAART
»Monthly follow-up for 48 weeks
• 3 treatment sites and 6 observation sites
• Would DAART strategy result in improved adherence to
ARVs?
% of clients with mean adherence
>95%
ARV Adherence  95%: Self Reports
100
99
98
100
97
90
95
92
80
Non-DAART
DAART
70
60
50
2 Months
4 Months
1-6 months: NS difference between groups
6 Months
% of clients with mean adherence
> 95%
ARV Adherence  95%:Pill Counts
99
98
100
93
99
93
99
90
80
84
77
70
73
60
77
76
Non-DAART
DAART
62
50
1 Month
2
Months
3
Months
4
Months
1-6 months: DAART 93% vs non-DAART 74%, p = .001
5
Months
6
Months
Other measures over 6 months,
significant within groups, not between
• CD4 cell counts more than double in both
groups
• 5 to 6 Kg. weight gain in both groups
• Depression scores in both groups decreased
• Quality of life score improve in both groups
Impact and Scale Up
• Initial adherence results are encouraging. On basis of
pill counts, DAART patients achieved 95% adherence
• Significant improvements in CD4 counts, weight,
depression, and QOL measures in both groups
• Now examining viral loads in Mombasa
• An adherence manual for trainers produced, 3,000
copies, widely used in Africa and Asia.
• Completing studies in Thailand and Zambia that
examine adherence and in India looking at paying and
non-paying ARV patients.
3. Gender Equity Programs
• Increasing awareness that gender role socialization
puts women and men at health risk (WHO 2000).
• e.g. Peer pressure on males for multiple sexual partners
• But, operationally, how to measure gender norms,
and what kind of interventions would be effective to
change norms and reduce HIV/STI risk.
Focus of Brazil Gender
Equitable Norms Research
• Changing inequitable gender norms
of young men in Brazil
• Building relationships based on
respect, equality, and intimacy
rather than sexual conquest
• Taking financial and caregiving
responsibility for children
• Being responsible for reproductive health and disease
prevention
• Opposing intimate partner violence
HIV/STI Risk at Baseline
Bangu
n = 258
13
Maré
n = 250
13
Control
N = 272
13
>= 2 Partners in past
month
39%
45%
39%
STI symptoms over
last 3 months
Condom use last sex
with primary partner
23%
31%
18%
58%
69%
64%
Mean age at first sex
Change in Reported STI Symptoms
% with symptoms
50
40
31
30
23
20
10
Baseline
6 Months
1 Year
25
18
*
14
12
*
5.8
4.1
*
0
Bangu
Maré
Control
*p < 0.05 - Chi-square test, No significant change in control
group
Change in Condom Use at Last Sex
100
*
% of change
87
79
80
60
87
69 70
58
64
59
40
20
0
Bangu
Maré
Control
*p < 0.05 - Chi-square test, No significant change in control
group
Baseline
6 Months
1 Year
“Used to be when I went out with a girl, if
we didn’t have sex within two weeks of
going out, I would leave her. But now (after
the workshops), I think differently. I want
to construct something (a relationship)
with her.”
Impact and Scale Up
• Work in Brazil now replicated in India
• Moved from the conceptual level to the operational
• Gender equitable scale developed to measure norms
• Program interventions can change gender norms
• Relationship between gender norms and reduced
HIV/STI risk
4. MSM Research in Africa
• Little information in Africa about MSM behaviors
• Widespread denial about the existence of MSM
in Africa
• No knowledge about the extent to which MSM
behaviors put men and their partners at risk of
HIV infection in Africa
Focus of First Senegal
MSM Study
• Sociodemographic characteristics of MSM
• Sexual health risk and prevention behaviors
• Sexual health problems
• Stigma and discrimination experiences
• Health-seeking behavior
Selected Findings: Risk Factors
Among 250 MSM in Senegal
• 88% ever had sex with a woman
• 2/3 received money in recent MSM encounter
• 43% reported being raped at least once
• 13% raped by policeman
• 42% experienced genital/anal health problems
• 23% used condom at last insertive sex, 14% last
receptive sex
Focus of Second Senegal Study:
Service Utilization
May 2003 – March 2005
• 5 providers in Dakar, 1 in each of 4 regions
• 774 MSM reached with clinical consultation
• 168 requested/referred for VCT
• 141 returned for results
• 63 HIV-
• 78 HIV+ or 10% of all 774 (in a country where the
overall prevalence is < 1%)
• 50 MSM under treatment, including ARVs
Third MSM Study in Kenya
Among 500 MSM
• 62% reported having sex with at least 1 man in
the last week, 90% in last month
• 61% reported having anal sex at least 1 time in
the last week
• 69% have ever had sex with a woman
• 59% said they always used condoms
• 25-35% ever experienced STI symptoms
• 57% had an HIV test, 98% received results
Conclusions From Senegal and Kenya
• MSM exist in both areas, not negligible
• Sexual behavior of MSM also involves women and has
reproductive health implications
• Condom use is high among MSM in Nairobi, low in
Senegal
• Sex with multiple partners is high
• Many experience discrimination, stigma, and violence
• Some receive money or gifts for sex
• Confidentiality most important in seeking health care
Impact and Scale Up in Africa
• Senegal AIDS control commission committed to
improving health of MSM and increasing preventive
behaviors
• MSM component in World Bank Programs for
Senegal, The Gambia, and Burkina Faso
• Ghana diagnostic study and service provision by
USAID Bilateral
• Bristol Meyers-Squibb committed to funding MSM
interventions in Mali and soon Burkina Faso
Final Conclusions
1. Multiple studies in multiple sites addressing a single
topic can identify issues, constraints, and solutions to
program problems that a single study might miss.
2. Impact can be substantial such as influencing an entire
country’s scale-up program in Kenya with PMTCT, or
focusing donor attention on an important, neglected
area such as health and risk behaviors of MSM.
Final Conclusions
3. Tools developed as part of study implementation are
important: training curriculum for PMTCT providers,
adherence manual for ARV trainers, valid scale to
measure gender equity,
4. Field based studies help shape policies and guide
programs on the basis of evidence, not ideology or best
guesses.