Transcript Johns Hopkins University Template

The feasibility of HIV prevention studies
for men who have sex with men in Malawi
Stefan Baral, MD, MPH, FRCPC
Key Populations Program, Center for Public Health and Human Rights
Department of Epidemiology
Johns Hopkins Bloomberg School of Public Health
July 1, 2013
MOAC0105
Outline
• HIV among MSM
– Epidemiology
– Prevention Sciences
• Malawi Context for MSM
• Methods
– Use of respondent driven sampling for accrual
into cohort
• Results
• Conclusions
Global HIV prevalence among MSM,
2007-2011
Source: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz,
Brookmeyer, The Lancet, 2012
HIV Prevalence among MSM in Africa
4.9%
(1,778)
4.4%
(90)
Morocco
Tunisia
5.7%
(259)
6.2%
(267)
5.9%
(262)
Egypt
21.5% 21.8%
(463) (501)
25.0%
(N/A)
Senegal
13.3%
(215)
The Gambia
9.3%
(713)
17.2%
13.4% (1,291)
(1,125)
7.3%
(406)
Sudan
Nigeria
13.2%
(306)
Ghana
19.0%
(563)
Uganda
Legend
24.6%
(285)
Kenya
Tanzania
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
21.4%
(201)
12.4%
(218)
Malawi
19.7%
(117)
Namibia
Botswana
25.0%
(200)
10.6%
(538)
Cape Town
Modified From : van Griensven, Baral, et al. The Global Epidemic of HIV Infection
among Men who have Sex with Men. Curr Opinion on HIV/AIDS, 2009
40.7%
(285)
28.9%
(249)
Soweto
Cape Town (Township)
12.3%
(509)
HIV Prevention Studies among MSM
Source: Sullivan, Sanchez, Coates, et al., The Lancet, 2012
MSM in Malawi
• Limited Disclosure of Same Sex Practices to Family or Health
Care Workers (~15%)
– Challenging for traditional approaches to trial recruitment
Study Objective
• Assess the feasibility of:
1. Accruing participants into a cohort using respondent
driven sampling of MSM in Blantyre
•
Characterize unbiased estimates of the epidemiology of HIV and
syphilis as well as the associations of prevalent HIV and syphilis
infections among MSM
2. Using a community-driven peer-based model to sustain
retention of MSM over 12 months
•
•
•
Achieve >= 90% Retention of MSM over 12 months
Assess the incidence of HIV among MSM in Blantyre
Provide training to health care centers in Malawi to be more
clinically and culturally competent in addressing the needs of
MSM in Blantyre
Study Methods
• Baseline
– Inclusion Criteria
• 18+ men who report having anal sex with another man in the previous 12
months
– Accrual
• 330 recruited via respondent-driven sampling
– Behavioral Survey
• Translated into Chichewa with modules representing multiple levels of HIV
risk
– Biological Testing
• HIV and syphilis
• Malawi National Guidelines with pre- and post-test counseling
Study Methods
• Follow Up
– Inclusion Criteria
• Planning on remaining in Blantyre for following 12 months
• Willing to provide mobile number and pseudonym
• HIV-uninfected participants
– Accrual
• Offered accrual during second RDS-related study visit
• Accrued until 100 in the cohort
– Visits
• 0, 3, 6, 9, 12 Months
• Intervention
– Health Sector Intervention
– Enhanced Peer Education Services
Health Sector Intervention
• Together with Fenway
Health Institute
• Two-day training,
December 2011
• Target
– Nurses and physicians
from private and
government clinics
• Curriculum
– Sexual history taking,
anal health, mental
health, risk reduction
counseling
Peer Educators
• 10 Peer Educators Trained
– Diversity in sexual orientation,
identity, demographics
– Provided information on
prevention and trained clinics,
condoms & condom
compatible lubricants
– Provided monthly stipend
– Each linked to 10 matched
participants to ensure retention
• matched according to
sociodemographic characteristics
and participant choice
Results
• Accrual for RDS took approximately
3 months
• Coupon return: 48%; maximum of 19
waves reached
– Approximately 50% of HIV-uninfected
MSM were successfully accrued into
cohort
RDS Recruitment Diagram (N= 338)
12
Results
Covariate
No.
%
18
5.3
4.90%
(3.06 – 7.61%)
Never
134
39.9
Once
123
36.6
More than once
79
23.5
Last 12 mo. (of ever tested; N=202)
114
56.4
Unadjusted (%)
52
15.8
12.5%
(9.62-16.17%)
Reported Unaware HIV infection (N=52)
47
90.3
Vaginal
176
57.9
Anal
44
14.5
All equal
83
27.3
75
22.5
Unadjusted
Syphilis Prevalence
RDS Adjusted (%, 95% CI)
HIV Testing
(Ever, n=336)
HIV Prevalence
Considered most ‘risky’
type of sex for HIV
transmission
RDS Adjusted (%, 95% CI)
Ever received HIV prevention information
(for same sex practices; N=334)
13
Results
• Retention at one year was 99% (99/100) with 7 incident HIV
infections
– Approximate HIV incidence of 7.1 (95%CI 2.0-12.0%)
• Increased utilization of trained health providers, peer educator
visits, and condoms and condom compatible lubricants
• Study site is being utilized frequently for HIV prevention needs
among study participants
Conclusions
• Scientific Agenda
– Appropriate population for HIV prevention strategies
• High HIV incidence
• Feasibility of retention of hidden population by leveraging:
– Existing community-based organizations and social networks evaluating communitydriven HIV prevention services for MSM in Malawi.
– HIV Prevention 2.0 includes:
• Combining community-driven HIV prevention services with novel HIV prevention
approaches such as:
– Active linkage to care using point of care approaches
– Engaging the Continuum of HIV Care from being unaware of HIV infection through to viral
suppression for those treatment eligible
– Feasibility of ART pre-exposure prophylaxis
– Rectal microbicides
• Development Agenda
– There is a group of men who are at high risk for HIV acquisition and
transmission that are currently underserved
Lilongwe, 2012
Acknowledgements
• Center for Development of People (CEDEP)
• Gift Trapence
Dunker Kamba
• Center for Public Health and Human Rights
– Chris Beyrer, Andrea Wirtz (Co-I), Susanne Stromdahl, Mark Berry
• R2P
– Deanna Kerrigan, Caitlin Kennedy
• Malawi College of Medicine
– Eric Umar (PI), Rajab Mkakosya (Lab PI), Vincent Jumbe
• Foundation for AIDS Research (amfAR)
– Health Sector Intervention
– Kevin Frost, Chris Collins, Owen Ryan, Kent Klindera, Michael Cowing
• USAID
– Sarah Sandison, Delivette Castor, Henry Cauley, Alison Cheng, Laurent Kapesa,
Beth Deutsch
The USAID | Project SEARCH, Task Order No.2, is funded by the U.S. Agency
for International Development under Contract No. GHH-I-00-07-00032-00,
beginning September 30, 2008, and supported by the President’s Emergency
Plan for AIDS Relief. The Research to Prevention (R2P) Project is led by the
Johns Hopkins Center for Global Health and managed by the Johns Hopkins
Bloomberg School of Public Health Center for Communication Programs
(CCP).