1. Department of Health and Human Services Centers for Disease Control and Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention An Ounce of Prevention with that Pound of Cure: Integrating HIV Prevention into Care and Treatment Pamela Bachanas, PhD Washington, DC October 2009

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 2008 alone, 2.7 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, Zambia, 2009 HIV negative, 86% HIV positive, 14% Only HIV+ individuals can transmit HIV ►Focusing on ~1m HIV-infected people rather than ~ 15m 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. Zambian Experience

23. STI Management in HIV Care Assess for signs and symptoms of STIs at every visit and treat as indicated Important for care – some STIs can be more severe and more difficult to treat in immunocompromised individuals Important for prevention – incident STIs marker of unprotected sex and need for risk reduction counseling Important for STI control - to stop the spread of the STI and to reduce reinfection through partner management

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!! Our Biggest Challenge and Our Best Solution

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. Lay Counselors Provide individual counseling on prevention issues (disclosure, partner testing, safer sex, alcohol reduction adherence, etc.) Meet individually with HIV+ patients before or after clinic visits (and between visits if needed) Test and counsel partners/spouses and family members of HIV+ patients Provide information/education in group format in clinic PLHIV are not only beneficiaries of these services, but are also employed as counselors and contribute to program development

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

33. HIV Prevention for People Living with HIV/AIDS: A Toolkit for HIV Care and Treatment Settings

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

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

36. Clinic – Community Linkages Clinic/Facility Reinforcement and Referral Community

37. Direct Service Provision and Referral Linkages

38. Lessons Learned and Next Steps Tiered approach to integration Target patients in early and later infection Expand and standardize preventive care for all PLHIV in facility and community settings Identify champions for PwP in Prevention and Care and Treatment

39. Lessons Learned and Next Steps Need for Prevention and HIV Care and Treatment coordination and collaboration (co- ownership of program) Adopt national training program and strategy Need for National TWG with all disciplines (HIV, Prevention, STI, RH/MCH, TB, HCT, PLHIV …) to lead/coordinate national efforts Incorporate/strengthen PwP in National Strategic Framework/Guidelines

40. Thank you!