Testing and linking different key population groups in Ukraine 08.11.2018 Testing and linking different key population groups in Ukraine Olga Denisiuk Project Manager: program optimization and research www.aph.org.ua

HIV treatment cascade among PWID (2017, IBBS data) www.aph.org.ua Around 30 000 PWID PLWHA are not aware of their HIV+ status 70 000 Cascade indicators are more than 2 times higher among clients of harm reduction projects

Description of the interventions contributing to continuum of care in harm reduction program in Ukraine HIV testing Donor1/Regions2/ Reached KPs3/ Coverage4 Directly assisted HIV self-testing at outreach: the model was introduced in 2015 as a change to the conventional rapid HIV testing provided by medical teams at NGOs. Assisted HIV testing is provided by blood rapid tests as part of the harm reduction outreach by community based organisations – legally it is self-testing with assistance of trained peer outreach worker. Testing is provided once in 6 months at time and place convenient to client by outreach workers. 1Global Fund; 2Implemented in all regions of Ukraine; 3PWID,SW, MSM. 4During 2017- 235 266 clients tested c; 3 577 (1,5%) received HIV positive test result. Optimised case finding (OCF): the model was introduced in 2016 as an additional effort to assisted HIV testing to improve case finding. OCF focuses on HIV testing in extended risk networks of HIV-positive PWIDs and MSM, identified through community-based harm reduction projects. Peers in extended risk networks are invited through referral coupons for HIV testing. It is an incentivized two step chain referral from positive (index- found at outreach) case to recruit extended risk network peers (“anyone you know who might be at risk and will benefit from HIV testing”) for assisted testing by trained “case finder” at CBO stationary point. 1PEPFAR (CDC); 2Implemented in 10 high burden regions of Ukraine; 3PWID, and their partners; MSM 4During 2016-2018 - 62 000 clients received HIV testing; 9600 (15,4%) – received HIV positive rapid test result. Linkage to Care and ART initiation CITI -Community initiated treatment intervention- the model was introduced in 2013 . CITI is a rapid linkage to care intervention which facilitates early treatment access for those who received HIV positive test result at outreach or OCF. It uses principles of peer navigation, case management and community support to help clients start HIV treatment and retain in care. 1Global Fund, PEPFAR (CDC); 2Implemented in 15 regions of Ukraine; 3PWID and their partners, MSM; 4During 2017, around 7000 clients started CITI support.

Change from VCT to Directly Assisted Self-testing Increase in number of people tested and number of people with positive results found People tested People with positive results 241%

Types of service delivery sites and service providers, who conducted/ assisted in testing GF project X 33 times X 9 times Service providers Types of service delivery sites

Case finding challenge: HIV rapid tests among key populations in Ukraine (SYREX data) During 11 years of HIV prevention program among key populations: 1,645,576 HIV testing sessions were conducted 57,867 HIV positive results were detected

Case finding challenge: HIV rapid tests among PWID, CSW and MSM in Ukraine (SYREX data)

% of HIV case found among new clients and existing clients (GF project, 2017) www.aph.org.ua

Optimized case finding design (OCF) to increase yield of HIV positive cases identified in the HIV testing at outreach Recruitment starts from positive index cases invited by coupons from HIV screening at outreach after they get positive HIV test. The coupon is provided by outreach worker who assist in testing. Once they come to OCF they are asked to invite 3 people who they think might be at risk of getting HIV (extended risk networks). All of the 3 contacts will get offer to invite 3 of their contacts despite their own HIV status. For each visit participants receive 70 UAH (2 USD) and 30 UAH (1 USD) for each recruit who come and participate in OCF. Person can participate every 6 month unless they seroconverted, in which case they become an index case to start 2 step recruitment

Oral Presentation : Predicting recruitment of HIV positive clients Random Forest machine learning algorithm was used for predicting presence of HIV-positives within two waves of recruitment The most informative predictors of recruitment of HIV-positives included size of recruited network for each participant, result of HIV rapid test at screening, region, experience of HIV testing before screening, and age. Sex, group of key population and marital status had the lowest contribution to prediction. High level of model accuracy suggests that application of Random Forest machine learning algorithm during recruitment could improve HIV- positive yield among recruited participants. Oral Presentation : Predicting recruitment of HIV positive clients with machine learning 25 July Wednesday 11.00 , Elicium 1

Community Initiated Treatment Intervention (CITI) Community initiated treatment intervention (CITI) is short term ( up to 5 months ) rapid linkage to treatment intervention which facilitate early treatment access for PWID, MSM and CSW. CITI aims to locate HIV positive clients in harm reduction and HIV prevention projects and link them to HIV treatment using a case management approach. CITI clients are recently tested positive or might know their status for a long time but are not accessing HIV treatment services. Most case managers are former outreach workers. The outreach workers /case-managers/ – already have a relationship with the service users and are generally highly trusted – are able to explain the benefits of starting HIV treatment promptly and to help with the bureaucratic processes of health services. They take on a mediating role between the patient and the doctor, advocating to ensure that patients receive the services they are entitled to.

Case management effect on cascade among PWID in 2017, GF project

HIV case-finding and linkage to treatment models 1-2% OCF-optimized case finding 9% CITI AIDS Centers Trust Cabinets Family Doctors Outreach testing (GF) The strategy includes combination of three components, each of which has an impact on the cascade indicators: reducing the number of new HIV cases; improving HIV case finding; early initiation of ART and support of adherence among HIV+ members of key populations PITC

Denisiuk@aph.org.ua