Effectiveness of a Pilot Voucher-Based Referral System to Enhance Uptake of HIV Testing by High Risk Clients in Northern Tanzania (VCT Plus) Oral Poster MOPDC0103 E. Reddy 1,2,3, R. Waters 1, B. Njau 2, A. Mtalo 4, P. Dominic 4, D. Itemba 5, J. Ostermann 3,6, N. Thielman 3 1 Duke University Medical Center, Durham, United States, 2 Kilimanjaro Christian Medical Center, KCMC-Duke Collaboration, Moshi, Tanzania, 3 Hubert-Yeargan Center for Global Health at Duke University, Durham, United States, 4 KIWAKKUKI (Women Fighting HIV in Kilimanjaro), Moshi, Tanzania, 5 Tanzania Women’s Research Foundation (TAWREF), Moshi, Tanzania, 6 Duke University Center for Health Policy, Durham, United States

Background Voucher programs have been used worldwide, including in sub-Saharan Africa, to recruit partners of persons with sexually transmitted infections for treatment To our knowledge, vouchers have never been assessed as a means of recruiting people for HIV testing

Objectives Utilize a voucher system to: Recruit first-time and high-risk testers to voluntary counseling and testing (VCT) Recruit untested partners of VCT clients and of persons living with HIV to testing

Methods Program piloted in rural Kilimanjaro region, Tanzania; estimated HIV seroprevalence 1.9% Vouchers were offered in 2 different settings – 3 village-based MVCT campaigns Randomly selected HIV – testers were offered vouchers All clients found to be HIV + offered vouchers – Nearby HIV Care and Treatment Centre (CTC) Offered vouchers to consecutive patients presenting for regular care (goal of up to 75 participants)

Vouchers TAKE CARE OF YOURSELF: EARLY TESTING SAVES LIVES! Protect yourself and your loved ones Test for HIV Voucher # __ __ __ __ - __ __ PROJECT-ASSOCIATED TESTING SITES Free LOCAL Mobile testing by KIWAKKUKI: Village dispensary: 19 – 23 Jan, April Village elementary school6 – 30 Jan, April OR VCT with transport reimbursement: ask for VCT Plus staff! Local HospitalToday – 30 June 2010 KIWAKKUKIToday – 30 June 2010 Vouchers encouraged testing at local MVCT campaigns (internal advertisement) Could be exchanged for transport reimbursement for presentation to testing at the nearby CTC (reducing privacy concerns of testing in village) Were confidentially linked to the index participant via an ID code Each participant was offered up to 5 vouchers

Study Location Regional Capital, Moshi TPC Hospital CTC MVCT Village 1 MVCT Village 2 MVCT Village 3 Mount Kilimanjaro Key * 5km *Distances are approximate TANZANIA Nyumba ya Mungu reservoir Kilimanjaro Region

CHARACTERISTICS OF INDEX PARTICIPANTS CTCMVCT difference* All75323 Male37 (49)162 (50)1.0 Age (median)4332<0.01 Primary or no education71 (95)291 (90)0.27 No dispensary-based testing in village49 (67)109 (34)<0.01 First time testers 75 (23)n/a HIV infected75 (100)11 (3)n/a Disclosed HIV status (if known) to current partner(s)29 (74)180 (73)0.85 Any current partner untested15 (38)112 (30) 0.86 Full disclosure to friends17 (23) n/a HIV diagnosed < 1 yr ago7 (9) n/a On ART59 (79) n/a Index participants=those offered vouchers; referrers=referred client linked to this participant presented for testing MVCT=mobile voluntary counseling and testing; CTC=HIV care and treatment center *between MVCT and CTC participants by chi-square or Wilcoxon rank sum Results

VOUCHER EFFECTIVENESS BY SITE OF INDEX ENROLLMENT CTCMVCTORp Vouchers Offered Vouchers Accepted 249 (66)702 (43)1.5<0.01 Referred clients recruited 41 (16)46 (7)2.8 <0.01 Site of presentation to testing 4344 Vouchers offered per each successful referral New testers 22 (54)12 (26)3.7<0.01 Seropositive testers 13 (32)1 (2)2.8<0.01 Proportion of testers partners of index clients 3 (10)9 (21) Cost per tester recruited* Cost per seropositive tester recruited* *Cost in USD as per 1 July 2011 exchange. Includes cost of 0.003USD per voucher for printing plus cost of average transportation fee reimbursed for referred clients

Successful referrers by site of index recruitment 15 of 75 index participants were successful referrers Successful referrers* – Referred and average of 2.3 clients each – Older (53 vs. 43 yrs.) – From villages with no in- village testing – Disclosed their HIV status outside of home *p <0.05 for difference between index participants and successful referrers

Conclusions Vouchers offered to persons receiving care for HIV were successful in recruiting high risk testers – Offering 9 vouchers resulted in 1 successful recruit to testing – Seroprevalence of referred testers >10x that of estimated local seroprevalence – Most referred clients were friends and neighbors of index participants; more work remains in recruiting partners to testing Vouchers offered to MVCT clients were less successful in recruiting new or high risk testers

Acknowledgements Study funds provided by Tibotec REACH grant KIWAKKUKI and TAWREF Dafrosa Itemba Eunice Maringo Antipas Mtalo Kireja Mlay Valentina Swai Eliakesia Shangali Waridi Kiravu Vicky Mkirere Novera George Bright Kilewo Prisca Dominic Teresia Susuma Epimark Ndanu Herment Kiwale Duke and KCMC Nathan Thielman Jan Ostermann Bernard Njau KCMC Biotechnology Laboratory Duke Global Health Institute TPC Hospital Antonia Stevens Mawenzi Hospital