Integrated Community HIV Testing Campaigns: Leveraging HIV infrastructure for non- communicable diseases July 23, 2012 Gabriel Chamie, Dalsone Kwarisiima, Tamara D. Clark, Jane Kabami, Vivek Jain, Elvin Geng, Maya L. Petersen, Harsha Thirumurthy, Moses R. Kamya, Diane V. Havlir, Edwin D. Charlebois, and the SEARCH Collaboration

HIV “test and treat” is under intense scrutiny as a global strategy Large unmet need in addressing non- communicable diseases (NCDs) Key first step in addressing both HIV and NCDs is diagnosis – many shared obstacles Implementation science questions – How do we test large numbers of people in a sustainable way? – How do we leverage HIV investment to address NCDs? Background

Sustainable East African Research on Community Health A broader approach to test and treat – Health (HIV, NCDs, and other diseases) – Education – Economics SEARCH Community Health Campaign

Community health campaign objectives – Rapid implementation of multi-disease diagnosis and linkage to care across a community – Reach community members not previously tested – Achieve high-throughput testing (1,000/day) – Integration of NCDs and other communicable diseases – Rapid assessment of community socio-economics Objectives

Campaign Procedures Demographic/SES Household Survey Testing HIV (Ab, CD4, VL) Malaria RDT DM HTN TB Screening in HIV+ GeneXpert Prevention TMP/SMX Condoms Vitamin A Counseling ITNs Treatment Coartem Albendazole Linkage to Care HIV, TB, DM, HTN Immediate ART: CD4<100 5 day campaign (May 16-21, 2011)

Local Council (LC) leaders from all villages designed and executed community mobilization during the month prior to campaign – Church (Easter) & Mosque announcements – Posters & pamphlets distributed widely – Radio announcements Community Mobilization

Rwanyamahembe Subcounty Headquarters May 16, 17, 2011 Karuyenje Primary School May 19, 20, 2011 H Bwizibwera Health Centre IV Nyakayojo Primary School May 21, km CHC Sites: Kakyerere, Uganda

Site 3 Site 2 Site 1

Campaign Field Laboratory 18 Lab technicians Rapid HIV Ab testing/confirmation Point-of-care CD4+ T cell count Finger-prick HIV viral load Malaria rapid diagnostic test Blood glucose Blood pressure

CHC Uganda Census CHC Coverage Adults2,3233,15074% Women1,5231,60095% Men8001,55052% Children2,0203,15064% Girls*1,0661,60067% Boys*9541,55062% Total4,3436,300 § 69% Female2,5893,200 § 81% Male1,7543,100 § 57% § 2011 Ugandan Bureau of Statistics Population Projection, Kakyerere Parish * <18 years old Study Population

Overall – Median of 95 minutes (IQR: ) – HIV-negative Median: 1 hour, 33 minutes (93 min, IQR: ) – HIV-positive Median: 2 hours, 51 minutes (171 min, IQR: ) Patient Transit Time Through Campaign

Adults: Age ≥ 15: 6.9% Ages 15-49: 8.0% Children: Age < 15: 0.5% HIV Prevalence women: 8.2% men: 4.5% women: 9.4% men: 5.3%

Campaign adult population (n=2,323): Never HIV tested = 802 (35%) HIV-infected adults (n=179): New diagnoses = 82 (46%) Known positive = 97 (54%) Prior HIV Testing & New Diagnoses

CD4+ T cell Counts in Adults Median CD4 = 415 (IQR: ), n=167 Substantial population was diagnosed with CD4 above Uganda ART initiation threshold (>350 cells/μL)

CD4 <200: 12% CD4 >350: 64% CD4+ T Cell Counts in New Diagnoses Median CD4 = 449 (IQR: ), n=77

Hypertension Prevalence (adults) – BP > 140/90: 23% – BP > 150/100: 12% New vs. prior diagnoses – 69% of BP>150/100 group unaware of their diagnosis – 61% with known HTN were not on anti-hypertensive treatment

Prevalence: – Random BG > 200, or reported prior dx of DM – 80 adults: 3.5% New diagnoses: – 18 adults: 23% On treatment: – 38/62 (61%) Diabetes

Linkage to care at 3 months HIV: 82/139 (59%) – Active Referral: 58% linked to care – Enhanced Referral: 75% linked & started ART Linkage to Care

High burden of undiagnosed HIV and non- communicable diseases in rural east Africa Shared obstacles, but also shared solutions HIV testing and referral can be leveraged in rural Africa to find and engage patients with undiagnosed NCDs Community Health Campaigns can drive universal HIV testing & offers opportunity and an immediate way forward for addressing NCDs in resource-limited settings Summary

Campaign Participants Kakyerere Parish LC Leaders SEARCH Community Campaign Staff Uganda Ministry of Health NIH/NIAID Thank you – SEARCH Team SEARCH Advisory Board MU-UCSF Research Collaboration Mbarara-Mulago Joint AIDS Program Mbarara University of Science & Technology PEPFAR  WHO  World Bank