1. Parastu Kasaie Johns Hopkins University
Modeling the integration of health services for HIV and other health conditions in Kenya, Nigeria, and India
Parastu Kasaie
Johns Hopkins University

2. Background - Kenya
The joint fourth largest HIV epidemic in the world, with 1.6 million PLHIV
Compared to South Africa:
Lower HIV prevalence in adults (5.4% vs. 18.9%)
Higher proportion of undiagnosed HIV (30% vs. 13%)
Increasing burden on non-communicable diseases (NCDs), accounting for 27% of all deaths and over 50% of hospital admissions
Attributed to late diagnosis and poor treatment outcomes
56% of people have never had their blood pressure measured
22% of those with increased blood pressure or hypertension are taking treatment
Opportunities for integration of HIV screening/treatment services with hypertension and diabetes

3. Methods - Kenya Model: Spectrum package by Avenir Health
Baseline: Maintaining fixed ART coverage over the next decade (2018 – 2028)
Intervention
Modeling a joint community-outreach campaign for HIV and NCDs screening, based on Project SEARCH
Targeting a geographically distinct area of Kenya comprising 10% of the population on an annual basis
90% of eligible adults aged 15 years or older would be successfully screened for HIV, diabetes and hypertension
Treatment uptake following diagnosis: 81% for HIV, 23% hypertension and 45% diabetes
Outcomes: Reduction in HIV incidence and mortality, Improvement to diagnosis and treatment for hypertension and diabetes
Spectrum is a suit of easy to use policy models providing policy makers with analytical tools to support decision making.

4. Projected effects of HIV & NCD integration on HIV outcomes
Baseline: Gradual reduction in HIV incidence over the next decade (by 13%)
Intervention: Modeling gradual increase in ART coverage (up to 78% in 2028)
Results:
44% reduction in HIV incidence (~216,000 new infections & ~244,000 deaths averted)
Marginal improvements to HIV prevalence (1.4% reduction by 2028)
Baseline: Gradual reduction in HIV incidence over the next decade (by 13%)
Intervention: Gradual increase in HIV diagnosis and ART coverage (up to 78% in 2028)
Results: 44% reduction in HIV incidence (~216,000 new infections and ~244,000 AIDS deaths averted)
SA with 40% ART initiation projects a 23% reduction in HIV incidence
Marginal improvements to HIV prevalence (1.4% reduction by 2028) – an aging population

5. Projected effects of HIV & NCD integration on NCD outcomes
Immediate impact on cascade of care
Treatment communities: Increasing treatment from 10% to 47% for diabetes and from 8% to 27% for hypertension in first year
Overall: Identifying ~686,000 individuals with untreated diabetes and 7.5 million individuals with untreated hypertension by 2028

6. Background - Nigeria
The second largest HIV epidemic in the world, with 3.2 million PLHIV
Compared to Kenya and South Africa:
Lower coverage of PMTCT (30% vs %)
Resulting in ~75,000 new infant HIV infections annually
Low coverage of contraception methods for limiting or spacing births
15% of Nigerian women age use contraceptives
Average birth rate of 6.5 per women
16% of married women with unmet need for contraceptives
Opportunities for integration of HIV services with reproductive health services for women in Nigeria

7. Methods - Nigeria
Model: Spectrum’s demproj, AIM/GOALs, and FamPlan modules
Baseline: Maintaining fixed PMTCT (26%) and contraceptive (15%) coverage over the next decade (2018 – 2028)
Interventions
Family planning: Increasing contraceptive coverage to 31% by 2023 and maintaining through 2028
PMTCT: Increasing PMTCT option B+ coverage to 90% (UNIAIDS & PEPFAR targets) by 2023 and maintaining through 2028
Outcomes: Reduction in HIV incidence, HIV diagnosis in infants, unwanted pregnancies and maternal and infant morbidity and mortality

8. Projected effects of HIV & family planning services integration
Baseline increase in number of women of reproductive age by 37% over next decade (growing need for family planning)
Impact:
15.5% reduction in fertility rate (from 6.5 to 5.49)
Averting more than 8 million cumulative unintended pregnancies
Growing need for family planning: Baseline increase in number of women of reproductive age by 37% over next decade
Fam plan intervention: % reduction in fertility rate (from 6.5 to 5.49), averting more than 8million cumulative unintended pregnancies
PMTCT: reduction in infant HIV by 56%, averting ~ 237,000 vertical HIV transmissions
FamPlan and PMTCT: 12% reduction in HIV incidence at a national level, averting ~300,000 new HIV infections, 3.5% reduction in prevalence

9. Projected effects of HIV & reproductive health services integration
Impact of PMTCT:
Reduction in infants’ HIV infection by 56% (averting ~237,000 vertical HIV transmissions)
Impact of joint programs at a national level:
12% reduction in HIV incidence (averting ~300,000 HIV infections)
3.5% reduction in HIV prevalence

10. Background - India
The third largest HIV epidemic in the world, with 2 million PLHIV
Concentrated epidemic among female sex workers (FSW), men who have sex with men (MSM) and people who inject drugs (PWID)
A reported HIV prevalence of 2.2% among FSW in 2016
Significant geographical variation: HIV prevalence of 17.9% in Maharashtra and 13.1% in Manipur among FSW in 2013
Similar trends for prevalence of other STIs
3.1% to 51.0% syphilis prevalence among FSW
2.5% to 28.0% syphilis prevalence among MSM and transgender people
Opportunities for integration of HIV/STI services for MSM and FSW in India

11. Methods – India Model: Spectrum package
Baseline: Maintaining fixed ART coverage among FSW and MSM over the next decade (2018 – 2028)
Interventions
Modeling a joint community-outreach campaign for HIV/Syphilis among MSM and FSW over 5 years (2018 – 2023), based on Avahan programme
Assuming 60% coverage form MSM and 90% for FSW
Assuming 81% ART initiation among those diagnosed with HIV (a 54% and 81% reduction in unmet need for ART among MSM and FSW)
PrEP: Modeling low (10%) and high (30%) coverage, with 50% adherence
Outcomes: Reduction in HIV incidence and mortality, increase in syphilis diagnosis and treatment

12. Projected effects of HIV & Syphilis services integration
Intervention: Gradual increase in coverage of ART (43% to 73% among MSM, 29% to 81% among FSW)
Impact among MSM: Reduction in HIV incidence by 34% (~43,000 new infections, and 59,000 AIDS deaths averted)
Impact among FSW: Marginal impact on HIV incidence but substantial impact on mortality (81% reduction, ~6,200 AIDS deaths averted)
PrEP: Averting 6,800 to 20,000 additional infections compared to ART scale-up alone
Syphilis: Intervention projected to diagnose and treat more than cases of syphilis in FSWs (5·8% prevalence) and MSM (3·5% prevalence) in 2018 alone
Baseline: A national level syphilis prevalence of 5.8% for FSW and 3.% for MSM
Intervention: gradual increase in coverage of ART (43% to 73% among MSM, 29% to 81% among FSW)
Reduction in HIV incidence by 34% among MSM (~43,000 new infections, and 59,000 deaths)
Marginal impact on HIV incidence among FSW (1.6% reduction) – but substantial impact on mortality (81% reduction – 6,200 deaths averted)
National level: a 7% reduction in incidence, averting 51,000 new infections and 81,000 deaths.
SA with lower ART initiation (40%): impact was roughly halved
PrEP::: low vs. high coverage averting 6.8K to 20K infections compared to ART scale-up alone
Diagnosing more than 510,000 syphilis cases

13. Summary Integration is not a one-size-fit-all approach
As currently envisioned, we anticipate that “optimistic but realistic” integration of HIV services with other healthcare delivery systems can:
Substantially reduce HIV incidence in the population targeted by integration
Marginally reduce HIV incidence, but will have only minimal impact on HIV prevalence in the country as a whole
Despite not reducing HIV prevalence on a large scale, integration – if done well – still likely has the potential to offer economic benefits (Brian Wier)
These results may overestimate the achievable scale of integration efforts (immediate scale-up to large proportions of the population) but also do not account for the substantial benefits that may be realized in health sectors other than HIV (e.g., NCD)
Should be designed with care to setting-specific factors and the context of HIV epidemic in the underlying population
Treated with care, not a ready to use guideline for implementing these interventions but rather a promise of impact

14. Acknowledgements Avenir Health
International AIDS Society
Johns Hopkins University
Chris Beyrer
David Dowdy
Brian Weir
Shannon Seopaul
Avenir Health
John Stover
Yu Teng
Johns Hopkins Center For AIDS Research (JHU-CFAR)