1. 1 Expansion of Couples Voluntary HIV Counseling and Testing in the Copperbelt Province in Zambia: an examination of the distribution of HIV serostatus within the province Carolina Kwok B.Sc (PT), MPH CVCT Program Manager, Copperbelt Zambia Emory HIV Research Project Afri-Can Synchronicity Forum Entebbe, Uganda 18 January 2013

2. 2 Outline Background of CVCT Methods Results Discussion Challenges Conclusion

3. 3 ZAMBIA

4. 4 Background of the Copperbelt ZAMBIA TOTAL POPULATION: 13,046,508 (Zambia Census, 2010) – Approximately 51% of the population are women and 49% are men – 61% live in rural areas, 39% live in urban residences – Population density of 17.3 persons/sq. km Copperbelt – population, 1,958,623 (Zambia Census, 2010) – Ndola – 455, 194 – Kitwe – 522,092 – Chingola –210,073 – Luanshya – 153,117 Copperbelt is the second most densely populated region in Zambia These districts are industrial and commercial hubs

5. 5 Background In Zambia, approximately 70% of HIV infections are acquired in marriage 15-20% of the couples counseled and tested at CVCT have discordant results Studies in Rwanda and Zambia have shown HIV transmission to HIV negative partners in discordant couples is 20-25% per year in couples that do not know they are discordant In discordant couples who underwent CVCT, HIV transmission to HIV negative partners decreased to 3-7% per year Previous publications have estimated that scale-up of Couples Voluntary HIV Counseling and Testing (CVCT) services can reduce heterosexual transmission by 35-80% in Zambia

6. 6 HIV PREVALENCE AMONG COHABITATING PARTNERS IN ZAMBIA (ZAMBIA DHS, 2007)

7. 7 Background of the Copperbelt - II Prevalence of HIV in the Copperbelt: – 17% of population (Zambia DHS, 2007) 21.6% in women aged 15-49 12.3% in men aged 15-49

8. 8 Began couples counseling and testing in Lusaka in 1994 Tested >11,000 couples in Ndola and Kitwe from 2004-2006 as part of a research protocol (clinical trial) Low-level testing at research site continued in Ndola CVCT programs in Chipulukusu, Lubuto clinics and the research site in Ndola from 2007- July 2010 reached more than 4000 couples HISTORY OF CVCT IN ZAMBIA AND THE COPPERBELT

9. 9 New grant from Canadian International Development Agency (CIDA), administered by PATH, under the Arise program, launched in October 2010 GOAL – To establish CVCT as a standard of care in government clinics TARGET – To expand CVCT to 60 Copperbelt clinics, reaching 56,000 couples in 30 months (= 15% of all cohabiting couples in target area to establish social norms) – Additional funding received in 2012 to expand testing to 68,000 couples and to increase weekday CVCT

10. 10 PROPOSED CVCT EXPANSION COPPERBELT PROVINCE

11. 11 METHODS - I Collaboration with the, Ministry of Health (MoH) District Health Management teams (DHMT) and Konkola Copper Mines, Plc (KCM) at all levels of implementation Selection of clinics and staff are made by the DHMT and KCM coordinators Trainings are conducted as per the standard training manuals developed by RZHRG in collaboration with the CDC – These include manuals for : Health Center Managers, Promoters, Data/Lab Managers, Promoter Managers and Counselors – www.cdc.gov/globalaids/resources/prevention/chct- training.html Trainings include didactic and practical components

12. 12 CVCT EXPANSION: COPPERBELT Funding approved August 2010 MoH-PMO Approval Sep 2010 Met with key stakeholders at DHMT August- October 2010 Identified clinics in Ndola August 2010 Trained clinic staff September 2010 - ongoing Opened first Ndola expansion clinic, October 2010 Start of expansion into Kitwe – 18 clinics March 2011 Start of expansion into Chingola clinics, October 2011 Start of expansion into Luanshya, May 2012 TODAY

13. 13 METHODS - II From project inception, ZEHRP has been able to open clinics every quarter up to August 2012 Requires the close collaboration with all clinic staff, ZEHRP trainers and staff and promotion teams

14. 14 CURRENT CVCT EXPANSION COPPERBELT PROVINCE

15. 15 METHODS - III Clinic health care providers trained by ZEHRP perform weekend CVCT and record test results anonymously in standardized logbooks Each couple given a unique ID, no names recorded Follow up and appropriate referral services are provided Weekend CVCT was initiated to minimize disruption to weekday clinic activities and to encourage increased male involvement

16. 16 RESULTS

17. 17 CVCT EXPANSION COPPERBELT PROVINCE From October 2010 - November 2012: – ZEHRP opened clinics in 4 districts in the Copperbelt Province: Ndola, Kitwe, Chingola and Luanshya ZEHRP has 54,498 tested couples in the Copperbelt Province Currently providing weekend CVCT services in: – 14 clinics in Ndola – 18 clinics in Kitwe – 12 Clinics in Chingola – 6 clinics in Luanshya

18. 18 Cumulative Number of Couples Tested in the Copperbelt, October 2010 – November 2012

19. 19 CHARACTERISTICS OF COUPLES TESTED IN THE COPPERBELT, OCTOBER 2010-NOVEMBER 2012

20. 20 Serostatus Distribution in the Copperbelt October 2010 – November 2012

21. 21 Serostatus distribution in 4 districts in the Copperbelt, October 2010 – November 2012

22. 22 Age distribution of women in discordant relationships per district, October 2010 – November 2012

23. 23 Age distribution of men in discordant relationships per district, October 2010 – November 2012

24. 24 PREGNANT WOMEN TESTED WITH PARTNERS AND THEIR HIV SEROSTATUS – per district October 2010 – November 2012

25. 25 Discussion The districts we have most data on, Kitwe and Ndola, reflect the provincial statistics In Chingola and Luanshya, CVCT is still being established and coverage of the population still is at early stages, however, general trend of higher prevalence of M-F+ noted Larger proportion of pregnant women in Ndola in M+F- partnerships, otherwise, no clear trend yet of HIV serostatus distribution in pregnant women tested with their partners

26. 26 Discussion - II Largest proportion of women in discordant relationships between the ages of 21-30 Largest proportion of men in discordant relationships are found in older age ranges, 25-40 Similar patterns found in all districts Majority of couples tested are in cohabitating relationships

27. 27 Challenges Logistics in transport, data management, mitigating unforeseen events – Strategies have been developed to manage these challenges including setting up satellite offices, having schedules for pick up and delivery of materials Ensuring fidelity to CVCT procedures – Solutions: training with regular refresher trainings and use of satellite sites for monitoring and evaluation Each district has their own vision of CVCT integration – Close collaboration with local DHMT and clinics ensures success Establishing CVCT as a social norm is still an ongoing process

28. 28 Conclusion Information on serostatus distribution can indicate areas of intervention – I.e.. Areas of high M-F+ couples can be prioritized for VMMC interventions – Identify at risk age groups and target CVCT promotions Confirms the need for CVCT in order to target a high risk group within Zambia – cohabitating partners Identification of discordant couples is integral in Zambia where the majority of HIV transmission occurs between cohabitating heterosexual couples Scale up of CVCT is a feasible endeavour with the close collaboration of all stakeholders

29. 29 ACKNOWLEDGEMENTS Special thanks to the support from: PATH CIDA IAVI NIH CDC Centre of Excellence Grant CANSSA Ministry of Health - Zambia

30. 30 THANK YOU!