1. Role of Routine HIV Testing in Concentrated Epidemics Operations Research for Optimizing the HIV Testing Program in an Urban Canadian Setting K Vasarhelyi, S Kok, JSG Montaner, AR Rutherford, R Barrios, K McPherson, M Thumath, L Tran, A Nathoo, R Gustafson

2. Collaboration of Academic and Public Health Partners BC Centre for Excellence in HIV/AIDS Vancouver Coastal Health Providence Health Care The IRMACS Centre A poster for the Vancouver Coastal Health / Providence Health Care social marketing campaign promoting routine HIV testing The IRMACS Centre The BC Centre for Excellence in HIV/AIDS & Providence Health Care

3. BACKGROUND

4. Stakeholder’s Questions 1.Should we do it? Can routine voluntary HIV testing make a useful contribution to controlling the HIV epidemic in Vancouver? 2.How can we do it? What is the best way to integrate routine voluntary HIV testing into the current testing program?

5. The HIV Epidemic in Vancouver Concentrated epidemic MSM, IDU, sex workers 1 HIV prevalence ~12 / 1000 2 >200 new diagnoses / year in past 10 years 3 <150 new diagnoses in 2012 3 HIV testing traditionally risk-based No routine testing guidelines in Canada (1)MSM – men who have sex with men; IDU – injection drug user (2)McInnes et al., 2009, Harm Reduction Journal (3)BC Centre for Disease Control (Vancouver’s population 600,000) / Vancouver Coastal Health

6. Routine Testing Generalized epidemics Lower yield Lower cost/test Risk-based Testing Concentrated epidemics Higher yield Higher cost/test What is the optimal mix of testing methods for Vancouver?

7. Routine Testing Generalized epidemics Lower yield Lower cost/test Risk-based Testing Concentrated epidemics Higher yield Higher cost/test YIELD COST What is the optimal mix of testing methods for Vancouver?

8. Objectives Minimize morbidity Minimize mortality Minimize HIV incidence

9. What is the optimal mix of testing methods for Vancouver? Objective Minimize morbidity Minimize mortality Minimize HIV incidence

10. Operations Research and Optimization Find best intervention to meet objective Intervention is resource allocation Optimal distribution of new resources Optimal realignment of existing resources

11. MODEL

12. Model Development Step 1 Qualitative Model for Cascade of Care Step 1 Qualitative Model for Cascade of Care Step 2 Qualitative Model for HIV Testing Program Step 2 Qualitative Model for HIV Testing Program Step 4 System Dynamics / HIV Transmission Simulation Model of Cascade of Care with Detailed HIV Testing Program Step 4 System Dynamics / HIV Transmission Simulation Model of Cascade of Care with Detailed HIV Testing Program Step 3 Combine

13. Model Development Step 1 Qualitative Model for Cascade of Care Step 1 Qualitative Model for Cascade of Care Step 2 Qualitative Model for HIV Testing Program Step 2 Qualitative Model for HIV Testing Program Step 4 System Dynamics / HIV Transmission Simulation Model of Cascade of Care with Detailed HIV Testing Program Step 4 System Dynamics / HIV Transmission Simulation Model of Cascade of Care with Detailed HIV Testing Program Step 3 Combine General Population MSM Other Key Populations (IDU, Sex workers)

14. Qualitative Model of the Cascade of Care Decisions and activities in the HIV care continuum defined through consultations with system experts

15. Qualitative Model of the Cascade of Care Decisions and activities in the HIV care continuum defined through consultations with system experts DIAGNOSIS LINKAGE TO CARE RETENTION IN CARE

16. Qualitative Model of the HIV Testing Program Vancouver Coastal Health for STOP HIV/AIDS Project, Vancouver, Canada (2013)

17. Qualitative Model of the HIV Testing Program Vancouver Coastal Health for STOP HIV/AIDS Project, Vancouver, Canada (2013) Routine Testing in HOSPITALS Routine Testing in HOSPITALS

18. HIV Testing Resources No $ estimate available Cost of 1 Risk-Based Test > Cost of 1 Routine Test Considered 1:1 to 9:1 cost ratios Number of Tests / Month Total HIV Testing Resources + Cost Ratio

19. RESULTS

20. Question 1 Is routine testing effective in reducing HIV incidence in Vancouver? SIMULATON SCENARIO 1.Increase total testing budget by 50%. 2.Invest all new resources in one program: Risk-based testing or Routine testing in high-prevalence settings or Routine testing in hospitals 3.Compare 5-year cumulative incidence.

21. Relative effectiveness of testing programs in reducing 5-year cumulative HIV incidence Risk-based Testing Up to 83 infections averted in 5 years Routine Testing in Hospitals Up to 104 infections averted in 5 years Routine Testing in High-Prevalence Settings Up to 274 infections averted in 5 years

22. Question 2 How many infections would be averted by increasing routine testing in hospitals and improving engagement in treatment? SIMULATION SCENARIO 1.Increase total testing budget by 50%. 2.Invest all new resources in routine testing in hospitals. 3.Increase immediate treatment initiation after linkage to care from 38% to 75% and reduce loss to follow- up from 26% to 10%. 4.Compare 5-year cumulative incidence.

23. Test Cost Ratio Risk-based :Routine Infections Averted Over 5 Years Change in Infections Averted Baseline Engagement Improved Engagement 1:14181+ 98 % 5:179121+ 53 % 9:1104147+ 41% Increasing routine testing in hospitals and improving engagement in treatment

24. Question 3 How many infections would be averted by realigning existing resources between risk- based and routine testing in hospitals? SIMULATION SCENARIO 1.Keep total testing budget the same. 2.Realign existing resources between risk-based testing and routine testing in hospitals in 5% increments. 3.Compare 5-year cumulative incidence.

25. Optimal resource allocation to risk-based testing and routine testing in hospitals to minimize HIV incidence Cost Ratio % Resources in Routine Testing in Hospitals Optimal % Hospital Admission s to Test (Current=12%) CurrentOptimal 1:138%0% 3:117%15%10% 5:111%30%32% 7:18%40%59% 9:16%45%83%

26. Optimal resource allocation to risk-based testing and routine testing in hospitals to minimize HIV incidence Cost Ratio % Resources in Routine Testing in Hospitals Optimal % Hospital Admission s to Test (Current=12%) CurrentOptimal 1:138%0% 3:117%15%10% 5:111%30%32% 7:18%40%59% 9:16%45%83%

27. CONCLUSIONS

28. Conclusions Routine HIV testing in Vancouver is likely to be averting infections, especially in high- prevalence settings. In general routine testing may play an important role in controlling concentrated HIV epidemics. Optimizing across the cascade of care could avert additional infections. Realigning existing resources may improve efficiency of the testing program.

29. Conclusions Next steps include – Morbidity and mortality as optimization objectives – Developing other parts of the model of cascade Operations research and optimization provide powerful methods to inform implementation of WHO guidelines on early treatment initiation.

30. Collaborators & Sponsors BC Centre for Excellence in HIV/AIDS Silvia Guillemi Guillaume Colley Susan Shurgold Benita Yip Vancouver Coastal Health & Providence Health Care Kendra McPherson Meaghan Thumath Lynn Tran Reka Gustafson Afshan Nathoo Allison Macbeth Chris Buchner Val Munroe Jat Sandhu Ellen Demlow Tim Chu Scott Harrison BC Centre for Disease Control Mark Gilbert Travis Salway Hottes Gina Ogilvie University of Zurich Lukas Ahrenberg IRMACS Pam Borghardt Peter Borwein Brian Corrie Felix Breden Kelly Gardner Alexa van der Waall

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