innovative clinical models in hiv prevention and...
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Innovative Clinical Models
in HIV Prevention and Care
Nittaya Phanuphak, MD, PhD
Thai Red Cross AIDS Research Centre, Bangkok, Thailand
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The HIV cascade model
Opportunities for PrEP
Opportunities
for TasP
• Community-based organizations are most suitable to “reach, recruit, test, treat/PrEP and retain" the risk individuals
• Online platform has high potential to enhance the cascade
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REC
RU
IT Conventional outreach methods
Online outreach
Online-to-offline platform
TEST Same-day HIV
testing
Community-based/led testing sites
Facility-based testing sites
Self-testing
TREA
T/P
REV
ENT Linkage to ART
service
Community-led ART/PrEP sites
Facility-based ART sites
RET
AIN Retention
support for both HIV-positive and HIV-negative clients
Online adherence and retention support for ART and PrEP clients
• Half of new HIV infections in Thailand occur among MSM but current HIV testing coverage among Thai MSM is less than 30%
• 60-65% of MSM returned for repeated HIV testing within a year
Data from IBBS, Thai Red Cross Anonymous Clinic and Silom Community Clinic
Recruit – Test – Treat & Prevention – Retain
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83% 74% 75%
diagnosed on treatment virally suppressed
THAILAND 2014
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Community-led Test & Treat and PrEP service delivery model
CHIANG MAI
CAREMAT/MPLUS
Type of clients: MSM and TG
BANGKOK
Rainbow Sky Association of
Thailand (RSAT)
Type of clients: MSM and TG
Service Workers IN Group
(SWING)
Type of clients: MSWs
SONGKHLA (HAT YAI)
RSAT
Type of clients: MSM and TG
CHONBURI (PATTAYA)
SISTERS
Type of clients: TG/TG sex workers
SWING
Type of clients: MSWs
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Service delivery capacity strengthening for TEST-TREAT-RETAIN
Didactic, hands-on, performance log
Finger prick blood collection, HIV testing, syphilis testing, POC CD4
STI counseling/sampling from anus, neovagina, oro-pharynx
TB screening and prevention
Ongoing coaching, QA/QI and case discussions
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Service delivery capacity strengthening for TEST-PrEP-RETAIN
Didactic training on use of ARVs for HIV prevention, with lots of Q&A
Community forum to create awareness, demand and support from MSM
and TG communities
Ongoing coaching, QA/QI and case discussions
Expansion to “Princess PrEP” program: free community-led PrEP service
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Updated Community-based Test and Treat Study“Total” Enrollment, by Partner, as of April 28, 2016
CBOsEnrolled
ParticipantsHIV-
NegativeInconclus
iveHIV-Positive
Seroconversion
Exclusion**%Consent for
ARTStart ART
SWING BKK6 May 2015
254 221 0 33 (13%) 1 6 100% 22 (79%)
RSAT BKK22 May 2015
462 328 0 130 (28%) 4 8 99% 107 (85%)
SISTERS26 June 2015
258 226 0 31 (12%) 1 7 100% 19(70%)
CAREMAT1 July 2015
557 490 1* 61(11%) 1 12 100% 40 (82%)
SWING PTY16 July 2015
147 109 0 36 (25%) 1 2 94% 27 (82%)
RSAT HDY5 Nov 2015
110 100 0 10 (9%) 0 0 100% 10 (100%)
Total 1,788 1,474 1 301 (17%) 8 35 99% 225 (81%)
*In follow-up process for repeat testing **Age <18 years or known HIV-positive status
79% successfully started ART
Median days to start ART 15 days (IQR 9-22)
5% within 2 weeks of diagnosis
16% didn’t start ART after 2 weeks of diagnosis
End of March 2016
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Community-based Test & Treat Cascade, by Population (May – Dec 2015)
CD4 COUNT AT DIAGNOSIS N = 172
<350 76 (44%)
350-500 48 (28%)
>500 48 (28%)
Median (IQR) 373 (280-507)
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Community-led PrEP Study Enrollment, as of April 28, 2016
RSAT BKK (26 Nov. 2015)
SISTERS PTY (22 Oct. 2015)
SWING BKK (29 Oct. 2015)
Enrollment: 98
Agreed to take PrEP: 59 (60%)
Enrollment: 126
Agreed to take PrEP: 62 (49%)
Enrollment: 45
Agreed to take PrEP: 20 (44%)
SWING PTY (24 Nov. 2015)
Enrollment: 33
Agreed to take PrEP: 23 (70%)
TOTAL ENROLLMENT: 302
(95% of total HIV-neg in T&T)AGREED TO TAKE PREP: 164 (54%)
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Princess PrEP Press Release in Bangkok, 16 Februay 2016
Chaired by the MOPH DDC Director General and Prof Praphan Phanuphak
Blessing quote from HRH Princess Soamsawali to support “community-led
PrEP services” was officially handed to CBO leaders
Expand PrEP to 3,000 MSM and TG over 3 years
11 January – 30 April 2016: 267 MSM and TG assessed 256 started PrEP
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Use MSM magnetic celebrities
to draw attention towards normalization of HIV and HIV testing
Sep 2011 – Aug 2015
- Visitors: 2.3M (21% repeat visitors), Page views: 10.8M pages
- Edutainment Video Views: 1.4M views
- Webboard / Facebook / E-mail: Average 20 questions/day
- 25% of TRC Anonymous Clinic clients came because of Adam’s Love
- >10,000 referrals to HIV and STI services
Adam’s Love website http://www.adamslove.org/
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APCOM’s engagement with MSM via virtual venues
Interactive approaches on MSM
websites
Engagement with social and
sexual networking apps
Coordinated social media-based
campaigns
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Princess PrEP program: Adam’s Love Online-to-Offline component
During Jan – April 2016
– 425 booked 325 visited clinics (76%)
– 148 decided to have HIV testing only
– 168 started PrEP
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Supported by amfAR GMT Initiative Grant
Online supervised HIV self-testing videos and manual
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• Piloting oral fluid rapid testing – Operations research and phased roll-out to partners
• Use of HIV testing in various venues– Outreach
– Mobile services
– Community events
– Home-based
• Concrete linkages to confirmation, treatment and support
Increased use of new diagnostic/screening test that make HIV testing easier
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A mobile application carried by community staff to:
• Collect client data• Track and manage cases across the
HIV cascade• Guide staff through complex EPM
processes• “Stay connected” with SMS
messaging• Improve performance over time
eCascade: Mobile app for real-time data collection and referrals tracking
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Connecting providers and their clients for better performance and service through eCascade
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Peer Mobilizer
• Short-term
with incentives
• No formal
training
• Recruits
clients within
their own
social network
Client
• Responsible
for own
health
• Opportunity
to become
new Peer
Mobilizer
Community-based
Supporter
• Long – term with
salary
• Training/mentoring
• Educates and retains
clients across the
cascade
Expanding reach through social networks
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No HIV+’s found by
peer mobilizers
High # of HIV+ found by
peer mobilizer
Super recruiter
White = reachedBlack = HIV tested
Red = HIV+Blue rim = first-time tester
Identifying high-value social networks
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Seed: af040224
Nickname: A
CBS: 1010112
Recruited: 29
Testing Rate: 96.5%
Testing Yield: 14.3%
Prioritizing effective peer mobilizers
94% HIV
testing uptake
83% ART
initiation
10% HIV+
yield
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Establishing and enhancing community-led HIV service models and online
platform are feasible and needed to achieve national and global targets to end
the HIV epidemic
CBOs are eager and proud to have their capacities built up beyond just being
outreach worker and recruiter for the research projects become
community research sites
Address structural barriers to institutionalize and finance community-led HIV
services and online platform
To enhance (for TG) and extend the community-led model to other key
populations (e.g. youths and PWID)
Conclusions and steps forward
More innovative and exciting models will continue
to arise where commitment and enthusiasm are
shared among stakeholders!