Community-Level Secondary (Behavioral) Outcomes of

NIMH Project Accept (HPTN 043)David D Celentano for the

Project Accept Study TeamIAS 2013

2 July 2013Kuala Lumpur, Malaysia

• HIV testing history = % participants reporting HIV testing in the prior 12 months

• Social norms regarding HIV testing = assessed with multiple items on prevailing community attitudes towards testing

• Sexual risk = self-reported of number of unprotected acts averaged over prior 6 months; Number of sexual partners

• Negative life-events = reports of partnership break-up, discrimination, estrangement, neglect or violence

Secondary Trial

Outcomes

• Discussion of HIV = proportion reports in prior 6 months

• Disclosure of HIV status

• HIV stigma = mean of 28 validated stigma items

Secondary Trial

Outcomes

• We hypothesized that in CBVCT communities, mobilization and modeling would lead to:– Increased rates of HIV testing– Increased discussion about HIV testing– Improved social norms regarding testing– Through more common discussion about

HIV– Disclosure of HIV status to partners– Reduced sexual risks associated with

VCT and post-test support services– All of which would lead to reduced HIV

stigma at the community levelThese would then result in reduced HIV incidence

Secondary Trial

OutcomeHypotheses

• Baseline assessment of 14,657 randomly selected community residents ages 18-32

• Post-intervention assessment of 56,683 randomly selected community residents ages 18-32 who provided biological samples and short behavioral questionnaire;

Subset of 14,364 participants completed a detailed behavioral assessment

• Response rates of 85% at baseline, 93% post-intervention long version, and 85% short survey and blood draw. Refusals < 5%, with no difference by arm

Secondary Trial

OutcomeAssessment

and Methods

• Overall increase in HIV testing in intervention communities by 25%

(95%CI = 12%-39%, p=0003)

• HIV testing increased by 45% among men

(95%CI=1.25-1.69; p<0.0001)

• 15% among women (95%CI=1.03-1.28; p=0.0134). – Many women had been

tested in antenatal clinics but the increase was still significant

HIV testing uptake

There has been gender equity in uptake for CBVCT

Thailand Zimbabwe Tanzania Soweto Vulindlela0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

47.8 45.9

59.850.2 47.1

52.2 54.1

40.249.8 52.9

Per

cent

We reached a relatively young group of clients

Thailand Zimbabwe Tanzania Soweto Vulindlela0

5

10

15

20

25

30

35

4036

2830

28

21

Project Sites

Med

ian

Age

(Yea

rs)

Proportion of the Population Using Mobile VCT

Country CBVCT SVCT Ratio

South Africa--Soweto 17% 1% 14.8

South Africa--Vulindlela 20% 1% 16.8

Zimbabwe 25% 8% 3.07

Tanzania 21% 7% 2.93

Thailand 35% 1% 35.0

Testing Uptake: 12 Months

Effecta 95% CI p-valueAll sites 1.06 1.03 – 1.09 0.0001Thailand 1.09 1.02 – 1.16

Zimbabwe 1.07 1.00 – 1.13

Tanzania 1.05 1.01 – 1.09

Vulindlela 1.07 0.97 – 1.18

Soweto 1.01 0.88 – 1.15

SVCT-B SVCT-P CBVCT-B CBVCT-P Ratio P-Value Overall 16% 26% 14% 32% 1.25 0.0003

Thailand 17% 15% 17% 24% 1.56

Zimbabwe 7% 26% 3% 32% 1.20

Tanzania 15% 32% 16% 37% 1.13

Vulindlela 20% 35% 19% 40% 1.14

Soweto 33% 37% 31% 41% 1.10

• Number of sexual partners reported by HIV positive individuals lower by 8%

(95% CI: 1% - 15%, p = 0.03)

• Number of sexual partners among HIV positive men lower by 18%

(95% CI = 5% to 28%, p = .009)

Reductions in number of

sexual partners

• CBVCT resulted in more favorable social norms in intervention communities

• Improved by 6% (95% CI= 03 – 09, p = 0.0001)

Social Norms

• Multiple sexual partners among HIV infected persons reduced by 30%

(95% CI: 0.54 – 0.92, p = 0.01)

• Multiple sexual partners among HIV positive men lower by 29% (95% CI: 0.57 to 0.89, p = .0006)

Reductions in Multiple

Sexual Partners

• No increase in negative life events in intervention communities – No increase

in violence towards women, break-up of marriage or sexual relationships, neglect by family, discrimination)

The Intervention

was Safe

Stigma Reduction

• No effect on stigma reduction as a secondary endpoint

• Scale values on stigma measure low at baseline, little room to decline

• People reluctant to report they stigmatize, even though such stigma may exist

• Modest reductions in incidence, except in older women where incidence reduced by a third

• Created more favorable social norms

• Effectively engaged men in HIV testing

• Reduced behavioral risk among HIV+ men

Conclusions

• HIV testing is the first and essential in the cascade for community-level virologic suppression

• A generation free of HIV necessitates widespread (and repeated) HIV testing, especially among men

Conclusions

• Principal Investigators– Soweto, South Africa: Thomas Coates / Glenda Gray– Tanzania: Michael Sweat / Jessie Mbwambo– Thailand: David Celentano / Suwat Chariyalertsak– Vulindlela, South Africa: Thomas Coates / Linda Richter /

Heidi van Rooyen– Zimbabwe: Steve Morin / Alfred Chingono

• NIMH Cooperative Agreement Project Officer: Chris Gordon

• Core Lab: Susan Eshleman/Estelle Piwowar-Manning

• Statistical Core: Michal Kulich, Deborah Donnell

Collaborators: NIMH Project Accept (HPTN 043)

We thank the communities that partnered with us in conducting this research, and all study participants for their contributions. We also thank study staff and volunteers at all participating institutions for their work and dedication.

Acknowledgements