AIDS 2012, July 24, 2012 Presented by: Sarah Rutstein

1. Differential Sexual Risk Behaviors Among Patients Receiving HIV Testing and Counseling in Lilongwe, Malawi AIDS 2012, July 24, 2012 Presented by: Sarah Rutstein Co-authors: C. Mapanje, G. Kamanga, S. Phiri, D. Nsona, A. Pettifor, N. Rosenberg, I. Hoffman, W. Miller

2. HIV testing in Malawi • Where to test: • HIV Testing and Counseling (HTC) centers • Higher observed HIV prevalence • Sexually Transmitted Infection (STI) clinics • Managed syndromically • Opt-out HIV testing and counseling

3. HIV Prevalence in Malawi • 11% nationwide • 20% in urban areas

4. HIV Risk Behaviors • Multiple sexual partners • Sex without condoms • Risk behaviors of partners • Concurrent sexual partnerships

5. Study objectives: • To explore HIV risk behaviors of patients seeking HIV testing at an HIV Testing and Counseling (HTC) center and nearby Sexually Transmitted Infection (STI) clinic in Lilongwe, Malawi.

6. Methods: Parent Study • Pilot study assessing public health benefit of behavioral and biomedical interventions for persons with acute HIV infection. • Pre-trial data collection assessing the feasibility of widespread screening for acute HIV infection in Lilongwe.

7. Study Population: • Eligibility: • ≥ 18 years old • Willing to provide 1,200 μL blood • Screened eligible participants at two sites • All-comers to HIV Testing and Counseling Center, Lilongwe • HIV-negative or discordantpatients at Sexually Transmitted Infection Clinic, Lilongwe

8. Data Collection • Sex partners (4 weeks & 3 months) • Condom use • Exchanging money for sex • Sex with HIV-infected partner • Concurrency • Gender • Age • Education • Marital status • Symptoms associated with acute retroviral illness

9. Capturing Concurrency • If more than 1 partner in past 3 months : • Were any of these partnerships overlapping in time? By overlapping, we mean that you had sex with one partner one day, then had sex with someone else another day, and after that had sex with the first partner again.

10. Data Analysis • Summary statistics from site & HIV status using independent group t-tests (continuous) and Pearson’s χ2 (categorical) • Bivariate analyses of demographic characteristics and reported partnership concurrency

11. Results: Study Population Screened (n=1,043) HIV-seronegative STI patients (7 Acute HIV) (n=200) HTC patients (n=843) No HIV results recorded (n=7) Eligible HTC patients (n=836) HIV-positive (n=167) HIV-seronegative (1 Acute HIV) (n=669) 19.9% HIV prevalence

12. Participant Demographics

13. Participant Risk Behaviors: Sexual partners p <0.01 p <0.01

14. Participant Risk Behaviors:Money for sex & Condom use p <0.01 p=0.60

15. Participant Risk Behaviors:Sex with HIV-infected partner & Concurrency Among persons with >1 partner: 74% concurrency (STI) 26% concurrency (HTC-seropositive) 33% concurrency (HTC-seronegative) p=0.33 p <0.01

16. Concurrency Analyses • Logistic regression restricted to males reporting concurrent partnerships in last 3 months (n=522). • Odds of concurrency, compared to STI: • Adjusting for age, marital status, # of sexual partners, sex-for-money, and condom use

17. Limitations • Only HIV-negative participants screened at STI • For HIV-positive HTC participants, recent behavior may not reflect the risk behaviors surrounding time of HIV acquisition • Imprecise capturing of concurrency • Recall biasSocial desirabilityConcurrency complexity

18. Conclusions & Public Health Implications • Differential risk behaviors among STI and HTC clients • High risk behavior among STI clinic patients could increase likelihood of HIV acquisition • Potential for ongoing HIV transmission among STI clinic patients with acute HIV infection

19. Acknowledgements • Thank you to all HTC and STI clinic counselors • Study supported by grants from NIH [DHHS/NIH/NIAID 5 T32 AI 07001-34 and NIAID R01 AI083059]