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Peter Godfrey-Faussett for Charlotte Watts

Interim report on behavioural studies and HIV model for ProTEST. Peter Godfrey-Faussett for Charlotte Watts. ProTEST Meeting, Durban February 2003. STI control IEC Lifeskills Condoms VCT Microbicides Peer educators. DOTS intensive case-finding

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Peter Godfrey-Faussett for Charlotte Watts

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  1. Interim report on behavioural studies and HIV model for ProTEST Peter Godfrey-Faussett for Charlotte Watts ProTEST Meeting, Durban February 2003

  2. STI control IEC Lifeskills Condoms VCT Microbicides Peer educators DOTS intensive case-finding reduce diagnostic delays improve adherence  HIV transmission Isoniazid preventive therapy  TB transmission  TB reactivation Strategies to control TB and HIV

  3. Decreased Risk Behaviours: VCT Efficacy Group • RCT in Kenya, Tanzania and Trinidad Voluntary HIV -1 Counselling and Testing Efficacy Group, 2000 • 3120 individuals and 586 couples randomly assigned to VCT or basic health information • At 6 month FU, HI offered VCT, VCT offered retesting, STIs dx’d and tx’d • Behavioural questionnaires at baseline, 6 months and 12 months

  4. Decreased Risk Behaviours:VCT Efficacy Group • Unprotected intercourse down 35% in men with VCT cf 13% with health education (HE) • In women, VCT: 39%, HE: 17% • in HIV+>HIV-, couples with at least 1 HIV+>uninfected couples • Couples reduced unprotected intercourse with enrolment partners but not with non-enrolment partners

  5. Voluntary HIV Counselling and Testing: Cost-Effectiveness • Cost per HIV infection averted: $249 in Kenya and $346 in Tanzania Sweat M, 2000 • Cost per DALY saved: • $12.77-$17.78 • if lower infectivity: $28.87-$45.73 • Peer education of CSWs ($0.35-$0.52) • Improved STI management ($9.45) • ARVs in pregnancy ($10.51) Jha P, 2001

  6. Protest behavioural study and epidemiological modellingUpdate on progress and baseline dataCharlotte WattsHealth Policy UnitDepartment of Public Health and PolicyLSHTM

  7. Components to study • Behavioural survey – clients attending urban VCT services in Lilongwe and Lusaka (one site in each city) • Epidemiological modelling of impact on HIV & TB • HIV estimates use VCT behavioural data from each site • TB projections build on model estimates of VCT impact on HIV incidence • Link with economic analysis to estimate cost per HIV infection averted and cost per DALY saved

  8. Behavioural study design • Collect behavioural data from HIV+/HIV- men and women before and after VCT • Interview 1,400 clients from MACRO, Lilongwe attending VCT services • Follow-up with HIV+/HIV- male and female clients 6 months later • Control population new clients attending VCT services during follow-up phase of study

  9. Steps in behavioural study - Malawi • Drafting and pre-testing of male and female questionnaire • Building of interview buildingsat MACRO • Development of accompanying materials • Selection and training of interviewers • Piloting of questionnaire in Lilongwe • Final revision / development of data entry screens • Base-line interviews (Jan – April 2002) • Follow-up & control interviews (6 months) (July - Dec 2002) • Data entry and cleaning (ongoing) • Analysis using SPSS (ongoing)

  10. Baseline survey – preliminary results • Interviews conducted Jan – April 2002 • Low levels of refusal • 1408 interviews completed and analysed • 73% male (1028), 27% female (380)

  11. Patterns of sexual behaviour - men Casual partner past 6 months 43% Have steady partner Male VCT 30% No other partners last 6 mths 57% 67% Single / sexually active Casual partner past 6 months 69% 3% No partners past 6 mths 31% Never had sex

  12. Patterns of sexual behaviour - women Casual partner past 6 months 7% Have steady partner Women VCT 35% No other partners last 6 mths 93% 59% Single / sexually active Casual partner past 6 months 64% 6% No partners past 6 mths 36% Never had sex

  13. Reported number non-regular sexual partners in past 6 months

  14. Over-view baseline results • Analysis preliminary • Majority of VCT clients aged 15 – 24 with at least primary level education • Approximately 2/3 male and female VCT clients are single • 1/3 of VCT clients have a regular / steady partner • 43% partnered men report casual partners in past 6 months • 7% partnered women report casual partners in past 6 months • 1/3 single VCT clients do not report having a sexual partner in the past 6 months • Large variation in the numbers of casual sexual partners reported – with single men having the greatest number of partners in the last 6 months • Results on reported condom use not presented – preliminary analysis suggests low levels of use • Late analysis will merge survey data with data on HIV infection status of clients

  15. Follow-up & control surveys Malawi • Designed to ensure that interviews with HIV+ve / HIV-ve males and females obtained • Requests to return, incentives and follow-up used to identify people for follow-up • Target for follow-up interviews: • All HIV+ve men and women interviewed • All HIV-ve women interviewed • 1/4 of HIV-ve men (other men interviewed using a short questionnaire) • 938 interviewed in follow-up – 509 with full questionnaire (71% of targeted follow-up group) • 770 control interviews completed

  16. Key features of HIV modelling • Deterministic, epidemiological model to consider transmission between VCT client and different sexual partners • Population of VCT clients will be stratified by characteristics of sexual behaviour, HIV infection status, condom use • For each sub-category model the impact of behaviour change on patterns of HIV transmission • Model includes role of high viraemia, role of one STI in facilitating HIV transmission, and dynamic of HIV and STI transmission over time • Focus of analysis to explore short term impact on HIV transmission (6 month and 2 year projections) • Impact estimates will depend on assumptions about HIV and STD prevalence among different types of sexual partners of VCT clients

  17. Format of HIV impact model to be used with each strata of VCT clients Sexual partners VCT clients (male / female) Steady HIV+ HIV & STD transmission over time Shortterm / occasional HIV- Commercial

  18. Progress with epidemiological modelling • Review of existing behavioural data from Malawi • Drafting of outline for epidemiological model(s) • Programming of beta version of model(s) • Analysis of baseline sexual behavioural data • Revision of model to reflect patterns of sexual behaviour seen / level of complexity • Analysis of follow-up & control sexual behaviour data – identification of main forms of behaviour change • Finalisation of alpha version of model to incorporate forms of behaviour change documented • Modelling of VCT impact on HIV incidence (comparing with and without VCT) • Estimation of associated impact on TB infection

  19. Next steps - Malawi January – March 2003 • Analysis of baseline data and revision of model March – May 2003 • Analysis of control and follow-up data • Comparisons between before and after data, control and intervention data • Revision of model and estimation of VCT impact on HIV • Use of data on impact on HIV incidence to estimate associated TB cases averted

  20. Next steps - Zambia and South Africa • Review Zambian budget and timeframe based on Malawi experience • South Africa is also planning to undertake behavioural study • Tools developed collaboratively by Malawi and South Africa • Possible location under discussion • Awaiting funding to commence

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