Using time-location sampling for HIV surveillance in street youth

1. Using time-location sampling for HIV surveillance in street youth Dmitry Kissin, MD, MPH Unintended pregnancy, STI, HIV Intervention Research (USHIR) Team, Youth Cluster Division of Reproductive Health Centers for Disease Control and Prevention

2. HIV Epidemic and Youth • About one half of all new HIV infections occur among youth aged 15 to 24 • Young people are vulnerable to HIV due to engagement in high-risk behaviors (having unprotected sex, having multiple partners or sharing needles while injecting drugs)

3. Street Youth • Youth living part- or full-time on streets • Band together into groups • High-risk lifestyle • Violence • Exploitation • Discrimination • Adverse health outcomes including HIV/AIDS • Estimated 100 million street youth globally Photos by Doctors of the World-USA, Mindanao Magazine, Canadian International Developmental Agency

4. Global HIV Epidemic Russia Ukraine Source: UNAIDS, 2008

5. Objectives • Assess HIV seroprevalence among street youth in 4 Eastern European cities • Identify risk factors for HIV infection

6. HIV Epidemic in Russia St. Petersburg Source: UNAIDS, 2007

7. Chernigiv Volyn Rivne Sumy Zhytomyr Kyiv Lviv Kharkiv Khmel-nytskiy Ternopil Poltava Luhansk Cherkasy Iv.-Frank. Vinnytsia Zakarpatska Kirovograd Chernivtsi Dnipropetrovsk Donetsk Zaporizhia Mykolaiv Odessa Kherson ARCrimea HIV Epidemic in Ukraine Kiev Number of registered cases < 1,000 1,000 – 3,999 4,000 – 8,999 > 9,000 Odessa Donetsk Source: Ukrainian AIDS Center, 2007 (registered cases of HIV-infected under medical care) 12

8. Assessment Cities

9. Methods: Sampling Frame • Comprehensive mapping of public sites (from NGOs and street youth themselves) • Classification of sites • DEFINITE – reported by 2+ organizations • PRESUMPTIVE – reported by 1 organization • POTENTIAL – typical street youth location, not reported • Outreach evaluation of PRESUMPTIVE and POTENTIAL sites(min. 3 visits to “empty” site) • Site inclusion criteria:DEFINITE site or site with 5+ youth observed over a 1-hour period

10. Methods: Selection of Sites and Participants • Sampling Stage I: Random selection of sites • Sampling Stage II: Universal selection of youth • Sample size calculation • 80% power • 95% significance • 2.5 risk ratio • 20% HIV+ IDU (exposed) and 8% HIV+ non-IDU (unexposed) • Need approximately 300 youth per city

11. Time-location Sampling of Street Youth Benefits Limitations • Preserves anonymity of participant • City-wide access to all groups more likely • Fast, efficient and inexpensive • Analytic approach well established • May be feasible to access only public sites

12. Sampling results

13. Definition of Street Youth 15-19 y/o 20-24 y/o • Found at street venues without parents AND • At least one of the following: • Living part-time or full-time on the street • Living out of family care • Self-identified as street youth • Attended school irregularly or not at all • At least one of the following: • Living part-time or full-time on the street • Self-identified as street youth • Plus: ability to express informed consent

14. Kiev 2008

15. Kiev 2008

16. Odessa 2008

17. 2 mobile teams (vans) ALL youth at each site evaluated for eligibility (return to site if not finished) Procedures (40-60 min/youth, 10.5 youth/day) Informed consent (verbal, comprehension of consent) HIV pretest counseling Rapid HIV testing Questionnaire HIV post-test counseling Field Assessment(takes 6-8 weeks)

18. Detects HIV-1 and HIV-2 Sensitivity: 100% Specificity: 99.9% Determine® HIV 1/2 Test Abbott Laboratories

19. Linkage of HIV+ youth into care • Follow-up options (by same social worker) • Escort to City AIDS Center the same day • Overnight shelter and escort to City AIDS Center the next day • Escorted to City AIDS Center at earliest possible day/time • City AIDS Center services • Confirmatory HIV testing • CD4 to assess need for ARV therapy • ARV therapy if needed and if compliance can be established • Referral according to specific needs (drug rehabilitation, prenatal care, other medical care)

20. Participation Rates

21. Youth characteristics

22. Chernigiv Volyn Rivne Sumy Zhytomyr Kyiv Lviv Kharkiv Khmel-nytskiy Ternopil Poltava Luhansk Cherkasy Iv.-Frank. Vinnytsia Zakarpatska Kirovograd Chernivtsi Dnipropetrovsk Donetsk Zaporizhia Mykolaiv Odessa Kherson ARCrimea HIV seroprevalence, street youth St. Petersburg: 37.4% Kiev: 18.6% Odessa:26.7% Donetsk:9.8%

23. Social risk factors

24. Sexual risk factors

25. Drug-related risk factors

26. Follow-up for HIV+ youth

27. Conclusions • Time-location sampling is an efficient, inexpensive and accurate method of HIV surveillance in street youth • High HIV seroprevalence among street youth in Russia and Ukraine • Street youth in each of the 4 cities had social, sexual and drug-related risk factors

28. Limitations • Few confirmatory tests • UNAIDS/WHO guidelines: 1 rapid test sufficient for surveillance purposes if HIV prevalence >10% • Cross-sectional data • Self-report data

29. Acknowledgements Doctors of the World – USA Tom Dougherty Erin Finnerty Allison Lynch Tara Ornstein Jennifer Leigh Vandana Tripathi Nadiya Pylypchuk Roman Yorick Konstantin Zakharov Anna Shapoval Halyna Skipalska Centers for Disease Control and Prevention Susan Hillis, PI Lauren Zapata Cheryl Robbins Denise Jamieson Polly Marchbanks Pauli Amornkul Holly Faber Keith Sabin International HIV/AIDS Alliance Tetiana Saliuk Andriy Klepikov Inna Shvab Elena Purik St. Petersburg, Russia, Team Natalia Kirik Maria Zagaynova Elena Cherkassova Larisa Kuzmina Elena Arkhipova Marina Margovich Elena Boguzh Elena Fedoseeva Arkady Genkin Vyacheslav Yanston Maria Nikitina Victor Vasiliev Kiev, Ukraine, Team Leonid Krysov* M. Sayko Vitaly Tkalitch Vitaly Tkachuk Elena Khodzhenski Elena Pysmennaya Vitaly Kabanets Natalia Timashova V. Yakovenko Eugene Kirik Alex Schedrygin Anton Panin Odessa, Ukraine, Team Natalya Kitsenko* Victoria Danilyuk Inna Lazaryuk Vitaly Demeshin Alla Evmenenko Tatiana Pylypenko Mikhail Zakharov Alexander Karpinsky Ruslana Yastreb Nadezgda Kalcheva Donetsk, Ukraine, Team Elena Kulakovskaya* L. Bereteli I. Kalinichenko Igor Birkin Olga Makeeva Leonid Zgilak Oksana Shuh M. Zagrebna Olga Baranova Tatiana Dolgova Anton Kolesnik St. Petersburg Collaborators and Consultants Center for Innovations Children’s Crisis Ctr. Humanitarian Action Russian Red Cross StellitElena Vinogradova Lydia Kryga Zoya Lisitsina Galina Volkova Ukraine Collaborators and Consultants Olga Sydorova Ludmyla Volynets Mykola kuleba Oleksandr Yurchenko Valery Novosvitny Mykola Grazhdanov Vasyl Panteliuk Leslie Perry Anna Teltschik

30. Thank you!