Sakchai Chaiyamahapurk Ph.D. student Health System and Policy

1. High risk strategy in HIV prevention : What is appropriate and effective? Draft of research Proposal Sakchai Chaiyamahapurk Ph.D. student Health System and Policy Faculty of Medicine, Naresuan University.

2. Literature review Epidemiology Prevention strategy Treatment HIV testing Provider initiated counseling testing Disclosure Rational Conceptual framework Objectives Research question Proposed methodology List of field study Concept of some field studies Outline of presentation

3. HIV/AIDS situation • Almost 40 million HIV-infected people worldwide • In Thailand, estimated 1,092,437 accumulatively HIV-infected person with report of 541,105 death. • Early epidemic, transmission mainly through commercial sex worker to men. • Currently, shift toward husband and wife – source of infection. (58.1% of new infection in 2005)

4. Source:Poolcharoen, W. "Report on the review of the National AIDS Prevention and Alleviation2002 – 2006."

5. HIV prevalence among pregnant women : 1989-2001(source : Division of Epidemiology, MOPH, Thailand) % %

6. HIV prevalence among male patients attending STD clinics: 1989-2001(source : Division of Epidemiology, MOPH, Thailand) %

7. HIV Seroprevalence among TB patientsTB Centers, Thailand 1989-2002

9. High risk Advantage: Intervention appropriate to individual, Subject motivation, Physician motivation , Cost-effective, Benefit-risk ratio favorable Disadvantage: difficulties and cost of screening, not radical, behaviourally inappropriate Population Advantage: radical, large potential for population, behaviourally appropriate Disadvantage: small benefit to individual, poor motivation of subject, poor motivation of patients, benefit:risk worrisome Rose, G. (2001). "Sick individuals and sick populations." Int. J. Epidemiol.30(3): 427-432. High risk VS Population strategy

10. Population VS High risk strategy in HIV prevention

11. High risk strategy • HIV testing • Disclosure • Pre-exposure prophylaxis • Post exposure prophylaxis • Safe sex in PWHA • Health promotion among PWHA • Public health measure • Law or regulation?

12. Access to treatment in Thailand • In 2002, Thai MOPH initiated National antiretroviral program (NAPHA) . • In 2006, program transferred to National Health Security Office. • Up to year 2008, it covered >80,000 PWHA.

13. Benefit package for HIV/AIDS (NHSO,2007) Anti HIV • All people at risk through VCT 2 times per year For PWHA • ARV • CD4 • Hemato, Blood Chemistry2 times per year

14. Exceptionalism of HIV testing • Exceptional from other laboratory testing, due to social stigmatization , voluntary counseling testing was adopted as standard of HIV testing. • Three principles as norm • confidentiality • counseling • consent

15. Paradigm shift? • Highly Active Antiretroviral Therapy (HAART) now is standard of care • From lethal disease to chronic illness with long term care. • A delayed diagnosis results in poor treatment outcome and missed opportunity to reduce transmission of HIV through change of risk behavior.

16. Evidence of delayed diagnosis (USA) • Up to 280,000 of 950,000 HIV-infected people in USA unaware of their HIV-positive status. • Up to 20,000 new HIV infection annually attributed from unaware people with HIV. • 41 % diagnosed as AIDS within a year after knowing of HIV-positive status.

17. Awareness of HIV status reduce HIV transmission .(Marks, Crepaz et al. 2005) • Meta-analysis show 68% reduce of unprotected anal or vaginal intercourse(UAV) in HIV person compared between person who aware their serostatus with those who not. • Increased emphasis on HIV testing and counseling is needed to reduce exposure to HIV(+) from persons unaware they are infected. • Ongoing prevention services are needed for persons who know they are HIV(+) and continue to engage in high-risk behavior

18. Sexual risk behavior in PLWH, USA • 70% sexually active • 10-60% unprotected sexual behavior • Psychological, social, interpersonal and medical variables correlate with sexual risk behaviors.

19. Early detection of HIV by clinical symptom is difficult • A study in the Kaiser Permanente Medical care program in USA , looking for early detection of HIV infection,reasonable access to medical care, a high prevalence of HIV infection • nearly one half with newly diagnosed HIV infection had AIDS-defining CD4 cell depletion or another AIDS-defining condition at first diagnosis of HIV infection, and 62% need ART at diagnosis • effective risk assessment before symptoms arise offers greater potential for raising the mean CD4 cell count at diagnosis than doesincreased awareness of selected HIV-associated clinical prompts. Klein, D., L. B. Hurley, et al. (2003). "Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection." J Acquir Immune Defic Syndr32(2): 143-52.

20. Evidence in Thailand • A study from Thai red cross clinic in Bangkok, Thailand in 1993/94 showed that • 80% having decreased their sexual activity and their number of sexual partners since receipt of the positive HIV test result. • more often abstaining from sex (42% vs 14%) • more often using condoms during all their last three incidences of sexual intercourse (44% vs 14%). (Muller, Sarangbin et al. 1995)

21. Sexual risk behavior in PWHA, Thailand • Young HIV patients treated with antiretroviral in Bangkok • consistent condom use at baseline (55.6%) • at 3-month visit (58.3%) • Sexual acts without a condom in both genders and nondisclosure among males were concerning. Rongkavilit, C., S. Naar-King, et al. (2007). "Health risk behaviors among HIV-infected youth in Bangkok, Thailand." J Adolesc Health40(4): 358 e1-8.

22. Four types of HIV testing(UNAIDS/WHO) • Voluntary counselling and testing : Client-initiated HIV testing • Diagnostic HIV testing • includes HIV testing for all tuberculosis patients. • Routine offer of HIV testing for asymptomatic people by health care providers (PITC?) • STD clinic • ANC clinic • clinical and community based health service settings where HIV is prevalent and antiretroviral treatment is available (IDU, ER, in-patients , out-patients) • Mandatory HIV screening for transfusion or for manufacture of blood products

23. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings, CDC 2006 • Diagnostic HIV testing and opt-out HIV screening as routine clinical care • Screening for HIV • Age 13-64 • Setting: ER, urgent-care, IPD, STD, TB, IVDU, community, correctional, primary care clinic • Unless prevalence<0.1%(1/1000) • All TB, STI patients • Repeat screening • Annually for high risk ie. CSW, IDU, MSM, partner of PWA

24. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings, CDC 2006 • Consent and pretest information • Voluntary and patient can opt-out • Informed orally or in written information • General informed consent for medical care is enough, no separate consent for HIV testing • If patient decline, decision should be documented in medical record

25. Major revisions of CDC recommendationof HIV testing in health-care settings • Opt-out screening, patient is notified that testing will be performed unless the patient declines • annually test for persons at high risk for HIV infection • written consent for HIV testing may not be required; general consent for medical care is sufficient • Prevention counseling not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. HIV prevention counseling- interative process of assessing risk, behaviors, plan to reduce risk

26. For pregnant women • HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women. • HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening).

27. Arguments support PITC • Reliable and inexpensive screening test • Available effective treatment (HAART) • Awareness of HIV status decrease HIV transmission • Link clinical care with prevention • Decrease barrier for testing ( work load for counseling, reluctance of provider and client for sexual risk assessment) • Destigmatize the testing process • Successful of PMTC program • Right to know • Impact on equity – due to • high levels of fear in people aware of their increased risk can lead to avoidance behaviour, • less accessible of information to people with low literacy skills.

28. Arguments against PITC • Lack of patient ‘s autonomy • Violate human rights • Without the three Cs, testing loses its power as a prevention tool • VCT not failed , but not adequately financed. • Increase negative outcomes of testing • False negative results can give false reassurance • Resource allocation (cost-effectiveness of intervention) • right not to be opportunistically confronted with knowledge about biomedical risks unrelated to reasons for seeing the doctor. • Conflict between provider and client (individual and pubic health interest)

29. HIV testing in Thailand

30. SUPPLY CAPACITY FOR SCALING UP THE VOLUNTARY COUNSELING & TESTINGAND ART PROGRAM IN THAILAND Chariyalertsak, S., P. Sanchaisuriya, et al. (2006). IHPP. MOPH • 95 hospitals in 8 province in study • VCT evolve from in STD clinic at PHO, VCT in PMPCT program VCT and ART clinic • High coverage across the country-at least one VCT in each district • Three components: HIV counseling, voluntary testing, confidentiality • Model: one stop service, integrated to general service model and extended clinic

31. SUPPLY CAPACITY FOR SCALING UP THE VOLUNTARY COUNSELING & TESTINGAND ART PROGRAM IN THAILAND Chariyalertsak, S., P. Sanchaisuriya, et al. (2006). IHPP. MOPH Service Utilization fiscal year 2005 • ANC clinic 53860/54351 • Pretest counselling 98.7% • HIV testing 99.1 % • HIV positive rate 1.21% • Return rate for post test counseling 95.8 % Couples service rarely performed ”fear of separation” • OPD 45619/7810397 • Pretest counselling rate 5.73 per 1000 OPD case • HIV testing 5.84 per 1000 OPD case • HIV positive rate 9.29% • Return rate for post test counseling 79.1 % community hospital 97.9 % large hospital 45.8 % In general, hospital do not follow the people who did not return for the test results Waiting time for patient to prepare mind for getting HIV test results

32. SUPPLY CAPACITY FOR SCALING UP THE VOLUNTARY COUNSELING & TESTINGAND ART PROGRAM IN THAILAND Chariyalertsak, S., P. Sanchaisuriya, et al. (2006). IHPP. MOPH • Model for VCT activation-target groups • Sex worker • Migrant worker • Young worker in industrial unit • Adolescent both in and out school • Drug user • Pre-marriage couple

33. Study from IHPP • Thai know ART more than VCT • 64% of Thai population knew about ART • 50% of Thai population knew about VCT, 31% had ever tested

34. Reason for HIV testing compare between study in general population and HIV person on waiting list of ART Chariyalertsak, S., P. Sanchaisuriya, et al. (2006). Demand for enrolment in antiretroviral program among HIV positive individuals who are on waiting list, IHPP, MOPH, Thailand. *In USA 44% were tested for HIV because of illness

35. Premarital testing • Sound logically effective to prevent transmission between regular partner • Criticized as violation of human right • High cost with low yield • May be cost-effective in high risk group: cohabitation, marginalized group • the counseling alone without testing for low and no risk and testing for the higher risk groups may be more cost effective.

36. Premarital testing in Illinois, USA • Start in 1988- 3 years • In 6 months period, 8 of 70846 applicants found positive • 312,000 US dollar per case identified • Decrease of marriage license by 22%, increase in surrounding state.

37. Premarital testing in Mexico • 7 of 32 states made mandatory premarital testing • Study from 1992-1993 in a state • 4 of 9014 (0.04%)applicants found positive, including one false positive.

38. Principles of partner notification (according to WHO) • Voluntary • Confidentiality • Access to appropriate care and support • Protection against physical harm such as violence, abuse and abandonment • Protection against social and economic harms

39. Methods of partner notification • Provider referral • Patient referral • Conditional referral

40. Factors to consider (2) • Time period for eliciting partners • Risk of violence • Number of partners to trace • Staff training (communication skills) • Staff time

41. Does partner notification work? • Cochrane review of 11 RCT studies of PN effectiveness A systematic review of strategies for partner notification for sexually transmitted diseases, including HIV/AIDS.Mathews C, Coetzee N, Zwarenstein M, Lombard C, Guttmacher S, Oxman A, Schmid G. Int J STD AIDS. 2002 May;13(5):285-300.

42. Finding • Provider-led referral (or a choice between provider- and patient-led referral) is more likely to result in partners presenting for medical care when compared to patient-led referral • Conditional referral for patients with GC is more effective compared to patient referral • Quarrels and domestic violence were reported from 3 studies 6% women had not told their partner due to fear of violence 11-19% of men and women had experienced quarrels and fighting in relation to partner notification • Women fear violence, Men fear being brought to court • Negative attitudes among health workers were considered a hindrance for seeking STI care • Men did not bring partners due to lack of money • Difficult to know which partner to bring

43. "Factors associated withnon-disclosure of HIV infection status of new mothers in Bangkok." Skunodom, N., R. W. Linkins, et al. (2006). Southeast Asian J Trop Med Public Health 37(4): 690-703. • 2 ANC clinic of hospitals in Bangkok • N=799 • Complete f/u at 1, 4 month= 647 of 799(81%) • 453/647=70% disclose at 1 mth • 647-453=194 , 48/194=24.7% disclose at 4 mth • 22.6% (146/647) still not disclose by 4 month not include those who lost to f/u n=152

44. Disclosure rate

45. Disclosure

46. Rationale for the study • High prevalence of HIV infection in Thailand • Highly accessible antiretroviral treatment • Estimated transmission between the spouses take around 58.1% of new infection in 2005, this might be prevented if people know their HIV status. • Uncertainty about • Uptake of HIV testing in STI patient • Cost-effectiveness of HIV screening in TB patients • Delay diagnosis of HIV infection by doctor • Feasibility and cost-effectiveness of HIV screening in premarital testing • Promotion of safe sex in PWHA • Role of partner notification

47. Conceptual framework • Enabling factors • Disclosure of HIV status to • sexual partner • Good social support • Regulation by Law? • Enabling factor • Clients ‘ awareness of HIV risk and available service • Free and convenient service • Confidentiality • Available treatment • Explicit guideline for HIV testing Decrease or stop of both unintentional and intentional HIV transmission Awareness of HIV seropositive HIV Testing • Barriers • Fear of stigma • Time constraint of health care provider for • voluntary counseling testing • Awareness of clinician • Reluctance of both provider and client for discussion of HIV risk • Risk labelling when prescribing HIV testing • Language barrier for minority or foreign immigrant worker • Informed consent? • Barriers • Depression • Social stigmatization • Antisocial behavior?

48. Purpose of the study • To find the optimal and appropriate HIV testing policy and intervention in vulnerable group that will benefit both individual and public health goal.

49. Objectives of study • To identify, clarify the practice of the HIV testing in STI patients • To propose the practice of HIV testing in TB patients and its cost-effectiveness. • To study the outcome of treatment of patient in national antiretroviral program. • To study the feasibility of Premarital testing • To identify delay diagnosis of HIV infection and barrier of diagnosis of HIV by doctor. • To identify the practice of promotion of safe sex in PWHA • To identify the practical and effective way of partner notification in HIV patients

50. Research question 1.What is the practice of the HIV testing in STI patients • identifying the current coverage of HIV testing in STI patients with respect to geographic and demographic variations and trends over time; • exploring the practice variations of screening programs implemented at the health facilities • assessing barrier and enabling factors of HIV testing in STI patients