Geibel, Scott

Population Council: Knowledge Commons

Population Council Knowledge Commons HIV and AIDS Social and Behavioral Science Research (SBSR) 1-15-2020 Reaching 90-90-90: Evidence from Project SOAR to strengthen the HIV response Scott Geibel Population Council Follow this and additional works at: https://knowledgecommons.popcouncil.org/departments_sbsr-hiv Recommended Citation Geibel, Scott. 2020. "Reaching 90-90-90: Evidence from Project SOAR to strengthen the HIV response," presentation at Project SOAR dissemination meeting, 15 January. This Presentation is brought to you for free and open access by the Population Council. Reaching 90-90-90:Evidence from Project SOAR to Strengthen the HIV Response1Today’s presentation • Overview of Project SOAR• Key Findings  Testing and treatment Social barriers• Research Utilization and Capacity Strengthening2What is Project SOAR? • “Supporting Operational AIDS Research” (SOAR) conducts HIV implementation science to inform programs and policy• 6 years (2014–2020), USAID funded• US$50+ million3MSM in sub-Saharan AfricacMPTs:       HIV & FPStigma Tools for hard to measure topicsSocial & gender  normsQuality of Care FrameworkEmpowermentfor AGYWMale circumcision  & HIV riskResearch use/ImpactData depository:  Girl Center Where SOAR works70 activities in 21 countries5Research utilization: core strategyKey to ensuring impact on programs/policy• Involvement of stakeholders at all stages of research process• Ensuring local ownership of findings• Creating champions to foster use of datahttp://www.projsoar.org/resources/resource-type/guide-and-tools/ 6Responding to major shifts in HIV global priorities• Scale up of AGYW programming (DREAMS)• Adoption of “test and start” guidelines• Pre-exposure prophylaxis• Undetectable=Untransmissible (U=U)• Key populations and stigma (KPIF, Stigma Index)7Project SOAR: contributes to global goals for controlling the epidemic(ART)ZERODiscriminationAdapted from UNAIDS 2017GenderEQUITY8Awareness of HIV status9Key takeaways• HIV self-testing (HIVST) effective in reaching undiagnosed key populations (KPs)• HIV screening tools for children/orphans and vulnerable children (OVC) achieved higher sensitivities, yet false negative rates remain unacceptably high• Re-testing HIV-negative pregnant and post-partum women is essential for pediatric case finding• A participatory, systems approach can increase the offer and uptake of facility-based HIV testing10HIV self-testing in Senegal• High use and acceptability of HIVST 94% used the HIVST, most within 2 days (89%) • Reached key populations (KPs) who had never taken an HIV test or those who had not tested in the last year• Confirmatory testing of positives was low(3%), and remains a challengeTested within the last 12 months34%First-time tester39%Tested, but not in the last 12 months28%MOH integrated HIVST in its test and treat guidelines.Project SOAR. 2019. “Can HIV self-testing help reach those at risk for HIV and not accessing traditional testing services in Senegal?,” Project SOAR Results Brief. Washington, DC: Population Council.11HIV screening tool for orphans and vulnerable children in Tanzania• High acceptability of home-based screening and testing of OVC• Overall low HIV-positive yield (n=76; 0.4%) at household and facilities• Screening tools remain imperfect High sensitivity (up to 70%) compared to Bandason tool, yet false negative screenings are 30–40% of true positives• Further studies needed to weigh financial costs of screening/ testing against human costs of missed or delayed diagnosis Project SOAR. 2019. “Evaluating an HIV risk screening tool among orphans and other vulnerable children in Tanzania,” Project SOAR Activity Brief. Washington, DC: Population Council. 1265%Of 95 mothers who had an HIV test at ANC, 65% tested negative42%Of 41 mothers who knew they were HIV positive, 42% did not receive ART during pregnancy27%Of 56 mothers who knew they were HIV positive but did not receive ART during breastfeedingLocal DHMTs/MOHs re-educating healthcare workers (HWs) on ART guidelines and re-testing HIV-negative pregnant and postpartum women. Pediatric case finding in Uganda and Kenya• Failure to (a) link HIV-positive women to antiretroviral therapy (ART) and (b) re-test HIV-negative women is responsible for missed pediatric HIV cases• Assessed 174 HIV-positive children (2–14) that were missedGill, Michelle M., Rose Masaba, and Eliab K. Natumanya. 2019. “Pediatric HIV active case finding in Kenya and Uganda: strategies and linkage to treatment," Project SOAR Final Report. Washington, DC: USAID | Project SOAR.13Utilizing a systems approach to increase facility-based HIV testing in South Africa• Formative research identified gaps and bottlenecks in HIV testing services (HTS) uptake• Changes implemented after discussion of findings with clinic staff:   Promotion of HTS in the waiting areas,  Offering HTS during registration or when taking vital signs Increasing efficiencies in counselor staffing management and working hours• Result: increased proportion of patients offered HTS (9% to 31%; p<0.001), among which uptake increased (8% to 21%; p<0.001)Mabuto, Tonderai, Bhakti Hansoti, Salome Charalambous, and Christopher Hoffmann. 2018. “Understanding the dynamics of HIV testing services in South African primary care facilities,” Project SOAR Results Brief. Washington, DC: Population Council.14Linking people to HIV treatment and retaining them in care15Key takeaways• “Test and start” is working• Integration of depression management in HIV care is feasible and acceptable• A family-centered care model encouraged HIV disclosure and treatment support, reduced stigma within the family• Receiving HIV treatment services at an accessible location in the community improved treatment initiation and retention for female sex workers (FSWs)• Monthly support groups and delivery of ARVs by community health agents improved treatment retention among adults living with HIV16Test and start in Namibia• Namibia transitioned in April 2017 • Time to initiation greatly decreased  43 days  3 days• Viral suppression improved:   Recent ART initiates: 89%  97%>90% treatment initiation within 7 days after test and start0%20%40%60%80%100%Q12015Q22015Q32015Q42015Q12016Q22016Q32016Q42016Q12017Q22017Q32017Q42017% initiated in 1 to 7 days of diagnosis% initiated on date of diagnosis2015                          2016                          2017    Project SOAR. 2019. “Viral load testing: room for improvement in Namibia’s antiretroviral treatment services,” Project SOAR Results Brief. Washington, DC: Population Council. 17Integration of depression screening and management into HIV care in Malawi• 86% of patients with mild depression initiated psychosocial counselling• 96% of patients with moderate–severe depression-initiated antidepressants• Feasible and acceptable But no impact on HIV outcomesProject SOAR. 2019. “Can depression treatment feasibly be integrated into high-volume, routine HIV care in Malawi?,” Project SOAR Results Brief. Washington, DC: Population Council.18Family-centered care model in Eswatini• Encouraged family members to disclose HIV status and support each other• Reduced HIV-related stigma within the family• Caregivers viewed the counseling as better than in standard of care• Allowed HWs to track family histories and identify family solutions to HIV care challenges78%90%Baseline 12 months19Project SOAR. 2018. “Effect of a family-centered model of HIV care on viral suppression and care retention among HIV-positive children in Swaziland,” Project SOAR Results Brief. Washington, DC: Population Council.• However, no difference in HIV outcomes between groups• Overall improvement in viral suppressionCommunity ART services for female sex workers in Tanzania72%87%100% 99%Midline Endline95%77%100% 99%Midline EndlineART initiation ART retentionComparisonInterventionGovernment used findings to inform national ART guidelines. Project SOAR. 2019. “Community-based delivery of antiretroviral treatment for female sex workers in Tanzania: high levels of initiation, use, and adherence,” Project SOAR Results Brief. Washington, DC: Population Council.20Community support intervention for adults living with HIV in Tanzania2185%77%70%62%6-month retention 12-month retentionIntervention(n=952)Control(n=1,018)Project SOAR. 2019. “The role of community-based HIV service providers in improving clients’ health and HIV outcomes in Tanzania: midline results,” Project SOAR Results Brief. Washington, DC: Population Council.Viral suppression22Key takeaways• Community treatment models strengthened ART program follow-up and improved ART retention, yet did not increase viral suppression substantially over 90%• Suboptimal pediatric ART regimens are still being used, resulting in lower viral suppression• Exposure to violence or psychological abuse is associated with viral load (VL) failure among young people• Viral load testing and documentation remains suboptimal; poor viral load literacy an important factor that needs to be addressed23Community-level interventions in Tanzania and Lesotho92% 90% 90%90% 90% 90%Tanzania(Adults)Tanzania(FSWs)Lesotho(Women PMTCT)Viral suppression at 12 months among retained patientsIntervention Control• Interventions in Tanzania and Lesotho effective at strengthening follow-up and retention of ART patients• Among retained people living with HIV (PLHIV), however, still need to find ways to improve viral suppression to >90%24Pediatric ART regimens in Eswatini• 43% of Eswatini children living with HIV on suboptimal ART regimen (NVP-based)• Those on suboptimal ART less likely to be virally suppressed than those on EFV-based regimen (72% vs 87%)MOH rolled out a plan to replace sub-optimal pediatric ART regimens.Project SOAR. 2018. “Effect of a family-centered model of HIV care on viral suppression and care retention among HIV-positive children in Swaziland,” Project SOAR Results Brief. Washington, DC: Population Council.25Violence and ART among youth in Zambia• Over 70% of young people transitioning to adult HIV services reported previous exposure to violence• Youth exposed to higher volumes of violence were ~3.5 times more likely to experience VL failure• Exposure to psychological abuse also associated with VL failure70%+Project SOAR. 2019. “Youth living with HIV in Zambia: interpersonal violence, self-stigma, and viral suppression,” Project SOAR Results Brief. Washington, DC: Population Council. 26Viral load testing and literacy in Namibia• VL testing has improved after test and start, but remains sub-optimal • Client education and engagement are needed to improve VL testing Clients lack knowledge Providers assumed that clients were more VL literate Breakdowns in transcribing VL results to client records56%92%66%96%Client records with VL results Viral suppressionBefore test and start After test and start27Social barriers: gender and stigma28Key takeaways• Community-based programs in high-prevalence settings can reduce harmful gender norms and violence• DREAMS programming reduces HIV vulnerability among adolescent girls and young women (AGYW)• Male partners who experience childhood trauma are more likely to perpetrate violence, have multiple partners • PLHIV Stigma Index has been updated to more effectively document stigma, led and owned by PLHIV • Key populations living with HIV experience multiple, intersecting stigmas29Gender-focused community intervention: South Africa• Stepping Stones implemented in informal settlements• Fewer women experienced and men perpetrated violence • Stronger support for equitable gender norms for both men and womenProject SOAR. 2018. “Men’s and women’s endorsement of common gender norms salient for HIV service uptake,” Project SOAR Results Brief. Washington, DC: Population Council. 30DREAMS in Malawi 82%92%16% 17%5%12%Sexual PhysicalExperience of violence from partnersChange over time in HIV-related factors among 20- to 24-year-old young women, bivariate regressionsSelf-reported HIV testing in last 12 months***Round 1 Round 2*** ******p≤0.001Project SOAR. 2018. “What are the HIV risk characteristics of out-of-school adolescent girls and young women in Malawi?: Findings from DREAMS implementation science research,” Project SOAR Results Brief. Washington, DC: Population Council.31Male partners of AGYW in Malawi40%28%4%15%8%24%8%1%Beaten at homeSaw/heard motherbeing beatenForced sexExperience of childhood traumaSometimes Often Very OftenExperience of childhood trauma increased odds of:• Perpetrating violence (OR=2.52, p<0.001)• Having 2+ sexual partners (OR=1.56, p<0.01)Project SOAR. 2018. “Engaging male partners of adolescent girls and young women in HIV services in Malawi: findings from DREAMS implementation science research,” Project SOAR Results Brief. Washington, DC: Population Council.32Consultative process to update the PLHIV Stigma IndexWorking group synthesizes recommendations from desk review, conversations, consultation and drafts updated questionnaireUpdated Stigma Index formally pilot testedUpdated questionnaire pre-tested @AIDS 2016Feedback incorporatedResults shared/final recommendations madeDesk review of Stigma Index country reportsKey informant conversationsIn-person stakeholder consultation (April 2016)Project SOAR. 2018. “The People Living with HIV Stigma Index 2.0: results from pilot testing in three countries,” Project SOAR Results Brief. Washington, DC: Population Council.33HIV-related stigma and testing and treatment delays: Cameroon, Senegal, Uganda23%32%41%28% 25%21%Hesitated to test due to fears of how people would react Delayed entering careCameroon(n=400)Senegal(n=406)Uganda(n=401)Project SOAR. 2018. “The People Living with HIV Stigma Index 2.0: results from pilot testing in three countries,” Project SOAR Results Brief. Washington, DC: Population Council. 34Multiple stigmas among HIV-positive sex workers in the Dominican Republic32%17% 15%25%34%11% 12%27%Family members madediscriminatory remarksPhysically abused Blackmailed Verbally harrassedDue to your selling sex Due to your HIV status35Red Dominicana de Personas que Viven con VIH/SIDA, Alianza Solidaria para la Lucha Contra el VIH y SIDA, and Population Council. 2019. People Living with HIV Stigma Index 2.0 Dominican Republic Country Assessment. Washington, DC: USAID | Project SOAR.Prevention36Modeling and costing• User-friendly tools making data accessible to inform programs and resource allocation DMMPT• Voluntary medical male circumcision (VMMC) costing and modeling• Pre-exposure prophylaxis (PrEP) modeling37Research utilization and capacity strengthening38Research utilization creates a team of researchers, program managers, and policy makersRESEARCHPOLICYPROGRAMSRU Highlights contextEngages stakeholdersSupports use of findingsBuilds ownership39Best practice: institutionalizing research utilization• Engaging stakeholders throughout studies and activities Research advisory committees Data use plans• Technical convenings Utilizing diverse sources of data (rigorous studies, HIS, routine, etc.) Youth and treatment Gender-based violence and treatment• Promoting research utilization experience with global audiences IAS 2019 and ICASA 2019 satellite sessions AIDS & Behavior manuscript40111oral/poster presentations given by SOAR PIs at international, regional, and national conferences45 program practices, guidelines, and tools have been influenced by exposure to SOAR research160researchers and/or institutions have used SOAR’s research findings41Capacity strengthening highlights• SOAR investigator workshops Conducting research and using findings• Interpreting and using key populations data 6 country Global Fund technical assistance• DREAMS partners: utilizing tools for targeting AGYW 5 country workshops42498in-country researchers have participated in a SOAR capacity strengthening activity113local institutions have received targeted SOAR activities designed to strengthen their research capacity135in-country researchers and other stakeholders serving as co-investigators on SOAR studies43More resources available at projsoar.org44Project SOAR (Cooperative Agreement AID-OAA-A-14-00060) is made possible by the generous support of the American people through the President’s Emergency Plan for AIDS Relief (PEFPAR) and United States Agency for International Development (USAID). The contents of this presentation are the sole responsibility of Project SOAR and Population Council and do not necessarily reflect the views of PEPFAR, USAID, or the United States Government.Through operations research, Project SOAR will determine how best to address challenges and gaps that remain in the delivery of HIV and AIDS care and support, treatment, and prevention services. Project SOAR is producing a large, multifaceted body of high-quality evidence to guide the planning and implementation of HIV and AIDS programs and policies. Led by the Population Council, Project SOAR is implemented in collaboration with Avenir Health, Elizabeth Glaser Pediatric AIDS Foundation, Johns Hopkins University, Palladium, and The University of North Carolina.Thank YouNEWSRESOURCESRESEARCHEVENTSVisit projsoar.org!45

Reaching 90-90-90: Evidence from Project SOAR to strengthen the HIV response

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Reaching 90-90-90: Evidence from Project SOAR to strengthen the HIV response

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