Integrated Community HIV Testing Campaigns:

Leveraging HIV infrastructure for non- communicable diseases

July 23, 2012Gabriel Chamie, Dalsone Kwarisiima, Tamara D. Clark, Jane Kabami, Vivek Jain, Elvin Geng, Maya L. Petersen, Harsha Thirumurthy, Moses R. Kamya, Diane V. Havlir, Edwin D. Charlebois, and the SEARCH Collaboration

• HIV “test and treat” is under intense scrutiny as a global strategy

• Large unmet need in addressing non-communicable diseases (NCDs)

• Key first step in addressing both HIV and NCDs is diagnosis – many shared obstacles

• Implementation science questions– How do we test large numbers of people in a

sustainable way? – How do we leverage HIV investment to address NCDs?

Background

• Sustainable East African Research on Community Health

• A broader approach to test and treat– Health (HIV, NCDs, and other diseases)– Education– Economics

SEARCH Community Health Campaign

• Community health campaign objectives– Rapid implementation of multi-disease diagnosis and

linkage to care across a community– Reach community members not previously tested– Achieve high-throughput testing (1,000/day)– Integration of NCDs and other communicable

diseases– Rapid assessment of community socio-economics

Objectives

Campaign ProceduresDemographic/SES Household SurveyTesting HIV (Ab, CD4, VL) Malaria RDT DM HTNTB Screening in HIV+ GeneXpertPrevention TMP/SMX Condoms Vitamin A Counseling ITNs

Treatment Coartem Albendazole

Linkage to Care HIV, TB, DM, HTN Immediate ART: CD4<100

5 day campaign(May 16-21, 2011)

• Local Council (LC) leaders from all villages designed and executed community mobilization during the month prior to campaign– Church (Easter) & Mosque

announcements– Posters & pamphlets

distributed widely– Radio announcements

Community Mobilization

Rwanyamahembe Subcounty HeadquartersMay 16, 17, 2011

Karuyenje Primary SchoolMay 19, 20, 2011

H

Bwizibwera Health

Centre IV

Nyakayojo Primary SchoolMay 21, 2011

3 km

CHC Sites: Kakyerere, Uganda

Site 3

Site 2

Site 1

Campaign Field Laboratory• 18 Lab technicians• Rapid HIV Ab testing/confirmation• Point-of-care CD4+ T cell count• Finger-prick HIV viral load• Malaria rapid diagnostic test• Blood glucose• Blood pressure

CHC Uganda Census CHC Coverage

Adults 2,323 3,150 74%

Women 1,523 1,600 95%

Men 800 1,550 52%

Children 2,020 3,150 64%

Girls* 1,066 1,600 67%

Boys* 954 1,550 62%

Total 4,343 6,300§ 69%

Female 2,589 3,200§ 81%

Male 1,754 3,100§ 57%

§ 2011 Ugandan Bureau of Statistics Population Projection, Kakyerere Parish* <18 years old

Study Population

• Overall – Median of 95 minutes (IQR: 71-129)– HIV-negative• Median: 1 hour, 33 minutes (93 min, IQR: 70-125)

– HIV-positive• Median: 2 hours, 51 minutes (171 min, IQR: 136-216)

Patient Transit Time Through Campaign

Adults: Age ≥ 15: 6.9% Ages 15-49: 8.0% Children: Age < 15: 0.5%

HIV Prevalence

women: 8.2%

men: 4.5%

women: 9.4%

men: 5.3%

Campaign adult population (n=2,323):• Never HIV tested = 802 (35%)

HIV-infected adults (n=179):• New diagnoses = 82 (46%)• Known positive = 97 (54%)

Prior HIV Testing & New Diagnoses

CD4+ T cell Counts in Adults

Median CD4 = 415 (IQR: 281-568), n=167

• Substantial population was diagnosed with CD4 above Uganda ART initiation threshold (>350 cells/μL)

0-200 201-350 >3500%

10%

20%

30%

40%

50%

60%

70%

CD4+ Count

• CD4 <200: 12%• CD4 >350: 64%

0-200 201-350 >3500%

10%

20%

30%

40%

50%

60%

70%

CD4+ Count

CD4+ T Cell Counts in New Diagnoses

Median CD4 = 449 (IQR: 281-592), n=77

Hypertension• Prevalence (adults)

– BP > 140/90: 23%– BP > 150/100: 12%

• New vs. prior diagnoses– 69% of BP>150/100 group unaware of their diagnosis– 61% with known HTN were not on anti-hypertensive treatment

0-14 15-24 25-34 35-44 45-54 55-64 65-74 >750

5

10

15

20

25

30

35

40

45Prevalence of Hypertension by Age

Age (years)

Prev

alen

ce H

TN

• Prevalence:– Random BG > 200, or reported prior dx of DM– 80 adults: 3.5%

• New diagnoses:– 18 adults: 23%

• On treatment:– 38/62 (61%)

Diabetes

Linkage to care at 3 months• HIV: 82/139 (59%)– Active Referral: 58% linked to care– Enhanced Referral: 75% linked & started ART

Linkage to Care

• High burden of undiagnosed HIV and non-communicable diseases in rural east Africa

• Shared obstacles, but also shared solutions• HIV testing and referral can be leveraged in

rural Africa to find and engage patients with undiagnosed NCDs

• Community Health Campaigns can drive universal HIV testing & offers opportunity and an immediate way forward for addressing NCDs in resource-limited settings

Summary

• Campaign Participants• Kakyerere Parish LC Leaders• SEARCH Community Campaign Staff• Uganda Ministry of Health• NIH/NIAID

Thank you – SEARCH Team• SEARCH Advisory Board• MU-UCSF Research Collaboration• Mbarara-Mulago Joint AIDS Program • Mbarara University of Science &

Technology• PEPFAR WHO World Bank