Results Imp.Ac.T. project Presentation at Final Conference 22 Nov. 2012 -Jenneke van Ditzhuijzen Acknowledgments: The Project Imp.Ac.T. – Improving Access

Results Imp.Ac.T. project

Presentation at Final Conference22 Nov. 2012 -Jenneke van Ditzhuijzen

Acknowledgments: The Project “Imp.Ac.T. – Improving Access to HIV/TB testing for marginalized groups” (Ref.: 2009 12 01) has received funding from the European

Commission under the Health Programme 2008-2013. However, the sole responsibility for the study lies with the author and the European Commission is not responsible for any use

that may be made of the information contained therein.

Presentation Outline

1. Methods

2. Results

3. Conclusions

4. Discussion and recommendations

Presentation Outline

1. Methods

2. Results

3. Conclusions

4. Discussion and recommendations

| 1 method | 2 results | 3 conclusions | 4 discussion |

Target group• Clients of participating low threshold organizations• Problematic Drug Users (PDU), also migrant PDU• Later also other drug users and non-drug users • Over 18 years old• Able to understand procedure and provide consent• Not tested for HIV in the last three months • Not HIV positive (but TB screening possible)


Questionnaire

Development • Based on EMCDDA DRID-tool (& more) • Developed with partners & AB• Tested in training session• Pilot

2 Questionnaires• Main Questionnaire• Follow up questionnaire


Questionnaire topics

A. RecruitmentB. Social demographyC. DrugsD. PrisonE. Sexual partnersF. HIV testingG. TB testingH. Remarks participantI. Remarks interviewer


Database• Main Q• Follow up Q• Test results section:

• HIV rapid test result• Confirmatory HIV test result• HIV Avidity test results• Presentation for HIV treatment• TB screening result• Sputum 1 and 2 result• Confirmatory TB test result


Database or online survey tool?

2 types of datacollection• Paper-pencil & data-entry• Online survey tool (Prague only)

Pros & cons online survey tool• Time saving: immediate data entry• Little or no mistakes• Routing logic: user friendly• Usually quite easy to program• Laptop + internet necessary


Response monitoring• Gender• Country of origin• Age• Eligible for project?• Eligible for HIV testing?• Willing?• If not willing: reason


Procedure


Recruitment: 1st contact

Response monitoring, eligibility,

willingness

Pre- test counselling

HIV Test & TB

screening

Informed consent

Main Questionnaire

Test results

Post-test counselling

TB screening +: sputum sample

1

HIV+: confirmatory

testing

Sputum sample 2

Avidity test

Presentation for treatment

Presentation for treatment

HIV/TB negative: follow

up Test + Questionnaire 1

Follow up 2

Follow up 3

Procedure

Focus groups

Why?• Gain insight into shared understanding• Exploring knowledge and attitudes further• More depth to questionnaire data• ‘Compare’ before and after

What is FG?• Group discussion (not group interview)• 1 moderator, 1 observer• 6-10 participants


Focus groups: howDevelopment• Topics developed by partners• Training by Gruppo Abele

Data collection• Audio recorded• Reporting format: Summary and exact quotes

‘Rules’ for moderators• Topics introduced with open questions• Guide discussion (without adding to it)• No mention of project• Education after FG


Topics FG

4 focus groups per city• T1: 2 before implementation (1 HIV, 1 TB)• T2: 2 after implementation (1 Imp.Ac.T. Participants,

1 others)Topics

• Knowledge on TB/HIV• Access to facilities• After implementation: perceived behaviour change• After implementation: evaluation by participants


Presentation Outline1. Method

2. Results

3. Conclusions

4. discussion and recommendations


Response

4855 persons approached, 2352 interviewed (48%)• Rome 53%• Turin 75%• Prague 45%• Bratislava 27%

Main reasons for non-response• No time/ in a hurry• No interest• HIV tested before• (Fear of results)


Sample sizeNumber of participants (PDU, ever IDU, recent IDU, non-PDU) interviewed and re-interviewed (follow up) Rome Turin Prague Bratislava Total Problem Drug Users (PDU; target group) 571 570 869 181 2191 Ever IDU (lifetime) 466 460 844 173 1943 Recent IDU (12 months) 422 417 801 169 1809 Active IDU (4 weeks) 393 325 713 159 1590 Not target group (non-PDU’s) 57 0 0 100 157 Main Questionnaire: total interviewed & tested 628 570 869 281 2352 Follow up questionnaire (retested participants) Follow up 1 25 32 124 40 221 Follow up 2 2 0 9 10 21 Follow up 3 0 0 0 1 1

0

100

200

300

400

500

600

700

800

900

n

Rome Turin Prague Bratislava

city

number of PDU's; ever, recent and active IDU's

Problem Drug Users(PDU; target group)

Ever IDU(lifetime)

Recent IDU (12months)

Active IDU (4weeks)


Sociodemographics (PDU)• Mostly male (73%), 25-34 years old (41%), often homeless (43%),

secondary school education level (50%), unemployed (67%) or undeclared work/sex worker (17%).

• Small percentages of migrants in Bratislava (3%) and Prague (6%), higher in Rome (16%) and Turin (25%).

• Non-pdu’s are slightly more often homeless or sex worker.


HIV test results Rome

(n=571) Turin

(n=570) Prague (n=869)

Bratislava (n=181)

TOTAL (n=2191)

HIV Rapid test successful 563 545 849 179 2292 HIV rapid test reactive 9 9 1 1 20 Not tested because already HIV positive1 2 21 1 1 25 Confirmatory HIV diagnosis Positive 4 1 0 0 5 Negative 0 0 1 0 1 Avidity testing done 4 0 0 0 4 Started treatment 3 Not yet - Not yet Newly diagnosed HIV infections 2 among Active IDU (in last 4 wks) 5 / 393 9 / 325 0 / 713 1 / 159 15 / 1590 among Recent IDU’s (12 months) 6 / 422 9 / 417 0 / 801 1 / 169 16 / 1809 Among PDU’s (target group) 9 / 571 9 / 570 0 / 869 1 / 181 19 / 2191 1 Not every participant in project was tested for HIV. Some participants were HIV positive but were eligible for TB-testing, and were included in the project

for that reason. 2 Based on rapid test results and confirmatory results, if available.


TB test results Rome

(n=571) Turin

(n=570) Prague (n=869)

Bratislava (n=181)

TOTAL (n=2191)

TB

TB screening positive 30 8 46 22 106

TB screening negative 536 543 809 157 2045

Sputum 1 collected 23 10 0 22 55

Sputum 2 collected 1 0 5 6

Result sputum 1 pos 0 0 0 0

Result sputum 2 pos 0 0 0

Result sputum 1 neg 23 8 22 53

Result sputum 2 neg 1 0 5 6

Confirmatory TB diagnosis

Positive 0 0 0 0 0

Negative 0 2 9 0 11

Not reached/ donÕt know 0 3 34 0 37


Descriptives HIV+ people (n=19)Risk factors HIV+

(n=19) Injecting drug use Active IDU 15 Recent IDU (last 12 months) 16 Ever IDU 18 Drugs used in last 4 weeks Heroin 12 Cocaine (also injecting) 11 Cannabis 7 Needle sharing Ever 5 Last 4 weeks 1 Sex risk behaviours Sexually active 16 Stable partners 11 No condom use with stable partner 8 Casual partners 8 No condom use with casual partner 2 Sex workers (mostly using condoms) 3

Demographics HIV+ (n=19)

Gender Male 12 Female 5 Transsexual 2 Mean age in years 36.6 Living situation Homeless 9 Migrant 4 Work situation Unemployed 14 Undeclared work 3 Employed 2 HIV tested before 16


Follow up of HIV+ cases


• 5 cases were followed up in Rome• 4 avidity tests:

• 1 infection longer than 6 months ago• 3 infections less than 6 months ago

• 3 started going to clinic• 1 started medical treatment• Follow up not finished

• Bratislava: 1 case lost • Turin: unknown

Behavioural data: Drug use last 4 wks


0 20 40 60 80 100

heroin alone

cocaine alone

heroin + cocain

heroin + met (pervitin)

refined coke

fentanyl

methadone

buprenorphine

other opiates

amphetamines (speed)

metamphetamines (pervitin)

benzodiazepines

ecstacy

ketamine

GHB/GBL

other pills

cannabis

alcohol

otherTy

pe

of

dru

gs

Percentage %

Bratislava (n=181)Prague (n=869)Turin (n=570)Rome (n=571)

Risk behaviour• Needle sharing

• ever: 60% (from 38% in Rome to 77% in Bratislava)

• last 4 weeks: 13% (from 10% in Rome to 28% in Bratislava)

• At follow up 15% was still sharing needles!

• Prison

• 52% has ever been in prison

• 25 % has injected drugs in prison

• Condom use

• sex workers and their clients ‘about half the time’ to ‘mostly’ (m=3.6)

• casual partners ‘occasionally’ to ‘about half the time’ (m=2.7)

• STD infection last 12 months: 6%


Behavioural data: HIV testing behaviour• 79% had HIV test before (Bratislava lowest 55%)

• Reasons NOT to get tested (barriers)• I don’t think I’m infected (284)

• Other priorities; e.g., scoring drugs (78)

• I’m afraid to do the test (51)

• Institutional barriers NOT IMPORTANT, only in Turin (a bit, mainly migrants)

• Intention to continue retesting regularly: 72% ‘yes/ quite likely’

• HIV risk behaviour change: 60% ‘not at all’


Behavioural data: TB testing behaviour• 49% vaccinated for TB, another 26% possibly

vaccinated

• TB tested before: 53%

• Reasons NOT to get tested (barriers)• I don’t think I’m infected (766)

• Other priorities; e.g., scoring drugs (188)

• Again, institutional barriers NOT IMPORTAN

• Intention to continue retesting regularly: 22% ‘yes/ quite likely’

• TB knowledge change: 78% ‘not at all’


Focus groups• Poor knowledge on TB “disease from the past”

• Rich knowledge on HIV “we know more than non-users”

• Barriers: not institutional, but in themselves: “I will go tomorrow”

• No behaviour change between T1 and T2

• Positive evaluation of project (incentives!)

• Should be continued

• Add HCV test (instead of TB?)


Summary test results• HIV

• 19 new infections found in 2191 PDU’s

• 16 new infections found in 1809 recent IDU’s --> less than 1% incidence

• No TB infection - why not?

• only active TB after screening; low accuracy of sputum test (1 sample only)???

• TB prevalence seems low???

• relatively small migrant population???


So.... What about the project aims?General aim: To broaden the access to HIV and TB testing, prevention, treatment and care

for vulnerable groups ((P)DU’s, migrant DU’s).

Specific objectives:1. Development of framework (guidelines/tools) 2. Increase access to HIV and TB testing for PDU’s and migrant DU’s3. To ensure treatment for HIV/ TB for PDU’s and migrant DU’s4. To promote healthier ways of life and risk reduction among PDU’s and

migrants5. To assess the effectiveness of HIV/ TB ‘street testing’ in terms of

proportion of new infections identified

We reached objectives 1, 2 and 53 and 4 partly: Ensuring treatment is a challenge

Changing health behaviour is a slow process


Lessons and recommendationsValue of Imp.Ac.T. Project

• example of ‘street’ intervention/data collection combi

• social workers as interviewers

• interviewing improved relationship with clients

Improvements

• conflicting role interviewer - social worker

• response monitoring: a lot of work!

• TB very hard to diagnose, no rapid test for active TB

• baseline data and good preparation essential (involve experts!)

• computer-assisted survey tool recommended


Documents

Results Imp.Ac.T. project Presentation at Final Conference 22 Nov. 2012 -Jenneke van Ditzhuijzen Acknowledgments: The Project Imp.Ac.T. – Improving Access