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S ETTING THE STAGE FOR COMBINATION HIV PREVENTION : DEVELOPING A STRATEGIC ASSESSMENT TO INFORM A CLUSTER - RANDOMIZED TRIAL IN I RINGA , TANZANIA Caitlin E. Kennedy 1 , Deanna D. Kerrigan 1 , Heena Brahmbhatt 1 , Samuel Likindikoki 2 , Jacob Ntogwisangu 2 , Sarah Beckham 1 , Justin Beckham 1 , David Celentano 1 , Jessie Mbwambo 2 1 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 2 Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania Introduction Local communities were grouped into clusters based on health care center catchment zones, population size, ANC HIV prevalence data, and geographical separation (Figure 3). HIV testing, treatment, male circumcision, and unconditional cash transfer interventions for young women will be enhanced and scaled-up for the trial, with integrated social and behavior change communication and outreach to MARPs (Figure 4). Caitlin Kennedy, PhD, MPH, Assistant Professor Johns Hopkins Bloomberg School of Public Health [email protected] Contact We began by working with stakeholders, including donors, local and national governments, implementing partner organizations, and academic research partners. We reviewed existing studies and gathered unpublished program reports from local implementing partners. Demographic and Health Survey (DHS) data were used to compare HIV-related trends in Iringa with other regions. Over 100 qualitative interviews were conducted with multiple groups, including: Local key informants (politicians, religious leaders, traditional leaders, clinicians, and program managers) Clients of HIV-related services (HIV testing, antiretroviral therapy, PMTCT, medical male circumcision, and gender-based violence services) Populations at heightened HIV risk (truck drivers, sex workers, plantation/migrant workers, and drug users). Visits to communities and services throughout the region were conducted with GPS mapping to collect data for selection of communities for cluster randomization. Methods Meaningful involvement from a wide variety of stakeholders, collection and analysis of existing data, and extensive qualitative research informed the development of a tailored combination HIV prevention research study and intervention package for Iringa, Tanzania. Initial development of combination prevention programs should be complemented by ongoing monitoring and evaluation, epidemiologic surveillance, and consideration of changing social norms and policies. Conclusions Combination HIV prevention, in which a mix of evidence- based biomedical, behavioral, and structural interventions are implemented synergistically, is the most promising strategy for reversing the global HIV epidemic. Several large-scale evaluations of combination prevention are currently under way or in development. Combination prevention programs must be tailored to specific epidemiologic, social, and programmatic settings. In preparation for a community-randomized trial of combination HIV prevention in Iringa, Tanzania, supported by PEPFAR and funded by USAID, we conducted a strategic assessment to inform development of a context-specific combination HIV package. Results The study was implemented by USAID | Project SEARCH, Task Order No.2, which is funded by the U.S. Agency for International Development under Contract No. GHH-I-00-07-00032-00, beginning September 30, 2008, and supported by the President’s Emergency Plan for AIDS Relief. The Research to Prevention (R2P) Project is led by the Johns Hopkins Center for Global Health and managed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP). Figure 4. Intervention conceptual framework www.jhsph.edu/R2P Men Women HIV Testing and Counseling (HTC) Including outreach to MARPS Social and Behavioral Change Communication Medical Male Circumcision (MMC) Including outreach to older men Cash Transfer (CT) Including vulnerable women HIV Care and Treatment & ART Using point of care CD4 technology Reduced biological susceptibility Reduced behavioral risk Reduced HIV acquisition and transmission Co-located services Referrals Causal pathway Figure 1. Photo of Iringa Town Interviews and analysis of existing data suggested that sex work, migration and mobility associated with the TanZam highway are unique drivers of HIV in Iringa, supporting an intervention focus on most-at-risk populations (MARPs). DHS analyses showed that in multivariate models, HIV status was correlated with younger age, cross-generational sex, and greater than 5 sexual partners to a greater extent in Iringa than nationally (Figure 2). Transactional and cross- generational sex were common interview themes, supporting an intervention focus on vulnerability of young women. Male circumcision rates are lower in Iringa than nationally (30% vs. 67%), supporting this as a key intervention. Results 1. Isimani 2. Image 3. Mtandika 4. Nduli 5. Uhambigeto 6. Ilula 7. Irole 8. Kalenga 9. Kihesa 10. Mkwawa 11. Kitwiru 12. Ukwega 13. Magulilwa 14. Mseke 15. Dabaga 16. Ukumbi 17. Bomalang'ombe 18. Rungemba 19. Mafinga 20. Igombavanu 21. Luhunga 22. Mninga 23. Nyololo 24. Makambako 1 4 3 2 5 6 7 8 9 10 11 12 13 14 16 15 17 18 20 19 23 22 21 24 Figure 3. Communities selected for intervention and control clusters THPE290 OR (95% CI) Tanzania N=15,044 Iringa N=445 Age gap with sexual partner 0 (ref) 1.00 1.00 1 to 10 years 2.20 (1.7-2.8) 2.50 (0.81-7.5) 10 years plus 1.90 (1.1-3.0) 4.60 (1.2-17.6) Number of sexual partners 1 (ref) 1.00 1.00 2 to 5 2.50 (1.5-4.0) 2.70 (0.3-25.0) 5+ 5.30 (3.1-9.1) 8.20 (1.1-62.0) Figure 2. Select DHS multi-variate analyses
