A Hora Agora The time is now Comprehensive

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A Hora É Agora ("The time is now"): Comprehensive Approach to HIV Testing and

A Hora É Agora ("The time is now"): Comprehensive Approach to HIV Testing and Linkage to Care for MSM in Brazil Raquel B. De Boni, MD, Ph. D National Institute of Infectology/FIOCRUZ On behalf of the A Hora é Agora Team 9 th IAS Conference on HIV Science (IAS 2017)

HIV in Brazil Proportion of AIDS cases in males 15 -24 by type of

HIV in Brazil Proportion of AIDS cases in males 15 -24 by type of exposure, Brazil, 2002 -14 80. 0 70. 0 Proporção 60. 0 50. 0 40. 0 30. 0 20. 0 10. 0 2002 2003 2004 2005 2006 2007 HSH 2008 Ano 2009 2010 2011 2012 2013 2014 Heterossexual Brazilian Mo. H ( 2016), Relatorio de Monitoramento Clinico do HIV ; UNAIDS(2016), Prevention GAP report; Kerr et al. (2013) AIDS

HIV in Curitiba SMS Curitiba (2014). , Boletim Epidemiologico. Kerr et al. , (2013),

HIV in Curitiba SMS Curitiba (2014). , Boletim Epidemiologico. Kerr et al. , (2013), AIDS

“A hora é agora” – The time is now • Community-wide intervention designed to

“A hora é agora” – The time is now • Community-wide intervention designed to increase HIV testing and linkage to care – for MSM from Curitiba with HIV status unknown/negative • Implementation science approach evaluating 3 HIV testing strategies (HTS) – Web-based HIV self-testing (“E-testing”) – Mobile testing (2 vans and 1 community LGBT NGO) – Governmental public health facility (COA) • SMS Curitiba, Department of IST/AIDS Brazilian Mo. H, FIOCRUZ, CDC Brazil and NGO Grupo Dignidade

E-Testing • Available at https: //www. ahoraeagora. org/ (PC /apps) • General information: HIV

E-Testing • Available at https: //www. ahoraeagora. org/ (PC /apps) • General information: HIV prevention, self-assessment of HIV risk, map of testing facilities • HIVST kits • Step-by-step video/ written test instructions • 24/7 hotline is available • Optional return of results at the website/regular mail • Users with reactive results instructed to seek confirmatory testing at COA – Oral fluid (Ora. Quick®) – Delivered by regular mail/ retrieved in public pharmacy – Anonymous and free-of-cost

E-testing results From February 6, 2015 to February 28, 2017: 101, 104 7, 480

E-testing results From February 6, 2015 to February 28, 2017: 101, 104 7, 480 4, 793 874 • Hits on the website • 23, 878 unique visitors (Google Analytics) • HIVST requests initiated • HIVST delivered (7, 006 tests) • Results reported to the project (18. 2%; n=874/4793) Non-reactive Reactive Indeterminate 824 (94. 3%) 36 (4. 1%) 14 (1. 6%) *% calculated assuming there are no duplicate results 64 individuals looked for confirmatory test at COA 55 positive

Mobile testing • Two mobile units, one partner NGO – Free rapid testing in

Mobile testing • Two mobile units, one partner NGO – Free rapid testing in alternative shifts (early to late evening) – Places of concentration of gay men and MSM – Linkage to care • Peer educators • Health system navigators Photos by Raphael Herzog

Mobile testing results From February 6, 2015 to February 28, 2017: Mobile Units 5,

Mobile testing results From February 6, 2015 to February 28, 2017: Mobile Units 5, 219 3, 773 1, 589 92 NGO • Individuals tested 774 • Men tested 600 • MSM (42. 1%) • Positive MSM (5. 8%; n=92/1589) 471 27 • Individuals tested • Men tested • MSM (78. 5%) • Positive MSM (5. 7%; n=27/471)

COA & results • Rapid testing (excluding confirmatory from the E-testing) • Well known

COA & results • Rapid testing (excluding confirmatory from the E-testing) • Well known by the community – Performing HIV testing since 1992 From February 6, 2015 to February 28, 2017: 802 668 657 190 • Individuals tested • Men tested • MSM (98. 4%) • Positive MSM (28. 9%; n=190/657)

MSM Demographics by HTS & Overall linkage to care. AHA, Curitiba, 2015 -17 Age

MSM Demographics by HTS & Overall linkage to care. AHA, Curitiba, 2015 -17 Age -median (IQR) Self-report as white Incomplete/complete graduation or more HIV testing for the 1 st time 350 300 250 200 150 100 50 0 E-testing Mobile units LGBT NGO 4356 (%) 1589 (%) 471 (%) 25 (21 -29) 26 (22 -33) 24 (20 -28) 3324 (76. 3) 927(58. 3) 267(56. 7) COA 657 (%) 25 (22 -29) 516 (78. 5) 3173 (72. 7) 870 (54. 8) 272 (57. 7) 295 (44. 9) 1354 (31. 0) 420 (26. 4) 110 (23. 4) 137 (20. 4) Linkage to care at A Hora é Agora. COA, Curitiba, 2015 -17 299 264 171 64. 8% MSM with new HIV diagnosis Eligible to be linkedᵃ ᵃ Live in Curitiba and signed informed consent ᵇ Collected viral load OR started ART in 90 days Linked to careᵇ

Lessons Learned & Achievements • Around 5% HIV positive MSM found in all strategies,

Lessons Learned & Achievements • Around 5% HIV positive MSM found in all strategies, except at the COA • 20 -31% first-time testers • E-testing was feasible and highly accepted – Useful for: never tested and high risk MSM needing frequent testing – Exemplary activity in the WHO HIV self-testing guidelines – HIVST was approved for over-the-counter sale in Brazil • Action, Orange. Life® (blood) • Continuous innovation keeps the project going – must be reinvented daily • Ongoing cost-effectiveness analysis • Expansion to other cities (São Paulo ~12 million/inhabitants)

Team & Funding CDC-RFA-GH 13 -1343 Grant number: U 2 GGH 01152 ENSP-FIOCRUZ Marly

Team & Funding CDC-RFA-GH 13 -1343 Grant number: U 2 GGH 01152 ENSP-FIOCRUZ Marly Cruz Vanda Cota Adriana Pinho Beto de Jesus Raquel Torres INI- FIOCRUZ Beatriz Grinsztejn Valdilea G. Veloso Nilo M. Fernandes Flavia Lessa Mo. H Department of IST, AIDS and Viral Hepatitis Adele Benzaken Renato Girade Correa Renato Lima Diego Calisto CDC Brasil Aristides Barbosa Nena Lentini Raquel Miranda CDC Atlanta Trista Bingham Secretaria Municipal de Curitiba Márcia Huçulak Juliane Oliveira Liza Rosso Ana Schlotag Adriane Wollmann Bernardo Almeida Clea Ribeiro Elina Sakurada Juliane Cardoso Simone Muniz NGO Grupo Dignidade Tony Reis David Harrad Thank you!