Moving Toward Reduced HIV Incidence: How the San Francisco

Moving Toward Reduced HIV Incidence: How the San Francisco

Moving Toward Reduced HIV Incidence: How the San Francisco Experience Can Inform National HIV/AIDS Strategy Implementation
Grant Colfax, MD
Director of HIV Prevention and Research
San Francisco Department of Public Health
Talk Outline
• Why San Francisco’s HIV prevention strategy is changing
• What we are changing
• How we will measure the effectiveness of our new approach
• What interventions we will scale‐up
• How NHAS is supporting local efforts
HIV Prevalence, Selected Regions and Subgroups
35
30
Prevalence (%)
25
20
15
10
5
0
Adapted from: El‐Sadr, et al. NEJM, 2010
HIV Incidence, United States
• HIV incidence peaked in 1984‐1985 at 130,000 infections/year
• Approximately 53,600 new infections each year stable
since 2000
• Incidence highest among MSM compared with other risk groups
• 53% of new infections among MSM
• 42 times higher compared with heterosexual men
• Black MSM 9‐fold higher incidence compared with white MSM
• Incidence stable among women since early 1990s
• Approximately 20,000 new infections per year
Hall, et al. JAMA, 2008
Relentless Inevitability of Infection among MSM
100%
AA MSM 85% by 60 years
HIV Prevalence
80%
60%
40%
MSM 60% by 60 years
20%
MSM 45% by 45 years
0%
20
25
30
35
40
Age
45
50
55
60
Stall, et al. AIDS Behav, 2009.
San Francisco’s Endemics
4500
4000
3500
3000
2500
2000
1500
1000
500
0
Gay men: Endemic
Injection drug users: Endemic
2008
2007
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
Heterosexuals: Neither
epidemic nor endemic
McFarland, 2009
Strategy Goals and Targets for 2015
Reducing New HIV Infections
• Lower the annual number of new infections by 25%
Increasing Access to Care and Improving Health Outcomes for People Living with HIV
• Increase the proportion of newly diagnosed patients linked to clinical care within three months of their HIV diagnosis from 65% to 85%
Reducing HIV‐related Health Disparities
• Increase the proportion of HIV diagnosed gay and bisexual men with undetectable viral load by 20%
Strategy URL: http://www.whitehouse.gov/administration/eop/onap/nhas
HIV Prevention 2011: From Plan to Practice
• Vision: End new HIV infections in San Francisco
• Goal: Reduce HIV incidence by 50% by 2017
•
Resources to populations at greatest risk for HIV:
•
•
•
MSM (70‐79%)
IDU (10‐20%)
TFSM (5‐8%)
www.sfhiv.org
Prevention Indicators, San Francisco
Parameters
2004‐5 (%)
2008‐9 (%)
Among MSM, HIV test in last 12 mos. 65
71 Undiagnosed
24
20
Engaged in care 71
76
ART coverage (PWA)
74 92
Virologic suppression
52 75
Prevention Indicators, San Francisco 2008
MSM
IDU
HIV‐
HIV+
HIV‐
HIV+
Free condoms
Free needles
79%
70%
67%
69%
N/A
N/A
76%
97%
Individual
counseling Group
counseling
11%
16%
17%
16%
5%
11%
8%
16%
Source: 2008 NHBS, HIV Epi Section, DPH
Principles of San Francisco DPH’s New HIV Prevention Strategy
• Efficient and effective use of limited resources
• Prioritizing based on scientific data, community input, scalability, and cost
• Emphasize case finding
• HIV testing scale‐up
• Reinforce interruption of transmission
• Condoms, syringe distribution
• Provide universal care and offer of treatment
• Reduce viral load • Target intensive behavioral interventions
• Substance use treatment
• Determine the effectiveness of our approach
• Population‐based monitoring
What would be an optimal HIV population‐based indicator of success? • Marker of both prevention and treatment
• Tells you where epidemic is in community
• Helps target resources efficiently
• Identifies disparities
• Helps set goals for achieving health equity • Temporally upstream of new HIV infections • By the time you have an HIV case to report, you’ve failed to prevent that case
Community Viral Load (CVL) • Population‐based measure of a community’s viral burden  Virometer
• Potential biologic indicator of the effectiveness of:
• Antiretroviral treatment
• HIV prevention Calculation of CVL • Used San Francisco’s comprehensive HIV/AIDS surveillance system
• Calculated two measures of CVL:
• Total:
 n

tCVL   mostrecentVL
i1


 n
  (mostrecentVL) 

• Mean: mCVL   i 1


n




Community Viral Load Results
Overall
San Francisco
Sub‐groups
Latino
African‐American
Women
IDU
MSM‐IDU
Mean CVL*
23,348
N
12,512
N
(%)
(100)
(%)
Mean CVL*
1822
1825
786
1011
1791
(15)
(15)
(6)
(8)
(14)
26,744
26,404
27,614
33,245
36,261
*(p<0.001 by Kruskal‐Wallis test) in mean CVL by treatment history, race/ethnicity, age, gender, HIV transmission risk category, insurance status, and clinical status.
Das, et al. 2010
Spatial Distribution of Total CVL by SF Neighborhood
Das, et al. 2010
Spatial Distribution of Mean CVL by SF Neighborhood
Das, et al. 2010
Mean CVL and New HIV Infections, 2004‐2008
935
(CI: 658, 1212)
792 (CI: 552, 1033)
25,000
Mean CVL copies/ml
1200
621
(CI: 462, 781)
20,000
15,000
600
523
10,000
518
400
434
5,000
200
0
Year 2004
(p= 0.028)
800
798
642
Mean CVL
1000
Number of HIV cases
30,000
0
2005
2006
2007
2008
Newly diagnosed and reported HIV cases
(Mean CVL & newly diagnosed HIV p=0.005)
HIV Incidence
(Mean CVL & HIV‐incidence p=0.3)
Das, et al. 2010
Recommended Action
Measure and utilize community viral load: Ensure that all high prevalence localities are able to collect data necessary to calculate community viral load, measure the viral load in specific communities, and reduce viral load in those communities where HIV incidence is high.
CVL: New York & Washington D.C.
Laraque, et al. CROI, 2011. Abstract #1024.
Castel, et al. CROI, 2011. Abstract #1023.
National HIV/AIDS Strategy Recommended Actions: Expand targeted efforts to prevent HIV infection and reduce HIV‐related disparities and health inequities
Intensify HIV prevention efforts in the communities where HIV is most heavily concentrated. Allocate public funding to geographic areas consistent with the epidemic and to high‐risk populations.
The following are scientifically proven approaches that reduce HIV transmission:
• HIV testing (medical and community‐based)
• HIV treatment (e.g. PEP, retention in care, treatment adherence, etc.)
• Abstinence from sex or substance use; limit the number of partners and other steps to lower risk
• Condom availability and distribution for prioritized populations
• Access to sterile needles and syringes
New Directions for SF HIV Prevention
To reduce new HIV infections by 50% by 2017, the HIV Prevention Plan prioritizes:
1.
2.
3.
4.
5.
HIV status awareness
Prevention with positives
Drivers of HIV (substance use)
Structural change
Syringe access
Source: HPPC, 2010 San Francisco HIV Prevention Plan
You are invited to the marriage of…
&
High Impact Combination Prevention
A Tiered Approach
Intensive Behavioral Interventions
Treatment & Viral Suppression
HIV Testing
MORE COVERAGE
MORE INTENSITY
PEP
Community‐Level Harm Reduction Frieden. AJPH, 2010.
Test and Treat
Universal voluntary HIV testing and immediate ART combined:
• 95% reduction in new HIV cases in 10 years
Granich, et al. Lancet, 2009
Honoring the combination prevention approach…
Coates. Lancet, 2008
… with a data‐supported increased emphasis on testing and treatment outcomes…
INFECTIONS PREVENTED WITH “TEST AND TREAT” FOR SF MSM
Year
Tx <500
Tx All
Text & Tx All
2014
1,554
2,169
2,810
2019
3,102
4,550
6,040
2029
4,940
8,221
12,189
PERCENT REDUCTION IN NEW INFECTIONS
Year
Tx <500
Tx All
Test & Tx All
2014
42%
59%
76%
2019
42%
61%
81%
2029
33%
55%
81%
Charlebois, Das, Porco, Havlir, et al. CID, 2011
HIV Status Awareness • What will be emphasized?
• Scaled‐up testing models
•
•
•
•
Routine testing for groups with high HIV prevalence
Routine testing in medical settings
Simplifying HIV test process and results notification
Less counseling with HIV‐negative results
• Expanded Partner Notification efforts by DPH
• New efforts to detect acute HIV infection • Outcome goals: •
•
•
•
30,000 HIV tests in DPH‐supported programs
All persons at high‐risk for HIV are tested at least every 6 months
New diagnosis > 1.2% at funded sites
90% of HIV‐positive persons are in care within 3 months of diagnosis
The Need for More HIV Testing among High‐risk Groups in SF
Behavioral Risk Populations At risk pop. size*
% not tested past 6 Testing deficit, 6 mos.**
mos.
MSM
48,329
54%
26,098
IDU
14,609
58%
8,473
TFSM
1,880
N/A
N/A
Min. total additional tests needed every 6 months
34,571
*Based on Consensus Estimates, 2010 San Francisco HIV Prevention Plan
**Source: National HIV Behavioral Surveillance (NHBS) study, San Francisco data
Testing in Social Networks: The Black Men Testing Project
Legend
HIV‐ = Blue
Known HIV+ = Red
New HIV+ = Green
38% of newly diagnosed cases referred by HIV+ MSM seeds Raymond, et al. AIDS Behav. In press.
Detection of New HIV Infections: SF High‐risk Sites • City Clinic, Magnet, and AIDS Health Project 2007‐2009:
• 32,494 HIV tests
• 538 (1.66%) new HIV‐diagnosis • 14,544 specimens pooled for RNA testing
• 54 (.37%) acute cases identified • Acutes account for 9% of all newly diagnosed
Expanded Testing in Primary Care Settings
• CDC‐funded initiative
• Goal: Normalize routine HIV testing in medical settings
• Implementation:
• First year goal: 20,000 HIV tests at SFDPH medical sites
• 14 clinics to scale‐up testing
• Jumpstart support: disclosure assistance, provider training “offer script,” linkage to care, partner services
Expanded Emergency Room Testing: San Francisco General Hospital
3,589
HIV negative
8
Not confirmed
44
Known positive
89 (2.4%)
Preliminary positive
81 (2.1%)
Confirmed positive
37 (1.0%)
New positive
July 08 ‐ Sep 09
3,768
Tests performed
National HIV/AIDS Strategy Recommended Actions: Increasing access to care and improving health outcomes for people living with HIV and reduce HIV‐related disparities and health inequities
To increase access to care and improve health outcomes, we must work to:
•
Establish a seamless system to immediately link people to continuous and coordinated quality care when they are diagnosed with HIV
Recommended Actions:
•
•
•
•
•
Facilitate linkages to care
Promote collaboration among providers
Maintain people living with HIV in care
Enhance client assessment tools and measurement of health outcomes
Address policies to promote access to housing and supportive services for people living with HIV
Prevention with Positives • What will be emphasized?
• Increased PWP in HIV medical care settings
• Focus on persons at high‐risk for transmitting HIV (high VL)
• Models that address barriers to care, including stigma, fear, and discrimination.
• Outcome goals:
• All HIV‐positive persons in care are offered treatment
• 90% of those on treatment have undetectable viral load
Universal offer of ART in San Francisco
“All patients, regardless of CD4 count, will be evaluated for initiation of antiretroviral therapy (ART)”
Decision to start ART made by the individual in conjunction with the provider
ART and HIV‐1 Transmission
Linked HIV‐1
Infection
Person Years
Rate
95% CI
No ART 102
4,558
2.24
(1.84‐2.72)
Initiated
After ART 1
273
0.37
(0.09‐2.04)
Initiation
Adjusted* Relative Risk = 0.08 (95% CI 0.002, 0.57), p=0.004
*For time on study and CD4 count
Donnell, et al. Lancet, 2010
We are doing well, but we can do better…
• Of 15,836 reported HIV cases in San Francisco:
• 24% did not have a CD4, VL or ART in prior year
• 2,317 known to have a detectable VL
• 241 known to have viral load >100k
• Correlates of higher viral load are: • Transgender, homeless, IDU, African American, MSM‐IDU; four SF neighborhoods with lowest median incomes
Source: SFDPH, 2011
HIV System Navigation: An Emerging Model to Improve HIV Care Access
• Assist with engagement in care, adherence, retention
• After one year with navigators:
• % with undetectable viral load went from 34.8% to 53.1% (p<.01)
• % with health insurance went from 79% to 91% (p=0.02) Bradford. AIDS Patient Care & STDs, 2007
Behavioral Model for Vulnerable Populations
INDIVIDUAL PATIENT CHARACTERISTICS:
PREDISPOSING FACTORS
TRADITIONAL
‐Age
‐Gender
‐Ethnicity
‐Education
‐Health benefits
‐Perception of HIV risk
ENABLING
‐Income
‐Insurance
‐Housing/transportation
‐Social support
‐Coping/self‐efficacy
‐Acceptance of diagnosis
VULNERABLE
‐Immigration status
‐Sexual orientation
‐Incarceration history
‐Psychiatric illness
‐Substance abuse
‐Stigma
NEED
‐Comorbitities/
opportunistic infections
‐Symptoms
‐Self‐perceived health status
‐HIV disease stage
MEDIATORS/BEHAVIORAL OUTCOMES
‐Linkage (connection to HIV clinic)
‐Retention (appointment adherence)
‐ART adherence
‐Transmission risk acts
‐Psychological well‐being
STRUCTURAL ENVIRONMENT
METHODS OF TESTING SITE
LINKAGE TO CARE
‐Diagnostic vs. screening ‐Passive vs. active
‐Targeted vs. nontargeted ‐Medical vs. ‐Pre‐counseled vs.
medical
not pre‐counseled
‐HIV clinic‐based
‐Medical vs. non‐medical ‐Length of follow up
‐Ambulatory vs. admitted ‐Intensity of effort
CLINIC
‐Insurance compatibility
‐Appointment availability
‐Psychiatric treatment
‐Vouchers
‐Reminder phone calls
‐Ease of check‐in
PROVIDER
‐Trust
‐Experience
‐Consensus
BIOLOGIC OUTCOMES
‐CD4 reconstitution ‐Opportunistic infections
‐VL suppression
‐Death
K. Christopoulos, et al. Adapted from Ulett, CID, 2011.
Goal: Navigation Supports Continuum of Care and Improves Outcomes
Median CD4 at HIV diagnosis
Percent Virologic Suppression
Median CD4 at ART initiation
Time to ART Initiation Time to Virologic Suppression Testing
Diagnosis
Primary Care
Linkage
Medical Testing
Testing
Engagement / Retention
Virologic Suppression
HIV
Engagement / Retention
Mental Health Services
Routine Community Treatment
Linkage & Partner Services
Substance Use Treatment
Housing Support
SFDPH Navigation Program
Treatment Adherence
Medical Case
Management
Das, et al. CROI, 2011
Health Outcome Metric
6 month, 12 month Virologic Suppression Rates (viral load <75 ) by Year of Diagnosis
Das, et al. CROI, 2011
The Riskiest of the High‐risk: Trends in Substance Use among San Francisco MSM
Drug
Methamphetamine
Cocaine
Crack
Poppers
2004
Use last 12 months
22%
17%
4%
20%
2008
Use last 12 months
13%
24%
4%
19%
Source: NHBS, San Francisco
Structural Change
• San Francisco HIV Prevention Plan definition: “New or •
modified programs, practices, or policies that are logically linkable to HIV transmission and acquisition and that can be sustained over time even when key actors are no longer involved.”
Examples: Ending HIV Exceptionalism
•
•
•
HIV screening as standard of care in medical settings for persons at risk for HIV
Changing laws to allow for electronic notification of HIV test results
Eliminating requirement of written informed consent for testing in community settings
The PrEP Puzzle
Potential implementation will be complex — feasibility, sustainability, and acceptability need to be looked at outside of RCTs
Achieving a More Coordinated Response to the HIV Epidemic
Emphasis must be placed on coordination of activities among agencies
• Increase the coordination of HIV programs across the Federal Government and between Federal agencies and State, territorial, local, and tribal governments.
•
Develop improved mechanisms to monitor and report on progress
•
Establish a seamless system to immediately link people to continuous and coordinated quality care
Recommended Actions:
• Ensure coordinated program administration
• Promote equitable resource allocation
• Streamline and standardize data collection
• Provide rigorous evaluation of current programs
• Provide regular public reporting
12‐City Initiative: Jumpstarting Local Efforts to Implement the NHAS
NHAS Recommended Actions:
Expand targeted efforts to prevent HIV infection using a combination of effective, evidence‐based approaches.
• Abstinence from sex or drug use (or limiting the number of partners or other steps to lower risk)
• HIV testing
• Condom availability
• Access to sterile needles and syringes
• HIV treatment ECHPP Activities:
SFDPH HIV Prevention Efforts:
• Interventions for PLWHA (e.g. linkage to care, partner services, retention and engagement in care, treatment adherence)
• Routine screening for HIV in clinical settings
• HIV testing in non‐clinical settings • Condom distribution prioritized to target HIV‐positive persons and persons at highest risk
• Access to sterile needles and syringes
• Provision of PEP
• Policies to support prevention efforts •
•
•
•
•
•
•
•
Implement Navigator System
Expand testing in primary care
Expand community‐based testing
Expand condom distribution
Support PEP Efforts Continue Syringe access
Expanded partner notification
Targeted use of surveillance data for prevention purposes
• Implementation of named‐reporting system to monitor use and effectiveness of services
Health Disparities: MSM HIV/STD Cases as Proportion of SF Male Population, 1999‐2008
Rate ratio MSM
vs. male non‐MSM: 85.90 15.17
6.14
59.64
*Cumulative syphilis data from 2004‐2008
Sources: HIV Epidemiology Report 2009; SFDPH STD Annual Summary 2008 CDC Program Collaboration and Service Integration (PCSI) Initiative DPH Laboratory
SFGH Laboratory HIV Health Services
Health Disparities
• Review the data and make recommendations so that DPH can maximize prevention opportunities by integrating service delivery. HIV Epidemiology
HIV Prevention
STD Prevention & Control
Clinical Guidelines • Create comprehensive DPH guidelines regarding appropriate integration of prevention, screening and treatment for HIV/AIDS, viral hepatitis, STDs, and TB
HIV Research
TB Control
Primary Care
DPH Data Systems
• Develop recommendations regarding integration of : 1) security and confidentiality standards to be used across all sections; and 2) data systems to ensure appropriate monitoring.
Success: No HIV‐infected Infants Born in SF Since 2004
20
Number of Births
15
10
5
0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year of Birth of Infant
HIV Infected
Seroreverted
Status Unknown
SF: The Proof of Concept Jurisdiction to Eliminate New HIV Infections
•
•
•
•
•
•
•
Strong community support and involvement
Excellent data
Well‐defined epidemic
Relatively well‐resourced
Good access to care and treatment
Research driving programmatic decisions
Strong political support
Acknowledgments
• HIV Prevention Planning Council
• SFDPH: Kyle Bernstein, Susan Buchbinder, Moupali Das, Teri Dowling, Noah Carraher, Jonathan Fuchs, Albert Liu, Willi McFarland, Israel Nieves‐Rivera, Tracey Packer, Mark Pandori, Susan Phillip, Henry‐Raymond Fisher, Michaela Varisto
• UCSF: Bradley Hare, Diane Havlir, Beth Kaplan, Diane Jones
• University of Miami: Lisa Metsch
• NIH
• CDC
A New HIV Diagnosis Reduces Risk Behavior
Colfax, et al. AIDS, 2002
HIV Prevention Section Core Functions
• Partners with HIV Prevention Planning Council (HPPC)
• Emphasis on community‐based input and feedback to set priorities
• Contracts with CBOs and other agencies to provide prevention programs
• Allocates funding in accordance with distribution of HIV epidemic
• Monitors and evaluates who we are reaching with prevention services
• Runs condom distribution program • Supports agencies in delivery of prevention work
• Oversees testing, counseling, and linkages to care • Assists agencies in delivery of interventions
• Coordinates and implements health education initiatives
• Conducts prevention research
• Develops and tests new prevention interventions
• Performs needs assessments of specific populations
• Disseminates research findings to prevention providers and community members
• Advocates for improved HIV prevention and treatment policy
• Involves local, state, national stakeholders
• Addresses both fiscal and legislative issues
Transmission Rate: Measure of Annual Transmissions in Relation to HIV Prevalence
• Current U.S. rate: 5 transmissions/100 persons living with HIV
• NHAS goal: 3.5 by 2015
• Reproductive rate = (Tx/100) * D, where D= duration of infectiousness
• Prevention goal: Reproductive rate below 1 Holtgrave, 2010
Calculated HIV Reproductive Rate at Various Transmission Rates and Levels of Years of Post‐infection Life Expectancy
T(x)
(Transmission Rate)
Levels of Years of Post‐infection Life Expectancy
28.73
33.66
40.00
5.0
1.44
1.68
2.00
4.5
1.29
1.51
1.80
4.0
1.15
1.35
1.60
3.5
1.01
1.18
1.40
3.0
0.86
1.01
1.20
2.5
0.72
0.84
1.00
2.0
0.57
0.67
0.80
1.5
0.43
0.50
0.60
1.0
0.29
0.34
0.40
Threshold T(x) for Reproductive Rate = 1
3.48
2.97
2.50
Holtgrave. Public Health Rep, 2010
Estimated HIV Transmission Rates, San Francisco, 2006‐2008
HIV INCIDENCE
PREVALENCE
CRUDE TRANSMISSION RATE
[per 100 Cases]
Using Living Reported
Incidence HIV/AIDS Cases Point Estimate
Point Estimate
95% CI
2006
975
801‐1,082
15,099
6.46
5.30‐7.17
2007
792
552‐1,033
15,298
5.18
3.61‐6.75
2008
621
462‐782
15,597
3.98
2.96‐5.01
95% CI
Data source: SFDPH HIV Surveillance 2008 Report
SFDPH Comprehensive System of HIV Prevention and Care
• HIV testing
• Partner services
• STD prevention
• Addressing drivers and co-factors of HIV
• Linkage to medical care and services
• Risk reduction activities
• Community mobilization efforts
• Public information efforts
• Condom distribution
• Syringe access
• PEP
• STD and HIV treatment
• Addressing Comorbidities
• Core Surveillance
• Incidence Surveillance
• Medical Monitoring
• NHBS
• Vaccine studies
• PrEP research
• Natural history cohort
• PWP studies
• Strand Study
• UNITY project
• HIV drug resistance testing
• Community viral load
• Substance abuse research
• Counseling studies
HIV and
STD
Prevention
HIV Care
and
Support
Services
Surveillance,
Evaluation
and
Research
Primary
Care and
Treatment
• Linkage to medical care and services
• Behavioral Health Services
• Home Health Service
• Non-medical case management
• Food Bank / Home-delivered meals
• Client Advocacy-related services
• Emergency financial assistance
• Legal services
• Housing services
• Oral health care
• Outreach services
• Engagement in care
• Treatment Adherence
• Centers of Excellence
• Medical Case management
• ADAP
• Healthy SF
• Community Health Care
• HIV specialty medical care
• City Clinic
• SFDPH Treatment Guidelines
• PHAST Team
• STD and TB
Nieves‐Rivera, UCHAPS 2010 Test and Treat
Universal voluntary HIV testing and immediate ART combined:
• 95% reduction in new HIV cases in 10 years
• HIV Incidence reduced from 15‐20,000 to 1,000 per million
• Prevalence decreases to less than 1% by 2050
Granich, et al. Lancet, 2009
Ongoing and Upcoming Testing Research, HIV Prevention Section
• STOP Study: Compares 3rd generation tests vs. 4th generation tests vs. RNA pooling • New diagnoses
• Cost
• Feasibility
• Symptom‐driven screening for acute HIV
• Collaborative effort with Pilcher, et. al. Prevention Indicators, San Francisco
Parameters
2004 (%)
2009 (%)
Among MSM, HIV test in last 12 mos.
65
HIV‐positive people unaware of status
24
15‐20
Engaged in care 71
76
ART coverage (PWA)
74 (2005)
92
Virologic suppression
52 (2005)
75
Outcomes of SF Partner Services, 2004‐2008
481 interviewed
419 partners named
263 (55%) did not name partners
56 (13%) not located
363 (87%) located
34 (9%) refused
16 (4%) OOJ
313 interviewed
95 (30%) HIV‐infected
200 (92%) of 212 remaining tested
44 (22%) of tested newly diagnosed HIV+
Marcus. AIDS, 2009. Is counseling efficacious in highest risk groups?
Project AWARE • Evaluates the effect of pre‐test counseling on STI incidence • Secondary outcomes: Reduction of sexual risk behaviors
• Cost and cost‐
effectiveness of counseling •
SITES
Columbia, SC
Jacksonville, FL
Los Angeles, CA
Miami, FL
San Francisco, CA
Pittsburgh, PA
Portland, OR
Seattle, WA
Washington, DC
N = 5,000 STUDY DESIGN
Recruitment and Enrollment
STI Testing
Baseline Assessment
Randomization
Risk‐reduction counseling with on‐site rapid HIV test
Information with on‐site rapid HIV test
STI testing repeated at 6 months
ARRA funded
Meta‐analysis of Behavioral Interventions for Methamphetamine use Colfax, et al. Lancet, 2010