HIV risk network-based outreach more effective, less costly

An outreach effort targeting the risk networks of people who may have HIV in Ukraine is more effective in locating additional HIV cases than other testing approaches in the eastern European country, according to researchers.

The effort, known as the Transmission Reduction Intervention Project (TRIP), is also less costly for each new HIV diagnosis than the other programs, they wrote in the Journal of the International AIDS Society.

According to the researchers, both “general and key population HIV testing projects require considerable resources” and test a significant number of people who are HIV negative for every person they identify as positive for the virus.

“Tracing social and risk networks has been found to help locate people recently infected with HIV, given that the virus is transmitted through sexual and injection risk networks,” Samuel R. Friedman, PhD, director of the Institute for Infectious Disease Research at the National Development and Research Institutes Inc. in New York City, said in a news release. “In addition, since social norms and rumors about HIV testing and treatment are likely to spread through social networks, which overlap to a considerable degree with risk networks, this also lets us zero in on groups who would usually be unlikely to get tested on their own.”

Identifying HIV cases has been critical in Ukraine, a country struck by an epidemic of the virus. Starting in 2002, officials there increased harm-reduction efforts, leading to a decline in infections. But armed conflict in eastern Ukraine between pro-Western and pro-Russian forces has disrupted those programs and threatened progress.

In 2013, researchers conducted the Integrated Biobehavioral Surveillance (IBBS) program in 29 Ukrainian cities. They interviewed people who inject drugs (PWID) about sexual and injection behaviors, previous HIV testing and other factors. Health care workers conducted rapid HIV tests for participants, who were encouraged to recruit secondary participants. All participants received modest financial rewards for taking part and additional rewards for recruiting others.

Another program — Outreach Testing for HIV — was conducted from 2013 to 2016. PWID were offered HIV testing at harm-reduction sites and vans in Ukrainian community settings. Starting in 2015, outreach workers began offering condoms and clean syringes to participants, along with HIV testing.

TRIP was also conducted during this period, in the southern city of Odessa, one of the areas in which the country’s HIV epidemic began in the 1990s. Unlike the other two HIV testing programs, TRIP involved both PWID and non-PWID.

People who were potentially infected with HIV were recruited as “seeds,” through whom the researchers would trace risk networks. Risk networks were defined as participants’ sex partners, people who injected drugs with participants, those who were present when participants injected drugs or had sex and those recruited from what the researchers considered small venues visited by participants to inject drugs or find sex partners.

TRIP conductors interviewed participants on questions similar to those in the IBBS program. They also asked them to name people in their risk networks and to name venues they had visited to engage in risky behavior. As in IBBS, monetary rewards were offered for participation and for helping recruit more participants.

The researchers compared the testing results and costs of TRIP with those of the other two programs. In TRIP, 1,252 people in seeds’ risk networks were tested. IBBS tested 400 people, and Outreach Testing included 13,936 people.

Of those tested under TRIP, 14.6% tested positive for HIV, compared with 5% in IBBS and 2.4% in Outreach Testing. The odds of a positive HIV test with TRIP were more than threefold compared with those in IBBS (OR = 3.25; 95% CI, 2.07-5.12) and about sevenfold compared with those in Outreach Testing (OR = 7.03; 95% CI, 5.95-8.31).

Also, under TRIP, recently infected participants had a higher proportion of positive tests (16.3%) than long-term infected participants (12.2%). Those recently infected had 41% higher odds of a positive test.

The cost per HIV case detected in TRIP was $249.81, compared with $387.50 in IBBS, $940.93 in Outreach Testing’s first year and $653.13 in its last year.

Friedman, who is also associate director and senior theoretician at the Center for Drug Use and HIV Research, said that targeting participants’ high-risk connections was likely key to TRIP’s relative success.

“The superiority of TRIP as a way to recruit undiagnosed positives probably stems from its design,” he said. “TRIP zeroes in on the social networks most likely to be infected rather than attempting to use ‘weak ties’ to recruit people who inject drugs who are socially and geographically distant from the seeds.” – by Joe Green

Disclosures: The authors report no relevant financial disclosures.