Reaching key populations with HIV services in India – perfecting the integrated model

Integrated services for key affected populations in India increased the number of people testing for HIV in the past 12 months by 31%, but the services did not reach enough people within the target groups to have a significant population-level effect.

In a cluster randomised control trial in 22 sites across India, investigators evaluated the effectiveness of a one-stop-shop care model which provided HIV testing, prevention and treatment services for people who inject drugs and men who have sex with men. Using pre- and post-implementation surveys, researchers assessed population-level effectiveness, and compared the results of the integrated service sites with the usual care.

In India, HIV-services including HIV testing and treatment are provided free of charge by the government, and while HIV testing is widely available in India, it is normally provided in separate venues and does not include wraparound services for key affected populations. Decentralised and integrated services have been proposed to reach key affected populations, which make up a significant proportion of the HIV burden in India.

According to a 2013 survey, HIV prevalence across 27 Indian cities was 7% among men who have sex with men and 21.1% among people who inject drugs. Only 35.3% and 44.6% respectively had ever been tested for HIV.

The study recruited 11,993 people who inject drugs and 9,997 men who have sex with men for the baseline survey between October 2012 and December 2013. The evaluation survey was conducted between August 2016 and May 2017, with 11,721 people who inject drugs and 10,005 men who have sex with men.  Only 14% of people who inject drugs were included in both surveys and 9% of men who have sex with men.

Integrated care services were provided in 11 cities, which were selected because of their high HIV prevalence for each group, low access to services and other logistical considerations, for example avoiding areas with travel challenges or civil unrest. Integrated care services were in operation for an average of 26 months across all sites before the final survey.

The evaluation showed that compared to those attending the usual government-run services, participants who attended the integrated care sites in this study were significantly more likely to have tested for HIV, be aware of their HIV status, be on antiretroviral treatment (ART) if they were HIV-positive, and have lower rates of risky injecting and/or sexual behaviour.

However, overall penetration of the intervention was low. A population-level survey of both groups, revealed the average exposure to the sites was 44% for people who inject drugs and 24% for men who have sex with men. When the population level-impact is considered, recent HIV testing increased, but not by a significant amount, and there was no effect on HIV care continuum outcomes or HIV incidence.

Despite reaching nearly 15,000 unique participants with HIV testing, larger than expected population sizes meant that they did not reach enough of the target populations. The investigators suggested that reach of the integrated-care intervention was perhaps constrained by the number of sites. In all but one city there was just one integrated care centre. They also suggested that their recruitment methods may have missed certain subsets within key populations. Target populations were recruited in each city starting at one site with two to three ‘seed’ participants – influential and well-connected community members – who were given two coupons and told to recruit their peers for the analysis.

“We hypothesise that scaling up more integrated care centres in the intervention sites or allowing the centres to operate longer would have yielded larger population-level improvements.”

The investigators concluded that future interventions should evaluate and take into account the size of the target key population, which could then inform the ‘dose’ of the intervention – meaning either more centres in a city, or opening the centres for a longer period – to affect real, sustained HIV outcomes at the population level.