Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi

BACKGROUND

Assisted index case testing (ICT), in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase status awareness in people living with HIV. While the available evidence from eastern and southern Africa suggests that assisted ICT can be an effective, efficient, cost-effective, acceptable, and low-risk strategy to implement in the region, it reveals that feasibility barriers to implementation exist. This study aims to inform the design of implementation strategies to mitigate these feasibility barriers by examining "assisting" health care workers' experiences of how barriers manifest throughout the assisted ICT process, as well as their perceptions of potential opportunities to facilitate feasibility.

METHODS

In-depth interviews were conducted with 26 lay health care workers delivering assisted ICT in Malawian health facilities. Interviews explored health care workers' experiences counseling index clients and tracing these clients' contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted ICT. Analysis included multiple rounds of coding and iteration with the data collection team.

RESULTS

Participants reported a variety of barriers to feasibility of assisted index case testing implementation, including sensitivities around discussing ICT with clients, privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, and logistical obstacles to tracing. Participants also reported several health care worker characteristics that facilitate feasibility (knowledge, interpersonal skills, non-stigmatizing attitudes and behaviors, and a sense of purpose), as well as identified process improvements with the potential to mitigate barriers.

CONCLUSIONS

Maximizing assisted ICT's potential to increase status awareness in people living with HIV requires equipping health care workers with effective training and support to address and overcome the many feasibility barriers that they face in implementation. Findings demonstrate the need for, as well as inform the development of, implementation strategies to mitigate barriers and promote facilitators to feasibility of assisted ICT.

TRIAL REGISTRATION

NCT05343390. Date of registration: April 25, 2022.

Partner notification service utilization and associated factors among clients attending anti-retroviral therapy clinics of public health facilities in Gimbi Town, West Ethiopia, 2023: a facility-based mixed-method cross-sectional study

BACKGROUND

Partner Notification Service is among the strategies used to conduct targeted Human Immunodeficiency Virus Testing Service by obtaining information about sexual contacts of index clients to refer for testing. But most people living with Human Immunodeficiency Virus are still unaware of their status, including Ethiopia. Limited studies are available on the magnitude of partner notification service utilization and associated factors in Ethiopia.

OBJECTIVE

The aim of this study was to assess the magnitude of partner notification service utilization and associated factors among people living with Human Immunodeficiency Virus attending anti-retroviral therapy clinics of public health facilities in Gimbi town, West Ethiopia.

METHODS

A facility-based mixed-method cross-sectional study design was used. Total of 455 study participants were selected by systematic random sampling for quantitative data and health workers were purposively selected for qualitative data until saturation of ideas was reached. The study was conducted from December 1, 2022 to January 30, 2023. Structured questionnaires and key informant interview guides were used for data collection. Quantitative data were analyzed using Statistical Package for Social Science version 25. Open code 4.02 software was used for qualitative data analysis. Frequencies and proportions were used to summarize descriptive statistics. Bivariable and multivariable logistic regression was used to identify associated factors then variables with a p value < 0.05 were declared to have an association with the dependent variable.

RESULT

Exactly 298 (65.5%) of the study participants were notified their HIV status to their sexual partners. Factors associated with Partner Notification Service Utilization were depression AOR: 0.12 (95% CI: 0.07, 0.20), urban settlers AOR: 2.21 (95% CI: 1.2, 3.83), fear of support loss AOR: 0.24 (95% CI: 0.14, 0.40) and intimate partner violence AOR: 0.55 (95% CI: 0.31, 0.97). From qualitative part of this study, factors associated to Partner Notification service utilization were fear of stigma, discrimination and fear of divorce.

CONCLUSION

Two-third of the study participants were utilized partner notification service, and efforts are important to prevent depression and intimate partner violence. Local government bodies and stakeholders should implement economic strengthening and strategies to address the rural community for HIV/AIDS prevention. Promotion of supportive and inclusive environment for PLHIV should also considered as way to increase PNS utilization.

Balancing public health and privacy rights: a mixed-methods study on disclosure obligations of people living with HIV to their partners in China

BACKGROUND

In 2021, a Chinese court, based on the newly enacted Civil Code, first revoked a marriage license due to the spouse's failure to disclose their HIV infection before the marriage. This landmark case ignited a fresh debate on whether people living with HIV (PLHIV) have a legal duty to inform their spouses and sexual partners. Advances in medicine have partially isolated HIV transmission from sexual contact, extending the legal basis for the obligation to disclose beyond disease prevention. This study investigates some possibly unforeseen challenges for PLHIV in China to fulfill this duty, and the outcomes of their decisions in light of the government's goal to promote health.

METHODS

This study aims to provide a detailed examination of the legal provisions and practices concerning partner notification among PLHIV in China. A mixed-methods research approach was employed between 2019 and 2020, combining questionnaire surveys, in-depth interviews, and participatory observations. A total of 433 valid responses were obtained through a questionnaire posted on a Chinese online platform for PLHIV. Following the collection and random coding of the questionnaire data, 40 individuals living with HIV were selected for in-depth interviews. Subsequently, a six-month field investigation was conducted in Guan ai jia yuan (Caring Home) in Jinhua City to further explore this issue.

RESULTS

A considerable proportion of PLHIV exhibit a high rate of disclosure to their spouses (nearly 80%). In the context of sexual partners, 56% of PLHIV stated that their sexual partners were aware of their HIV infection. Whether married PLHIV disclosing to their spouses or unmarried/divorced PLHIV disclosing to sexual partners, however, a substantial majority expressed apprehension about the potential disruption to their relationships that the disclosure might cause. The sole exception was observed among married PLHIV in extramarital relationships who demonstrated a slightly diminished level of concern in this context. Reasons for non-disclosure predominantly included undetectable viral load and the adoption of protective measures.

DISCUSSION

This study reveals that a prevailing "HIV stigma" hinders PLHIV from voluntarily fulfilling the disclosure duties bestowed by Article 38 of the Regulations on the Prevention and Control of HIV/AIDS, and the unclear legal provisions of the new Civil Code play a significant role in this regard. Addressing this issue necessitates not only increasing societal tolerance toward PLHIV and reducing instances of social exclusion but also shifting the legal basis of disclosure duties from disease prevention to rights and obligations within the legal relationships of the parties involved. When it comes to the recipients of disclosure, for instance, it is crucial to differentiate between spouses and sexual partners. As for PLHIV failing to fulfill their disclosure duties, apart from interventions involving indirect notifications, the addition of further legal responsibilities may not be advisable. Intentional transmission actions, on the other hand, should still be subject to severe penalties.

CLINICAL TRIAL NUMBER

Not applicable.

Examining the feasibility of assisted index case testing for HIV case-finding: a qualitative analysis of barriers and facilitators to implementation in Malawi

Background

Assisted index case testing, in which health care workers take an active role in referring at-risk contacts of people living with HIV for HIV testing services, has been widely recognized as an evidence-based intervention with high potential to increase PLHIV status awareness. Promising evidence for the approach has led to several attempts to scale assisted index case testing throughout eastern and southern Africa in recent years. However, despite effective implementation being at the heart of any assisted index case testing strategy, there is limited implementation science research from the perspective of the HCWs who are doing the "assisting". This study examines the feasibility of assisted index case testing from the perspective of health care workers implementing the approach in Malawi.

Methods

In-depth interviews were conducted with 26 lay health care workers delivering assisted index case testing in Malawian health facilities. Interviews explored health care workers' experiences counselling index clients and tracing these clients' contacts, aiming to inform development of a blended learning implementation package. Transcripts were inductively analyzed using Dedoose coding software to identify and describe key factors influencing feasibility of assisted index case testing. Analysis included multiple rounds of coding and iteration with the data collection team.

Results

Participants reported a variety of barriers to feasibility of assisted index case testing implementation, including privacy concerns, limited time for assisted index case testing amid high workloads, poor quality contact information, logistical obstacles to tracing, and challenges of discussing sexual behavior with clients. Participants also reported several health care worker characteristics that facilitate feasibility: robust understanding of assisted index case testing's rationale and knowledge of procedures, strong interpersonal skills, positive attitudes towards clients, and sense of purpose in their work.

Conclusions

Findings demonstrate that maximizing assisted index case testing's potential to increase HIV status awareness requires adequately equipping health care workers with appropriate knowledge, skills, and support to address and overcome the many feasibility challenges that they face in implementation.

Trial Registration Number

NCT05343390 Date of registration: April 25, 2022.

Assessment of the proportion and the factors associated with partner and family-based index case HIV testing in Woliso Town, Oromia, Ethiopia: a cross-sectional study

INTRODUCTION

Around 40% of estimated people with HIV infection remain undiagnosed globally. In Ethiopia, only 72% of people with HIV know their status. This study aims to assess the proportion and the factors associated with partner and family-based index case HIV testing in Woliso Town.

METHODS

A facility-based cross-sectional study was conducted among 346 people currently on ART. Data were entered into Epi Info™ 7.2.3.1 and analyzed using SPSS 21. Significance of odds ratios was determined with 95% CI and p < 0.05.

RESULTS

Among 345 study participants, 333 (96.5%) with 95% CI (94.5-98.3) index cases have families tested for HIV. The odds of HIV testing were 7.22 times higher among those who disclosed their HIV status (AOR = 7.22 95% CI: 1.45, 35.82) compared to those who did not disclose. Those who stayed <12 months on ARTwere 87% less likely to have tested families (AOR = 0.13 95% CI: 0.03, 0.63) compared to those who stayed ≥12 months on ART.

CONCLUSION

Higher proportions of index cases have tested families. Partner and family-based index case HIV testing has association with HIV status disclosure and duration the index cases stayed on ART. The platform of partner and family-based index case HIV testing should be sustained through strengthening disclosure counseling.

Effect of index HIV self-testing for sexual partners of clients enrolled in antiretroviral therapy (ART) programs in Malawi: A randomized controlled trial

BACKGROUND

HIV testing among the sexual partners of HIV-positive clients is critical for case identification and reduced transmission in southern and eastern Africa. HIV self-testing (HIVST) may improve uptake of HIV services among sexual partners of antiretroviral therapy (ART) clients, but the impact of HIVST on partner testing and subsequent ART initiation remains unclear.

METHODS AND FINDINGS

We conducted an individually randomized, unblinded trial to assess if an index HIVST intervention targeting the partners of ART clients improves uptake of testing and treatment services in Malawi. The trial was conducted at 3 high-burden facilities in central and southern Malawi. ART clients attending HIV treatment clinics were randomized using simple randomization 1:2·5 to: (1) standard partner referral slip (PRS) whereby ART clients were given facility referral slips to distribute to their primary sexual partners; or (2) index HIVST whereby ART clients were given HIVST kits + HIVST instructions and facility referral slips to distribute to their primary sexual partners. Inclusion criteria for ART clients were: ≥15 years of age, primary partner with unknown HIV status, no history of interpersonal violence (IPV) with partner, and partner lives in facility catchment area. The primary outcome was partner testing 4-weeks after enrollment, reported by ART clients using endline surveys. Medical chart reviews and tracing activities with partners with a reactive HIV test measured ART initiation at 12 months. Analyses were conducted based on modified intention-to-treat principles, whereby we excluded individuals who did not have complete endline data (i.e., were loss to follow up from the study). Adjusted models controlled for the effects of age and marital status. A total of 4,237 ART clients were screened and 484 were eligible and enrolled (77% female) between March 28, 2018 and January 5, 2020. A total of 365 participants completed an endline survey (257/34 index HIVST arm; 107/13 PRS arm) and were included in the final analysis (78% female). Testing coverage among sexual partners was 71% (183/257) in the index HIVST arm and 25% (27/107) in the PRS arm (aRR: 2·77, 95% CI [2·56 to 3·00], p ≤ 0.001). Reported HIV positivity rates did not significantly differ by arm (16% (30/183) in HIVST versus 15% (4/27) in PRS; p = 0.99). ART initiation at 12 months was 47% (14/30) in HIVST versus 75% (3/4) in PRS arms; however, index HIVST still resulted in a 94% increase in the proportion of all partners initiating ART due to higher HIV testing rates in the HIVST arm (5% partners initiated ART in HVIST versus 3% in PRS). Adverse events including IPV and termination of the relationship did not vary by arm (IPV: 3/257 index HIVST versus 4/10 PRS; p = 0.57). Limitations include reliance on secondary report by ART clients, potential social desirability bias, and not powered for sex disaggregated analyses.

CONCLUSIONS

Index HIVST significantly increased HIV testing and the absolute number of partners initiating ART in Malawi, without increased risk of adverse events. Additional research is needed to improve linkage to HIV treatment services after HIVST use.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03271307, and Pan African Clinical Trials, PACTR201711002697316.

Prevalence and correlates of intimate partner violence following partner notification among index HIV clients attending primary healthcare facilities in Uganda

Assisted partner notification (APN) program was adopted by Uganda to increase individuals testing for HIV through their partners who test HIV positive. Thus, early enrollment in treatment and ensuring prevention services for the affected couple. However, APN is associated with high levels of Intimate partner violence (IPV). We aimed at determining the prevalence of IPV following APN in a cross-sectional study of newly diagnosed HIV clients in southwestern Uganda. We used the modified version of the Conflict Tactics Scale to assess IPV. We also collected information on sociodemographics of the index clients and their sexual partners, and outcome of linkage to care of partner. Logistic regression was used to determine the factors associated with IPV. We enrolled 327 index clients, mean age was 39.1, 63.6% were female and 35.5 experienced IPV following APN. The likelihood of experiencing IPV was more than twice if a health worker/provider disclosed the status to the partner. However, if the partners turned out to be HIV positive, it was protective against experiencing IPV, adjusted odds ratio 0.39, 95% confidence interval 0.23-0.69, p = 0.001. We conclude that IPV is common following partner notification in rural Uganda and should be screened and addressed.

"I feel good because I have saved their lives": Acceptability of assisted partner services among female index clients and male sexual partners in Kenya

INTRODUCTION

Assisted partner services (APS), or notification for sexual partners of people diagnosed with HIV, is an efficient, effective, and high yield strategy to identify people living with HIV and is recommended by the World Health Organization (WHO). However, there remains a need to further understand the acceptability of APS qualitatively from a client lens, particularly when APS is integrated into the national health system. We investigated acceptability of APS when integrated into HIV services in Kenya.

METHODS

Starting in May 2018, APS was implemented in 31 health facilities in Kisumu and Homa Bay counties in western Kenya. From January to December 2019, we conducted in-depth interviews (IDIs) with female index clients (n = 16) and male sexual partners (n = 17) in 10 facilities participating in an APS scale up study. Interviews assessed APS satisfaction, perceived benefits of the intervention, and challenges that may affect delivery or uptake. We applied the Theoretical Framework of Acceptability by Sekhon et al. (2017) as a guide to organize our findings.

RESULTS

We find that views of APS are often guided by an individual's trust in the intervention's design and implementation, and an interest to preserve one's health and that of one's family and children. There were strong and consistent acceptable views of APS as "doing good" and "saving a life" and as a means of showing love towards one's partner(s). The initial acceptability framing of individuals engaging with APS was predicated either on a feeling of comfort with the intervention, or a wariness of divulging sex partner personal information. Health care workers (HCWs) were seen to play an important role in mitigating participant fears linked with the intervention, particularly around the sensitive nature of HIV disclosure and sexual partners. Clients noted considerable challenges that affected acceptability, including the risk to the relationship of disclosing one's HIV status, and the risk of intimate partner violence.

DISCUSSION

We found that APS is acceptable as a strategy to reach male sexual partners of females diagnosed with HIV, and these findings provide opportunities to inform recommendations for further scale-up. Opportunities such as focusing on intervention confidentiality and appropriate counseling, excluding female clients at risk of IPV from this intervention, and highlighting the altruistic benefits of APS to potential clients. Understanding the perspectives of clients receiving APS in a real-world setting may be valuable to policy-makers and stakeholders interested in scaling up or enhancing APS within health systems.

Implementation process and challenges of index testing in Côte d'Ivoire from healthcare workers' perspectives

A major limiting factor in combatting the HIV epidemic has been the identification of people living with HIV. Index testing programs were developed to face that challenge. Index testing is a focused HIV testing service approach in which family members and partners of people living with HIV are offered testing. Despite the implementation of index testing, there is still a gap between the estimated number of people living with HIV and those who know their status in Côte d'Ivoire. This study aimed to understand the implementation process of index testing in Côte d'Ivoire and to identify implementation challenges from healthcare workers perspectives. In January and February 2020, we conducted a qualitative study through 105 individual semi-structured interviews regarding index testing with clinical providers (physicians, nurses, and midwives) and non-clinical providers (community counselors and their supervisors) at 16 rural health facilities across four regions of Côte d'Ivoire. We asked questions regarding the index testing process, index client intake, contact tracing and testing, the challenges of implementation, and solicited recommendations on improving index testing in Côte d'Ivoire. The interviews revealed that index testing is implemented by non-clinical providers. Passive referral, by which the index client brought their contact to be tested, and providers referral, by which a healthcare worker reached out to the index client's contact, were the preferred contact tracing and testing strategies. There was not statistically significant difference between immediate and delayed notification. Reported challenges of index testing implementation included index cases refusing to give their partner's information or a partner refusing to be tested, fear of divorce, societal stigma, long distances, lack of appropriate training in index testing strategies, and lack of a private room for counseling. The recommendations given by providers to combat these was to reinforce HIV education among the population, to train healthcare workers on index testing strategies, and to improve infrastructure, transportation, and communication resources. The study showed that the elements that influenced the process of index testing in Côte d'Ivoire were multifactorial, including individual, interpersonal, health systems, and societal factors. Thus, a multi-faceted approach to overcoming challenges of index testing in Côte d'Ivoire is needed to improve the yield of index testing.

Integration of assisted partner services within Kenya's national HIV testing services program: A qualitative study

Assisted partner service (aPS) augments HIV case-finding among sex partners to individuals newly diagnosed with HIV. In 2016, aPS was incorporated into the national HIV testing services (HTS) program in Kenya. We evaluated the extent of, barriers to, and facilitators of aPS integration into HTS. We conducted semi-structured in-depth interviews (IDIs) with 32 stakeholders selected using purposive sampling at national, county, facility, and community levels. IDIs were conducted at two timepoints, at baseline from August-September 2018 in Kisumu and January-June 2019 in Homa Bay, and at follow-up from May-August 2020 to understand changes in aPS integration over time. We defined integration as the creation of linkages between the new intervention (aPS) and the existing HTS program. Data were analyzed using thematic content analysis. We found varying degrees of aPS integration, highest in procurement/logistics and lowest in HTS provider recruitment/training. At baseline, aPS integration was low and activities were at an introductory phase. At follow-up, aPS was integrated in almost the entire HTS program with the exception of low community awareness, which was noted at both baseline and follow-up. There was increasing routinization with establishment of clear aPS cycles, e.g., quarterly data review meetings, annual budget cycles and work-plans. Major barriers included limited government funding, staff constraints, and inadequate community-level sensitization, while key facilitators included increased resources for aPS, and community health volunteer (CHV) facilitated awareness of aPS. Varying degrees of aPS integration across different units of the national HTS program highlights challenges in funding, human resource, and public awareness. Policymakers will need to address these barriers to ensure optimal provision of aPS.

"It is a process" - a qualitative evaluation of provider acceptability of HIV assisted partner services in western Kenya: experiences, challenges, and facilitators

Background

Assisted partner service (APS) is effective for increasing HIV testing services (HTS) uptake among sexual partners of people diagnosed with HIV with rare social harm. The acceptability of APS to HTS providers is important for the quality and effectiveness of APS delivery. Within a larger ongoing implementation science study of APS in western Kenya, we qualitatively evaluated the provider acceptability of APS.

Methods

From May–June 2020, we conducted virtual, semi-structured in-depth interviews with 14 HTS providers recruited from 8 of 31 study health facilities in Homa Bay and Kisumu counties. Participants were selected using criteria-based purposive sampling to maximize variation on patient volume (assessed by the number of index clients tested for HIV) and APS performance (assessed by sexual partners elicitation and enrollment). Interviews inquired providers’ experiences providing APS including challenges and facilitators and the impact of contextual factors. Data were analyzed using an inductive approach.

Results

Overall, HTS providers found APS acceptable. It was consistently reported that doing APS was a continuous process rather than a one-day job, which required building rapport and persistent efforts. Benefits of APS including efficiency in HIV case finding, expanded testing coverage in men, and increased HIV status awareness and linkage to care motivated the providers. Provider referral was perceived advantageous in terms of independent contact with partners on behalf of index clients and efficiency in partner tracing. Challenges of providing APS included protecting clients’ confidentiality, difficulty obtaining partners’ accurate contact information, logistic barriers of tracing, and clients’ refusal due to fear of being judged for multiple sexual partners, fear of breach of confidentiality, and HIV stigma. Building rapport with clients, communicating with patience and nonjudgmental attitude and assuring confidentiality were examples of facilitators. Working in rural areas and bigger facilities, training, supportive supervision, and community awareness of APS promoted APS delivery while low salaries, lack of equipment, and high workload undermined it.

Conclusions

HTS providers found APS acceptable. Delivering APS as a process was the key to success. Future scale-up of APS could consider encouraging provider referral instead of the other APS methods to improve efficiency and reduce potential harm to clients.

Strategies for Optimising Uptake of Assisted Partner Notification Services Among Newly Diagnosed HIV Positive Adults at Ndirande Health Centre, Malawi

UNAIDS Fast-Track goals for 2025 include ensuring that 95% of the people with HIV know their HIV status. In 2019, the Malawi Ministry of Health introduced its approach for achieving this: an active index testing (AIT) policy with assisted partner notification services (APNS). Under this policy, health centers can actively reach out to a contact of newly-diagnosed HIV positive client (the index) to offer voluntary HIV testing services. However, APNS uptake has been sub-optimal at many health facilities. This qualitative study considers strategies to optimize the uptake of APNS among newly-diagnosed HIV positive clients at Ndirande Health Center in Blantyre, Malawi. We conducted in-depth interviews, between February and April 2020, with 24 participants, including new HIV positive index clients, their sexual partners, and key health workers. We employ a maximum variation purposive sampling technique. Thematic inductive and deductive data analysis was done manually according to the social-ecological model. Interviewees discussed various strategies for optimizing APNS uptake among newly diagnosed HIV-infected clients. Interpersonal strategies included maximizing the use of client profiling techniques and sensitization on APNS to create demand. Institutional-level strategies were also suggested, such as providing transportation for home visits, strengthening referral notification approaches, and additional training for health workers. Policy-level recommendations included introducing home-based partner testing and intensifying use of partner notification slips. APNS is a key strategy to maximize HIV case identification. However, achieving optimal APNS in Malawi requires strengthening existing strategies and conducting additional research to identify other APNS strategies tailored to the local context.

Uptake of HIV Testing Services Through Novel Community-Based Sexual and Reproductive Health Services: An Analysis of the Pilot Implementation Phase of the Yathu Yathu Intervention for Adolescents and Young People Aged 15-24 in Lusaka, Zambia

Adolescents and young people aged 15-24 are underserved by available HIV-testing services (HTS). Delivering HTS through community-based, peer-led, hubs may prove acceptable and accessible to adolescents and young people, thus increasing HIV-testing coverage. We used data from the pilot phase of a cluster-randomised trial of community-based sexual and reproductive health services for adolescents and young people in Lusaka, Zambia, between September 2019 and January 2020, to explore factors associated with uptake of HTS through community-based hubs. 5,757 adolescents and young people attended the hubs (63% female), among whom 75% tested for HIV (76% of females, 75% of males). Community-based hubs provided HTS to 80% of adolescents and young people with no history of HIV-testing. Among females, uptake of HTS was lower among married/cohabiting females; among males, uptake was lower among unmarried males and among individuals at risk of hazardous alcohol use. The high number of adolescents and young people accessing hubs for HIV testing suggests they are acceptable. Enhanced targeting of HTS to groups who may not perceive their HIV risk needs to be implemented.

Perspectives on voluntary assisted partner notification among providers, people with HIV and the general population in Indonesia: a formative qualitative study

BACKGROUND

Voluntary assisted partner notification (aPN) services are effective in increasing access to and uptake of HIV testing among partners of people with HIV. Following recommendations by the World Health Organization in 2016, Indonesia evaluated various approaches to aPN. We present the lessons learned from formative operational research undertaken to understand provider and patient perspectives on aPN from three demonstration sites in cities with a high HIV burden.

METHODS

We conducted a formative qualitative study in three cities: Jakarta, Semarang, and Denpasar between September and October 2019. We conducted six focus group discussions (FGDs) (n = 44 participants) among health-care providers, people living with HIV and the general population. We explored participant preferences and concerns about how aPN should be delivered, including the methods of and messaging for contacting partners. All FGDs were conducted in the Indonesian language. Qualitative data were analysed using thematic analysis.

RESULTS

aPN was acceptable across different participant populations, although with caveats. Some differences were observed between the general population, providers and people living with HIV. People living with HIV were mainly concerned with confidentiality of the procedure and preferred the use of telecommunication and messages that avoid explicit mention of HIV exposure. Providers preferred similar approaches but for different reasons, being concerned mainly with self-efficacy and security. There was consensus regarding dual referral models. The use of phone calls and short messages were preferred as these are perceived to minimize negative reactions and stigma, protect client confidentiality and are suitable in the current legal situation. The general population was mainly concerned with effectiveness and prefer direct provider-led approaches, such as preferring in-person meeting with explicit notification of potential HIV exposure.

CONCLUSIONS

We found consensus among stakeholders on acceptance of aPN, especially dual referral methods. Development and implementation of aPN protocols should also consider clients' individual situations and concerns regarding safeguarding of confidentiality, and offer a range of options to accommodate all stakeholders involved.

Is HIV index testing and partner notification safe for adolescent girls and young women in low- and middle-income countries?

INTRODUCTION

While HIV index testing and partner notification (PN) services have the potential to reach adolescent girls and young women (AGYW) aged 15 to 24 and their sexual partners in need of HIV testing services, the potential social harms have not yet been studied. This commentary highlights the risks of this approach, including intimate partner violence (IPV), stigma and discrimination, and outlines an urgent research agenda to fully understand the potential harms of PN for AGYW, calling for the development of mitigation strategies.

DISCUSSION

A substantial evidence base exists demonstrating the feasibility, acceptability and effectiveness of index testing and partner notification for adults aged 18 years and older in low- and middle-income countries (LMICs), particularly for men, and for adults who are married/cohabiting and referring a current sexual partner. AGYW who are most vulnerable to HIV infection in LMICs do not reflect these demographics. Instead, they are often in age-disparate partnerships, have limited negotiating power within relationships, experience high rates of violence and face economic challenges that necessitate transactional sex. PN services may be particularly difficult for adolescent girls under 18 who face restrictions on their decision making and are at increased risk of rape. Adolescent girls may also face coercion to notify partners due to unequal power dynamics in the provider-adolescent client relationship, as well as judgemental attitudes towards adolescent sexual activity among providers.

CONCLUSIONS

As index testing and PN with AGYW is already being rolled out in some LMICs, research is urgently needed to assess its feasibility and acceptability. Implementation science studies should assess the availability, accessibility, acceptability and quality of HIV PN services for AGYW. Qualitative studies and routine monitoring with age-disaggregated data are critical to capture potential social harms, PN preferences and support needs for AGYW aged 15 to 17, 18 to 20 and 21 to 24. To mitigate potential harms, PN methods should prioritize confidentiality and avoidance of adverse outcomes. Healthcare providers should be trained to conduct routine enquiry for IPV and provide first-line support. Support services for AGYW living with HIV and survivors of violence should be implemented alongside HIV PN.

Perceived Facilitators and Barriers regarding Partner Notification in People Living With HIV in Hunan, China: A Qualitative Study From the Patient Perspective

Consensus has been reached about the important role of partner notification (PN) for HIV prevention and control programs. We used a qualitative study to explore facilitators of and barriers to PN to understand reasons for disclosure and nondisclosure by people living with HIV in China. Our main goal was to identify information related to PN that may be unique to the Chinese cultural context. Of 41 participants who were interviewed, 33 had disclosed their HIV status to sexual partners. Facilitators for PN included preserving the integrity of the partnership, social support, and potential benefits of notification; barriers included perceived discrimination/stigma, possible negative consequences, and safety concerns. Participant physical health conditions, strength of the relationship, and concordant identification were found to be conditional factors of PN. Our findings provide information for a better understanding of PN in Chinese culture and offer a reference for developing more specific strategies to facilitate PN.

HIV Positivity and Referral to Treatment Following Testing of Partners and Children of PLHIV Index Patients in Public Sector Facilities in South Africa

Background

There is an imperative need for innovative interventions to identify people living with HIV and initiate them on antiretroviral therapy (ART). The objective of this study was to determine the feasibility of providing index partner/child testing of people living with HIV.

Methods

We trained 86 nurses and counsellors in 56 public health facilities in six high HIV burden Districts in 2017 to provide index partner/child testing (tracing and testing of partners/children of people living with HIV). We collected programmatic data including index partner/child HIV positivity by age, gender and location of testing. In sub-analyses, we evaluated factors associated with identifying HIV-positive partners and children in separate models using multivariable logistic regression.

Results

We tested 16,033 partners and children of index patients between October 2017 and June 2018. Most of those tested were female (61%) and 20–39 years old (39%). Overall, 6.4% were 10–14 years old, 9.5% were 15–19 years; 8% were >50 years. HIV positivity was 38% (95% CI=36%−40%). In children ages 10–14, 13% were HIV-infected (95% CI=11%−14%). In subanalyses, HIV positivity in partners was associated with their increased age (adjusted odds ratio [aOR] for increase in 5-year age category=1.21; 95% CI=1.04, 1.42), female gender (aOR=1.38; 95% CI=1.04, 1.82) and bringing the partner in for HIV testing vs. referring the partner through the provider or recommending testing to the partner (aOR=1.94, 95% CI=1.43, 2.63), adjusting for location of testing. Almost all patients diagnosed (97%) were referred to ART.

Conclusion

Providing index partner/child testing was feasible and we identified a very high yield when testing partners/children of index patients. Index partner/child testing should be offered to all patients living with HIV to improve case finding.

Assisted partner notification services for patients receiving HIV care and treatment in an HIV clinic in Nairobi, Kenya: a qualitative assessment of barriers and opportunities for scale-up

INTRODUCTION

Identifying HIV-positive individuals is increasingly recognized as one of the most important and most challenging of the UNAIDS 90-90-90 goals. Assisted partner notification services (aPNS) involves tracing and offering HIV testing to partners of HIV-positive individuals, and is effective and safe when provided to newly diagnosed HIV-positive patients. Voluntary aPNS is now part of the World Health Organization's guidelines for HIV prevention and care. However, uptake of aPNS is significantly lower among adults with established HIV infection already engaged in care compared to newly diagnosed individuals. We sought to describe barriers encountered and potential opportunities to providing aPNS to established patients living with HIV.

METHODS

We conducted focus group discussions and in-depth interviews at Nairobi's largest public HIV clinic in April to May 2016 to elucidate barriers to and opportunities for aPNS among established patients engaged in HIV care. Participants included HIV-positive adults in care, their partners, and healthcare workers (HCWs). Qualitative data analysis took a grounded theory approach.

RESULTS

Barriers to aPNS fell under three main categories. Fear of disclosure to partners included concerns over relationship repercussions, loss of trust, blame and violence. Stigma and discrimination were described in the healthcare setting, at church and in general society. Participants described difficulties approaching communication, including cultural barriers and differences in education. For almost every barrier a potential solution was also identified, and a barrier-opportunity relationship emerged. Opportunities included using couples testing centres to aid in disclosure, focusing on the ambiguous introduction of the infection, and sensitization of HCWs and community leaders.

CONCLUSIONS

aPNS among established HIV patients is associated with different barriers and opportunities than aPNS among newly diagnosed patients, and HCWs should build their capacity to support aPNS in this population. There is a strong need for increased training and sensitization on the use of aPNS in different circumstances and for different clients, taking into consideration factors such as timing of partner notification, characteristics of the relationship and duration of knowledge discordance. The overall success of this intervention among populations living with HIV may rely on customization of services and key messages to meet the patients' specific needs.

Assisted HIV partner services training in three sub-Saharan African countries: facilitators and barriers to sustainable approaches

INTRODUCTION

Healthcare worker training is essential to successful implementation of assisted partner services (aPS), which aims to improve HIV testing and linkage-to-care outcomes for previously unidentified HIV-positive individuals. Cameroon, Kenya and Mozambique are three African countries that have implemented aPS programmes and are working to bring those programmes to scale. In this paper, we present and compare different aPS training strategies implemented by these three countries, and discuss facilitators and barriers associated with implementation of aPS training in sub-Saharan Africa.

DISCUSSION

aPS training programmes in Cameroon, Kenya and Mozambique share the following components: the development of comprehensive and interactive training curricula, recruitment of qualified trainees and trainers with intimate knowledge of the community served, continuous training, and rigorous monitoring and evaluation activities. Cameroon and Kenya were able to engage various stakeholders early on, establishing multilateral coalitions that facilitated attainment of long-term buy-in from the local governments. Ministries of Health and various implementing partners are often included in strategic planning and delivery of training curricula to ensure sustainability of the training programmes. Kenya and Mozambique have integrated aPS training into the national HTS guidelines, which are being rolled out nationwide by the Ministries of Health and implementing partners. Continual revision of training curricula to reflect the country context, as well as ongoing monitoring and evaluation, have also been identified as key facilitators to sustain aPS training programmes. Some of the barriers to scale-up and sustainability of aPS training include limited funding and resources for training and scale-up and shortage of aPS providers to facilitate on-the-job mentorship.

CONCLUSIONS

These three programmes demonstrate that aPS training can be implemented and scaled up in sub-Saharan Africa. As countries plan for initial implementation or national scale-up of aPS services, they will need to establish government buy-in, expand funding sources, address the shortage of staff and resources to provide aPS and on-the-job mentorship, and continuously collect data to evaluate and improve aPS training plans. Development of national standards for aPS training, empowered healthcare providers, increased government commitment, and sustained funding for aPS services and training will be crucial for successful aPS implementation.

Enhancing an HIV index case testing passive referral model through a behavioural skills-building training for healthcare providers: a pre-/post-assessment in Mangochi District, Malawi

INTRODUCTION

Although knowledge of HIV positivity is a necessary step towards engagement in HIV care, more than one quarter of HIV-positive Malawians remain unaware of their HIV status. Testing the sexual partners, guardians and children of HIV-positive persons (index case finding or ICF) is a promising way of identifying HIV-positive persons unaware of their HIV status. ICF can be passive where the HIV-positive individual (index) invites a partner (or contact) for HIV testing or active where a health provider assists the index with partner notification and offers HIV testing to the partner. Strategies to improve passive ICF have not been thoroughly studied. We describe the impact of a behavioural skills-building training to enhance healthcare workers' (HCWs) implementation of Malawi's passive ICF programme.

METHODS

In June 2017, HCWs from 36 health facilities in Mangochi were oriented to Malawi's ICF programme and began implementation. In February and April 2018, a total of 573 HCWs from these facilities received further training from the Tingathe Programme. The training focused on eliciting more untested sexual contacts from indexes and better equipping indexes on issuing "family referral slips" to contacts. Monthly programmatic data were abstracted from clinical registers from October 2017 to July 2018. Monthly programmatic indicators were collected from the Index Case Testing Register and the HIV Counselling and Testing Register and were entered into a data set with one record per facility per month. T-tests were used to compare the means of these indicators.

RESULTS

During the ten-month study period, there were 200 facility-months observed before and 124 facility-months observed after training. The mean number of indexes identified per facility-month remained stable after training (pre = 18.9, post = 21.2, p = 0.74), but the mean number of sexual partners listed per facility-month (pre = 6.3, post = 10.6, p < 0.001) increased. The mean number of contacts who received HIV testing (pre = 11.1, post = 24.8, p < 0.001) and the mean number of HIV-positive contacts identified per facility-month (pre = 1.3, post = 2.3, p < 0.001) also increased.

CONCLUSIONS

A brief behavioural skills-building training impacted a range of meaningful outcomes, including identification of HIV-positive individuals in a passive ICF programme. Such approaches could facilitate the identification of HIV-positive persons unaware of their HIV status, a necessary step for engagement in HIV care.

HIV Partner Notification Values and Preferences Among Sex Workers, Fishermen, and Mainland Community Members in Rakai, Uganda: A Qualitative Study

HIV partner notification involves contacting sexual partners of people who test HIV positive and referring them to HIV testing, treatment, and prevention services. To understand values and preferences of key and general populations in Rakai, Uganda, we conducted 6 focus group discussions and 63 in-depth interviews in high prevalence fishing communities and low prevalence mainland communities. Participants included fishermen and sex workers in fishing communities, male and female mainland community members, and healthcare providers. Questions explored three approaches: passive referral, provider referral, and contract referral. Qualitative data were coded and analyzed using a team-based matrix approach. Participants agreed that passive referral was most suitable for primary partners. Provider referral was acceptable in fishing communities for notifying multiple, casual partners. Healthcare providers voiced concerns about limited time, resources, and training for provider-assisted approaches. Options for partner notification may help people overcome barriers to HIV serostatus disclosure and help reach key populations.

Reaching the First 90 in Uganda: Predictors of Success in Contacting and Testing the Named Sexual Partners of HIV+ Index Clients in Kiboga District

Assisted partner notification programs represent one strategy for targeted HIV testing and treatment of exposed individuals in high-risk populations. This study of a pilot Partner Services program in rural Uganda describes predictors of successful contact tracings and testing of partners of HIV+ individuals and possible barriers to contact. Partner contact tracing data was extracted from registers at seven Ministry of Health facilities between May and October 2016, to inform program implementation and scale up. A total of 464 HIV+ index clients named 660 sexual partners; 334/660 (51%) were contacted, 193/334 (58%) tested for HIV, and 61/193 (32%) tested HIV+. Current relationship status predicted contact [AOR = 0.23; (95% CI 0.15, 0.37), p < 0.0001] and testing [AOR = 0.19; (95% CI 0.09, 0.36), p < 0.0001]. Partner contact information type was associated with contact (p < 0.0001), and assisted disclosure with testing (p < 0.0001). Partner contact tracing is an effective means of identifying undiagnosed HIV infections.

Improving Laboratory Efficiency in the Caribbean to Attain the World Health Organization HIV Treat All Recommendations

Scientific evidence showing the benefits of early initiation of antiretroviral therapy (ART) prompted World Health organization (WHO) to recommend that all persons diagnosed as HIV positive should commence ART irrespective of CD4 count and disease progression. Based on this recommendation, countries should adopt and implement the HIV "Treat All" policy to achieve the UNAIDS 90-90-90 targets and ultimately reach epidemic control. Attaining this goal along the HIV treatment cascade depends on the laboratory to monitor progress and measure impact. The laboratory plays an important role in HIV diagnosis to attain the first 90 and in viral load (VL) and HIV drug resistance testing to reinforce adherence, improve viral suppression, and measure the third 90. Countries in the Caribbean region have endorsed the WHO HIV "Treat all" recommendation; however, they are faced with diminishing financial resources to support laboratory testing, seen as a rate-limiting factor to achieving this goal. To improve laboratory coverage with fewer resources in the Caribbean there is the need to optimize laboratory operations to ensure the implementation of high quality, less expensive evidence-based approaches that will result in more efficient and effective service delivery. Suggested practical and innovative approaches to achieve this include: (1) targeted testing within HIV hotspots; (2) strengthening sample referral systems for VL; (3) better laboratory data collection systems; and (4) use of treatment cascade data for programmatic decision-making. Furthermore, strengthening quality improvement and procurement systems will minimize diagnostic errors and guarantee a continuum of uninterrupted testing which is critical for routine monitoring of patients to meet the stated goal.