Improving HIV test uptake and case finding with assisted partner notification services

Alcohol Drinking by Husbands/Partners is Associated with Higher Intimate Partner Violence against Women in Angola

Intimate partner violence (IPV), as the most prevalent form of violence against women, is a commonly encountered phenomenon across sub-Saharan African countries, including Angola. As a fast-growing economy, Angola is experiencing a booming alcohol industry and persistent IPV and women’s rights issues, along with weak prohibition and enforcement against this practice. However, so far, there is no systematic research investigating the predictors of IPV in Angola and whether spousal alcohol drinking has any relationship with women’s experience of IPV. Therefore, in this study, we aimed to assess the predictors of IPV (defined as physical, emotional, and sexual violence) among Angolan women with a special focus on their partners’ alcohol drinking habit. Cross-sectional data on 7669 women aged 15–49 years from the Angola Demographic and Health Survey were used for this study. Data were analyzed using descriptive and logistic regression methods. Results indicated that physical IPV (32.3%, 95% Confidence Interval = 30.3 to 34.5) was most prevalent, followed by emotional (27.3%, 95% CI = 25.3 to 29.4) and sexual IPV (7.4%, 95% CI = 6.6 to 8.4). In the multivariate analysis, higher education and household wealth status showed protective effects against certain forms of IPV. Alcohol drinking by husbands/partners was associated with significantly higher odds of experiencing physical [OR = 2.950; 95% CI = 2.632, 3.306], emotional [OR = 2.470; 95% CI = 2.187,2.789], and sexual IPV [OR = 2.729; 95% CI = 2.220, 3.354] among women. Women who reported experiencing physical IPV had increased odds of drinking alcohol [OR = 1.474; 95% CI = 1.290, 1.684] compared with those who did not. These findings reflect the widespread prevalence of IPV in sub-Saharan African countries. Special focus should be given to married men with alcohol drinking habits to reduce women’s vulnerability to IPV and dependence on alcohol use.

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.

A Systematic Review of the Current Status of Safer Conception Strategies for HIV Affected Heterosexual Couples in Sub-Saharan Africa

We conducted a systematic review of safer conception strategies (SCS) for HIV-affected couples in sub-Saharan Africa to inform evidence-based safer conception interventions. Following PRISMA guidelines, we searched fifteen electronic databases using the following inclusion criteria: SCS research in HIV-affected couples; published after 2007; in sub-Saharan Africa; primary research; peer-reviewed; and addressed a primary topic of interest (SCS availability, feasibility, and acceptability, and/or education and promotion). Researchers independently reviewed each study for eligibility using a standardized tool. We categorize studies by their topic area. We identified 41 studies (26 qualitative and 15 quantitative) that met inclusion criteria. Reviewed SCSs included: antiretroviral therapy (ART), pre-exposure prophylaxis, timed unprotected intercourse, manual/self-insemination, sperm washing, and voluntary male medical circumcision (VMMC). SCS were largely unavailable outside of research settings, except for general availability (i.e., not specifically for safer conception) of ART and VMMC. SCS acceptability was impacted by low client and provider knowledge about safer conception services, stigma around HIV-affected couples wanting children, and difficulty with HIV disclosure in HIV-affected couples. Couples expressed desire to learn more about SCS; however, provider training, patient education, SCS promotions, and integration of reproductive health and HIV services remain limited. Studies of provider training and couple-based education showed improvements in communication around fertility intentions and SCS knowledge. SCS are not yet widely available to HIV-affected African couples. Successful implementation of SCS requires that providers receive training on effective SCS and provide couple-based safer conception counseling to improve disclosure and communication around fertility intentions and reproductive health.

Effect of clients Strategic Index Case Testing on community-based detection of HIV infections (STRICT study)

BACKGROUND

Strategic Index Case Testing (STRICT), a form of partner notification service, was initiated to track, identify and notify sexual partners of people living with HIV (Index clients) with the sole aim of testing them to determine their HIV status and linking clients who are positive to Anti-Retroviral Therapy (ART). This research analyzed the HIV sero-prevalence among sexual partners of HIV positive clients using STRICT and determines the role of STRICT in HIV epidemic control.

METHODS

This is a non-control Interventional study that determined the impact of Strategic Index Case Testing (STRICT) on detecting previously undiagnosed HIV infections among sexual partners of positive index clients. This study was conducted in seven Local Government Areas (LGAs) of Karu, Nasarawa, Lafia, Doma, AMAC, Bwari, and Ushongo. These LGAs were selected for HIV epidemic control due to projected high prevalence of HIV from previous program level data. HTS was offered to sexual partners of index PLHIV from facility and community within the LGAs. Index clients were PLHIV diagnosed from outreaches, hot spots set up in strategic places and Provider Initiated Testing and Counseling (PITC) in comprehensive and primary health care facilities. Newly diagnosed PLHIV and those already enrolled and commenced on ART from October 2015 to July 2016 were identified from source registers. These index clients were counseled on how to notify their sexual partners about their HIV status and on bringing them for HIV Testing and Counseling (HTS). Those unable to do so after a given period of time were assisted by health workers in informing their various sexual partners based on the confidential agreement and informed consent signed by the Index clients.

FINDINGS

A total of 1277 index cases were counseled and interviewed with 879 index clients agreeing to disclosure, giving a disclosure rate of 68.3%. We identified 888 sexual partners from the interviews and traced 870 (97.9%) sexual contacts. A total of 741 (85.2%) of 870 sexual contacts traced were tested for HIV, out of which 378 (51%) tested positive using an HIV rapid test kit, and this was statistically significant at P Value=0.0254. A total of 348 (92.1%) out of 378 HIV positive sexual partners were immediately commenced on ART using the recommended UNAIDS Test and Treat approach to HIV epidemic control.

INTERPRETATION

STRICT identifies the need for reaching out to sexual partners of index clients and providing them with HIV Testing Services (HTS) as they belong to a high risk priority population and also linking them to care and treatment. This group of people must be reached with HTS strategies in order to end the HIV epidemic as evidenced by high sero-prevalence of 51% among them.

Think global, act local: the experience of Global Fund and PEPFAR joint cascade assessments to harmonize and strengthen key population HIV programmes in eight countries

INTRODUCTION

The Global Fund and the US President's Emergency Plan for AIDS Relief (PEPFAR) are major donors to HIV services with key populations (KPs) to achieve the UNAIDS 95-95-95 epidemic control goals. The programmes they fund are not always well aligned or coordinated, decreasing their effectiveness. Joint assessments are designed and led by LINKAGES, a project funded by PEPFAR and the US Agency for International Development, to improve coordination among donors and on-the-ground implementation of KP HIV programmes. Joint assessments help identify barriers that prevent KPs from accessing interventions along the cascade of prevention, diagnosis and treatment services, and provide recommendations to improve and align programmes. Detailed reports from eight assessments in Malawi, Cameroon, Swaziland, Haiti, Angola, Nepal, Côte d'Ivoire and Botswana were analysed for thematic challenges, and recommendations are presented. The purpose of the paper is to identify commonalities across KP HIV programmes that were found through the assessments so others can learn and then strengthen their programmes to become more effective.

DISCUSSION

The joint cascade assessments offered countries feedback on HIV programme challenges and recommendations for strengthening them at national, subnational and local levels. Shared intervention areas included: (1) robust population size estimates to inform service delivery targets and to budget resources for KP outreach; (2) accessible and KP-friendly services most relevant to individuals to increase retention in the HIV cascade; (3) decentralized, community-based services for HIV testing and antiretroviral therapy, and new approaches including self-testing and PrEP; (4) addressing structural issues of stigma, discrimination and violence against KPs to create a more enabling environment; and (5) more effective and continual tracking of KPs across the cascade, and coordinated, harmonized monitoring tools and reporting systems between donor-funded and national programmes.

CONCLUSIONS

The assessment teams and country stakeholders viewed the assessments as a best practice for coordinating donor-funded programmes that may overlap or inefficiently serve KPs. Global and national HIV programmes need investments of time, resources, and commitment from stakeholders to continually course-correct to align and improve programmes for sustained impact. The type of continued partnership demonstrated by the joint assessments is key to address HIV among KPs globally.

Social network methods for HIV case-finding among people who inject drugs in Tajikistan

INTRODUCTION

HIV testing programmes have struggled to reach the most marginalized populations at risk for HIV. Social network methods such as respondent-driven sampling (RDS) and peer-based active case-finding (ACF) may be effective in overcoming barriers to reaching these populations. We compared the client characteristics, proportion testing HIV positive (yield), and number of new cases found through two RDS strategies and an ACF approach to HIV case-finding among people who inject drugs (PWID) in Tajikistan.

METHODS

Routine programme data from adult PWID recruited to testing under the HIV Flagship Project in Tajikistan were analysed to compare client demographic and clinical characteristics across the three approaches. We also compared the number of previously untested clients, the number of new HIV cases found, and the yield across the case-finding strategies, and evaluated predictors of new HIV diagnosis using fixed-effects logistic regression.

RESULTS

From 24 October 2016 to 30 June 2017, Flagship tested 10,300 PWID for HIV, including 2143 under RDS with unrestricted waves (RDS1, yield: 1.5%), 3517 under restricted RDS (RDS2, yield: 2.6%), and 4640 under ACF (yield: 1.5%). Clients recruited under ACF were similar in age (35.8 vs. 36.8) and gender (91% vs. 90% male) to those recruited through RDS, though ACF clients were more likely to report being a first-time tester (85.1% vs. 68.3%, p < 0.001). After controlling for age, sex, previous testing history and accounting for clustering at the site level, we found that clients tested under both RDS1 (aOR: 1.74, 95% CI: 1.04 to 2.90) and RDS2 (aOR: 1.54, 95% CI: 1.11 to 2.15) had higher odds of testing newly positive for HIV relative to clients recruited through ACF. We did not find significant differences in the odds of new HIV infection between those recruited from RDS1 versus RDS2 (aOR: 1.12, 95% CI: 0.67 to 1.86).

CONCLUSIONS

RDS-based interventions resulted in higher yields and overall case-finding, especially when recruitment was restricted. However, ACF identified a higher proportion of first-time testers. To find at least 90% of PWID living with HIV in Tajikistan, it may be necessary to implement multiple case-finding approaches concurrently to maximize testing coverage.

Outcomes and Experiences of Men and Women with Partner Notification for HIV Testing in Tanzania: Results from a Mixed Method Study

A growing evidence base supports expansion of partner notification in HIV testing services (HTS) in sub-Saharan Africa. In 2015, a cross-sectional study was conducted in Njombe region, Tanzania, to evaluate partner notification within facility-based HTS. Men and women newly diagnosed with HIV were enrolled as index clients and asked to list current or past sexual partners for referral to HTS. Successful partner referral was 2.5 times more likely among married compared to unmarried index clients and 2.2 times more likely among male compared to female index clients. In qualitative analysis, male as well as female index clients mentioned difficulties notifying past or casual partners, and noted disease symptoms as a motivating factor for HIV testing. Female index clients mentioned gender-specific challenges to successful referral. Women may need additional support to overcome challenges in the partner notification process. In addition to reducing barriers to partner notification specific to women, a programmatic emphasis on social strengths of males in successfully referring partners should be considered.