"If the patients decide not to tell what can we do?"- TB/HIV counsellors' dilemma on partner notification for HIV

Impart: findings from a prison-based model of HIV assisted partner notification in Indonesia

INTRODUCTION

Assisted partner notification (APN) safely and effectively increases partner awareness of HIV exposure, testing and case identification in community settings. Nonetheless, it has not been specifically developed or evaluated for use in prison settings where people with HIV often are diagnosed and may have difficulty contacting or otherwise notifying partners. We developed Impart, a prison-based APN model, and evaluated its efficacy in Indonesia to increase partner notification and HIV testing.

METHODS

From January 2020 to January 2021, 55 incarcerated men with HIV were recruited as index participants from six jail and prison facilities in Jakarta in a two-group randomized trial comparing the outcomes of self-tell notification (treatment as usual) versus Impart APN in increasing partner notification and HIV testing. Participants voluntarily provided names and contact information for sex and drug-injection partners in the community with whom they had shared possible HIV exposure during the year prior to incarceration. Participants randomized to the self-tell only condition were coached in how to notify their partners by phone, mail or during an in-person visit within 6 weeks. Participants randomized to Impart APN could choose between self-tell notification or anonymous APN by a two-person team consisting of a nurse and outreach worker. We compared the proportion of partners in each group who were notified of exposure by the end of 6 weeks, subsequently tested and HIV diagnosed.

RESULTS

Index participants (n = 55) selected 117 partners for notification. Compared to self-tell notification, Impart APN resulted in nearly a six-fold increase in the odds of a named partner being notified of HIV exposure. Nearly two thirds of the partners notified through Impart APN (15/24) completed HIV testing within 6 weeks post notification compared to none of those whom participants had self-notified. One-third of the partners (5/15) who completed HIV testing post notification were diagnosed as HIV positive for the first time.

CONCLUSIONS

Voluntary APN can be successfully implemented with a prison population and within a prison setting despite the many barriers to HIV notification that incarceration presents. Our findings suggest that the Impart model holds considerable promise to increase partner notification, HIV testing and diagnosis among sex and drug-injecting partners of HIV-positive incarcerated men.

"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.

Impact of information diffusion on epidemic spreading in partially mapping two-layered time-varying networks

We propose a new epidemic model considering the partial mapping relationship in a two-layered time-varying network, which aims to study the influence of information diffusion on epidemic spreading. In the model, one layer represents the epidemic-related information diffusion in the social networks, while the other layer denotes the epidemic spreading in physical networks. In addition, there just exist mapping relationships between partial pairs of nodes in the two-layered network, which characterizes the interaction between information diffusion and epidemic spreading. Meanwhile, the information and epidemics can only spread in their own layers. Afterwards, starting from the microscopic Markov chain (MMC) method, we can establish the dynamic equation of epidemic spreading and then analytically deduce its epidemic threshold, which demonstrates that the ratio of correspondence between two layers has a significant effect on the epidemic threshold of the proposed model. Finally, it is found that MMC method can well match with Monte Carlo (MC) simulations, and the relevant results can be helpful to understand the epidemic spreading properties in depth.

Epidemic spreading with awareness and different timescales in multiplex networks

One of the major issues in theoretical modeling of epidemic spreading is the development of methods to control the transmission of an infectious agent. Human behavior plays a fundamental role in the spreading dynamics and can be used to stop a disease from spreading or to reduce its burden, as individuals aware of the presence of a disease can take measures to reduce their exposure to contagion. In this paper, we propose a mathematical model for the spread of diseases with awareness in complex networks. Unlike previous models, the information is propagated following a generalized Maki-Thompson rumor model. Flexibility on the timescale between information and disease spreading is also included. We verify that the velocity characterizing the diffusion of information awareness greatly influences the disease prevalence. We also show that a reduction in the fraction of unaware individuals does not always imply a decrease of the prevalence, as the relative timescale between disease and awareness spreading plays a crucial role in the systems' dynamics. This result is shown to be independent of the network topology. We finally calculate the epidemic threshold of our model, and show that it does not depend on the relative timescale. Our results provide a new view on how information influence disease spreading and can be used for the development of more efficient methods for disease control.

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.

"I was referred from the other side": Gender and HIV testing among older South Africans living with HIV

South Africa has a Universal Test and Treat (UTT) policy in place to ensure that everyone tests for HIV and can access treatment if they test positive. The aim of this study is to document the pathways that older South Africans who are living with HIV take to access testing and treatment in this context. Despite the aging of the HIV epidemic in South Africa and clear evidence that testing older persons (over age 50) is necessary, very little is known about the circumstances under which older persons test for HIV or their motivations for doing so. In this study, we analyze 21 qualitative, in-depth interviews with women and men aged 50 and over who are living with HIV from two townships outside of Cape Town. Using grounded theory to specify emerging themes, we find similarities and differences between older men and women in their pathways to testing. Men primarily test for HIV when their spouse is diagnosed or in connection with TB testing and treatment. Older women, who are more likely to be widowed or divorced, often test for HIV only when they are symptomatic or not responding appropriately to care for non-communicable diseases. Most importantly, we find that older South Africans do not seek testing as a response to risk. Instead, older men and women test only once they are symptomatic and referred by a provider, or as a result of a partner's status. Our respondents, particularly the women, expressed "shock" and confusion at learning they were HIV-positive because they do not see themselves as at risk of acquiring HIV. Because the benefits of UTT are greatest with early detection and treatment, older persons' tendency to test at such a late stage of illness decreases the individual and population level advantages of UTT. More research is needed to understand older persons' risk and testing behavior so that policy and programs include HIV testing messages that reach this population.

HIV Status Communication with Sex Partners and Associated Factors Among High-Risk MSM and Transgender Women in Lima, Peru

Men who have sex with men (MSM) and transgender women (TW) are key populations in the HIV epidemic. HIV status communication between sex partners can inform decisions regarding sexual behavior. MSM and TW were asked about HIV status communication with sex partners at baseline, 9- and 18-months. GEE models assessed associations with HIV status communication at baseline using prevalence ratios (PRs) and longitudinally using odds ratios (ORs). At baseline, those who had previously had an HIV test, disclosed their HIV status to 42 % of their sex partners. HIV status communication was associated with knowing their sex partner's HIV status at baseline (aPR 5.20) and longitudinally (aOR 1.86). HIV positivity at baseline was negatively associated with HIV status communication during follow-up (aOR 0.55). All reported aPRs and aORs have p < 0.05. Interventions promoting HIV status communication and more frequent HIV testing should be explored as current efforts are insufficient.

The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence

BACKGROUND

Global progress towards HIV prevention and care is contingent upon increasing the number of those aware of their status through HIV testing. Provider-initiated HIV testing and counseling is recommended globally as a strategy to enhance uptake of HIV testing and is primarily conducted by nurses and midwives. Research shows that provider-initiated HIV testing and counseling implementation is sub-optimal. The reasons for this are unclear.

OBJECTIVES

The review aimed to explore nurses' and midwives' views and experiences of the provision and management of provider-initiated HIV testing and counseling.

INCLUSION CRITERIA

TYPES OF PARTICIPANTS

All cadres of nurses and midwives were considered, including those who undertake routine HIV testing as part of a diverse role and those who are specifically trained as HIV counselors. Types of phenomenon of interest: The review sought to understand the views and experiences of the provision and management of provider-initiated HIV testing and counseling (including perceptions, opinions, beliefs, practices and strategies related to HIV testing and its implementation in practice).

CONTEXT

The review included only provider-initiated HIV testing and counseling. It excluded all other models of HIV testing. The review included all countries and all healthcare settings. Types of studies: This review considered all forms of qualitative study design and methodology. Qualitative elements of a mixed method study were included if they were presented separately within the publication.

SEARCH STRATEGY

A three-step search strategy was utilized. Eight databases were searched for papers published from 1996 to October 2014, followed by hand searching of reference lists. Only studies published in the English language were considered.

METHODOLOGICAL QUALITY

Methodological quality was assessed using the Qualitative Assessment and Review Instrument developed by the Joanna Briggs Institute.

DATA EXTRACTION

Qualitative findings were extracted using the Joanna Briggs Institute Qualitative Assessment and Review Instrument.

DATA SYNTHESIS

Qualitative research findings were pooled using a pragmatic meta-aggregative approach and the Joanna Briggs Institute Qualitative Assessment and Review Instrument software.

RESULTS

This review included 21 publications from 18 research studies, representing a wide range of countries and healthcare settings. There were 245 findings which were aggregated into 12 categories and five synthesized findings. 1. Nurses/midwives are supportive of provider-initiated HIV testing and counseling if it is perceived to enhance patient care and to align with perceived professional roles. 2. Nurses'/midwives' ability to perform provider-initiated HIV testing and counseling well requires an appropriate infrastructure and adequate human and material resources. 3. At the organizational level, nurses'/midwives' engagement with provider-initiated HIV testing and counseling is facilitated by an inclusive management structure, alongside the provision of ongoing training and clinical supervision. Provider-initiated HIV testing and counseling is hindered by difficulties in fitting it into existing workloads and routines. 4. Nurses/midwives perceive that good quality care in provider-initiated HIV testing and counseling involves finding a balance between public health needs and individual patient needs. Good care requires time and the ability to apply a patient centred approach. 5. The emotional work involved in provider-initiated HIV testing and counseling can be stressful. Nurses/Midwives may require support to deal with complex moral and ethical issues.

CONCLUSIONS

This review shows that provider-initiated HIV testing and counseling is supported by nurses/midwives who strive to implement it according to principles of good care and a patient centered approach. Nurses/midwives face multiple operational, infra-structural, resource and ethical challenges in the implementation of provider-initiated HIV testing and counseling.

IMPLICATIONS FOR PRACTICE

The implementation process for provider-initiated HIV testing and counseling would benefit from using a quality improvement framework. Nurses/midwives undertaking provider-initiated HIV testing and counseling require management support, ongoing training and adequate infrastructure/resources. Additional guidance is required on legal/ethical issues in testing of children and in third party disclosure.

IMPLICATIONS FOR RESEARCH

Operational research is required to determine an optimal skill mix and optimal methods of integrating provider-initiated HIV testing and counseling into existing work routines.

Analysis of medical confidentiality from the islamic ethics perspective

Confidentiality is one of the old rules of the medical profession. While emphasizing the necessity of confidentiality in religious teachings, disclosure of other's secrets to commit sin deserves punishment hereafter known. Today, progress in medical science and invention of new diagnostic and therapeutic procedures, as well as the extent of information and disclosure of the secrets of the patients, have provided more than ever. After explaining the concepts and principles of confidentiality in medical ethics, the Islamic-oriented Virtue Ethics, in a comparative review, share the differences in these two sets of ethical review and explain the issue of confidentiality. In professional medical ethics, only the behaviors of health staff are evaluated and moral evaluation of the features cannot be evaluated, but in Islamic ethics, the moral evaluation of the features that are sensual, confidentiality is more stable, without any external supervision will maintain its efficiency.

Rewards and challenges of providing HIV testing and counselling services: health worker perspectives from Burkina Faso, Kenya and Uganda

The rapid scale-up of human immunodeficiency virus (HIV) testing, counselling and treatment throughout sub-Saharan Africa has raised questions about how to protect patients' rights to consent, confidentiality, counselling and care in resource-constrained settings. The Multi-country African Testing and Counselling for HIV (MATCH) study investigated client and provider experiences with different modes of testing in sub-Saharan Africa. One component of that study was a survey of 275 HIV service providers in Burkina Faso, Kenya and Uganda that gathered quantifiable indicators and qualitative descriptions using a standardized instrument. This article presents provider perspectives on the challenges of obtaining consent, protecting confidentiality, providing counselling and helping clients manage disclosure. It also explores health workers' fear of infection within the workplace and their reports on discrimination against HIV clients within health facilities. HIV care providers in Burkina Faso, Kenya and Uganda experienced substantial rewards from their work, including satisfaction from saving lives and gaining professional skills. They also faced serious resource constraints, including staff shortages, high workloads, lack of supplies and inadequate infrastructure, and they expressed concerns about accidental exposure. Health workers described heavy emotional demands from observing clients suffer emotional, social and health consequences of being diagnosed with HIV, and also from difficult ethical dilemmas related to clients who do not disclose their HIV status to those around them, including partners. These findings suggest that providers of HIV testing and counselling need more resources and support, including better protections against HIV exposure in the workplace. The findings also suggest that health facilities could improve care by increasing attention to consent, privacy and confidentiality and that health policy makers and ethicists need to address some unresolved ethical dilemmas related to confidentiality and non-disclosure, and translate those discussions into better guidance for health workers.

The social and gender context of HIV disclosure in sub-Saharan Africa: a review of policies and practices

This paper reviews the legal and policy context of HIV disclosure in sub-Saharan Africa, as well as what is known about rates, consequences and social context of disclosure, with special attention to gender issues and the role of health services. Persistent rates of nondisclosure by those diagnosed with HIV raise difficult ethical, public health and human rights questions about how to protect the medical confidentiality, health and well-being of people living with HIV on the one hand, and how to protect partners and children from HIV transmission on the other. Both globally and within the sub-Saharan African region, a spate of recent laws, policies and programmes have tried to encourage or - in some cases - mandate HIV disclosure. These policies have generated ethical and policy debates. While there is consensus that the criminalization of transmission and nondisclosure undermines rights while serving little public health benefit, there is less clarity about the ethics of third party notification, especially in resource-constrained settings. Despite initiatives to encourage voluntary HIV disclosure and to increase partner testing in sub-Saharan Africa, health workers continue to grapple with difficult challenges in the face of nondisclosure, and often express a need for more guidance and support in this area. A large body of research indicates that gender issues are key to HIV disclosure in the region, and must be considered within policies and programmes. Taken as a whole, this evidence suggests a need for more attention to the challenges and dilemmas faced by both clients and providers in relation to HIV disclosure in this region and for continued efforts to consider the perspectives and rights of all those affected.