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Sharma M, Mambo BW, Kingston H, Otieno G, Masyuko S, Lagat H, Katz DA, Wamuti B, Macharia P, Bosire R, Mugambi M, Kariithi E, Farquhar C. Providing HIV-assisted partner services to partners of partners in western Kenya: an implementation science study. J Int AIDS Soc 2024; 27 Suppl 1:e26280. [PMID: 38965979 PMCID: PMC11224583 DOI: 10.1002/jia2.26280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 05/08/2024] [Indexed: 07/06/2024] Open
Abstract
INTRODUCTION Assisted partner services (APS), or exposure notification and HIV testing for sexual partners of persons diagnosed HIV positive (index clients), is recommended by the World Health Organization. Most APS literature focuses on outcomes among index clients and their partners. There is little data on the benefits of providing APS to partners of partners diagnosed with HIV. METHODS We utilized data from a large-scale APS implementation project across 31 facilities in western Kenya from 2018 to 2022. Females testing HIV positive at facilities were offered APS; those who consented provided contact information for all male sexual partners in the last 3 years. Male partners were notified of their potential HIV exposure and offered HIV testing services (HTS). Males newly testing positive were also offered APS and asked to provide contact information for their female partners in the last 3 years. Female partners of male partners (FPPs) were provided exposure notification and HTS. All participants with HIV were followed up at 12 months post-enrolment to assess linkage-to antiretroviral treatment (ART) and viral suppression. We compared HIV positivity, demographics and linkage outcomes among female index clients and FPPs. RESULTS Overall, 5708 FPPs were elicited from male partners, of whom 4951 received HTS through APS (87% coverage); 291 FPPs newly tested HIV positive (6% yield), an additional 1743 (35.2%) reported a prior HIV diagnosis, of whom 99% were on ART at baseline. At 12 months follow-up, most FPPs were taking ART (92%) with very few adverse events: <1% reported intimate partner violence or reported relationship dissolution. FPPs were more likely than female index clients to report HIV risk behaviours including no condom use at last sex (45% vs. 30%) and multiple partners (38% vs. 19%). CONCLUSIONS Providing HIV testing via APS to FPP is a safe and effective strategy to identify newly diagnosed females and achieve high linkage and retention to ART and can be an efficient means of identifying HIV cases in the era of declining HIV incidence. The high proportion of FPPs reporting HIV risk behaviours suggests APS may help interrupt community HIV transmission via increased knowledge of HIV status and linkage to treatment.
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Affiliation(s)
- Monisha Sharma
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | | | - Hanley Kingston
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Institute of Public Health GeneticsUniversity of WashingtonSeattleWAUSA
| | | | - Sarah Masyuko
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Ministry of HealthNairobiKenya
| | - Harison Lagat
- School of NursingUniversity of WashingtonSeattleWashingtonUSA
| | - David A. Katz
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Beatrice Wamuti
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Paul Macharia
- School of Computing and Engineering SciencesStrathmore UniversityNairobiKenya
| | - Rose Bosire
- Centre for Public Health ResearchKenya Medical Research Institute (KEMRI)NairobiKenya
| | | | | | - Carey Farquhar
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- School of NursingUniversity of WashingtonSeattleWashingtonUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
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Aheron S, Paredes-Vincent A, Patton ME, Gross J, Medley A, Mona G, Mtimkulu N, Nkuna K, Grund JM. Improving HIV Case Finding Through Index Testing: Findings from Health Facilities in 12 Districts of South Africa, October 2019-September 2021. AIDS Behav 2024; 28:1708-1718. [PMID: 38358586 PMCID: PMC11070287 DOI: 10.1007/s10461-024-04269-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2024] [Indexed: 02/16/2024]
Abstract
To assess the importance of index testing in HIV case finding, we analyzed quarterly data from October 2019 to September 2021 from 371 facilities in 12 districts in South Africa. Index testing accounted for 2.6% of all HIV tests (index and non-index) (n = 163,633), but 17.8% of all HIV-positive results, with an HIV-positivity 4-times higher than non-index testing modalities (4.1%). Despite twice as many adult females ≥ 15 years accepting index testing (n = 206,715) compared to adult males ≥ 15 years (n = 102,180), females identified fewer contacts (n = 91,123) than males (n = 113,939). Slightly more than half (51.2%) of all contacts elicited were tested (n = 163,633/319,680), while 19.7% (n = 62,978) of elicited contacts were previously diagnosed as HIV-positive and not eligible for further testing. These findings indicate index testing can be effective in increasing HIV diagnoses in South Africa. Further operational research is needed to address gaps identified in the index testing cascade, including elicitation and testing of contacts.
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Affiliation(s)
- Sarah Aheron
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Pretoria, South Africa.
| | - Ariana Paredes-Vincent
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Pretoria, South Africa
| | - Monica E Patton
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Pretoria, South Africa
| | - Jessica Gross
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Amy Medley
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Atlanta, GA, USA
| | - Gugu Mona
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Pretoria, South Africa
| | | | - Khensani Nkuna
- Wits Reproductive Health and HIV Institute (WRHI), Johannesburg, South Africa
| | - Jonathan M Grund
- Division of Global HIV and TB, Centers for Disease Control & Prevention, Pretoria, South Africa
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Nante RW, Muyinda H, Kiweewa JM, Ndagire R, Ssendikwanawa E, Ojiambo KO, Nangendo J, Nakku J, Semitala FC. Acceptance of assisted partner notification among HIV-positive adults with severe mental illness at a national referral hospital in Uganda: a cross-sectional study. BMC Health Serv Res 2024; 24:319. [PMID: 38459486 PMCID: PMC10924341 DOI: 10.1186/s12913-024-10770-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 02/22/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND HIV mostly affects people with severe mental illnesses (SMIs) than the general population. In 2015, the World Health Organization (WHO) introduced assisted partner notification (APN) as a strategy to increase HIV testing. Although research has demonstrated the effectiveness of APN in the general population, its use among people living with HIV (PLHIV) who have SMI is not well understood. This study sought to determine the acceptance of the APN strategy among PLHIV who had a diagnosis of SMI. METHODS This study used a cross-sectional study design that was retrospective to determine acceptance of APN among PLHIV with a documented diagnosis of SMI. We enrolled participants with a diagnosis of both HIV and SMI from August 2018 to January 2022, attending the HIV clinic at Butabika Hospital. We used pretested questionnaires to extract participants' demographic and clinical data from their existing clinical charts, antiretroviral therapy (ART) registers and APN registers. We defined acceptance of APN as the number of PLHIV with SMI diagnoses who agreed to provide information about their sexual partners. We used modified Poisson regression analysis to assess the factors associated with the acceptance of APN. RESULTS A total of 125 participants were enrolled, of whom 83 (66.4%) were female. The median age was 30 (interquartile range (IQR) (25-34)), and 41 (33%) of them accepted APN (95% CI: 25.05-41.61). Receipt of at least three counselling sessions before enrollment in APN (aPR = 1.8, 95% CI: 1.72-1.98) was the most significant factor associated with increased acceptance of APN. Poor adherence to ART (aPR = 0.62, 95% CI: 0.54-0.80), being escorted to hospital by a distant relative (aPR = 0.55, 95% CI: 0.39-0.80), being married/cohabiting (aPR = 0.65, 95% CI: 0.60-0.81), and being a Seventh Day Adventist (SDA) (aPR = 0.53, 95% CI: 0.45-0.71) or Pentecostal (aPR = 0.44, 95% CI: 0.22-0.98) by faith were associated with reduced acceptance of APN. CONCLUSION AND RECOMMENDATION The acceptance of APN is low among PLHIV with a diagnosis of SMI. More structured counselling would facilitate earlier identification of undiagnosed HIV-positive partners. We recommend a follow-up study to compare acceptance of APN among PLHIV with SMI and those without SMI.
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Affiliation(s)
- Rachel Wangi Nante
- Clinical Epidemiology Unit, Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.
- Africa Centre for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Herbert Muyinda
- Child Health and Development Centre (CHDC), College of Health Sciences, Makerere University, Kampala, Uganda
| | - John M Kiweewa
- Education Department, Fairfield University, Fairfield, CT, USA
| | - Regina Ndagire
- Clinical Epidemiology Unit, Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Africa Centre for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Emmanuel Ssendikwanawa
- Clinical Epidemiology Unit, Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Kevin Ouma Ojiambo
- Clinical Epidemiology Unit, Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Africa Centre for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joanita Nangendo
- Clinical Epidemiology Unit, Department of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Juliet Nakku
- Butabika National Referral Mental Hospital, Kampala, Uganda
| | - Fred C Semitala
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Mulago Immune Suppression Syndrome Clinic, Mulago National Referral Hospital, Kampala, Uganda
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Oljira H, Rata A, Mulatu B, Abera T. 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. BMC Public Health 2024; 24:687. [PMID: 38438988 PMCID: PMC10913634 DOI: 10.1186/s12889-024-18196-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 02/23/2024] [Indexed: 03/06/2024] Open
Abstract
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.
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Affiliation(s)
- Habtamu Oljira
- Department of Biomedical Science, School of Medicine, Wallaga University, Nekemte, Oromia, Ethiopia.
| | - Abiriham Rata
- Nekemte Blood Bank, Oromia Health Beuareu, Nekemte, Oromia, Ethiopia
| | - Befirdu Mulatu
- Department of Public Health, Institute of Health Science, Wallaga University, Nekemte, Oromia, Ethiopia
| | - Tesfaye Abera
- Department of Nursing, School of Nursing and Midwifery, Wallaga University, Nekemte, Oromia, Ethiopia
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O’Bryan G, Chirairo H, Munyayi F, Ensminger A, Barnabee G, Dzinotyiweyi E, Mwandingi L, Ashipala L, Forster N, O’Malley G, Golden MR. Assisted Partner Notification Services in Namibia: Comparison of Case-Finding in Persons With New and Previously Diagnosed Human Immunodeficiency Virus, and Success as a Platform for PrEP Referral. Sex Transm Dis 2024; 51:214-219. [PMID: 38412468 PMCID: PMC10901442 DOI: 10.1097/olq.0000000000001922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Assisted partner notification services (APS) are widely implemented throughout sub-Saharan Africa. The effectiveness of APS among persons with previously diagnosed human immunodeficiency virus (HIV) infection is uncertain, and there are few published data on the success of integrating referrals for HIV preexposure prophylaxis (PrEP) into APS. METHODS Staff in 22 Namibian Ministry of Health and Social Service clinics offered APS to patients newly and previously diagnosed with HIV (index cases [ICs]) between October 2019 and June 2021. Counselors used a structured interview guide to elicit ICs' sex partners and biological children and assisted ICs to arrange testing of contacts. Contacts testing HIV-positive were linked to HIV services and those 14 years or older testing negative were offered PrEP. The primary outcome was the case-finding index (contacts testing HIV-positive ÷ ICs receiving APS). RESULTS Staff provided APS to 1222 (78%) of 1557 newly diagnosed ICs eliciting 1155 sex partners and 649 biological children. Among 280 previously diagnosed ICs, 279 sex partners and 158 biological children were elicited. The case-finding index was higher among ICs with newly diagnosed HIV compared with previously diagnosed HIV (0.14 vs 0.09, P = 0.46), though this difference was not statistically significant. Most sex partners testing HIV-negative were initiated on PrEP (67% in sex partners from newly diagnosed ICs; 74% in sex partners from previously diagnosed ICs). CONCLUSIONS Assisted partner notification services successfully identified sex partners and biological children with undiagnosed HIV infection when provided to both newly and previously diagnosed ICs. Integration of referral to PrEP resulted in many HIV-negative partners initiating PrEP.
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Affiliation(s)
- Gillian O’Bryan
- International Training and Education Center for Health (I-TECH), University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
| | - Harugumi Chirairo
- Department of Global Health, University of Washington, Seattle, USA
- International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Farai Munyayi
- Department of Global Health, University of Washington, Seattle, USA
- International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Alison Ensminger
- International Training and Education Center for Health (I-TECH), University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
| | - Gena Barnabee
- International Training and Education Center for Health (I-TECH), University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
| | | | | | - Laimi Ashipala
- Ministry of Health and Social Services (MHSS), Windhoek, Namibia
| | - Norbert Forster
- Department of Global Health, University of Washington, Seattle, USA
- International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Gabrielle O’Malley
- International Training and Education Center for Health (I-TECH), University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
| | - Matthew R. Golden
- International Training and Education Center for Health (I-TECH), University of Washington, Seattle, USA
- Center for AIDS and STD, University of Washington, USA
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Tembo TA, Mollan K, Simon K, Rutstein S, Chitani MJ, Saha PT, Mbeya-Munkhondya T, Jean-Baptiste M, Meek C, Mwapasa V, Go V, Bekker LG, Kim MH, Rosenberg NE. Does a blended learning implementation package enhance HIV index case testing in Malawi? A protocol for a cluster randomised controlled trial. BMJ Open 2024; 14:e077706. [PMID: 38253452 PMCID: PMC10806658 DOI: 10.1136/bmjopen-2023-077706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/07/2024] [Indexed: 01/24/2024] Open
Abstract
INTRODUCTION Index case testing (ICT) is an evidence-based approach that efficiently identifies persons in need of HIV treatment and prevention services. In Malawi, delivery of ICT has faced challenges due to limited technical capacity of healthcare workers (HCWs) and clinical coordination. Digitisation of training and quality improvement processes presents an opportunity to address these challenges. We developed an implementation package that combines digital and face-to-face modalities (blended learning) to strengthen HCWs ICT skills and enhance quality improvement mechanisms. This cluster randomised controlled trial will assess the impact of the blended learning implementation package compared with the standard of care (SOC) on implementation, effectiveness and cost-effectiveness outcomes. METHODS AND ANALYSIS The study was conducted in 33 clusters in Machinga and Balaka districts, in Southern Malawi from November 2021 to November 2023. Clusters are randomised in a 2:1 ratio to the SOC versus blended learning implementation package. The SOC is composed of: brief face-to-face HCW ICT training and routine face-to-face facility mentorship for HCWs. The blended learning implementation package consists of blended teaching, role-modelling, practising, and providing feedback, and blended quality improvement processes. The primary implementation outcome is HCW fidelity to ICT over 1 year of follow-up. Primary service uptake outcomes include (a) index clients who participate in ICT, (b) contacts elicited, (c) HIV self-test kits provided for secondary distribution, (d) contacts tested and (e) contacts identified as HIV-positive. Service uptake analyses will use a negative binomial mixed-effects model to account for repeated measures within each cluster. Cost-effectiveness will be assessed through incremental cost-effectiveness ratios examining the incremental cost of each person tested. ETHICS AND DISSEMINATION The Malawi National Health Science Research Committee, the University of North Carolina and the Baylor College of Medicine Institutional Review Boards approved the trial. Study findings will be disseminated through peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER NCT05343390.
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Affiliation(s)
- Tapiwa A Tembo
- Research, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Katie Mollan
- The University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Katherine Simon
- Research, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Sarah Rutstein
- The University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Mike Jones Chitani
- Research, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Pooja T Saha
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Milenka Jean-Baptiste
- The University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Caroline Meek
- The University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | | | - Vivian Go
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Linda Gail Bekker
- Department of Medicine, University of Cape Town, Observatory, South Africa
| | - Maria H Kim
- Research, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Nora E Rosenberg
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
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Hurley EA, Mayatsa J, Matovu JKB, Schuetz N, Wanyenze R, Wagner G, Goggin K. Piloting Gain and Loss-Framed PrEP and Childbearing Messaging to Promote HIV Testing in Uganda: Perspectives from Couples and Providers. JOURNAL OF HEALTH COMMUNICATION 2023; 28:669-679. [PMID: 37642350 DOI: 10.1080/10810730.2023.2251919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Fears of relationship dissolution and the inability to bear healthy children remain barriers to HIV testing in sub-Saharan Africa. Pre-exposure prophylaxis (PrEP) carries both clinical and symbolic benefits that counter these fears. We conducted a pilot messaging intervention through Uganda's assisted partner notification (APN) program, where providers assist HIV-positive index clients in notifying sexual partners and encourage testing. We randomized providers at three clinics to implement phone scripts over two months with (1) gain-framed or (2) loss-framed information about PrEP and childbearing; or (3) usual care. In 23 in-depth interviews with providers, index clients, and partners, five major themes emerged on intervention acceptability and feasibility: (1) value of PrEP and childbearing messaging in APN; (2) value of this messaging coming earlier in APN; (3) overall preference for gain-framed messages; (4) need to tailor timing of messaging; and (5) need for messaging outside of APN. Register data (109 index clients, 145 partners) indicated most index clients (95%) wanted their potential conception partners informed about PrEP. Preliminary trends suggest the intervention sites outperformed usual care in testing rates among potential conception partners. Messaging that highlights PrEP and safe childbearing may be a promising new communication strategy to promote HIV testing.
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Affiliation(s)
- Emily A Hurley
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jimmy Mayatsa
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joseph K B Matovu
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Community and Public Health, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Nik Schuetz
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Rhoda Wanyenze
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Kathy Goggin
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri, USA
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Golden MR, Mamudo A, Vio F, Branigan E, Paredes Z, Maiela A, Augusto O, Couto A, Amane G, Chicuecue N, Wate J, Mudender F. Assisted Partner Notification Services Are Safe and Effective as They Are Brought to Scale in Mozambique. J Acquir Immune Defic Syndr 2023; 93:305-312. [PMID: 37040123 DOI: 10.1097/qai.0000000000003203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 01/03/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND The World Health Organization recommends that persons diagnosed with HIV be offered assisted partner notification services (APS). There are limited data on the safety of APS as implemented in public health programs. SETTING Three public health centers in Maputo, Mozambique, 2016-2019. METHODS Counselors offered APS to persons with newly diagnosed HIV and, as part of a program evaluation, prospectively assessed the occurrence of adverse events (AEs), including (1) pushing, abandonment, or yelling; (2) being hit; and (3) loss of financial support or being expelled from the house. RESULTS Eighteen thousand nine hundred sixty-five persons tested HIV-positive in the 3 clinics, 13,475 (71%) were evaluated for APS eligibility, 9314 were eligible and offered APS, and 9219 received APS. Index cases (ICs) named 8933 partners without a previous HIV diagnosis, of whom 6137 tested and 3367 (55%) were diagnosed with HIV (case-finding index = 0.36). APS counselors collected follow-up data from 6680 (95%) of 7034 index cases who had untested partners who were subsequently notified; 78 (1.2%) experienced an AE. Among 270 ICs who reported a fear of AEs at their initial APS interview, 211 (78%) notified ≥1 sex partner, of whom 5 (2.4%) experienced an AE. Experiencing an AE was associated with fear of loss of support (odds ratio [OR] 4.28; 95% confidence interval [CI]: 1.50 to 12.19) and having a partner who was notified, but not tested (OR 3.47; 95% CI: 1.93 to 6.26). CONCLUSION Case-finding through APS in Mozambique is high and AEs after APS are uncommon. Most ICs with a fear of AEs still elect to notify partners with few experiencing AEs.
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Affiliation(s)
- Matthew R Golden
- University of Washington Center for AIDS and STD, Seattle, WA
- International Training and Education Center for Health-Mozambique, Maputo, Mozambique
| | - Allend Mamudo
- International Training and Education Center for Health-Mozambique, Maputo, Mozambique
| | - Ferruccio Vio
- International Training and Education Center for Health-Mozambique, Maputo, Mozambique
| | - Erin Branigan
- International Training and Education Center for Health-Seattle, Seattle, WA
| | - Zulmira Paredes
- International Training and Education Center for Health-Mozambique, Maputo, Mozambique
| | - Adelina Maiela
- International Training and Education Center for Health-Mozambique, Maputo, Mozambique
| | - Orvalho Augusto
- Faculdade de Medicina, Universidade Eduardo Mondlane, Cidade de Maputo, Mozambique
- Department of Global Health, University of Washington, Seattle, WA; and
| | | | | | | | - Joaquim Wate
- International Training and Education Center for Health-Mozambique, Maputo, Mozambique
| | - Florindo Mudender
- International Training and Education Center for Health-Mozambique, Maputo, Mozambique
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9
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Mugumba E, Kagwa M, Muhumuza D, Namukwaya R, Amunyongire R, Maling S. Prevalence and correlates of intimate partner violence following partner notification among index HIV clients attending primary healthcare facilities in Uganda. AIDS Care 2023; 35:859-866. [PMID: 36120933 PMCID: PMC10020122 DOI: 10.1080/09540121.2022.2122390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
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.
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Affiliation(s)
- Eria Mugumba
- Department of Medical Laboratory Science, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark Kagwa
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Dickson Muhumuza
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Racheal Namukwaya
- Department of Physiotherapy, Mbarara University of Science and Technology, Mbarara Uganda
| | - Ronaldo Amunyongire
- Department of Nursing, Mbarara University of Science and Technology, Mbarara Uganda
| | - Samuel Maling
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
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Naughton B, Owuor M, Wamuti B, Katz DA, Sharma M, Liu W, Lagat H, Kariithi E, Mugambi M, Bosire R, Masyuko S, Farquhar C, Weiner BJ. "I feel good because I have saved their lives": Acceptability of assisted partner services among female index clients and male sexual partners in Kenya. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001842. [PMID: 37224122 DOI: 10.1371/journal.pgph.0001842] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 03/28/2023] [Indexed: 05/26/2023]
Abstract
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.
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Affiliation(s)
- Brienna Naughton
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | | | - Beatrice Wamuti
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - David A Katz
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Wenjia Liu
- Department of Child, Family & Population Health Nursing, University of Washington, Seattle, Washington, United States of America
| | | | | | | | - Rose Bosire
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Sarah Masyuko
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Ministry of Health, Nairobi, Kenya
| | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
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Sharma M, Naughton B, Lagat H, Otieno G, Katz DA, Wamuti BM, Masyuko S, Bosire R, Mugambi M, Roy Paladhi U, Weiner BJ, Kariithi E, Farquhar C. Real-world impact of integrating HIV assisted partner services into 31 facilities in Kenya: a single-arm, hybrid type 2 implementation-effectiveness study. Lancet Glob Health 2023; 11:e749-e758. [PMID: 37061312 PMCID: PMC10156000 DOI: 10.1016/s2214-109x(23)00153-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 02/14/2023] [Accepted: 02/27/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND Assisted partner services (APS), or exposure notification and HIV testing for sexual partners of individuals diagnosed with HIV (index clients), have been shown to be safe and effective in clinical trials. We assessed the real-world effectiveness of APS when integrated into HIV clinics in western Kenya. METHODS In this single-arm, hybrid type 2 implementation science study, we facilitated APS implementation in 31 health facilities in Kenya by training existing health-care staff. We focused on male partner outcomes to assess the impact of APS in reaching male individuals in sub-Saharan Africa, who have lower rates of HIV testing than female individuals. Female individuals (aged ≥18 years or emancipated minor) who tested positive for HIV at participating facilities in Kenya were offered APS; consenting female participants provided contact information for all male sexual partners in the past 3 years. Male partners were notified of their potential HIV exposure and offered a choice of community-based or facility-based HIV testing services (HTS). Female index clients and male partners with HIV were followed up at 6 weeks, 6 months, and 12 months after enrolment, to assess linkage to antiretroviral treatment. Viral load was assessed at 12 months. FINDINGS Between May 1, 2018, and March 31, 2020, 32 722 female individuals received HTS; 1910 (6%) tested positive for HIV, of whom 1724 (90%) received APS. Female index clients named 5137 male partners (median 3 per index [IQR 2-4]), of whom 4422 (86%) were reached with exposure notification and HTS. 524 (12%) of the male partners tested were newly diagnosed with HIV and 1292 (29%) reported a previous HIV diagnosis. At 12 months follow-up, 1512 (88%) female index clients and 1621 (89%) male partners with HIV were taking ART, with few adverse events: 25 (2%) female index clients and seven (<1%) male partners reported intimate partner violence, and 60 (3%) female index clients and ten (<1%) male partners reported relationship dissolution. INTERPRETATION Evidence from this real-world APS scale-up project shows that APS is a safe, acceptable, and effective strategy to identify males with HIV and retain them in care. FUNDING The US National Institutes of Health.
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Affiliation(s)
- Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Brienna Naughton
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | | | | | - David A Katz
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Sarah Masyuko
- Department of Global Health, University of Washington, Seattle, WA, USA; Kenya Ministry of Health, Nairobi, Kenya
| | - Rose Bosire
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Unmesha Roy Paladhi
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Bryan J Weiner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
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Joel JN, Awuor P, Blanco N, Lavoie MCC, Lascko T, Ngunu C, Mwangi J, Mutisya I, Ng'eno C, Wangusi R, Koech E. Scale-up of HIV index testing in an urban population: Experiences and achievements from Nairobi County, Kenya. Trop Med Int Health 2023; 28:116-125. [PMID: 36538038 DOI: 10.1111/tmi.13843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe the implementation strategies of the index testing program across Nairobi County in Kenya, assess outcomes along the HIV index testing cascade (acceptance, elicitation ratio, HIV positivity and linkage to treatment), and assess annual changes along the HIV index testing cascade during the first 2 years of implementation. METHODS Retrospective analysis of programmatic aggregate data collected from October 2017 to September 2019 after the roll-out of index testing services in 48 health facilities in Nairobi County. Proportions and ratios were calculated for acceptance, elicitation ratio, testing uptake and HIV positivity. We compared these outcomes between years using a chi-squared test, Fisher's exact test or Wilcoxon sign test, and we assessed trends using the Mann-Kendall test. RESULTS Testing among eligible partners increased from 42.4% (1471/3470) to 74.9% (6114/8159) in the general population, and the positivity yield remained high across both years (25.2% in year 1 and 24.1% in year 2). Index testing positivity yield remained significantly higher than other testing modalities (24.3% vs. 1.3%, p < 0.001). The contribution of index testing services to the total number of HIV-positive individuals identified increased from 7.5% in the first year to 28.6% in the second year (p < 0.001). More men were tested, but the positivity yield was higher among women (30.0%) and those aged 50 years or older (32.4%). Testing eligible partners in key populations (KPs) decreased from 52.4% (183/349) to 40.7% (109/268) (p = 0.674); however, the HIV positivity yield increased from 8.6% to 23.9% (p < 0.001) by the second year of implementation. The HIV positivity yield from index testing remained higher than other testing modalities (14% vs. 0.9%, p < 0.001) for KPs. CONCLUSION Index testing was well-accepted and effective in identifying individuals living with HIV in a Kenyan urban setting across both general populations and KPs. Ongoing adaptations to the strategies deployed as part of index testing services helped improve most of the outcomes along the index testing cascade.
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Affiliation(s)
- Javies Ngui Joel
- Center for International Health, Education, and Biosecurity, Maryland Global Initiatives Corporation, Nairobi, Kenya
| | - Patrick Awuor
- Center for International Health, Education, and Biosecurity, Maryland Global Initiatives Corporation, Nairobi, Kenya
| | - Natalia Blanco
- Center for International Health, Education, and Biosecurity, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Marie-Claude C Lavoie
- Center for International Health, Education, and Biosecurity, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Taylor Lascko
- Center for International Health, Education, and Biosecurity, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Carol Ngunu
- Department of Health, Nairobi Metropolitan Services, Nairobi, Kenya
| | - Jonathan Mwangi
- Division of Global HIV and TB, Center for Global Health, US Centers for Disease Control & Prevention, Nairobi, Kenya
| | - Immaculate Mutisya
- Division of Global HIV and TB, Center for Global Health, US Centers for Disease Control & Prevention, Nairobi, Kenya
| | - Caroline Ng'eno
- Center for International Health, Education, and Biosecurity, Maryland Global Initiatives Corporation, Nairobi, Kenya
| | - Rebecca Wangusi
- Center for International Health, Education, and Biosecurity, Maryland Global Initiatives Corporation, Nairobi, Kenya
| | - Emily Koech
- Chief Executive Officer, Center for International Health, Education, and Biosecurity-Kenya, Nairobi, Kenya
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Puleni PC, Nyondo-Mipando AL. Strategies for Optimising Uptake of Assisted Partner Notification Services Among Newly Diagnosed HIV Positive Adults at Ndirande Health Centre, Malawi. Health Syst Reform 2022; 8:2151697. [PMID: 36534137 DOI: 10.1080/23288604.2022.2151697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Paul Chiwa Puleni
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi
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Jahun I, Dirlikov E, Odafe S, Yakubu A, Boyd AT, Bachanas P, Nzelu C, Aliyu G, Ellerbrock T, Swaminathan M. Ensuring Optimal Community HIV Testing Services in Nigeria Using an Enhanced Community Case-Finding Package (ECCP), October 2019-March 2020: Acceleration to HIV Epidemic Control. HIV AIDS (Auckl) 2021; 13:839-850. [PMID: 34471388 PMCID: PMC8403567 DOI: 10.2147/hiv.s316480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/19/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose The 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) showed Nigeria’s progress toward the UNAIDS 90-90-90 targets: 47% of HIV-positive individuals knew their status; of these, 96% were receiving antiretroviral therapy (ART); and of these, 81% were virally suppressed. To improve identification of HIV-positive individuals, Nigeria developed an Enhanced Community Case-Finding Package (ECCP). We describe ECCP implementation in nine states and assess its effect. Methods ECCP included four core strategies (small area estimation [SAE] of people living with HIV [PLHIV], map of HIV-positive patients by residence, HIV risk-screening tool [HRST], and index testing [IT]) and four supportive strategies (alternative healthcare outlets, performance-based incentives for field testers, Project Extension for Community Healthcare Outcomes, and interactive dashboards). ECCP was deployed in nine of 10 states prioritized for ART scale-up. Weekly program data (October 2019–March 2020) were tracked and analyzed. Results Of the total 774 LGAs in Nigeria, using SAE, 103 (13.3%) high-burden LGAs were identified, in which 2605 (28.0%) out of 9,294 hotspots were prioritized by mapping newly identified PLHIV by residential addresses. Over 22 weeks, among 882,449 individuals screened using HRST, 723,993 (82.0%) were eligible and tested for HIV (state range, 43.7–90.4%), out of which 20,616 were positive. Through IT, an additional 3,724 PLHIV were identified. In total, 24,340 PLHIV were identified and 97.4% were linked to life-saving antiretroviral therapy. The number of newly identified PLHIV increased 17-fold over 22 weeks (week 1: 89; week 22: 1,632). Overall mean HIV positivity rate by state was 3.3% (range, 1.8–6.4%). Conclusion Using ECCP in nine states in Nigeria increased the number of PLHIV in the community who knew their status, allowing them to access life-saving care and decreasing the risk of HIV transmission.
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Affiliation(s)
- Ibrahim Jahun
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health - Nigeria, Abuja Federal Capital Territory, Nigeria
| | - Emilio Dirlikov
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health, Atlanta, GA, USA
| | - Solomon Odafe
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health - Nigeria, Abuja Federal Capital Territory, Nigeria
| | - Aminu Yakubu
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health - Nigeria, Abuja Federal Capital Territory, Nigeria
| | - Andrew T Boyd
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health, Atlanta, GA, USA
| | - Pamela Bachanas
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health, Atlanta, GA, USA
| | | | - Gambo Aliyu
- National Agency for the Control of AIDS (NACA), Abuja, Federal Capital Territory, Nigeria
| | - Tedd Ellerbrock
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health, Atlanta, GA, USA
| | - Mahesh Swaminathan
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health - Nigeria, Abuja Federal Capital Territory, Nigeria
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