- Category: HIV Testing & Diagnosis
- Published on Wednesday, 06 April 2016 00:00
- Written by Roger Pebody
Partner notification programs, offering testing to the sexual partners of people newly diagnosed with HIV, have rarely been implemented in African countries, but can be highly effective there, studies presented at the recent Conference on Retroviruses and Opportunistic Infections (CROI 2016)show. A randomized study in Kenya found that partner notification services were able to test 42% of partners mentioned, increasing testing rates 4-fold.
Partner notification (also referred to as partner services) aims to curb the spread of sexually transmitted infections (STIs) by testing and treating the sexual partners of newly diagnosed people. The intervention typically involves a public health worker interviewing people diagnosed with an STI (called "index cases") about their sexual partner(s) and then helping the index case notify his or her partners and arrange testing for them. Index cases may contact partners themselves, or contact may be made by healthcare workers, usually without revealing the identity of the index patient.
Although it is resource-intensive, partner notification can be cost-effective as it can prevent new cases of HIV infection. Although widely used in the U.S., there is limited experience on using partner notification in African countries. Some of the only data come from Malawi and Cameroon. Differences in culture, health systems, perceptions of HIV infection, the social status of women and young people, and existing rates of HIV testing could affect the feasibility and effectiveness of partner notification in Africa.
Peter Cherutich from the Kenyan Ministry of Health and the University of Washington presented the findings of a cluster randomized trial, conducted at 18 rural and urban voluntary counseling and testing facilities across Kenya. Although 1 in 20 Kenyans are living with HIV, half are not aware of their infection.
The researchers aimed to find out whether providing partner services to sexual partners of people newly diagnosed with HIV could result in more partners getting tested and linked to medical care.
In the 9 facilities randomized to receive the intervention, counselors were trained to deliver partner notification services. This involved collecting a detailed sexual history from individuals who were newly diagnosed with HIV and asking them for permission to contact sexual partners from the past 3 years. Women at risk of intimate partner violence were not asked for details about their partners.
Healthcare workers contacted the partners by phone within 48 hours. They engaged the partner in a discussion about their sexual health but did not disclose that the person was being approached because their name had been given by a sexual partner -- early experience showed that some people would insistently ask to know who the index case was.
Staff encouraged the partner to attend a convenient testing facility. When this was not possible, staff arranged to meet the partner and carried out an HIV test themselves. If the partner tested HIV-positive, support with linkage to care was provided.
In the 9 facilities randomized to the control arm, provision of partner notification was delayed for 6 weeks. In the meantime, newly diagnosed individuals were encouraged to disclose to their partners and advise them to get tested.
Between the 2 arms, 1119 index cases were enrolled and they identified 1872 sexual partners. The average age of index cases was 30 years, just over half were women, just over half were married or monogamous, and they reported an average of 4 partners over their lifetime.
In the immediate notification arm, 392 partners were tested, compared to 85 partners in the delayed arm -- a 4-fold increase (incidence rate ratio 4.8). There was also a particularly stark difference between the arms in the number of partners who were taking an HIV test for the first time -- 81 in the immediate arm and 4 in the delayed arm.
Of those testing in the immediate arm, 136 were newly diagnosed with HIV and 88 were linked with care. Overall, 4.2 partners needed to be identified for each 1 diagnosed with HIV.
Partner services in rural areas reached undiagnosed individuals slightly more easily than in urban or peri-urban areas, probably reflecting the lower coverage of HIV testing in rural areas.
As well as a few dozen cases of intimate partner violence that were not thought to be related to the partner services or the study, there were 2 cases which were possibly related, 1 in each arm of the study. However, Cherutich said that in fact each incident had happened before partner notification occurred. The safety of partner services should continue to be evaluated, he said.
The conference also heard results from Tanzania, where individuals diagnosed through voluntary or provider-initiated testing and counseling in hospitals in a high-prevalence region were enrolled as index cases. They were given the choice of approaching their partners themselves or having a healthcare worker anonymously contact the partner with the recommendation to come for HIV testing.
The researchers were surprised to find that almost all chose the first approach -- it is therefore different from the Kenyan study, in which partner notification in the intervention arm was always conducted by healthcare workers.
A total of 390 index cases identified 438 sexual partners, 238 of whom received HIV testing. The prevalence of HIV in those testing was extremely high, at 62%.
Presenting the findings, Marya Plotkin said that index partners newly diagnosed with HIV were looking for a way to reach out to their spouses. She said that the data provides strong evidence in favor of integrating partner notification into HIV testing services in health facilities in sub-Saharan Africa.
P Cherutich, MR Golden, B Wamuti, et al. Effectiveness of Partner Services for HIV in Kenya: A Cluster Randomized Trial. Conference on Retroviruses and Opportunistic Infections. Boston, February 22-25, 2016. Abstract 50.
M Plotkin, C Kahabuka, A Amuri, et al. Effective, High-Yield HIV Testing for Partners of Newly Diagnosed Persons in Tanzania. Conference on Retroviruses and Opportunistic Infections. Boston, February 22-25, 2016. Abstract 978.