Partner notification feasible and effective in African settings

Partner notification programmes, offering HIV 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 to the Conference on Retroviruses and Opportunistic Infections (CROI 2016) in Boston show. A randomised study in Kenya found that partner notification services were able to test 42% of partners mentioned, increasing testing rates fourfold.

Partner notification (also referred to as 'partner services') aims to curb the spread of sexually transmitted infections 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 their partners and arrange testing. 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.

Glossary

linkage to care

Refers to an individual’s entry into specialist HIV care after being diagnosed with HIV. 

cost-effective

Cost-effectiveness analyses compare the financial cost of providing health interventions with their health benefit in order to assess whether interventions provide value for money. As well as the cost of providing medical care now, analyses may take into account savings on future health spending (because a person’s health has improved) and the economic contribution a healthy person could make to society.

culture

In a bacteria culture test, a sample of urine, blood, sputum or another substance is taken from the patient. The cells are put in a specific environment in a laboratory to encourage cell growth and to allow the specific type of bacteria to be identified. Culture can be used to identify the TB bacteria, but is a more complex, slow and expensive method than others.

control group

A group of participants in a trial who receive standard treatment, or no treatment at all, rather than the experimental treatment which is being tested. Also known as a control arm.

referral

A healthcare professional’s recommendation that a person sees another medical specialist or service.

Although widely used in North America and the United States, there is limited experience of 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. 

Kenyan intervention

Peter Cherutich of the Kenyan Ministry of Health and the University of Washington presented the findings of a cluster randomised trial, conducted at 18 rural and urban voluntary counselling and testing facilities across Kenya. One in twenty Kenyans are living with HIV but 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 sexual partners getting tested and linked to medical care.

In the nine facilities randomised to receive the intervention, counsellors 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 three years. Women at risk of intimate partner violence were not asked for details of 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 positive, support with linkage to care was provided.

In the nine facilities randomised to the control arm, provision of partner notification was delayed for six weeks. In the meantime, newly diagnosed individuals were encouraged to disclose to their partners and advise them to get tested.

Kenyan results

Between the two arms, 1119 index cases were enrolled and they identified 1872 sexual partners. The average age of index cases was 30, just over half were women, just over half were married or monogamous and they reported an average of four partners over their lifetime.

In the immediate arm, 392 partners were tested, compared to 85 partners in the delayed arm – a fourfold 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 very 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 one 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 two cases which were possibly related, one 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.

Tanzanian experience

The conference also heard results from Tanzania, where individuals diagnosed through voluntary or provider-initiated testing and counselling 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’s therefore different to 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 favour of integrating partner notification into HIV testing services in health facilities in sub-Saharan Africa.

References

Cherutich P et al. Effectiveness of partner services for HIV in Kenya: a cluster randomized trial. Conference on Retroviruses and Opportunistic Infections, Boston, abstract 50, 2016.

View the abstract on the conference website.

View a webcast of this session on the conference website.

Plotkin M et al. Effective, high-yield HIV testing for partners of newly diagnosed persons in Tanzania. Conference on Retroviruses and Opportunistic Infections, Boston, abstract 978, 2016.

View the abstract on the conference website.

View a webcast of this session on the conference website.