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Implementation Science

High Acceptability of Assisted Partner Notification Services Among HIV-Positive Females in Kenya: Results From an Ongoing Implementation Study

Sharma, Monisha ScM, PhDa; Kariithi, Edward MBChBb; Kemunto, Emily BAb; Otieno, George BAb; Lagat, Harison BAb; Wamuti, Beatrice MBChB, MBA, MPHa; Obongo, Chris BAb; Macharia, Paul BAc; Masyuko, Sarah MBChB, MPHa,c; Bosire, Rose MBChB, MPHd; Mugambi, Mary MBChBc; Weiner, Bryan MA, PhDa; Farquhar, Carey MD, MPHa,e,f

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: January 1, 2021 - Volume 86 - Issue 1 - p 56-61
doi: 10.1097/QAI.0000000000002527
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Abstract

INTRODUCTION

HIV continues to cause significant morbidity and mortality, disproportionately impacting sub-Saharan Africa (SSA) where over 70% of the world's new HIV infections occur.1 Globally, only 75% of persons living with HIV know their status, indicating that expanded testing strategies are needed to achieve the first 95 of UNAIDS′ ambitious testing, treatment, and viral suppression targets.2 Potential funding shortages have increased policymakers' demand for efficient testing approaches with high yield for detecting HIV-positive persons.3 Assisted partner services (aPS) involves notification and HIV testing for sexual partners of persons diagnosed HIV positive (index clients) and is recommended by the World Health Organization (WHO) as a targeted strategy to identify new HIV cases.4 Types of aPS include (1) provider notification: providers contact partners directly and offer testing, (2) contract referral—index cases are given a set amount of time to notify partners, after which providers conduct notification, and (3) dual referral: both index clients and providers contact partners and providers often conduct couples HIV testing.5 In practice, aPS is often implemented as a mix of these options and all forms of aPS require voluntary consent from index clients. APS clinical trials and demonstration projects in SSA have found high positivity rates of 30%–63% among sexual partners of index clients and high CD4 median counts, indicating that individuals are identified earlier in their disease course compared with clinic testing.6–10 Early case detection and linkage can improve clinical outcomes and reduce onward transmission.7,11,12 Mathematical modeling analyses indicate that aPS is a cost-effective strategy to reduce HIV burden in SSA.13

Furthermore, aPS is an effective method to reach HIV-exposed men through their HIV-positive female partners, because women test for HIV at higher rates than men. Men in SSA are more likely to start antiretroviral therapy (ART) at advanced disease stages and have worse clinical outcomes compared with women.14,15 Low male testing and treatment rates also increase HIV transmission to female partners. However, the impact of aPS on the HIV epidemic is contingent on high acceptance rates among index clients who provide contact information for their sexual partners for partner tracing and notification. Assessing the demographics of women who refuse aPS and their reasons for nonenrollment may help target counseling messages and improve uptake. We sought to assess aPS acceptability, reasons, and predictors of nonenrollment among females in an ongoing implementation project of aPS scale-up in western Kenya, a region with high HIV prevalence (15%).16

METHODS

aPS Scale-Up Project

This analysis was performed using data from an ongoing aPS scale-up project in western Kenya, a collaboration between the University of Washington (UW), PATH: a nongovernmental organization, and the Ministry of Health in Kenya. The overall goal of aPS scale-up is to implement and evaluate aPS integration into health facilities in western Kenya using government-used health care workers who perform aPS as part of their routine clinic duties. Although, aPS is being offered to both male and female index clients, we only collect program data on female indexes and their male partners. HIV testing services counselors assess eligibility among individuals at participating clinics and offer aPS to those who are eligible at the time of HIV diagnosis. Females testing HIV positive are eligible for aPS if they are ≥15 years of age, not at risk of intimate partner violence (IPV), not pregnant, newly diagnosed HIV-positive, and report at least one sexual partner within the last 3 years. Consenting females are asked to provide names and contact information for all sexual partners in the last 3 years. Index clients are offered aPS by contract referral, provider referral, or dual referral approaches according to WHO guidelines. Only one reason for refusal or ineligibility was documented per index client. HIV-testing services counselors contact sexual partners through phone or physical tracing to notify them of their potential exposure and offer HIV testing. Partners are told that they may have been exposed to HIV but are not provided details regarding the exposure nor any identifying information regarding the index client. Both female indexes and HIV-positive male partners are followed up at 6 weeks, 6 months, and 12 months postenrollment to assess linkage to ART, IPV, and relationship dissolution. In addition, viral load testing is conducted at 12 months. To date, aPS has been integrated into 31 health care facilities in western Kenya; 16 in Kisumu County, and 15 in Homa Bay County. The health care facilities selected are largely government-run clinics and hospitals providing HIV care services supported by the Kenya Ministry of Health and implementing partners including PATH. Two of the 31 facilities included are private clinics. All facilities provide routine health care services in addition to HIV care. APS implementation began in Kisumu County in May 2018 and was later scaled up to Homa Bay in November 2018. Study data are collected on tablets using the open-source Open Data Kit platform developed at the UW.17 All data are encrypted for storage on the devices and transferred immediately over an encrypted connection to a secure server at the Kenya Ministry of Health. Deidentified data are transferred nightly to a secure server at UW.

Study Population and Statistical Analysis

We analyzed data from HIV-positive females (age ≥15 years) in 31 health facilities offering aPS in western Kenya from May 2018 to August 2019. Sociodemographics of females were compared by aPS enrollment status (accepted, refused, and ineligible) and reasons for refusal and ineligibility were tabulated. We used multivariate binomial regression with robust standard errors to assess the association between female demographics and aPS refusal. Demographics that were statistically significant in univariate regression (P < 0.05) and improved model fit were included in the multivariate model; age was included as an a priori confounder. Income was collected as a dichotomous variable (≥10,000 shillings vs <10,000 schillings/month) We also visually assessed trends in aPS refusal and over time by county and used a χ2 test to evaluate differences in refusal rates by scale-up year. Analyses were conducted using Stata Software.18

RESULTS

Across facilities, 24,418 females received HIV testing and 1050 (4.3%) tested HIV positive. The average age of HIV-positive women was 29 years range (15–74), and history of prior HIV testing was high (86% had tested for HIV in their lifetime). Most females were married or cohabitating with their partners (54%) with an additional 8% reporting being in polygamous marriages. Females generally had low levels of education: 70% had a primary school education or lower, and 83% earned less than 10,000 shillings ($96 USD) per month. The primary modality of HIV testing was provider-initiated (71%) rather than client-initiated. Most women were identified in clinics in Kisumu County (66%) because of earlier aPS rollout compared with Homa Bay County. Female index participants enrolled in aPS reported an average of 1.7 sexual partners (data not shown).

APS coverage rates were high; overall 839 females enrolled in aPS (80%), 59 refused (6%), and 152 were ineligible (14%) (Table 1). APS uptake did not differ by age, testing history, or testing type (provider vs client initiated). In addition, aPS uptake among adolescents and young adults (age 15–24 years), who comprised 35% of the sample, were similar to those of older females (data not shown). APS refusal rates increased with higher levels of education. For example, 28% of females who accepted aPS completed some primary school as their highest level of education compared with 20% of those who refused. By contrast, 15% of females accepting aPS had completed some secondary school as their highest education level vs to 25% of those who refused. Females refusing aPS were more likely to be divorced/separated, never married, or widowed. Similar to refusal patterns, ineligibility for aPS did not differ by age, testing modality, or testing history. Females who were ineligible for aPS were more likely to be divorced/separated, never married, or widowed compared with women enrolled in aPS.

TABLE 1. - Characteristics of Female Index Clients by the aPS Enrollment Status From 31 Health Facilities in Western Kenya*
Accepted aPS (N = 839) Refused aPS (N = 59) Ineligible for aPS (N = 152)
Age (mean, IQR) 28 (27–29) 31 (29–34) 31 (29–32)
Education
 Postsecondary 50 (6) 7 (12) 6 (4)
 Completed secondary 129 (15) 15 (25) 34 (22)
 Some secondary 168 (20) 11 (19) 34 (22)
 Completed primary 228 (27) 14 (24) 41 (27)
 Some primary 236 (28) 12 (20) 34 (22)
 Never attended school 28 (3) 0 (0) 3 (2)
Monthly income ≤10,000 Kenyan shillings ($96 USD) 709 (85) 42 (71) 29 (81)
Marital status
 Married monogamous/cohabitating 493 (59) 19 (32) 53 (35)
 Married polygamous 70 (8) 3 (5) 9 (6)
 Divorced/separated 68 (8) 8 (14) 29 (19)
 Single, never married 153 (18) 16 (27) 29 (19)
 Widow 55 (7) 13 (22) 32 (21)
Ever tested 721 (86) 48 (81) 129 (85)
Testing type
 Provider initiated 604 (72) 42 (71) 110 (72)
 Client initiated 235 (28) 17 (29) 42 (28)
County
 Kisumu 526 (63) 56 (95) 115 (76)
 Homa Bay 313 (37) 3 (5) 37 (24)
*Percentages are listed in brackets.
aPS, Assisted Partner Notification Services; IQR, interquartile range.

Table 2 shows the testing outcomes among male partners elicited by enrolled female index clients by county. Overall 77% of male partners named by female index clients were traced and tested for HIV by aPS providers; 44% were HIV positive, and 17% were newly diagnosed HIV-positive. Of partners who were known HIV-positive at the time of tracing, the majority self-reported to be on ART (97%). At 6 weeks after aPS enrollment, 93% of index clients and 91% of male partners were reached through phone and self-reported to be on ART; 1.9% of female indexes reported relationship dissolution and 0.7% reported IPV at 6 weeks postenrollment (data not shown).

TABLE 2. - Testing Outcomes Among Male Partners Elicited by Female Index Clients
Male Partner Outcomes Homa Bay Kisumu Total
Partners elicited 666 1114 1780
Partners HIV tested (/total elicited) 515 (77%) 779 (70%) 1294 (73%)
Partners tested HIV-positive (/total tested) 230 (45%) 344 (44%) 574 (44%)
Partners newly diagnosed HIV-positive (/total tested) 91 (18%) 132 (17%) 223 (17%)
Partners on ART at baseline (/known positive) 136 (97%) 206 (97%) 342 (97%)

Table 3 displays the reasons for aPS refusal reported by female index clients. The most common reason for refusing aPS was not being emotionally ready (31%), followed by reporting not to have any sexual partners in the last 3 years (22%). Fear of IPV or fear their partner will find out was cited by 12% and 3% of females, respectively. Having sex partners who lived outside of the catchment region (10%) or outside the country (3%) were also reported as reasons for refusal. Seven percent of females reported that they did not have sufficient contact information for their sexual partners and 3% refused to provide contact information.

TABLE 3. - Reasons for Refusal Among aPS Among Female Index Clients
Reasons for Refusal (N = 59) N (%)
Not emotionally ready 18 31
Reported to not have any sexual partners 13 22
Fear of IPV 7 12
All sex partners live outside catchment region 6 10
Index did not have sufficient contact info for sex partners 4 7
All sex partners live outside country 2 3
Fear that partner will find out 2 3
Refused to provide info for sex partners 2 3
Reason not specified 5 8
Total 59 100
aPS, Assisted Partner Notification Services; IPV, intimate partner violence.

Table 4 shows the reasons for aPS ineligibility as determined by health care workers. Approximately half of females listed as ineligible for aPS did not have a reason listed. Among reasons reported, pregnancy was the most common (14%) followed by risk of IPV (9%), only having 1 partner who is known HIV-positive (7%) or being a widow with no recent partners (7%). Couple testing was conducted in 9% of cases, and health care workers reported not have enough time to provided aPS in 3% of cases.

TABLE 4. - Reasons for Ineligibility Among aPS Among Female Index Clients
Reasons for Ineligibility (N = 152) N %
No reason listed 78 51
Couples testing 13 9
Risk of IPV 13 9
Female is known HIV positive 2 1
Not able to provide informed consent 1 1
Not enough time 4 3
Index has only one partner who is known HIV-positive 10 7
Pregnant 21 14
Widow, no additional partners 10 7
Total 152 100
aPS, Assisted Partner Notification Services; IPV, intimate partner violence.

In multivariate regression, females who refused aPS were more likely to have completed secondary school [adjusted relative risk (aRR) 2.03, 95% confidence interval (CI): 1.13 to 2.82] and be divorced/separated (aRR: 3.09, 95% CI: 1.39 to 6.86), single (aRR: 2.66, 95% CI: 1.31 to 5.42), or widowed (aRR: 4.41, 95% CI: 2.18 to 8.96) compared with married/cohabitating (Table 5). Income was not statistically significantly associated with aPS refusal after controlling for education and other relevant covariates. Age was not associated with aPS refusal.

TABLE 5. - Association Between aPS Refusal and Demographics of Female Index Clients in Kenya
RR (95% CI) aRR (95% CI)
Age (yr) 1.04 (1.00 to 1.06) 1.03 (0.99 to 1.06)
Ever HIV tested 0.73 (0.39 to 1.37)
Provider initiated testing (vs client initiated) 0.96 (0.56 to 1.66)
Completed secondary school 2.06 (1.24 to 3.41) 2.03 (1.13 to 2.82)
Monthly income >10,000 Kenyan shillings ($96 USD) 2.07 (1.21 to 3.53) 1.56 (0.86 to 2.81)
Marital status
 Married monogamous/cohabitating Ref. Ref.
 Married polygamous 1.11 (0.34 to 3.65) 1.08 (0.33 to 3.51)
 Divorced/separated 2.83 (1.29 to 6.25) 3.09 (1.39 to 6.86)
 Single, never married 2.55 (1.34 to 4.84) 2.66 (1.31 to 5.42)
 Widow 5.15 (2.67 to 9.96) 4.41 (2.18 to 8.96)
aPS, Assisted Partner Notification Services; aRR, adjusted relative risk; RR, relative risk; Ref., reference.

Figure 1 displays the proportion of HIV-positive female index clients that refused aPS over time across facilities in Kisumu and Homa Bay County. Refusal rates were higher in the first 6 months of aPS implementation compared with the later months; for example, the average refusal rate in Kisumu was 13% during May 2018 and October 2018 compared with just 5% during November 2018 and August 2019. Refusal rates were lower in Homa Bay compared with Kisumu overall (2% vs 8%). Chi-squared tests demonstrated that aPS refusal was statistically significantly higher in 2018 compared with 2019 for both Kisumu (P = 0.001) and Homa Bay (P = 0.01). However, we do not incorporate data on time trends and therefore cannot infer causality. APS ineligibility did not show clear patterns over time or by county (data not shown).

F1
FIGURE 1.:
Proportion of female indexes refusing aPS over time.

DISCUSSION

We assessed the real-world acceptability of aPS in a large-scale implementation program across 31 facilities in western Kenya. Overall, aPS had high uptake among HIV-positive female index clients regardless of age or previous HIV testing history. Similarly, uptake did not vary by testing modality, indicating that females identified through provider-initiated testing were equally likely to accept aPS as those who sought out HIV testing (client-initiated). Furthermore, aPS had high coverage in adolescents and young adults, a WHO priority population, who may be less likely to accept HIV interventions because of distrust of health care workers or concerns about disclosure to parents/caregivers.19 In addition, aPS refusal rates declined over time with program scale-up, suggesting health care workers developed improved messaging strategies that increased aPS acceptability.

Because of the high positivity rates among HIV-exposed sexual partners (30%–50%), even small increases in aPS acceptability among female index clients can have clinical benefits in identifying new HIV cases and preventing transmission.6–10 We found that females who were divorced, separated, or single were 2 to 3 times more likely to refuse aPS compared with those who were married or cohabitating, after controlling for participant demographics. In addition, females with higher education had 2-fold higher aPS refusal rates. Targeted counseling strategies may be needed to address the distinct concerns of these women. It is possible that females who are no longer together with their partner have less motivation to protect their former partner's health. They also may be less likely to have contact information for former partners. Future qualitative research can improve our understanding of the barriers to aPS acceptance among women with higher education or those who are not married/cohabitating.

Almost one third of females who refused aPS reported not feeling emotionally ready. An HIV diagnosis can take time to process, therefore following up with females after several weeks regarding aPS enrollment can increase uptake. Further research on effective approaches to increase uptake among these women is needed, including evaluating strategies such as HIV-self testing or couples HIV counseling and testing. Similarly, females who report not having contact information for their sexual partners can benefit from follow-up if they are given time to locate this information. Almost 25% of females who refused aPS cited not having any sexual partners in the last 3 years. However, because a new HIV diagnosis is often associated with recent sexual activity and this group excludes widows, it is possible that some of the females reporting no sexual activity did not want to disclose their partners. Health care worker follow-up may encourage aPS uptake among these females. Having sexual partners that live outside the catchment area was another reason for aPS nonenrollment. Migration for employment is common in many regions of Kenya because aPS is scaled-up case referrals between counties can increase program coverage. Furthermore, providing aPS at a subsequent visit for clients when there was not enough time to for aPS can increase coverage. Health care facilities are often busy and understaffed so this may become a common barrier to aPS with scale-up. Finally, couple testing was a commonly cited reason for not providing aPS. Couples testing and disclosure is associated with increased condom use in serodiscordant relationships and increased ART adherence and should be encouraged.20 However, it is possible that persons testing HIV positive through couples testing may have partners outside of their primary relationship. Separately following up with index clients to offer aPS can identify additional HIV-exposed partners.

IPV was identified as a barrier to aPS uptake, both because of women refusing aPS because of fear of IPV or health care worker assessment that females were at moderate or high IPV risk and therefore ineligible to receive aPS. IPV is highly prevalent in SSA; according to the Kenya Demographic Health Survey, 40% of ever married females in Kenya had experienced IPV.21 In addition, IPV is more commonly reported among HIV-positive females and may increase HIV acquisition through limited safe sex negotiation, forced sex, or increased risk taking behavior.22,23 In addition, IPV is associated with poorer ART adherence and therefore increased transmission to partners and poorer clinical outcomes.24 Behavioral interventions to address IPV are important for the success of HIV prevention programs including aPS and the overall well-being of women in SSA. It is worthwhile to note that aPS provision is shown to be safe and effective among women with a history of lifetime IPV and aPS is associated with a low risk of social harms.25,26 Therefore, aPS can be safely scaled-up in SSA to achieve high coverage among female index clients.

Our analysis has several limitations. Because we used programmatic data, the quality was not as robust as that of a clinical trial. For example, reasons for aPS ineligibility were missing in 51% of cases, which might result in drivers of ineligibility that we could not explore. However, we conducted extensive data cleaning and followed-up with facilities to obtain data that were missing or verify that values were coded correctly. Furthermore, reasons for refusals were well characterized with only 8% missing. In addition, there is some overlap between refusals and ineligibility because some females refused for reasons that may make them ineligible. Also, only one reason for refusal/ineligibility was collected per woman, who may have had multiple reasons for nonenrollment in aPS. Despite testing a large number of females across facilities and identifying over 1000 HIV-positive women, our sample size for refusal was small (N = 59). Although we were able to assess the association of demographics with aPS refusal, we did not have sufficient power to assess refusal patterns by geographic location or facility size. As more program data are collected with aPS scale-up, studies evaluating heterogeneity in aPS acceptability can identify important differences that impact aPS coverage. Furthermore, because the program collected limited demographic data, we could not assess the impact of other covariates (sexual behavior, socioeconomic status, and mental health) on aPS acceptability. In addition, because the aPS scale-up study is only collecting data on female index clients, we cannot report reasons for refusal among men. However, aPS implementation studies in SSA show that most index clients are female (>70%) because they have are more likely than men to seek out HIV testing.9 Furthermore, their male partners are more likely to have undiagnosed HIV compared with female partners of male indexes because men present later in the course of their HIV disease, and their female partners are more likely to have been tested. However, future studies investigating aPS uptake and reasons for nonenrollment among male index clients can increase program acceptability. In addition, although some pregnant women receive aPS outside of clinic settings, it is not offered within the facilities, thus cannot assess acceptability in this population. Overall, there are a lack of data on aPS safety and effectiveness among pregnant women as they have generally been excluded from aPS clinical trials. However, male partners of pregnant females can also benefit from aPS and linkage to care if HIV positive, which can protect their health and enable them to continue providing for their growing families. Future studies assessing aPS in pregnant females can maximize the health impact of this intervention. Similarly, we evaluate aPS acceptability among women newly diagnosed with HIV. However, females who are known positive but not yet linked to care or virally suppressed likely have sexual partners at high risk of HIV. The population of persons living with HIV who are not virally suppressed is likely larger than that of newly diagnosed persons so evaluating the outcomes of expanding aPS coverage to known positive persons is an important priority for future research.

The strengths of our study include the ability to analyze data from a large-scale implementation study to assess aPS acceptability outside a clinical trial. Health care facilities in our sample include urban and rural regions and a range of clinic sizes that are representative of facilities in western Kenya. Our findings of high real-world acceptability suggest that aPS scale-up has the potential to increase testing coverage to reach the first 95 of UNAIDS ambitious testing and treatment targets and strengthen the HIV care cascade in SSA.2

ACKNOWLEDGMENTS

The authors acknowledge the contributions of the Kenya Ministry of Health, PATH, the aPS scale-up study team, health care workers, and the participants.

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Keywords:

HIV counseling and testing; sub-Saharan Africa; partner notification; partner services; women

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