Assisted partner notification services to augment HIV testing and linkage to care in Kenya: study protocol for a cluster randomized trial

Background: HIV case-finding and linkage to care are critical for control of HIV transmission. In Kenya, >50% of seropositive individuals are unaware of their status. Assisted partner notification is a public health strategy that provides HIV testing to individuals with sexual exposure to HIV and are at risk of infection and disease. This parallel, cluster-randomized controlled trial will evaluate the effectiveness, cost-effectiveness, and feasibility of implementing HIV assisted partner notification services at HIV testing sites (clusters) in Kenya. Methods/design Eighteen sites were selected among health facilities in Kenya with well-established, high-volume HIV testing programs, to reflect diverse communities and health-care settings. Restricted randomization was used to balance site characteristics between study arms (n = 9 per arm). Sixty individuals testing HIV positive (‘index partners’) will be enrolled per site (inclusion criteria: ≥18 years, positive HIV test at a study site, willing to disclose sexual partners, and never enrolled for HIV care; exclusion criteria: pregnancy or high risk of intimate partner violence). Index partners provide names and contact information for all sexual partners in the past 3 years. At intervention sites, study staff immediately contact sexual partners to notify them of exposure, offer HIV testing, and link to care if HIV seropositive. At control sites, passive partner referral is performed according to national guidelines, and assisted partner notification is delayed by 6 weeks. Primary outcomes, assessed 6 weeks after index partner enrollment and analyzed at the cluster level, are the number of partners accepting HIV testing and number of HIV infections diagnosed and linked to care per index partner. Secondary outcomes are the incremental cost-effectiveness of partner notification and the costs of identifying >1 partner per index case. Participants are closely monitored for adverse outcomes, particularly intimate partner violence. The study is unblinded due to practical limitations. Discussion This rigorously designed trial will inform policy decisions regarding implementation of HIV partner notification services in Kenya, with possible application to other parts of sub-Saharan Africa. Examination of effectiveness and cost-effectiveness in diverse settings will enable targeted application and define best practices. Trial registration ClinicalTrials.gov NCT01616420

Scale-up of assisted partner services in Kenya: assessing linkage to care, integration and costs

Thesis (Ph.D.)--University of Washington, 2021Despite marked progress in achieving universal 95-95-95 targets, gaps still exist, especially in improving individual awareness of HIV status. According to the 2018 Kenya Population-based HIV Impact Assessment (KenPHIA) report, approximately 79.5% of individuals were aware of their status, 96.0% were on antiretroviral therapy, and 90.6% were virally suppressed. Men were less likely to be aware of their HIV status compared to women (72.6% vs 82.7%) necessitating HTS strategies to effectively target this ‘hard-to-reach’ group. HIV assisted partner services (aPS), or healthcare provider supported notification of sex partners to newly diagnosed HIV-positive individuals, have been used to bridge this gap in HIV testing, and have been shown to be safe, effective, and cost-effective. aPS was scaled up within the national HIV testing services (HTS) program in Kenya in 2016 after World Health Organization (WHO) recommended the intervention. Our objective was to assess linkage to care, integration, and costs of scaling up aPS within the national HTS program in Kenya. In the first study, we used data from nine facilities randomized to receive immediate aPS in a cluster-randomized trial conducted in Kenya. We estimated linkage to care - defined as HIV clinic registration - and ART initiation separately for index clients and their sex partners. We found that only two-thirds of newly diagnosed HIV-positive sex partners, and known HIV-positive sex partners not enrolled in care at study enrolment, linked to care after receiving aPS. However, once linked to care, ART initiation was high (>85%) regardless of whether the participant was an index client, newly-diagnosed or known HIV-positive sex partner not previously linked to care. We recommend that HIV aPS programs optimize HIV care for these individuals, especially those who are younger and single. In the second study, we used an integrated conceptual framework to assess the extent of aPS integration, institutionalization, and sustainability in routine HTS programs. This study was conducted within the aPS scale-up project – an implementation science study to implement and evaluate the effectiveness of aPS when integrated within routine HTS, and assess implementation outcomes including implementation fidelity, acceptability, demand, and costs. We conducted semi-structured key informant in-depth interviews with aPS stakeholders at national, county, facility and community levels, and found that aPS was well integrated into the national HTS program within two years of scale-up. Funding limitations, human resource constraints, and low community awareness were noted as major barriers to service provision and long-term sustainability. To overcome these barriers, we recommend increased resource allocation for aPS (funding, human resources) and community health volunteer-facilitated community-level awareness. In the third study, using a payer perspective, we estimated the cost of integrating aPS into routine HTS within the aPS scale-up project in Kisumu and Homa Bay counties. We conducted microcosting, analyzing costs by start-up (August 2018), and recurrent costs one-year after aPS implementation (Kisumu: August 2019, Homa Bay: January 2020), and conducted time-and-motion observations. The average weighted incremental cost of integrating aPS into the existing HTS program was $7,485.97 per facility per year, with recurrent costs accounting for approximately 90$34.54, $42.50,$108.71 and $152.28, respectively, and varied by county and facility type, with larger volume facilities, especially county and sub-county hospitals, having higher total incremental costs and lower average unit costs. The largest cost drivers were personnel (49%) and transport (13%). We found significant cost variations across facilities offering aPS with high volume facilities having low average unit costs per MSP. We recommend facility prioritization to improve efficiency in resource allocation, especially healthcare personnel, potentially reducing the time and cost spent on delivering aPS. This dissertation contributes to the growing implementation science literature on aPS and highlights the need to prioritize resources as funding support towards HIV programs declines. As aPS is scaled-up, especially in resource-limited settings, policymakers and implementers will need to regularly review program data to identify sub-groups of PLWH requiring additional support before linking to HIV care and treatment services, and address communication gaps on aPS. Future research on cost-efficient strategies optimizing healthcare worker allocation during aPS is also critically important

Case finding among sexual partners to HIV positive individuals in Cameroon.

Thesis (Master's)--University of Washington, 2017-08Background: Heterosexual transmission of HIV accounts for a significant proportion of new HIV infections in sub-Saharan Africa with individuals unaware of HIV status at risk of transmitting the virus to their sexual partners. Partner services (PS) have been in use at the Cameroon Baptist Convention Heath Services (CBCHS) program to promote partner notification, early HIV testing, diagnosis and initiation to treatment for sexual partners to newly diagnosed HIV positive individuals (index persons). The goal of this study is to define the scalability, effectiveness and safety of partner services within the CBCHS PS program. Methods: We conducted a secondary analysis of CBCHS program data from 2007 to 2015 to evaluate the overall scale and partner notification outcomes; using data from 2014-2015, we determined index person (IP) and program factors associated with HIV case-finding; as well as adverse outcomes including partnership dissolution, loss of financial support and physical intimate partner violence (IPV). Descriptive analyses were used to define the overall scale of the program; and adverse outcomes at enrolment and follow-up, overall and stratified by gender. Logistic regression with clustering on the IP was used to describe factors associated with HIV case finding. Results: Overall, the CBCHS program interviewed 18,730 IPs who mentioned 21,057 sexual partners (index: partner ratio = 1:1.08) with a 10-fold increase in number of individuals that occurred mainly from 2007- 2010 before slowing down from 2011 - 2015. Between 2014 and 2015, 1261 IPs and 1357 sexual partners were mentioned. IPs were mainly female (63.8%), median age: 36 years (Interquartile Range [IQR]: 30, 43), married monogamous: 47.9% and seen at rural facilities (70.1%). Sexual partners were male (61.3%), median age 36 years (IQR: 30, 42), and married (57.0%). Ninety percent (n=1224) of the 1357 sexual partners, were notified in-person either by the IP or the health advisor and were offered HIV testing services. HIV prevalence among the 1224 notified sexual partners was 27.2% [previously diagnosed: 170/1224, 13.9%; newly diagnosed HIV positive: 163/1224, 13.3%]. HIV case finding was less likely to be associated with health advisor notification compared to IP notification [adjusted odds ratio [aOR] = 0.66, 95% confidence interval [CI]: 0.47, 0.93]. 19.7% of the IPs reported a history of IPV at enrolment to the PS program (female: 24.2%, male: 15.8%). On IP follow-up after receipt of PS, 61 (6.3%) had partnership dissolution, 15 (1.5%) had lost financial support while 11 (1.1%) sustained physical IPV. Three clients of the eleven reporting physical IPV after receiving PS (27.3%) attributed it to the intervention. Discussion: The CBCHS PS program was scalable, safe and had high HIV case finding compared with other HIV testing methods. IPV was relatively common in Cameroon. However, very few IPs receiving PS reported adverse outcomes following receipt of partner services. Partner services can be a useful component of routine HIV services to augment HIV testing to individuals at risk of HIV acquisition in sub-Saharan Africa countries

Assessment of client satisfaction with service delivery models at the Kenyatta National Hospital voluntary counseling and testing center

Submitted in partial fulfillment of the requirements for the Degree of Masters of Business AdministrationIntroduction: High quality service is critical to client satisfaction by affecting retention and loyalty. The main service delivery models within the healthcare industry are vertical and the integrated. Kenyatta National Hospital (KNH) Voluntary Counseling and Testing (VCT) has used the vertical model since inception. However, with over 50% of HIV infected clients in Kenya unaware of their HIV status, the integrated model was adopted to improve VCT service delivery. We assessed the relationship between client satisfaction and service delivery models at KNH VCT, and evaluated staff views. Methodology: Cross-sectional analysis was carried out on 196 clients (stratified random sampling) and 24 VCT staff (convenience sampling). Participants were consented and structured questionnaires administered. Data analysis was conducted using SPSS (Statistical Package for Social Sciences) Version 16. Descriptive statistics were used to report the socio-demographic characteristics. Multivariate analysis using Pearson’s Chi-square test and Multivariate Analysis of Variance (MANOVA) was used to establish and test the strength of relationship between satisfaction and type of service delivery model. Results: Clients had a high level of satisfaction with KNH VCT services. People were rated highest (4.74) while physical infrastructure was rated lowest (4.13). There was no significant differences in satisfaction between vertical and integrated models except in overall booking process (p=0), waiting time before booking (p=0), waiting time before counseling (p=0), and adequacy of pre-test counseling session (p=0.003). The staff scored people highest (4.40) and physical infrastructure (3.97) with no significant differences between the two models. Waiting times was rated lowest overall. There was a significant difference in strength of relationship with clients consistently rating services higher than staff in all parameters. Conclusion: Clients rated KNH VCT services highly with staff receiving the highest ratings and physical infrastructure the lowest; similar to staff perspectives. Improvements in physical infrastructure and waiting times will likely improve overall satisfaction

HIV partner services in Kenya: a cost and budget impact analysis study

Abstract Background The elicitation of contact information, notification and testing of sex partners of HIV infected patients (aPS), is an effective HIV testing strategy in low-income settings but may not necessarily be affordable. We applied WHO guidelines and the International Society for Pharmaco-economics and Outcomes Research (ISPOR) guidelines to conduct cost and budget impact analyses, respectively, of aPS compared to current practice of HIV testing services (HTS) in Kisumu County, Kenya. Methods Using study data and time motion studies, we constructed an Excel-based tool to estimate costs and the budget impact of aPS. Cost data were collected from selected facilities in Kisumu County. We report the annual total and unit costs of HTS, incremental total and unit costs for aPS, and the budget impact of scaling up aPS over a 5-year horizon. We also considered a task-shifted scenario that used community health workers (CHWs) rather than facility based health workers and conducted sensitivity analyses assuming different rates of scale up of aPS. Results The average unit costs for HIV testing among HIV-infected index clients was US$25.36 per client and US$ 17.86 per client using nurses and CHWs, respectively. The average incremental costs for providing enhanced aPS in Kisumu County were US$1,092,161 and US$ 753,547 per year, using nurses and CHWs, respectively. The average incremental cost of scaling up aPS over a five period was 45% higher when using nurses compared to using CHWs (US$5,460,837 and US$ 3,767,738 respectively). Over the five years, the upper-bound budget impact of nurse-model was US$1,767,863, 63$ 1,258,854, which was 71.2% lower than the nurse-based model. The budget impact was sensitive to the level of aPS coverage and ranged from US$28,547 for 30$ 1,267,603 for 80% coverage using nurses in 2018. Conclusion Scaling aPS using nurses has minimal budget impact but not cost-saving over a five-year period. Targeting aPS to newly-diagnosed index cases and task-shifting to community health workers is recommended

Assisted partner notification services to augment HIV testing and linkage to care in Kenya: study protocol for a cluster randomized trial

Abstract Background HIV case-finding and linkage to care are critical for control of HIV transmission. In Kenya, >50% of seropositive individuals are unaware of their status. Assisted partner notification is a public health strategy that provides HIV testing to individuals with sexual exposure to HIV and are at risk of infection and disease. This parallel, cluster-randomized controlled trial will evaluate the effectiveness, cost-effectiveness, and feasibility of implementing HIV assisted partner notification services at HIV testing sites (clusters) in Kenya. Methods/design Eighteen sites were selected among health facilities in Kenya with well-established, high-volume HIV testing programs, to reflect diverse communities and health-care settings. Restricted randomization was used to balance site characteristics between study arms (n = 9 per arm). Sixty individuals testing HIV positive (‘index partners’) will be enrolled per site (inclusion criteria: ≥18 years, positive HIV test at a study site, willing to disclose sexual partners, and never enrolled for HIV care; exclusion criteria: pregnancy or high risk of intimate partner violence). Index partners provide names and contact information for all sexual partners in the past 3 years. At intervention sites, study staff immediately contact sexual partners to notify them of exposure, offer HIV testing, and link to care if HIV seropositive. At control sites, passive partner referral is performed according to national guidelines, and assisted partner notification is delayed by 6 weeks. Primary outcomes, assessed 6 weeks after index partner enrollment and analyzed at the cluster level, are the number of partners accepting HIV testing and number of HIV infections diagnosed and linked to care per index partner. Secondary outcomes are the incremental cost-effectiveness of partner notification and the costs of identifying >1 partner per index case. Participants are closely monitored for adverse outcomes, particularly intimate partner violence. The study is unblinded due to practical limitations. Discussion This rigorously designed trial will inform policy decisions regarding implementation of HIV partner notification services in Kenya, with possible application to other parts of sub-Saharan Africa. Examination of effectiveness and cost-effectiveness in diverse settings will enable targeted application and define best practices. Trial registration ClinicalTrials.gov NCT01616420