#IAS2017 | @IAS_conference Increasing HIV test uptake & case finding through assisted HIV partner notification 25 July, 2017 Shona Dalal Department of HIV/AIDS World Health Organization, Geneva #TellYourPartner

No conflicts of interest to declare

Smallpox Smallpox contact tracing, Brazil, 1960s.

Ebola A burial team assistant interviews the brother of a man who died in a community in Freetown, Sierra Leone.

STIs

TB Health workers in Ethiopia are part of TB control programs, identifying suspected TB cases in the community.

HIV

What is Partner Notification? Partner notification or contact tracing, is a voluntary process whereby a trained provider asks people diagnosed with HIV about their sexual partners and/or drug injecting partners and then, if the HIV-positive client agrees, offers these partners HTS. Passive referral (HIV+ client contacts their partners themselves) Assisted approaches (health provider assists with contacting partners) Provider-referral – provider contacts partners directly Contract referral – client enters into “contract” with provider to refer partners within a specific period. If the partner doesn’t access HTS in that time, provider contacts partner Dual referral – Provider accompanies HIV+ clients when they disclose their status to partners and offer HTS

Systematic Review Objective Inclusion Outcomes Systematic review on HIV partner notification services to assess effectiveness Searched 5 Electronic databases until 1 June, 2016 Inclusion Study design comparing people diagnosed HIV-positive offered PN using assistance offered passive referral or no PN Measured one or more outcomes Published in a peer-reviewed journal or conference abstract Outcomes HIV test uptake Percentage of partners who tested HIV-positive Adverse events or social harm among HIV-positive patients and partners CD4 or viral load among partners Linkage to clinical assessments or ART for HIV-positive partners Linkage to HIV prevention among HIV-negative partners

Results Passive Notification/Control Groups   Passive Notification/Control Groups Assisted Notification Groups Study design Countries Population Index cases (median, range) Partners tested (range) Partners HIV+ (range) Index cases (median, range) Partners tested (range) 3 RCT + 1 Cluster RCT Kenya, Malawi, USA Women, MSM, PWID, STI, pregnant women, HIV testing center clients 89 (35-569) 3-52% 20-71% 132 (39-852) 51-74% 25-72% 6 Observational Cameroon, Mozambique, Spain, Taiwan, Tanzania, USA Hospitals, clinics, inpatients, MSM, ANC, VCT 281 (42-670) 2-65% 0-59% 43 (14-870) 21-89% 12-86%

Results 3 RCT + 1 Cluster RCT Kenya, Malawi, USA   Passive Notification/Control Groups Assisted Notification Groups Study design Countries Population Index cases (median,range) Partners tested (range) Partners HIV+ (range) Index cases (median, range) Partners tested (range) 3 RCT + 1 Cluster RCT Kenya, Malawi, USA Women, MSM, PWID, STI, pregnant women, HIV testing center clients 89 (35-569) 3-52% 20-71% 132 (39-852) 51-74% 25-72% 6 Observational Cameroon, Mozambique, Spain, Taiwan, Tanzania, USA Hospitals, clinics, inpatients, MSM, ANC, VCT 281 (42-670) 2-65% 0-59% 43 (14-870) 21-89% 12-86%

Uptake of HIV testing among partners of index cases a) Identified partners as denominator b) Rate of partner test or return to clinic per index patient Dalal et al., in press AIDS 2017

Proportion of Partners Diagnosed HIV Positive Note: Denominator was all identified partners Dalal et al., in press AIDS 2017

Linkage to Care Among HIV Positive Partners Dalal et al., in press AIDS 2017

Adverse events Very few adverse events Potential for harm should be discussed with HIV-positive clients before PN Note: AEs assessed with intimate partner violence/abandonment using locatable partners as the denominator Dalal et al., in press AIDS 2017

Timing of PN May Be Important Source: Brown et al., JAIDS. 2011;56(5):437-42. Source: Rosenberg et al. Lancet HIV. 2015;2(11):e483-e91.

Example of assisted PN of a young woman engaged in transactional sex Source: LVCT Health, Kenya.

New WHO Recommendation Voluntary assisted partner notification services should be offered as part of a comprehensive package of testing and care offered to people with HIV

Limitations 4 RCTs, one before ARVs were available Statistical heterogeneity for some outcomes Sensitivity analyses using different denominators and methods of outcome measurement found consistent results Pooled synthesis on harm indicated very few events Quality of evidence downgraded due to imprecision and risk of bias Similarly few adverse events from observational data Suggests that rate of harm is unlikely to differ between assisted and passive partner notification approaches

Conclusions Assisted PN is an effective means of reaching people with undiagnosed HIV Increased HIV test uptake among partners High proportions of HIV-positive people diagnosed Increased linkage to treatment and care among partners Few reports of harm Voluntariness, confidentiality, choice are critical Offer PN periodically, can be an ongoing process Laws or policies that stigmatize, criminalize or discriminate against key populations or people with HIV make PN challenging Global policy review: 21 countries with mandatory notification

Moving forward

World Health Organization Acknowledgements Cheryl Johnson, Virginia Fonner, Caitlin Kennedy, Nandi Siegfried, Carmen Figueroa, and Rachel Baggaley Special thanks to all who assisted with developing this recommendation: Steering Committee, Guideline Development Group, peer reviewers, contributors of case examples, editors, designers, administrative, communications and technical support teams. Funding of the partner notification guidelines provided by the Bill & Melinda Gates Foundation and the United States Agency for International Development through the President’s Emergency Plan for AIDS Relief.