1. #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

2. No conflicts of interest to declare

3. Smallpox
Smallpox contact tracing, Brazil, 1960s.

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

5. STIs

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

7. HIV

8. 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

9. 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

10. 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%

11. 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%

12. 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

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

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

15. 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

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

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

18. 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

19. 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

20. 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

21. Moving forward

22. 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.