1. Implementation Experiences & Insights from the Scale-Up of an HIV Assisted Partner Notification Intervention in Central Asia
Kristen M. Little, Maxim Kan, Olga Samoylova, Altynai Rsaldinova, Daniyar Saliev, Faridun Ishokov, Robert Gray, Nina S. Hasen
22 July 2019

2. Conflicts of Interest I have no conflicts of interest to declare
This work was supported by the USAID Central Asia HIV Flagship Activity Project (Contract Number: AID-176-C )

3. Background The HIV epidemics in Central Asia are highly concentrated
Disproportionately impact people who inject drugs (PWID)
Sexual partners of PWID
An estimated 168,600 PWID in Kazakhstan, the Kyrgyz Republic, and Tajikistan

4. HIV Prevalence among PWID
Background
9.3%
Kazakhstan
12.4%
Kyrgyz Republic
13.5%
Tajikistan
HIV Prevalence among PWID
HIV prevalence estimates among PWID range from 9.3%-13.5%
Compared to 0.13%-0.19% among the general population
Obstacles to HIV epidemic control
Laws and policies that discriminate against key populations
Stigma and marginalization that limit access to HIV services
Minimal epidemiological data to inform program design and targeting

5. Background
WHO recommends assisted partner notification (APN) services for people living with HIV (PLHIV)
These services have not been widely scaled in Central Asia
We describe the results from an APN intervention implemented within a program focused on PLHIV and PWID in Kazakhstan, the Kyrgyz Republic, and Tajikistan
USAID-funded Flagship Project

6. Program Overview Pre-APN Period: APN Period:
Consenting index cases recruited sexual and injecting partners using passive referral
Coupon-based referral
APN Period:
Had choice of passive (coupon-based) referral or APN
APN included provider, contract, or dual-referral options

7. Methods
To better understand differences in outcomes between the pre-APN and APN periods, we:
Analyzed de-identified routine program data before/after APN launch
Index cases and their sexual and injecting partners
Equal-length periods before and after APN intervention scaled
One month wash-out period during APN scale-up
Compared the demographic characteristics of index cases and sexual/injecting partners from pre-APN and APN periods,
Number/proportion of HIV cases found (positivity rate)
Comparison of index case characteristics before/after APN
Comparison of partner characteristics before/after APN
Estimated partners recruited per index case & the number of index cases needed to find one new partner with HIV

8. Results

9. The number of index cases decreased under APN, while number of partners increased
Number of index cases recruited fell from 4,418 to 2,675 under APN
Partners recruited increased 1.7 times, from 2,245 to 3,735

10. Index Case Characteristics Before/After APN
Variable
Kazakhstan (N=2,581)
Kyrgyz Republic (N=2,372)
Tajikistan (N=2,140)
Pre-APN (n=1,491)
APN (n=1,090)
P-value
Pre-APN (n=1,416)
APN (n=956)
Pre-APN (n=1,511)
APN (n=629)
N (%)
Female
568 (38.1)
406 (37.3)
0.661
622 (43.9)
367 (38.4)
0.007
660 (43.7)
233 (37.0)
0.005
Age (Median, IQR)
38 (33-43)
37 (32-43)
0.002
39 (33-45)
39 ( )
0.764
39 (32-45)
36 (30-44)
<0.001
Project Entry
Newly found
70 (4.7)
108 (9.9)
157 (11.2)
224 (23.4)
168 (11.1)
228 (36.3)
Lost to follow-up
292 (19.6)
136 (12.5)
253 (18.0)
118 (12.3)
304 (20.1)
107 (17.0)
Pre-ART Care
1,129 (75.7)
846 (77.6)
997 (70.9)
614 (64.2)
1,039 (68.8)
294 (46.7)
Has not disclosed status to anyone
229 (16.2)
260 (24.0)
528 (37.9)
540 (56.7)
354 (23.4)
189 (30.1)
0.001
ART Status
Never on ART
621 (41.7)
327 (30.0)
370 (26.1)
348 (36.4)
142 (9.4)
151 (24.0)
Newly started
368 (24.7)
513 (47.1)
387 (27.3)
364 (38.1)
332 (22.0)
288 (45.8)
Reinitiated
415 (27.8)
156 (14.3)
534 (37.7)
210 (22.0)
843 (55.8)
123 (19.6)
Already on ART
2 (0.1)
0 (0.0)
22 (1.6)
Previously on ART
85 (5.7)
94 (8.6)
103 (7.3)
34 (3.6)
194 (12.8)
67 (10.7)

11. Index Case Characteristics Before/After APN
Variable
Kazakhstan (N=2,581)
Kyrgyz Republic (N=2,372)
Tajikistan (N=2,140)
Pre-APN (n=1,491)
APN (n=1,090)
P-value
Pre-APN (n=1,416)
APN (n=956)
Pre-APN (n=1,511)
APN (n=629)
N (%)
Female
568 (38.1)
406 (37.3)
0.661
622 (43.9)
367 (38.4)
0.007
660 (43.7)
233 (37.0)
0.005
Age (Median, IQR)
38 (33-43)
37 (32-43)
0.002
39 (33-45)
39 ( )
0.764
39 (32-45)
36 (30-44)
<0.001
Project Entry
Newly found
70 (4.7)
108 (9.9)
157 (11.2)
224 (23.4)
168 (11.1)
228 (36.3)
Lost to follow-up
292 (19.6)
136 (12.5)
253 (18.0)
118 (12.3)
304 (20.1)
107 (17.0)
Pre-ART Care
1,129 (75.7)
846 (77.6)
997 (70.9)
614 (64.2)
1,039 (68.8)
294 (46.7)
Has not disclosed status to anyone
229 (16.2)
260 (24.0)
528 (37.9)
540 (56.7)
354 (23.4)
189 (30.1)
0.001
ART Status
Never on ART
621 (41.7)
327 (30.0)
370 (26.1)
348 (36.4)
142 (9.4)
151 (24.0)
Newly started
368 (24.7)
513 (47.1)
387 (27.3)
364 (38.1)
332 (22.0)
288 (45.8)
Reinitiated
415 (27.8)
156 (14.3)
534 (37.7)
210 (22.0)
843 (55.8)
123 (19.6)
Already on ART
2 (0.1)
0 (0.0)
22 (1.6)
Previously on ART
85 (5.7)
94 (8.6)
103 (7.3)
34 (3.6)
194 (12.8)
67 (10.7)

12. Index Case Characteristics Before/After APN
Variable
Kazakhstan (N=2,581)
Kyrgyz Republic (N=2,372)
Tajikistan (N=2,140)
Pre-APN (n=1,491)
APN (n=1,090)
P-value
Pre-APN (n=1,416)
APN (n=956)
Pre-APN (n=1,511)
APN (n=629)
N (%)
Female
568 (38.1)
406 (37.3)
0.661
622 (43.9)
367 (38.4)
0.007
660 (43.7)
233 (37.0)
0.005
Age (Median, IQR)
38 (33-43)
37 (32-43)
0.002
39 (33-45)
39 ( )
0.764
39 (32-45)
36 (30-44)
<0.001
Project Entry
Newly found
70 (4.7)
108 (9.9)
157 (11.2)
224 (23.4)
168 (11.1)
228 (36.3)
Lost to follow-up
292 (19.6)
136 (12.5)
253 (18.0)
118 (12.3)
304 (20.1)
107 (17.0)
Pre-ART Care
1,129 (75.7)
846 (77.6)
997 (70.9)
614 (64.2)
1,039 (68.8)
294 (46.7)
Has not disclosed status to anyone
229 (16.2)
260 (24.0)
528 (37.9)
540 (56.7)
354 (23.4)
189 (30.1)
0.001
ART Status
Never on ART
621 (41.7)
327 (30.0)
370 (26.1)
348 (36.4)
142 (9.4)
151 (24.0)
Newly started
368 (24.7)
513 (47.1)
387 (27.3)
364 (38.1)
332 (22.0)
288 (45.8)
Reinitiated
415 (27.8)
156 (14.3)
534 (37.7)
210 (22.0)
843 (55.8)
123 (19.6)
Already on ART
2 (0.1)
0 (0.0)
22 (1.6)
Previously on ART
85 (5.7)
94 (8.6)
103 (7.3)
34 (3.6)
194 (12.8)
67 (10.7)

13. Positivity rate increased slightly under APN
Increases seen in KZ, TJ, and overall
Overall increase statistically significant
Decrease in positivity rate observed in KG
Number of new HIV cases found increased in all 3 countries
From 161 to 322 overall

14. Partner Characteristics Before/After APN
Variable
Kazakhstan (N=2,401)
Kyrgyz Republic (N=2,072)
Tajikistan (N=1,507)
Pre-APN
(N=1,333
55.5%)
APN
(N=1,068,
44.5%)
P-value
(N=405,
19.6%)
(N=1,667,
80.5%)
(N=507,
33.6%)
(N=1,000,
66.4%)
N (%)
Female
618 (46.4)
478 (44.8)
0.433
258 (63.7)
859 (51.5)
<0.001
253 (49.9)
623 (62.3)
Age (Median, IQR
37 (31-43)
36 (30-42)
0.018
38 (31-45)
36 (30-43)
0.010
37 (30-44)
34 (28-40)
Tested for HIV previously* --
128 (31.8)
85 (16.1)
76 (15.0)
108 (10.8)
0.019
Shared needles with recruiter**
2 (0.2)
3 (0.3)
0.465
20 (5.1)
13 (2.5)
0.035
6 (2.8)
63 (26.8)
Had sex with recruiter***
1,311 (99.9)
1,066 (99.8)
0.448
400 (99.0)
524 (99.2)
0.703
216 (100)
201 (85.5)
Migration experience†
224 (44.2)
329 (32.9)
Positive HIV test
58 (4.4)
65 (6.1)
0.058
32 (7.9)
105 (6.3)
0.247
71 (14.0)
152 (15.2)
0.537

15. Partner Characteristics Before/After APN
Variable
Kazakhstan (N=2,401)
Kyrgyz Republic (N=2,072)
Tajikistan (N=1,507)
Pre-APN
(N=1,333
55.5%)
APN
(N=1,068,
44.5%)
P-value
(N=405,
19.6%)
(N=1,667,
80.5%)
(N=507,
33.6%)
(N=1,000,
66.4%)
N (%)
Female
618 (46.4)
478 (44.8)
0.433
258 (63.7)
859 (51.5)
<0.001
253 (49.9)
623 (62.3)
Age (Median, IQR
37 (31-43)
36 (30-42)
0.018
38 (31-45)
36 (30-43)
0.010
37 (30-44)
34 (28-40)
Tested for HIV previously* --
128 (31.8)
85 (16.1)
76 (15.0)
108 (10.8)
0.019
Shared needles with recruiter**
2 (0.2)
3 (0.3)
0.465
20 (5.1)
13 (2.5)
0.035
6 (2.8)
63 (26.8)
Had sex with recruiter***
1,311 (99.9)
1,066 (99.8)
0.448
400 (99.0)
524 (99.2)
0.703
216 (100)
201 (85.5)
Migration experience†
224 (44.2)
329 (32.9)
Positive HIV test
58 (4.4)
65 (6.1)
0.058
32 (7.9)
105 (6.3)
0.247
71 (14.0)
152 (15.2)
0.537

16. Number of partners recruited per index case increased under APN
Increased from 0.5 partners per index in the pre-APN period to 1.4 under APN
Increase largest in KG (0.3 to 1.7) and TJ ( )

17. The number of index cases needed to find one positive partner decreased under APN
The number of index cases needed to find one new HIV+ partner fell from 27.4 during pre-APN to 8.3 under APN
Decreases seen across countries
Largest drops in KG (80%) and TJ (81%)

18. Conclusions

19. Limitations Analysis based on routine monitoring data
Monitoring system not designed to link index cases to partners
Unable to assess whether differences among index cases accounted for improved outcomes
Unable to assess factors behind country-level heterogeneity
Did not collect information on the proportion of PLHIV agreeing to serve as index cases
No information on the proportion of index cases who recruited a partner
Risk behaviors based on self-report
Limited demographic and behavioral data collected
High missingness for some variables

20. Conclusions APN services feasible in Central Asia
Able to be implemented alongside other HIV case-finding/management services
In context of PWID-focused HIV case-finding and management program
Though positivity rates varied across countries, APN resulted in:
Increases in the number of new HIV cases diagnosed among partners
Significant increases in number of partners recruited per index case
Significant reductions in number of index cases needed to find a new HIV-positive partner
Focusing additional resources on APN, using good practice tools and methods, may be feasible approach to improve HIV case-finding among hard-to-reach populations
Scale-up of APN services needed in Central Asia
More operational and implementation science research needed to optimize efficiency and effectiveness of APN in this setting

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22. Acknowledgements Co-authors Flagship and PSI staff
NGO implementing partners
Peer Navigators and clients in Central Asia
USAID