IAS 2017 IASconference Increasing HIV test uptake case

#IAS 2017 | @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 #Tell. Your. Partner

#IAS 2017 | @IAS_conference No conflicts of interest to declare

#IAS 2017 | @IAS_conference Smallpox contact tracing, Brazil, 1960 s.

#IAS 2017 | @IAS_conference Ebola A burial team assistant interviews the brother of a man who died in a community in Freetown, Sierra Leone.

#IAS 2017 | @IAS_conference STIs

#IAS 2017 | @IAS_conference TB Health workers in Ethiopia are part of TB control programs, identifying suspected TB cases in the community.

#IAS 2017 | @IAS_conference HIV

#IAS 2017 | @IAS_conference 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

#IAS 2017 | @IAS_conference Systematic Review • Objective – Systematic review on HIV partner notification services to assess effectiveness – Searched 5 Electronic databases until 1 June, 2016 • Inclusion 1) 2) 3) • 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 1) 2) 3) 4) 5) 6) HIV test uptake Percentage of partners who tested HIV-positive Adverse events or social harm among HIV-positive patients and partners CD 4 or viral load among partners Linkage to clinical assessments or ART for HIV-positive partners Linkage to HIV prevention among HIV-negative partners

#IAS 2017 | @IAS_conference Results Study design Countries Passive Notification/Control Groups Partners Index cases tested HIV+ (median, range) (range) Population Women, MSM, PWID, 3 RCT + 1 Cluster Kenya, STI, pregnant women, 89 (35 -569) RCT Malawi, USA HIV testing center clients Cameroon, Mozambiqu Hospitals, clinics, e, Spain, 6 Observational inpatients, MSM, ANC, 281 (42 -670) Taiwan, VCT Tanzania, USA Assisted Notification Groups Index cases Partners (median, tested HIV+ range) (range) 3 -52% 20 -71% 132 (39 -852) 51 -74% 25 -72% 2 -65% 0 -59% 43 (14 -870) 21 -89% 12 -86%

#IAS 2017 | @IAS_conference Results Study design Countries Population Passive Notification/Control Groups Partners tested HIV+ Index cases (median, range) (range) Women, MSM, PWID, 3 RCT + 1 Cluster Kenya, STI, pregnant women, 89 (35 -569) RCT Malawi, USA HIV testing center clients Cameroon, Mozambiqu Hospitals, clinics, e, Spain, 6 Observational inpatients, MSM, ANC, 281 (42 -670) Taiwan, VCT Tanzania, USA Assisted Notification Groups Partners HIV+ Index cases Partners (median, range) tested (range) 3 -52% 20 -71% 132 (39 -852) 51 -74% 25 -72% 2 -65% 0 -59% 43 (14 -870) 21 -89% 12 -86%

#IAS 2017 | @IAS_conference 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

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

#IAS 2017 | @IAS_conference Linkage to Care Among HIV Positive Partners Dalal et al. , in press AIDS 2017

#IAS 2017 | @IAS_conference 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

#IAS 2017 | @IAS_conference 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): e 483 -e 91.

#IAS 2017 | @IAS_conference Example of assisted PN of a young woman engaged in transactional sex Source: LVCT Health, Kenya.

#IAS 2017 | @IAS_conference 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

#IAS 2017 | @IAS_conference 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

#IAS 2017 | @IAS_conference 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

#IAS 2017 | @IAS_conference Moving forward

#IAS 2017 | @IAS_conference 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.