Need to include couples’ HIV counselling and testing as a strategy to improve HIV partner notification services

Dear Editors

We read the recent publication, “Assisted HIV partner notification services: A systematic review and meta-analysis” by Dalal et al. with great interest [1]. The authors demonstrated the dearth of research on HIV partner notification, with only 10 studies identified. The paper highlighted the effectiveness of partner assisted referrals, mainly assisted by healthcare providers, compared to passive referral, not assisted by healthcare providers, in improving partner testing and notification of serostatus. We noted however that the authors did not identify couple’s HIV counselling and testing (CHCT) as a strategy to assist in partner notification and HIV testing and counselling. This is surprising because the World Health Organization (WHO) developed guidelines on CHCT in 2012 that recommend offering HIV testing and counselling to couples to facilitate disclosure of serostatus results [2]. Moreover, Dalal et al. state: “Three RCTs compared assisted partner notification services (provider or contract referral) with passive approaches, and the fourth cluster RCT compared immediate assisted notification with a passive referral group that received delayed assisted partner notification after outcomes were assessed. The study populations included pregnant women attending antenatal care (Rosenberg et al, 2015)…”. The referenced RCT developed by Rosenberg et al in Malawi compares passive invitation to passive invitation plus contact tracing [3]. In that study, contact tracing was not used to notify partners of index partner status, but rather to recruit men to get tested with their partner to facilitate HIV status disclosure thereby using CHTC as a mechanism for partner notification and mutual serostatus disclosure. However, the couples testing together was not mentioned in the systematic review.

Further, our recent research in South Africa demonstrates the impact of partner notification using CHCT following the diagnoses of one partner with HIV. The Department of Health in South Africa is making progress in reaching its 90-90-90 goals that 90% of people living with HIV know their status, 90% of those who know their status are on antiretroviral therapy (ART) and 90% of those on ART are virally suppressed. In South Africa, the National Strategic Plan for HIV includes the goal of increasing the proportion of PLHIV who know their HIV status from 60% to 90%, consistent with the 90-90-90 approach [5]. However, to meet the UNAIDS and South African 90-90-90 goals, effective approaches are urgently needed to diagnose the remaining 40% of PLHIV who don’t know their status, or those who know their status but are not yet on ART. For example, in Gauteng Province, from April 2016 to March 2017 the HIV prevalence among those tested in public health facilities was only 8.3% compared to the overall HIV prevalence of 14.8% among males and 22.2% among females 15–49 years old [5].

To improve the case finding and ART initiation, we adapted the CDC/WHO CHCT guidelines to focus on tracing and testing partners and children of HIV-infected individuals in Gauteng Province [4]. Our pilot study trained 35 nurses and lay counsellors in 10 large public health care facilities in March, 2017. In addition to partner tracing and testing, our training included specific training on how to conduct CHCT for serodiscordant and concordant HIV-positive couples, facilitate disclosure of serostatus results where one partner is HIV-infected. Trained healthcare providers promoted CHCT in case the individual wanted to return and test with his or her partner together, to promote mutual disclosure and supportive counselling.

Between March and June, 2017 we tested over 350 partners of HIV-infected patients who were recently diagnosed or already on ART to facilitate partner notification. Acceptance was very high (over 90%), especially among patients who were recently diagnosed. Importantly, we noticed that almost two-thirds of patients were testing with their partner (63%). Of the couples tested, 62% were concordant HIV-positive and 38% were serodiscordant, and 13 couples tested with a child or children. None of the partners who were diagnosed with HIV were on treatment. Female partner positivity was slightly higher (64% in females vs. 57% in males) and men were more likely to be brought in for CHCT vs. individual testing. In addition, we provided HIV testing to 140 children, of which 41% were HIV-infected. BroadReach is in the process of scaling up the training and intervention to four other Districts in which we work.

We urge the authors of the systematic review to include the role of CHCT in partner notification strategies. CHCT can be promoted among patients recently diagnosed with HIV, or on ART, to provide opportunities for couples to come together and mutually disclose their status and be provided with counselling that can alleviate blame around HIV, and promote ART initiation, and retention in care.