Healthcare providers’ perspective on barriers to optimal HIV index testing: an interview-based study

Introduction

Global HIV testing services (HTS) and antiretroviral therapy have seen a substantial scale up¹. About 15 years ago, only an estimated 12% of the global population who required an HIV test were tested, and only 10% of people living with HIV (PLHIV) knew their HIV status in Africa¹. By end of 2019 it was estimated that about 80% of PLHIV, and nearly 85% of PLHIV in southern and eastern Africa, knew their HIV status¹. While this progress has been registered, PLHIV who do not know their HIV status have been missed continuously in many settings, and this has been associated with poorly targeted HTS¹. This requires new and targeted approaches to reach undiagnosed people with HIV, such as HIV partner services¹.

A study conducted in Zambia in 2020 revealed that index testing coupled with targeted community-led HTS are useful strategies to diagnose men living with HIV². Many studies have shown that index partner testing has the potential to increase HTS uptake, and identify and diagnose HIV infected partners (yield ranging from 35% to 62% without reported intimate partner violence)³. However, there are barriers to effective HIV index testing, for instance difficulties in notifying past or casual partners for both male and female index cases⁴. Disease symptoms are a motivating factor for HIV testing for men as well as women. Studies have shown that gender determinants, such as tolerant attitudes about intimate partner violence and unequal power dynamics within relationships, have noticeable effects for men and women on deciding to get tested for HIV⁵. Gender-specific barriers for female index clients to successful referral include the following: women face gender roles and inequalities in relationships such as lack of education, lack of resources or ability to access services; fear of abandonment, violence or other abuse associated with partner notification^4,6,7. Therefore, they may need additional support to overcome challenges in the partner notification process. Antenatal care exposure makes women more likely to get tested for HIV. For men, especially those in sub-Saharan Africa, the following challenges to HIV testing and disclosure have been previously noted: stigma, gender and social roles prescribing that men should be healthy, strong, and dominant^8,9. Studies have shown that men, compared to women, underestimate their level of risk of HIV infection⁷. However, once men are tested, they may be more likely to disclose their HIV status as per culture⁷. Some men believe that their role of breadwinner for the family protects them from rejection when disclosing their HIV positive status¹⁰.

Effective approaches to HIV testing such as index testing are needed to reach undiagnosed people and link them to HIV care and treatment as part of the UNAIDS 95-95-95 goals¹¹. As defined by UNAIDS¹², Index testing, also referred to as partner testing/partner notification services, is an approach whereby the exposed contacts (sexual partners, biological children and anyone with whom a needle was shared) of an HIV-positive person (index client), are elicited and offered HIV testing services. Understanding barriers to index testing is crucial for planning appropriate interventions to improve HIV testing yield and to provide appropriate care for both index clients and their partners. In this context, the aim of this study was to assess the barriers to optimal index testing for improved HIV testing yield in Lusaka, an urban district of Zambia. The specific objectives are: 1) to understand the perceived facilitators and barriers to HIV partner testing from the perspective of the health-care provider; 2) to propose interventions necessary for improved HIV case finding.

Methods

Results

A total of 18 index testing providers from three health facilities (Matero first level hospital, George health centre, and Matero main clinic) participated in the study. The interviewees were: two medical officers, two head of HIV testing services departments, three health systems strengthening nurses, five index community liaison officers, and six index testing counselors (See Table 1 below).

Main activities of an index testing provider:

In the past one year, the major activities of providers included ensuring that all newly tested HIV clients were listed, counseling was provided to them on partner notification service, elicitation of sexual contacts, contact tracing, testing of contacts and linkage of positive contacts to care.

Index providers’ collaboration:

Index testing workers worked together with other providers and implementing partners to provide index testing. Specifically, index testing providers from respective facilities worked hand in hand with program implementation partners to ensure activities were coordinated.

Success stories:

There were many successes or experiences reported by respondents arising from index testing. Providers were open to share their experiences and lessons learned while providing services.

Barriers and facilitators:

Barriers and facilitators to effective index testing were also identified by respondents.

Challenges:

Inadequate elicitation skills among the newly trained community healthcare workers, treatment supporters and counsellors; trained providers such as healthcare workers not fully involved; age and sex differences (provider Vs client); low number of volunteers trained in index testing; inadequate index testing knowledge among staff; limiting elicitation of index partners to only wife and husband (not eliciting all sexual partners); limited transport for contact tracing (long distances to reach contacts); and limited space dedicated to conduct elicitation of index clients (lack of privacy) were challenges affecting providers.

Mobile communities due to seasonal activities such as cross boarder trades (e.g. truck drivers) and farming; sex work; some index clients do not live in the same district/town as the index clients; key populations and adolescents index clients do not have contact details for some of their contacts; provider’s age or gender difference for some clients; and missing details on client locator forms or wrong details provided were challenges affecting the clients.

Specific challenges related to index clients’ identification and elicitation of index contacts: Some clients did not open up easily (as this was the first time to meet a counselor) or immediately and others were not providing full contact information. This was usually resolved within two weeks of follow-up, as clients become more comfortable interacting with ART providers.

Specific challenges related to testing of index contacts. Various logistic challenges were noted with regards to tracing and testing of contacts.

Perceived factors causing/contributing to sub-optimal index testing were reported as gender, age, stigma, social status, health system, facility structure, staff, and skill level.

Providers’ recommendations:

Following the interviews with key informants, the following were proposed as solutions to address identified challenges:

Discussion

In summary, provider related challenges included inadequate elicitation skills among healthcare workers; low number of volunteers trained in index testing; inadequate index testing knowledge among staff; age and sex differences (difficulties to obtain more information from younger or older clients and those of opposite gender); limited elicitation of index partners to only wife and husband (not eliciting all sexual partners); limited logistics for contact tracing; and limited space dedicated to conduct elicitation of index clients. Client-related challenges were: mobile communities due to seasonal activities such as cross boarder trades and farming; sex work; some key populations and adolescent index clients do not have contact details for their casual relationships; provider’s old or younger age as compared to the client or opposite gender for some clients; missing details on client locator forms or wrong details provided; and stigma and discrimination.

These findings are in keeping with evidence from other studies^2–5, that showed that non-disclosure of HIV status (due to fear of marital discord), non-disclosure and under-disclosure of the number of sexual partners by the index clients, fear of negative consequences, difficulties notifying past or casual partners, geography/remote partners, and risk perception were major barriers for using testing services. Key populations and people with casual partners were less able or willing to identify partners.

The proposed recommendations are listed in the result section above. These innovativive corrective actions need urgent implementation to help address identified challenges in this context. In 2020, USAID proposed a few more interventions following analysis of data from HIV counseling and testing services in Burkinafaso¹⁷, including:

Conclusion

Our research highlighted that younger clients may feel intimidated in discussions with older healthcare providers, while gender dynamics often complicate communication, particularly in conservative communities. Many providers lack adequate training to engage sensitively with clients of diverse ages and genders, leading to missed opportunities for fostering trust and openness. Effective communication tailored to age and gender can enhance client comfort levels and improve testing rates.

In conclusion, our study underscores the critical need for age and gender sensitivity in HIV index testing practices. The findings indicate that both client and provider perceptions are significantly influenced by demographic factors, which can impact testing uptake, overall engagement in care, and adherence to treatment. We observed that clients of different ages and genders experience unique barriers and facilitators that shape their interactions with healthcare providers, ultimately affecting the outcomes of HIV testing initiatives.

By recognizing and addressing the nuanced needs of diverse populations within the context of HIV index testing, we can enhance engagement, reduce stigma, and ultimately, contribute to improved health outcomes in our communities. It is imperative that both providers and policymakers commit to implementing these findings to create a more inclusive and effective healthcare environment.