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. It is now estimated that about 80% of PLHIV, and nearly 85% of PLHIV in southern and eastern Africa, know their HIV status, by the end of 2019¹. While this progress has been registered, poorly targeted HTS have continued to miss PLHIV who do not know their HIV status in many settings¹. This requires new and targeted approaches to reach undiagnosed people with HIV, such as HIV partner services¹.

A study conducted in Zambia 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 status⁷. 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 are needed to reach undiagnosed people and link them to HIV care and treatment as part of the UNAIDS 90-90-90 goals. 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 participants (index providers) were interviewed; 13 women and 5 men. Table 1 presents demographic characteristics of participants.

Major activities of an index testing provider in the past one year 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 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.

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 to effective index testing were also identified by respondents.

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.

Discussion

In this research, barriers to accessing HTS were divided into provider- and client-related challenges.

Provider-related challenges: Inadequate elicitation skills among the newly trained community healthcare workers, treatment supporters and counsellors; trained providers such as healthcare workers not fully involved; 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); and limited transport for contact tracing (long distances to reach contacts).

Client-related challenges: Mobile communities due to seasonal activities such as cross boarder trades (e.g. truck drivers), sex work and farming; 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; missing details on client locator forms or wrong details provided; and limited space dedicated to conduct elicitation of index clients (lack of privacy).

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. Barriers to partner notification services also included concerns around privacy/confidentiality and intimate partner violence. Lack of awareness of risk for HIV infection/misconceptions; structural, psychological, financial, were barriers to being tested.

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

Conclusion

The challenges identified have future implications for index partner testing. These barriers were also gender and age specific. HIV testing services need to adapt to the social context of Zambia where HIV-related stigma and discrimination is still persistent and overwhelming. HIV programs need to explore and address barriers to HIV partner testing services to maximize HIV case identification. As Zambia makes significant progress towards achieving HIV epidemic control, more effort is needed to reach specific high risk, but hard to reach populations in HIV programs, such as men, adolescent girls and young women.

Data availability