Effects of index client and geo-targeting on HIV case identification: an observational study

Background: Despite huge investments in HIV prevention, treatment, and care in sub-Saharan Africa, fewer than one in 10 individuals knows their HIV status, and 40% of individuals living with HIV are not cognisant of their positive status. Efforts to improve and strengthen HIV service delivery, particularly in HIV testing, are necessary to increase efficiency in HIV case finding and optimise service delivery. Standard approaches to HIV testing have not been effective in addressing this gap. Our objective was to evaluate a targeted approach for HIV case identification in a PEPFAR-supported HIV programme in Nigeria. Methods: Between October, 2016, and June, 2017, we implemented a strategy that included index client testing, geo-targeted HIV testing, and provider-initiated counselling and testing in 14 local government areas in Akwa Ibom, southern Nigeria. The tests were administered in conjunction with the conventional method of testing and were in line with the PEPFAR impact agenda. We estimated the number of individuals who needed to be tested by each method in order to meet a benchmark of 8000 new diagnoses per quarter. We described dispersion using median and IQR. Findings: Conventional methods in the 14 local government areas required testing of 600 000 individuals (median 50 000 [IQR 741 000]) whereas using our targeted approach, we met 60% of the benchmark in each quarter by testing 214 000 individuals on average (median 14 000 [IQR 12 000]). Interpretation: We demonstrated that use of a targeted approach to HIV testing can increase the efficiency of case identification. This process can therefore help increase early initiation of treatment and retention of subjects diagnosed with HIV. Funding: PEPFAR