Identifying individuals living with HIV in need of care and treatment: investigating real world implementation of HIV testing interventions in East Africa

Thesis (Ph.D.)--University of Washington, 2022Globally, an estimated 6.1 million people living with HIV do not know their HIV status. In sub-Saharan Africa (SSA), which continues to be disproportionately affected by HIV, people living with HIV are generally identified through facility-based HIV testing; however, testing coverage has been insufficient to curb the epidemic, particularly in men and key populations. Finding undiagnosed individuals, getting them tested, and getting them linked to care is critical to achieving the UNAIDS 95-95-95 objectives by 2025. Assisted partner services (APS) is an important public health strategy aimed to prevent the spread of sexually transmitted infections, including HIV, by identifying, testing, and treating sexual partners of newly diagnosed individuals. Additionally, the use of HIV self-testing (HIVST) kits has been shown to be a safe, accurate, and convenient alternative to facility-based testing in SSA that has the potential to overcome barriers associated with facility-based HIV. We aimed to understand the effectiveness, barriers, and facilitators for pragmatic implementation of these methods. We used data from an APS scale-up project, a hybrid type II implementation science study, conducted in western Kenya, and qualitative data from a study of pregnant women and male partners investigating perceptions of secondary distribution and use of HIV self-testing kits in Uganda. The specific dissertation aims included: (1) evaluating the real-world impact of scaling up APS in Kenya; (2) defining acceptability of APS among female clients and male partners in Kenya; and (3) determining relationship factors impacting HIV self-testing distribution and use among pregnant women and male partners in Uganda. From the APS scale-up project, we found evidence demonstrating that APS is a safe, acceptable, and effective strategy to identify men living with HIV who are unaware of their status and to link them to care. Our results are an important finding from a real-world implementation context, and can inform programmatic decisions regarding APS scale up in Kenya and similar settings. We also found that the real-world APS scale-up project demonstrates acceptability of APS as an important strategy to reach HIV-exposed male partners, while also highlighting the nuances and priorities to the acceptability of intervention. With the HIVST study, we found that HIV-negative women in relationships with positive predisposing factors may be the most likely to deliver HIVST to their partners, and to leverage interdependent coping behaviors. Interdependent relationship factors can influence and motivate distribution and uptake of HIVST, and subsequent health-enhancing behaviors, among pregnant women and their male partners, which can inform recommendations as HIVST continues to be scaled up. Ultimately, our research provided evidence on the implementation, perceptions, and importance of APS and HIVST integration, and our findings provide opportunities to inform recommendations for further scale-up both for APS and for HIVST