Improving the Efficiency and Effectiveness of Assisted Partner Services for HIV in Western Kenya

Thesis (Ph.D.)--University of Washington, 2023To control the HIV epidemic in Sub-Saharan Africa, it is crucial to increase the proportion of people who know their serostatus. In Kenya, approximately 1.6 million people are living with HIV (PLWH), of whom it is estimated that 21% are unaware of their status. Assisted partner services (APS) are programs that help to identify and locate sexual and injecting partners of individuals diagnosed with HIV, and provide these partners with testing options, connection to care, and counseling. The World Health Organization (WHO) has recommended that APS be broadened as a HIV tracing mechanism to locate hard to reach populations. Furthermore, the onset of the COVID-19 pandemic has highlighted the need to increase HIV testing services (HTS) that are successfully offered remotely. While the WHO and Centers for Disease Control and Prevention (CDC) encourage offering HIV self-testing (HIVST) as part of comprehensive HTS, there is a significant gap in knowledge including the effectiveness of HIVST in low-resource APS programs, like Kenya. In this dissertation, we proposed three distinct aims to investigate the effectiveness of HIVST compared to provider-delivered testing alone in increasing partners tested within an APS program, using behavioral economics theory on utilizing non-financial incentives to increase HIVST uptake. We determined whether offering HIVST during APS as an option for partner testing increases HIV testing, first-time testing, new HIV diagnoses, and linkage to HIV care among partners of index clients compared to Standard APS (Aim 1). We also examined the effectiveness of offering multiple HIV self-test kits as an incentive to increase HIVST uptake among sexual partners of PLWH participating in APS (Aim 2). Finally, we compared characteristics of sexual partners successfully contacted in-person versus via phone in an APS program (Aim 3). In an established APS program in Western Kenya, we found no statistically significant differences in HIV testing, first-time testing, new HIV diagnoses, and linkage to care among partners offered a choice of HIVST or provider-delivered testing versus provider-delivered testing alone (Aim 1). In the same setting, we found that offering two HIVSTs as an incentive compared to a single HIVST did not increase HIV testing, first-time testing, new diagnosis, or linkage to care. However, it did reach and test people at risk for HIV beyond the scope of more typical APS approaches, mostly sexual partners of the named partners (Aim 2). Lastly, we found that those who were contacted in-person for APS were more likely to receive a new HIV diagnosis, compared to those reached via phone and those who were contacted by phone were more likely to be male and have completed higher education levels (Aim 3). These studies provide strong evidence for integration of HIVST into APS in Kenya to increase uptake for this method of HIV testing in this region