HIV testing of sexual partners of HIV-positive clients (index testing) is critical for case identifications and reducing transmission. Current index testing strategies have limited reach – only 20% of partners in Malawi are tested using standard partner referral slips (PRS) – a paper version of passive facility referrals for partners. Delivery of HIVST to partners at their home may address barriers to index testing. We evaluated an index HIVST intervention among partners of ART clients in Malawi.
A randomized trial was conducted at 3 district hospitals in Malawi between March28-June13, 2018. ART clients were screened during routine services. Inclusion criteria were: >15 years of age; sexual partner with unknown HIV status; no history of interpersonal violence with that partner; and partner lives in facility catchment area. Clients were randomized 1:2: (1) standard PRS or (2) HIVST (Oraquick HIV Self-Test(c) demonstration and distribution and referral for confirmation by blood-based testing). Baseline and follow-up surveys were conducted with ART clients and a subset of sexual partners willing to present at facilities for a survey. Primary outcomes (partner tested, test result, confirmatory testing) were reported by ART clients. Uni- and multivariate logistic regressions were conducted.
365 ART clients enrolled in the study, with median age 37 years and 22% male. Only 3 clients refused HIVST. 91% and 92% of clients in HIVST and PRS arms respectively reported distributing the intervention to their partners (p-value=0.70; Table). However, 81% of partners in HIVST tested compared to only 29% of partners in PRS (AOR:9.6; p-value<0.001). Positivity rates did not differ by arm (19% in HIVST versus 16% in PRS; p=0.74). Among newly diagnosed HIV-positive partners in HIVST, only 20% received a confirmatory, blood-based test within 4-weeks. 99% and 97% of ART clients reported being comfortable providing HIVST and demonstrating use to partners, respectively. Among partners who used HIVST and completed a survey (n=126; median age 39 years; 67% men), 16% reported challenges understanding HIVST instructions and 8% were unable to interpret HIVST results. Reported adverse events (psychological IPV/end of relationship) did not vary by arm (~8%).
Index HIVST greatly increased HIV testing without increased risk of adverse social events. Inadequate interpretation and test confirmation limits the impact of index HIVST and requires further study.