Scaling Up Testing for Human Immunodeficiency Virus Infection Among Contacts of Index Patients — 20 Countries, 2016–2018

Arielle Lasry, PhD; Amy Medley, PhD; Stephanie Behel, MPH; Mohammed I. Mujawar, MS; Meagan Cain, MPH; Shane T. Diekman, PhD; Jacqueline Rurangirwa, MPH; Eduardo Valverde, DrPH; Robert Nelson, MPH; Simon Agolory, MD; Achamyeleh Alebachew, MD; Andrew F. Auld, MD; Shirish Balachandra, MD; Sudhir Bunga, MD; Thato Chidarikire, MD; Vinh Q. Dao, MD; Jacob Dee, MPH; L.E. Nicole Doumatey, MSc; Edington Dzinotyiweyi, MA; Eric J. Dziuban, MD; K. Alexandre Ekra, MPH; William B. Fuller, MPH; Amy Herman-Roloff, PhD; Nely B. Honwana, MA; Nompumelelo Khanyile; Evelyn J. Kim, PhD; S. Francois Kitenge, MD; Romel S. Lacson, PhD; Peter Loeto, MA; Samuel S. Malamba, PhD; André H. Mbayiha, MD; Alemayehu Mekonnen, MD; Mirtie G. Meselu, MPH; Leigh Ann Miller, PhD; Goabaone P. Mogomotsi, MPH; Mary K. Mugambi; Lloyd Mulenga, MD; Jane W. Mwangi, MD; Jonathan Mwangi, MD; Amassanh A. Nicoué, MSc; Mtemwa K. Nyangulu, MCHD; Ismelda C. Pietersen, MPH; Puleng Ramphalla, MSc; Chanie Temesgen, MD; Alfredo E. Vergara, PhD; Stanley Wei, MD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(21):474-477. 

In This Article

Abstract and Introduction

Introduction

In 2017, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that worldwide, 36.9 million persons were living with human immunodeficiency virus (HIV) infection, the virus infection that causes acquired immunodeficiency syndrome (AIDS). Among persons with HIV infection, approximately 75% were aware of their HIV status, leaving 9.4 million persons with undiagnosed infection.[1] Index testing, also known as partner notification or contact tracing, is an effective case-finding strategy that targets the exposed contacts of HIV-positive persons for HIV testing services. This report summarizes data from HIV tests using index testing in 20 countries supported by CDC through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) during October 1, 2016–March 31, 2018. During this 18-month period, 1,700,998 HIV tests with 99,201 (5.8%) positive results were reported using index testing. The positivity rate for index testing was 9.8% among persons aged ≥15 years and 1.5% among persons aged <15 years. During the reporting period, HIV positivity increased 64% among persons aged ≥15 years (from 7.6% to 12.5%) and 67% among persons aged <15 years (from 1.2% to 2.0%). Expanding index testing services could help increase the number of persons with HIV infection who know their status, are initiated onto antiretroviral treatment, and consequently reduce the number of persons who can transmit the virus.

To end the HIV epidemic by 2020, UNAIDS set multiple targets, including increasing to 90% the percentage of persons with HIV infection who knew their HIV status.[2] Results from population-based HIV impact assessments in 10 African countries indicated that, as of 2018, the percentage of persons with HIV infection who knew their status ranged from 37% in Côte d'Ivoire to 86% in Namibia.[3]

Since 2003, PEPFAR has provided approximately $72 billion to implement HIV testing and treatment programs in 37 countries and regions with high HIV prevalence.[4] PEPFAR funds are administered through multiple U.S. governmental agencies, including CDC, that support international and local organizations and governments for HIV-related program implementation. In 2017, PEPFAR supported 85.5 million HIV rapid tests and linked 14 million adults and children to antiretroviral treatment.[5]

Because HIV testing service resources from donors and governments are scarce, targeted strategies are needed to reach persons with undiagnosed HIV infection. In index testing, also known as partner notification or contact tracing, HIV-positive index patients voluntarily identify their sexual and needle-sharing partners and biologic children. Partners and children of index patients, who might have been exposed to HIV, are then contacted by the index patient or the provider, and those whose HIV infection status is not known are offered HIV testing services. Studies have demonstrated the effectiveness and cost-effectiveness of index testing as a strategy for identifying HIV-positive adults and children.[6–9]

HIV program implementing partners supported by PEPFAR collect and report data for performance monitoring and evaluation purposes on a quarterly basis in accordance with the U.S. fiscal year (October 1–September 30). The primary HIV testing indicator is the number of persons who have received HIV testing services, categorized by HIV result, age group, sex, and testing service delivery approach. Age group categories are classified as <1 year, 1–9 years, 10–14 years, 15–19 years, 20–24 years, 25–49 years, and ≥50 years. Sex is not reported for children aged <10 years. Delivery approaches for HIV testing services include 1) community-based testing in mobile clinics; 2) voluntary drop-in centers; 3) facility-based provider-initiated testing in tuberculosis, sexually transmitted infection, outpatient, and antenatal clinics; 4) testing in hospital emergency and inpatient departments; and 5) since October 1, 2016, index testing.

This report includes the six most recent fiscal quarters for which index testing data were available (October 1, 2016–March 31, 2018). Among 33 countries reporting index testing data during this period, seven countries (Angola, China, Dominican Republic, El Salvador, Guyana, Honduras, and Thailand) that reported <1,000 persons tested using index testing and four countries (India, Kazakhstan, Kyrgyzstan, and Tajikistan) that reported <500 tests during October 1, 2017–March 31, 2018 were excluded from this analysis. Also excluded were Nigeria and Ukraine in response to requests from the country offices. The number of HIV tests reported using index testing and the percentage of positive tests among different demographic groups in CDC-supported PEPFAR programs in 20 countries* were summarized for this report.

From October 1, 2016, to March 31, 2018, CDC-supported implementing partners reported a total of 1,700,998 persons tested for HIV using index testing among the 20 countries evaluated, including 889,599 (52%) persons aged ≥15 years and 799,976 persons aged <15 years (Table 1). Overall, 99,201 (5.8%) persons were reported as HIV-positive, including 87,266 persons aged ≥15 years and 11,814 persons aged <15 years. Index testing from three countries (Kenya, Mozambique, and Tanzania) accounted for more than half of all HIV tests and positive results reported. By age group, 9.8% of HIV test results among persons aged ≥15 years and 1.5% among persons aged <15 years were positive. The rate of HIV positivity by country ranged from 0.7% to 24.5% among persons aged <15 years and from 2.8% to 29.1% among persons aged ≥15 years.

During the six fiscal quarters covered by this report, the number of persons tested for HIV using index testing among the 20 countries increased from 166,108 to 356,573 from the first to sixth quarter (Figure). During this period, the number of positive results more than tripled from 8,186 to 27,893. The quarterly rates of HIV positivity increased from 4.9% to 7.8% overall, from 7.6% to 12.5% among persons aged ≥15 years, and from 1.2% to 2.0% among persons aged <15 years (Figure).

Figure.

Percentage of quarterly human immunodeficiency virus (HIV) index tests with HIV-positive results, overall and by age group — 20 countries,* October 1, 2016–March 31, 2018
*Botswana, Cameroon, Côte d'Ivoire, Democratic Republic of the Congo, Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, South Sudan, Tanzania, Uganda, Vietnam, Zambia, and Zimbabwe.

Among the 865,126 persons aged ≥15 years tested for whom sex was reported, 55% were females and 45% were males (Table 2). HIV index testing positivity rates were lowest among males and females aged 10–14 years (1.1% and 1.3%, respectively) and highest among men and women aged 25–49 years (13.0% and 13.5%, respectively). Overall, the mean rate of index testing HIV positivity was 7.5% among females and 6.8% among males.

*Botswana, Cameroon, Côte d'Ivoire, Democratic Republic of the Congo, Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, South Sudan, Tanzania, Uganda, Vietnam, Zambia, and Zimbabwe.

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