A randomized controlled trial evaluating combination detection of HIV in Malawian sexually transmitted infections clinics

Abstract

IntroductionHIV diagnosis is the necessary first step towards HIV care initiation, yet many persons living with HIV (PLWH) remain undiagnosed. Employing multiple HIV testing strategies in tandem could increase HIV detection and promote linkage to care. We aimed to assess an intervention to improve HIV detection within socio‐sexual networks of PLWH in two sexually transmitted infections (STI) clinics in Lilongwe, Malawi.MethodsWe conducted a randomized controlled trial to evaluate an intervention combining acute HIV infection (AHI) screening, contract partner notification and social contact referral versus the Malawian standard of care: serial rapid serological HIV tests and passive partner referral. Enrolment occurred between 2015 and 2019. HIV‐seropositive persons (two positive rapid tests) were randomized to the trial arms and HIV‐seronegative (one negative rapid test) and ‐serodiscordant (one positive test followed by a negative confirmatory test) persons were screened for AHI with HIV RNA testing. Those found to have AHI were offered enrolment into the intervention arm. Our primary outcome of interest was the number of new HIV diagnoses made per index participant within participants’ sexual and social networks. We also calculated total persons, sexual partners and PLWH (including those previously diagnosed) referred per index participant.ResultsA total of 1230 HIV‐seropositive persons were randomized to the control arm, and 561 to the intervention arm. Another 12,713 HIV‐seronegative or ‐serodiscordant persons underwent AHI screening, resulting in 136 AHI cases, of whom 94 enrolled into the intervention arm. The intervention increased the number of new HIV diagnoses made per index participant versus the control (ratio: 1.9; 95% confidence interval (CI): 1.2 to 3.1). The intervention also increased the numbers of persons (ratio: 2.5; 95% CI: 2.0 to 3.2), sexual partners (ratio: 1.7; 95% CI: 1.4 to 2.0) and PLWH (ratio: 2.3; 95% CI: 1.7 to 3.2) referred per index participant.ConclusionsCombining three distinct HIV testing and referral strategies increased the detection of previously undiagnosed HIV infections within the socio‐sexual networks of PLWH seeking STI care. Combination HIV detection strategies that leverage AHI screening and socio‐sexual contact networks offer a novel and efficacious approach to increasing HIV status awareness.

Profile of partners who completed HIV testing and received a new HIV diagnosis in Ukraine’s HIV index testing program: a retrospective cohort study to inform program improvement

“…Our research revealed potential areas for optimizing IT services in Ukraine, including promotion of provider-assisted notification to increase HIV testing and case detection, a finding substantiated by the literature. A meta-analysis comprising over 5,000 patients in both high resource and resource limited settings found that provider-assisted partner services resulted in a 1.5-fold increase in HIV testing over passive referral by clients [ 26 ], and a recent randomized trial in Malawi that compared social network testing using contract notification to passive client referral found a 1.9-fold increase in HIV case finding [ 27 ]. Despite the demonstrated benefits of provider-assisted notification, however, our data showed that ICs chose provider-assisted notification less than 25% of the time, suggesting that additional intervention or education for both providers and ICs on the benefits of provider-assisted notification may improve HIV testing and case detection.…”

Uptake of voluntary medical male circumcision among men with sexually transmitted infections in Lilongwe, Malawi: a protocol for a pre-interventional and post-interventional study

“…The overall HIV prevalence among adults aged 15–64 years in Malawi is 10.6%, and 11.5% in the Lilongwe city 23. The HIV prevalence among patients with STI in Malawi is around 18.0%–22.0%15 24 and around 13.3% at Bwaila STI clinic 25…”

“…23 The HIV prevalence among patients with STI in Malawi is around 18.0%-22.0% 15 24 and around 13.3% at Bwaila STI clinic. 25…”

Characterizing Network-Based HIV Testing Interventions to Guide HIV Testing and Contact Tracing at STI Clinics in Lilongwe, Malawi

“…In a randomized controlled trial (RCT) among PWH at 2 sexually transmitted infection (STI) clinics in Malawi, 20 we previously demonstrated that a combination intervention of cPN, social contact referral, and AHI screening increased the rate of new HIV diagnoses within participants' sociosexual networks compared with pPN alone (standard of care). However, cPN and the successful identification of persons with AHI require available staff and enhanced testing services, which can be resource-intensive.…”