Scale-Up and Case-Finding Effectiveness of an HIV Partner Services Program in Cameroon

Abstract

Background Partner services (PSs) are a long-standing component of HIV control programs in the United States and some parts of Europe. Small randomized trials suggest that HIV PS can be effective in identifying persons with undiagnosed HIV infection. However, the scalability and effectiveness of HIV PS in low-income countries are unknown. Methods We used data collected from 2009 to 2010 through a large HIV PS program in Cameroon to evaluate HIV PS in a developing country. HIV-positive index cases diagnosed in antenatal care, voluntary counseling and testing, and inpatient facilities were interviewed to collect information on their sexual partners. Partners were contacted via telephone or home visit to notify, test, and enroll those found to be HIV positive in medical care. Results Health advisors interviewed 1462 persons with HIV infection during the evaluation period; these persons provided information about 1607 sexual partners. Health advisors notified 1347 (83.8%) of these partners, of whom 900 (66.8%) were HIV tested. Of partners tested, 451 (50.1%) were HIV positive, of whom 386 (85.6%) enrolled into HIV medical care. An average 3.2 index cases needed to be interviewed to identify 1 HIV case. Conclusions HIV PS can be successfully implemented in a developing country and is highly effective in identifying persons with HIV infection and linking them to care.

Perspective on Providing Partner Notification Services for HIV in Sub-Saharan Africa

“…41,42 Both the Malawi and Cameroon trials have mostly laid these concerns to rest, as could have been predicted from a reading of the previous literature on STD PN in sub-Saharan Africa. 1 The reported HIV PN trials 2,3 suggest that the financial burden is not prohibitive and, being remarkably productive and cost-effective 4 in identifying HIV-infected individuals and referring them to (life-saving and transmission-dampening) HIV care, could therefore probably persuade funding agencies, foreign and domestic, to provide resources. As Hosseinipour and Rosenberg reflect in the editorial accompanying the Cameroonian PN initiative, 42 similar a priori concerns were expressed "against many new HIV-related services in sub-Saharan Africa-[like] the introduction of HIV counseling and testing and the use of ART.…”

“…Specifically, two recently reported trials, one each from Cameroon and Malawi, 2,3 suggestions for obtaining evidence on multiple fronts to solve this puzzle. Here is not the place to summarize this exceptional analysis of the realities on the ground, only to point out a relevant omission: nowhere in their report do the authors suggest using PN/contact tracing as a potentially useful investigatory tool to help close this "research gap" 7 and neither do the seasoned researchers.…”

“…Both historically and presently, most investigations into the HIV epidemics in sub-Saharan Africa have (surprisingly) focused almost exclusively on sexual intercourse variables and related risk markers. 9 Rarely are non-sexual modes of transmission considered or measured, a criticism that extends to the otherwise well-conducted PN trials in Cameroon and Malawi, 2,3 where named sexual partners who were identified as HIVinfected were presumed to have acquired HIV, by default, from sex. No attempt was apparently made to consider or investigate non-sexual exposures.…”

“…(For readers who object to this priority ranking, consider that, as of this writing, not much PN for HIV/AIDS is being conducted in any event, prioritized or not.) 2,34 Given that the most efficient way to transmit HIV sexually is via (especially receptive) anal intercourse 35 and given the flurry of recent reports from sub-Saharan Africa suggesting that anal intercourse may be much more widely practiced than previously believed, [36][37][38][39] specifically asking patients about anal sex, and analyzing the data separately from reports tested the feasibility, acceptability, and potential yield of PN for HIV. Each trial consisted of interviewing newly diagnosed HIV/AIDS cases to collect identifying data on sexual partners and to assist in confidentially referring them to medical examination.…”

“…3 A broadly similar profile was noted in the Cameroon trial, where only 6.7% of partners were successfully referred by the index patient and the rest via provider-assisted referral. 2 of penile-vaginal exposure, would provide an evidence-based rationale for warning local populations about very high-risk sexual practices. In the Cameroonian trial, such a question was asked, presumably without embarrassment, but the authors regretfully report findings under the undifferentiated rubric "Any vaginal or anal sex …."…”