Index Testing in Uganda: Identifying HIV-Positive Patients, One Phone Call at a Time
For Elizabeth Mutambuze, a midwife and counselor at Mengo Hospital in Kampala, Uganda, a typical day begins with a prayer asking that she be successful in bringing at least one client in for HIV testing and then for treatment, if needed. As the focal person for the hospital’s Assisted Partner Notification (APN) system, Elizabeth knows how difficult it is to convince sexual partners of known HIV-positive index clients of their need to be tested.
Index clients—individuals newly diagnosed as HIV-positive and/or an HIV-positive individual who is enrolled in HIV treatment services—are the key to APN’s index-testing approach. Index testing, also known as partner notification, is an effective case-finding strategy that targets the exposed contacts of HIV-positive persons for HIV-testing services. It is a voluntary process where counsellors and/or health care workers ask index clients to list all of their sexual or injecting drug partners within the past year and their children. All index testing must be consensual, confidential, and include counseling, correct test results, and connection to treatment or prevention services. If the index client agrees, each listed partner and child is contacted, informed that they have been exposed to HIV, and offered voluntary HIV testing services (HTS). The goal of index testing is to break the chain of HIV transmission by offering HTS to persons who have been exposed to HIV and linking them to treatment, if positive, or prevention services, if negative
“Hello, my name is Elizabeth from Mengo Hospital. I am a midwife and counselor,” Elizabeth says, beginning the sometimes difficult telephone conversation. “I call to request that you accompany your wife to hospital tomorrow as she is supposed to return for her antenatal care.” After some pleading and explaining that her facility offers much-needed health services for those at risk of HIV infection, including HTS screenings for sexually transmitted infections, and voluntary medical male circumcisions, the spouse of her index client agrees to come in. Mengo uses a multi-disease approach to patient care, which can help to reduce stigma.
Elizabeth continues down her list of names. “Hello, my name is Elizabeth from Mengo Hospital,” she says to the person on the other end of the phone. “I’m calling to interest you to come for HIV testing because you have been exposed.” This time, the barrage of questions from the other side of the line is intimidating: “Who are you and how did you get my number, and what do you mean I have been exposed? How did you know? How do you know me?” “Well,” she calmly responds, “It is not important how I got the number, but more important that you come and get an HIV test to know your status. If you are HIV-positive, we immediately enroll you in free treatment and support for you to stay healthy and live longer. If you are HIV-negative, we can teach you and provide the support you need to stay uninfected.”
For the first two hours of her day, Elizabeth makes 20-30 calls using different strategies, dependent on a profile derived from index clients identified the previous day. She may also call upon those that have not honored their promise to come in for testing. Elizabeth works with counselors and HTS teams from different testing centers including the Outpatient Department, antenatal care, and across the hospital’s wards. Their approach is to first conduct an HIV test with these index clients and then seek their consent to track their sexual partners. The staff also keep an APN registry for documenting contact information of HIV-positive clients’ sexual partners. Elizabeth receives a daily roster of HIV-positive individuals from which immediate follow-up can be made. “We prioritize testing for sexual partners of all newly identified HIV-positive individuals, sexual partners of patients with a non-suppressed HIV viral load, and document and track all sexual partner elicited in through the APN registry,” Elizabeth explains.
The Infectious Diseases Institute, a CDC-funded local partner under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), supports Mengo Hospital’s HIV clinic to provide training in sustaining friendly conversations, probing skills and customer care, working with difficult clients, and in populating the filing to the APN registry. “Even after training, it’s not a straight forward journey to convince these partners to come forward and take the test,” Elizabeth notes. Despite completed calls, only a few of those contacted present themselves at the hospital. Nevertheless, Elizabeth does not give up. “You said you are coming, how far have you reached?” she asks one in a follow-up call. For those on those who promised to come but don’t, she lets it be known, “I keep calling until they come.”
In great part thanks to Elizabeth’s dedication and tenacious efforts, 410 HIV-positive index clients identified between May and September 2018 in Mengo Hospital resulted in 387 sexual partners elicited of which 296 were notified and tested – with 72 testing positive. That equates to a 24% HIV-positive yield, which is much higher than for most other methods.
Elizabeth’s Client Experience
“When the clients finally come, they are very cooperative,” she says. “Moreover, the aggressive ones often turn out to be HIV-positive. Perhaps they know that they have been involved in risky sexual behavior and feel guilty… perhaps it’s because of fear…or simply fear of who else knows their HIV-status.” She notes that female clients can be the hardest to convince. Their reasons for resisting range from not having transportation, to not having permission from a spouse to leave the home or lack of childcare. However, when they come to know that a hospital team is available and ready to provide emotional support and needed assistance with child or elder care, her female contacts eventually present themselves. An additional challenge is often an unwillingness to disclose their male sexual partners for fear of being judged. For adolescent girls and young women, there can be the fear of physical violence and/or losing financial support that is provided them in their relationship. “But I know how to deal with these fears and they eventually open up,” Elizabeth notes with satisfaction.
For men, they often say they are too busy to make the visit or that they are not in town. They too eventually come in — “so that I stop calling them,” Elizabeth notes with a smile. With men, she has observed a willingness to disclose sexual partner contacts which differs from that of her female patients. “But what is interesting is many of them are already in care. They will not tell you on the phone because they are not sure whom they are speaking to but when they come, they open up. And this helps us to get their partners.”
Passionate About Her Role
“I really love my job. Every day, I retire satisfied that I spoke to someone about the benefit of HIV counseling and testing. During training, they told us that when you qualify, do it with all your heart because you may be that one person that will help the individual on the other line to stay alive or healthy,” she says. “They also told us that identifying HIV-positive individuals and linking them to treatment helps stop HIV transmission, which benefits my children and my grandchildren when we achieve an AIDS-free generation.”
Mengo Hospital is among the leading facilities in Uganda in terms of index testing and contact tracing. Data from contact tracing show the practice increases the uptake of HIV testing among the partners of HIV-positives individuals as compared to passive patient referrals. This high-yield testing approach is helping PEPFAR programs in Uganda and around the world inch closer and closer to HIV epidemic control.