Research Article: HIV index testing to improve HIV positivity rate and linkage to care and treatment of sexual partners, adolescents and children of PLHIV in Lesotho

Date Published: March 27, 2019

Publisher: Public Library of Science

Author(s): Makhahliso Jubilee, Faith Jiyeong Park, Knowledge Chipango, Kenoakae Pule, Albert Machinda, Noah Taruberekera, Justyna Dominika Kowalska.


Despite years of HIV testing and other interventions, Lesotho continues to experience an incredibly high HIV burden. Prevalence of HIV among children ages 0–14 years is at 2.1% and 25.6% among adults ages 15–59 years. Among adults living with HIV, 77.2% know their status, 90.2% of those with known HIV positive status are currently receiving ART and 88.3% are virally suppressed. In order to identify adults, adolescents and children at high risk of HIV infection, Population Services International (PSI)/Lesotho with support from the Centers for Disease Control and Prevention (CDC) introduced the HIV Index testing model in 2015. PLHIV recruited for index testing, were accessed through health facilities and community testing at PSI New Start channels in five districts. Consenting index clients received home visits for HIV testing of their biological children and sexual partners with unknown status. Routine monitoring of data gathered between May 2015 and November 2017 was analyzed to assess feasibility of this approach. For HIV index testing, 49.2% of children below 15 years and 37.3% of adolescents ages 15–19 were first time testers while 18.8% of all adults aged 20 years and above tested were testing for the first time. Higher HIV positivity rates among clients tested through the HIV index testing model across all age groups in comparison to other HIV testing models were statistically significant. Among children ages 2–14 years, the HIV positivity rate was 1.4%, adolescents ages 15–19 years had a positivity rate of 2.4% and adults ages 20 years and above had a positivity rate of 17.6%. Linkage rates of 92%, 73% and 72% for children, adolescents and adults, respectively, achieved with the HIV index testing model were higher than linkage rates observed with other HIV testing models. Results indicate that testing of biological children and sexual partners utilizing the HIV index testing model can be viable to identify and link children, adolescents and adults into care and treatment.

Partial Text

Lesotho experiences an incredibly high HIV prevalence of 25.6% among adults ages 15–59 years, translating to 306,000 PLHIV in 2016 [1]. The HIV prevalence is at 2.1% amongst children ages 0–14 years representing 13,000 children living with HIV [1]. Despite an increase of antiretroviral therapy (ART) coverage among children from 43% in 2015 to 58% in 2016, there still remains a huge gap in diagnosis and initiation of ART among children in Lesotho [2]. Thus, there is an immediate need for scaled-up HIV Testing Services (HTS) to identify and link PLHIV with unknown status to care and treatment.

A total of 7,916 clients diagnosed with HIV (index clients) were approached for family member testing (biological children and sexual partners) in five scale-up districts and 5,937 (75%) consented for home visits (Fig 2). Among all index clients who consented for home visits, 5,862 (99%) were provided with home testing. A total of 10,854 individuals were tested through HIV index testing. Biological children accounted for 91% (9,872) while sexual partners represented only 9% (982). Of all eligible family members elicited for testing, 72% (10,854/14,986) were tested for HIV. The proportion of eligible sexual partners getting tested at 86% (982/1,139) was much higher than that of eligible children getting tested at 71% (9,872/13,847).

We found that HIV index testing was effective in the provision of HTS to biological children and sexual partners of PLHIV who received home visits through the outreach approach. This finding was consistent with observations made in Kenya which found that an index model increased HIV testing among family members [5]. Results in this study indicated that HIV positivity rate among sexual partners was the highest. This aligns with a study conducted in Tanzania using partner notification approach [17]. It was further observed in this study that the HIV positivity rate was higher among children and sexual partners of index clients who were first time testers than those who had negative HIV status before. This may be because first time testers perceive themselves to be at lower risk of infection [18]. Further, re-testers may not expose themselves to risk behaviors after knowing their negative status. In this study, for HIV positive results, we only included the newly diagnosed HIV positive results and those who reported previous HIV positive were excluded.

The HIV Index testing model produced higher HIV positivity and linkage rates across all age groups compared to other HTS models in community settings. This makes the model a viable approach to enhance identification of PLHIV and linking them to care and treatment.




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