Date Published: August 24, 2017
Publisher: Lippincott Williams & Wilkins
Author(s): Shona Dalal, Cheryl Johnson, Virginia Fonner, Caitlin E. Kennedy, Nandi Siegfried, Carmen Figueroa, Rachel Baggaley.
Despite the enormous expansion of HIV testing services (HTS), an estimated 40% of people with HIV infection remain undiagnosed. To enhance the efficiency of HTS, new approaches are needed. The WHO conducted a systematic review on the effectiveness of assisted partner notification in improving HIV test uptake and diagnosis, and the occurrence of adverse events, to inform the development of normative guidelines.
We systematically searched five electronic databases through June 2016. We also contacted experts in the field and study authors for additional information where needed. Eligible studies compared assisted HIV partner notification services to passive or no notification. Where multiple studies reported comparable outcomes, meta-analysis was conducted using a random-effects model to produce relative risks (RRs) or risk ratios and 95% confidence intervals (CIs).
Of 1742 citations identified, four randomized controlled trials and six observational studies totalling 5150 index patients from eight countries were included. Meta-analysis of three individually randomized trials showed that assisted partner notification services resulted in a 1.5-fold increase in HTS uptake among partners compared with passive referral (RR = 1.46; 95% CI: 1.22–1.75; I2 = 0%). The proportion of HIV-positive partners was 1.5 times higher with assisted partner notification than with passive referral (RR = 1.47; 95% CI: 1.12–1.92; I2 = 0%). Few instances of violence or harm occurred.
Assisted partner notification improved partner testing and diagnosis of HIV-positive partners, with few reports of harm. WHO strongly recommends voluntary assisted HIV partner notification services to be offered as part of a comprehensive package of testing and care.
HIV testing and counselling services (HTS) and the availability of antiretroviral therapy have expanded enormously over the past three decades. Starting with diagnostic testing offered to people with symptoms suggestive of HIV infection and antenatal testing, HTS now encompasses a range of approaches such as community, home-based, and mobile testing to reach larger and more varied populations earlier in their course of infection. As a result, by the end of 2015, 17 million people with HIV infection were receiving antiretroviral treatment . Yet it is currently estimated that over 14.5 million people living with HIV worldwide remain undiagnosed . To address this gap – in particular, the first of the UN 90-90-90 goals to diagnose 90% of people with HIV infection by 2020  – new approaches that enhance the efficiency of testing and increase the coverage of treatment are needed. HIV partner notification is an approach that has the potential to particularly identify people with undiagnosed HIV infection who remain unlinked to prevention, treatment and care services, and continue to be at risk of transmitting HIV vertically or through sexual and drug-injecting partners.
We followed the methods described in the PRISMA statement for the reporting of systematic reviews and meta-analyses.
The searches yielded 1742 citations; four RCTs (three individually randomized trials and one cluster-randomized) met our eligibility criteria (Fig. 1). We included observational studies that compared types of partner notification services but either did not randomize index patients or did not have a nonintervention control arm, in order to provide an indication of broader geographic and population types for the main outcomes; these were not included in meta-analyses. For one cluster RCT  and observational study , we included results from a conference abstract in addition to results subsequently published in a peer-reviewed article [19,20], respectively, that were made available after the cut-off date for our initial search.
When HIV positive index patients were offered assistance in notifying their sexual and drug-injecting partners of their exposure to HIV infection, our analyses show that it resulted in higher uptake of partner HIV testing, identified higher proportions of HIV-infected persons, and increased linkage to care through the referral of newly identified HIV-infected partners to ART services. Although there were few RCTs in our meta-analyses, the results are consistent towards favouring assisted approaches, as are the results from observational studies with control groups. Across all studies, high proportions of partners returned for HIV testing when contacted by a provider, whichever method was used. Overall, index patients identified an average of two partners each and this resulted in 0.44 (range 0.01–1.8) partners per index patient eventually testing, following attrition between identified and notified partners, and acceptance of testing. The proportion of partners who tested HIV positive following assisted notification across all studies ranged from 12 to 86%, and between 29 and 40% of couples were serodiscordant.
We thank Ping Teresa Yeh, Caitlin Payne, and Sophie Morse for their assistance with the literature search and screening process, and the WHO guideline development group members: Kindi Adam, Oliver Anene, Karen Champenois, Kathleen Charters, Martin Choo, Miriam Franchini, Rebecca Guy, Mehdi Karkouri, Dasha Matyushina Ocheret, Getrude Ncube, Sabin Nsanzimana, Bathabile Nyathi, Carla Obermeyer, Niluka Perera, Archana Sarkar, Jennifer Stuart-Dixon, Joseph Tak Fai Lau, Jane Thiomi, Francois Venter, and Vincent Wong. Thanks also to the WHO guideline steering committee members: Wale Ajose, Annabel Baddaley, Michel Beusenberg, Brian Chirombo, Lastone Chitembo, Rosalind Coleman, Meg Doherty, Philippa Easterbrook, Shaffiq Essajee, Haileyesus Getahun, Peter Godfrey-Faussett, Joumana Hermez, Naoko Ishikawa, Lali Khotenashvili, Daniel Low Beer, Frank Lule, Christine Mushanu, Simbarsha Mabaya, Buhle Ncube, Augustine Ntilivamunda, Ishmael Nyasulu, Martina Penazzato, Carmen Perez Casas, Julie Samuelson, Anita Sands, Willy Urassa, Freddy Perez, Razia Pendse, Bharat Rewari, Ying Ru Lo, Mukta Sharma, Nicole Seguy, Annette Verster, and Teodora Wi.