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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 1-7

Policy brief on increasing partner disclosure among human immunodeficiency virus-infected persons in stable relationship in Nigeria


1 Department of Community Medicine, Benjamin Carson Senior School of Medicine, Babcock University; Department of Community Medicine, Babcock University Teaching Hospital, Ilishan-Remo, Ogun State, Nigeria
2 Department of Paediatrics, Benjamin Carson Senior School of Medicine, Babcock University; Department of Paediatrics, Babcock University Teaching Hospital, Ilishan-Remo, Ogun State, Nigeria
3 Department of Surgery, Benjamin Carson Senior School of Medicine, Babcock University; Department of Surgery, Babcock University Teaching Hospital, Ilishan-Remo, Ogun State, Nigeria

Date of Web Publication13-Jul-2017

Correspondence Address:
Layi S Babatunde
Department of Community Medicine, Benjamin Carson Senior School of Medicine, Babcock University, Ilishan.Remo, Ogun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-9157.210593

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  Abstract 

Human immunodeficiency virus (HIV) infection contributes significantly to early death. Rate of partner disclosure is low among HIV-infected person in stable relationship preventing uptake of HIV prevention, treatment, and care by partners. Persons in stable relationship account for about 50% new infection in Nigeria largely resulting from nondisclosure by HIV-infected partner. Partner notification (PN) strategies are available for HIV-infected persons in stable relationship. In spite of the perceived barriers to partner disclosure among HIV-infected persons in stable relationship, there is ample evidence they will positively respond to PN service. The incorporation of PN strategy into the 2014 Integrated National Guideline for HIV Prevention, Treatment, and Care has created a window of opportunity for local action on PN in HIV-infected persons in stable relationship. This evidence brief summarizes available evidence on PN strategies for increasing PN among HIV-infected persons in stable relationship. The evidence brief is intended to contribute to the local implementation strategy on PN in HIV prevention, treatment, and care as specified in the Integrated National Guidelines for HIV Prevention, Treatment, and Care in Nigeria. It is also aimed at senior management teams in state agencies for the control of AIDS and all local government health departments in Nigeria.

Keywords: Human immunodeficiency virus infection, Nigeria, partner notification, stable relationship


How to cite this article:
Babatunde LS, Babatunde OT, Oladeji SM. Policy brief on increasing partner disclosure among human immunodeficiency virus-infected persons in stable relationship in Nigeria. J HIV Hum Reprod 2016;4:1-7

How to cite this URL:
Babatunde LS, Babatunde OT, Oladeji SM. Policy brief on increasing partner disclosure among human immunodeficiency virus-infected persons in stable relationship in Nigeria. J HIV Hum Reprod [serial online] 2016 [cited 2017 Aug 21];4:1-7. Available from: http://www.j-hhr.org/text.asp?2016/4/1/1/210593


  The Problem Top


Morbidity and mortality

Despite advances toward controlling human immunodeficiency virus (HIV) infection, it remains one of the leading causes of mortality and morbidity, especially in Sub-Saharan Africa where the impact is evident.[1] Seventy percent of the world's burden of the infection occurs in this region; half of which occurs in Nigeria.[2] According to the 2010 ANC Survey Report, Nigeria has an estimated 3.4 million people living with HIV, second only to that in South Africa, and approximately 54% of these individuals are within the 15–64 years age range.[3] The prevalence of HIV in Nigeria varies across states ranging from 1% to 12.7%. In 2012, 388,864 new cases of HIV infections were reported with approximately 217,148 AIDS related deaths.[3] In this regard, Nigeria currently bears nearly 10% of the global burden of HIV/AIDS.[3]

Heterosexual transmission accounts for the majority of HIV transmissions in Nigeria.[3] The 2010 Mode of Transmission Study 1 reported that 34.6% of new HIV infections occur among couples considered as engaging in “low-risk” sex while 23% occur among most at risk populations. More than a third of all new infections were linked to female sex workers, their clients, and partners.[3]

Nondisclosure of human immunodeficiency virus status

Partner notification (PN) by persons with HIV infection in stable relationship is a key strategy for HIV prevention as it promotes safer sex practices and prevents new infections. It also supports risk reduction and facilitates access to prevention and care services. However, sexual relationships within stable relationships in Sub-Saharan Africa are often associated with nondisclosure of HIV status to the individual partners which can lead to sexual transmission of HIV within such relationships.[4] In spite of the benefits of partner disclosure in the prevention and control of HIV infection, disclosure rate in developing countries - Nigeria inclusive - remains largely low as it ranges from 16.7% to 86%.[5] Disclosing HIV-positivity status is a difficult and yet an important decision for all infected persons. In Nigeria, close to 40% of new infections occur in this group of people.[6]

If HIV-infected persons in stable relationship can notify and disclose their HIV status to their partners, it would enable such partners access HIV prevention, treatment, and care services. This will lead to reduction in the rate of new HIV infection and also link more persons with HIV infection to care. There is an increasing body of evidence on the impact PN services have on sexually transmitted infections (STIs) (including HIV infection) management in Western countries. There is also an emerging body of evidence on the feasibility and cost-effectiveness of some PN strategies in early identification of HIV-infected persons in Sub-Saharan Africa. There is currently an upscale of getting people tested for HIV infection. The theme from the year 2011-2015 for World AIDS Day campaign was, “Getting to zero: zero new HIV.”

Why do we need to look at this problem now?

PN of HIV infection status by infected persons in stable relationship being a serious local and national public health issue, the Integrated National Guidelines for HIV Prevention, Treatment, and Care published in 2014, obliges health-care providers involved in HIV care to provide PN services using a range of strategies which includes:

  • Client/patient referral: The patient agrees to inform his or her partners
  • Provider referral: The provider (typically a trained health department counselor but potentially a clinician, nurse, or health educator) is responsible for confidentially notifying the patient's partners
  • Contract referral: The patient agrees to attempt to notify his or her partners, but if they fail to do so within a prespecified period of time, the provider confidentially notifies any remaining partner.


Each of these PN strategies requires different approaches and different evidences:

  • To address the low rate of PN among HIV-infected persons in stable relationship, effective PN service needs to be provided in health-care settings
  • The implementation of PN services cannot be successful without local HIV health service providers utilizing evidence-based strategies
  • It is necessary to gain an understanding of how HIV-infected persons in stable relationship and health-care providers involved in HIV care management perceive PN services.


Given the importance of HIV disclosure, it is important to gain understanding of the PN strategies that may be effective in increasing HIV disclosure rate among persons with HIV infection in stable relationship. This will ensure that effective resource allocation for the control of HIV infection is based on informed decision-making. This policy brief is aimed at informing decisions by HIV prevention, treatment, and care providers about how best to ensure HIV status disclosure to partners of infected persons. It examines the current evidence base for the effectiveness of the various PN strategies that may be adopted and HIV care provider and patients' attitudes that might affect PN strategies.


  Policy Options Top


Three policy options that could improve PN among HIV-infected persons are:

  1. Use of client/patient referral: An approach in which health service personnel encourage index patients to notify their own partners which may be in the form of spoken advice from health-care personnel about the need for sexual partners to receive treatment
  2. Provider referral: Whereby the provider is responsible for confidentially notifying the patient's partners. This should only be done with the explicit consent of the index patient
  3. Contract referral: An approach whereby index patients determine to notify their partners and agree to a specific time frame in which they will do so. Patients agree that if they do not notify the selected partners within the established time frame, the provider will notify the partners.


Examination of evidence – methods

The following search question was used as a basis for locating and examining available evidence on PN strategies:

“What partner notification strategy option could be most effective in increasing partner disclosure rates among HIV infected persons in stable relationships in Nigeria?"

The PICO framework was used as it allows a range of interventions to be compared which is what is needed for the research question. Outcome measures included partners that were notified or accessed HIV care.

Evidence including a systematic review, a quantitative study, and a qualitative study was examined in detail. Research findings from the study were examined and synthesized with local knowledge. The summary findings were used to inform recommendations.

Systematic review

PubMed, TRIP, Google Scholar, and Cochrane Library online databases were used to identify suitable systematic reviews [Appendix 1] [Additional file 1]. The Cochrane review Interventions for Strategies for partner notification for sexually transmitted infections, including HIV,[7] was chosen because it closely matches the research question, included some studies conducted in settings similar to Nigeria, has been recently updated, and conforms to rigorous Cochrane collaboration standards.

The review included 26 randomized control trial studies from the USA, UK, Denmark, Australia, Malawi, South Africa, Uganda, Zambia, and Zimbabwe. Majority of the trials (21) were conducted in public health clinics, one in a large academic medical center, three in general practice, and one on a university campus. However, only 25 studies characteristics were provided in the review. Two trials were conducted among HIV-infected persons while the other studies were conducted among patients with various STIs. The review covered four main PN strategies which include:

  • Strategies to enhance patient referral PN including enhanced patient referral PN strategy
  • Expedited partner therapy (EPT)
  • Provider referral PN strategy
  • Contact referral PN strategy
  • Combinations of the above.


This evidence brief discounted 14 reviewed studies which included study trials that assessed strategies not applicable in the prevention and care of HIV infection (EPT or combination of this with other PN strategies) and outcome measure that did not include number of partners notified or that presented for HIV care. The quality of the systematic review was assessed using the Critical Appraisal Skills Programme (CASP) randomized control trial 11-question checklist. This systematic review did not access acceptability and cost-effectiveness of PNS.

The authors were cautious in their evidence analysis in terms of risks to the validity of the findings and assessment of risk of bias which was hampered by incomplete reporting in more than half of the included studies with inadequate methods of allocation concealment. The quality of evidence is adjudged to be low for most of the included studies. When the body of evidence about PN strategies was considered by the authors, evidences that summarize PN with notification outcome or partners coming for care were not reviewed.

The authors concluded in this systematic review that there is currently no significant supporting evidence for a single optimal strategy for PN. Few of the included studies evaluated PN strategies in HIV infection. Authors recommend further research using large randomized controlled trials for PN to compare the outcomes of provider referral with methods of enhanced patient referral, to look at the acceptability of various PN strategies to index patients and partners, and to compare the costs and potential harms of various PNs.

In summary, this systematic review does not recommend any single PN strategy or in combinations. Findings of studies are summarized in the table characteristics in [Appendix 2] [Additional file 2].

Quantitative study

A quantitative study to augment the findings of the systematic review was accessed. The study, cost-effectiveness of provider-based HIV PN in urban Malawi,[8] was identified using a direct search as for locating the systematic review. The quality of the study was assessed using the CASP Economic Evaluation 12-question checklist and adjudged to be of high quality. This study was considered because cost of program implementation is important in a resource-limited setting such as Nigeria.

The trial was conducted in Lilongwe, Malawi, in STI clinic settings similar to treatment settings in Nigeria. The study evaluated the cost-effectiveness of PN strategies to identify sexual partners of HIV-infected index patients at STI clinics. It estimated the costs associated with tracing and testing locatable partners of index patients, and modeled transmission rates and behavioral modifications after testing to evaluate cost per partner tested, cost per new case identified, and cost-effectiveness of HIV transmissions averted by each PN strategies. The finding suggests:

  1. Both provider and contract PN strategies are more effective compared with passive or patient referral strategy in identifying partners of index patients and getting them to receive HIV testing services
  2. Contract PN strategy identified more partners of index patients, got them to receive HIV testing services; and also identified greater number of new HIV cases compared with provider PN strategy
  3. Contract referral was the most cost effective of the three PN strategies.


Qualitative study

The success of a PN program can be hampered by the attitudes of service providers and patients to the strategies adopted. There are limited studies that have addressed this issue. Database searches of PubMed and TRIP revealed the study: Understanding attitudes, barriers, and challenges in a small island nation to disease and PN for HIV and other sexually transmitted infections: A qualitative study [9] which addresses this issue and was conducted in a developing country. The study was evaluated using the CASP qualitative research 10-question checklist.

It was a focused ethnographic study with a diverse group of people interviewed to understand the likely attitudes, barriers, and challenges to introducing mandatory disease notification and PN for HIV and other STIs in Barbados.

The study revealed that contract referral and provider referral were chosen as the most and least acceptable methods, respectively. Contract referral was seen as preserving patients' autonomy to some extent while provider referral has a “total suspension of patients' rights.” Although patient referral was more acceptable than provider referral, it was considered to be the least effective of the three strategies. Challenges identified included time and effort needed for successful contact tracing, lack of appropriate legislation for testing, and maintenance of confidentiality.

In all, irrespective of the strategy adopted, judgmental attitudes of health-care workers, and a lack of trust in them may also constitute barriers. Stigma and discrimination also made concerns about confidentiality more important.

The findings suggest that patient referral may not be as effective as the other strategies. It also identifies the need for extra counseling to get patients to notify partners or to give the provider permission to do so.


  Discussion Top


The Cochrane review assessed above showed some evidence that both contract referral and provider referral resulted in more partners presenting for care and testing positive than simple patient referral in patients with HIV and likewise in those with other STIs. Similarly, slight differences were reported in the various studies that compared various methods of enhancing patient referral with simple patient referral. However, most of the results were insignificant. Hence, the conclusion that the evidence assessed in the systematic review did not identify any single optimal strategy for PN for HIV or any particular STI. This conclusion needs to be taken with caution in view of the heterogeneity of the studies reviewed and the low grade of quality of most of the studies.

Although the systematic review could not identify any optimal strategy and did not assess the cost, the quantitative study provides some evidence that both provider referral and contract referral are more effective than patient referral. Evidence from the study indicates that contract referral is more cost effective than provider referral. This is instructive in the light of the limited resources and the current economic challenge that Nigeria is facing.

Optimizing the effectiveness of any option adopted requires an understanding of factors that might hamper the effectiveness. The evidence available suggests that contract referral might be the most acceptable while provider referral was the least acceptable.

Factors that might affect patient referral method include concerns about partner violence, loss of economic support, shame in having to admit unfaithfulness to a regular partner and a loss of confidentiality, a lack of concern, not liking to give bad news, and procrastination, with people not notifying partners despite promising to do so.

Identified challenges that might mitigate the effectiveness of provider referral include time and effort needed for successful contact tracing and lack of appropriate legislation. Maintaining confidentiality would also be a greater challenge in contact tracing compared to patient referral as it requires additional persons having access to the results.

Apart from the time and effort needed for successful contact tracing when required, determining the correct length of time to allow the patient to notify partners could be a challenge. Some persons might feel that sufficient time has not been given some may need extra time as partners may be difficult to locate.

In all, irrespective of the strategy adopted, judgmental attitudes of health-care workers, and a lack of trust in them may also constitute barriers. Stigma and discrimination also made concerns about confidentiality more important.


  Conclusion Top


The findings suggest that PN can be successfully implemented with some impact on the spread of HIV if the right strategy option is adopted.

The key points from the available evidence are:

  • No sufficient evidence to support a particular option as the best
  • While contract referral might be the most supported method by the available evidence, the choice of method to be used for any particular person should be informed by consideration of several factors such as acceptability
  • It is possible to optimize the benefits of PN in the control of the spread of HIV.


The recommendation of the National Guideline on Prevention, Treatment, and Care of HIV is that PN services be provided. The following are therefore recommended:

  • Development of an implementation strategy for PN service in Nigeria
  • Strengthen of capacity of health facilities at the primary, secondary, and tertiary levels for the provision of effective PN service through training of health-care workers involved in HIV management and care
  • Development of strategies to address potential barriers to HIV status disclosure.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ortblad KF, Lozano R, Murray CJ. The burden of HIV: Insights from the Global Burden of Disease Study 2010. AIDS 2013;27:2003-17.  Back to cited text no. 1
    
2.
Joint United Nations Programme on HIV/AIDS. GAP Report-beginning of the End of the AIDS Epidemic. Geneva: UNAIDS; 2011.  Back to cited text no. 2
    
3.
Federal Ministry of Health. Integrated National Guideline For HIV Prevention Treatment and Care. Abuja: FMOH, Nigeria; 2014.  Back to cited text no. 3
    
4.
Bashorun A, Nguku P, Kawu I, Ngige E, Ogundiran A, Sabitu K, et al. A description of HIV prevalence trends in Nigeria from 2001 to 2010: What is the progress, where is the problem? Pan Afr Med J 2014;18 Suppl 1:3.  Back to cited text no. 4
    
5.
Sagay AS, Musa J, Ekwempu CC, Imade GE, Babalola A, Daniyan G, et al. Partner disclosure of HIV status among HIV positive mothers in Northern Nigeria. Afr J Med Med Sci 2006;35 Suppl: 119-23.  Back to cited text no. 5
    
6.
Joint United Nations Programme on HIV/AIDS. New HIV Infections by Mode of Transmission in West Africa: A Multi-country Analysis. Geneva: UNAIDS/WHO; 2010.  Back to cited text no. 6
    
7.
Ferreira A, Young T, Mathews C, Zunza M, Low N. Strategies for partner notification for sexually transmitted infections, including HIV. Cochrane Database Syst Rev 2013;(10):CD002843.  Back to cited text no. 7
    
8.
Rutstein SE, Brown LB, Biddle AK, Wheeler SB, Kamanga G, Mmodzi P, et al. Cost-effectiveness of provider-based HIV partner notification in urban Malawi. Health Policy Plan 2014;29:115-26.  Back to cited text no. 8
    
9.
Adams OP, Carter AO, Redwood-Campbell L. Understanding attitudes, barriers and challenges in a small island nation to disease and partner notification for HIV and other sexually transmitted infections: A qualitative study. BMC Public Health 2015;15:455.  Back to cited text no. 9
    




 

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