Index and targeted community-based testing to optimize HIV case finding and ART linkage among men in Zambia

Abstract

Introduction: Current healthcare systems fail to provide adequate HIV services to men. In Zambia, 25% of adult men living with HIV were unaware of their HIV status in 2018, and 12% of those who were unaware of their HIV statu were not receiving antiretroviral therapy (ART) due to pervasive barriers to HIV testing services (HTS) and linkage to ART. To identify men and key and priority populations living with HIV in Zambia, and link them to care and treatment, we implemented the Community Impact to Reach Key and Underserved Individuals for Treatment and Support (CIRKUITS) project. We present HTS and ART linkage results from the first year of CIRKUITS.

Methods: CIRKUITS aimed to reach beneficiaries by training, mentoring, and deploying community health workers to provide index testing services and targeted community HTS. Community leaders and workplace supervisors were engaged to enable workplace HTS for men. To evaluate the effects of these interventions, we collected age- and sex-disaggregated routinely collected programme data for the first 12 months of the project (October 2018 to September 2019) across 37 CIRKUITS-supported facilities in three provinces. We performed descriptive statistics and estimated index cascades for indicators of interest, and used Chi square tests to compare indicators by age, sex, and district strata.

Results: Over 12 months, CIRKUITS tested 38,255 persons for HIV, identifying 10,974 (29%) new people living with HIV, of whom 10,239 (93%) were linked to ART. Among men, CIRKUITS tested 18,336 clients and identified 4458 (24%) as HIV positive, linked 4132 (93%) to ART. Men who tested HIV negative were referred to preventative services. Of the men found HIV positive, and 13.0% were aged 15 to 24 years, 60.3% were aged 25 to 39, 20.9% were aged 40 to 49 and 5.8% were ≥50 years old. Index testing services identified 2186 (49%) of HIV-positive men, with a positivity yield of 40% and linkage of 88%. Targeted community testing modalities accounted for 2272 (51%) of HIV-positive men identified, with positivity yield of 17% and linkage of 97%.

Conclusions: Index testing and targeted community-based HTS are effective strategies to identify men living with HIV in Zambia. Index testing results in higher yield, but lower linkage and fewer absolute men identified compared to targeted community-based HTS.

Keywords: HIV care continuum; HIV testing; differentiated care; finding men; index testing services; linkage to care; sub-Saharan Africa.

Figure 1

Map of Zambia with HIV prevalence among adults aged 15 to 49 by province. Arrows indicate the provinces in which CIRKUITS was implemented. Data from ZDHS 2018 [3].

Figure 2

CIRKUITS (Community Impact to Reach Key and Underserved Individuals for Treatment and Support) steps for index testing. Boxes in shaded area represent facility‐based activities; other boxes represent activities taking place in the community. Text in blue italics reflects relevant programme metrics. These steps were initially developed by UMB, and then adopted in the National Zambia Consolidated Guidelines for Prevention and Treatment of HIV Infection 2020 [25]. FP, family planning; GBV, gender‐based violence; ITS, index testing services; PLHIV, people living with HIV; PrEP, pre‐exposure prophylaxis; VMMC, voluntary medical male circumcision.

Figure 3

Overall index testing cascade.

Figure 4

Index cascade for men.