In December 2016, the World Health Organization (WHO) recommended scale-up of assisted
partner notification services (APS) as a strategy to increase HIV testing among persons
living with HIV (PLWH). APS offers PLWH assistance to confidentially notify their sex and
needle-sharing partners of their exposure and link them to testing and treatment.
Randomized controlled trials (RCTs) have shown that APS increases HIV testing and
case-finding, and is cost-effective. APS is scalable in routine practice, but typically
with lower HIV case-finding than was observed in RCTs. APS outcomes are sub-optimal when
recipients only name their current sex partner, or when partner notification and testing
does not occur. There are an estimated 240,000 PLWH in Ukraine, of whom roughly three in
four know their HIV status. While population-level HIV prevalence is 1.0%, prevalence
among persons who inject drugs (PWID) and men who have sex with men (MSM) is 23% and 8%,
respectively.
In 2019, the Ukraine Ministry of Health began scaling APS services. Despite trainings
that emphasized the need to elicit >1 partner for each index client, health workers (HW)
elicited only 1.14 for sexual and needle-sharing partners per index client, on average.16
Only 5.6% of APS clients identified as MSM or PWID and 45.9% of partners with unknown
status had not yet completed HIV testing after 30 days.
The CASI-Plus mHealth intervention seeks to improve partner elicitation and testing,
through a mHealth client engagement tool using computer-assisted self-interview (CASI).
The CASI-Plus tool supports the initial APS encounter (providing information on how APS
works, eliciting names of all sexual or injection partners, screening for risk of
intimate partner violence [IPV], and planning for partner notification), and facilitates
case management through partner testing (via repeat follow-up surveys to assess for
barriers to notification, interest in provider assistance, IPV, and completion of
notification). While CASI has reduced social desirability bias in surveys of sexual
behavior across diverse settings, it has not yet been used in APS programs in low- or
middle-income countries (LMICs). This implementation science research will provide useful
evidence on whether CASI-Plus can improve partner elicitation and HIV testing in a
routine APS program operating at scale, toward the ultimate goal of linkage to HIV
prevention and treatment services among those at highest risk of HIV.
Aim 1 (R21): Conduct formative research from health worker and client perspectives to
design the CASI-Plus mHealth intervention. Approach: The investigators will complete
in-depth interviews with APS clients (N=10) and focus group discussions with HWs (N=2
groups of 8 HWs) to elicit barriers to partner elicitation and testing, use this
information to design the CASI-Plus tool and its integration within the APS workflow, and
test the tool for technical performance, usability, and acceptability. Hypothesis:
CASI-Plus will be perceived by both clients and HWs as easy to navigate, acceptable, and
technically sound.
Aim 2 (R21): In a RCT, assess adoption of CASI-Plus and its impact on contact
elicitation. Approach: In one high-volume health facility, the investigators will
randomize PLWH (N=154) to either the CASI-Plus or standard care (SC) APS workflow, and
measure the use of the tool and contact index using routinely-collected data. Hypothesis:
Clients will complete initial and follow-up surveys, and will report more partners when
using the tool.
Aim 3 (R33): In an expanded RCT, test CASI-Plus on the HIV testing index. Approach: The
investigators will expand the RCT to three high-volume health facilities and test its
effectiveness in improving the HIV testing index (number of partners with unknown HIV
status tested per index client; primary outcome, N=888). Secondary outcomes include the
percentage of index clients disclosing MSM or PWID partners, HIV case-finding index, and
APS-associated adverse events. Hypothesis: The intervention will increase the HIV testing
index and participation of PWID and MSM, without increasing adverse events.
Aim 4 (R33): Assess appropriateness and feasibility of the CASI-Plus intervention and its
impact on overall acceptability of APS services. Approach: The investigators will use
exit surveys of HWs (N=36) and CASI-Plus clients (N=444) to assess appropriateness and
feasibility of the intervention. Researchers will assess CASI-Plus impact on overall APS
acceptability, via measures of satisfaction and perceived stigma, in an exit survey with
clients in both study arms (N=888). Hypothesis: CASI-Plus will be appropriate, feasible,
and improve APS acceptability.
The proposed research team brings together experienced researchers, APS program
specialists, and digital health specialists from the University of Washington (UW) and
the Ministry of Health's Public Health Center (PHC). The project builds upon the existing
national platform for APS within public-sector HIV clinics, and lays the foundation for a
simple intervention to optimize APS delivery which could be evaluated for implementation
outcomes and effectiveness at scale in a future cluster-randomized controlled clinical
trial.