With the support of the United States Agency for International Development (USAID) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR), PSI/E, through the USAID MULU Key Populations Activity has been working on HIV prevention, care, and treatment focusing on key and priority populations.
The goal is to expand comprehensive community-based HIV services for female sex workers (FSW) and priority populations (PP), their children, high-risk men inclusive of FSWs’ paying and non-paying sexual partners, and at-risk out-of-school adolescent girls and young women (AGYW). The Activity providers integrated HIV and other clinical services through its network of client-friendly Drop-In Centers (DIC) and outreach teams.
The Activity’s HIV case identification strategy mainly focuses on index case testing (ICT) through DIC’s and outreach activities. It’s a focused HIV testing approach in which providers work with individuals living with HIV (index clients) to elicit their sexual partners, their biological children, and/or needle-sharing partner(s)and reach them with HIV services.
ICT provides an opportunity for assisted disclosure in a partner/spousal setting, a closer rapport between DIC providers and DIC clients, and a higher HIV case identification rate.
THE NEED FOR ICT & WHY IT IS EFFECTIVE
FSWs usually resist HIV testing due to fear of diagnosis as well as self-perceived and societal stigma and discrimination towards HIV-positive people. However, through continuous follow-up and counseling, many clients will opt for HIV testing.
Clients are offered pre-counseling sessions before every HIV testing with an option to choose either assisted or unassisted HIVST options. Depending on the test result, a post-test counseling session on combined prevention approach including PrEP (Pre pre-phylaxis), and ART (Antiretroviral Therapy) services. For those who are HIV positive, linkage to ART treatment will be facilitated at the DIC or preferred public-private facility.
Before and after every HIV test a counselor will always explain the purpose and benefits of ICT. Counselors build rapport and create a trusting environment before clients provide personal information about their sexual partners. For a successful ICT, the counselors use several methods depending on the situation or case:
Client referral: The provider encourages the client to disclose his/ her status to their sexual partners and encourages them to suggest HIV testing to their partners. The provider will not make any contact with the referrals until the point at which they come in for testing.
Provider referral: With the consent of the index client, a trained provider confidentially contacts the person’s referrals directly and offers the referrals voluntary HIV testing.
Contract referral: The index client enters a contract with a trained provider and agrees to disclose his/her status and/or referral partners to HIV testing services (HTS) within a specific time. If the partners of the HIV-positive individual do not access services or fail to contact the health provider within that period, the provider will contact the partners directly.
Dual referral: The provider offers support and accompaniment to index clients to disclose their HIV status and offer testing services to the partners.
CHALLENGES OF IMPLEMENTING ICT
For the ICT to be successful, it's mandatory to build trust and confidentiality. Clients usually have a hard time openly discussing their situation mostly due to a lack of trust in the health providers because of potential judgment and stigma that come with being HIV positive.
When asking to contact index clients, FSWs are usually uncomfortable because they don’t want their status to be disclosed. DIC counselors sometimes call the index clients using the lottery method telling them that they can get free health service, counseling, and testing but it’s not as efficient as targeted phone calls asking clients about their health status and their availability to take HIV tests.
Challenges that ICT faces have future implications for index partner testing include non-disclosure and under-disclosure of the number of sexual partners by the index clients. Many women fear negative outcomes for disclosing their status including fear of violence by their partner.
Moreover, the index clients are usually out of reach and highly mobile. This makes it challenging to reach them.
OPPORTUNITIES FOR FUTURE EXPANSION
The FSW is usually contacted by the opposite gender that works in the DIC. This strategy has been successful to build trust because the FSW are comfortable talking freely and meeting with them at their convenience. Counselors usually adapt to the type of attitude that the FSW displays and respond to that behavior. They have received training in VCT (Voluntary Counseling and Testing) but most of them say effectiveness comes with experience.
ICT further provides an opportunity for assisted disclosure in a partner/spousal setting, a closer rapport between DIC providers and DIC clients, and a higher HIV case identification rate. The ICT strategy has huge potential to improve disclosure in FSW and their partners through DIC provider assistance.
“There was an incident in which a counselor at the DIC had to contact a client after she was informed by an FSW who tested HIV positive that she just had unsafe sex with her boyfriend in the past 24 hours. The client was immediately put on PreP after testing negative the same day because the counselor insisted to meet with him immediately. He tested negative after 3 months and thanked the counselor by gifting her a gold necklace” Counselor at DIC
Challenges that ICT faces have future implications for index partner testing include non-disclosure and under-disclosure of the number of sexual partners by the index clients.
CONTINUING THE SUCCESS OF ICT
To have better results from ICT, counselors are doing more to follow up with all newly identified HIV positives as early as possible and record complete client biodata during each session.
For FSWs Having a place to stay and receive integrated services is very important. On the same note, the need for an ART site has become more of a necessity moving forward because it creates a complete service approach for FSW who test positive for HIV. Traveling and accessing health centers for ART provision is both mentally tiring for FSWs and PPs, and logistically draining for DIC health providers.
Experience sharing forums between DIC health service providers and government bodies are also important to create awareness and increase buy-in.
“There was an incident in which a counselor at the DIC had to contact a client after she was informed by an FSW who tested HIV positive that she just had unsafe sex with her boyfriend in the past 24 hours
REAL LIFE STORY OF AN ICT CLIENT
During hot-spot mapping activities, counselors conducted a mini outreach HIV testing session equipped with test kits around Kuchera, in the Shola area. The woreda is an attraction for daily laborers, small coffee shops, and bars filled with young people. In this area, one FSW is believed to have about 20 regular sexual partners. While testing in the area, counselors came across Haal, who worked as a daily laborer who was willing to be tested for HIV. After the test turned out to be positive, he was given post-counseling service and referred to a health center for ART provision. Haal had mentioned that he had unsafe sex with an FSW, Abse.
Abse was contacted to be tested for HIV but was scared to be tested because she had unsafe sex. She agreed to further counseling and reassurance from providers that it was within her best interest to do so. After testing positive, she stated that her boyfriend also had other sexual partners by the names of Enat and Chika. She provided the contact numbers for them but asked that her identity be kept secret.
The counselor then went to the hotel that the FSW- Chika frequents to meet clients. The counselor went under the pretext of distributing condoms and offering HIV counseling and testing service. After building rapport with all the girls who work there, she offered a free HIV test for the next day without singling out Chika. The following day the counselor took an HIV testing kit for Chika, but she was not willing to be tested while girls were around. The counselor took the contact information of all the girls and informed them that the DIC is open for any of them if they would like to come to rest and get other health training.
After a couple of days, Chika contacted and met with Nurse Meron at the DIC and shared intimate personal information about her boyfriend and multiple sexual partners. She also shared with her that she usually drinks alcohol, chews khat, and engages in unprotected sex. Chika was first scared to be tested for HIV, but then decided to go ahead with it because Meron comforted her by building trust and giving her a friendly nudge that usually includes talking to her about her interests, her day-to-day life and her aspirations. After testing positive, Chika was devastated but also felt like she knew for a while. “It was like her worst nightmares were realized”- Meron. After post counselling Meron took Chika to the health center for ART services. Currently her partners and boyfriend are in the process of being contacted to be tested.
The YEKA DIC counselors are working collaboratively to reach the previously mentioned three FSW to successfully trace their partners.
Names used on the story have been changed to maintain confidentiality.