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HIV Prevention: Partner Services Interventions to Increase HIV Testing

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What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 27 studies. Studies were identified from a previous Community Guide review (search period 1985 to 2004, Hogben et al., 2007), and an update search (search period 2004 to April 2020). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to HIV prevention, treatment, and care.

This recommendation updates and replaces the 2005 findings for interventions to identify people with HIV infection through partner notification by provider referral (recommended) pdf icon [PDF – 299 KB], patient referral (insufficient evidence) pdf icon [PDF – 295 KB], or contract referral (insufficient evidence ) pdf icon [PDF – 293 KB].

Context

Ending the HIV Epidemic in the U.S. (EHE) External Web Site Icon is the operational plan developed by agencies across the U.S. Department of Health and Human Services (HHS) to pursue the goal of reducing new HIV infections by 75% by 2025 and 90% by 2030. HHS identified four key strategies to achieve these goals in the United States: diagnose people living with HIV as early as possible after infection, treat people with HIV rapidly and effectively to reach sustained viral suppression, prevent new HIV transmission through evidence-based interventions such as pre-exposure prophylaxis, and respond quickly to potential HIV outbreaks. The HIV National Strategic Plan (2021-2025) External Web Site Icon, also developed by HHS, is closely aligned with, and complements, Ending the HIV Epidemic. This plan focuses on collaboration between all sectors of society to prevent new HIV infections, improve health outcomes of people with HIV, and reduce HIV-related disparities and health inequities. Both of the HHS plans identify testing for HIV as the first step, and it is important to implement interventions that increase HIV screening and testing, especially among population groups with the highest rates of diagnosis.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 27 studies.

  • Fourteen included studies reported intervention effectiveness for the following outcomes:
    • Identifying partners—the median partner index ratio was 2.4, meaning 2.4 index patients were interviewed to identify one sexual or needle-sharing partner (12 studies).
    • Notifying partners—a median of 59.8% percent of identified partners were notified 59.8% (10 studies).
    • Getting partners tested—a median of 55.1% of notified partners were tested for HIV (11 studies).
    • Diagnosing partners with HIV infections—a median of 14.6% of tested partners were diagnosed with HIV infection (14 studies).
      • A median of 9.4 index patients were interviewed to find one partner newly diagnosed with HIV infection (13 studies).
      • A median of 1.7 index patients were interviewed to identify one partner with HIV infection (newly or previously diagnosed (8 studies).
    • Linking index patients and partners with HIV infection to care—index patients and partners who received partner services were more likely to be linked to care within 90 days of diagnosis when compared with persons not receiving these services (2 studies).
  • Sixteen studies examined whether intervention effectiveness varied with intervention or population characteristics.
    • Context for the initial interview
      • In person interviews were more effective at getting partners tested for HIV (1 study) and finding partners newly diagnosed with HIV infection (1 study) when compared with initial interviews done remotely.
      • Multiple interview sessions with the index patient were more effective at identifying partners newly diagnosed with HIV infection (1 study) when compared with one interview session.
    • Partner notification process
      • Referral approaches—provider referral was more effective at notifying, testing, and finding partners newly diagnosed with HIV infection (5 studies) when compared with self or third-party referral.
      • Notification context—internet or text notifications were more effective at notifying partners (2 studies) when compared with traditional notification methods such as in-person or over the phone. In-person notifications were more effective at identifying partners newly diagnosed with HIV infection (3 studies) when compared with notification through internet or text.
    • Partner testing site—offering point-of-care testing was more effective at getting partners tested than referring partners to clinics for testing (1 study).
    • Index patient, acute or non-acute infection—index patients with acute HIV infection identified more partners newly tested positive for HIV infection than did index patients with non-acute or long-standing HIV infection (1 study).
    • Index patient, pregnancy— index patients who were pregnant identified more partners newly tested positive for HIV infection than did index patients who were not pregnant (1 study).
    • Partner mode of transmission—the number of index patients interviewed to find one partner newly diagnosed with HIV infection was over 10 times lower for index patients’ male-to-male sexual or intravenous drug use contacts than it was for index patients’ heterosexual contacts (1 study).

Summary of Economic Evidence

Economic evidence shows HIV partner services to increase HIV testing are cost-effective, based on cost per quality-adjusted life year (QALY) estimates that were either cost-saving or below a conservative benchmark of $50,000 per QALY gained. The systematic economic review included six studies (search period January 2000 through July 2021). Monetary values are reported in 2020 U.S. dollars.

  • The mean intervention cost per person tested was $1,761 (2 studies) and the median intervention cost per person newly diagnosed with HIV was $22,144 (4 studies).
  • The mean net cost per QALY gained was $25,526 (2 studies), and two studies reported net cost less than zero indicating cost-savings.

Applicability

Based on results from the systematic review, the CPSTF finding should be applicable to all urban settings in the United States and all types of index patients and partners, independent of age, gender, race, ethnicity, or HIV transmission category.

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

  • How effective are partner services interventions at reconnecting persons out-of-care to HIV medical care? Partners identified by index patients may know their HIV status but out-of-care. Partner services interventions may help link these people with medical care. None of the included studies reported on this outcome.
  • How effective are partner services interventions at increasing partners’ access to PrEP or repeat testing? Partners who test negative for HIV and remain at high risk for exposure may be offered HIV prevention services such as PrEP or repeat HIV testing.
  • How effective are partner services interventions in rural areas? Is the intervention cost-effective when used in rural settings?
  • Does intervention effectiveness differ by racial and ethnic group? How effective are partner services interventions for American Indian and Alaska Native communities?
  • Does intervention effectiveness differ by the socioeconomic status (SES) of index patients and partners?
  • What are the economic effects of using enhanced technologies such as internet, e-mail, texts, and social media for HIV partner services?
  • What are the effects of adding self-testing kits for index patients to distribute to their partners on both the effectiveness and economics of the intervention?

Study Characteristics

  • Included studies were conducted in the United States (22 studies), Canada (1 study), Taiwan, China (1 study), Spain (1 study), Sweden (1 study), and the United Kingdom (1 study).
  • Studies evaluated state-wide interventions (5 studies) or programs that were implemented in urban (21 studies) or rural (1 study) areas.
  • Index patients were interviewed to identify sexual partners only (7 studies), sexual or needle-sharing partners (18 studies), or sexual, needle-sharing, or social network partners (2 studies).
  • Index patients were offered provider referral (19 studies), self and provider referral (7 studies), or a mix of self, third party, and provider referral (1 study).