Monitoring progress towards the first UNAIDS target: understanding the impact of people living with HIV who re‐test during HIV‐testing campaigns in rural Mozambique

Abstract

IntroductionAwareness of HIV‐infection goes beyond diagnosis, and encompasses understanding, acceptance, disclosure and initiation of the HIV‐care. We aimed to characterize the HIV‐positive population that underwent repeat HIV‐testing without disclosing their serostatus and the impact on estimates of the first UNAIDS 90 target.MethodsThis analysis was nested in a prospective cohort established in southern Mozambique which conducted three HIV‐testing modalities: voluntary counselling and testing (VCT), provider‐initiated counselling and testing (PICT) and home‐based testing (HBT). Participants were given the opportunity to self‐report their status to lay counsellors and HIV‐positive diagnoses were verified for previous enrolment in care. This study included 1955 individuals diagnosed with HIV through VCT/PICT and 11,746 participants of a HBT campaign. Those who did not report their serostatus prior to testing, and were found to have a previous HIV‐diagnosis, were defined as non‐disclosures. Venue‐stratified descriptive analyses were performed and factors associated with non‐disclosure were estimated through log‐binomial regression.ResultsIn the first round of 2500 adults randomized for HBT, 1725 were eligible for testing and 18.7% self‐reported their HIV‐positivity. Of those tested with a positive result, 38.9% were found to be non‐disclosures. Similar prevalence of non‐disclosures was found in clinical‐testing modalities, 29.4% (95% CI 26.7 to 32.3) for PICT strategy and 13.0% (95% CI 10.9 to 15.3) for VCT. Prior history of missed visits (adjusted prevalence ratio (APR) 4.2, 95% CI 2.6 to 6.8), younger age (APR 2.5, 95% CI 1.4 to 4.4) and no prior history of treatment ((APR) 1.4, 95% CI 1.0 to 2.1) were significantly associated with non‐disclosure as compared to patients who self‐reported. When considering non‐disclosures as people living with HIV (PLWHIV) aware of their HIV‐status, the proportion of PLWHIV aware increased from 78.3% (95% CI 74.2 to 81.6) to 86.8% (95% CI 83.4 to 89.6).ConclusionMore than one‐third of individuals testing HIV‐positive did not disclose their previous positive HIV‐diagnosis to counsellors. This proportion varied according to testing modality and age. In the absence of an efficient and non‐anonymous tracking system for HIV‐testers, repeat testing of non‐disclosures leads to wasted resources and may distort programmatic indicators. Developing interventions that ensure appropriate psychosocial support are needed to encourage this population to disclose their status and optimize scarce resources.

Continuum of HIV Care in Rural Mozambique: The Implications of HIV Testing Modality on Linkage and Retention

“…This prospective cohort study consecutively enrolled patients with a new HIV diagnosis after HCT from trained counselors through VCT, outpatient PICT, and HBT between May 2014 and June 2015, before test and treat. 17 The cohort inclusion criteria were adults older than 18 years willing to participate, resident in the Manhiça District Hospital (MDH) catchment area, and receiving a first HIV-positive result. Pregnant and TB co-infected patients who were diagnosed with HIV at the antenatal clinic or at the TB clinic, followed a specific model of integrated care and were thus excluded.…”

National HIV testing and diagnosis coverage in sub-Saharan Africa: a new modeling tool for estimating the “first 90” from program and survey data

“…First, information on HIV testing in the past year is not used in model calibration due to evidence that this likely overstates the true annual testing rate [14,35] , perhaps due to "telescoping bias" in which respondents may inadvertently recall testing that occurred beyond the last 12 months [36] (see supplemental materials, Text S3). Second, information on self-reported awareness of HIV-positive status, even when partially adjusted for detection of ART among PLHIV who report not knowing their status, is not incorporated due to evidence of systematic nondisclosure of knowledge of status [9,10,[37][38][39][40][41][42][43][44] . In particular, non-disclosure of HIV status was found to be 1.4 times higher among individuals not on ART in Mozambique [38] compared to those on ART.…”

“…Second, information on self-reported awareness of HIV-positive status, even when partially adjusted for detection of ART among PLHIV who report not knowing their status, is not incorporated due to evidence of systematic nondisclosure of knowledge of status [9,10,[37][38][39][40][41][42][43][44] . In particular, non-disclosure of HIV status was found to be 1.4 times higher among individuals not on ART in Mozambique [38] compared to those on ART. This implies that adjustments for presence of ART metabolites may be insufficient, especially when ART coverage is low.…”

“…There are few empirical estimates of awareness status among PLHIV and, as described above, these estimates are likely to reflect substantial underreporting of HIV awareness [9,10,[37][38][39][40][41][42][43][44] . We therefore validated the F90 model by performing both in-sample comparisons (A) and out-ofsample predictions (B and C) of the proportion of the population ever tested for HIV (stratified by sex and HIV status).…”

Correlates of Undiagnosed HIV Infection and Retesting Among Voluntary HIV Testing Clients at Mildmay Clinic, Uganda

“…The proportion of testers who are retesters, that is, people who have been diagnosed with HIV but who test again, is often unknown and could artificially increase the yield of HIV positivity. In one study in Mozambique, for instance, 13.0% of HIV-positive voluntary counseling and testing clients and 29.4% of those testing through provider-initiated counseling and testing were retesters [10]. Efforts to diagnose 90% of HIV infections require that testing targets the right people, especially those most at risk.…”