Uptake of HIV Testing Services through Assisted Partner Notification (APN) among Men in Wakiso District

List Of Abbreviations

MOH: Ministry of Health

APN: Assisted Partner notification

HIV: Human Immunodeficient Virus

HTS: HIV testing services

IRB: Institutional review board

WHO: Word Health Organization

Introduction

Globally, there has been positive strides to scale up HIV testing for people who contract HIV. However, of the 38 million people estimated to be living with HIV (PLHIV) globally in 2020, about 16% were thought to be unaware of having contracted the virus [1]. Recently, Assisted Partner Notification (APN) services have gained attention and increased implementation as an innovative method to mitigate this challenge [2]. Assisted partner notification services have been implemented as a public health intervention to identify individuals most at risk of HIV infection, screen and test those who consent and link those who are HIV positive to treatment [3]. Typically, partner notification can be provided using either passive or assisted approaches. Passive partner notification occurs when HIV-positive clients are encouraged by a trained provider to disclose their status to their sexual and/or drug injecting partners by themselves, and to also suggest HIV testing services (HTS) to the partner(s) given their potential exposure to HIV infection [2].

While an assisted approach is one in which, with the consent of the HIV-positive client, a trained provider confidentially contacts the person’s partner(s) directly and offers the partner(s) voluntary HIV testing [4].

Globally, HIV testing services (HTS) uptake and coverage for men continues to be lower than for women with nearly 64% of adult HIV diagnoses reported in low and middle-income countries [5]. Whereas HIV testing is widely offered to women attending antenatal clinics, there are fewer opportunities for men to get tested. In African countries, no more than a third of men take an HIV test during their female partner’s pregnancy, but there are particular advantages to engaging with men at this time [6]. According to UNAIDS report, men and boys in Sub-Saharan Africa living with HIV were 20% less likely than women and girls living with HIV to know their HIV status, and 27% less likely to be accessing treatment [7]. Additionally, African men account for the majority of deaths from HIV and AIDS related illnesses, despite having higher burden of new HIV infections amongst women aged 15 and older, representing 59% of the 980, 000 million new adult HIV infections in 2017 [8]. This clearly demonstrates vulnerability of men and hence reaching more men with HIV testing through APN and treatment services is not only critical to breaking cycles of HIV transmission and reducing HIV incidence among young women, but also reducing HIV related mortality. Assisted partner notification services significantly and safely increases the uptake of HIV testing services (HTS) for partners of newly diagnosed PLHIV and can improve caseâ?finding and linkage to care [3]. However, various barriers have been reported to hinder its full uptake such as fear for stigma and discrimination and missing or incorrect partner contact information [9].

In Uganda, APN was introduced in 2015 and was recommended as part of a comprehensive prevention Package [10]. A pilot study conducted in Kiboga district demonstrated that partners were effectively notified and tested for HIV, and among partners tested, 38% were HIV-positive [11]. Building on this success, the Uganda Ministry of Health committed itself to rolling out APN nationwide,replicating implementation in all other parts of the country. In Uganda, APN acceptability is relatively good at 67% with high yield of 29.7% within the rural and peri-urban centers in Uganda [12]. However, 40% of the men notified by their female counter parts did not access testing services at the notifying facility in Wakiso District with low yield of 1.4% compared to other Districts in Uganda [12]. In spite of the achievements by the Ministry of Health Uganda to improve partner notification through APN, a substantial testing gap for men through in Wakiso District remains. Therefore, there is need to explore more about the best partner notification strategies for men and methods for HIV disclosure in Wakiso District. This is the gap the study seeks to cover

Methods

Study Design, Setting and Population

This study utilized a narrative study design and was conducted in three sites in Wakiso district. The study sites included three high volume and accessible health facilities namely Entebbe Regional Referral Hospital, Kajjansi and Wakiso Health Center IVs which were supported by Mildmay Uganda programs. The study population included male partners of index female HIV positive clients that were notified of possible HIV exposure and documented in the health facility APN register, and the health workers from the selected health facilities.

Sample Size and Sampling Procedure

Male partners of index female HIV positive clients that were notified of possible HIV exposure and documented in the health facility APN register were recruited in this study. The APN register is a primary paper-based national tool in Uganda used for collection of routine HIV testing services through APN. It captures the details of the index HIV positive clients and all the elicited sexual contacts with details of their phone contacts and/ or physical location, notification status, HIV test and the HIV test result for those that received the HIV test among other parameters. The study engaged facility-based APN focal persons, who are professional counselors or health workers providing HIV testing services, successfully to recruit study participants in collaboration with the research assistants. This resulted in a total of 18 study participants.

Data Collection and Management

Data were collected through in-depth interviews, conducted in either English or Luganda, depending on the participant’s language preference. An interview guide specifically developed for this study was used to ensure consistency across interviews. Each interview lasted between 45 and 60 minutes. All interviews were audio-recorded, and the recordings were transcribed verbatim. In addition to the recordings, field notes were taken to capture contextual observations and non-verbal cues.

Data Analysis

Field notes were inserted in relevant sections of the transcripts to clarify the context in which statements were made, as well as to clarify statements resulting from poor sound quality. All the transcripts were loaded into NVIVO v12 for analysis. Data analysis was conducted thematically following the six steps of thematic approach [13]. Data was coded and the codes developed were synthesized and grouped into exhaustive themes. The codes were developed progressively and in an inductive manner. Important reported quotes from the interviews were highlighted and marked for referencing.

Results

A total of 16 males were recruited for this study. Half of the participants were notified and agreed to undergo HIV testing, while the other half were notified but declined the test. Additionally, two healthcare workers were included in the study.

Three themes were developed with corresponding nine sub- themes. The themes included perception about HIV testing, reactions to notification and preference of notification approaches as summarized in Table 1 below.

                                                                                      Table 1: Thematic Summary

Theme 1: Perceptions about HIV Testing

Sub-Theme 1: Perceived Benefits

Table 1: Thematic Summary They expressed concerns around a lack of awareness about APN and pointed out that engaging in something they do not Participants perceived HIV testing under APN to be beneficial due to its privacy and confidentiality, convenience and efficiency, personal empowerment, increased detection of infection, ease of use and potential for saving lives. Participants believed that APN is beneficial for increasing the detection of infections, leading to early treatment initiation and improved outcomes. In addition, participants recognized the opportunity to test themselves and their family members in the comfort of their homes in the event that the health worker visited them. The freedom to perform the test at a chosen time and place, was viewed as advantageous and time saving. Furthermore, HIV testing was noted to help couples protect each other once they know their status, promotes HIV prevention practices to avoid infection and plan for the life after knowing their HIV status.

“HIV testing with APN helps you to protect your partner. In case both of you are negative, you will know that you have to remain negative. It also helps you to know your HIV status, contentment about your HIV status, helps you protect yourself from getting HIV after knowing you are negative” (IDI-E-02; IDI-E03; IDI-K-03).

It is convenient to perform the test and to discover one's HIV status early, allowing for early medication initiation. When the nurse visits me at home, I have the opportunity to test at my own comfort with utmost confidentiality” (IDI-E-05; IDI-W-O3; IDI-K-05).

Sub-Theme 2: Perceived Harm/Costs

Respondents reported their perceptions on possible harm or costs associated with HIV testing services.

They expressed concerns around a lack of awareness about APN and pointed out that engaging in something they do not understand raises doubts especially when they are called to be notified of possible risk of exposure. Also, it was expressed that partner notification by a partner without the presence of a medical professional at home could yield more harm than intended purpose. This was typically associated with the likely disturbances that could arise from knowing that one’s partner is HIV positive such as domestic violence, stress, anxiety, heart attack, family breakage, shame, fear to mention but a few. They highlighted the need for professional guidance and support during such situations.

“Most men believe that HIV acts fast when you get to know your status, and when they disclose to you that you are positive, you develop depression, heart attack, therefore it shortens your life span” (IDI-E-02; IDI-W-02, IDI-E-04)

“If I happen to test from home and for example that day I was stressed with many other things and I happen to test positive at home, I might do something scary out of anger like suicide of beat the person who infected me” (IDI-W-03, IDI-E-05)

Health workers emphasized the above effects since knowing one’s HIV status could cause fears, anxiety and doubts including depression. Furthermore, this could cause marriage domestic violence and worse still it could lead to early deaths especially among those that turn HIV positive.

Sub-Theme 3: Perceived Drivers/Facilitators

The participants reported that the desire to know their status was a major driver to accessing HIV testing services. It was mentioned that most of them want to know their HIV status and plan for their lives for better living. Other factors that push men to accessing HIV testing included: having many sexual partners, deterioration of health status and suspicion of extra marital affairs by the female counter parts among others. Relatedly, employment and travel requirements to certain destinations especially amongst those seeking jobs outside Uganda since HIV status was considered a prerequisite for possible considerations. This was noted to compel some males to undertake HIV testing since they wish to benefit from such opportunities. Health workers added that much as some people go for HIV testing to help them know their HIV status, others do so because they have more than one sexual partner and yet may not know their HIV status.

“Curiosity to know their HIV status stand can make people test for HIV. For instance, someone might be living a healthy lifestyle and all of a sudden, his health starts deteriorating. He starts losing weight and therefore forced to go and test “(IDI-K-04, IDI-E-02)

Sub-Theme 4: Perceived Barriers

• Fear to know their status

Participants’ own perception of their physical health was the overarching barrier to uptake of HIV testing. They measured good health in terms of functional ability and not the clinical presence of HIV infection. This was cited as a major hinderance to HIV testing thus preference to stay with unknown HIV status. Health workers emphasized that some people prefer not to know their HIV status because of fear of having a positive HIV test result.

• Psychological burden of living with HIV

Whereas some respondents acknowledged that the HIV-positive status of their partners meant that they too could be infected, paradoxically, the perceived psychological burden of confirming that they also had HIV undermined the uptake of HIV testing. They preferred to live without knowing their HIV status. They perceived knowing one’s HIV status as having a deleterious mental health effect, which in turn, was perceived as hastening deterioration of physical health;

“While others do not do so because they don’t want stress if positive. So, they would rather not know their HIV status and live longer than knowing and living a depressed life full of worries” (IDI-E-03)

“Others prefer not to test because they want to avoid depression or fear of divorce in case results are discordant and fear of lifelong treatment in case one turns positive” (IDI-E-04).

• Self-stigma

It was established that stigma associated with HIV can lead to feelings of shame, fear of disclosure, isolation, and despair. These feelings can keep people from getting tested and treated for HIV. Both male partners and health workers reported that the misconceptions of the society, myth and stigma prevents them from testing for HIV;

“Stigma, some people fear other people to know about their status because when they go for the testing, they think their status will be told to the public. That’s why some people feel not to tell or to go for the testing” (IDI-K-01; IDI-K-05; IDI-W-03).

• Long term medication

Some male partners were worried about taking the drugs for the rest of their lives. So, they feared getting test because they were not prepared to start treatment if found to be HIV-positive;

“…the fear of swallowing medications if someone turns out HIV positive, while others are afraid to take that medication and they wait to first become weak and then they visit the health center (IDI-K-04, IDI-K-06).

• Fending off blames/accusations

Non-uptake of HIV testing by male partners was also meant to fend off blame or accusations of being responsible for the HIV infection. This was most likely in distrustful relationships, in which partners would blame their HIV-positive partners as responsible for their HIV infection.

Therefore, by not testing for HIV, some study participants pointed out that they were able to maintain moral credibility in their marital relationship, as they were then seen as not responsible for HIV infection;

“Sometimes the best way to avoid problems with women is not to test. They cannot blame you for HIV because you have not tested even if deep down your heart, you know that you may be the one who contracted HIV and then infected your wife” (IDI-E-02).

Theme 2: Reactions to Notification

This theme describes the immediate reactions and final decisions made by the male partners after they were notified about the results of their sexual partners.

Sub-Theme 1: Response to Notification

Respondents reported mixed reactions in response to the notification. Whereas, some reported bad and scaring experience characterized by development of fear, anger, and disbelief in the communication received at the time, others took it calmly. Respondents expressed that they felt afraid and even developed thoughts of being conned.

“I told the health worker that she had called a wrong number. At first, I wondered why would they suspect me of all people? In fact, I even developed a thought may be this person was a conman (mufere as it is termed locally) and wanted to cone me” (IDI-E-04).

“When she (wife) told me I was afraid, but then I told her that let me first come back home and we discuss it in person. When I came back, I was very afraid. I even reached an extent of getting diarrhea. I was too afraid that my wife had the virus” (IDI-K-05).

Sub-Theme 2: Immediate Feeling After Notification

Many of the respondents developed bad feelings immediately after notification. The reactions included regrets for being born into this world, anger and even suicidal thoughts. The situation also threatened marriage stability with some people experiencing periods of no communication within the homestead and others even regretting their marriage;

“I felt so bad and I even started regretting why I was born on earth and I felt that I should just hang myself, but that couldn’t work because I have a family, I have children. So, I felt so bad but still I insisted that I can’t go to the hospital (IDI-W-06).

Sub-Theme 3: Reaction to Partner HIV Results

• Took an HIV test

After the notification about the partners’ HIV results, some of the respondents had to also opt for testing in order to know their status as well.

• Fear/panic

Fear, panic and hopelessness were felt immediately after their notification, especially those whose partners had tested positive. The worry and fear were all about how to take the life-time medication and how to live an HIV positive life while one expressed that his sexual partner would have rather notified him by herself rather than through a health worker;

• Psychologically tortured

Psychological harm was another effect that resulted from partner notification. One of the respondents described how he almost had a mental health crisis over the positive results of his sexual partner while another one expressed being sleepless for days;

“I even wanted to run mad, I don’t know, I can’t tell. I was crazy, panicking and the pressure was high” (IDI-E-01).

“I was sleepless. I had no rest at all because every time I was listening to that voice which came unto me to go for testing, I lost the guts for sleep. I lost sleep, I felt stressed and I thought I should ignore work because I felt like the end of age has come to pass, like I have no future anymore” (IDI-W-06).

• Relief for disclosure

Whereas some respondents reported being ‘shocked’ with the disclosure, others already knew their HIV positive status but were afraid how best to inform their spouses about their status. One respondent expressed his relief since the wife had finally known his status;

“I felt good since my wife had indirectly gotten to know my HIV status and I got to know hers as well” (IDI-K-04).

“I was surprised to get a call from a health worker telling me to go for an HIV test yet I was already on HIV medication” (IDI-K-05).

• Feeling of betrayal

Some of the respondents who were notified, felt betrayed by their partner’s HIV results. They described the betrayal in terms of allowing the health workers to notify them rather than the partner themselves, which to them showed lack of trust and breach of confidentiality.

Theme 4: Preference of Notification Approaches

This theme explored the notification approaches used by the health workers and female partners to notify the male partners about their HIV results. It further looked at the satisfaction of these approaches by the male partners and their preferences amongst the approaches used.

Sub-Theme 1: Satisfaction with the Approaches Used

Respondents had mixed reactions on the satisfaction with the notification approaches used. Some respondents expressed their satisfaction with the way they were notified, highlighting that the presence of the health worker gave them confidence since they were able to get all the information they needed. However, others were not contented with the approach used. The use of phone call to notify them was not appreciated by some respondents highlighting that their moods at the time the call was made could not be favorable to receive such “bad” news. In addition, the phone call created some suspicion about who was calling since they did not have their numbers. Some participants questioned how the health workers obtained their contact information, while others expressed doubt because their female partners had not mentioned it to them.

“Phone calls should be modified or improved by telling us the partners to go for an HIV test than telling him that I am at risk, that your sexual partner is HIV positive and may have infected etc " (IDI-E-03).

“Personally, I wouldn’t advise the health workers to call people who are suspected to be having HIV using phone directly, because some people are depressed. You don’t know the person you are calling. You might be calling somebody who is drunk and by disclosing to him that he is positive, he can end up taking his life, hanging himself” (IDI-E-02).

Sub-Theme 2: Preferred Notification Approaches

Joint notification was the most favorable notification approach and this was highlighted by the majority of the respondents. Health worker notification was the second favored notification while self- notification was the third preferred method of notification.

“Joint notification is better ie by telling wife to come with the partner and be tested together then we get notified, Because It would appear as if we are getting to know our HIV status for the first time together from the health workers” (IDI-E-04, IDI-K-03, IDI-W-01, IDI-E-02).

Discussion

This study found out that the male participants reported various benefits to HIV testing which included privacy and confidentiality, convenience and efficiency, personal empowerment, increased detection of infection and ease of use. It also increased the detection of infections, leading to early treatment initiation and improved outcomes. In addition, HIV testing helps to know the HIV status for healthy living and protection of their partners from infection. This was consistent with the findings of similar study which reported that HIV testing was associated with highly favorable outcomes, including decreased late diagnosis, lower HIV-related mortality, and lower all-cause mortality, among people diagnosed with HIV infection [14]. In addition, another study conducted in Europe reported that early knowledge of HIV status allows for timely linkage to medical care and treatment that can reduce morbidity and mortality and improve quality of life [15]. The current study also identified mistrust and suspicion of partners having extramarital sexual encounters as another push for HIV testing. In line with these findings, a recent study conducted in Malawi revealed that some participants perceived HIV testing as a strategy to substantiate their own or their partner’s faithfulness [16].

The current study identified barriers to HIV testing such as fear of positive HIV test results and the likely consequences such as anxiety, feels of having a heart attack, depression and suicide which in turn, could eventually lead to marriage breakdown and early death. In addition, self-stigma was also reported as a barrier to HIV testing leading to feelings of shame, fear of disclosure, isolation, and despair. These findings are in tandem with findings of the study conducted in USA which found out that most people feared to go for HIV testing to avoid the consequences of HIV positive test results such as fear, anger, and a sense of being overwhelmed [17]. The same study reported that after discovering that they were HIV positive most participants felt helpless, sad, and anxious about their illness, despite knowing that HIV can be effectively treated, while others developed negative thoughts related to the stigma of an HIV diagnosis [15]. This study also found out that males feared to take HIV tests to fend off blame or accusations of being responsible for the HIV infection. The participants perceived that not testing for HIV as means of maintaining moral credibility in the marital relationship. These findings were consistent with the findings of a similar study where participants consistently expressed their fear of consequences following HIV testing and one of the feared consequences was blame for being unfaithful by their partner and in society more generally and breaking-up of the relationship [18]. The fear for blame of unfaithfulness has also been reported in other studies conducted in Uganda where suspicion of infidelity was a key reason for some individuals in a relationship to go for HIV testing [19-21]. The current study further found that fear of taking life-time medication of ARVs hindered them from taking HIV test. This was supported by the findings of another previous study which reported participants still feared to take HIV treatment despite the increasingly wider availability of life-saving ART [22].

In the current study, the key players in the APN were health workers and female spouses. In addition, most men rated the process of APN notification as good, since it allowed couples to notify each other after confirmation of their HIV status with the engagement of health workers. The major means of notification included physical clinic visits and phone calls due to confidentiality and anonymity matters. Moreover, it was reported that participants developed bad feelings immediately after notification. The reactions included regrets for being alive and thought of committing suicide. The situation also threatened marriage stability for some people where partners took time without communicating with each other, even regretting why they got married. These findings were supported by other previous studies which reported that the aftermath of an HIV- positive diagnosis was filled with immediate emotional reactions and potential long-term consequences such as shock, shame, fear and worry [18]. The same study reported that participants expressed fear and worry regarding the public and societal reactions to their HIV status leading to self and anticipated social stigma [18]. Similarly, the study found out that participants preferred physical notification where the spouse together with the health worker jointly notified them. This was consistent with the findings of other studies that have applauded joint partner notification as advantageous since it requires that only sexual partners be notified that have been in contact with a sexually transmissible infection by the trained health worker and hence considered to be a confidential process [22,23]. Another study reported that joint partner notification is preferred because details of the index cases are known only to the health professionals treating them and their sexual partners but not divulged to disease notification systems [24].

Conclusions

This study demonstrated that HIV testing was perceived to be beneficial since its one way that participants could get to know their HIV status and hence plan better for healthy living with their spouses. However, some barriers such fear for early death, life-time treatment, family breakdown, blame, anxiety, stress, anger and stigma hindered the uptake of the services. Joint notification was the most preferred method by male participants since it ensured that both the female spouse and health worker were present at the time of notification. Therefore, there is need for sensitization of males about HIV testing to eliminate the fears that hinder their uptake of the service. In addition, joint notification should be encouraged since the health worker is able to counsel the male participants on HIV related matters hence encouraging them to take the service.

Study Limitations

When interpreting the study results, it is important to consider the following limitations: The study was conducted in urban and peri- urban settings, where healthcare systems may be more developed, and participants' experiences may differ from those in rural areas. As a result, their opinions might not fully represent the perceptions of beneficiaries in rural settings. Additionally, this subjectivity may lead to alternative interpretations of the findings. Since this study follows a qualitative narrative research design, its findings cannot be generalized beyond this context. The results are also limited to the perceptions and experiences of the respondents, based on their descriptions. Furthermore, establishing causal relationships is challenging with this approach

Declarations

Funding

The funding for this study was provided by the micro research foundation

Author Contributions

The authors contributed to this study as follows: Authors SE, MO, EN, VN, CD, and AS played a leading role in conceptualizing the study. Authors SE and EN led the data collection, analysis, and writing of the original draft, and were responsible for the initial analysis and methodology. All authors contributed equally to writing, reviewing, and editing the manuscript.

Availability of Data and Materials

All the data and material for this study are available with the corresponding author on request.

Acknowledgement

We extend our gratitude to Micro research foundation, Mildmay Uganda and Wakiso district local government whose support and partnership enabled the successful implementation of this study in Wakiso district.

Ethics Approval and Consent to Participate

Ethical clearance was obtained from the Mildmay Uganda Research and Ethics Committee and from the Uganda National Council of Science and Technology. Before conducting any interviews, participant consent was obtained at enrollment with all participants providing their informed consent to participate in the study. A detailed explanation of the study's objectives and procedures was provided to each participant. Afterward, they signed the informed consent forms. Participants unable to sign the consent form affixed their thumbprint. Additionally, this study adhered to the Helsinki Declaration.

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