Community-based index case testing (ICT) among female sex workers and their sexual partners in Ethiopia: effective strategies for overcoming barriers

Background: Female sex workers (FSWs) in Ethiopia are disproportionately affected by HIV, with an estimated prevalence of 23% (national MARPs Survey, 2013, EPHI), compared to a national prevalence of 0.9% (EDHS, 2016). While index case testing and assisted partner notification (ICT/PNS) is recognized as an essential component of the HIV response, it has until recently been considered less feasible among FSWs, because there is a perception that their sexual networks are unstable and that FSWs are reluctant to disclose their partners names. PSI, under the USAID-funded MULU Activity, has developed successful approaches for ICT/PNS with FSW in two of the highest burden regions in Ethiopia: Addis Ababa and Amhara.  

Method and Result MULU launched community ICT/PNS as its key HIV case finding modality in July 2018. The project applied various techniques to overcome barriers to disclosue and HIV testing uptake included: use of skilled nurses both to elicit contacts from FSW and to reach out to clients – hired staff with appropriate skills and attitudes,  reaching out to clients with a non-sensitive platform– free health services at Drop-in-Centers, and planning for repeated contacts with partnersthe program utilized anonymous and disguised testing techniques for elicited contacts. Nurses have been trained to use a daily microplanning tool on number index clients counseled, number contacts elicited, number contacted and tested and number tested. Standard operating procedure by all community level staff for effective interpersonal communication between client and health provider was implemented.  

Lessons Learned: In FY19, 3,471 individuals (FSWs and their sexual partners) were tested through ICT/PNS, with 721 new HIV positives identified (20.8% yield). This significantly exceeded HIV case finding through other modalities: VCT (2.9% yield); mobile (3.6%) and PITC (2.8%). An average of 3 contacts per index FSW were elicitedEffective interpersonal communication by skilled health providers, fidelity to the daily micro planning tool , as well as teamwork, has paved the way for active tracing of elicited contacts 

Conclusions: ICT/PNS is the most effective and efficient case finding modality among key populations to be scaled up at all HIV high impact HIV hotspots.