Reaching men through index testing can speed path to first "90" -- and epidemic control

To control the global health threat of HIV by 2030, according to UNAIDS, these goals must be reached by 2020: To diagnose 90 percent of all HIV-positive persons, provide antiretroviral therapy for 90 percent of those diagnosed, and to achieve viral suppression for 90 percent of those treated. The initial step in achieving this aim is, obviously, to reach and diagnose the first 90 . . .

Mahua Mandal The following is a guest post by Mahua Mandal, PhD, of MEASURE Evaluation Although many HIV prevention programs target adolescent girls and young women, data from Zimbabwe suggest that an important, and perhaps faster, way to reach 90 percent of people living with HIV being aware of their infection -- the first 90 of UNAIDS 90-90-90 goals --  is to target men. In most countries, however, men are less likely to have ever been tested for HIV than are women and are less likely to visit health clinics. While women are more likely to seek care, especially during pregnancy and for child immunizations, men are more likely to assume they don't need medical care. This leaves the question: If men do not regularly show up at clinics, how can they be reached? A recent brief from MEASURE Evaluation, funded by USAID and the United States President’s Emergency Plan for AIDS Relief, reviewed and analyzed index testing data from Zimbabwe and Tanzania in 2018. Data from Demographic and Health Surveys from 16 countries showed that, on average, only 54 percent of people living with HIV knew it. This is where index testing is useful, the brief said, noting that in Zimbabwe, "two-thirds of index clients were female, but a higher proportion of male index clients listed contacts who tested positive for HIV." Paying attention to men, the brief noted, "is a crucial part of reaching the first of the 90-90-90 targets…” Index testing starts when a service provider asks individual clients newly diagnosed with HIV to list all sexual or injection drug-use partners within the past year, as well as biological family members. If the client consents to name contacts, those individuals are traced, informed that they have been exposed to HIV, and offered voluntary testing. Index testing increases the proportion of HIV-positive partners who are tested and diagnosed, compared to “passive referral,” which refers to HIV clients being encouraged by a trained provider to disclose their status to their sexual partners or drug injection partners and also to suggest that those partners seek HIV testing.* This last fact may be because female clients are likely to name men as contacts and those men are less likely to appear at a clinic for testing; whereas male clients are more likely to name women as contacts and women traced are more likely to come to a clinic. As one of the authors, I see the practical implication of the finding: HIV program design should use strategies that include and target men. Men should be encouraged to accompany their partners to antenatal care visits where clinic workers can offer them HIV testing and refer them to care if they test positive. Male testing also should be integrated into other types of health programs that include family planning, while health communication campaigns should directly target men to increase male participation. Engagement of religious leaders, peer-to-peer interactions -- especially among younger men -- and media ads also intercept, influence and include men. For more information, visit www.measureevaluation.org *An analysis in Tanzania found that following notification about 57 percent of listed contacts came to a clinic for testing. It also found that the successful referral of recent partners was more than double for male clients compared with female clients. Mahua Mandal, PhD, is a monitoring and evaluation specialist at MEASURE Evaluation, the University of North Carolina at Chapel Hill.