Do No Harm: A Review of Social Harms Associated with HIV Partner Notification

Dawn Greensides; Kristina Bishop; Liz Manfredini; Vincent Wong

doi:10.9745/GHSP-D-23-00189

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TABLE.

Studies Included in Review of Adverse Events of Social Harm Associated with HIV Partner Notification Services

Author, Year	Country, Study Description, and Sample Characteristics	Index Clients Experiencing Social Harm, No. (%) and Type of Social Harm	Study Conclusions
Kahabuka et al., 2017²	Tanzania; cross-sectional study assessing the acceptability and measured effectiveness of PNS (passive, contract, provider); general population. Sample: 390 index clients (53% female).	0 (0) (The study did not actively follow index clients for IPV reporting.) No notification-related harms reported.	Partner notification could dramatically increase the number of previously undiagnosed PLHIV who learn their status and are linked to care.
Cherutich et al., 2017⁴	Kenya; cluster randomized control trial looking at safety and effectiveness of immediate versus delayed APNS; general population. Sample: 1,119 index clients (62% female).	2 (0.2) Type of harm not defined but determined to be related to passive notification not APNS.	APNS are safe and significantly increase HIV testing and case detection among partners of men and women testing HIV-positive in the clinical setting. Programs should consider screening clients to identify those at highest risk of IPV, counseling them, and referring them to specialized IPV management centers.
Tih et al., 2019⁵	Cameroon; review of programmatic findings of Cameroon Baptist Convention Health Services APNS program; general population. Sample: 976 index clients (no gender breakdown).	11 (1.1) IPV; 15 (1.5) loss of financial support; 61 (6.3) relationship dissolution.	The implementation of APNS as a large-scale public health program is feasible. APNS helped identify many PLHIV who did not know their status, who were then counseled on HIV prevention strategies if HIV-negative or referred to HIV care if HIV-positive. Social harms and IPV occurred infrequently after APNS.
Brown et al., 2011¹⁵	Malawi; comparison of patient referral, contract referral, and provider referral among clients with newly diagnosed HIV in an STI clinic setting; general population. Sample: 240 index clients (58% female).	2 (0.8) Relationship dissolution (n=1), police report (n=1).	Active partner notification was feasible, acceptable, and effective among STI clinic clients. Partner notification will increase early referral to care and facilitate risk reduction among high-risk uninfected partners.
Dijkstra et al., 2021¹⁶	Kenya; assess whether HPN services offered to GBMSM and TGW is acceptable, feasible, and safe; key populations. Sample: 17 index participants.	0 (0) No notification-related harms reported.	HPN services offered to GBMSM and TGW appeared acceptable, feasible, and safe.
Goyette et al., 2018¹⁷	Kenya; an analysis of a subset of index participants from Cherutich et al.⁴ to determine whether history of IPV modifies the effectiveness and risk of relationship dissolution associated with HIV APNS; high-risk women. Sample: 81 index clients who experienced physical or sexual IPV >1 month before enrollment.	2/1,119 (0.2) from Cherutich et al.⁴ APNS was not associated with physical or sexual IPV.	Among participants who had not experienced IPV in the last month but had experienced IPV in their lifetimes, the results suggest that APNS are an effective and safe partner notification strategy. Unrelated to APNS, those with a history of IPV had higher rates of relationship dissolution than those without a history of IPV.
Henley et al., 2013¹⁸	Cameroon; structured program evaluation of HIV partner services from ANC, voluntary counseling and testing, and inpatient facilities; general population. Sample: 1,462 index clients interviewed (73% female).	0 (0) No notification-related harms reported.	HIV partner services can be successfully implemented and are highly effective in identifying and linking people to care. Further investigation of the social harms and benefits associated with partner services is needed.
Kariithi et al., 2021¹⁹	Kenya; hybrid type 2 implementation science study to the effectiveness of APNS when integrated into routine HTS and evaluate the integration, implementation fidelity, acceptability, demand, and costs of the intervention; general population. This report is based on preliminary analyses. Sample: 1,724 index clients (100% female).	35 (2) Events were listed solely as “IPV,” including 32 relationship dissolutions.	APNS is an effective modality for reaching those who are undiagnosed. Final results of the study will help bridge the gap between clinical research findings and real-world practice and provide guidance regarding optimal strategies for APNS integration into routine HIV service delivery.
Klabbers et al., 2020²⁰	Uganda; mixed-methods study to understand the role of interpersonal violence in APNS for HIV; refugees. Sample: 195 index clients (no gender breakdown).	8 (4) 7 of the 8 involved sexual partners for whom a prior history of IPV had been reported Interpersonal violence defined as physical, sexual, or psychological violence, or deprivation and neglect, perpetrated by partners, family, or community members.	Fear and occurrence of disclosure-related violence are intertwined with cultural perceptions and associations regarding HIV. Future research is needed to prospectively evaluate how prior experiences of violence affect APNS participation and to investigate whether APNS is associated with subsequent violence.
Mutale et al., 2021²¹	Zambia; 2 parallel randomized trials to address gaps in male partner testing: HIV-positive and HIV-negative pregnant women from ANC setting randomized to receive APNS or secondary distribution of HIV self-test kits; ANC attendees. Sample: 100 HIV-positive women; 200 HIV-negative women.	1 (0.3) IPV, male partner abandonment, emotional and legal harm.	Adding HIV self-testing to PNS can expand the coverage of male partner HIV testing and help to identify those in immediate need of HIV prevention or treatment. Strategies relying on secondary distribution of HIV self-test kits can place an undue burden on pregnant and breastfeeding women. Given the challenges inherent to HIV status disclosure, resources are needed to minimize IPV and social harms and actively support those who face such issues.
Myers et al., 2016²²	Mozambique; pilot APNS program to assess acceptability, effectiveness, and safety in a large, urban clinic; general population. Sample: 206 index clients (79% female).	2 (1) Relationship dissolution (n=2) with loss of financial support (n=1). Additionally, none of the 173 partners interviewed reported experiencing social harm after their partner's diagnosis	APNS that relies on a community health worker labor force is acceptable to clients, safe, and effective in promoting HIV testing among the sex partners of newly diagnosed HIV-infected persons. While continued consideration of IPV is needed, this concern should not be an impediment to the scale-up of APNS.
Namimbi et al., 2020²³	Uganda; examination of the acceptability and effectiveness of APNS services in 2 urban health facilities; general population. Sample: 35,704 index clients (65% female).	354 (1) Post-notification GBV, not further defined.	APNS is a feasible and efficient approach for identification of HIV-positive cases and should be integrated into routine clinical services. However, there is a need to monitor trends and strengthen GBV services.
Nguyen et al., 2019²⁴	Vietnam; Implementation study to understand and assess the feasibility and effectiveness of implementing APNS as part of community testing services for key populations. Sample: 186 index clients (no gender breakdown).	0 (0) No notification-related harms reported.	As part of community-led HTS, APNS is an effective and feasible HIV case-finding strategy for key populations. It is critical that programs sensitize communities and health workers and prepare and train peer educators to provide the necessary support, messages, and tools to monitor and report social harm.
Plotkin et al., 2018²⁵	Tanzania; mixed-methods, cross-sectional study on PNS to analyze differences in success of referral for HTS among male vs. female and between married and unmarried index clients; general population. Sample: 390 index clients (53% female).	4 (1) Relationship dissolution.	PNS integrated into routine facility HTS is an effective way to reach previously undiagnosed HIV-infected individuals. Formative studies of gender dynamics and gender-related barriers and facilitators of partner notification for men compared to women, including studies of both attitudes to and experiences with IPV, are recommended either before partner notification programs are rolled out or associated with roll-out.
Rosenberg et al., 2015²⁶	Malawi; unblinded, randomized control trial to compare 2 strategies for recruiting male partners for couples HTS through ANC: invitation only versus invitation plus tracing; ANC attendees. Sample: 181 index clients (100% female).	3 (1.7) Relationship dissolution (n=2), emotional distress (n=1).	An invitation plus tracing strategy is highly effective at increasing couples' HTS uptake. Invitation plus tracing with couples' HTS could have many substantial benefits if brought to scale. Those concerned about partner anger, violence, or abandonment were less inclined to return with a partner. These findings suggest women can judge whether partner recruitment is safe.
Sharma et al., 2021²⁷	Kenya; assessment of APNS acceptability, reasons, and predictors of non-enrollment among females in an ongoing implementation project of APNS scale up; general population. (Same study as Kariithi et al.¹⁹) Sample: 839 index clients (100% female).	0.7% IPV; 1.9% relationship dissolution. (Numerical data not provided).	APNS has high acceptability among HIV-positive females regardless of age or testing history and can be safely scaled up among female index clients.

Abbreviations: ANC, antenatal care; APNS, assisted partner notification services; GBMSM, gay, bisexual, and other men who have sex with men; GBV, gender-based violence; HPN, HIV partner notification; HTS, HIV testing services; IPV, intimate partner violence; MSM, men who have sex with men; PLHIV, people living with HIV; PNS, partner notification services; STI, sexually transmitted infection; TGW, transgender women.