Overview of Study Outcomes
Figure 2 depicts the number of HIV-positive individuals approached, enrolled index clients, and listed and successfully referred sexual partners by sex. Of the 653 newly diagnosed HIV-positive men and women, 390 (46.9% males and 53.1% females) were enrolled as index clients. The enrolled clients listed 439 sexual partners (224 female partners and 215 male partners). No index clients listed same-sex sexual partners. Of the listed partners, 249 (56.7%) were successfully referred (i.e., came to a study facility following the notification). Overall, 63.4% of the female partners and 49.8% of the male partners were successfully referred. Among partners who were successfully referred to the facility, testing was close to universal for both female and male partners (96.5% and 95.3%, respectively).
Enrollment and Eligibility
Enrollment and eligibility information is presented to augment understanding of the type of client seen in a typical service delivery setting who may or may not be interested or eligible for partner notification. Of the 653 HIV-positive individuals who were screened, 31 were ineligible since they were under 18 years of age, and 232 did not enroll in the study for other various reasons. The most frequently reported reason for non-enrollment was not having had a partner in the past 24 months (n = 167), followed by being distraught or decline to participate (n = 36), or other reasons (n = 13) (Fig. 3).
Table 1 presents demographic information on the 390 (enrolled) index clients and on the 232 newly diagnosed HIV-positive people above the age of 18 who did not enroll. Married people were much more likely to enroll in the study than unmarried people (76.2% vs. 24.8%).
Type of Referral and Relationship Status
Almost all index clients (91.6%) chose passive referral, meaning that they contacted their listed sexual partners themselves (data not shown). Table 2 shows the tendency of index clients to list multiple partners and success of partner referral, by sex and marital status of the index clients. Among index clients, 47 listed more than one sexual partner: in multivariate analysis, male index clients were 6.2 times more likely to list more than one sexual partner than female index clients. In multivariate analysis, male index clients were 2.2 times more likely than female index clients to be successful in referring at least one partner. In multivariate analysis, married index clients were 2.5 times more likely than unmarried index clients to be successful in referring at least one partner.
Characteristics of Sexual Partners
Table 3 presents demographic information on the 249 successfully referred sexual partners. Successfully referred male partners tended to be older than female partners (27% vs. 9.2% were 45 years and above) (p < 0.00). While the majority of all partners (66.3%) had primary education, more male partners (73.8%) had completed primary education than female partners (60.6%) (p = 0.012). More of the male partners were formally employed than female partners (14% vs. 2.1%) (p < 0.000).
Table 4 presents successful referral and HIV status of listed sexual partners by the sex, marital status, and relationship status of the listed sexual partners. In multivariate analysis, female sexual partners were 1.5 times more likely to be successfully referred than male sexual partners, and married partners 3.7 times more likely than unmarried. Partners who were listed as being a girlfriend/boyfriend or casual sex partner were less likely to be successfully referred: 30.4% of boyfriends/girlfriends and 33.9% of casual partners were successfully referred, compared to 72.5% wives and 54.7% of husbands.
A total of 46 participants (26 index clients and 20 sexual partners) were interviewed as part of the IDI’s. Half were male and half female. Table 5 presents demographic characteristics of the IDI participants.
Language Used in Notifying Partner
Many of the index clients interviewed chose to use indirect language (i.e., avoided direct reference to HIV testing or avoided disclosing that they had been tested) when notifying and referring their partner. Multiple male index clients interviewed told their partners that the health care provider would not reveal their test results unless the partner came for testing as well. Some female index clients pretended they had not yet tested, or claimed to have a health problem for which their partner’s assistance was needed.
Index Client KRH-068/no trace/M/40/Married: To be honest… I did not want to tell her. I tried to convince her, by telling her that “I will not get my results until I go with you,” She wanted to know why do others go there and get their results? I told her that is for those who are not married. I insisted that I have gone there but I could not get the results without going with her: that is where we ended our conversation.
Index client MTH203/trace/F/39/Married: I called him, I told him that you are needed here; he asked “what for!?” I told him to come because they have told me that I have anemia, “You have to come, for you to get the information by yourself; they need to tell you many things,” so he agreed to come…. [To what extent was the way you used effective?] Very effective… .
Partner IDDH-020-1/-ve/M/19/Single: (Liked the indirect method of notification his partner used) I think it was a right method, because the way she told me she has a problem without telling me what it is, made me anxious to know what is it.
Some index clients, however, told their partners directly that they had tested positive during the referral to HTS. Generally, partners who were informed directly expressed appreciation for the candid disclosure:
Partner MTH-119-01/+ ve/F/30/Married: “I was encouraged when he told me: “Myself, I am affected so I ask you to go and get tested”…. I was encouraged because he told me openly.”
Index client MTH-132/trace/F/29/Living together: I told him that I have tested already and the results are known…. He told me that what I did was good. He told me yes, it’s true we both need to go for test; I need also to know my status.
Index client IDDH-009/M/age/Unmarried: (Female partner suggested index test due to continuing illness. He was afraid of her reaction to the results. The second time he talked to her, he told her that she needed to come to the facility to talk to the health care provider. When she guessed that he was positive, he hung up the phone.) She phoned me back and said, “Don’t worry, if you’re positive just tell me. You should not be afraid.”
Barriers to Referral of Partners for Testing or Partner Notification
Time/Distance as a Barrier
Many index clients made contact with their partners over the phone. Index clients—those who were successful in referring partners as well as those who were not—mentioned barriers involving time and geographical distance.
Index client MTH122/trace/M/42/Married: [Why were you not able to remember most of your partners?] Because these people, I was with them in a far off location from here, I think I got this problem [HIV infection] not here, but there in Madibira. That’s why I was not able to remember all of them.
Some female index clients noted that male partners whose jobs required frequent travel were particularly difficult to locate and/or refer.
Bad End or Long Duration of Separation as a Barrier
Male as well as female index clients were reluctant to get in touch with former partners who were suspected, or were known, to have married, or with whom the relationship had ended poorly.
Index client KRH-042/trace/F/43/Married: [For the partner you could not convince to come for testing, what do you think was a major obstacle?] I could not, because those [relationships] are from a long time ago, since the year before last year. Would you call someone who you had broken up with? The person has a wife or wives and you broke up with a fight. You do not call each other! Why would you call such a person?!
Index client IDDH-009/trace/M/36/Married: As I told you earlier we separated, not in a peaceful way, it wasn’t in a manner that we could later look for one another. She moved on and got married, and had a child with someone else.
Absence of Symptoms as a Barrier
Many index clients reported that either they or their partners did not feel they should test for HIV because of a lack of symptoms of opportunistic infections. In some cases, the presence of symptoms prompted testing-seeking behavior in the partner; in some cases it motivated the index client to seek testing. Alternatively, the absence of symptoms served as justification for the decision not to test, for male partners in particular.
Index client MTH-107 no trace/F/26/Married (bar worker): They [my partners] have refused; I am still in the process of mobilizing them to come [for testing]…. Both replied that they are not ready…. The first one said he is confident that he is healthy, and the other one… he is not ready to test until he gets sick.
Symptoms were mentioned in numerous cases as the reason that the index client sought HIV testing.
Index client MTH-148/no trace/M/54/Married: So those diseases were troubling us, she was complaining sometimes about back pain, sometimes stomach ache. Sometimes we feel hungry, she cooks but we can’t eat…. She said, “My husband, when you go there you should check this [HIV].”
Index client IDDH-007/trace/F/37/Married: I got that courage because I was sick… and it seems this was the root cause. That is why I had the courage to talk to him. I said I can’t keep on being afraid, as am already infected and I am the one suffering.
Type of Relationship and Success in Referral
When index clients discussed casual or multiple concurrent partners, they characterized this as difficult for partner notification or expressed reluctance to engage in partner notification:
Index client MTH-090/no trace/F/28/Single: [Were you able to remember all of the partners you had within 24 months?] Really I can’t recall them…. Even if I recall them it won’t be easy for me to give them this information… because others have their own families already. We just met as “friends for a day.” You can meet someone when traveling or at work. If you met someone just for a day, do you think you can tell him this matter?
Index client MTH-060/no trace/M/30/Married: So I told them [my partners] that I have checked and I have been found with problems, please you must also go for a checkup. One of them said you have told me a very important thing. But another one felt I did something wrong. [What did she say?] She said what is yours is yours and what is mine is mine…. [Are you living with one of those three or they are just sex partners?] These are my sex partners, apart from my wife. I told my wife, but she did not say anything.
Multiple women brought up the issue of having a child with their partner. If a woman did not have a child with her male partner, this was often presented as a less serious relationship or as a problematic relationship with poorer success at partner notification. The theme in this quote was echoed in multiple other female index clients’ quotes:
Index client IDDH-011/no trace/F/29/Single: [What stopped him from coming into test?] Maybe he wasn’t interested in me…. He once told me the way I am sick, “I’m tired of spending my money, because you mean nothing,” because I didn’t bear him a child…. [Therefore, the main reason is a child.] Yes, he said he can’t take care of me every time because I don’t have a child.
Two female index clients indicated that they were engaged in commercial sex as a livelihood, one married and one unmarried. These women suggested that commercial sex work made partner notification very difficult.
Index client MTH-107/no trace/F/26/Married: [Do you think you can remember all of your partners within the past 24 months?] No, I can’t remember them. [Why?] Because of my working environment… in a bar. There are those you see them once and never see them again. Up until now I only have two whom I have here with me.
Negative Outcomes to Partner Notification
None of the index clients or partners interviewed reported being physically hurt as a result of their participation in the notification or referral process, and none of the participants in the qualitative assessment reported cases of IPV. However, four of the interviewed female index clients (one married and three unmarried) mentioned, at the time of the interview, that the HIV diagnosis resulted in the end of the relationship.
KRH-053/trace/F/23/Single (engaged): We entered in the counseling room and had a health checkup. Then he tested and my partner was found clean, while on my side there was a problem. After that we decided to have a meeting…. I told him finally, I’m ready to break up and you are free to marry another woman if you decide…. And that was the end of the relationship.
MTH-090/no trace/F/28/Single: I don’t know what he is thinking but what I know is one day he will go to test voluntarily. Right now is like I am forcing him. He is rude. Since I told him about going to test we are not in good terms, we are not close anymore, we don’t see each other, it’s like he is not around. He doesn’t call me… just because I told him about testing.
Only one male index client (MTH122/trace/M/42/Married) noted strong negative feedback, and this was from his in-laws rather than his sexual partner.
Female as well as male sexual partners interviewed experienced stress-related physical and/or psychological distress after being notified of their potential HIV exposure.
Partner MTH-076-1/-ve/M/42/Married: It was difficult… for sure you cannot feel good… you feel as if you don’t deserve to live.
Partner KRH-001-1/+ve/F/35/Married: I got stomach problems since I was shocked to the extent that I experienced diarrhea…. But I was encouraged later. I continued to recover…. I reached a point where I had to encourage myself that I should persevere. I will be treated… .
Precaution Adoption Process Model (PAPM) for Partner Notification
When applying the (PAPM) (Fig. 1)  to the process of partner notification evaluated in this study, we found that the equivalent to Stage 1 was when the partner notification process made sexual partners aware of their exposure to HIV. Following notification, many partners reported a period of shock or distress, during which they were unable or unwilling to contemplate getting tested (Stage 2). For partners who did not test, it is unclear whether they stayed at Stage 2, unengaged in the decision of whether to test for HIV, or if they went through the decision-making process and ended up at Stage 4 (decided not to test). We were not able to interview any partners who did not come in for testing. Our analysis centered around those partners who reached Stage 6, successful referral. The quantitative and qualitative data both show that the decision to test (Stage 5) and successful referral (Stage 6) were heavily influenced by the relationship between index clients and their sexual partners (specifically whether or not they were married), with married partners as the group most likely to reach Stage 6. The PAPM highlighted the decision-making process around testing for HIV faced by partners, influenced by barriers and facilitators, some sex and gender-related, some of which were described to us by participants in the study.