Distinctive model for HIV index testing (IT) in Eastern Europe: results of Ukraine's physician-led, integrated IT programme.

OBJECTIVES: The effectiveness of HIV index testing (IT) in Eastern Europe has not been described. This study reports the performance of a scaled IT programme in Ukraine. DESIGN: This observational study included clients enrolled in IT services in 2020, and used routinely collected data from programme registers and the national electronic health record system. SETTING: The study covered 39 public-sector health facilities where IT services were integrated into medical visits for persons living with HIV (PLHIV) already enrolled in HIV care. PARTICIPANTS: Participants included PLHIV with both recent (<6 months) and previously established (≥6 months) HIV diagnoses. INTERVENTION: Ukraine's physician-led IT model involves a cascade of steps including voluntary informed consent, partner elicitation, selection of partner notification method and follow-up with clients to ensure partners are notified, tested for HIV and linked to HIV prevention and treatment services, as needed. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcomes included contact index, testing, index and HIV case-finding index disaggregated by index client (IC) subgroups, including people with current or past injection drug use (PWID) and men who have sex with men (MSM). RESULTS: Of 14 525 ICs offered index testing, 51.9% accepted, of whom 98.3% named at least one sexual, injection or biological child partner. In total, 14.9% of ICs were PWID and 3.5% were MSM. Clients named 8448 unique partners (contact index=1.14). HIV case finding averaged 0.14 cases per client, and was highest among clients with recent HIV diagnosis (0.29) and among PWID (0.23), and lower among clients with established HIV diagnosis (0.07). More than 90% of all partners with new HIV diagnoses were linked to care. CONCLUSIONS: There was a high case-finding index among ICs with recent HIV and high linkage to care for all partners, demonstrating the effectiveness of this integrated, physician-led model implemented in 39 health facilities in Ukraine.

Profile of partners who completed HIV testing and received a new HIV diagnosis in Ukraine's HIV index testing program: a retrospective cohort study to inform program improvement.

BACKGROUND: Approximately one-third of people living with HIV in Ukraine are unaware of their HIV status. Index testing (IT) is an evidence-based HIV testing strategy that supports voluntary notification of partners with HIV risk, so they can receive HIV testing, prevention, and treatment services. METHODS: Ukraine scaled up IT services in 2019. This observational study of Ukraine's IT program covered 39 health facilities located in 11 regions with high HIV burden. The study used routine program data from January-December 2020 to describe the profile of named partners and explore index client (IC) and partner factors associated with two outcomes: 1) completing testing; and 2) HIV case finding. Analysis used descriptive statistics and multilevel linear mixed regression models. RESULTS: The study included 8,448 named partners, of whom 6,959 had unknown HIV status. Among them,72.2% completed HIV testing and 19.4% of those tested were newly diagnosed with HIV. Two-thirds of all new cases were among partners of ICs who were recently diagnosed and enrolled in care (< 6 months), while one third were among partners of established ICs. In adjusted analysis, partners of ICs with unsuppressed HIV viral load (VL) were less likely to complete HIV testing (adjusted odds ratio [aOR] = 0.11, p < 0.001), but more likely to receive a new HIV diagnosis (aOR = 1.92, p < 0.001). Partners of ICs who cited injection drug use or having a known HIV + partner as their own reason for testing were more likely to receive a new HIV diagnosis (aOR = 1.32, p = 0.04 and aOR = 1.71, p < 0.001 respectively). Involving providers in the partner notification process was associated with completed testing (aOR = 1.76, p = 0.001) and HIV case finding (aOR = 1.64, p < 0.01), compared with notification by ICs. CONCLUSION: HIV case detection was highest among partners of recently diagnosed ICs, but IT participation among established ICs still yielded an important share of all newly-identified HIV cases. Areas for improvement in Ukraine's IT program include completing testing for partners of ICs with unsuppressed HIV VL, with history of injection drug use or discordant partnerships. Using intensified follow-up for the sub-groups at risk of incomplete testing may be practical. Greater use of provider-assisted notification could also accelerate HIV case finding.

Pharmacist prescribing of hormonal contraceptives: results of the Direct Access study.

OBJECTIVE: To describe implementation of a collaborative drug therapy protocol to screen and counsel women for safe use of hormonal contraceptives prescribed by community pharmacists. DESIGN: Community-based intervention study. SETTING: Metropolitan Seattle, Wash., from June 2003 to December 2005. PARTICIPANTS: 26 community pharmacists and 214 women enrollees. INTERVENTION: Pharmacists identified women at risk of unintended pregnancy and offered to evaluate them to determine whether they could safely use oral contraceptives, contraceptive patches, or the contraceptive vaginal ring. Interested women self-administered medical and contraceptive history questionnaires. Pharmacists measured weight and blood pressure and prescribed hormonal contraceptives according to the protocol guidelines. Study interviewers followed up with women via telephone at 1, 6, and 12 months. MAIN OUTCOME MEASURES: Effectiveness of pharmacist interventions was measured by continuation of hormonal methods by women. Feasibility was determined by measuring acceptability and sustainability. Acceptability was measured by interviewing women and pharmacists. Sustainability was measured by evidence of willingness to pay for the services. RESULTS: 195 women (91%) were prescribed hormonal contraceptives by participating pharmacists. A self-administered screening tool and physical measurement of weight and blood pressure enabled pharmacists to evaluate women for safe use of contraceptives. Most women (87%) were experienced users of hormonal contraceptives. More than 80% of women paid for the pharmacists' services out of pocket. After 12 months, 70% of women responding to an interview reported continuing use of hormonal contraceptives. Women reported that they would want to obtain a gynecologic exam within 3-year intervals while taking hormonal contraceptives. Both women and pharmacists were satisfied with the experience. Nearly all respondents expressed willingness to continue to see pharmacist prescribers and to receive other services from them. CONCLUSION: Community pharmacists can efficiently screen women for safe use of hormonal contraceptives and select appropriate products. Women and pharmacists were satisfied with the services, and women were willing to pay for them.

Agreement between women's and providers' assessment of hormonal contraceptive risk factors.

OBJECTIVE: To measure agreement between women's self-administered risk factor questionnaire and their providers' evaluation of their medical eligibility for hormonal contraceptive use. METHODS: This was an anonymous cross-sectional study. Participants were women 15-45 years old who completed a 20-item self-administered questionnaire. Women were recruited from six public health family planning clinics in the Seattle Metropolitan area. A matching medical evaluation questionnaire was completed concurrently by each participant's health care provider. Using provider evaluation as the "gold standard" against which we compared self-reported medical history, we calculated participant-provider agreement with point estimates and 95% confidence interval (CI). RESULTS: Of 399 participant and provider pairs, participant-provider agreement was obtained for 392 participant pairs. The majority of the participants (90.3%) were 15-30 years old and 77.7% had used a hormonal contraceptive method for more than 1 year. The estimated proportion of the overall agreement was 96% (95% CI, 0.92-0.98). Women were more likely to report severe headaches (12.4% vs. 3.3%), possible pregnancy (7.3% vs. 3.5%) and smoking (6.2% vs. 2.1%) than providers, but less likely to report smoking more than 15 cigarettes per day (2.6% vs. 9.2%) and irregular menses (6.5% vs. 9.9%). CONCLUSION: Overall, a high proportion of the women in this study completed our medical history questionnaire in concordance with their health care providers' same-day medical evaluation. Agreement on critical medical eligibility criteria such as hypertension was well above 90%. For criteria on which there was disagreement, women were more likely to identify contraindications than were their providers.

Attitudes and intentions of future health care providers toward abortion provision.

CONTEXT: Induced abortion is one of the most common procedures performed among women in the United States. However, 87% of all counties had no abortion provider in 2000, and little is known about the attitudes and intentions of future health care providers, including advanced clinical practitioners, regarding abortion provision. METHODS: During March 2002, first- and second-year students in health sciences programs (i.e., medicine, physician assistant and nursing) at the University of Washington were anonymously surveyed. Univariate, bivariate and multivariate analyses were used to determine students' attitudes and intentions regarding provision of abortion services. RESULTS: Of the 312 students who completed the survey, 70% supported the availability of legal abortion under any circumstances. Thirty-one percent intended to provide medical abortion in their practice, and 18% planned to offer surgical abortion. Fifty-two percent of all respondents agreed that advanced clinical practitioners should be able to provide medical abortion, and 37% agreed that they should be able to provide surgical abortion services; however, greater proportions of advanced clinical practitioners (45-83%) than of medical students (21-43%) expressed such support. Sixty-four percent of all respondents were willing to attend a program whose curriculum requires abortion training. CONCLUSIONS: Although it may not be possible to require abortion training for every future health care provider, making abortion a standard part of clinical training would provide opportunities for future physicians and advanced clinical practitioners, and would likely ameliorate the abortion provider shortage.