HIV partner notification program found effective in prisons
A program that notifies the partners of incarcerated men who test positive for HIV was found effective in jails and prisons in Jakarta, Indonesia. The study, conducted by researchers from the University of Illinois Chicago College of Nursing and School of Public Health with collaborators in Indonesia, is the first to test this type of model in a prison setting.
Participation in the program, called Impart, led to a sixfold increase in notification of inmates’ drug and sex partners. Half of those notified also received HIV testing, and one-third of those tested were diagnosed as HIV-positive for the first time.
The research shows that assisted partner notification — where health workers inform at-risk partners of their potential HIV exposure — can work within the prison system, providing a potent opportunity to reduce the spread of the disease.
“Globally, prisons and jails are important sites for intercepting people with undiagnosed and untreated illness, intervening to improve their health outcomes and also to reduce transmission to the community,” said Gabriel Culbert, associate professor in the UIC Department of Population Health Nursing Science. “If you’re not doing prison health, you’re not doing community health.”
Assisted partner notification programs have been studied for three decades and found effective across settings and cultures for increasing HIV testing and detection. In 2016, the World Health Organization endorsed these models as a key component of global HIV services. But their efficacy had not previously been tested with incarcerated populations, where many individuals first learn of their HIV-positive status upon intake.
With Impart, the researchers adapted assisted partner notification to the unique privacy and logistical challenges of prisons and jails. Culbert said the project was inspired by conversations with inmates during a prior study of incarcerated individuals with HIV.
“One young man said, ‘I just learned my status, but who should I tell? I have a girlfriend who’s waiting for me, I think she should know because I think she should be tested. But I have no idea what to do. And here I am in prison,’” Culbert said.
In the study, when an inmate tested HIV-positive, prison doctors and nurses told them about the Impart program and asked if they wanted to participate. If they agreed, community workers unaffiliated with the prison facilitated further steps, such as confidentially gathering information on partners with whom the inmate shared needles or was sexually active.
They enrolled 55 men — 83% of those asked — from six Jakarta jails and prisons who agreed to participate in the program. Half of the individuals were coached on how to tell partners themselves about their HIV infection, and half were allowed to choose between self-notification or allowing the Impart team to find and notify their partners.
Once Impart participants provided names and contact information, a team consisting of a nurse and a community health care worker attempted to locate them for an in-person meeting. The search involved significant legwork, including finding sex workers within brothel complexes that sprawl over multiple city blocks and using high-traffic community locations, such as soup sellers, to find people without a reliable home address.
In all, the Impart teams were able to locate and notify roughly half of the at-risk partners identified by inmates in the program. By comparison, only 18% of partners were notified by inmates in the self-tell group. And while half of the partners notified via Impart subsequently received an HIV test, none of the partners contacted by the inmates themselves had been tested six weeks after the notification.
The results support the effectiveness of the intervention for helping people outside of the prison system, Culbert said.
“Notification resulted in identifying several new cases very efficiently as a percentage of all who were tested,” Culbert said. “Many of them were learning their status for the first time, but we also encountered people who were not being treated and knew their status but didn’t know the additional steps to get into care.”
Building on the positive results of this study, the research team sees potential for similar programs in regions with emerging HIV epidemics, such as former Soviet Union countries, Southeast Asia and sub-Saharan Africa. The team has also applied for a broader grant to implement the model across Indonesia.
“This project showed that assisted partner notification services can be delivered feasibly and ethically in a prison setting and that such services effectively increased HIV testing and earlier detection amongst partners,” said Agung Waluyo, co-author of the study and associate professor of medical surgical nursing at Universitas Indonesia. “We hope that the study’s findings will encourage the model’s adoption in Indonesia and other countries where HIV is prevalent in prisons.”
The study is the latest in a long collaboration between Culbert and Waluyo, who studied together under esteemed global health researcher Beverly McElmurry in the UIC Nursing PhD program. Together, the two have examined several aspects of health in prison populations and tested interventions for addiction, HIV and other infectious diseases.
“I think this is truly a collaboration between two investigators who bring lessons back and forth between Chicago and Jakarta,” Culbert said.
The paper, which was published in Journal of the International AIDS Society June 20, was funded by National Institute of Mental Health grant R34MH115779. Additional co-authors include Judith Levy of the UIC School of Public Health, Alana Steffen of UIC Nursing, Valerie Earnshaw of University of Delaware and Arie Rahadi of the AIDS Research Center at Atma Jaya Catholic University in Indonesia.