How task shifting improved HIV index testing performance in Liberia

BACKGROUND: The USAID and PEPFAR funded EpiC project, led by FHI 360, collaborates with the National AIDS and STI Control Program (NACP) in Liberia to scale up index testing to improve HIV case finding. Initially, index testing was led by existing clinical staff, but not systematically offered to all people living with HIV (PLHIV). Moreover, acceptance and willingness to refer contacts was low among those offered index testing, so we used task shifting to improve the results.
DESCRIPTION: EpiC introduced index testing services in Liberia in October 2019 through 17 health facilities and nine civil society organizations (CSOs). An assessment of quality standards done in April 2020 helped identify areas for improvement. Based on results, EpiC and NACP launched an intensive optimization strategy, which included task shifting index testing services to 21 newly identified and trained counselors. Standardized service delivery tools, conducted trainings, and mentorship for 39 clinical staff were introduced to address identified gaps. Data from pre-optimization, when services were led by existing clinical staff (October'December 2019) were compared to post-optimization, when services were led by dedicated index testing counselors (October'December 2020).
LESSONS LEARNED: During pre-optimization, 1,329 PLHIV were offered index testing counseling. Only 63% accepted index testing; 77% of contacts elicited were tested (Table 1). Case finding among contacts was 23%, and 77% of them were linked to treatment. During post-optimization, 3,583 PLHIV were reached with index testing counseling resulting in higher acceptance (83%), increased uptake of HIV testing among partners elicited (86%), and better linking to treatment (98%). Although case finding was lower (17%), the number of PLHIV offered index testing increased threefold and the absolute number of HIV cases identified nearly doubled.

Table 1: Uptake of index testing

Period	Known HIV positive clients reported to clinic	New HIV diagnosis	PLHIV offered index testing	Number accepted index testing	Number contacts elicited	Number partners eligible for testing	Number tested for HIV	Number found HIV positive (%)	Number linked to treatment (%)
Pre-optimization (October-December 2019)	851	478	1329	839 (63%)	1164	1125	871 (77%)	201 (23%)	155 (77%)
Post- optimization (October-December 2020)	2817	766	3583	2959 (83%)	2738	2528	2170 (86%)	367 (17%)	360 (98%)

CONCLUSIONS: Strategic human resource optimization for index testing, including task shifting to dedicated counselors and providing training, mentorship, and standardized tools can significantly improve index testing performance. The collaborative relationship between EpiC and NACP was critical to the success. Beyond technical and financial resources, advocacy among leadership and health professionals is needed to accelerate implementation.