Test and Prevent: Evaluation of a Pilot Program Linking Clients With Negative HIV Test Results to Pre-exposure Prophylaxis in Zimbabwe

Widespread HIV testing is identifying individuals who are not infected but are at high risk of HIV exposure. These individuals may be good candidates for pre-exposure prophylaxis (PrEP). We developed an intervention called Test and Prevent to intentionally link individuals with negative HIV test results to PrEP, which led to high rates of completed PrEP referrals and uptake.
Key Findings We implemented and monitored an intervention, called Test and Prevent, to intentionally link clients with a negative HIV test result to oral pre-exposure prophylaxis (PrEP). Most clients (98%) who were referred for PrEP immediately after their negative test result completed their referrals and started PrEP. The rate of screening for PrEP eligibility was low (61%). Among those screened, only 6% were deemed eligible for PrEP via the national PrEP screening tool. Although the subsequent referral rate (3%) was low, both clients and providers reported satisfaction with the intervention and its importance in connecting clients who test negative to PrEP. Key Implications Intentionally linking clients who receive a negative HIV test result to PrEP using methods from the test and treat literature could help increase PrEP uptake. Screening approaches for PrEP eligibility need further examination and validation to ensure they don't unintentionally screen out clients who could benefit from prevention. As PrEP scale-up continues, staff shortages and training needs should be addressed.
Background: As HIV testing increases worldwide, programs are reaching individuals without HIV infection who are at risk of exposure and may be candidates for oral pre-exposure prophylaxis (PrEP). Although linkage of individuals with HIV infection to treatment is a global priority (referred to as “test and treat”), less attention is given to individuals with negative HIV test results. We developed the “Test and Prevent” pilot program to intentionally link at-risk clients with negative HIV test results to PrEP services. The intervention included risk assessment of all clients with a negative result from HIV testing (with national risk assessment tool), accompanied referral, fast-tracking, and targeting follow-up. Methods: The intervention was conducted in Bulawayo, Zimbabwe, at 6 public sector sites from October 2019 to February 2020. We collected routine monitoring data from all study sites and tracked referral completion and PrEP initiation among clients who enrolled. We conducted in-depth interviews with providers (n=12), facility managers (n=5), and female clients (n=17) to explore acceptability. Results: Among clients referred for PrEP (n=206), 98% completed their referrals and started PrEP. However, only 3% of clients who received a negative test result during the study period were referred. Low referrals stemmed from lack of screening (39% of clients with negative HIV test results were not screened) and lack of eligibility among clients who were screened (only 6% of those screened qualified as candidates for PrEP per the national screening tool). Qualitative results indicate that some providers purposefully did not complete screening with clients they felt were not at risk and that workload could have contributed to low screening uptake. Qualitative interviews showed that Test and Prevent was acceptable among both providers and clients. Clients were happy to learn about PrEP following HIV testing, and the additional support of accompanied referrals and fast-tracking encouraged them to access PrEP and made them feel valued. Providers were burdened by workload constraints but felt that Test and Prevent was important and should be scaled to other sites. Conclusion: Intentionally linking clients with negative results to PrEP immediately following HIV testing was found to be acceptable from both provider and client perspectives, yet screening procedures need closer examination and reinforcement for the program to realize a larger impact.