Index Testing

Jeremiah Serrano
Research Associate – EpiC HIV Project
What is
Index
Testing?
Index testing is a case-finding approach that focuses on eliciting the sexual or
needle-sharing partners and biological children (<15) of HIV-positive individuals
and offering them HIV testing services. Index testing is a completely voluntary
service offered to people living with HIV, and they are free to accept or decline.

Index Client

Sexual partners Needle-sharing partners

Biological children
Index testing is sometimes
referred to as:

• Partner notification

• Contact tracing

• Partner referral
DEFINITION OF TERMS
Index Client - the PLHIV from whom we will be eliciting contacts and or family
members from

Elicit - the process of getting the names and contact details of eligible individuals
provided voluntarily and with consent by the Index Client

Refer – client encourages their partner/child to come to the facility for testing, the
client allows a provider to contact partner/child for testing
Summary of evidence on index
testing
• Effective at increasing HIV testing
and early diagnosis
• PLHIV-led referral usually preferred,
especially with steady partners
• Importance of options
• Must be voluntary and protect client
safety
• Safe, voluntary disclosure can
improve index client support and
treatment outcomes – but is NOT
REQUIRED
TRUE OR FALSE?
1) Key populations are generally at the same risk of violence as
everyone else.
2) It is OK to notify an index client’s sexual partner of their risk of
infection without the index client’s consent if you don’t mention the
index client’s name.
3) Index testing can be introduced at any point of the client’s treatment
journey.
4) Index clients are required to refer their partners and friends.
5) Index clients should be informed of the HIV status of the partners
they refer.
Index Testing in the Philippines
INDEX TESTING DATA

Tested Positive
National Policy
DOH (AO 2022 – 0035)
National Policy
DOH (AO 2022 – 0035)
Index Testing Guidelines
Conducting Index Testing
 STEPS FOR INDEX TESTING
1) Introduce the concept of index testing during pre-test session / initial
visit / refill
2) Offer index testing as a voluntary service to all clients who test HIV
positive and are virally unsuppressed.
3) If client accepts participation, obtain consent to inquire about their
partner(s) and biological child(ren).
4) Obtain a list of sex and needle-sharing partners and biological children
<15 with unknown HIV status.
5) Conduct an intimate partner violence (IPV) risk assessment for each
named partner.
 STEPS FOR INDEX TESTING

6) If client consents, determine the client’s preferred method of partner

notification or child testing for each named partner/child.
7) Using preferred approach, contact all named partners and biological
children <15 with unknown status.
8) Record outcomes of partner notification and family testing.
9) Provide appropriate services for children and partner(s) based on HIV
status.
10) Follow up with client to assess for any adverse events associated
with index testing.
Determining a preferred method for partner referral

• Client referral
• Provider-assisted referral
• Dual referral
Index testing: Client referral

Index client directly encourages their partner(s) and biological children to come
to the facility for a test or meet a counselor in the community to screened.
Index testing: Provider-assisted referral

Counselor or other health care provider calls or visits the index client’s
partner(s) and recommends that they test for HIV.
Index testing: Dual referral

Counselor/provider sits with index client and partner(s) to support index

client in telling partner(s) about HIV status (if they choose to disclose);
or provides a safe space for testing together.
IMPORTANT CONSIDERATIONS
• Offer index testing continuously and strategically to:
– PLHIV who are not on treatment/recently started
– PLHIV who are not virally suppressed or have acute
infection
– PLHIV who recently returned to treatment after LTFU/IIT

• Assess client safety, security, readiness, and consent

• Ensure that program has available services for clients,
partners, and children
Disclosure of the Index Client is
VOLUNTARY and is NOT
REQUIRED for Index Testing
Standards for a Safe and Ethical Index Testing
POTENTIAL BENEFITS OF INDEX TESTING

• Increased uptake of HIV testing among partners of PLHIV

• Increased case finding
• Earlier diagnosis
• Improved and earlier linkage to care and treatment
• Safer disclosure and/or links to violence services for
those who disclose abuse
• Reduced transmission among serodiscordant couples
• Prevention services for partners
Potential barriers and risks
There is no such thing as zero risk; all HIV
testing programs involve some risk,
including …
• Violence
• Rejection
• Criminalization
• Forced disclosure
• Confidentiality breach
 1.
Monitor compliance
with minimum
standards

2.
5. Obtain
Quality assurance informed
and accountability Safe and consent

Ethical Index
Testing
Services
4. 3.
Adverse event Intimate partner
violence risk
monitoring and assessment and service
reporting provision
 • Adherence to 5 C’s
1. – Consent, Confidentiality, Counseling, Correct test results, and
Connection to prevention/treatment
Compliance
with Minimum
Standards
• IPV risk assessment and first-line response
– Including safety check and referrals to clinical/nonclinical violence
response services
(if not provided on site)

• Site-level adverse events monitoring and

reporting system
• Providers trained and supervised on index
testing procedures
– 5 C’s, IPV screening, adverse event monitoring, and ethics
(respect for the rights of clients, informed consent. and ‘do no
harm’)

Source: PEPFAR 2020 Guidance for Implementing Safe and Ethical Index Testing Services
 The 5 C’s and the Core Principles of HIV Testing
Core principles of HIV testing
• Adhere to the 5 C’s
– Confidential Client centered Voluntary and
Confidential
– Consent
and focused non-coercive

– Counseling
Culturally,
– Correct test results Free Nonjudgmental linguistically

– Connection to services
appropriate

• And to the Core Principles

Accessible and Comprehensive
available to all and integrative

Source: PEPFAR 2020 Guidance for Implementing Safe and Ethical Index Testing Services; & WHO
Sample
Patient Bill
of Rights
Index clients should be informed of and understand…
• Purpose of index testing
• What will happen, by whom, where
2.
Obtain • It’s voluntary; they will still have access to other
informed health services if they decline
consent
• Different options available for notifying partners
• Potential risks and benefits; how to minimize risks
• How and to what extent privacy and confidentiality
can be protected
• Where support services are available; how to
contact and access those services if needed,
particularly if harm is experienced
Consent among children and adolescents
• Providers of index testing must always follow their country’s
guidelines on age of consent as stated in the national HTS guidelines.
• When an older child or adolescent meets the national age of consent,
they must receive age-appropriate pre-test counseling.
• HIV testing counselors should always communicate with
children/adolescents in ways that are appropriate to their age and
level of maturity.
• When a child/adolescent is not of the age to provide consent for
testing, providers must obtain their parent’s consent after providing
appropriate pre-test information/counseling to them on the importance
of knowing the HIV status of their biological child.
What is Index Testing and
the Data Privacy and
Confidentiality Agreement
When was IT offered?

Client Consent

Client Refusal and Reasons

Elicitation, IPV Risk,

Notification Plan and
Follow-up
Tools / Resources
Implementation
• Workflow
• Index testing consent form
• Scripts/talking points/job aids
• Intimate partner violence (IPV) screening questions, SOPs,
referral forms to violence-response services
Documentation, data, and monitoring and evaluation (M&E)
• Data sharing agreement (if necessary)
• Documentation forms (registry/excel/log)
• Data analysis and visualization
• Monitoring and evaluation tools
 INDEX
TESTING
WORKFLOW
Scripts and talking points for introducing index testing

Source: PEPFAR 2020 Guidance for Implementing Safe

and Ethical Index Testing Services
What is Index Testing and
the Data Privacy and
Confidentiality Clauses
When was IT offered?

Client Consent

Client Refusal and Reasons

Elicitation, IPV Risk,

Notification Plan and
Follow-up
 Sample data sharing agreement Sample confidentiality statement

Index Client Information Confidentiality Form

Sample Data Sharing Agreement
[Date] [Version Number]
[Note: This template provides an example for a memorandum of I _____________________________________ agree to maintain the
understanding between two organizations (or health facilities) who would like confidentiality of client information and records at all times. At no
to engage in a shared confidentiality relationship in order to facilitate index time will I disclose the names of clients, their contacts, or any
testing, linkage to treatment, defaulter tracing, and other HIV services. information within their medical records. I will also comply with
Organizations should feel free to adapt and customize this agreement as the following:
appropriate.]
• I will treat all information I obtain/collect from clients and their
I. NAME OF ORGANIZATIONS ENTERING INTO AGREEMENT contacts as confidential.
Organization 1
Name of Organization: • I will not discuss the identity of clients and their contacts with
Address:
anyone except those who are authorized to have access to this
information.
Organization 2
Name of Organization: • I will not use collected information for any purpose other than my
Address:
work-related duties.
• I will maintain all written medical charts, registers, forms and other
II. PURPOSE OF THE AGREEEMENT materials in a locked filing cabinet.
In this section, both organizations should state in non-technical language the
purpose(s) for which they are entering into the agreement. For example, • I will store all electronic files on a password-protected computer or
data will be shared between the facility partner and the community partner to tablet that has current virus protection software. I will back up these
facilitate tracing and testing of partner(s) and biologic children elicited in the files every night before I leave.
health facility by the community organization. • Etc.
Etc.
Sample index testing register
ADVERSE EVENT FORM
Beneficiary Abuse Disclosure and Response Form
Index Testing Workflow
 INTRODUCTION TO INDEX TESTING
Phase 1
 INTRODUCTION TO INDEX TESTING (JOB AID)

Client journey Intro to IT

1. Pre-test counseling & Waiting for results • Priming
- HIV 101 transmission
- Get tested, Get treated, Reach U=U
2. Post-test counseling for reactive result • Priming
- With Tx, U=U for client and contact
• Offer
3. Confirmatory testing / sdART • Offer
4. ART refill / Other TCS services
5. Conversations w/
life coach / peer GC / learning group session
6. VL
INTRODUCTION TO INDEX TESTING (JOB AID DRAFT)
 CONTACT ELICITATION
Phase 2
 Minimum requirements that must be in place before
you ask about violence
3.
Intimate
partner
violence risk
assessment
and service
provision

Written Standard set of Providers are Providers Providers only System for
Index testing requires
protocol/ questions are trained on offer first- ask about referrals to
asking about IPV. SOP for the used to how to ask line support violence in a violence
Providers cannot ask provision of facilitate about and (LIVES) private response
about IPV unless the violence documentation, respond to setting, services is in
response and safe storage confidentiality place
following supportive services is in mechanisms are
violence
ensured
elements are in place to place in place
limit potential harm.

Source: Adapted from USAID, Office of HIV/AIDS, Gender and Sexual Diversity Branch
 Scripts and talking points for
IPV SOPs calling contacts
• Violence screening SUGGESTED SCRIPT FOR NOTIFYING PARTNERS VIA A
questions/tool PHONE CALL FOR CLIENTS CHOOSING PROVIDER
REFERRAL

• The provision of first-line support Magandang araw. Ako po si ___________ at ako ay

counselor/provider sa __[Facility Name]_. Maari po bang malaman
and referral in instances of kung si __partner’s name__ ito?

violence [IF NOT THE PARTNER]: Maari po bang makausap si __partner’s

name__?

• Safe data storage and sharing [If partner is not available]: Salamat po. Tatawagan ko nalang po
regarding disclosures of violence siya sa ibang araw.

[If YES]: Maari po bang itanong kung nasa pribadong lugar po

• Determining appropriate kayo? Mayroon lamang po akong ibabahagi sa inyo na maaring
sensitibo na marinig ng iba.
notification approach
[If NO]: Pwede po bang malaman kung kalian po ako ulit pwede

• Etc. tumawag?

Etc.
 IPV RISK ASSESSMENT
Assess EACH NAMED PARTNER for possible violence
• Has [partner’s name] ever hit, kicked, slapped, or otherwise physically hurt
you?
• Has [partner’s name] ever forced you to do something sexually that made you
feel uncomfortable?
• Has [partner’s name] ever withheld resources or access to necessities to
punish or control you?
• Has [partner’s name] ever made you feel afraid, humiliated, or insulted you?
• Has [partner’s name] ever threatened to hurt you, including ‘outing’ you?

Do you think [partner's name] can do any of those listed above if we proceed
with testing?
If someone says “no” to all questions on violence
• Even if you suspect that someone is experiencing
violence, accept their reply.
• Let them know that you’re here for them if they
remember any incidents or anything happens in
the future.
• Many people at health facilities are not expecting
questions about violence. They may not come
prepared to share this information. However, after
thinking about it, they may be willing to come
back and describe their experiences.
If someone says “yes” to IPV screening, what
do you do?
• Do not disqualify them (Index Client) from index
testing or begin discussing another partner.
• Experience of IPV can affect treatment
adherence, viral load, and overall well-being.
• Disclosures of violence should be responded to
immediately with first-line support.
• Failure to do so can cause harm.
First-line support
Task Explanation
Listen Listen closely with empathy and no
judgment
Inquire about Assess and respond to various needs
needs and and concerns—emotional, physical,
concerns social, safety
Validate their Show you believe and understand,
experiences assure victim that they are not to blame
Enhance Discuss a plan to protect the victim
safety from further harm if violence occurs
again
Support Support the victim to connect with
additional services
Source: WHO, 2014. Health care for women subjected to intimate partner violence or
sexual violence
 NOTIFICATION, TESTING, AND OUTCOMES MANAGEMENT
Phase 3
What is an adverse event?
An incident that results in harm to clients, partners, children, providers,
or anyone else as a result of their participation in index testing services
Adverse events (AEs) include:
1. Threats of physical, sexual, or emotional harm to the index client, their partner(s) or
family members, or the index testing provider
2. Occurrences of physical, sexual, or emotional harm to the index client, their sexual or
needle-sharing partner(s) or family members, or the index testing provider
3. Threats or occurrences of economic harm (e.g., loss of employment or income) to the
index client, their partner(s) or family members
4. Abandonment or forced removal of children less than 15 years old from the home
5. Withholding HIV treatment or other services
6. Forced or unauthorized disclosure of client or contact’s name or personal information
7. Health-site-level stigma or criminalization

Source: PEPFAR 2020 Guidance for Implementing Safe and Ethical Index Testing Services
 Monitoring of consent and adverse
events (AEs)
4.
Adverse event
monitoring • All sites must have/use tools to document and
and reporting monitor obtaining consent and the frequency of
AEs (including IPV) and actively monitor:
– Reasons for refusal of index testing services
– Prevalence of IPV and other AEs (e.g., confidentiality
breaches, stigmatization, coercive tactics, etc.)

• Investigate each reported AE and develop a

follow-up plan
Supervision tools Monitoring and reporting tools
• Minimum Standards Checklist • Adverse events form
• Supportive supervision tools • Customer Complaint Form
• Security Incident Log

• Paper-based client
feedback surveys;
comment boxes

• Community Scorecard
• Client exit interviews

• Community Advisory Boards

 Site level monitoring
4. • Routinely ask index clients if they experienced
Adverse event
monitoring any AE following participation in index testing
and reporting – Suggested question: “Nakaranas ka ba ng
violence/harm sa iyong partner, health care
provider, or sino man habang o dahil sa resulta ng
index testing services dito sa [facility or site]?
Kasama dito ang physical, emotional, sexual, or
economic harm.”
• Can be done at client’s next visit or via phone
2–4 weeks after index testing service provided
• All reports of adverse events should be
documented
 Summary of inputs into quality
5. assurance and accountability
Quality
assurance
and • Index Testing indicators for M&E
accountability
• Minimum Standards Checklist for providers and sites
• Tools for index testing
• Community-led monitoring and feedback mechanism
• Adverse events monitoring and reporting tools
– Beneficiary Abuse Disclosure and Service Provision Form
– Customer Complaint Form
– Security Incident Log
 MONITORING AND EVALUATION
Measure Definition
1. OFFERED - Number of reactive individuals (potential Index
Clients)
who were offered to participate in Index Testing
2. ACCEPTED - Number of reactive individuals
who accepted and consented to become an Index
Client
3. ELICITED - Number of partners identified per index client

4. CHILDREN - Number of biological infant and young

children identified by index client

5. TESTED - Number of elicited contacts (Index Referral)

who are successfully tested
 MONITORING AND EVALUATION

Measure Definition
6. POSITIVE - Number of tested referrals that tested positive

7. LINKAGE - Number and proportion of referrals who are linked

to care
8. ADVERSE EVENTS - Number and type of adverse events following IT
services
 OFFERED
ART Form

OHASIS
 ACCEPTED
ART Form
 ELICITED/CHILDREN
IT Form
 TESTED/LINKAGE
HTS Form

(UIC of Index Client)

OHASIS
Steps for index testing
Introduce index testing services to index client
during pre-test counseling or ART visit Safe and Ethical Index
Testing Services
Compliance
Obtain consent from the client to proceed with index with minimum Quality
standards assurance and
testing services accountability

Obtain
Obtain a list of sexual/needle-sharing partners and informed
exposed children under age 15 with unknown status consent

Conduct an IPV risk assessment for each named

partner, and respond appropriately to any disclosures
Intimate
Determine preferred method of partner notification partner
violence risk
for each named partner and record assessment
and service
Obtain provision
Contact all named partners and biological children informed
under age 15 using the preferred approaches consent

Adverse event
Record and track notification outcomes monitoring
and reporting

Provide appropriate services to client, partners,

and children
TRUE OR FALSE?
1) Key populations are generally at the same risk of violence as
everyone else.
2) It is OK to notify an index client’s sexual partner of their risk of
infection without the index client’s consent if you don’t mention the
index client’s name.
3) Index testing can be introduced at any point of the client’s treatment
journey.
4) Index clients are required to refer their partners and friends.
5) Index clients should be informed of the HIV status of the partners
they refer.
EpiC is a global cooperative agreement dedicated to achieving and maintaining
HIV epidemic control. It is led by FHI 360 with core partners Right to Care,
Palladium, Population Services International (PSI), and Gobee Group.