Development of a screening tool to improve the yield of HIV testing in Provider Initiated HIV testing and counseling for family-members of HIV infected persons and patients at JaramogiOgingaOdinga Teaching and Referral Hospital

The prevalence of undiagnosed HIV infection among the Kenyan population was approximated to be 2%in 2012 and with the maturing of the epidemic, there is a need to focus resources on ensuring those who are HIV positive are on ART, andto identify the undiagnosed HIV infected persons. With an average cost per test estimated to be between USD 2-8, the present cost-benefit ratio ofuniversal HIV Testing and Counselling (HTC) programs are close to intolerable limits. However, HIV infected persons who are unaware of their status continue to unknowingly transmit HIV to their sexual partners who may also in-turn infect other partners and propagate the spread of the infection. We propose to develop a screening interview (prior to HIV testing) that would have the highest yield in identifying new HIV diagnoses among ambulatory and in patients at the JaramogiOgingaOdinga Teaching and Referral hospital (JOOTRH) and families of HIV infected persons enrolled at the JOOTRH HIV Clinic. A mixed methods study design will be employed. A retrospective medical record review will be conducted at JOOTRH to describe the yield of HIV testing among various patient categories and family members of HIV infected persons at the HIVclinic. We will review records of 1500in patients and out patients who were seen at JOOTRH between January-December 2014 and HIV testing records of approximately 400family members of HIV infected persons enrolled at the JOOTRH HIV clinic. From this, a screening interview to increase the yield of HIV testing will be developed.Prospectively we will operationally compare the yield of the newly developed algorithm to routine testing. This will be conductedamong 831patients in 24 hospital departments and among family members of 277index cases at the JOOTRH HIV clinic. Variables to be collected include patient demographics (age , gender, occupation, residence), clinical characteristics including presenting complaint, medical history, physical examination findings, vital signs, admission notes, diagnoses, treatment, whether it is a new or repeat visit and date of last visit. Variables collected for index clients at the JOOTRH HIV clinic will include all their clinical information, data on family size, age of family members, history of previous testing of family members and knowledge of HIV status, health status of family members. Data from the JOOTRH HIV clinicpatient databases will then be linked to the Provider Initiated Testing and Counseling, PITC database. The JOOTRH HIV clinic database contains all clinical information for the patient who are enrolled at the HIV clinic; this will be merged to family members’ database. Analysis of the prediction model will be performed using a multivariable logistic regression model. Selection of the variables will largely follow sequential manual steps based on knowledge of the HIV epidemiology and hypothesized associations between patient characteristics and HIV infection. We will then develop the risk score by multiplying the final prediction model’s regression coefficients by 10. A 10-fold cross-validation method will be used to evaluate the internal validity of the model. Receiver operating characteristic (ROC)curve will be constructed and area under the curve calculated to assess discrimination. The predicted HIV positivity with the observed HIV positivity will be plotted fitting a linear regression line and calculating the slope and R2to assess calibration. We anticipate developing a screening interview that would have a high sensitivity, specificity, negative predictive value and positive predictive value in identifying persons who are in need of a HIV test result. Consequently, HIV programs can achieve a higher yield for HTC with a more cost-effective method.