Index Case Testing Saves Lives in Malawi
At the time that Grace Mathunda started to fall ill, she also grew increasingly concerned over the poor health of her second child. Eventually he became so weak that he stopped going to school. When Mathunda, 32, became pregnant again, she went to Makhetha Health Center in Blantyre, Malawi, where she was tested for HIV. As with over 30 percent of people living with HIV in the country, Mathunda was unaware of her status. She tested positive.
Due to the policy of test and treat, Mathunda was put on antiretroviral therapy (ART) and was enrolled in the Prevention of Mother-to-Child Transmission program, which resulted in her child being born HIV negative.
When she heard about family testing days, she decided that her other two children and husband should find out their status as well. Her second son tested positive, but her first child and her husband were negative. Both Mathunda and her HIV-positive son were started on ART and their health has improved considerably.
When people do not know if they are infected with HIV, they can unknowingly transmit the virus to others through unprotected sex. In addition, mothers can pass it on to their unborn children. To increase the number of people tested, the District Health Systems Strengthening (DHSS) Project, funded by the US Centers for Disease Control and Prevention through the, President’s Emergency Plan for AIDS Relief (PEPFAR), developed and supported a package of case-finding strategies:
- Provider-initiated testing and counseling during visits to antenatal care, tuberculosis, sexually transmitted disease, and in-patient and out-patient clinics
- Targeted community-based outreach testing, including outreach to hotspots, moonlight testing, and workplace testing
- Index case testing
In index case testing, the first family member identified as HIV positive is given a family referral slip for other members of the family to be tested. Partners, children, and other family members are asked to come for HIV testing on Saturdays, or any other day that better suits them. Families receive priority testing services at clinics.
To help increase the number of Malawians tested for HIV and, thereby, help reduce the number of new infections, DHSS, which is led by Keanahikishime, recruited 190 HIV diagnostic assistants (HDAs) at facilities with high patient loads and introduced family testing days in 90 health facilities. DHSS provides regular supportive supervision and mentorship to the HDAs, as well as financial support in form of lunch allowances.
Through index case testing, from October 2016 to September 2017, a total of 19,583 adults and children from families living with HIV/AIDS were tested in 90 facilities, of which 52 percent (10,251) were female. The average positivity rate was 24 percent, which is high for index case testing compared to the average in Malawi, which is estimated at 13.1 percent. The individuals identified as HIV positive over the 12 months contributed 14 percent (4,689) of all (34,742) HIV-positive cases identified across the 96 facilities supported by the project over the same period. Therefore, case finding through index patients is a promising strategy to maximize HIV case detection.
As a result of the testing, life has changed considerably for Grace Mathunda and her family.
“My second-born child is now stable and able to attend school unlike before,” she said. “We are a happy family now and able to fend for ourselves.”
 Malawi Population-Based HIV Impact Assessment, 2016.