https://orcid.org/0000-0003-3604-0509
Figures
Abstract
Assisted partner service (aPS) augments HIV case-finding among sex partners to individuals newly diagnosed with HIV. In 2016, aPS was incorporated into the national HIV testing services (HTS) program in Kenya. We evaluated the extent of, barriers to, and facilitators of aPS integration into HTS. We conducted semi-structured in-depth interviews (IDIs) with 32 stakeholders selected using purposive sampling at national, county, facility, and community levels. IDIs were conducted at two timepoints, at baseline from August-September 2018 in Kisumu and January-June 2019 in Homa Bay, and at follow-up from May-August 2020 to understand changes in aPS integration over time. We defined integration as the creation of linkages between the new intervention (aPS) and the existing HTS program. Data were analyzed using thematic content analysis. We found varying degrees of aPS integration, highest in procurement/logistics and lowest in HTS provider recruitment/training. At baseline, aPS integration was low and activities were at an introductory phase. At follow-up, aPS was integrated in almost the entire HTS program with the exception of low community awareness, which was noted at both baseline and follow-up. There was increasing routinization with establishment of clear aPS cycles, e.g., quarterly data review meetings, annual budget cycles and work-plans. Major barriers included limited government funding, staff constraints, and inadequate community-level sensitization, while key facilitators included increased resources for aPS, and community health volunteer (CHV) facilitated awareness of aPS. Varying degrees of aPS integration across different units of the national HTS program highlights challenges in funding, human resource, and public awareness. Policymakers will need to address these barriers to ensure optimal provision of aPS.
Citation: Wamuti BM, Owour M, Obong’o C, Liu W, Kariithi E, Lagat H, et al. (2023) Integration of assisted partner services within Kenya’s national HIV testing services program: A qualitative study. PLOS Glob Public Health 3(2): e0001586. https://doi.org/10.1371/journal.pgph.0001586
Editor: Joel Msafiri Francis, University of the Witwatersrand, SOUTH AFRICA
Received: March 16, 2022; Accepted: January 17, 2023; Published: February 10, 2023
Copyright: © 2023 Wamuti et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The data contain potentially identifying or sensitive participant information. In this study, participants were assured that `All the information collected is kept private and confidential’ and that `Only authorized study staff will have access to this information.’ This approach to access study data was approved by the Kenyatta National Hospital—University of Nairobi Ethics and Research Committee (KNH-UON ERC), which requires that we release data from Kenyan studies (including de-identified data) only after they have provided their written approval for additional analyses. As such, data for this study will be available upon request, with written approval for the proposed analysis from the KNH/UON ERC. Requests may be addressed to uonknh_erc@uonbi.ac.ke. Their application forms and guidelines can be accessed at http://erc.uonbi.ac.ke/. To request these data, individuals can contact KRTC administrator at kenyares@uw.edu.
Funding: CF was funded by the U.S. National Institutes of Health (NIH) NIAID R01AI134130. BMW and SM received support from the Fogarty International Center under award numbers D43 TW009580, D43 TW009783 and D43 TW010905. MS received support from NIMH K01MH115789. DAK received additional support from the University of Washington/Fred Hutch Center for AIDS Research (NIH P30 AI027757). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the article.
Competing interests: The authors have declared that no competing interests exist.
Introduction
There are approximately 38.4 million living with HIV (PLWH), of whom 5.9 million (15%) are unaware of their HIV-positive status [1]. HIV case-finding is the first step in offering preventive messaging, referral and linkage to HIV care and treatment services for PLWH, and includes such interventions as assisted partner services (aPS) [2]. aPS has been used to augment HIV case-finding and involves tracing, testing and linking to care sex and drug-injecting partners of individuals diagnosed with HIV [2]. aPS was first recommended in 2016 by the World Health Organization (WHO) and included as part of the HIV testing services (HTS) package [2]. In many African countries, aPS is being promoted through ministries of health (MOHs) as it supports the UNAIDS 95-95-95 targets i.e., 95% of people living with HIV know their HIV status, 95% of people who know their status are receiving treatment, and 95% of people on HIV treatment achieve viral suppression [3–8].
After a successful cluster-randomized controlled trial in Kenya that found aPS to be effective, safe and cost-effective, the Kenyan MOH incorporated aPS into its national HTS program [9–12]. It is known that new interventions that were efficacious in controlled trials may have reduced effectiveness in real-life settings [13]. Also, most aPS literature is from controlled trials or pilot programs with a paucity of studies systematically evaluating national scale-up of the program [5,14–20]. These evaluations of pilot projects in Tanzania [21] and program-level integration in Cameroon [5] and Mozambique [14] do not describe how to effectively integrate the intervention into national HTS programs.
Integration, defined as the creation of linkages between new interventions and existing programs to improve healthcare delivery, occurs across institutional subsystems, defined as operational divisions within the healthcare system responsible for HTS e.g., procurement logistics, and service delivery [22–24]. For seamless integration of aPS to occur, it is important to identify key barriers and facilitators and manage them appropriately. Studies exploring the integration of new interventions into HTS programs have generally focused on service delivery at the facility level and not within subsystems at the national level, while none have evaluated the extent of integration over time [25]. In a study evaluating the integration of HIV pre-exposure prophylaxis (PrEP) in Kenya, authors focused on process flows at the facility level [26] while in a systematic review of family planning integration into HIV programs, most studies focused on client outcomes with few focusing on policy level implementation processes [27].
In our study, we explored the extent of, barriers to, and facilitators of aPS integration into the national HTS program in Kenya. This was conducted as part of a larger project evaluating the effectiveness of aPS implementation in western Kenya. We qualitatively described the extent of aPS integration across key MOH subsystems and compared the levels of aPS integration over time.
Methods
Study design
Qualitative in-depth interviews (IDIs) were nested within the aPS scale-up study, a collaboration between MOH, PATH-Kenya, and the University of Washington, described in detail elsewhere [28]. The study took place in 31 healthcare facilities in Kisumu and Homa Bay, two counties in western Kenya with the highest HIV prevalence in the country [29]. Briefly, women newly testing HIV-positive (female index clients) were enrolled to the study and details on their male sex partners was collected. HTS providers then traced and notified these partners of their potential HIV exposure and offered HIV testing. Partners testing HIV positive were referred for HIV care and treatment, while those testing HIV negative received counselling on HIV prevention.
Study participants
Using purposive sampling, we conducted 40 interviews (twenty each at baseline and follow-up) with 32 key aPS stakeholders at the national, county, facility, and community levels. Eight of these individuals were interviewed twice by virtue of their job positions. This sample was selected to include perspectives from all healthcare system levels in Kenya and provide a holistic perspective of aPS integration. At the national level, we interviewed MOH policy makers at the National AIDS and STI Control program (NASCOP) and at implementing partner organizations. NASCOP is the main governmental institution in charge of HTS in Kenya while implementing partner organizations are typically large non-governmental organizations offering technical assistance and implementation support for HTS.
At the county level, we interviewed county and sub-county AIDS coordinators (CASCOs, sub-CASCOs) who are NASCOP staff who translate national HTS policy at the counties and sub-counties, respectively. At the facility level, we interviewed facility-in-charges who are government workers supervising individual healthcare facilities and supporting policy implementation and service delivery. At the community level, we interviewed community representatives who are trusted community members appointed by local leaders as liaisons between their communities and the healthcare facilities. They were selected after discussions with facility-in-charges and PATH-Kenya staff to gain community perspectives on aPS integration. We included this group during the follow-up interviews when it became apparent at baseline that we were missing the voices of the communities receiving aPS.
Conceptual framework
We developed our conceptual framework after extensive review of literature on integration of new interventions into national programs, and combined concepts from three theoretical frameworks, namely integration by Grepin & Reich, institutionalization by Goodman & Steckler, and sustainability by Pluye (Figs 1 and 2) [22,24,30]. Integration was defined as the creation of linkages between aPS and the existing HTS program [22]; institutionalization was defined as the viability of aPS [24]; and sustainability was defined as the long-term continuation of aPS in HTS [30].
Integration was operationalized in three ways: full, partial, or minimal integration, referring to complete, incomplete, or limited aPS incorporation to HTS, respectively [22].
Institutionalization was operationalized using a two-dimensional matrix of organizational subsystems and levels of institutionalization [24]. We defined five organizational sub-systems: 1) adaptive subsystem that modifies MOH’s organizational structure and processes to allow for aPS; 2) supportive subsystem that procures resources for aPS provision; 3) maintenance subsystem that reinforces the roles of aPS staff; 4) production subsystem that delivers aPS through HTS providers by offering partner elicitation, tracing, and notification services; and 5) managerial subsystem that reviews key aPS indicators. We also defined three levels of institutionalization: passages that describe the introduction of aPS into HTS, routinization that describes its recurrent adoption through cycles e.g., budget cycles, and niche saturation that refers to long-term aPS provision within HTS.
Sustainability was operationalized in three ways: weak sustainability–absence of aPS routines, medium sustainability–presence of non-standard aPS routines e.g., activities not supported through government endorsed tools, and strong sustainability—presence of aPS that are supported at state level e.g. through government supported aPS guidelines [30].
Study procedures and data collection
Key aPS stakeholders were approached to participate in IDIs, each lasting one to two hours. IDIs were conducted at baseline and follow-up to better understand perceived changes in aPS integration over time. Baseline interviews were conducted in two phases; first, from August-September 2018 in Kisumu, and second from January-June 2019 in Homa Bay as its facilities entered the study five months after the start of the Kisumu baseline interviews. Follow-up interviews occurred approximately one and a half years later from May-August 2020 in both counties.
Semi-structured interview guides based on the conceptual framework were administered (S2 and S3 Files). IDIs were conducted either in person or on phone in either English, Swahili, or Luo by two qualified qualitative interviewers (baseline: CO, follow-up: MO), neither of whom were known to the respondents. While the baseline interviews were conducted in person, all the follow-up interviews were conducted on phone due to COVID-19 social distancing restrictions. IDIs were audio-recorded and transcribed by a transcriber familiar with the three languages. The qualitative interviewers verified all transcripts and corrected any inconsistencies.
Data analysis
Personal identifiers were removed from recorded interviews and corresponding transcripts which were then assigned identification numbers. CO, MO, and BMW used deductive and inductive coding to develop the codebook based on structured codes from the conceptual framework and emerging codes from the interviews. We identified 112 codes that were organized into 10 themes and 34 sub-themes. The codebook was pilot tested on two transcripts and revised. Researchers then coded the remaining transcripts independently, reviewed each other’s coded transcripts, and reached consensus through discussion. Interview transcripts were analyzed using thematic content analysis and coders wrote memos to organize conceptual categories and track emerging insights on the data. Demographic characteristics of the interviewees, selected excerpts of interview quotes, and the degree of integration have been presented using tables and quotes. Analyses were conducted using ATLAS.Ti version 8.4.4 and Microsoft Excel.
Ethical considerations
This study received ethical approval from the Kenyatta National Hospital–University of Nairobi Ethics and Research Committee (P465/052017) and the University of Washington Institutional Review Board (STUDY00002420). All interviewees provided written informed consent prior to participation.
Results
Sociodemographic characteristics for the 32 aPS stakeholders are described in Table 1. Five MOH policy makers, 10 HIV implementing partner organization representatives, five CASCO/SCASCOs, eight facility-in-charges, and four community representatives were interviewed. Most interviewees had post-secondary education, and there was an almost equal number of male and female interviewees.
aPS integration, institutionalization, and sustainability by HTS subsystem
At baseline, aPS had been fully integrated into the national HTS procurement and logistics systems (supportive subsystem) and this persisted into program roll-out. This included the routine supply of medical supplies and commodities to support HTS for traced sex partners e.g., HIV test kits and gloves. It was seen to have strong sustainability since procurement procedures were well prescribed and supported by the national medical supplies’ reporting tools (Table 2, Fig 3).
At both baseline and follow-up, aPS had been fully integrated into HTS delivery (production subsystem) (Table 2, Fig 3). It had been routinized as a daily task for all HTS providers and was considered part of their key performance indicators. aPS procedures and metrics were also well defined in the national aPS guidelines indicating strong sustainability of the intervention.
There was partial integration of aPS into the adaptive subsystem (planning, sensitization) at baseline that persisted into follow-up (Table 2, Fig 3). Although the MOH had finalized on aPS guidelines and training materials, community level sensitization was lagging due to lack of a clear communication strategy. At follow-up, there were well-defined planning cycles including quarterly and annual work plans included in the aPS guidelines indicating strong sustainability. However, the lack of a communication strategy meant that low community awareness persisted.
At baseline and follow-up, there was partial integration of aPS in monitoring, evaluation, and supervision by CASCOs, sub-CASCOs and implementing partner organization staff (managerial subsystem) (Table 2, Fig 3). There was a failure to integrate aPS indicators into the national HTS register that had just been updated prior to aPS being adopted into the HTS program. aPS indicators were, therefore, collected on separate data collection tools provided by the implementing partner organizations at the facility level and relayed through the counties to the national level, making it difficult to proactively track the status of aPS in the country. Despite this challenge, the presence of clear aPS indicators in the national aPS guidelines indicated strong sustainability with plans for the MOH to revise the HTS registers at a later date.
There was partial integration observed in the recruitment and training of HTS providers (maintenance subsystem) at both baseline and follow-up (Table 2, Fig 3). At baseline, training of HTS providers on aPS was ongoing largely through support from implementing partner organizations. At the same time, the county governments had halted the hiring of new HTS providers due to funding limitations. At follow-up, refresher training on aPS was ongoing. It also emerged that implementing partner organizations were hiring contract HTS providers with approval from the county governments due to persistent funding challenges at the county level, compromising the sustainability of the intervention.
Funding emerged as a key standalone theme that had not been distinctly outlined in our conceptual framework (Table 2, Fig 3). At both baseline and follow-up, funding budgets had not been integrated with implementing partner organizations operating their own aPS budgets separate from the government. To facilitate county-wide aPS activities, CASCO / SCASCOs held annual work plan meetings with implementing partner organizations to align on budgetary support for aPS related activities. However, the lack of funding budget for aPS ratified by the government compromised sustainability of the intervention.
Barriers to aPS integration
Major barriers to aPS integration included human resource constraints, funding gaps, and client concerns with aPS (Table 3). First of all, stakeholders reported that hiring restrictions on HTS providers constrained service delivery leading to demotivation among existing providers and poor performance in some facilities. Secondly, they felt that limited government funding led to inadequate mentorship, training, and supervision of aPS compromising the service quality. Lastly, client concerns regarding privacy, confidentiality and safety due to inadequate community sensitization on aPS contributed to low client awareness.
Facilitators of aPS integration
Stakeholders noted two crucial facilitators to aPS integration (Table 3). First, they noted that aPS was resource intensive requiring additional funding and human resources to effectively facilitate partner tracing and notification. Additional resources would go a long way in facilitating aPS integration and service delivery. Secondly, stakeholders thought that community health volunteers (CHVs) could play a pivotal role in increasing community awareness of aPS and supporting HTS providers during partner tracing and notification.
Discussion
From 2016 to 2018, Kenya had made significant progress in integrating aPS into its national HTS program with varying levels of integration across organizational subsystems. Overall, aPS had become routine practice supported by national guidelines and policies that detailed inputs, processes and procedures implying high sustainability of the intervention. Funding limitations, staff hiring constraints, and low community awareness were key barriers to effective integration. However, increased resource allocation towards aPS-related activities, and strategies to promote community awareness would go a long way in improving its integration.
aPS comes along side several other interventions that have been integrated to HTS programs e.g., tuberculosis (TB) screening, provision of PrEP, and family planning [26,27,31]. In our study, we found that aPS had been fully integrated into procurement and service delivery indicating that partner notification services were being provided to clients. Despite this improved access to aPS, challenges were noted during implementation, similar to other studies. In a systematic review of integrated HIV / TB services, there was improved TB case-finding among clients testing for HIV [31]. Despite the feasibility of this integration, authors encountered programmatic, staffing, infrastructural challenges due to paucity of financial and human resources that negatively impacted the integration process, akin to what we found in our study [32]. MOH policymakers will need to ensure adequate financial support to ensure sustainability of programs even as external funding support declines.
In our study, we found partial integration in recruitment, training, monitoring, evaluation, and supervision of HTS providers (maintenance and managerial subsystems) largely due to limited government funding. Implementing partner organizations, which play a major role supporting aPS budgets, might be hesitant to support budgets to which both the national or county governments have not committed any resources. Similar challenges were noted in family planning integration where human resource challenges, inadequate planning and limited budgets were noted as key impediments [27]. In in Zimbabwe, competing clinical responsibilities and insufficient training budgets were seen as major limitations to family planning integration [33]. Policymakers will need to negotiate with national treasuries to support hiring and training of HTS providers to support aPS and engage contract staff as a stopgap measure in case of limited funding.
We found low community awareness of aPS, similar to a systematic review evaluating the integration of essential family planning and prevention of mother to child transmission interventions to HTS [27]. Participants reported poor access to family planning information with authors recommending the incorporation of female peer educators living with HIV to deliver family planning information to the community. In our study, stakeholders advocated for a two-pronged approach involving: (1) a comprehensive community engagement strategy to improve mass education on both aPS and HIV testing, and (2) an individualized approach offering targeted aPS and HTS to sex partners through HTS providers and CHVs. These approaches will improve awareness on aPS but will require extensive stakeholder consultations on resource allocation against competing health interests e.g., COVID-19 response.
Another program that has recently been integrated to the national HTS program in Kenya is PrEP. In a review of PrEP integration in the country, authors noted service bottlenecks as a challenge to integration with clients initiating PrEP spending an additional 18 minutes on PrEP-specific activities [26]. aPS integration into HTS could potentially lead to such bottlenecks when traced sex partners are referred for further care and treatment at health facilities. Healthcare managers will need to anticipate such constraints and either avail the necessary resources or adapt HTS infrastructure to support additional patients. This may include engaging volunteer HTS providers to elicit, trace, notify, test and link sex partners.
Our study had several strengths. First, we used a conceptual framework combining concepts from program integration, institutionalization, and program sustainability literature, providing a holistic assessment of integration across subsystems. Second, using a subsystems approach, we were able to gain a more granular view of aPS integration. Such an approach will enable stakeholders to more accurately identify integration gaps and develop mitigation plans as appropriate. Third, using qualitative data collected at two time-points, we were able to demonstrate aPS integration over time, highlighting areas with persistent challenges and recommend improvements. Lastly, our purposive sampling approach that included national, county and community level stakeholders enabled a more inclusive view of aPS integration through the different healthcare levels in Kenya.
There are several limitations and methodological challenges in our study. First, our sample size was small compared to those typically used in quantitative studies. However, it was appropriate for qualitative research as it gave an in-depth understanding of stakeholder viewpoints. Second, due to changes in interviewer availability, we engaged two different qualitative researchers at baseline and follow-up which might have affected the consistency of the interviews. However, both interviewers thoroughly reviewed the conceptual framework, interview guides, and codebook before conducting the interviews to ensure uniformity. Third, baseline interviews were conducted at different times because Homa Bay facilities entered the study five months after the start of Kisumu baseline interviews. These temporal differences might have affected the baseline context of aPS integration in the country. Lastly, follow-up interviews were conducted on phone, and not in-person, due to COVID-19 social distancing restrictions which might have led to potential loss of contextual data and compromised probing.
Conclusion
In summary, our study systematically assessed the integration of aPS into Kenya’s national HTS program. We observed varying degrees of aPS integration across different subsystems highlighting challenges in funding, human resource, and public awareness. To overcome these barriers, we recommend increased resource allocation (funding, human resources) and widespread community-level awareness on aPS. As aPS is being scaled up across many high HIV-burden African countries, further evaluation of national integration efforts and mitigation strategies against implementation gaps is required.
Supporting information
S1 File. Inclusivity questionnaire: PLOS questionnaire on inclusivity in global research.
https://doi.org/10.1371/journal.pgph.0001586.s001
(DOCX)
S2 File. Interview guide: Baseline interview guides.
https://doi.org/10.1371/journal.pgph.0001586.s002
(PDF)
S3 File. Interview guide: Follow-up interview guides.
https://doi.org/10.1371/journal.pgph.0001586.s003
(PDF)
Acknowledgments
The authors would like to acknowledge the contributions of the Kenya Ministry of Health, PATH, the aPS scale-up study team, healthcare workers, and the participants.
References
- 1.
Global HIV & AIDS statistics—Fact sheet. [cited 7 Oct 2022]. Available: https://www.unaids.org/en/resources/fact-sheet.
- 2.
World Health Organization. Guidelines on HIV self-testing and partner notification: supplement to consolidated guidelines on HIV testing services. World Health Organization; 2016.
- 3.
Joint United Nations Programme on HIV/AIDS (UNAIDS). Understanding fast-track. Accelerating action to end the aids epidemic by 2030. Geneva: UNAIDS; 2015.
- 4.
Index and partner notification testing toolkit. In: PEPFAR Solutions Platform (BETA) [Internet]. [cited 12 Oct 2022]. Available: https://www.pepfarsolutions.org/tools-2/2018/4/11/index-and-partner-notification-testing-toolkit.
- 5. Henley C, Forgwei G, Welty T, Golden M, Adimora A, Shields R, et al. Scale-up and case-finding effectiveness of an HIV partner services program in Cameroon: an innovative HIV prevention intervention for developing countries. Sexually Transmitted Diseases. 2013;40: 909–914. pmid:24220349
- 6. Hogben M, McNally T, McPheeters M, Hutchinson AB. The effectiveness of HIV Partner counseling and referral services in increasing identification of HIV-positive individuals: A systematic review. American Journal of Preventive Medicine. 2007;33: S89–S100. pmid:17675019
- 7. Mathews C, Coetzee N, Zwarenstein M, Lombard C, Guttmacher S, Oxman A, et al. A systematic review of strategies for partner notification for sexually transmitted diseases, including HIV/AIDS. International Journal of STD & AIDS. 2002;13: 285–300. pmid:11972932
- 8. Landis SE, Schoenbach VJ, Weber DJ, Mittal M, Krishan B, Lewis K, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. New England Journal of Medicine. 1992;326: 101–106. pmid:1445500
- 9. Cherutich P, Golden MR, Wamuti B, Richardson BA, Ásbjörnsdóttir KH, Otieno FA, et al. Assisted partner services for HIV in Kenya: a cluster randomised controlled trial. The Lancet HIV. 2017;4: e74–e82. pmid:27913227
- 10. Wamuti BM, Erdman LK, Cherutich P, Golden M, Dunbar M, Bukusi D, et al. Assisted partner notification services to augment HIV testing and linkage to care in Kenya: study protocol for a cluster randomized trial. Implementation Science. 2015;10: 23. pmid:25884936
- 11. Sharma M, Smith JA, Farquhar C, Ying R, Cherutich P, Golden M, et al. Assisted partner notification services are cost-effective for decreasing HIV burden in western Kenya. AIDS. 2018;32: 233–241. pmid:29135576
- 12. Goyette MS, Mutiti PM, Bukusi D, Wamuti BM, Otieno FA, Cherutich P, et al. HIV assisted partner services among those with and without a history of intimate partner violence in Kenya. Journal of Acquired Immune Deficiency Syndromes. 2018.
- 13. Singal AG, Higgins PD, Waljee AK. A primer on effectiveness and efficacy trials. Clinical and Translational Gastroenterology. 2014;5: e45. pmid:24384867
- 14. Myers RS, Feldacker C, Cesár F, Paredes Z, Augusto G, Muluana C, et al. Acceptability and effectiveness of assisted Human Immunodeficiency Virus partner services in Mozambique: Results From a Pilot Program in a Public, Urban Clinic. Sexually Transmitted Diseases. 2016;43: 690–695. pmid:27893598
- 15. Kamanga G, Brown L, Jawati P, Chiwanda D, Nyirenda N. Maximizing HIV partner notification opportunities for index patients and their sexual partners in Malawi. Malawi Medical Journal. 2015;27: 140–144. pmid:26955435
- 16. Kahabuka C, Plotkin M, Christensen A, Brown C, Njozi M, Kisendi R, et al. Addressing the first 90: a highly effective partner notification approach reaches previously undiagnosed sexual partners in Tanzania. AIDS and Behavior. 2017;21: 2551–2560. pmid:28299518
- 17. Nguyen VTT, Phan HT, Kato M, Nguyen Q, Le Ai KA, Vo SH, et al. Community‐led HIV testing services including HIV self‐testing and assisted partner notification services in Vietnam: lessons from a pilot study in a concentrated epidemic setting. Journal of the International AIDS Society. 2019;22: e25301. pmid:31321903
- 18. Malik M, Jamil MS, Johnson CC, Pasha MS, Hermez J. Integrating assisted partner notification within HIV prevention service package for people who inject drugs in Pakistan. Journal of the International AIDS Society. 2019;22. pmid:31321894
- 19. Brown LB, Miller WC, Kamanga G, Nyirenda N, Mmodzi P, Pettifor A, et al. HIV partner notification is effective and feasible in sub-Saharan Africa: opportunities for HIV treatment and prevention. Journal of Acquired Immune Deficiency Syndrome. 2011;56: 437–442. pmid:22046601
- 20. Little KM, Kan M, Samoylova O, Rsaldinova A, Saliev D, Ishokov F, et al. Implementation experiences and insights from the scale‐up of an HIV assisted partner notification intervention in Central Asia. Journal of the International AIDS Society. 2019;22: e25313. pmid:31321890
- 21. Plotkin M, Kahabuka C, Christensen A, Ochola D, Betron M, Njozi M, et al. Outcomes and experiences of men and women with partner notification for HIV testing in Tanzania: Results from a Mixed Method Study. AIDS Behaviour. 2018;22: 102–116. pmid:29090397
- 22. Grepin KA, Reich MR. Conceptualizing integration: a framework for analysis applied to neglected tropical disease control partnerships. PLoS Neglected Tropical Diseases. 2008;2: e174. pmid:18446203
- 23.
Katz D, Kahn RL. The social psychology of organizations. Wiley New York; 1978.
- 24. Goodman RM, Steckler A. A model for the institutionalization of health promotion programs. Family & Community Health. 1989;11: 63–78.
- 25. Mutisya R, Wambua J, Nyachae P, Kamau M, Karnad SR, Kabue M. Strengthening integration of family planning with HIV/AIDS and other services: experience from three Kenyan cities. Reproductive Health. 2019;16: 1–8.
- 26. Pintye J, Kinuthia J, Roberts DA, Wagner AD, Mugwanya K, Abuna F, et al. Integration of PrEP services into routine antenatal and postnatal care: experiences from an implementation program in Western Kenya. Journal of acquired immune deficiency syndromes (1999). 2018;79: 590.
- 27. Haberlen SA, Narasimhan M, Beres LK, Kennedy CE. Integration of family planning services into HIV care and treatment services: a systematic review. Studies in family planning. 2017;48: 153–177. pmid:28337766
- 28. Kariithi E, Sharma M, Kemunto E, Lagat H, Otieno G, Wamuti BM, et al. Using assisted partner services for HIV testing and the treatment of males and their female sexual partners: Protocol for an implementation science study. JMIR research protocols. 2021;10: e27262. pmid:34014172
- 29.
National AIDS and STI Control Programme (NASCOP), Preliminary KENPHIA 2018 Report. Nairobi: NASCOP; 2020.
- 30. Pluye P, Potvin L, Denis J-L. Making public health programs last: conceptualizing sustainability. Evaluation and program planning. 2004;27: 121–133.
- 31. Uyei J, Coetzee D, Macinko J, Guttmacher S. Integrated delivery of HIV and tuberculosis services in sub-Saharan Africa: a systematic review. The Lancet infectious diseases. 2011;11: 855–867. pmid:22035614
- 32. Howard AA, El-Sadr WM. Integration of tuberculosis and HIV services in sub-Saharan Africa: lessons learned. Clinical Infectious Diseases. 2010;50: S238–S244. pmid:20397954
- 33. Sarnquist CC, Moyo P, Stranix-Chibanda L, Chipato T, Kang JL, Maldonado YA. Integrating family planning and prevention of mother to child HIV transmission in Zimbabwe. Contraception. 2014;89: 209–214. pmid:24332254