Partner notification techniques

Public health opportunities and challenges in the provision of partner notification services: the New England experience

BACKGROUND

Partner notification services (PNS) are recommended by the Centers for Disease Control and Prevention as a public health intervention for addressing the spread of HIV and other sexually transmitted diseases (STDs). Barriers and facilitators to the partner notification process from a public health perspective have not been well described.

METHODS

In 2015, a coalition of New England public health STD directors and investigators formed to address the increasing STD prevalence across the region (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) and to promote communication between state STD programs. To evaluate barriers and facilitators of PNS programs, a survey was administered to representatives from each state to describe PNS processes and approaches.

RESULTS

Of the six PNS programs, Connecticut, Maine, Massachusetts, Vermont, and New Hampshire had combined HIV and STD PNS programs; Rhode Island's programs were integrated but employed separate disease intervention specialists (DIS). All states performed PNS for HIV and syphilis. Maine, New Hampshire and Vermont performed services for all gonorrhea cases. Rhode Island, Connecticut, and Massachusetts performed limited partner notification for gonorrhea due to lack of resources. None of the six states routinely provided services for chlamydia, though Maine and Vermont did so for high-priority populations such as HIV co-infected or pregnant individuals. Across all programs, clients received risk reduction counseling and general STD education as a component of PNS, in addition to referrals for HIV/STD care at locations ranging from Planned Parenthood to community- or hospital-based clinics. Notable barriers to successful partner notification across all states included anonymous partners and index cases who did not feel comfortable sharing partners' names with DIS. Other common barriers included insufficient staff, inability of DIS to identify and contact partners, and index cases declining to speak with DIS staff.

CONCLUSIONS

In New England, state health departments use different strategies to implement PNS programs and referral to STD care. Despite this, similar challenges exist across settings, including difficulty with anonymous partners and limited state resources.

The effectiveness of HIV partner counseling and referral services in increasing identification of HIV-positive individuals a systematic review

Partner counseling and referral services (PCRS) are part of the spectrum of care for HIV-positive people and their sexual or needle-sharing partners. Referral includes notifying partners of exposure, after which they are (ideally) tested and receive prevention or risk reduction counseling or enter into care (if they test positive). Using The Guide to Community Preventive Services's methods for systematic reviews, the effectiveness of PCRS was evaluated, including partner notification, in identifying a population at high risk of HIV infection and in increasing testing in those populations. In this review, PCRS efforts using provider referral were found to be effective in reaching a population with a high prevalence of HIV. Nine studies qualified for the review. In these studies, a range of one to eight partners was identified per index case (a person newly diagnosed with HIV who has partners who should be notified); a mean of 67% of identified partners were found and notified of their potential exposure to HIV, and a mean of 63% of those notified were tested (previously known "positives" were not tested). Of those tested, a mean of 20% were HIV positive. Therefore, even given that not all partners could be found and notified and that some who could be found did not accept testing, 1% to 8% of people named as potentially exposed and not previously known to be HIV positive were identified as HIV positive through partner notification (although these people were not necessarily infected by the index case). Evidence was insufficient to determine whether PCRS, including partner notification, was also effective in changing behavior or reducing transmission because available studies did not generally report on these outcomes. Little empirical evidence was available to assess potential harm of the interventions, but current studies have not shown substantial harms. Based on Community Guide rules of evidence, sufficient evidence shows that PCRS with partner notification by a public health professional ("provider referral") effectively increases identification of a high-prevalence target population for HIV testing.

The transformation of partner notification

Since 1996, several traditional epidemiological studies of program efficacy have done little to alter the fixed opinions of promoters or detractors of partner notification. Modeling studies have appeared that confirm the value of the contact-tracing approach in locating and treating persons who may be important in transmission. These provide a theoretical base for a number of empirical studies that have applied social network methods to classical partner-notification approaches, which have demonstrated the dense networks and geographic clustering of persons involved in sexually transmitted disease transmission and have provided justification for focusing efforts on small groups that may be critical to epidemicity or its maintenance. These initial studies would appear to warrant a broad-based inclusion of network concepts into programmatic activities, with careful monitoring and analysis of the impact they have on both the traditional indices of partner notification as well as the larger effect on disease transmission.

Risk factors for syphilis among incarcerated women in Rhode Island

Syphilis remains a significant problem in the United States. The prison environment is an ideal location to identify and treat syphilis. We undertook this study to describe the correlates and risk factors for syphilis among incarcerated women in Rhode Island. The study design was a review of all cases of syphilis identified through routine screening in the state prison and a case control study. Between 1992 and 1998, among 6,249 incarcerated women, 86 were found to have syphilis; of these, 29 were primary and secondary cases representing 49% of infectious cases of syphilis in women in the state. The prison environment offers a unique opportunity for the diagnosis and treatment of syphilis.