Secondary prevention of STD transmission during adolescence: Partner notification

Approach to Managing Sex Partners of People with Sexually Transmitted Infections

Partner management of sexually transmitted infection (STIs) is essential to identify and treat new cases, prevent reinfection in the index case, interrupt chains of transmission, reduce STI-related morbidity, and target STI screening and treatment interventions. The responsibility for partner notification and treatment falls on the health care provider. Approaches to partner management include patient referral, provider referral, contractual referral, and expedited partner therapy (EPT), with EPT and enhanced partner referral outperforming other methods. This article provides an overview of clinical recommendations regarding partner management, with particular emphasis on EPT, and an update on new and emerging evidence in the field.

Differences in Sexual Behavior and Partner Notification for Sexually Transmitted Infections Between the Out of School Youth and University Students in a Peri-Urban District in South Africa-A Cross-Sectional Survey

The increase in sexually transmitted infections (STIs) in young people is a public health concern. Among those in university and out of school, different contextual factors contribute to their risky sexual behavior and increased susceptibility to STIs and HIV. There are limited comparative studies examining risky sexual behavior and partner notification (PN) between these two groups, particularly in South Africa. We investigated sexual behaviors, self-reported STI diagnosis, health seeking behavior, and preferred PN methods of university students and out of school youth. A descriptive cross-sectional survey was used using convenient sampling to select 917 students across five health sciences universities and through periodic sampling 699 out of school youth were selected from two main local shopping centers in South Africa. Descriptive statistics, bivariate and multivariable logistic analysis were performed using Stata IC version 14. More university students (71.7%) than out of school youth were in casual relationships (28.3%), with half of out of school youth being in steady relations (50.2%). Moreover, university students (65.7%) used a condom in the past 6 months compared to their counterparts (34.3%). Of the 124 youth who were diagnosed with STI in the past 12 months, majority (n = 106, 85%) were out of school youth. The probability of notifying a partner about a STI infection was 82% among university students compared to their counterparts (p = >0.05). The odds of notifying a partner was 1.79 times more for those having multiple sexual partners than those who had only one partner. Both groups preferred a face-to-face STI disclosure with partner; however, more university students (67%) preferred SMS notification than PN referral slips as compared to out of school youth (42%). Both the university students and the out of school youth engaged in risky sexual behaviors. Both groups preferred face-to-face and clinic SMS partner notifications, even though university students were in the majority. There is a need for developing health promotion scripts on disclosing STIs to sexual partners to empower the majority of the youth who prefer face-to-face PN over the prescribed methods.

Survey of partner notification practices for sexually transmissible infections in the United States

Background Partner notification (PN) for sexually transmissible infections (STIs) is a vital STI control method. The most recent evaluation of PN practices in the United States, conducted in 1999, indicated that few STI patients were offered PN services. The objectives of this study were to obtain a preliminary understanding of the current provision of PN services in HIV/STI testing sites throughout the US and to determine the types of PN services available.

METHODS

A convenience sample of 300 randomly selected testing sites was contacted to administer a phone survey about PN practices. These sites were from a large database maintained by the Centers for Disease Control and Prevention. Sites were eligible to participate if they provided testing services for chlamydia, gonorrhoea, HIV or syphilis and were not hospitals or Planned Parenthood locations.

RESULTS

Of the 300 eligible sites called, 79 sites were successfully reached, of which 74 agreed to participate, yielding a response rate of 24.7% and a cooperation rate of 93.7%. Most surveyed testing sites provided some form of PN service (anonymous or non-anonymous) on site or through an affiliate for chlamydia (100%), gonorrhoea (97%), HIV (91%) and syphilis (96%) infection. Anonymous PN services were available at 67-69% of sites. Only 6-9% of sites offered Internet-based PN services.

CONCLUSIONS

Most surveyed testing sites currently offer some type of PN service for chlamydia, gonorrhoea, HIV or syphilis infection. However, approximately one-third of surveyed sites do not offer anonymous services. Novel, Internet-based methods may be warranted to increase the availability of anonymous services.

Partner Notification for Youth Living With HIV in 14 Cities in the United States

BACKGROUND

Identifying factors associated with partner notification among youth living with HIV is critical for effective HIV prevention and treatment strategies.

METHODS

A total of 924 male and female behaviorally infected youth aged 13-24 across 14 U.S. cities completed an audio computer-assisted self-interview including questions about demographics and experiences with patient- and provider-referral partner notification.

RESULTS

The majority of participants self-identified as male (82.5%), Black/non-Hispanic (70.1%), and Hispanic/Latino (18.2%). Most males (93.4%) reported engaging in male-to-male sexual contact. Over three-quarters (77.6%) reported that all or some of their partners were contacted, while 22.4% indicated that none were contacted regarding potential HIV exposure. Most (52.4%) reported that only one person talked to them about notifying partners including the HIV tester (36.5%) followed by their health care provider/doctor (27.6%). Less than a fifth (18.3%) were themselves notified of their own exposure to HIV. Using multivariable logistic regression, 3 factors were associated with successful partner notification: (1) when more than one person talked to participants about partner notification (AOR = 1.87, 1.33-2.62); (2) if they themselves had been notified of their own HIV exposure (AOR = 1.83, 1.13-2.95); and (3) if their education included some college or technical school versus less than high school (AOR = 1.72, 1.04-2.85).

CONCLUSIONS

Partner notification among youth living with HIV is unsuccessful at least 22.4% of the time, although minimal criteria for partner services are being met almost universally. Partner notification might benefit from enhanced guidelines that call for both HIV testers and HIV care providers to discuss this important strategy with HIV-positive youth.

Experiences and outcomes of partner notification among men and women recently diagnosed with Chlamydia and their views on innovative resources aimed at improving notification rates

OBJECTIVE

To describe the partner notification experiences of individuals diagnosed with chlamydia and to determine what supports might best assist them.

GOAL

To determine what supports might best assist chlamydia infected individuals to notify their partners.

STUDY DESIGN

A telephone survey was undertaken with men and women recently diagnosed with chlamydia across 3 Australian jurisdictions between August 2007 and January 2008.

RESULTS

Of the 286 individuals who agreed to be contacted about the study, 202 (71%) completed the survey. Twenty-three percent (333/1458) of recent partners were notified: men who had sex with men (MSM) notified 15% (133/880) of their partners, heterosexual men 31% (114/370), and women 46% (86/188) of their partners (P < 0.001). Overall, 84% (169/202) of individuals notified at least one partner. The main reasons for informing partners were out of concern for them (44%) or because it was considered "the right thing to do" (37%). The preferred methods for contacting partners were telephone (52%) and face-to-face (30%). E-mail (8%) and short message service (SMS) (11%) were less commonly used; however, if offered a website with anonymous e-mail and SMS services, nearly half of individuals indicated they would find this useful. Of those who had not informed all partners with known contact details (n = 94), 34% reported that if web-based tools were available they would have contacted more partners. Over half of participants would like to have been given antibiotics to give to their partner.

CONCLUSION

The availability of tailored resources may assist in improving partner notification for chlamydia.

Strategies for partner notification for sexually transmitted infections, including HIV

BACKGROUND

Partner notification (PN) is the process whereby sexual partners of an index patient are informed of their exposure to a sexually transmitted infection (STI) and the need to obtain treatment. For the person (index patient) with a curable STI, PN aims to eradicate infection and prevent re-infection. For sexual partners, PN aims to identify and treat undiagnosed STIs. At the level of sexual networks and populations, the aim of PN is to interrupt chains of STI transmission. For people with viral STI, PN aims to identify undiagnosed infections, which can facilitate access for their sexual partners to treatment and help prevent transmission.

OBJECTIVES

To assess the effects of different PN strategies in people with STI, including human immunodeficiency virus (HIV) infection.

SEARCH METHODS

We searched electronic databases (the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE) without language restrictions. We scanned reference lists of potential studies and previous reviews and contacted experts in the field. We searched three trial registries. We conducted the most recent search on 31 August 2012.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) or quasi-RCTs comparing two or more PN strategies. Four main PN strategies were included: patient referral, expedited partner therapy, provider referral and contract referral. Patient referral means that the patient notifies their sexual partners, either with (enhanced patient referral) or without (simple patient referral) additional verbal or written support. In expedited partner therapy, the patient delivers medication or a prescription for medication to their partner(s) without the need for a medical examination of the partner. In provider referral, health service personnel notify the partners. In contract referral, the index patient is encouraged to notify partner, with the understanding that the partners will be contacted if they do not visit the health service by a certain date.

DATA COLLECTION AND ANALYSIS

We analysed data according to paired partner referral strategies. We organised the comparisons first according to four main PN strategies (1. enhanced patient referral, 2. expedited partner therapy, 3. contract referral, 4. provider referral). We compared each main strategy with simple patient referral and then with each other, if trials were available. For continuous outcome measures, we calculated the mean difference (MD) with 95% confidence intervals (CI). For dichotomous variables, we calculated the risk ratio (RR) with 95% CI. We performed meta-analyses where appropriate. We performed a sensitivity analysis for the primary outcome re-infection rate of the index patient by excluding studies with attrition of greater than 20%. Two review authors independently assessed the risk of bias and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We included 26 trials (17,578 participants, 9015 women and 8563 men). Five trials were conducted in developing countries. Only two trials were conducted among HIV-positive patients. There was potential for selection bias, owing to the methods of allocation used and of performance bias, owing to the lack of blinding in most included studies. Seven trials had attrition of greater than 20%, increasing the risk of bias.The review found moderate-quality evidence that expedited partner therapy is better than simple patient referral for preventing re-infection of index patients when combining trials of STIs that caused urethritis or cervicitis (6 trials; RR 0.71, 95% CI 0.56 to 0.89, I(2) = 39%). When studies with attrition greater than 20% were excluded, the effect of expedited partner therapy was attenuated (2 trials; RR 0.8, 95% CI 0.62 to 1.04, I(2) = 0%). In trials restricted to index patients with chlamydia, the effect was attenuated (2 trials; RR 0.90, 95% CI 0.60 to 1.35, I(2) = 22%). Expedited partner therapy also increased the number of partners treated per index patient (three trials) when compared with simple patient referral in people with chlamydia or gonorrhoea (MD 0.43, 95% CI 0.28 to 0.58) or trichomonas (MD 0.51, 95% CI 0.35 to 0.67), and people with any STI syndrome (MD 0.5, 95% CI 0.34 to 0.67). Expedited partner therapy was not superior to enhanced patient referral in preventing re-infection (3 trials; RR 0.96, 95% CI 0.60 to 1.53, I(2) = 33%, low-quality evidence). Home sampling kits for partners (four trials) did not result in lower rates of re-infection in the index case (measured in one trial), or higher numbers of partners elicited (three trials), notified (two trials) or treated (one trial) when compared with simple patient referral. There was no consistent evidence for the relative effects of provider, contract or other patient referral methods. In one trial among men with non-gonococcal urethritis, more partners were treated with provider referral than with simple patient referral (MD 0.5, 95% CI 0.37 to 0.63). In one study among people with syphilis, contract referral elicited treatment of more partners than provider referral (MD 2.2, 95% CI 1.95 to 2.45), but the number of partners receiving treatment was the same in both groups. Where measured, there was no statistical evidence of differences in the incidence of adverse effects between PN strategies.

AUTHORS' CONCLUSIONS

The evidence assessed in this review does not identify a single optimal strategy for PN for any particular STI. When combining trials of STI causing urethritis or cervicitis, expedited partner therapy was more successful than simple patient referral for preventing re-infection of the index patient but was not superior to enhanced patient referral. Expedited partner therapy interventions should include all components that were part of the trial intervention package. There was insufficient evidence to determine the most effective components of an enhanced patient referral strategy. There are too few trials to allow consistent conclusions about the relative effects of provider, contract or other patient referral methods for different STIs. More high-quality RCTs of PN strategies for HIV and syphilis, using biological outcomes, are needed.

Partner notification of sexually transmitted infections among pregnant women

The object of this study was to determine the factors associated with partner notification (PN) of sexually transmitted infection (STI) exposure among pregnant, low income, Mexican-American (MA) and African-American (AA) women and their male sexual partners. We used a cross-sectional analysis of 166 pregnant women with an STI, enrolled in a randomized controlled trial of behavioural intervention to prevent recurrent STIs. The primary outcome, PN, is notification of, or intent to notify male sexual partner(s) of STI exposure. Pregnant women with one (n = 136) versus multiple (n = 30) partners reported PN for 88.2% and 54.5% of male partners, respectively (P < 0.001). Multivariate logistic regression demonstrated three variables that independently predicted PN: a steady relationship, with one male sexual partner and recent (<30 days) intercourse with the partner. Among the low income, pregnant MA and AA women, the three relationship variables predicted 81.6% of PN and correctly classified 78.5% of males notified and 65.7% of males not notified.

Preventing recurrent sexually transmitted diseases in minority adolescents: a randomized controlled trial

OBJECTIVE

To compare the efficacy of a randomized controlled trial of the Sexual Awareness For Everyone (SAFE) behavioral intervention on teenagers (aged 14 to 18 years) compared with adult rates of reinfection with Neiserria gonorrhea or Chlamydia trachomatis cervicitis, and to identify behaviors associated with recurrent infection.

METHODS

Mexican-American and African-American females with a nonviral sexually transmitted disease (STD) were enrolled in SAFE or assigned to the control group. All participants were interviewed and examined at baseline, 6, and 12 months. The primary outcome variable was reinfection with N. gonorrhea or C. trachomatis. Secondary outcomes were changes in risky sexual behavior.

RESULTS

Teens randomized to participation in SAFE had a statistically lower incidence of recurrent N. gonorrhea and C. trachomatis at 0 to 6 months (52%, P=.04) and cumulatively (39%, P=.04) compared with teens in the control group. Cumulatively, teens as a group had higher rates of reinfection (33.1%) than adults (14.4%) (P<.001). Adolescent reinfection was explained by unprotected sex with untreated partners (adjusted odds ratio [OR] 5.58), nonmonogamy (adjusted OR 5.14), and rapid partner turnover (adjusted OR 2.02). In adults, reinfection was predicted by unprotected sex with untreated partners (adjusted OR 4.90), unsafe sex (adjusted OR 2.18), rapid partner turnover (adjusted OR 3.13), and douching after sex (adjusted OR 2.14).

CONCLUSION

Sexual Awareness for Everyone significantly reduced recurrent STDs in teenagers. Adults and teens randomized to the SAFE intervention had significant decreases in high-risk sexual behaviors as compared with those in the control group. Although not specifically designed for teens, the SAFE intervention worked very well in this high-risk population.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov, ClinicalTrials.gov, HSC2004415H.

LEVEL OF EVIDENCE

I.

Partner Notification of Sexually Transmitted Infections: A Large Cohort of Mexican American and African American Women

OBJECTIVES

To determine factors associated with partner notification (PN) of sexually transmitted infection (STI) exposure among low-income Mexican American and African American women and their male sexual partners.

GOAL

To identify women most likely to notify their partners about an STI exposure.

STUDY DESIGN

Cross-sectional analysis of 775 women with a nonviral STI. The primary outcome, PN, is notification of, or intent to notify male sexual partner(s) of STI exposure. A comprehensive intake interview was used to obtain sociodemographic, psychosocial, communication, and relationship information for the patients and each male sexual partner. Chi square analysis and multivariate logistic regression analysis were used to determine factors independently associated with PN.

RESULTS

The 775 women identified 1122 male sexual partners. Of women with 1, 2, and 3 or more partners, 87.9%, 41.4%, and 25.0% reported PN for all partners respectively. Logistic regression demonstrated that 5 variables independently predicted PN: a "steady" relationship (OR: 5.25; CI: 2.82-4.91), 1 partner (OR: 2.10; CI: 1.71-2.56), recent intercourse (OR: 1.37; CI: 1.21-1.54), anticipated ongoing sexual activity (OR: 1.48; CI: 1.04-2.10), and/or desire for pregnancy with that partner (OR: 1.68; CI: 1.10-2.58). Patient and partner sociodemographic variables were not significantly associated with PN. Responses to specific relationship and communication variables, although significant, did not remain independent in the final logistic regression model.

CONCLUSION

Among low-income Mexican American and African American women, the perception that a relationship with individual partner(s) was committed was predictive of PN.

Are adolescent girls with Chlamydia infection notifying their partners?

OBJECTIVES

(1) To determine the proportion of inner-city adolescent girls diagnosed with chlamydial cervicitis who notify their sex partners; (2) to examine girls' attitudes and perceptions about partner notification and treatment; and (3) to assess whether or not girls knew if their partners were treated for chlamydia infection.

DESIGN/METHODS

Adolescent girls who had a positive DNA hybridization test for chlamydial cervicitis from March 2000 to May 2002 completed a 37-item self-administered survey assessing sexual behavior and partner notification, as well as the Rosenberg self esteem scale. Subjects completed the survey 1-3 months after the diagnosis of chlamydia infection.

RESULTS

Fifty-five adolescent girls (46% Hispanic, 36% African American) aged 13-21 years (mean 18.3 years) completed the survey. The median age at first intercourse was 14 (SD = 1.6); median number of lifetime sex partners was 4. Forty-one subjects (75%) notified their sex partners. The most common reasons for partner notification were"I did not want my sex partner to give the infection back to me"and"I wanted to let my sex partner know that he/she had given me the infection". There was a trend toward increased notification if the girls were 18 years of age or older (P = 0.07) or had only one lifetime sex partner (P = 0.08). Of the 41 subjects who notified their partners, 22 (54%) reported that the partners were treated; 16 did not know, and three knew that partners were not treated.

CONCLUSIONS

The majority of inner-city girls in this study notified their partners about chlamydia infection. Self-protection from re-infection was an important reason given for notification and suggests that girls in committed ongoing relationships might be more likely to notify partners.

Understanding partner notification (Patient self-referral method) by young women

STUDY OBJECTIVE

To understand the communication process involved in the patient-self referral method among adolescent females with chlamydia and gonococcal infection.

DESIGN

A cross-sectional descriptive study using a convenience sample was conducted in 54 predominantly African-American females, 13 to 20 years-old, with gonococcal and/or chlamydia cervicitis at an urban hospital based reproductive health clinic. Subjects interviewed at their treatment visit were asked what method of notification they used to tell their partner(s). Subjects who had not notified their partner were asked about their intended communication method and what they envisioned they would say to their partner. Coding methodology was used to analyze the information. In addition to qualitative information, outcome measures were the proportion of subjects who notified their partner(s), their communication method, style, and barriers to communication.

RESULTS

According to the treatment visit, 57% (31/54) of subjects reported notifying their partner. Most had notified their partner by phone or face-to-face, stated basic facts about the infection, and used a "direct" and "sensitive" communication style. Of the subjects who had not notified their partner (23/54), several barriers to notification were reported, but 82% said they intend to notify their partner(s).

CONCLUSIONS

Strategies to promote the patient-self referral method among young women who do not notify their partner(s) need further assessment.