Divergent Approaches to Partner Notification for Sexually Transmitted Infections Across the European Union

Sexual health behaviours and partner notification practices related to sexually transmitted infections in young adults in Ireland

BACKGROUND

Sexually transmitted infections (STIs) impose burdens on individuals and communities, while their prevalence in young people has risen continually in recent years. Partner notification is an effective public health strategy which can limit STI transmission.

AIMS

This study aimed to explore young adults' sexual health behaviours, attitudes toward STI testing, and feelings toward visiting a sexual health clinic. It also aimed to investigate preferences for partner notification and the role of self-efficacy in people's intentions to notify a partner for STIs including the human immunodeficiency virus (HIV).

METHODS

A quantitative, cross-sectional design was applied. Participants were 400 adults aged 18-34 years (M = 23 years; SD = 4.27), recruited from the Republic of Ireland.

RESULTS

Over half of the participants reported never being tested for STIs. These young people placed less importance on undergoing regular STI testing and testing after unprotected sex than their counterparts who had been tested for STIs. Self-efficacy was significantly associated with intentions to notify partner(s) for STIs including HIV.

CONCLUSIONS

As STIs are becoming increasingly prevalent in young adults, it is important to gain a deeper understanding of the interventions used to break the transmission chain and how different beliefs and attitudes may affect them. Self-efficacy was a key component in PN intentions, suggesting that the belief in someone's ability or skillset to perform a sexual health behaviour is positively related to their intention to perform the behaviour.

Assessing complex interventions: a systematic review of outcomes used in randomised controlled trials on STI partner notification in high-income countries

BACKGROUND

Partner notification interventions are complex and assessing their effectiveness is challenging. By reviewing the literature on the effectiveness of partner notification interventions, our aim was to evaluate the choice, collection, and interpretation of outcomes and their impact on study findings.

METHODS

We conducted a systematic review of individual-level randomised controlled trials evaluating the effectiveness of partner notification interventions for bacterial STIs, HIV or sexually transmitted HCV in high-income countries since 2000. Partner notification interventions included assisted patient referral interventions and expedited treatment. The content analysis was carried out through a narrative review.

RESULTS

In the 9 studies that met the inclusion criteria, 16 different outcomes were found. In most studies, one or two outcomes assessing partner notification practices were associated with an outcome reflecting STI circulation through index case reinfections. These outcomes assessed the main expected effects of partner notification interventions. However, partner notification is composed of a succession of actions between the intervention on the index case and the testing and/or treatment of the notified partners. Intermediate outcomes were missing so as to better understand levers and barriers throughout the process. Potential changes in participants' sexual behaviour after partner notification, e.g. condom use, were outcomes reported in only two studies assessing interventions including counselling. Most outcomes were collected through interviews, some weeks after the intervention, which might lead to desirability and attrition biases, respectively. Assessment of the effectiveness of partner notification interventions on partner testing/treatment was limited by the collection of data from index cases. Few data describing index cases and their partners were provided in the studies. Additional data on the number and type of exposed partners and the proportion of partners already aware of their infection before being notified would help to interpret the results.

CONCLUSIONS

These insights would help to understand why and under what conditions the intervention is considered effective and therefore can be replicated or adapted to other populations and contexts.

Assisted partner services for HIV in Kenya: a cluster randomised controlled trial

BACKGROUND

Assisted partner services for index patients with HIV infections involves elicitation of information about sex partners and contacting them to ensure that they test for HIV and link to care. Assisted partner services are not widely available in Africa. We aimed to establish whether or not assisted partner services increase HIV testing, diagnoses, and linkage to care among sex partners of people with HIV infections in Kenya.

METHODS

In this cluster randomised controlled trial, we recruited non-pregnant adults aged at least 18 years with newly or recently diagnosed HIV without a recent history of intimate partner violence who had not yet or had only recently linked to HIV care from 18 HIV testing services clinics in Kenya. Consenting sites in Kenya were randomly assigned (1:1) by the study statistician (restricted randomisation; balanced distribution in terms of county and proximity to a city) to immediate versus delayed assisted partner services. Primary outcomes were the number of partners tested for HIV, the number who tested HIV positive, and the number enrolled in HIV care, in those who were interviewed at 6 week follow-up. Participants within each cluster were masked to treatment allocation because participants within each cluster received the same intervention. This trial is registered with ClinicalTrials.gov, number NCT01616420.

FINDINGS

Between Aug 12, 2013, and Aug 31, 2015, we randomly allocated 18 clusters to immediate and delayed HIV assisted partner services (nine in each group), enrolling 1305 participants: 625 (48%) in the immediate group and 680 (52%) in the delayed group. 6 weeks after enrolment of index patients, 392 (67%) of 586 partners had tested for HIV in the immediate group and 85 (13%) of 680 had tested in the delayed group (incidence rate ratio 4·8, 95% CI 3·7-6·4). 136 (23%) partners had new HIV diagnoses in the immediate group compared with 28 (4%) in the delayed group (5·0, 3·2-7·9) and 88 (15%) versus 19 (3%) were newly enrolled in care (4·4, 2·6-7·4). Assisted partner services did not increase intimate partner violence (one intimate partner violence event related to partner notification or study procedures occurred in each group).

INTERPRETATION

Assisted partner services are safe and increase HIV testing and case-finding; implementation at the population level could enhance linkage to care and antiretroviral therapy initiation and substantially decrease HIV transmission.

FUNDING

National Institutes of Health.

Surveillance of HIV assisted partner services using routine health information systems in Kenya

BACKGROUND

The utilization of routine health information systems (HIS) for surveillance of assisted partner services (aPS) for HIV in sub-Saharan is sub-optimal, in part due to poor data quality and limited use of information technology. Consequently, little is known about coverage, scope and quality of HIV aPS. Yet, affordable electronic data tools, software and data transmission infrastructure are now widely accessible in sub-Saharan Africa.

METHODS

We designed and implemented a cased-based surveillance system using the HIV testing platform in 18 health facilities in Kenya. The components of this system included an electronic HIV Testing and Counseling (HTC) intake form, data transmission on the Global Systems for Mobile Communication (GSM), and data collection using the Open Data Kit (ODK) platform. We defined rates of new HIV diagnoses, and characterized HIV-infected cases. We also determined the proportion of clients who reported testing for HIV because a) they were notified by a sexual partner b) they were notified by a health provider, or c) they were informed of exposure by another other source. Data collection times were evaluated.

RESULTS

Among 4351 clients, HIV prevalence was 14.2 %, ranging from 4.4-25.4 % across facilities. Regardless of other reasons for testing, only 107 (2.5 %) of all participants reported testing after being notified by a health provider or sexual partner. A similar proportion, 1.8 % (79 of 4351), reported partner notification as the only reason for seeking an HIV test. Among 79 clients who reported HIV partner services as the reason for testing, the majority (78.5 %), were notified by their sexual partners. The majority (52.8 %) of HIV-infected patients initiated their HIV testing, and 57.2 % tested in a Voluntary Counseling and Testing (VCT) site co-located in a health facility. Median time for data capture was 4 min (IQR: 3-15), with a longer duration for HIV-infected participants, and there was no reported data loss.

CONCLUSION

aPS surveillance using new technologies is feasible, and could be readily expanded into HIV registries in Kenya and other sub-Saharan countries. Partner services are under-utilized in Kenya but further documentation of coverage and implementation gaps for HIV and aPS services is required.

Background review for the '2015 European guideline on the management of Chlamydia trachomatis infections'

SummaryChlamydia trachomatis infections are major public health concerns globally. Of particular grave concern is that the majority of persons with anogenital Chlamydia trachomatis infections are asymptomatic and accordingly not aware of their infection, and this silent infection can subsequently result in severe reproductive tract complications and sequelae. The current review paper provides all background, evidence base and discussions for the 2015 European guideline on the management of Chlamydia trachomatis infections (Lanjouw E, et al. Int J STD AIDS 2015). Comprehensive information and recommendations are included regarding the diagnosis, treatment and prevention of anogenital, pharyngeal and conjunctival Chlamydia trachomatis infections in European countries. However, Chlamydia trachomatis also causes the eye infection trachoma, which is not a sexually transmitted infection. The 2015 European Chlamydia trachomatis guideline provides up-to-date guidance regarding broader indications for testing and treatment of Chlamydia trachomatis infections; clearer recommendation of using validated nucleic acid amplification tests only for diagnosis; advice on (repeated) Chlamydia trachomatis testing; recommendation of increased testing to reduce the incidence of pelvic inflammatory disease and prevent exposure to infection and recommendations to identify, verify and report Chlamydia trachomatis variants. Improvement of access to testing, test performance, diagnostics, antimicrobial treatment and follow-up of Chlamydia trachomatis patients are crucial to control its spread.

The relative clinical effectiveness and cost-effectiveness of three contrasting approaches to partner notification for curable sexually transmitted infections: a cluster randomised trial in primary care

BACKGROUND

Partner notification is the process of providing support for, informing and treating sexual partners of individuals who have been diagnosed with sexually transmitted infections (STIs). It is traditionally undertaken by specialist sexual health services, and may involve informing a partner on a patient's behalf, with consent. With an increasing proportion of STIs diagnosed in general practice and other community settings, there is a growing need to understand the best way to provide partner notification for people diagnosed with a STI in this setting using a web-based referral system.

OBJECTIVE

We aimed to compare three different approaches to partner notification for people diagnosed with chlamydia within general practice.

DESIGN

Cluster randomised controlled trial.

SETTING

General practices in England and, within these, patients tested for and diagnosed with genital chlamydia or other bacterial STIs in that setting using a web-based referral system.

INTERVENTIONS

Three different approaches to partner notification: patient referral alone, or the additional offer of either provider referral or contract referral.

MAIN OUTCOME MEASURES

(1) Number of main partners per index patient treated for chlamydia and/or gonorrhoea/non-specific urethritis/pelvic inflammatory disease; and (2) proportion of index patients testing negative for the relevant STI at 3 months.

RESULTS

As testing rates for chlamydia were far lower than expected, we were unable to scale up the trial, which was concluded at pilot stage. We are not able to answer the original research question. We present the results of the work undertaken to improve recruitment to similar studies requiring opportunistic recruitment of young people in general practice. We were unable to standardise provider and contract referral separately; however, we also present results of qualitative work aimed at optimising these interventions.

CONCLUSIONS

External recruitment may be required to facilitate the recruitment of young people to research in general practice, especially in sensitive areas, because of specific barriers experienced by general practice staff. Costs need to be taken into account together with feasibility considerations. Partner notification interventions for bacterial STIs may not be clearly separable into the three categories of patient, provider and contract referral. Future research is needed to operationalise the approaches of provider and contract partner notification if future trials are to provide generalisable information.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN24160819.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 5. See the NIHR Journals Library website for further project information.

2015 European guidelines for the management of partners of persons with sexually transmitted infections

BACKGROUND

Partner management is the process of identifying the contacts of a person infected by a sexually transmitted infection (STI) and referral to a health care provider for appropriate management. It represents a public health activity.

METHODS

This guideline is produced by the IUSTI European Guideline Editorial Board and EDF Guideline Committee.

RESULTS

It provides recommendations concerning the infections that require partner management, the lookback periods for this STI and the main steps to follow for partner management (offering support to patients, notifying partners, identification of contacts). Partner management is voluntary and needs to be performed with respect to human rights, social, cultural and religious behaviours.

CONCLUSIONS

In European countries, there are different approaches to the partner management; some common type of actions can enhance the fight against STI.

Effectiveness of a pilot partner notification program for new HIV cases in Barcelona, Spain

BACKGROUND

An estimated 30% of HIV cases in the European Union are not aware of their serological status. This study aimed to assess the effectiveness of a pilot HIV partner notification program.

METHODS

HIV cases diagnosed between January 2012 and June 2013 at two healthcare settings in Barcelona were invited to participate in a prospective survey. We identified process and outcome measures to evaluate this partner notification program, including the number of partners identified per interviewed index case, the proportion of partners tested for HIV as a result of the partner notification, and the proportion of new HIV diagnoses among their sex or needle-sharing partners.

RESULTS

Of the 125 index cases contacted, 108 (86.4%) agreed to provide information about partners. A total of 199 sexual partners were identified (1.8 partners per interviewed index case). HIV outcome was already known for 58 partners (70.7% were known to be HIV-positive), 141 partners were tested as result of partner notification, and 26 were newly diagnosed with HIV. The case-finding effectiveness of the program was 18.4%.

CONCLUSION

This pilot program provides evidence of the effectiveness of a partner notification program implemented in healthcare settings. This active partner notification program was feasible, acceptable to the user, and identified a high proportion of HIV-infected patients previously unaware of their status.

Pilot study to introduce a notification card for partner notification of sexually transmitted infections in Catalonia, Spain, June 2010 to June 2011

We conducted a cross-sectional study in 10 primary care centres in Catalonia, to determine applicability, acceptability and effectiveness of partner notification cards used by patients diagnosed of a sexually transmitted infection (STI) and to characterise these and their sexual partners. Statutorily notifiable STIs included Chlamydia infection, gonorrhoea, syphilis, human immunodeficiency virus (HIV) infection or other STIs as deemed necessary by the treating physician. Between June 2010 and June 2011, 219 index cases were enrolled, of whom 130 were men (59.4%), 71 of them men who have sex with men (54.6%). Chlamydia infection (41.1%), gonorrhoea (17.8%) and syphilis (16.0%) were the STIs most frequently diagnosed. HIV infection accounted for 4% of cases. A total of 687 sexual partners were reported, and 300 of these were traceable through the notification card (45.7%). Those who did not report traceable contacts were older (mean age: 34 years versus 31 years, p=0.03). The main reason for not distributing the card was anonymous sexual intercourse (38%). Patient referral notification cards can reach a high percentage of sexual partners at risk. However, only few notified sexual partners attended participating health centres. Internet-based partner notification may be considered in order to reach those partners not otherwise traceable.

Partner notification uptake for sexually transmitted infections in China: a systematic literature review

OBJECTIVE

China's sexually transmitted infection (STI) epidemic requires comprehensive control programmes. Partner services are traditional pillars of STI control but have not been widely implemented in China. This study was a systematic literature review to examine STI partner notification (PN) uptake in China.

METHODS

Four English and four Chinese language databases were searched up to March 2011 to identify articles on PN of STIs including HIV in China. PN uptake was defined as the number of partners named, notified, evaluated or diagnosed per index patient.

RESULTS

A total of 11 studies met inclusion criteria. For STI (excluding HIV) PN, a median 31.6% (IQR 27.4%-65.8%) of named partners were notified, 88.8% (IQR 88.4%-90.8%) of notified partners were evaluated and 37.9% (IQR 33.1%-43.6%) of evaluated partners were diagnosed. For HIV PN, a median 15.7% (IQR 13.2%-36.5%) of named partners were notified, 86.7% (IQR 72.9%-90.4%) of notified partners were evaluated and 27.6% (IQR 24.1%-27.7%) of evaluated partners were diagnosed. A mean of 80.6% (SD=12.6%) of patients attempted PN, and 72.4% (IQR 63.8%-81.1%) chose self-referral when offered more than one method of PN. Perceived patient barriers included social stigma, fear of relationship breakdown, uncertainty of how to notify and lack of partner contact information. Perceived infrastructure barriers included limited time and trained staff, mistrust of health workers and lack of PN guidelines.

CONCLUSION

PN programmes are feasible in China. Further research on STI PN, particularly among men who have sex with men and other high-risk groups, is an important public health priority. PN policies and guidelines are urgently needed in China.

Partner notification for Chlamydia trachomatis urogenital infections: eight years of patient referral experience in the major Portuguese sexually transmitted infections clinic, 2000–07

The aim of this study was to perform a retrospective evaluation of the success of patient referral for partner notification of chlamydial infections to the major Portuguese sexually transmitted infection (STI) clinic. A total of 8277 patients were screened for Chlamydia trachomatis during 2000–2007, and 695 (8.4%) tested positive. The sexual partners of 34% of these index cases attended the clinic as contacts following partner referral. In univariate analysis, heterosexual men referred partners more frequently than men who have sex with men (MSM) and HIV-negative index cases referred partners four-fold more frequently than HIV-positives; however, these associations were non-significant after multivariate analysis (adjusted odds ratio [OR] 1.4, 95% confidence interval [CI] 0.7–2.6; adjusted OR 4.2, 95% CI 0.9–18.7, respectively). Index patients who reported lower numbers of partners referred more frequently, and this association remained significant after multivariate analysis. One-third of the referred individuals tested C. trachomatis-positive; the risk for infection was three-fold higher for referred partners from symptomatic index cases ( P < 0.001, adjusted OR, 95% CI 1.8–6.3). In conclusion, the results of the present study concerning sexual behaviour, HIV status and clinical signs highlight the need for further evaluations that may shape future partner notification strategies in order to reduce the chlamydial disease burden.

HIV testing in Europe: mapping policies

OBJECTIVES

In the absence of treatment and in the context of discrimination, HIV testing was embedded within exceptional procedures. With increasing treatment effectiveness, early HIV diagnosis became important, calling for the normalization of testing. National HIV testing policies were mapped to explore the characteristics and variations across European countries.

METHODS

Key informants within the health authorities of all EU/EEA countries were questioned on HIV testing policies, which were assessed within a conceptual framework and the level of exceptionalism and normalization was scored based on defined attributes.

RESULTS

Twenty-four out of 31 countries participated in the survey. Policies tended to support confidential voluntary testing, informed consent, and counselling. In the majority of countries, specific groups were targeted for provider-initiated testing. Taking together all attributes of HIV testing, 14 countries obtained a high score for exceptionalism, while only 3 achieved a high score on normalization. Italy, Lithuania and Romania had primarily exceptional procedures; Norway leant more towards normalization; Netherlands, the United Kingdom, and Denmark scored high in both.

CONCLUSIONS

In most EU/EEA countries, policies are integrating HIV testing in health care settings, through voluntary and targeted testing strategies. Current HIV testing policies exhibited a high level of exceptionalism with varying degrees of normalization. Further research should compare HIV testing policies with practices.

2010 European guideline for the management of Chlamydia trachomatis infections

This guideline aims to provide comprehensive information regarding the management of infections caused by Chlamydia trachomatis in European countries. The recommendations contain important information for physicians and laboratory staff working with sexually transmitted infections (STIs) and/or STI-related issues. Individual European countries may be required to make minor national adjustments to this guideline as some of the tests or specific local data may not be accessible, or because of specific laws.

Infectious syphilis in high-income settings in the 21st century

In high-income countries after World War II, the widespread availability of effective antimicrobial therapy, combined with expanded screening, diagnosis, and treatment programmes, resulted in a substantial decline in the incidence of syphilis. However, by the turn of the 21st century, outbreaks of syphilis began to occur in different subpopulations, especially in communities of men who have sex with men. The reasons for these outbreaks include changing sexual and social norms, interactions with increasingly prevalent HIV infection, substance abuse, global travel and migration, and underinvestment in public-health services. Recently, it has been suggested that these outbreaks could be the result of an interaction of the pathogen with natural immunity, and that syphilis epidemics should be expected to intrinsically cycle. We discuss this hypothesis by examining long-term data sets of syphilis. Today, syphilis in western Europe and the USA is characterised by low-level endemicity with concentration among population subgroups with high rates of partner change, poor access to health services, social marginalisation, or low socioeconomic status.

Norwegian men diagnosed with genital Chlamydia trachomatis infection notified two-thirds of their sexual partners

Chlamydia trachomatis (CT) is a widespread, sexually transmitted disease with potential long-term effects on female reproductive health. The objective of this study was to investigate compliance to treatment, partner notification, and attendance for test-of-cure among Norwegian men diagnosed with CT. We conducted a longitudinal case-series study among 81 CT positive men identified in a cross-sectional study (n = 1032, April-December 2005). Participants were interviewed on partner notification intentions at the treatment visit and on partner notification actions at the test-of-cure visit. Of the 81 patients, 8 (10%) did not meet for treatment, 2 were treated elsewhere, and 6 were treated but not interviewed. At the treatment visit, the 65 interviewed men reported that they intended to notify 100 out of 165 partners (61%). 40 of 71 treated patients attended for test-of-cure (56%). Four men (10%) needed repeated treatment. The 35 men interviewed at test-of-cure visit reported that 63 out of 95 partners (68%) had been notified. In conclusion, men diagnosed with CT infection are relatively open on notifying sexual partners but have low compliance to meeting for test-of-cure.

Improved effectiveness of partner notification for patients with sexually transmitted infections: systematic review

OBJECTIVE

To examine the effectiveness of methods to improve partner notification by patient referral (index patient has responsibility for informing sex partners of their exposure to a sexually transmitted infection).

DESIGN

Systematic review of randomised trials of any intervention to supplement simple patient referral.

DATA SOURCES

Seven electronic databases searched (January 1990 to December 2005) without language restriction, and reference lists of retrieved articles.

REVIEW METHODS

Selection of trials, data extraction, and quality assessment were done by two independent reviewers. The primary outcome was a reduction of incidence or prevalence of sexually transmitted infections in index patients. If this was not reported data were extracted according to a hierarchy of secondary outcomes: number of partners treated; number of partners tested or testing positive; and number of partners notified, located, or elicited. Random effects meta-analysis was carried out when appropriate.

RESULTS

14 trials were included with 12 389 women and men diagnosed as having gonorrhoea, chlamydia, non-gonococcal urethritis, trichomoniasis, or a sexually transmitted infection syndrome. All studies had methodological weaknesses that could have biased their results. Three strategies were used. Six trials examined patient delivered partner therapy. Meta-analysis of five of these showed a reduced risk of persistent or recurrent infection in patients with chlamydia or gonorrhoea (summary risk ratio 0.73, 95% confidence interval 0.57 to 0.93). Supplementing patient referral with information for partners was as effective as patient delivered partner therapy. Neither strategy was effective in women with trichomoniasis. Two trials found that providing index patients with chlamydia with sampling kits for their partners increased the number of partners who got treated.

CONCLUSIONS

Involving index patients in shared responsibility for the management of sexual partners improves outcomes. Health professionals should consider the following strategies for the management of individual patients: patient delivered partner therapy, home sampling for partners, and providing additional information for partners.

Patient-Delivered Partner Treatment and Other Partner Management Strategies for Sexually Transmitted Diseases Used by New York City Healthcare Providers

OBJECTIVES

The objectives of this study were to measure frequency and predictors of patient-delivered partner treatment (PDPT) and the frequency of other partner management strategies among New York City healthcare providers (HCPs) as well as to determine whether use of PDPT detracts from other partner management strategies.

STUDY DESIGN

The authors conducted a cross-sectional survey of New York City HCPs.

RESULTS

Frequent patient referral was reported by 93.6% (368 of 393) of healthcare providers; only 20% (80 of 401) reported frequent use of provider referral. Overall, 49.2% (196 of 398) of HCPs reported ever using PDPT and 27.1% (108 of 398) reported using PDPT frequently. HCP specialty, practice setting, duration of practice, report of frequent provider referral practice, and HCP race/ethnicity were the strongest predictors of PDPT use. HCPs reporting PDPT use were more likely to report frequent provider referral than those who had never used PDPT (26.7% vs. 12.6%; P <0.001).

CONCLUSIONS

PDPT use is common and is being used in conjunction with other partner management strategies.