The role and effectiveness of partner notification in STD control: a review

Predictors of HIV Molecular Cluster Membership and Implications for Partner Services

Public health surveillance data used in HIV molecular cluster analyses lack contextual information that is available from partner services (PS) data. Integrating these data sources in retrospective analyses can enrich understanding of the risk profile of people in clusters. In this study, HIV molecular clusters were identified and matched to information on partners and other information gleaned at the time of diagnosis, including coinfection with syphilis. We aimed to produce a more complete understanding of molecular cluster membership in Houston, Texas, a city ranking ninth nationally in rate of new HIV diagnoses that may benefit from retrospective matched analyses between molecular and PS data to inform future intervention. Data from PS were matched to molecular HIV records of people newly diagnosed from 2012 to 2018. By conducting analyses in HIV-TRACE (TRAnsmission Cluster Engine) using viral genetic sequences, molecular clusters were detected. Multivariable logistic regression models were used to estimate the association between molecular cluster membership and completion of a PS interview, number of named partners, and syphilis coinfection. Using data from 4,035 people who had a viral genetic sequence and matched PS records, molecular cluster membership was not significantly associated with completion of a PS interview. Among those with sequences who completed a PS interview (n = 3,869), 45.3% (n = 1,753) clustered. Molecular cluster membership was significantly associated with naming 1 or 3+ partners compared with not naming any partners [adjusted odds ratio, aOR: 1.27 (95% confidence interval, CI: 1.08-1.50), p = .003 and aOR: 1.38 (95% CI: 1.06-1.81), p = .02]. Alone, coinfection with syphilis was not significantly associated with molecular cluster membership. Syphilis coinfection was associated with molecular cluster membership when coupled with incarceration [aOR: 1.91 (95% CI: 1.08-3.38), p = .03], a risk for treatment interruption. Enhanced intervention among those with similar profiles, such as people coinfected with other risks, may be warranted.

Smittesporing ved seksuelt overførbare infeksjoner i Norge gjennom 120 år

BAKGRUNN

Smittesporing har fått ny aktualitet grunnet covid-19, men har lenge vært viktig i bekjempelsen av seksuelt overførbare infeksjoner. I denne artikkelen vil vi belyse hvordan smittesporingen ved seksuelt overførbare infeksjoner i Norge har endret seg de siste 120 årene.

MATERIALE OG METODE

Kildegrunnlaget er årsberetninger fra Kristiania Sundhetskommission og Oslo Helseråd, årsrapporter fra Meldingssystem for smittsomme sykdommer ved Folkehelseinstituttet (MSIS), skjema for innkalling av pasienter, et originalt maskinskrevet manuskript av helseinspektør Harald Christian Gjessing (1896-1988) samt personlige meddelelser fra Øivind Jul Nilsen, seniorrådgiver ved Folkehelseinstituttet.

RESULTATER OG FORTOLKNING

Smittesporing er i varierende grad dokumentert i årsberetningene fra Kristiania Sundhetskommission fra slutten av 1800-tallet og fram til dagens MSIS-rapporter. Politiet var sterkt involvert i kontrollen av kjønnssykdommene på slutten av 1800-tallet, men legene overtok mer av ansvaret ut over 1900-tallet. Under den annen verdenskrig ble igjen politiet mer involvert i kontroll og smittesporing. I 1947 kom lov om åtgjerder mot kjønnssykdommer, som stadfestet behandlende leges plikt til å utføre smittesporing. Denne loven ble erstattet av smittevernloven i 1995. Kvaliteten på smittesporingen over tid er noe vanskelig å vurdere, da datagrunnlaget for statistikken har endret seg. Fra å være et moralsk anliggende, med sterke elementer av tvang og hjelp fra sedelighetspolitiet, ble smittesporing etter hvert basert på frivillighet og samarbeid mellom lege og pasient.

Perceptions, experiences, and preferences for partner services among Black and Latino men who have sex with men and transwomen in North Carolina

OBJECTIVES

In the United States, sexually transmitted infections (STIs) disproportionately affect men who have sex with men (MSM) and transwomen of color. Partner services can prevent STI transmission by facilitating testing and treatment for partners of individuals diagnosed with an STI. Understanding client perspectives towards partner services is critical to their acceptance and uptake. This study examined perceptions, experiences, and preferences for partner services among Black and Latino MSM and transwomen in North Carolina.

DESIGN

We conducted seven audio-recorded focus groups in English (n = 5) and Spanish (n = 2). The audio was transcribed verbatim and we inductively analyzed data using field notes, systematic coding, and thematic comparison.

RESULTS

Black MSM reported the most exposure and experiences with partner services, and most perceived partner services negatively. Feeling supported and having flexibility characterized positive experiences with partner services among Black MSM; feeling judged or harassed characterized negative experiences. Black transwomen had less exposure to partner services and had a mix of positive reactions to the approach, along with concerns about client confidentiality. Most Latino participants were unaware of partner services and expressed openness to their potential. All participants preferred self-notifying and wanted flexible, discreet, supportive partner services with linkages to other wellness resources.

CONCLUSION

Building off positive partner services experiences and responding to client preferences can enhance trust, acceptability, and service use.

Health Worker Perspectives on Barriers and Facilitators of Assisted Partner Notification for HIV for Refugees and Ugandan Nationals: A Mixed Methods Study in West Nile Uganda

Assisted partner notification (APN) is recommended by the World Health Organization to notify sexual partners of HIV exposure. Since 2018, APN has been offered in Uganda to Ugandan nationals and refugees. Distinct challenges faced by individuals in refugee settlements may influence APN utilization and effectiveness. To explore APN barriers and facilitators, we extracted index client and sexual partner data from APN registers at 11 health centers providing care to refugees and Ugandan nationals in West Nile Uganda and conducted qualitative interviews with health workers (N = 32). Since APN started, 882 index clients participated in APN identifying 1126 sexual partners. Following notification, 95% (1025/1126) of partners tested for HIV; 22% (230/1025) were diagnosed with HIV with 14% (139/1025) of tested partners newly diagnosed. Fear of stigma and disclosure-related violence limit APN utilization and effectiveness. Prospective research involving index clients and sexual partners is needed to facilitate safe APN optimization in refugee settlements.

Low male partner attendance after syphilis screening in pregnant women leads to worse birth outcomes: the Syphilis Treatment of Partners (STOP) randomised control trial

Background Maternal syphilis causes poor birth outcomes, including congenital syphilis. Testing and treatment of partners prevents reinfection, but strategies to improve partner attendance are failing. The aim of this study was to determine the effectiveness of three partner notification strategies.

METHODS

Pregnant women with a positive point-of-care treponemal test at three antenatal clinics (ANCs) in Kampala, Uganda, were randomised 1:1:1 to receive either notification slips (NS; standard of care), NS and a text messages (SMS) or NS and telephone calls. The primary outcome was the proportion of partners who attended the ANC and were treated for syphilis.

RESULTS

Between 2015 and 2016, 17130 pregnant women were screened; 601 (3.5%) had a positive treponemal result, and 442 were enrolled in the study. Only 81 of 442 partners (18.3%; 23/152 (15.1%), 31/144 (21.5%) and 27/146 (18.5%) in the NS only, NS + SMS and NS + telephone call groups respectively) attended an ANC for follow-up; there were no significant differences between the groups. Twelve per cent of women attended the ANC with their male partner, and this proportion increased over time. Partner non-treatment was independently associated with adverse birth outcomes (odds ratio 2.75; 95% confidence interval 2.36-3.21; P < 0.001).

CONCLUSIONS

Only 18.3% of partners of pregnant women who tested positive for syphilis received treatment. Female partners of non-attendant men had worse birth outcomes. Encouraging men to accompany women to the ANC and testing both may address the urgent need to treat partners of pregnant women in sub-Saharan Africa to reduce poor fetal outcomes.

A Patient-Initiated Digital COVID-19 Contact Notification Tool (TellYourContacts): Evaluation Study

Background

Contact notification is a method used to control the spread of infectious disease. In this process, a patient who tests positive for an infectious disease and public health officials work to identify the patient’s close contacts, notify them of their risk of possible exposure to the disease, and provide resources to facilitate the decreased spreading of disease. Contact notification can be done physically in person, via phone call, or digitally through the use of media such as SMS text messages and email. When alerts are made through the latter, it is called digital contact notification.

Objective

For this study, we aim to perform a preliminary evaluation of the use of the TellYourContacts website, a digital contact notification tool for COVID-19 that can be used confidentially and anonymously. We will gather information about the number of website users and message senders, the types of messages sent, and the geographic distribution of senders.

Methods

Patients who chose to get tested for COVID-19 and subsequently tested positive for the disease were alerted of their positive results through Curative Inc (a COVID-19 testing laboratory) and Healthvana (a results disclosure app). Included in the notification was a link to the TellYourContacts website and a message encouraging the person who tested positive for COVID-19 to use the website to alert their close contacts of exposure risk. Over the course of three months, from May 18, 2020, to August 17, 2020, we used Google Analytics and Microsoft Excel to record data on the number of website users and message senders, types of messages sent, and geographic distribution of the senders.

Results

Over the course of three months, 9130 users accessed the website and 1474 unique senders sent a total of 1957 messages, which included 1820 (93%) SMS text messages and 137 (7%) emails. Users sent messages from 40 US states, with the majority of US senders residing in California (49%).

Conclusions

We set out to determine if individuals who test positive for COVID-19 will use the TellYourContacts website to notify their close contacts of COVID-19 exposure risk. Our findings reveal that, during the observation period, each unique sender sent an average of 1.33 messages. The TellYourContacts website offers an additional method that individuals can and will use to notify their close contacts about a recent COVID-19 diagnosis.

Sustained high HIV case-finding through index testing and partner notification services: experiences from three provinces in Zimbabwe

INTRODUCTION

Several countries in southern Africa have made significant progress towards reaching the Joint United Nations Programme on HIV/AIDS goal of ensuring that 90% of people living with HIV are aware of their status. In Zimbabwe, progress towards this "first 90" was estimated at 73% in 2016. To reach the remaining people living with HIV who have undiagnosed infection, the Zimbabwe Ministry of Health and Child Care has been promoting index testing and partner notification services (PNS). We describe the implementation of index testing and PNS under the Zimbabwe HIV Care and Treatment (ZHCT) project and the resulting uptake, HIV positivity rate and links to HIV treatment.

METHODS

The ZHCT project has been implemented since March 2016, covering a total of 12 districts in three provinces. To assess the project's performance on index testing, we extracted data on HIV testing from the district health information system (DHIS 2) from March 2016 to May 2018, validated it using service registers and calculated monthly HIV positivity rates using Microsoft Excel. Data were disaggregated by district, province, sex and service delivery point. We used SPSS to assess for statistical differences in paired monthly HIV positivity rates by sex, testing site, and province.

RESULTS

The average HIV positivity rate rose from 10% during the first six months of implementation to more than 30% by August 2016 and was sustained above 30% through May 2018. The overall facility HIV positivity rate was 4.1% during the same period. The high HIV positivity rate was achieved for both males and females (mean monthly HIV positivity rate of 31.3% for males and 33.7% for females), with females showing significantly higher positivity compared to males (p < 0.001). The ZHCT mean monthly HIV positivity rate from index testing (32.6%) was significantly higher than that achieved through provider-initiated testing and counselling and other facility HIV testing modalities (4.1%, p < 0.001).

CONCLUSIONS

The ZHCT project has demonstrated successes in implementing index testing and PNS by attaining a high HIV positivity rate sustained over the study period. As the country moves towards HIV epidemic control, index testing and PNS are critical strategies for targeted HIV case identification.

A pill for the partner via the chlamydia patient? Results from a mixed method study among sexual health care providers in the Netherlands

Background

Chlamydia prevalence in the Netherlands remains high despite targeted efforts. Effective Partner Notification (PN) and Partner Treatment (PT) can interrupt transmission and prevent re-infections. Patient Initiated Partner Treatment (PIPT) may strengthen chlamydia control. This study explores the current practice of PN and PT, and benefits of, and barriers and facilitators for PIPT among professionals in sexual health care in the Netherlands.

Methods

A qualitative study was performed among GPs, GP-assistants (GPAs), physicians and nurses working at Sexual Health Clinics (SHC) and key-informants on ethnical diversity using topic lists in focus groups (N = 40) and semi-structured questionnaires in individual interviews (N = 9). Topics included current practices regarding PN and PT, attitude regarding PIPT, and perceived barriers and facilitators for PIPT. Interviews were taped, transcribed verbatim, and coded using ATLAS.ti. A quantitative online questionnaire on the same topics was sent to all physicians and nurses employed at Dutch SHC (complete response rate 26% (84/321)).

Results

The qualitative study showed that all professionals support the need for more attention to PN, and that they saw advantages in PIPT. Mentioned barriers included unwilling PN-behaviour, Dutch legislation, several medical considerations and inadequate skills of GPs. Also, concerns about limited knowledge of cultural sensitivity around PN and PT were raised. Mentioned facilitators of PIPT were reliable home based test-kits, phone-contact between professionals and notified partners, more consultation time for GPs or GPAs and additional training. The online questionnaire showed that SHC employees agreed that partners should be treated as soon as possible, but also that they were reluctant towards PIPT without counselling and testing.

Conclusions

Professionals saw advantages in PIPT, but they also identified barriers hampering the potential introduction of PIPT. Improving PN and counselling skills with specific focus on cultural sensitivity is needed. PIPT could be considered for specific partners. PIPT in combination with home based testing and using e-healthcare should be further explored and developed.

Partner Notification for Gonorrhea and Syphilis in Belgrade

“Contact tracing” or “partner notification” refers to clinicians’ efforts to identify sex partners of infected persons to ensure their medical evaluation and treatment. For many years partner notification has been a cornerstone in the management of patients diagnosed with sexually transmitted infections (STIs) and it is the essential component in the control of these infections. Clinicians’ efforts to ensure the treatment of a patient’s sex partners can reduce the risk for re-infection and potentially diminish transmission of STIs. Partner notification includes three different approaches for notifying the sexual partners of the person infected with a STI: provider referral, patient referral, and contract referral. The aim of our study was to evaluate the efficacy of partner notification among syphilis and gonorrhea cases registered at the City Institute for Skin and Venereal Diseases in Belgrade in 2016, and its contribution to prevention and control of these diseases. A retrospective chart review of patients with gonorrhea and early syphilis registered in 2016 was undertaken. We analyzed data about the possible source of infection as well as sexual orientation, provided on the official form for notification of syphilis and gonorrhea. The study included 112 male patients, 67 with gonorrhea and 45 with syphilis. Out of three modalities of partner notification offered to patients, only patient notification of sexual partner/s was accepted. Although all patients accepted this type of partner notification, index patients with gonorrhea notified only 17 partners (25.4%) and index patients with syphilis also notified 17 partners (37.8%). The effectiveness of partner notification for gonorrhea and syphilis cases was only 30.4%, and its contribution to prevention and control of these diseases was lower than we expected. National guidelines offering standardized protocols for partner notification service provision can improve this process, as a novel approach with non-traditional method of partner notification such as patient-delivered partner therapy.

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 Ballseye programme: a mixed-methods programme of research in traditional sexual health and alternative community settings to improve the sexual health of men in the UK

Background

Sexually transmitted infection (STI) diagnoses are increasing and efforts to reduce transmission have failed. There are major uncertainties in the evidence base surrounding the delivery of STI care for men.

Aim

To improve the sexual health of young men in the UK by determining optimal strategies for STI testing and care

Objectives

To develop an evidence-based clinical algorithm for STI testing in asymptomatic men; model mathematically the epidemiological and economic impact of removing microscopy from routine STI testing in asymptomatic men; conduct a pilot randomised controlled trial (RCT) of accelerated partner therapy (APT; new models of partner notification to rapidly treat male sex partners of people with STIs) in primary care; explore the acceptability of diverse venues for STI screening in men; and determine optimal models for the delivery of screening.

Design

Systematic review of the clinical consequences of asymptomatic non-chlamydial, non-gonococcal urethritis (NCNGU); case–control study of factors associated with NCNGU; mathematical modelling of the epidemiological and economic impact of removing microscopy from asymptomatic screening and cost-effectiveness analysis; pilot RCT of APT for male sex partners of women diagnosed withChlamydia trachomatisinfection in primary care; stratified random probability sample survey of UK young men; qualitative study of men’s views on accessing STI testing; SPORTSMART pilot cluster RCT of two STI screening interventions in amateur football clubs; and anonymous questionnaire survey of STI risk and previous testing behaviour in men in football clubs.

Settings

General population, genitourinary medicine clinic attenders, general practice and community contraception and sexual health clinic attenders and amateur football clubs.

Participants

Men and women.

Interventions

Partner notification interventions: APTHotline [telephone assessment of partner(s)] and APTPharmacy [community pharmacist assessment of partner(s)]. SPORTSMART interventions: football captain-led and health adviser-led promotion of urine-based STI screening.

Main outcome measures

For the APT pilot RCT, the primary outcome, determined for each contactable partner, was whether or not they were considered to have been treated within 6 weeks of index diagnosis. For the SPORTSMART pilot RCT, the primary outcome was the proportion of eligible men accepting screening.

Results

Non-chlamydial, non-gonococcal urethritis is not associated with significant clinical consequences for men or their sexual partners but study quality is poor (systematic review). Men with symptomatic and asymptomatic NCNGU and healthy men share similar demographic, behavioural and clinical variables (case–control study). Removal of urethral microscopy from routine asymptomatic screening is likely to lead to a small rise in pelvic inflammatory disease (PID) but could save > £5M over 20 years (mathematical modelling and health economics analysis). In the APT pilot RCT the proportion of partners treated by the APTHotline [39/111 (35%)], APTPharmacy [46/100 (46%)] and standard patient referral [46/102 (45%)] did not meet national standards but exceeded previously reported outcomes in community settings. Men’s reported willingness to access self-sampling kits for STIs and human immunodeficiency virus infection was high. Traditional health-care settings were preferred but sports venues were acceptable to half of men who played sport (random probability sample survey). Men appear to prefer a ‘straightforward’ approach to STI screening, accessible as part of their daily activities (qualitative study). Uptake of STI screening in the SPORTSMART RCT was high, irrespective of arm [captain led 28/56 (50%); health-care professional led 31/46 (67%); poster only 31/51 (61%)], and costs were similar. Men were at risk of STIs but previous testing was common.

Conclusions

Men find traditional health-care settings the most acceptable places to access STI screening. Self-sampling kits in football clubs could widen access to screening and offer a public health impact for men with limited local sexual health services. Available evidence does not support an association between asymptomatic NCNGU and significant adverse clinical outcomes for men or their sexual partners but the literature is of poor quality. Similarities in characteristics of men with and without NCNGU precluded development of a meaningful clinical algorithm to guide STI testing in asymptomatic men. The mathematical modelling and cost-effectiveness analysis of removing all asymptomatic urethral microscopy screening suggests that this would result in a small rise in adverse outcomes such as PID but that it would be highly cost-effective. APT appears to improve outcomes of partner notification in community settings but outcomes still fail to meet national standards. Priorities for future work include improving understanding of men’s collective behaviours and how these can be harnessed to improve health outcomes; exploring barriers to and facilitators of opportunistic STI screening for men attending general practice, with development of evidence-based interventions to increase the offer and uptake of screening; further development of APT for community settings; and studies to improve knowledge of factors specific to screening men who have sex with men (MSM) and, in particular, how, with the different epidemiology of STIs in MSM and the current narrow focus on chlamydia, this could negatively impact MSM’s sexual health.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Next-Generation Methods for HIV Partner Services: A Systematic Review

Partner notification is a widely accepted method whose intent is to limit onward HIV transmission. With increasing use of new technologies such as text messaging, e-mail, and social network sites, there is growing interest in using these techniques for "next-generation" HIV partner services (PS). We conducted a systematic review to assess the use and effectiveness of these technologies in HIV PS. Our literature search resulted in 1343 citations, with 7 meeting inclusion criteria. We found programs in 2 domains: (1) Public Health Department usage of new technologies to augment traditional partner notification (n = 3) and (2) patient or provider-led usage of partner notification Web sites (n = 4) The health department-based efforts showed an ability to find new cases in a previously unreachable population but in the limited comparisons to traditional PS had a lower rate of successful contact. Usage data from the partner notification Web sites revealed a high total number of e-notifications sent, with less than 10% of cards sent for HIV. Clear evidence on outcomes and directly traceable utilization for these Web services was lacking. When given a choice, most clients chose to send e-notifications via text versus e-mail. Although successful notification may be lower overall, use of next-generation services provides an avenue to contact those who would previously have been untraceable. Additional research is needed to determine to what extent technology-enhanced PS improves the identification of newly infected persons as well as the initiation of new prevention interventions for HIV-negative clients within high-risk networks.

Developing and testing accelerated partner therapy for partner notification for people with genital Chlamydia trachomatis diagnosed in primary care: a pilot randomised controlled trial

Background

Accelerated partner therapy (APT) is a promising partner notification (PN) intervention in specialist sexual health clinic attenders. To address its applicability in primary care, we undertook a pilot randomised controlled trial (RCT) of two APT models in community settings.

Methods

Three-arm pilot RCT of two adjunct APT interventions: APTHotline (telephone assessment of partner(s) plus standard PN) and APTPharmacy (community pharmacist assessment of partner(s) plus routine PN), versus standard PN alone (patient referral). Index patients were women diagnosed with genital chlamydia in 12 general practices and three community contraception and sexual health (CASH) services in London and south coast of England, randomised between 1 September 2011 and 31 July 2013.

Results

199 women described 339 male partners, of whom 313 were reported by the index as contactable. The proportions of contactable partners considered treated within 6 weeks of index diagnosis were APTHotline 39/111 (35%), APTPharmacy 46/100 (46%), standard patient referral 46/102 (45%). Among treated partners, 8/39 (21%) in APTHotline arm were treated via hotline and 14/46 (30%) in APTPharmacy arm were treated via pharmacy.

Conclusions

The two novel primary care APT models were acceptable, feasible, compliant with regulations and capable of achieving acceptable outcomes within a pilot RCT but intervention uptake was low. Although addition of these interventions to standard PN did not result in a difference between arms, overall PN uptake was higher than previously reported in similar settings, probably as a result of introducing a formal evaluation. Recruitment to an individually randomised trial proved challenging and full evaluation will likely require service-level randomisation.

Trial registration number

Registered UK Clinical Research Network Study Portfolio id number 10123.

Partner notification in the context of HIV: an interest-analysis

Codes of confidentiality play an essential role in the intimate discourses in many learned professions. Codes with various prescriptions exist. The Hippocratic Oath for example, prescribes rewards to the secret keeper, for keeping secret what ought to be kept secret, and punishments for failing. In public health practice, partner notification, arguably is one endeavor that tests the durability of this secret keeping doctrine of the health professional. We present an interest-analysis of partner notification in the context of HIV service rendition. Using principles-based analysis, the interests of the individual, the state/public health, and the bioethicist's are discussed. The public health interests in partner notification, which are usually backed by state statutes and evidence, are premised on the theory that partners are entitled to knowledge. This theory posits that knowledge empowers individuals to avoid continuing risks; knowledge of infection allows for early treatment; and that knowledgeable partners can adapt their behavior to prevent further transmission of infection to others. However, persons infected with HIV often have counter interests. For instance, an infected person may desire to maintain the privacy of their health status from unnecessary disclosure because of the negative impacts of disclosure, or because notification without a matching access to HIV prevention and treatment services is detrimental. The interest of the bioethicist in this matter is to facilitate a resolution of these conflicted interests. Our analysis concludes that governmental interests are not absolute in comparison with the interests of the individual. We reiterate that any effort to morally balance the benefits of partner notification with its burdens ought to first recognize the multivalent nature of the interests at play.

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.

Tuskegee redux: evolution of legal mandates for human experimentation

Human health experiments systematically expose people to conditions beyond the boundaries of medical evidence. Such experiments have included legal-medical collaboration, exemplified in the U.S. by the Public Health Service (PHS) Syphilis Study (Tuskegee). That medical experiment was legal, conforming to segregationist protocols and specific legislative authorization which excluded a selected group of African Americans from any medical protection from syphilis. Subsequent corrective action outlawed unethical medical experiments but did not address other forms of collaboration, including PHS submission to laws which may have placed African American women at increased risk from AIDS and breast cancer. Today, anti-lobbying law makes it a felony for PHS workers to openly challenge legally anointed suspension of medical evidence. African Americans and other vulnerable populations may thereby face excess risks-not only from cancer, but also from motor vehicle crashes, firearm assault, end stage renal disease, and other problems-with PHS workers as silent partners.

"If the patients decide not to tell what can we do?"- TB/HIV counsellors' dilemma on partner notification for HIV

Background

There is a global consensus towards universal access to human immunodeficiency virus (HIV) services consequent to the increasing availability of antiretroviral therapy. However, to benefit from these services, knowledge of one's HIV status is critical. Partner notification for HIV is an important component of HIV counselling because it is an effective strategy to prevent secondary transmission, and promote early diagnosis and prompt treatment of HIV patients' sexual partners. However, counsellors are often frustrated by the reluctance of HIV-positive patients to voluntarily notify their sexual partners. This study aimed to explore tuberculosis (TB)/HIV counsellors' perspectives regarding confidentiality and partner notification.

Methods

Qualitative research interviews were conducted in the Northwest Region of Cameroon with 30 TB/HIV counsellors in 4 treatment centres, and 2 legal professionals between September and December 2009. Situational Analysis (positional map) was used for data analysis.

Results

Confidentiality issues were perceived to be handled properly despite concerns about patients' reluctance to report cases of violation due to apprehension of reprisals from health care staffs. All the respondents encouraged voluntary partner notification, and held four varying positions when confronted with patients who refused to voluntarily notify their partners. Position one focused on absolute respect of patients' autonomy; position two balanced between the respect of patients' autonomy and their partners' safety; position three wished for protection of sexual partners at risk of HIV infection and legal protection for counsellors; and position four requested making HIV testing and partner notification routine processes.

Conclusion

Counsellors regularly encounter ethical, legal and moral dilemmas between respecting patients' confidentiality and autonomy, and protecting patients' sexual partners at risk of HIV infection.

This reflects the complexity of partner notification and demonstrates that no single approach is optimal, but instead certain contextual factors and a combination of different approaches should be considered. Meanwhile, adopting a human rights perspective in HIV programmes will balance the interests of both patients and their partners, and ultimately enhance universal access to HIV services.

Effect of single session counselling on partner referral for sexually transmitted infections management in Bangladesh

OBJECTIVES

This study evaluated the role of single session counselling on partner referral among index cases diagnosed as having sexually transmitted infections (STIs) in Bangladesh.

METHODS

A quasirandomised trial was conducted in 1339 index cases with symptomatic STIs in 3 public and 3 non-government organisation operated clinics.

RESULTS

Out of 1339 index cases, partner referral was achieved by 37% in the counselling group and 27% in the non-counselling group. Index cases in the counselling group and non-counselling group were similar in terms of condom use rates, STI symptoms and duration of disease. A quarter of the index cases reported having more than one sex partner in last 3 months, and 39% reported having commercial sex partners. Only 8% of the index cases reported using condoms during their last sex act. Partner referral rates were higher among index clients with higher age, higher income, those who attended NGO clinics, those who had only one partner and among those who had no commercial partners, but counselling had significantly positive impact in all of these subgroups. In multivariate analysis, the probability of partner referral was 1.3 times higher among index cases in the counselling group (prevalence ratio 1.3; 95% CI 1.1 to 1.6) as compared to index cases in the non-counselling group.

CONCLUSIONS

Patient-oriented single session counselling was found to have a modest but significant effect in increasing partner referral for STIs in Bangladesh, greater emphasis should be placed on examining further development and dissemination of partner referral counselling in STI care facilities.

Telling partners about chlamydia: how acceptable are the new technologies?

Background

Partner notification is accepted as a vital component in the control of chlamydia. However, in reality, many sexual partners of individuals diagnosed with chlamydia are never informed of their risk. The newer technologies of email and SMS have been used as a means of improving partner notification rates. This study explored the use and acceptability of different partner notification methods to help inform the development of strategies and resources to increase the number of partners notified.

Methods

Semi-structured telephone interviews were conducted with 40 people who were recently diagnosed with chlamydia from three sexual health centres and two general practices across three Australian jurisdictions.

Results

Most participants chose to contact their partners either in person (56%) or by phone (44%). Only 17% chose email or SMS. Participants viewed face-to-face as the "gold standard" in partner notification because it demonstrated caring, respect and courage. Telephone contact, while considered insensitive by some, was often valued because it was quick, convenient and less confronting. Email was often seen as less personal while SMS was generally considered the least acceptable method for telling partners. There was also concern that emails and SMS could be misunderstood, not taken seriously or shown to others. Despite these, email and SMS were seen to be appropriate and useful in some circumstances. Letters, both from the patients or from their doctor, were viewed more favourably but were seldom used.

Conclusion

These findings suggest that many people diagnosed with chlamydia are reluctant to use the new technologies for partner notification, except in specific circumstances, and our efforts in developing partner notification resources may best be focused on giving patients the skills and confidence for personal interaction.

Partner notification for sexually transmitted infections in developing countries: a systematic review

BACKGROUND

The feasibility and acceptability of partner notification (PN) for sexually transmitted infections (STIs) in developing countries was assessed through a comprehensive literature review, to help identify future intervention needs.

METHODS

The Medline, Embase, and Google Scholar databases were searched to identify studies published between January 1995 and December 2007 on STI PN in developing countries. A systematic review of the research extracted information on: (1) willingness of index patients to notify partners; (2) the proportion of partners notified or referred; (3) client-reported barriers in notifying partners; (4) infrastructure barriers in notifying partners; and (5) PN approaches that were evaluated in developing countries.

RESULTS

Out of 609 screened articles, 39 met our criteria. PN outcome varied widely and was implemented more often for spousal partners than for casual or commercial partners. Reported barriers included sociocultural factors such as stigma, fear of abuse for having an STI, and infrastructural factors related to the limited number of STD clinics, and trained providers and reliable diagnostic methods. Client-oriented counselling was found to be effective in improving partner referral outcomes.

CONCLUSIONS

STD clinics can improve PN with client-oriented counselling, which should help clients to overcome perceived barriers. The authors speculate that well-designed PN interventions to evaluate the impact on STI prevalence and incidence along with cost-effectiveness components will motivate policy makers in developing countries to allocate more resources towards STI management.

Predicting undetected infections during the 2007 foot-and-mouth disease outbreak

Active disease surveillance during epidemics is of utmost importance in detecting and eliminating new cases quickly, and targeting such surveillance to high-risk individuals is considered more efficient than applying a random strategy. Contact tracing has been used as a form of at-risk targeting, and a variety of mathematical models have indicated that it is likely to be highly efficient. However, for fast-moving epidemics, resource constraints limit the ability of the authorities to perform, and follow up, contact tracing effectively. As an alternative, we present a novel real-time Bayesian statistical methodology to determine currently undetected (occult) infections. For the UK foot-and-mouth disease (FMD) epidemic of 2007, we use real-time epidemic data synthesized with previous knowledge of FMD outbreaks in the UK to predict which premises might have been infected, but remained undetected, at any point during the outbreak. This provides both a framework for targeting surveillance in the face of limited resources and an indicator of the current severity and spatial extent of the epidemic. We anticipate that this methodology will be of substantial benefit in future outbreaks, providing a compromise between targeted manual surveillance and random or spatially targeted strategies.

Contact tracing to control infectious disease: when enough is enough

Contact tracing (also known as partner notification) is a primary means of controlling infectious diseases such as tuberculosis (TB), human immunodeficiency virus (HIV), and sexually transmitted diseases (STDs). However, little work has been done to determine the optimal level of investment in contact tracing. In this paper, we present a methodology for evaluating the appropriate level of investment in contact tracing. We develop and apply a simulation model of contact tracing and the spread of an infectious disease among a network of individuals in order to evaluate the cost and effectiveness of different levels of contact tracing. We show that contact tracing is likely to have diminishing returns to scale in investment: incremental investments in contact tracing yield diminishing reductions in disease prevalence. In conjunction with a cost-effectiveness threshold, we then determine the optimal amount that should be invested in contact tracing. We first assume that the only incremental disease control is contact tracing. We then extend the analysis to consider the optimal allocation of a budget between contact tracing and screening for exogenous infection, and between contact tracing and screening for endogenous infection. We discuss how a simulation model of this type, appropriately tailored, could be used as a policy tool for determining the appropriate level of investment in contact tracing for a specific disease in a specific population. We present an example application to contact tracing for chlamydia control.

Optimal mix of screening and contact tracing for endemic diseases

Two common means of controlling infectious diseases are screening and contact tracing. Which should be used, and when? We consider the problem of determining the cheapest mix of screening and contact tracing necessary to achieve a desired endemic prevalence of a disease or to identify a specified number of cases. We perform a partial equilibrium analysis of small-scale interventions, assuming that prevalence is unaffected by the intervention; we develop a full equilibrium analysis where we compare the long-term cost of various combinations of screening and contact tracing needed to achieve a given equilibrium prevalence; and we solve the problem of minimizing the total costs of identifying and treating disease cases plus the cost of untreated disease cases. Our analysis provides several insights. First, contact tracing is only cost effective when prevalence is below a threshold value. This threshold depends on the relative cost per case found by screening versus contact tracing. Second, for a given contact tracing policy, the screening rate needed to achieve a given prevalence or identify a specified number of cases is a decreasing function of disease prevalence. As prevalence increases above the threshold (and contact tracing is discontinued), the screening rate jumps discontinuously to a higher level. Third, these qualitative results hold when we consider unchanged or changed prevalence, and short-term or long-term costs.

The prevalence of chlamydia, gonorrhea, and trichomonas in sexual partnerships: implications for partner notification and treatment

BACKGROUND

Treatment of sex partners by patient-delivered partner therapy (PDPT) may prove to be an effective strategy in reducing reinfection and preventing the sequelae of sexually transmitted infections (STIs). However, limited data exists regarding STIs within sexual partnerships (dyads).

OBJECTIVE

The objective of this study was to determine the prevalence of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (GC), and Trichomonas vaginalis (TV) in sexual dyads to estimate the potential yield and limitations of PDPT.

METHODS

Male and female STI clinic attendees were invited to participate. Index subjects and partners were interviewed and tested for CT, GC, and TV. All partners were sought regardless of infection status of the index subject.

RESULTS

Of 210 dyads, the prevalence in index subjects was CT, 46%; GC, 18%; and TV, 14%. Considering the partners of 72 CT-only-infected index subjects, 57% had CT, 6% had GC, and 11% had TV. Considering the partners of 35 index subjects with GC or GC-CT coinfection, 57% had GC and/or CT; however, in 20% of partners, unsuspected TV was present. Among 74 dyads with uninfected index subjects, 26% of partners had an STI. Among the partners of 19 index subjects with TV only, 11% had CT, 5% had GC, and 37% had TV.

CONCLUSION

In our clinic population, a substantial number of partners had infections different from or in addition to those infections in the index. Many of these infected partners would not be diagnosed and treated using PDPT. Partners of index attendees without detected infection were at high risk (26%) for STI, mostly CT.

Doing the analysis differently. Using narrative to inform understanding of patient participation in contact tracing for sexually transmissible infections

The aims and objectives of this paper were to understand the key influences hindering patients, participation in the contact tracing process for sexually transmissible infection exposure; to study the anatomy of acomplex sexual network through the eyes of a committed contact tracer and a group of teenagers; and to identify lessons from the research. Unstructured and group interviews were undertaken with a group of sixth form students and an unstructured interview with a contact tracer. Cue (storyboards) cards and hypothetical sexual networks were used--the outcome demonstrated that generated narrative about sexual network experiences can be analysed using a schema of representation of experience and could be subjected to Labov's structural categories for assignment of spheres of action, to undertake interpretation. Themes identified include: confidentiality, secrecy, friendship, community, the law and social sanctions. We conclude that contact tracing is under the spotlight and that we need to understand the personal experiences of being subjected to a process where little consideration has been given to the social and psychological consequences. Narrative analytic strategies can be applied to gain this much-needed rich data.

Outreach health adviser in a community clinic screening programme improves management of genital chlamydia infection

OBJECTIVE

To assess the effectiveness of an outreach health adviser on treatment, partner notification and outcome for clients diagnosed with genital chlamydia (CT) infection at a community young people's clinic.

METHODS

From August 1999 to March 2000, a genitourinary medicine (GUM) based health adviser helped to develop testing and undertook outreach management of clients aged under 26 years diagnosed with CT infection. In addition to facilitating referral to GUM, she gave antibiotic treatment based on a GUM derived patient group direction to those not wishing to travel to the GUM clinic. She also advised them on contact tracing and the need for a compliance check (CC).

RESULTS

Chlamydia positive tests with ligase chain reaction (LCR), on first void urine, were obtained for 62 (12.9%) of 481 female clients, one (5%) of 20 male clients, and nine (53%) of 17 male contacts of female positive cases. All 72 testing positive received their result and were treated. Two urine samples positive for CT showed positive LCR tests for gonorrhoea. Proportions of named contacts seen (67%) and reattendances for compliance checks (60%) were similar to those for women seen in GUM services.

CONCLUSIONS

Health adviser input with the ability to treat can be effective in reducing the growth of identified but untreated genital chlamydia infection consequent upon community based screening. Such a strategy appears comparable with, and can add to, GUM based treatment of infection. It helps to address the need for alternative management strategies in the light of the national sexual health strategy.

Sex difference in partner notification: results from three population based surveys in France

OBJECTIVES

To estimate the proportion of individuals in the general population who did not notify their sexual partners at the time of an STD diagnosis, according to the sex of the patient and the type of partner.

METHODS

We analysed behaviour at the time of diagnosis of a self reported STD, using data from three large French national population based surveys of adults (ACSF, Barométre Santé) and adolescents (ACSJ). Univariate and multivariate analyses took into account the complex sampling design.

RESULTS

In the ACSF, 14% (95% CI: 4% to 24%) of men reported that they had not informed their main sexual partner compared with only 2% (95% CI: 0% to 5%) of women (p = 0.03). This sex difference was independent of the nature of the STD, the patient's age, level of education, and number of partners. Similarly, in the ACSJ, 51% (95% CI: 21% to 81%) of boys reported that they had not talked about this STD with their current sexual partner compared with only 9% (95% CI: 0% to 26%) of girls (p = 0.04). Notification by a sexual partner had led to discovery of the STD more frequently in male subjects than in female subjects, both in adults (32% of men compared with 4% of women (p=0.04)), and adolescents (36% of boys compared with 12% of girls). Most subjects, irrespective of sex, had not informed partners other than their main or current partner: 73% (95% CI: 62% to 84%) of adults and 86% (95% CI: 77% to 95%) of adolescents.

CONCLUSIONS

Procedures must be developed urgently to improve the notification of sexual partners, particularly female partners and adolescents, who are unlikely to be tested early without such notification.

Interventions against sexually transmitted infections (STI) to prevent HIV infection

STIs have taken on a more important role with the advent of the HIV/AIDS epidemic, and there is good evidence that their control can reduce HIV transmission. The challenge is not just to develop new interventions, but to identify barriers to the effective implementation of existing tools, and to devise ways to overcome these barriers. This 'scaling-up' of effective strategies will require an international and a multisectoral approach. It will require the formation of new partnerships between the private and public sectors and between governments and the communities they represent.

Operational performance of an STD control programme in Mwanza Region, Tanzania

OBJECTIVES

To describe important details of the design and operational features of the Mwanza sexually transmitted diseases (STD) control programme. To assess the feasibility of the intervention, the distribution of STD syndromes observed, the clinical effectiveness of syndromic STD case management, the utilisation of STD services by the population, and the quality of syndromic STD services delivered at rural health units.

METHODS

The intervention was integrated into rural primary healthcare (PHC) units. It comprised improved STD case management using the syndromic approach, facilitated by a regional programme office which ensured the training of health workers, a reliable supply of effective drugs, and regular support supervision. Five studies were performed to evaluate operational performance: (i) a survey of register books to collect data on patients presenting with STDs and reproductive tract infections (RTIs) to rural health units with improved STD services, (ii) a survey of register books from health units in communities without improved services, (iii) a survey of register books from referral clinics, (iv) a home based cross sectional study of STD patients who did not return to the intervention health units for follow up, (v) a cross sectional survey of reported STD treatment seeking behaviour in a random cohort of 8845 adults served by rural health units.

RESULTS

During the 2 years of the Mwanza trial, 12,895 STD syndromes were treated at the 25 intervention health units. The most common syndromes were urethral discharge (67%) and genital ulcers (26%) in men and vaginal discharge (50%), lower abdominal tenderness (33%), and genital ulcers (13%) in women. Clinical treatment effectiveness was high in patients from whom complete follow up data were available, reaching between 81% and 98% after first line treatment and 97%-99% after first, second, and third line treatment. Only 26% of patients referred to higher levels of health care had presented to their referral institutions. During the trial period, data from the cohort showed that 12.8% of men and 8.6% of women in the intervention communities experienced at least one STD syndrome. Based on various approaches, utilisation of the improved health units by symptomatic STD patients in these communities was estimated at between 50% and 75%. During the first 6 months of intervention attendance at intervention units increased by 53%. Thereafter, the average attendance rate was about 25% higher than in comparison communities. Home visits to 367 non-returners revealed that 89% had been free of symptoms after treatment, but 28% became symptomatic again within 3 months of treatment. 100% of these patients reported that they had received treatment, but only 74% had been examined, only 57% had been given health education, and only 30% were offered condoms. Patients did not fully recall which treatment they had been given, but possibly only 63% had been treated exactly according to guidelines.

CONCLUSIONS

This study demonstrated that it is feasible to integrate effective STD services into the existing PHC structure of a developing country. Improved services attract more patients, but additional educational efforts are needed to further improve treatment seeking behaviour. Furthermore, clear treatment guidelines, a reliable drug supply system, and regular supervision are critical. All efforts should be made to treat patients on the spot, without delay, as referral to higher levels of care led to a high number of dropouts. The syndromic approach to STD control should be supported by at least one reference clinic and laboratory per country to ensure monitoring of prevalent aetiologies, of the development of bacterial resistance, and of the effectiveness of the syndromic algorithms in use.

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.

A collaborative approach to management of chlamydial infection among teenagers seeking contraceptive care in a community setting

OBJECTIVES

To develop and assess a coordinated model of care for effective management of genital chlamydial infection in young women, identified through a selective screening programme in a community based teenage health clinic.

METHODS

Selective screening for genital Chlamydia trachomatis was undertaken among young women aged 13-19 years who were having a routine cervical smear test, being referred for termination of pregnancy, or who reported behavioural risk factors, for, and/or symptoms of, genital infection. Collaboration among family planning, genitourinary medicine (GUM), and public health staff was used to enhance management of infected individuals, with particular focus on partner notification.

RESULTS

94 young women had confirmed genital chlamydial infection, representing 11% of those tested. All index patients received appropriate antibiotic therapy and follow up; 93 (99%) of these were counselled by a health adviser, of whom 62 (66%) were able to provide sufficient details for partner notification, resulting in treatment of male partners associated with 51 (82%) of these young women. Younger age (< or = 16 years) was significantly associated with delay in attending for treatment.

CONCLUSIONS

Effective management of genital chlamydial infection is achievable in settings outside GUM clinics using a collaborative approach which incorporates cross referencing between community based services and GUM clinics.

Do the factors associated with successful contact tracing of patients with gonorrhoea and Chlamydia differ?

OBJECTIVE

To assess and compare factors which may be associated with successful contact tracing in patients with gonorrhoea and chlamydia.

STUDY DESIGN

Prospective observational study of patients attending a genitourinary medicine clinic with a diagnosis of gonorrhoea or chlamydia. Multivariate analysis model including demographic, socioeconomic, and behavioural variables.

RESULTS

The attendance of at least one sexual contact was associated with naming more contacts for patients with gonorrhoea (OR 1.44, 95% CI 1.04-2.01). A history of gonorrhoea was associated with successful contact tracing for patients with chlamydia (OR 1.46, 95% CI 1.12-1.9). Successful contact tracing, as defined by at least one confirmed contact attendance after the index case, was not associated with age, sex, sexual orientation, history of chlamydia, use of condoms, marital status, ethnicity, or socioeconomic status for either gonorrhoea or chlamydia.

CONCLUSIONS

Differences in the composition of the core groups infected with gonorrhoea and chlamydia are not explained by differences in contact tracing success. In the clinic setting studied, the outcome of contact tracing was not associated with a variety of demographic, socioeconomic, and behaviour factors.

Partner notification for gonorrhoea: a comparative study with a provincial and a metropolitan UK clinic

OBJECTIVE

To compare partner notification practice and outcomes at a provincial and a metropolitan clinic.

DESIGN

Prospective study, following standardisation of partner notification policy.

SETTINGS

Sheffield Department of Genitourinary Medicine, Royal Hallamshire Hospital and Jefferiss Wing Centre for Sexual Health, St Mary's Hospital, London.

SUBJECTS

Consecutive patients with culture positive gonorrhoea between October 1994 and March 1996 who were interviewed by a health adviser.

RESULTS

In Sheffield, 235 cases reported 659 outstanding contacts, of whom 129 (20%) were subsequently screened, and 65 (50%) had gonorrhoea. At St Mary's 510 cases reported 2176 outstanding contacts, of whom 98 (5%) were known to have been screened, and 53 (54%) had gonorrhoea. Patient or provider referral agreements appeared more productive in Sheffield, where 60% resulted in contact attendance, compared with 13% at St Mary's. Provider referral was used more frequently in Sheffield, for 44% of referrals, compared with 1% at St Mary's. Multivariate analysis showed that partner notification was less effective for casual and short term (< 7 days) partnerships in both centres, and for homosexual men at St Mary's.

CONCLUSION

Partner notification outcomes were better in the provincial setting where contact attendance could be recorded more reliably and provider referral was used more extensively. The high proportion of contacts who remained untraced in both settings indicates the need for complementary screening and prevention initiatives.

Patient referral outcome in gonorrhoea and chlamydial infections

OBJECTIVE

To describe the outcome of patient referral at the STD clinic of the University Hospital Rotterdam. To study characteristics of heterosexual index patients and partnerships related to referral outcome.

METHODS

In 1994, patients with gonorrhoea and chlamydia were referred to public health nurses for interview and patient referral. Referral outcome was classified as "verified" if partners attended the STD clinic and as "believed" if partners were said to have attended elsewhere.

RESULTS

Of 454 patients, 250 (55%) participated in the study. The outcome of patient referral for the 502 eligible partners was 103 (20.5%) verified referrals, 102 (20%) believed referrals, and 297 (59%) with unknown follow up. Of the 103 partners examined, 43 had an STD of which 63% reported no symptoms. The contact finding ratio was higher for chlamydia patients and heterosexual men. Also, referral was more effective for index patients with recent sexual contact, with follow up visits to the public health nurse, for men who were not commercial sex worker (CSW) clients, and, to a lesser degree, for Dutch patients and patients who sometimes used condoms. For steady partners, referral was improved if the last sexual contact was more recent. Casual partners visited the clinic more often if sexual contact occurred more than once, if the last contact was more recent, if they were older, and if they were Dutch.

CONCLUSIONS

Patient referral was more effective for certain groups, such as chlamydia patients and steady partners, but was inadequate for others, including CSW and their clients, other "one night stands", young partners, and ethnic minorities.