Preview Chapter 11

Introduction

Partner notification is essential to interrupting the chain of STD transmission. It also offers an opportunity to provide focused STD/HIV education. However, it is one of many strategies, not the sole strategy, in a comprehensive STD/HIV prevention program.

Background

Notification of exposure to STDs, including HIV, can be carried out by the infected person (the index patient) or by a health care provider. The program must be voluntary and the infected individual must choose to be involved. Other STD/HIV intervention services such as counseling, testing, and medical and social services should always be offered in conjunction with partner notification.

Types of Partner Notification

• Patient referral
• Provider referral
• Combination referral

Principles of Partner Notification

• Voluntary participation
• Confidentiality
• Accessibility
• Quality assurance
• Do no harm

Patient Education Information

Basic information should be communicated to the index patient regardless of who does the notification. This should include such things as how STDs are transmitted and the implications of infection.

Partner Notification Activities

Preventing STD/HIV transmission and averting complications from infection are the goals of partner notification. Numerous educational and other activities (outlined in this section) should be included in partner notification programs.

Appropriate Settings for Partner Notification

Any health care facility–from a primary health care clinic to a hospital outpatient department–can serve as a suitable setting for partner notification. Informal providers such as pharmacists and traditional healers can also be involved in educating patients about partner referral. Referral cards are an efficient way to expedite diagnosis and treatment (examples are provided).

Setting Priorities for Partner Notification

Primary health care clinics in most countries have limited resources. If partner notification can identify core groups–partners most likely to transmit infection to others–the disease control impact will be greater.

Conclusion

Since partner notification must occur in a unique cultural and medical environment, no single program can be applied universally. Cost is a factor in most countries, and some components of a program can be implemented inexpensively, such as with index patients using referral cards. However, the cost of establishing a provider referral system may be too high for most programs.

---

Introduction

The objectives of an STD/HIV prevention and control program are to prevent and interrupt disease transmission and prevent the development of STD complications. These objectives cannot be achieved merely by providing treatment for individuals presenting with signs or symptoms of STDs. Other public health measures are required to identify susceptible populations.

One important public health intervention to interrupt the chain of STD transmission is partner notification, in which the partners of those identified as having STD are located, informed of their potential risk of infection, and offered medical and counseling services. Partner notification also offers an opportunity to provide focused STD/HIV education to individuals who are by definition at highest risk of infection. Counseling and focused education may be a means of achieving behavior modification to reduce high-risk sexual behavior.

Partner notification may identify partners who are asymptomatic or who have minimal symptoms and would not otherwise present for medical treatment. For example, STDs have severe, long-term and potentially life-threatening complications in women, including infertility and ectopic pregnancy. Yet many women with STDs have no signs or symptoms of disease. These women may not receive curative treatment unless they are screened for asymptomatic infection. Partner notification is often the only way to identify these women at risk of infection and to prevent damaging STD complications.

Partner notification should be considered in any STD prevention program and in any situation where STD clinical services are provided. However, it is only one of many activities needed for effective STD prevention. Partner notification should not be a program's sole prevention strategy and should only be implemented within a comprehensive STD/HIV prevention program.

Background

Efforts to notify people who may have been exposed to STDs, including HIV, can be carried out either by the infected person (the index patient) or by a health-care provider (previously known as contact tracing). In traditional STD control programs, the primary reason to notify the partners of index patients is to ensure that at-risk individuals have the opportunity to receive therapeutic or preventive treatment before serious disease complications develop. In addition, by treating exposed individuals early in the course of a disease, providers can reduce the length of the period of communicability and break the chain of disease transmission.

In contrast, the primary purpose of HIV partner notification is to stop the spread of HIV by providing individual risk reduction education to those who are HIV-positive and to those who, although uninfected, are at risk of infection. Health-care providers or the index patients themselves counsel partners of HIV-infected individuals about safer sexual behaviors and about the availability of HIV testing. This process also allows health-care providers to offer HIV-infected individuals medical evaluation and support services earlier in the course of infection. If the partners choose to be tested and test positive for HIV, they are told how to protect their health and can be informed about the medical and support services available to them.

Providing the names of sex partners (or needle-sharing partners) during the interview should always be voluntary. Ensuring confidentiality–protecting the patient's identity and the privacy of named partners–is crucial to securing the cooperation of patients. Any process designed to identify partners that is coercive to index patients or partners, does not ensure the confidentiality of its participants, or does not depend on the voluntary participation of the patients should not be called a "partner notification" program.

In the United States as well as several other countries, partner notification has been performed almost entirely by trained health department professionals, known in some programs as disease intervention specialists (or DIS). In most programs, patients are offered the option of notifying their partners and referring them for assessment and treatment. Many patients wish to remain anonymous, however, and prefer having health department staff inform their partners.

STD and HIV partner notification programs are, by definition, voluntary since the infected individuals must choose to be involved in the process. In addition, partner notification should always be offered in conjunction with other STD/HIV intervention services, such as counseling, testing, and medical and social services.

Types of Partner Notification

Partner notification can be carried out through two distinct strategies–patient referral or provider referral–or through a combination of both strategies.

Patient Referral

Through patient referral, an index patient is encouraged to notify partners of their potential exposure to infection. The health-care provider is not directly involved in notification. Providers should, however, offer counseling to the index patient about the importance of partner treatment and encourage index patients to bring their partners to the clinic for services.

The success of patient referral is absolutely dependent on index patient and partner motivation and the quality and appropriateness of counseling received by the index patient. Patient referral is often the most acceptable form of partner notification because it does not require additional resources or personnel, and because patients do not have to identify partners by name to a health-care provider.

Provider Referral

In provider referral, a health worker locates partners identified by the index patient and offers them treatment. In some settings, outreach or community health workers may be able to ask partners to come into a clinic to see a health worker without having to explain (or even know) that the visit arises from partner notification for an STD.

Patients' concerns about confidentiality may limit the disclosure of information identifying partners. Index patients should be counseled and assured that confidentiality will be maintained and that their own clinical treatment will not be jeopardized by their participation in this process.

Combination Referral

In practice, only clinics that specialize in STD services are likely to have active provider referral programs. However, partner notification as practiced in these settings usually results from a combination of patient and provider referral. With combination referral, index patients may name some partners but notify other partners themselves. Sometimes index patients are given an interval of time to bring partners to the clinic for follow-up before providers begin to notify named partners. Often clinics offer provider referral for syphilis and patient referral for all other STDs.

Principles of Partner Notification

Regardless of the type of partner notification approach used in a given program, the following five principles must be followed:

Voluntary Participation

Disclosing the names or identity of partners should always be voluntary. STD/HIV counseling, testing and referral services should be available to index patients regardless of whether or not they choose to participate in partner notification. Occasionally a person who is infected with HIV consistently refuses to notify his or her partner or to identify these partners to a health worker. If the health worker knows the person's partners, he or she may feel obligated to inform them. However, such disclosure is illegal in some countries. This difficult ethical question needs to be addressed in the local context of each situation. It is always better to continue talking to the patient to obtain voluntary cooperation. Partner referral should not be a condition for receiving treatment. Experience has shown that such coercive measures can deter patients from seeking care or even encourage them to bring in any person whether they are a sexual partner or not.

Confidentiality

All records must be kept strictly confidential. Partners' names must be used only for field investigation and notification purposes. In no instance should partners be told the name or identity of the index patient, the date or period of exposure, or the infection status of the index patient.

Confidentiality of STD/HIV records, particularly those relating to partner notification, should be legally protected if possible. Lack of confidentiality will be a barrier to implementing partner notification programs. Unless index patients and communities at risk perceive benefit from the STD/HIV services, including partner notification, they may be reluctant to come forward for treatment and may turn instead to other possibly inadequate sources of care.

When confidentiality of records cannot be ensured, health providers should destroy written records relating to the index case as well as locating information regarding partners after partner notification has been initiated.

Accessibility

Program managers should ensure that referred partners have access to STD care and preventive services.

Quality Assurance

Program managers should routinely evaluate the performance of counselors and other program personnel to ensure that high-quality services are being delivered. They should also establish quality assurance and training guidelines to be followed by all professionals engaged in the partner notification process. Whatever partner notification model is selected, health providers must ensure that procedures for managing patient records are well-developed, detailed and confidential. In addition, all participating personnel should have completed a structured training course covering STD/HIV infection control, interviewing skills, partner notification techniques and confidentiality provisions.

Staff training for partner notification should include the following elements:

• Basic counseling and education skills, including crisis intervention, relationship counseling and skills in discussing sexual behavior
• The natural history of STD/HIV
• The epidemiology of STD/HIV among specific populations within geographic areas and local communities, including sexual transmission, asymptomatic carriage and consequences of non-treatment
• The psychosocial implications of STD/HIV infection
• Index patient interviewing skills and techniques.
• Risk-reduction issues
• Referral resources
• Record keeping
• Evaluation

Do No Harm

Program managers should ensure that clinical care providers consider the possible social consequences of partner referral for each individual patient. For example, in Nairobi, Kenya, some women with STDs may be at risk of violence from their partners when they request their attendance at a clinic. ¹

Patient Education Information

Regardless of who carries out the notification, certain basic information should be communicated to the index patient. Education should include information about:

• The modes of STD including HIV transmission
• The disease process
• The possibility that infected partners may be completely asymptomatic
• The possibility of reinfection if partners are not adequately treated
• Complications that could occur if partners are not adequately treated
• Recommendations for modifying patient and partner behavior
• The location of STD/HIV treatment, counseling and testing services
• Referral to support groups, HIV testing facilities and other medical facilities if available

Partner Notification Activities

The goals of STD/HIV partner notification programs are to prevent STD/HIV transmission and avert complications of STD infection. To meet these objectives, programs should include the following activities:

• Educating STD/HIV patients about how they can prevent transmission of STDs to others
• Referring patients for medical evaluation when appropriate
• Locating sex and/or needle-sharing partners identified by the patient and notifying them of their risk of infection
• Treating partners of STD patients epidemiologically; that is, treating the partner for the same STD syndromes as the index patient (see Table 1)
• Educating uninfected partners about how to reduce their risk of exposure to STDs/HIV
• Referring partners for medical evaluation and further counseling when appropriate

In most settings all pathogens common to the STD syndromes are not readily diagnosed. For example, identification of Chlamydia trachomatis and Hemophilus ducreyi is not available in the vast majority of STD patient encounters. Consequently, if all specific etiologic agents cannot be excluded and confirmed for each syndrome, then therapy in the referred partner as well as for the index patient should be syndromic.

Appropriate Settings for Partner Notification

Few countries have well-developed public health infrastructures to carry out provider referral activities. In general, where these services exist, provider referral is available only within specialized STD clinics. However, patient referral can and should be a part of comprehensive patient care for any STD patient, regardless of where treatment is delivered.

Partner notification can be made available from any health facility, including primary health-care clinics, maternal and child health clinics, family planning clinics, outpatient departments of hospitals, workplace health centers and private clinicians' offices. STD care is also available in many countries in the informal sector through pharmacists, traditional healers and street vendor. STD programs should involve these informal providers in educating patients about the need for partner referral.

Partner Notification in Clinic Settings

At a minimum, health-care providers seeing STD patients should educate patients about the importance of informing partners of their need for treatment. The index patient would then carry out partner notification, informing partners and advising them of their need for treatment. Patient referral may be enhanced by the use of special cards given to the patient to pass on to his/her other sex partners. These cards can help clinicians provide prompt diagnosis and treatment when partners present to the clinic for care (See example cards, Figures 1 to 3).

These referral cards can be designed to allow a clinic or program to estimate the percentage of index patients who actually refer partners. In Rwanda, for example, partner referral slips linked by a code number to the index patient were used to estimate that partners of 45 percent of index patients came in for evaluation. They were also able to determine that pregnant index patients were the most successful in referring partners.²

In many countries, cultural barriers to the development of partner notification programs may exist. For example, notifying the male spouse of an infected female patient might cause social disruption to the family or even physical harm to the wife. Strong community opposition to these programs may impede their effectiveness. In some countries, for example, homosexual men have perceived partner notification for HIV as discriminatory and have been reluctant to cooperate with health-care workers. STD/HIV programs that maintain good relationships with their patients and communities at risk will achieve greater patient compliance and ultimately greater public health success.

In most settings where referral patterns have been evaluated, women identified with STDs are more likely to refer their male partners for treatment than are male STD patients. Nonetheless, all the female partners, including the spouse of the male STD patient, should be referred for evaluation and treatment if possible. The referral of female partners of male index patients may be one of the only ways to identify asymptomatic STDs in women. In Malawi, for example, asymptomatic contacts of men with urethritis had STD prevalence rates similar to commercial sex workers and symptomatic women (see Table 2).³

In some instances, trained outreach workers may carry out provider referral, interviewing patients to identify partners and obtain locating information. In Zimbabwe and Haiti a combination of patient and provider referra<l was used involving the already existing community outreach worker (see Box 1).^4,5 At the Wachira Venereal Disease clinic in Bangkok, Thailand, social workers are able to reach 70 to 80 percent of the wives of male STD patients through combined patient and health provider referral.⁶

Setting Priorities for Partner Notification

In most countries primary health-care clinics and specialized STD clinics have limited resources for STD management including provider referral systems. The STD program manager must consider a number of possible factors that will influence the policies and priorities of a partner referral system.

1. Partners of patients with STDs are very likely to be infected and may be asymptomatic.
2. STDs may be managed syndromically (see Chapter 8) without etiologic confirmation.
3. The likelihood that a patient has an STD is very high in the following syndromes:
   • Urethritis in males
   • Genital ulcer disease in males and females
   • Pelvic inflammatory disease
   • Gonococcal ophthalmia neonatorum

   Therefore, the partners (or the parents of babies) of these patients should receive epidemiologic treatment for the syndrome.

   Vaginal discharge is less specific for the presence of an STD. The decision to treat male partners of women with vaginal discharge should be made based on the overall prevalence of STD in the community and the availability of laboratory diagnosis. For example, if speculum examinations are performed, the presence of cervical mucopurulent discharge is a specific enough clinical sign to suggest infection with either gonococcal or chlamydial infection.

4. Partners of persons with reactive syphilis serology should be referred and either tested for syphilis or treated epidemiologically.

   Focusing outreach efforts on particular types of partners will have different effects on the prevalence of STD in a population (see Chapter 13). If partner notification can identify partners most likely to transmit infection to others (core groups), then the disease control impact will be greater (see Table 3). If notification efforts identify monogamous female partners, however, the program will primarily prevent complications of STDs in these female partners and their infants. Some programs have used male index patient reports to identify high risk settings (i.e., brothels) rather than individuals. With this information, intensified treatment and prevention efforts can be directed more effectively. Thailand, for example, used reports of male STD clients to identify previously unknown sites used by commercial sex workers.

What to Refer

The following STD syndromes should be included in a partner referral program.

1. Partners of male index patients with:
   • Urethritis
   • Genital ulcer disease
   • Positive syphilis serology
   • Partners of mother of baby with gonococcal ophthalmia neonatorum
2. Partners of female index patients with:
   • Genital ulcer disease
   • Pelvic inflammatory disease
   • Positive syphilis serology
   • Purulent cervical discharge
3. Parents of baby with gonococcal ophthalmia neonatorum:

The decision to treat male partners of women with vaginal discharge should be made based on the overall STD prevalence in the community and the availability of other laboratory diagnostics.

Who to Refer

Although from a public health point of view treating high risk partners will have the greatest impact on the prevalence of STDs in a population, in reality, STD patients should be encouraged to refer all sexual partners. The importance of interventions targeted at high risk groups is discussed in Chapter 13.

Specific, culturally appropriate messages can enhance the motivation of the index patient to refer his/her partners. For example:

• The desire for a healthy baby in a pregnant woman with reactive serology
• The risk of infertility in a wife of a man with urethritis in cultures where many children are desired

How to Refer

At a minimum, all health-care providers seeing STD patients should encourage patients to refer their sexual partners for treatment. Although this is inexpensive and easy, it has several disadvantages.

• There will be no record of the disease exposure of the referred partner unless the partner can be linked back to the original patient. As such, since the partner may be asymptomatic, epidemiologic treatment is impossible.
• There are no records for evaluation of the referral system. Is the health-care provider informing patients to refer their partners? What percentage of patients actually refer in their partners?

By introducing a referral card to be given by the index patient to the partner(s) the above mentioned disadvantages can be overcome. The card should contain, at a minimum:

• Diagnosis of the index patient (often coded for confidentiality)
• Instructions for the partner on where to seek care (see section, "Partner Notification in Clinic Settings")

Partner cards for monitoring the proportion of partners seeking care could be designed in several ways. Sequential serial numbers could identify index patients on the cards; portions of the cards could be detachable and retained in the clinic to link to index patients. Alternatively, carbon copies could be retained in the clinic.

The decision to upgrade a referral system to include provider referral would be costly and must be carefully weighed against other STD program needs.

Conclusion

In conclusion, no single type of partner notification program can be designed to suit the needs of every country because each program must operate in a unique social, cultural and medical environment. However, some components of a program can be implemented almost universally at low cost. It has been shown in several sites that simple patient referral using cards given to the index patient can lead to partner treatment rates of up to 50 percent of the index patients seen.

However, at this point, the cost benefit of establishing a provider referral system is unknown. For most programs in developing countries, it is not a realistic option.

References

1. Jenniskens F, Obwaka E, Kirisuah S, Moses S, Mohamedali Yasufali F, et al. Syphilis control in pregnancy: decentralization of screening facilities to primary care level, a demonstration project in Nairobi, Kenya. Int J Obst Gyn 1995; 48 (suppl):S121—S128.
2. Steen R, Seleman C, Bucyana S, Dallabetta G. Partner notification as a component of integrated STD service in two Rwandan towns. Genitourin Med 1996; 72:56—59.
3. Dallabetta G, personal communication, 1995.
4. Winfield J, Latif AS. Tracing contacts of persons with sexually transmitted diseases in a developing country. Sex Transm Dis 1985;12:5—7.
5. Desormeaux J, Behets F, Adrien M, et al. Introduction of partner referral & treatment for control of sexually transmitted diseases in a poor Haitian community. In: Abstract book from the tenth international conference on AIDS/international conference on STD. Yokohama, Japan: Abstract 365C; 1994.
6. Chitwarakorn A, personal communication, 1995.

Suggested Readings

1. Toomey KE, Cates WC Jr. Partner notification for the prevention of HIV infection. HIV/AIDS 1989; (suppl 1): S57—S62.
2. Potterat JJ, Meheus A, Gallwey J. Partner notification: operational considerations. Int J STD AIDS 1991;2(6):411—415.
3. Woodhouse DE, Potterat JJ, Muth JB, Pratts CI, Rothenberg RB, Foble JS. A civilian-military partnership to reduce the incidence of gonorrhea. Public Health Reports 1985;100:61—65.