Partner Notification Strategies Research Articles

Strategies for partner notification for sexually transmitted infections, including HIV

Strategies for partner notification for sexually transmitted infections, including HIV

Women's preferences for testing and management of sexually transmitted infections among low-income New York City family planning clients

High prevalence of chlamydia in the USA persists despite efforts to annually screen women under the age of 26. Tailoring sexually transmitted infection (STI) services to client preferences may strengthen existing programmes. We report women's preferences for STI services from a family planning clinic in New York City serving low-income women. Seventy-eight percent (995/1275) of eligible women participated, with a mean age of 26 (SD±7). Ninety-one percent self-identified as Latina. Nineteen percent reported a past STI. Women preferred self-collection (65%) for testing to a speculum exam (20%); 15% had no preference. Women with a previous STI were more likely to prefer a pelvic exam to women with no previous STI (50% versus 32%, P < 0.01). Nearly all women (94%) preferred informing a sex partner about a positive STI test themselves, but 88% were willing to bring expedited partner therapy to a partner. Women were more likely to prefer third party partner notification if their last partner was casual rather than a main partner (14% versus 3%, respectively, P < 0.01). Forty-four percent of participants worried about physical violence after partner notification. Self-collecting specimens for screening was widely acceptable. Partner notification strategies should be based on understanding partnership status, including fears of violence.

Cost-effectiveness of provider-based HIV partner notification in urban Malawi.

Provider-initiated partner notification for HIV effectively identifies new cases of HIV in sub-Saharan Africa, but is not widely implemented. Our objective was to determine whether provider-based HIV partner notification strategies are cost-effective for preventing HIV transmission compared with passive referral. We conducted a cost-effectiveness analysis using a decision-analytic model from the health system perspective during a 1-year period. Costs and outcomes of all strategies were estimated with a decision-tree model. The study setting was an urban sexually transmitted infection clinic in Lilongwe, Malawi, using a hypothetical cohort of 5000 sex partners of 3500 HIV-positive index cases. We evaluated three partner notification strategies: provider notification (provider attempts to notify indexes' locatable partners), contract notification (index given 1 week to notify partners then provider attempts notification) and passive referral (index is encouraged to notify partners, standard of care). Our main outcomes included cost (US dollars) per transmission averted, cost per new case identified and cost per partner tested. Based on estimated transmissions in a 5000-person cohort, provider and contract notification averted 27.9 and 27.5 new infections, respectively, compared with passive referral. The incremental cost-effectiveness ratio (ICER) was $3560 per HIV transmission averted for contract notification compared with passive referral. Provider notification was more expensive and slightly more effective than contract notification, yielding an ICER of $51 421 per transmission averted. ICERs were sensitive to the proportion of partners not contacted, but likely HIV positive and the probability of transmission if not on antiretroviral therapy. The costs per new case identified were $36 (provider), $18 (contract) and $8 (passive). The costs per partner tested were $19 (provider), $9 (contract) and $4 (passive). We conclude that, in this population, provider-based notification strategies are potentially cost-effective for identifying new cases of HIV. These strategies offer a simple, effective and easily implementable opportunity to control HIV transmission.

Acceptance of referral for partners by clients testing positive for human immunodeficiency virus

Background:Human immunodeficiency virus (HIV)-positive individuals who do not disclose their HIV status to their partners are more likely to present late for HIV and acquired immune deficiency syndrome (AIDS) care than those who have disclosed their HIV status to their partners. A major area of challenge with regards to HIV counseling for clients is disclosure of their HIV status to their partners. The main methods of partner notification are patient referral, provider referral, contract referral, and outreach assistance. The emphasis on a plausible and comprehensive partner referral strategy for widespread positive case detection in resource-limited countries needs to be thought out and developed.Methods:A qualitative study was conducted among newly HIV-positive clients to identify partners for notification and acceptance of referral by their partners. Health service providers working in HIV testing and counseling clinics were also provided with semistructured questionnaires in order to assess their view towards partner notification strategies for clients testing positive for HIV.Results:Fifteen newly diagnosed HIV-positive clients were counseled to provide referral slips to their partners. All clients agreed and took the referral card. However, only eight were willing and actually provided the card to their partners. Five of the eight partners of clients who tested HIV-positive and who were provided with referral cards responded to the referral and were tested for HIV. Three were positive and two were negative. Nine of 11 counselors did not agree to requesting partner locator information from HIV-positive clients for contractual referral and/or outreach assistance. The findings from the study were categorized by nine themes. A comprehensive and integrated approach of partner notification and a referral framework with active counselor involvement was developed.Conclusion:Partner notification and referral can be improved by an integrated and comprehensive framework, with active involvement of HIV counselors in the disclosure process.

Global Policy on Sexually Transmitted Infections: Frameworks and interventions in Zimbabwe

The discussion is on the Global Strategy for the Prevention and Control of Sexually Transmitted Infections (2006-2015), and the Zimbabwe National HIV and AIDS Strategic Plan (2011-2015), a policy intervention ratified towards this end. The Global Strategy was initiated for adoption by national governments to contribute towards Millennium Development Goal number six. It is aimed at providing a framework to guide an accelerated global response for the prevention and control of sexually transmitted infections. STI prevention and control interventions advocated include the promotion of health sexual behavior, provision of condoms and other barrier methods, delivery of prevention and care, strategies for sexual partner notification, provision of medicines, and vaccines, syndromic management and improving information for policy and programme development. The Strategic Plan in Zimbabwe is a multi-sectoral framework developed to provide strategic direction in planning, coordination, implementation, monitoring and evaluation of the national multi-sectoral and decentralized STI, HIV and AIDS interventions. This strategy is being implemented through the Public Sector, Private Medical Sector and the Not for Profit Health Sector. It was concluded that Zimbabwe’s policy intervention is in line with the global strategy. From the discussion, it was recommended that Zimbabwe must to systematically build the capacity of STI interventions to contribute effectively towards the realization of Millennium Development Goal Number Six. Key words: Policy, STIs, Global, Zimbabwe

A Randomized, Controlled Trial of inSPOT and Patient-Delivered Partner Therapy for Gonorrhea and Chlamydial Infection Among Men Who Have Sex With Men

The efficacy of patient-delivered partner therapy (PDPT) and inSPOT, a web-based partner notification service, in increasing partner treatment and/or notification among men who have sex with men (MSM) has not been evaluated. We enrolled MSM with chlamydia and/or gonorrhea in a randomized, controlled trial with the following 4 arms: inSPOT, PDPT, combined inSPOT and PDPT (inSPOT/PDPT), and standard partner management. Men were offered enrollment when contacted for partner services. Participants completed baseline and follow-up interviews approximately 2 weeks apart. We offered enrollment to 393 eligible MSM, of whom 75 (19%) enrolled and 318 (81%) declined enrollment. The study was halted early due to low enrollment. Among the 75 enrollees, 53 (71%) completed baseline and follow-up interviews. Of these 53 men, 13, 10, 17, and 13 were assigned to the PDPT, inSPOT, inSPOT/PDPT, and standard arms, respectively; participants provided information about 186 partners. The number of partners treated per original patient was 2.33 in the PDPT arm and 1.52 in the non-PDPT arms. PDPT assignment increased the mean number of partners treated per original patient by 54% (ratio of means = 1.54, 95% confidence interval: 1.01-2.34), after adjustment for inSPOT assignment. Among 27 men assigned to inSPOT or inSPOT/PDPT, 1 (4%) used inSPOT to notify ≥ 1 partner. inSPOT did not affect partner notification, but decreased partner human immunodeficiency virus testing (ratio of means: 0.42, 95% confidence interval: 0.18-0.99). PDPT may increase partner treatment among MSM. Few MSM appear to be willing to use inSPOT to notify their sex partners. Traditional randomized trials of partner notification strategies may not be feasible among MSM.

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

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

Is Accelerated Partner Therapy (APT) a cost-effective alternative to routine patient referral partner notification in the UK? Preliminary cost–consequence analysis of an exploratory trial

ObjectivesTo undertake a cost–consequence analysis to assess two new models of partner notification (PN), known as Accelerated Partner Therapy (APT Hotline and APT Pharmacy), as compared with routine patient referral...

P1-S4.17 Interactive demonstration of a model to calculate costs and cost effectiveness of different strategies for chlamydia screening and partner notification

BackgroundWe have developed a model to calculate costs and cost effectiveness of different intervention strategies for chlamydia screening, which can be used by commissioners to evaluate and plan their local service provision. The model and an analysis of national data have been recently published in BMJ. Increasingly, financial constraints will mean that tools such as ours will be vital to provide value for money in healthcare.MethodWe will give a live demonstration of our spreadsheet model using the example from our recent study. We invite delegates to input their own data in real time to a laptop for comparison and testing against the national and international picture. We plan to promote this before the meeting.Main outcome measuresCost effectiveness of screening (as cost per individual tested, cost per positive diagnosis, total cost of screening, number screened, number infected, sex ratio of those tested and treated). We will show how to compare current programmes with a planned change eg, in screening coverage or partner notification efficacy.ResultsIn 2008−2009 screening was estimated to cost £46.3 m and £506 per infection treated. The model results suggest that increasing male screening coverage from 8% to 24% (to match female coverage) would cost an extra £22.9 m and increase the cost per infection treated to £528. Increasing partner notification efficacy from 0.4 to 0.8 partners per index case would cost an extra £3.3 m and reduce the cost per infection diagnosed to £449.ConclusionsThe results are broadly representative of the national picture, but further evaluation of the cost effectiveness of partner notification and screening is urgently needed. We encourage practitioners who want to test this tool in their own setting to contact us (katy.turner@bristol.ac.uk).BMJ2011; 342:c725010.1136/bmj.c7250.

O5-S1.02 Acceptability of in SPOT and patient-delivered partner therapy among men who have sex with men seeking medical care

BackgroundPatient-delivered partner therapy (PDPT) and internet partner notification (PN) sites (eg, inSPOT) are being adopted in some areas to improve PN outcomes. Neither intervention has been well-studied in men who...

Assessing the effectiveness of a patient-driven partner notification strategy among pregnant women infected with syphilis in Bolivia

ObjectiveAssess the feasibility and acceptability of a patient-led syphilis partner notification strategy among pregnant women with syphilis, their male partners and treatment completion in Bolivia.MethodsIn four provinces, women who had...

Is Accelerated Partner Therapy partner notification for sexually transmissible infections acceptable and feasible in general practice?

Partner notification in primary care is problematic and of limited effectiveness despite enthusiasm from primary care providers to engage with sexually transmissible infection (STI) management. Innovative partner notification strategies must be relevant to the primary care context. The aim of the present study was to explore the opinions of general practitioners (GP) and practice nurses on the acceptability and feasibility of a new form of partner notification developed in the specialist setting known as Accelerated Partner Therapy (APT), for sex partners of those diagnosed with a bacterial STI in general practice. APT is defined as partner notification strategies that reduce time for sex partners to be treated, and include partner assessment by appropriately qualified health care professionals and here involve telephone and community pharmacy assessment. Semi-structured qualitative interviews were conducted with a purposive sample of GP and practice nurses in East London, UK. All participants appreciated the importance of partner notification in STI management and felt that APT would improve their practice. They supported prioritising antibiotic provision for the sex partners with provision for future comprehensive STI screening. Although both models were acceptable and feasible, the majority preferred the sexual health clinic telephone assessment over the pharmacy model. GP and practice nurses welcome new strategies for partner notification and believe APT could provide rapid and convenient treatment of sex partners in general practice. This supports further evaluation of APT models as a partner notification strategy in primary care.

Costs and cost effectiveness of different strategies for chlamydia screening and partner notification: an economic and mathematical modelling study

Objectives To compare the cost, cost effectiveness, and sex equity of different intervention strategies within the English National Chlamydia Screening Programme. To develop a tool for calculating cost effectiveness of...

Distribution and characteristics of sexual health service provision in primary and community care in England

The objective of this paper was to identify and describe enhanced sexual health services (ESHSs) commissioned for testing, diagnosis and management of sexually transmitted infections (STIs) in primary and community care settings in England. ESHSs commissioned by Primary Care Trusts (PCTs) in England were determined by telephone survey. Further information on service provision was collected by a follow-up email survey. By April 2009, 464 ESHSs had been commissioned to offer testing, diagnosis and treatment of STIs. Most providers were enhanced general practices (56%). Two in five PCTs did not offer any ESHSs and five PCTs had neither genitourinary medicine services nor ESHSs. Among 52 ESHSs that responded, screening and partner notification strategies varied. The distribution and characteristics of ESHS provision in England are heterogeneous emphasizing the need to establish clear clinical care pathways between services. Routine reporting and analysis of service activity could help ensure provision meets local needs.

Is everyone treated equally? Management of genital Chlamydia trachomatis infection in New Zealand

Health disparities often reflect inequitable access to appropriate health care. This study aimed to establish if cases of genital chlamydia infection were managed equitably by age, gender and ethnicity in a region of New Zealand with high rates of chlamydia infection (858 per 100,000 population). Clinical records of 415 genital chlamydia cases from 19 different health-care sites, including general practice and community settings, were reviewed. Data were analysed by demographic variables. For those treated, men were treated more quickly than women (median 3 days versus 6 days, P < 0.001), but there was no difference by ethnicity. Cases without documented treatment were more likely to be women (8.2% versus 2.1%, P = 0.037) and more likely to be Māori than non-Māori (13.6% versus 4.8%, P = 0.036). Overall, the most notable issue was the lack of effective partner notification across all demographic variables. Ongoing efforts are required to ensure equitable access to timely treatment and to ensure that more effective partner notification strategies are implemented.

Achieving successful partner notification: putting together the pieces of the puzzle

Partner notification as a public health measure to reduce transmission of sexually transmitted infections (STIs) is a cornerstone of STI control in most countries. The success of any partner notification strategy is conditional on its acceptability and feasibility to both patients and health-care professionals, its compliance with relevant professional and legislative guidance, and its cost-effectiveness.

Exposure to HIV Partner Counseling and Referral Services and Notification of Sexual Partners among Persons Recently Diagnosed with HIV

Among HIV-infected persons, we evaluated use of client partner notification (CPN) and health-department partner notification strategies to inform sex partners of possible HIV exposure, and prior exposure to partner counseling and referral services. We conducted a cross-sectional, observational study of 590 persons diagnosed with HIV in the prior 6 months at 51 HIV test, medical, and research providers in Chicago and Los Angeles in 2003 and 2004. Logistic regression was used to identify independent correlates of using CPN to notify all locatable partners. Participants reported a total of 5091 sex partners in the 6 months preceding HIV diagnosis; 1253 (24.6%) partners were locatable and not known to be HIV-positive. Of 439 participants with ≥1 locatable partners, 332 (75.6%) reported notifying 696 (55.5%) partners by CPN (585, 84.1%), health-department partner notification (94, 13.5%), or other means (17, 2.4%); 208 (47.4%) used CPN to notify all locatable partners. Independent correlates of CPN included having fewer locatable partners and discussing the need to notify partners with an HIV medical-care provider (black and Hispanic participants only). Many participants reported that their HIV test or medical-care provider did not discuss the need to notify partners (48.8%, 33.7%, respectively) and did not offer health-department partner-notification services (60.8%, 52.8%). Many locatable sex partners who might benefit from being notified of potential HIV exposure are not notified. In accordance with national policies, HIV test and medical-care providers should routinely provide partner counseling and referral services to HIV-infected clients so that all locatable partners are notified and provided an opportunity to learn their HIV status.

Maternal Syphilis and Intimate Partner Violence in Bolivia

Use a gender perspective to analyze a partner notification study conducted in antenatal clinics in Bolivia to assess the association between intimate partner violence (IPV) and partner notification. Guide the implementation of a safe, feasible, and culturally appropriate partner notification strategy in Bolivia in order to reduce the potential of IPV. We conducted a cross-sectional survey with women (n = 209) and their notified partners (n = 137) and structured interviews with a subsample of participants. Nearly 40% of women reported IPV in the past year and 28% mentioned fear of violence as a barrier to notifying their partners. Overall, 65% of women reported that they had notified their partners about their positive syphilis test results. Women who did not perceive violence as a barrier had greater odds of notifying their partner of their syphilis status (OR = 1.82; CI [0.93-3.60]; P <0.08). Women who could not protect themselves against partners' syphilis had a lower odds of notifying their partner (OR = 0.06; CI [0.049-0.656]; P <0.0001). Women who notified their partners said it was a favorable experience. Most men said they responded well to their partner's disclosure but could understand other men acting violently, especially when infidelity was involved. The majority of women who participated were able to notify male partners of their positive syphilis diagnosis but also reported high levels of domestic violence. The data suggest that public health practitioners should concomitantly screen for IPV and syphilis during pregnancy and assist women in abusive relationships on how to communicate sensitive disclosure information to partners.

Patient-led partner notification for syphilis: Strategies used by women accessing antenatal care in urban Bolivia

Maternal syphilis adversely affects close to one million pregnancies worldwide every year with consequences that may include spontaneous abortion, stillbirth, neonatal death, premature birth, neurological impairment and bone deformities of the neonate. In Bolivia, the maternal syphilis rate has been estimated at 4.3% among women with live births and 26% among women with stillbirths. Partner notification is critical to the prevention of maternal re-infection and vertical transmission of syphilis. Patient-led partner notification, also known as patient referral, is the recommended starting point for partner notification programs in resource poor settings because it requires less infrastructure and provider involvement. Though patient referral requires a higher level of engagement on the part of individuals, few studies have examined, in depth, the process of patient-led notification. Further, we found no studies of this type conducted in Bolivia, a country where culturally acceptable and appropriate interventions are needed to control maternal syphilis.This study examined partner notification, for the first time, from the perspective of women accessing treatment for maternal syphilis in Bolivia. Semi-structured interviews were conducted with 18 women who had attempted or planned to attempt notifying their partner. The interview guide was designed to investigate the experience of patient-led partner notification for syphilis with particular emphasis on the strengths and capacities of the participants. Accordingly, we applied an existing theoretical model for individual empowerment in the analysis of the interviews with the participants. This emphasis on the positive, solution-finding capacities of the participants allowed us to investigate the ways in which participants took control over an aspect of concern to their health. More studies are needed which examine successful patient-led strategies for partner notification and their connections with long-term health outcomes.

Epidemiological, social, diagnostic and economic evaluation of population screening for genital chlamydial infection

To investigate epidemiological, social, diagnostic and economic aspects of chlamydia screening in non-genitourinary medicine settings. Linked studies around a cross-sectional population-based survey of adult men and women invited to collect urine and (for women) vulvovaginal swab specimens at home and mail these to a laboratory for testing for Chlamydia trachomatis. Specimens were used in laboratory evaluations of an amplified enzyme immunoassay (PCE EIA) and two nucleic acid amplification tests [Cobas polymerase chain reaction (PCR), Becton Dickinson strand displacement amplification (SDA)]. Chlamydia-positive cases and two negative controls completed a risk factor questionnaire. Chlamydia-positive cases were invited into a randomised controlled trial of partner notification strategies. Samples of individuals testing negative completed psychological questionnaires before and after screening. In-depth interviews were conducted at all stages of screening. Chlamydia transmission and cost-effectiveness of screening were investigated in a transmission dynamic model. General population in the Bristol and Birmingham areas of England. In total, 19,773 women and men aged 16-39 years were randomly selected from 27 general practice lists. Screening invitations reached 73% (14,382/19,773). Uptake (4731 participants), weighted for sampling, was 39.5% (95% CI 37.7, 40.8%) in women and 29.5% (95% CI 28.0, 31.0%) in men aged 16-39 years. Chlamydia prevalence (219 positive results) in 16-24 year olds was 6.2% (95% CI 4.9, 7.8%) in women and 5.3% (95% CI 4.4, 6.3%) in men. The case-control study did not identify any additional factors that would help target screening. Screening did not adversely affect anxiety, depression or self-esteem. Participants welcomed the convenience and privacy of home-sampling. The relative sensitivity of PCR on male urine specimens was 100% (95% CI 89.1, 100%). The combined relative sensitivities of PCR and SDA using female urine and vulvovaginal swabs were 91.8% (86.1, 95.7, 134/146) and 97.3% (93.1, 99.2%, 142/146). A total of 140 people (74% of eligible) participated in the randomised trial. Compared with referral to a genitourinary medicine clinic, partner notification by practice nurses resulted in 12.4% (95% CI -3.7, 28.6%) more patients with at least one partner treated and 22.0% (95% CI 6.1, 37.8%) more patients with all partners treated. The health service and patients costs (2005 prices) of home-based postal chlamydia screening were 21.47 pounds (95% CI 19.91 pounds, 25.99) per screening invitation and 28.56 pounds (95% CI 22.10 pounds, 30.43) per accepted offer. Preliminary modelling found an incremental cost-effectiveness ratio (2003 prices) comparing screening men and women annually to no screening in the base case of 27,000 pounds/major outcome averted at 8 years. If estimated screening uptake and pelvic inflammatory disease incidence were increased, the cost-effectiveness ratio fell to 3700 pounds/major outcome averted. Proactive screening for chlamydia in women and men using home-collected specimens was feasible and acceptable. Chlamydia prevalence rates in men and women in the general population are similar. Nucleic acid amplification tests can be used on first-catch urine specimens and vulvovaginal swabs. The administrative costs of proactive screening were similar to those for opportunistic screening. Using empirical estimates of screening uptake and incidence of complications, screening was not cost-effective.