Partner notification and HIV: a case study.
This article outlines the essentials of partner notification and reviews outcome for one individual following a positive diagnosis, using a case study that demonstrates these principles in action.
The aim of partner notification (PN) is to identify and treat asymptomatic or incubating infection in the contacts of diagnosed cases, so that the average duration of infection is reduced and chains of transmission are broken. Effective and timely partner notification is therefore essential to prevent transmission and late diagnosis of HIV. Modern partner notification methods were introduced in Europe in the 1930s to help control syphilis. The original model for tracing the contacts of syphilis cases involved field workers, known as medical social workers or health visitors, who would go into the community to find contacts . This is what we now call provider referral.
Under the 1946 Tyneside scheme, one of the UK's first organised contact tracing systems, contacts of patients with syphilis or gonorrhoea were persuaded to attend a clinic by a health visitor. By 1970, contacts were attending following the efforts of the patients themselves .
Partner notification uses three methods:
* Patient referral involves the index patient contacting their sexual partner/s in person. With HIV this can be difficult when the index patient does not wish their partner/s to know their HIV status.
* Provider referral involves the healthcare worker contacting sexual partner/s on the index patient's behalf (as the health visitors or medical social workers in the 1930s). This method can protect the patient's identity and allow the healthcare professional to follow up the contacts' attendance more effectively.
* Contract referral is a combination of these two methods. When an index patient fails to notify a contact within a given time, the healthcare professional will initiate a provider referral. Setting timeframes with patients can be useful in this context, because patients will often tell us what we want to hear and say they will inform partners. However, a contract referral gives the patient control initially to tell partners, knowing that the healthcare provider will act if they do not.
A patient in the UK with a new HIV result therefore has four options: tell their contacts themselves, have the healthcare practitioner contact partners using provider referral, opt for contract referral--or do nothing, as partner notification is not mandatory. Although doing nothing is not in the best interest of the contacts, this may be what the patient decides and should be respected.
In recent years online partner notification services have been developed to assist the patient and healthcare practitioner. Several studies have shown higher rates of risky, anonymous internet sex with men who have sex with men (MSM), one study showing 65% of MSM having anonymous internet sex .
GMFA (Gay Men Fighting AIDS) are currently piloting a UK online partner notification tool for men who have sex with men (full article on page 3). This will enable patients to contact partners through anonymous text, email or message through online dating sites. The use of online partner notification in other countries has shown that this method can significantly reduce transmission rates of HIV and other STIs. Studies suggest that internet partner notification programmes would be highly acceptable to MSM who use the internet to meet sexual partners .
Partner notification should be carried out by a sexual health advisor or other professional experienced in partner notification techniques. Because the process is voluntary, its success requires the patient to co-operate--therefore the healthcare professional may need to spend time working with the index patient. Partner notification is often done shortly after a new diagnosis, when the patient is still coming to terms with their status and may want to blame previous partners. During this time the patient may not be receptive to partner notification and it may need to be deferred until the patient is ready.
If the ex-partner is (by inference) HIV positive, he could be undiagnosed and unknowingly infecting others. Although this was discussed at length, the team agreed that, if the ex-partner was having unprotected sex, he had a responsibility to himself to test. Given Paul's reluctance for his ex-partner to be contacted, an anonymous provider referral without his consent would have addressed this issue.
However, if the clinic team goes against the patient's wishes, this can have a negative impact on the patient's care when the patient is informed. We had noticed that Paul's attendance dropped when partner notification was raised--and our primary responsibility is always to the patient.
Whilst this case study looked at long-term partners, we know that HIV-positive patients also have casual partners. Does a health visitor have a right to contact casual partners as well, if we know about them? If the patient reports using condoms all the time, is this any different to an HIV-positive patient reporting a one-night stand and not disclosing to them.
This one case study demonstrates the complexity of partner notification in HIV. There is no right answer or best option, as each case is individual and different clinics will arrive at different outcomes. All options should be reviewed with the patient, who should decide which method best suits their circumstances, and it is equally important to involve all members of the team in discussions.
If the patient declines notification, their wishes should be respected. Patients receiving a new HIV-positive diagnosis need time to adjust and deal with the initial shock and fear. The best results are achieved by experienced staff building up a relationship with the patient. This is often a long process that cannot be rushed. Informing the patient of the advantages, and addressing any concerns, will allow them to make an informed decision--which ultimately we have to respect.
[1.] Brandt A. No magic bullet: a social history of venereal disease in the United States since 1880. Oxford University Press, New York, 1985.
[2.] Wigfield AS. 27 years of uninterrupted contact tracing. The 'Tyneside Scheme'. British Journal of Venereal Diseacse, 1972, 48, 37-50.
[3.] Hogben M. Paffel J, Broussard D et al. Syphilis partner notification with men who have sex with men: a review and commentary. Sexually Transmitted Disease, 2005, 32(10 Suppl), S43-S47.
[4.] Mimiaga MJ, Reisner SL, Tetu AM. Psychosocial and behavioural predictors of partner notification after HIV and STI exposure and infection among MSM. AIDS and Behavior, 2009, 13, 738-745.
[5.] Society of Sexual Health Advisers (SSHA). Manual for Sexual Health Advisers. SSHA, London, 2004. Available at: www.ssha.info (accessed October 2011).
Case study: Paul
Paul is a 31-year-old gay man who is well known in the gay community. He was seen in clinic as a result of a provider referral (Andy). His point-of-care and confirmation test were positive.
Andy was diagnosed HIV positive but had had a negative HIV test 3 months previously. Paul was his only contact since his negative test and there were no other partners in the window period of this first test.
Issues and problems
Paul's last negative HIV test had been 6 years earlier, and he had had one other long-term partner since this test. Paul declined to give details initially for fear of this former partner finding out his status.
He was seen on a regular basis by the health advisors who discussed the different options for partner notification. Paul agreed that his ex-partner should be contacted for a provider referral and gave details, which were documented in his notes. Shortly after leaving the clinic, Paul changed his mind and phoned the health advisor to withdraw consent to contact the ex-partner. This is a common reaction during the time of a new diagnosis, when patients are coming to terms with their result, and we agreed to postpone the provider referral. When revisiting this a month later, Paul said he did not ever want the provider referral to happen.
This was discussed within the team and it was felt that there was a high risk of the ex-partner being HIV positive for the following reasons:
1. Paul had a negative test 6 years earlier and had only had two partners since.
2. One of the partners was recently diagnosed positive (Andy), whereas a test in this clinic 12 weeks earlier had been negative.
3. Paul remembers a seroconversion-type illness during his relationship with the ex-partner, although this cannot be proven.
The options discussed by the team were: either carry out an anonymous provider referral against Paul's wishes and without his consent (which might be a concern for him); or continue working with him in the hope that he would agree and the referral could proceed with his permission.
It was difficult for the health advisors to work with Paul as every time he came into clinic he was always too busy to wait--he would have his blood test, collect medication and then leave. The health advisors therefore started to take Paul's bloods so there was time to talk to him then. The health advisors would address the fears that Paul had about his contact identifying him and suggest ways of minimising this risk by using the support of other clinics to initiate the provider referral. We also looked at the negative impacts of not informing the contact, such as onward transmission to others and late diagnosis of his ex-partner. We noticed that Paul was not referring to his ex-partner by name, as though disassociating from him. The Manual for Sexual Health Advisers, published by the Society of Sexual Health Advisers (SSHA)  gives advice on managing resistance to partner notification and for this specific situation suggests building a sense of familiarity and making the person as real as possible, moving from superficial details (age, appearance), to circumstances and personality.
Paul was seen by a health advisor a few months on and disclosed that he had a new partner who was also unaware of his status; he had been in a relationship for 6 months and using condoms all the time.
Team decision and outcome
It was decided by the team not to go any further with the initial provider referral. It had been noticed that, when the provider referral was discussed, Paul would start to miss appointments--and the team were concerned he might stop attending altogether if pushed too much. As Paul had recently started ART and had a low CD4 count (<200 cells per ml), our priority was to maintain adherence to treatment and improve his CD4 cell count; pressuring him over partner notification could have an effect on this.
A while later, Paul started asking the health advisors for advice on disclosure and was working towards telling his current partner. After a few weeks a contract referral for his previous partner was agreed. Had provider referral been required as part of this process, we would have been able to involve other clinics to help (provider referral can be problematic when the contact is in a new relationship).
Paul attended clinic recently with his partner and disclosed with the support of the health advisor. His partner tested negative. This led us to raise the issue of his previous partner again, but Paul then confirmed that he did not, after all, want any form of referral to take place.
Senior Sexual Health Advisor, St Helens and Knowsley Teaching Hospitals NHS
Trust, Liverpool, UK
Correspondence to: Gary Barker Sexual Health Clinic (GUM) St Helens and Knowsley Teaching Hospitals NHS Trust Marshall Cross Road, St Helens Liverpool WA9 3DA, UK (email: email@example.com)
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|Article Type:||Case study|
|Date:||Dec 22, 2011|
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