What are the purposes of Partner Notification?
Partner notification (PN) is an essential public health intervention for the control of sexually-transmitted infections (STIs). Ideally, when patients are diagnosed with an STI, their sexual partners are notified of exposure as well as invited for testing, counselling, and, if necessary, treatment. Partner notification helps to ensure that affected individuals get treatment and also helps to reduce the further spread of STIs. PN is important for all STIs, but may be especially critical for infections that are often asymptomatic or latent, such as Syphilis and Chlamydia, in which case partners may not be aware of the need for testing and treatment. Research also suggests that PN with high-risk populations, such as men who have sex with men (MSM), can lead to behaviour changes that reduce the spread of infection as well as the chances of re-infection.
Are there standards for Partner Notification?
Currently, partner notification is highly recommended in the Canadian Guidelines on Sexually Transmitted Infections, but it is not required in most provinces and territories. As a result, PN practices vary considerably by jurisdiction. Research also demonstrates that that there are significant gaps between PN guidelines and PN practices.
In one study, for example, only 60 per cent of family practitioners reported that it is their usual practice to recommend PN to index patients with Chlamydia while only 42 per cent of male index patients and 26 per cent of female index patients were advised to notify current and recent sexual partners
Who is responsible for Partner Notification?
Approaches to PN can be classified according to who takes responsibility for informing partners of exposure to an STI. Patient-based referral – also known simply as patient referral or self-referral – involves the index patient notifying current and/or recent sexual partners of the risk of infection and the need for medical assessment. In the case of provider referral, a health care worker or trained public health officer elicits information about sexual partners from the index patient and then notifies those partners while maintaining the confidentiality of the index patient. Contract referral, also known as conditional referral, is a combination of the previous two. It starts with the index patient taking responsibility for notifying partners and a provider becomes involved only if the index patient does not follow up within a previously agreed upon time frame (usually 24-48 hours).
How is Partner Notification done?
PN can be accomplished using different methods of communication. Traditionally, in-person conversations, telephone calls, and mailed correspondence have been the main approaches to partner notification. In recent years, however, technology has created new avenues for PN, including dedicated websites, internet forums, blogs, social media, email, and text-messaging. These approaches are often referred to collectively as internet partner notification (IPN).
Which is the “best” approach to Partner Notification?
No single method for PN is appropriate for every patient or every public health agency. Many factors shape decisions about which approach to use in any given situation, including: the preferences, comfort, and safety of index patients; the challenges involved in identifying and locating partners; the capacity of public health agencies; the cost and cost-effectiveness of different approaches.
In general, index patients prefer to tell their sexual partners about STI exposure. But specific circumstances may make it inadvisable for patients to take responsibility for PN. When an index patient contracts an infection through sexual assault or fears emotional and/or physical reprisals, provider referral becomes the method of choice for PN.
Index patients also tend to favour traditional approaches to PN because face-to-face and telephone conversations are seen as more caring, respectful, and courageous than electronic communication. But internet partner notification is becoming increasingly acceptable. According to one American study, 92 per cent of MSM using sex-partner websites were also prepared to use the internet to notify partners of STIs. Other research demonstrates consistent support for partner notification by email, both in the general population and among MSM. Text messaging appears to be the least popular alternative, though it is more likely to popular with males under the age of 25 who have access to a mobile phone and higher education.
Traditional methods for PN may be preferred by patients, but they may not work with sexual partners who are anonymous – who do not exchange names and contact information. For example, when individuals meet through the internet, they may be known to each other only by an email address or an on-line “handle” (electronic name). Historically, men who have sex with men (MSM) have been the population with the highest numbers of anonymous partners, but anonymous sex is not confined to MSM. It is also common in the general population, with as much as 60 per cent of those with STIs reporting that they have ever had an anonymous partner. In such cases, partner notification may only be possible using the internet and related technologies.
Provider referral is generally regarded as more effective than patient referral, particularly for past and casual or anonymous partners. Disease Intervention Specialists (DIS), non-medical staff with specialized training in communicable disease follow-up activities, appear to have the most success tracing partners, perhaps because, unlike healthcare providers, they do not have to split their time and energy between PN and other clinical responsibilities.
While provider referral may be more effective than patient referral, it is also more costly. One review of research in the United States found that provider referral is four to eight times as expensive as patient referral. It is difficult to determine with certainty which form of provider referral is most cost-effective because calculations must take a number of factors into account: the incidence of specific STIs in both low and high risk populations; the number of partners identified for each index patient; the number of positive partners discovered through PN; the costs of using various forms of communication; the number of hours spent with each index patient and partners; and the wages for staff conducting PN.
At the same time, the costs of patient and provider referral must be weighed against the costs of care for those who might have avoided infection through PN. For example, a 2006 study in Canada estimated that HIV PN programs cost $6,100 per infection prevented as compared with $385,200 to treat the average HIV infection. Contract referral may represent an effective and cost-effective compromise: it combines the economic benefits of patient referral with the assurance of provider referral as back-up.
What’s new in the field of Partner Notification?
Several innovative approaches to PN have emerged in recent years. Among them are two websites dedicated to partner notification: InSpot, which was developed in the United States in 2004 and has been used across the United States as well as in Canada; and Let Them Know, which was developed in Australia around the same time. These websites allow index patients to use a variety of modes of electronic communication to contact sexual partners, including e-cards, emails, and text messages. There is some encouraging evidence of use of these on-line tools, but further research is needed to determine if they result in increased screening, testing, and treatment, and reductions in the spread of STIs.
A second development in PN is cluster or network referral. This approach, like other types of referral, includes contacting sexual partners of the index patient, but it also extends notification to others in the index patient’s social and geographic networks, such as friends, acquaintances, and associates. Cluster or network referral emerged in the 1990s and is based on the idea that a social network in which there are sexual interactions among members is likely to include individuals exposed to infection from a variety of sources.
Contacting individuals in the social-sexual network of index patients may help to identify individuals infected by someone other than the index patient, thereby increasing and improving case finding. Peer-driven cluster referral for HIV has already been successfully implemented in Saskatchewan and has potential for other jurisdictions and for other STIs.
A third innovation in PN is patient-delivered partner therapy (PDPT), also known as expedited patient-initiated treatment. PDPT is a strategy in which index patients are provided with medication to give to their sexual partners after informing them that they may have been exposed to an STI. This approach to PN aims to increase the proportion of partners treated by eliminating the need for medical assessment and testing. Some research suggests that PDPT may be particularly useful with high-risk and hard-toreach populations, but it remains controversial because it involves a presumptive diagnosis as well as the prescription of treatment without a medical examination, which is prohibited in some jurisdictions. Questions about the legality of PDPT may reduce the willingness and ability of health care providers to adopt this method.
What’s next in the field of Partner Notification?
Partner notification is a critical dimension of the control and management of STIs in Canada, yet there is little consensus and limited research on how best to approach PN. Potential next steps for improving PN in Canada include:
• Establishing minimum standards for PN;
• Developing outcome measures for the evaluation of PN;
• Documenting PN policies and practices across jurisdictions;
• Monitoring PN practices and outcomes as part of the routine surveillance of STIs;
• Evaluating and addressing any potential harms associated with PN;
• Exploring opportunities for and barriers to the implementation of PDPT for various STIs;
• Comparing the cost and cost-effectiveness of diverse approaches to PN;
• Creating mechanisms to share promising practices for PN;
• Investigating diverse approaches to PN in the Canadian context.