Prevention for Positives
Case 5: Discussion
Introduction to Partner Counseling and Referral Services
For decades, contact tracing, or partner notification, has played a key role in public health efforts to prevent the spread of communicable diseases, such as tuberculosis, measles, and sexually transmitted diseases (STDs). During the initial phase of the HIV epidemic in the United States, however, many activists and medical providers opposed routine partner notification for HIV. Name-based case reporting, a necessary public health measure if health departments are to identify and contact persons with newly diagnosed infections, was opposed in many states. In that era, HIV infection differed significantly from other communicable diseases for which partner notification had previously been utilized in that treatment options for the partner were limited and the diagnosis of HIV carried a unique social stigma. More recently, as excellent treatment options for HIV have become available and as individuals living with HIV have become less ostracized, momentum has shifted toward more widespread support for partner notification. Moreover, recent studies suggest that most persons with HIV support partner notification and counseling referral services (PCRS)[1,2]. Indeed, PCRS is an integral component to the "Prevention for Positives" initiative as outlined by the CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America in 2003. Currently, PCRS is a confidential service that assists in notifying partners who have been exposed to HIV and facilitates linking these partners to appropriate testing and counseling services. In most instances, PCRS is also tied to public health efforts to assure that persons with newly diagnosed infections receive needed medical care and social services. Most states (and some cities) have laws and regulations related to partner notification.
Types of Partner Referral Services
Partner notification is handled differently within different public health jurisdictions, but characteristically involves two key components. First, the patient is counseled regarding partner notification and helped to compile a list of potentially exposed sex or injection partners (most often focused on partners exposed since the patient's last HIV test or within the prior year, although the interview period can vary). Second, based on the patient's preference, partners are notified of the possible exposure by one of four methods: patient referral, provider referral, contract referral, or dual referral (Figure 1). In patient referral, the patient agrees to inform his or her partners. In provider referral, the provider (typically a trained health department counselor, but potentially a clinician, nurse, or health educator) is responsible for confidentially notifying the patient's partners. In contract referral, the patient agrees to attempt to notify his or her partners, but if they fail to do so within a pre-specified period of time, the provider confidentially notifies any remaining partners. In dual referral, the patient informs the partner with the provider present. Most health department HIV partner notification programs in the United States primarily use provider referral (Figure 2).
Potential Benefits of PCRS
For the patient, PCRS has a number of beneficial features (Figure 3), including the support to fulfill what many patients see as an ethical obligation to inform their partners of an HIV exposure. It also offers them the option to notify their partners anonymously. Furthermore, if they prefer to personally tell their partner(s) of the HIV exposure, they can either receive coaching from a trained counselor before telling them alone or notify the partner in conjunction with a counselor who likely could better answer technical questions regarding HIV. Finally, in many health department jurisdictions, PCRS is intimately linked to the referral of persons with newly diagnosed HIV to appropriate medical care and social services. For the partners, PCRS can provide important information regarding a HIV exposure and can serve as a catalyst to undergo HIV testing if they have not recently done so. The exposed partners who then test positive for HIV will likely then receive timely medical care related to their HIV disease. Moreover, many persons reduce HIV-related risk behavior after receiving a diagnosis of HIV[5,6], so an early diagnosis in HIV-infected individuals who may not have otherwise been tested for HIV can have important public health benefits. Partners who test negative for HIV infection should still receive additional STD testing and risk-reduction counseling. Similarly, if exposed persons are already aware they have HIV infection, they should receive counseling regarding HIV-associated risk behavior, including the disclosure of their HIV serostatus to future partners.
Potential Drawbacks Related to PCRS
Despite the potential benefits of PCRS, potential concerns include loss of patient confidentiality, dissolution of relationships, and violent repercussions for the HIV-infected patient. The public health providers involved in PCRS receive special training on how to avoid disclosing any information about persons with HIV to their exposed partners. Situations in which a partner has only had one potential exposure pose a special challenge to patient confidentiality and should be approached with great sensitivity. In addition, evidence suggests that PCRS is not associated with higher than normal rates of relationship dissolution. Finally, providers should carefully screen all cases for the potential for physical or emotional abuse after partner notification, but few patients in the United States report such negative consequences as a result of partner notification.
Clinician's Role in PCRS
Although clinicians can fully participate in PCRS, many merely advise their patients to notify their partners. Nevertheless, through appropriate referrals, even busy clinicians can play an important role in successful partner notification. In order to provide such referrals, the clinician needs to initiate a discussion with the patient about sexual or injection partners who may have also been exposed to HIV. At a minimum, all HIV care providers (or trained clinical staff) should be able to (1) follow all local and state reporting requirements; (2) ask all patients at the initial visit if their sex and injection partners have been informed of their potential exposure to HIV; (3) inform patients with newly diagnosed HIV that they should expect to be contacted by their local health department regarding PCRS if they have not already been interviewed by public health authorities (in locations where public health PCRS is routine); and 4) ask all patients periodically during follow-up visits about new sex or injection partners. To identify available PCRS for their patients, clinicians should contact their local health departments. If patients choose to self-refer and decline to meet with a health department counselor, the clinician should help them formulate a plan for informing the partner. The clinician should also assess patients' ability to disclose their HIV status to partners as well as their capability to refer partners to appropriate resources for HIV testing. The CDC recommends that clinicians who choose to provide PCRS themselves, instead of referring patients to the health department, become familiar with state health department guidelines and participate in an in-depth standardized PCRS training course. In addition, the 1998 CDC Guide on HIV Partner Counseling and Referral Services is an excellent resource for clinicians. Of note, in many states with name-based HIV reporting, the health department may directly contact patients with newly diagnosed HIV infection to discuss PCRS without clinician input.
Evaluation of PCRS
The success of PCRS can be measured by several endpoints: (1) acceptability to patients, (2) rates of implementation, (3) numbers of partners notified and new cases detected, (4) success in referring cases and partners for medical care, and (5) cases of new HIV averted. To date, evaluations of PCRS have concentrated on the first three of these endpoints. In general, HIV-infected persons and individuals at risk for HIV appear to support partner notification. For example, a study of HIV-infected men who have sex with men in King County, Washington found that 84% believed that health department should routinely offer everyone diagnosed with HIV help in notifying their partners. Although some public health programs have encountered resistance to PCRS, most health departments with PCRS programs successfully interview more than 50% of reported cases that they contact, and some interview them all, demonstrating that most patients will agree to talk to public health PCRS staff. A substantially smaller proportion of patients, however, actually choose provider referral when this service is offered to them. Whether interviewed cases who refuse provider referral notify more partners themselves is unknown.
Among all PCRS programs in the United States in areas with mandatory HIV reporting, public health department personnel interview only approximately one-third of patients with newly diagnosed HIV infection. Nevertheless, existing evidence suggests that PCRS programs can effectively identify new cases. To date, only a single randomized trial has evaluated public health HIV PCRS efforts. The trial was conducted in the early 1990s, enrolled 74 people with HIV, and compared conditional referral to patient referral; patient referral involved only an interview with public health staff with no follow-up. The trial observed that 50% of partners of persons receiving conditional referral and 7% of those assigned to patient referral where notified. More new cases of HIV were identified among partners of persons assigned to the conditional referral group. Data collated from United States health departments further supports the case finding efficacy of PCRS. In large metropolitan areas, health departments needed to interview 14 persons with newly diagnosed HIV to identify one person with unidentified HIV. Notably, areas with higher proportion of HIV cases among MSM had a greater number needed to interview. Based on conservative estimates made in 1998 (taking into account the cost of HIV care, the cost of PCRS, and the potential for PCRS to prevent new HIV infections), PCRS is cost-effective if it results in prevention of HIV infection in at least 1 of 51 partners reached via PCRS, an easily reachable threshold by programs. The North Carolina PCRS program has been relatively successful in identifying previously undiagnosed cases of HIV (Figure 4).
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