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Int J STD AIDS OnlineFirst, published on August 19, 2014 as doi:10.1177/0956462414547398
Original research article
Partner notification among men who have sex with men and heterosexuals with STI/HIV: different outcomes and challenges
International Journal of STD & AIDS 0(0) 1–9 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414547398 std.sagepub.com
Fleur van Aar1, Yolanda van Weert1, Ralph Spijker2, Hannelore Go¨tz1,3 and Eline Op de Coul1 for the Partner Notification Group*
Abstract Partner notification effectiveness among index clients diagnosed with HIV, syphilis and/or gonorrhoea at sexually transmitted infection (STI) clinics was evaluated between 2010 and 2012. We explored percentages of identifiable, notified and tested partners by sexual preference and gender. Partner notification trends were studied using the national STI database. Men who have sex with men (n ¼ 304), heterosexual men (n ¼ 33) and women (n ¼ 35) reported, respectively, 6.7, 3.8 and 2.3 partners per index. Percentages of identifiable partners differed between groups (men who have sex with men: 46%, heterosexual men: 63%, women: 87%, p < 0.001). The percentage of notified partners (of those identifiable) was lowest for heterosexual men (76%; men who have sex with men: 92%; women: 83%; p < 0.001). STI positivity rates among notified partners were high: 33%–50% depending on sexual preference. Among men who have sex with men, having HIV was associated with not notifying all identifiable partners. Percentages of notified clients at STI clinics increased between 2010 and 2012: from 13% to 19% among men who have sex with men, from 13% to 18% among heterosexual men and from 8% to 11% among women (p < 0.001 for all groups). The percentage of STI/HIV detected through partner notification increased among men who have sex with men (from 22% to 30%) and women (from 25% to 29%; p < 0.001). Unidentifiable partners among men who have sex with men, lower partner notification effectiveness for HIV and the relative large proportion of heterosexual men not notifying their partners appeared important partner notification challenges.
Keywords Partner notification, contact tracing, sexually transmitted infection, HIV, men who have sex with men, heterosexuals, sexually transmitted infection clinic Date received: 19 February 2014; accepted: 17 July 2014
Introduction Partner notification (PN) is generally acknowledged to be an important element of controlling sexually transmitted infection (STI) and HIV.1 PN aims to reduce re-infections, the spread of HIV and other STIs by informing sexual partners of newly diagnosed individuals (index clients) of their exposure risk and of their need to visit a health service. Evidence for the effectiveness of PN practices in the Netherlands is limited. Therefore in 2010, the ‘Partner Notification group’ (PN group) with experts from five STI clinics, the National Institute for Public Health and the
1 Epidemiology and Surveillance, Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands 2 STI AIDS Netherlands, Amsterdam, the Netherlands 3 Department Infectious Disease Control, Public Health Service Rotterdam-Rijnmond, Rotterdam, the Netherlands
*Partner Notification Group: A Casanovas (Public Health Service [PHS], Amsterdam), M Hulstein (PHS: ‘Veiligheids – en Gezondheidsregio’ Gelderland Midden [VGGM], D van Veldhuizen (VGGM), J Rodriquez (PHS, The Hague), L Vasen (PHS Rotterdam-Rijnmond), Y van Weert (RIVM, Bilthoven), E Op de Coul (RIVM, Bilthoven), R Spijker (STI AIDS Netherlands, Amsterdam), F van Aar (RIVM, Bilthoven). Corresponding author: Fleur van Aar, National Institute for Public Health and the Environment, Epidemiology and Surveillance, Centre for Infectious Disease Control, PO Box, 3720 BA, Bilthoven, the Netherlands. Email: [email protected]
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[1–9] [PREPRINTER stage]
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International Journal of STD & AIDS 0(0)
Environment (RIVM) and STI AIDS Netherlands, started a 3-year pilot examining barriers in current practices of PN, as well as PN outcomes through a newly developed PN-registration system.2 The PN group also developed, as a collaborative effort with a motivational interviewing (MI) expert, a PN training for specialised nurses in STI/HIV (STI professionals).3 The effectiveness of PN can be affected by perceived or experienced barriers among health care providers and/or index clients. A focus group session with the PN group indicated that important barriers of health care providers were a lack of time to discuss PN during the consult, resistance to PN by index clients, anonymous partners and socially desirable answers.3 The PN training for STI professionals, in which these barriers were addressed, significantly improved the PN skills and behaviour of these professionals, compared to a control group of professionals who did not receive this training.3 However, it is unknown whether reduced barriers among STI professionals subsequently improved numbers of notified partners. Among index clients, barriers to PN include anger towards the (ex-)partner, shame to notify partners, fear of negative reaction, being stigmatised and/or rejected, uncertainty of how to notify partners and lack of partner contact information.4–6,7 Such (perceptions of) barriers may differ between men who have sex with men (MSM), heterosexual men and women, leading to different PN outcomes and a need for different approaches in daily PN practices. The results of data collected among MSM in the first year of this 3-year pilot demonstrated the cascade of the PN process, in which sexual partners were lost in each step.2 Lack of partner contact information appeared to be the major challenge in this group. If partners were identifiable, MSM were willing and able to notify the majority (87%) of their partners.2 However, the cascades of PN among heterosexual men and women have not been reported previously. The primary aim of the current study is to compare the (updated) PN outcomes between MSM, heterosexual men and women by analysing data from the PN database. Furthermore, we explored PN outcomes before and after the implementation of the PN training in two databases; the PN database and the national STI surveillance database.
Methods Data collection The methods of the PN data collection and the national STI surveillance have previously been described in
detail.2,8 Briefly, a PN registration system was implemented at STI clinics in five regions between January 2010 and July 2012. The first 1.5 years (January 2010–September 2011) of data collection are considered the ‘baseline situation’ (hereafter referred to ‘baseline’).2 In the following 9 months (‘follow-up’ period), a training for STI professionals was implemented to enhance PN practices at the five STI clinics.3 The database included self-reported partner information by index clients who were newly diagnosed with an STI/HIV. Insight into the effectiveness of PN was based on partner information and PN outcome measures: the numbers of eligible partners (‘partners at risk’), identifiable partners (an address, email or phone number was available), notified partners, STI/HIV tested partners and partners with a (positive) test result. Clients of 16 years or older and diagnosed with gonorrhoea, syphilis or HIV were eligible as index clients. Numbers of infections in the PN database are not representative for the infection numbers at STI clinics, since the data collection started with HIV as a priority disease and in a later phase, syphilis and gonorrhoea were added. Data on other STI, such as chlamydia, were not collected due to large numbers (resulting in high workload for professionals) unless they were diagnosed as co-infection with HIV, syphilis or gonorrhoea. The national STI surveillance database contains information on STI consultations in all 26 STI clinics that provide low threshold (anonymous and free of charge) care, exclusively for high-risk groups according to the following criteria: MSM, persons referred through PN, persons with STI-related complaints, people younger than 25 years of age, migrant populations, persons with high-risk behaviour (defined as 3 partners in the past 6 months) and commercial sex workers (CSW) and clients. Persons who do not fulfil these criteria are referred to the general practitioner (GP) for STI/HIV testing.2,8
Statistical analyses PN database. Characteristics of index clients were studied by gender and sexual preference using descriptive statistics (Chi square test). We excluded index clients from whom partner information was missing, those for whom PN was not indicated (e.g. no partners at risk reported) and those who were transgender or CSW, from the analysis. PN outcomes included percentages of identifiable, notified and tested partners. The percentage of notified partners was calculated with a denominator of the number of identifiable partners, as well as with the number of all partners at risk. Since index clients can be diagnosed with more than one STI, we calculated
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PN outcomes for all STI (including HIV) together. PN outcomes among MSM diagnosed with HIV were also explored separately, while numbers of HIVinfected heterosexual index clients were too small to conduct this analysis. We explored differences in PN outcomes by gender and sexual preference, and between baseline and follow-up (among MSM only) using the Chi square test. The overall STI and HIV case-finding effectiveness of PN was calculated among all partners for whom test results were available. We calculated the effectiveness irrespective of the STI that partners were at risk for, because STI clinics offer tests for all main STIs (chlamydia, gonorrhoea, syphilis, HIV and hepatitis B) and, partners could have been at risk of STIs other than being notified for. We were also interested in determinants associated with suboptimal PN, defined as: not all identifiable partners were notified. For these analyses, we included the larger group of MSM, and we categorised MSM with identifiable partners into two groups: (1) those who notified all identifiable partners and (2) those who did not notify all identifiable partners. As anonymous (unidentifiable) partners could not be reached for PN, we excluded MSM who reported unidentifiable partners only (n ¼ 23). Univariable and multivariable logistic regression analyses were performed to compare the two groups. Variables with p value
(STD)
[1–9] [PREPRINTER stage]
Int J STD AIDS OnlineFirst, published on August 19, 2014 as doi:10.1177/0956462414547398
Original research article
Partner notification among men who have sex with men and heterosexuals with STI/HIV: different outcomes and challenges
International Journal of STD & AIDS 0(0) 1–9 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414547398 std.sagepub.com
Fleur van Aar1, Yolanda van Weert1, Ralph Spijker2, Hannelore Go¨tz1,3 and Eline Op de Coul1 for the Partner Notification Group*
Abstract Partner notification effectiveness among index clients diagnosed with HIV, syphilis and/or gonorrhoea at sexually transmitted infection (STI) clinics was evaluated between 2010 and 2012. We explored percentages of identifiable, notified and tested partners by sexual preference and gender. Partner notification trends were studied using the national STI database. Men who have sex with men (n ¼ 304), heterosexual men (n ¼ 33) and women (n ¼ 35) reported, respectively, 6.7, 3.8 and 2.3 partners per index. Percentages of identifiable partners differed between groups (men who have sex with men: 46%, heterosexual men: 63%, women: 87%, p < 0.001). The percentage of notified partners (of those identifiable) was lowest for heterosexual men (76%; men who have sex with men: 92%; women: 83%; p < 0.001). STI positivity rates among notified partners were high: 33%–50% depending on sexual preference. Among men who have sex with men, having HIV was associated with not notifying all identifiable partners. Percentages of notified clients at STI clinics increased between 2010 and 2012: from 13% to 19% among men who have sex with men, from 13% to 18% among heterosexual men and from 8% to 11% among women (p < 0.001 for all groups). The percentage of STI/HIV detected through partner notification increased among men who have sex with men (from 22% to 30%) and women (from 25% to 29%; p < 0.001). Unidentifiable partners among men who have sex with men, lower partner notification effectiveness for HIV and the relative large proportion of heterosexual men not notifying their partners appeared important partner notification challenges.
Keywords Partner notification, contact tracing, sexually transmitted infection, HIV, men who have sex with men, heterosexuals, sexually transmitted infection clinic Date received: 19 February 2014; accepted: 17 July 2014
Introduction Partner notification (PN) is generally acknowledged to be an important element of controlling sexually transmitted infection (STI) and HIV.1 PN aims to reduce re-infections, the spread of HIV and other STIs by informing sexual partners of newly diagnosed individuals (index clients) of their exposure risk and of their need to visit a health service. Evidence for the effectiveness of PN practices in the Netherlands is limited. Therefore in 2010, the ‘Partner Notification group’ (PN group) with experts from five STI clinics, the National Institute for Public Health and the
1 Epidemiology and Surveillance, Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands 2 STI AIDS Netherlands, Amsterdam, the Netherlands 3 Department Infectious Disease Control, Public Health Service Rotterdam-Rijnmond, Rotterdam, the Netherlands
*Partner Notification Group: A Casanovas (Public Health Service [PHS], Amsterdam), M Hulstein (PHS: ‘Veiligheids – en Gezondheidsregio’ Gelderland Midden [VGGM], D van Veldhuizen (VGGM), J Rodriquez (PHS, The Hague), L Vasen (PHS Rotterdam-Rijnmond), Y van Weert (RIVM, Bilthoven), E Op de Coul (RIVM, Bilthoven), R Spijker (STI AIDS Netherlands, Amsterdam), F van Aar (RIVM, Bilthoven). Corresponding author: Fleur van Aar, National Institute for Public Health and the Environment, Epidemiology and Surveillance, Centre for Infectious Disease Control, PO Box, 3720 BA, Bilthoven, the Netherlands. Email: [email protected]
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(STD)
[1–9] [PREPRINTER stage]
2
International Journal of STD & AIDS 0(0)
Environment (RIVM) and STI AIDS Netherlands, started a 3-year pilot examining barriers in current practices of PN, as well as PN outcomes through a newly developed PN-registration system.2 The PN group also developed, as a collaborative effort with a motivational interviewing (MI) expert, a PN training for specialised nurses in STI/HIV (STI professionals).3 The effectiveness of PN can be affected by perceived or experienced barriers among health care providers and/or index clients. A focus group session with the PN group indicated that important barriers of health care providers were a lack of time to discuss PN during the consult, resistance to PN by index clients, anonymous partners and socially desirable answers.3 The PN training for STI professionals, in which these barriers were addressed, significantly improved the PN skills and behaviour of these professionals, compared to a control group of professionals who did not receive this training.3 However, it is unknown whether reduced barriers among STI professionals subsequently improved numbers of notified partners. Among index clients, barriers to PN include anger towards the (ex-)partner, shame to notify partners, fear of negative reaction, being stigmatised and/or rejected, uncertainty of how to notify partners and lack of partner contact information.4–6,7 Such (perceptions of) barriers may differ between men who have sex with men (MSM), heterosexual men and women, leading to different PN outcomes and a need for different approaches in daily PN practices. The results of data collected among MSM in the first year of this 3-year pilot demonstrated the cascade of the PN process, in which sexual partners were lost in each step.2 Lack of partner contact information appeared to be the major challenge in this group. If partners were identifiable, MSM were willing and able to notify the majority (87%) of their partners.2 However, the cascades of PN among heterosexual men and women have not been reported previously. The primary aim of the current study is to compare the (updated) PN outcomes between MSM, heterosexual men and women by analysing data from the PN database. Furthermore, we explored PN outcomes before and after the implementation of the PN training in two databases; the PN database and the national STI surveillance database.
Methods Data collection The methods of the PN data collection and the national STI surveillance have previously been described in
detail.2,8 Briefly, a PN registration system was implemented at STI clinics in five regions between January 2010 and July 2012. The first 1.5 years (January 2010–September 2011) of data collection are considered the ‘baseline situation’ (hereafter referred to ‘baseline’).2 In the following 9 months (‘follow-up’ period), a training for STI professionals was implemented to enhance PN practices at the five STI clinics.3 The database included self-reported partner information by index clients who were newly diagnosed with an STI/HIV. Insight into the effectiveness of PN was based on partner information and PN outcome measures: the numbers of eligible partners (‘partners at risk’), identifiable partners (an address, email or phone number was available), notified partners, STI/HIV tested partners and partners with a (positive) test result. Clients of 16 years or older and diagnosed with gonorrhoea, syphilis or HIV were eligible as index clients. Numbers of infections in the PN database are not representative for the infection numbers at STI clinics, since the data collection started with HIV as a priority disease and in a later phase, syphilis and gonorrhoea were added. Data on other STI, such as chlamydia, were not collected due to large numbers (resulting in high workload for professionals) unless they were diagnosed as co-infection with HIV, syphilis or gonorrhoea. The national STI surveillance database contains information on STI consultations in all 26 STI clinics that provide low threshold (anonymous and free of charge) care, exclusively for high-risk groups according to the following criteria: MSM, persons referred through PN, persons with STI-related complaints, people younger than 25 years of age, migrant populations, persons with high-risk behaviour (defined as 3 partners in the past 6 months) and commercial sex workers (CSW) and clients. Persons who do not fulfil these criteria are referred to the general practitioner (GP) for STI/HIV testing.2,8
Statistical analyses PN database. Characteristics of index clients were studied by gender and sexual preference using descriptive statistics (Chi square test). We excluded index clients from whom partner information was missing, those for whom PN was not indicated (e.g. no partners at risk reported) and those who were transgender or CSW, from the analysis. PN outcomes included percentages of identifiable, notified and tested partners. The percentage of notified partners was calculated with a denominator of the number of identifiable partners, as well as with the number of all partners at risk. Since index clients can be diagnosed with more than one STI, we calculated
Downloaded from std.sagepub.com at UCSF LIBRARY & CKM on March 12, 2015
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(STD)
[1–9] [PREPRINTER stage]
van Aar et al.
3
PN outcomes for all STI (including HIV) together. PN outcomes among MSM diagnosed with HIV were also explored separately, while numbers of HIVinfected heterosexual index clients were too small to conduct this analysis. We explored differences in PN outcomes by gender and sexual preference, and between baseline and follow-up (among MSM only) using the Chi square test. The overall STI and HIV case-finding effectiveness of PN was calculated among all partners for whom test results were available. We calculated the effectiveness irrespective of the STI that partners were at risk for, because STI clinics offer tests for all main STIs (chlamydia, gonorrhoea, syphilis, HIV and hepatitis B) and, partners could have been at risk of STIs other than being notified for. We were also interested in determinants associated with suboptimal PN, defined as: not all identifiable partners were notified. For these analyses, we included the larger group of MSM, and we categorised MSM with identifiable partners into two groups: (1) those who notified all identifiable partners and (2) those who did not notify all identifiable partners. As anonymous (unidentifiable) partners could not be reached for PN, we excluded MSM who reported unidentifiable partners only (n ¼ 23). Univariable and multivariable logistic regression analyses were performed to compare the two groups. Variables with p value
