Current Trends Partner Notification for Preventing Human Immunodeficiency Virus (HIV) Infection -- Colorado, Idaho, South Carolina, Virginia

Partner notification, a component of sexually transmitted disease (STD) control programs for many years (1), is a means to identify and target risk-reduction education to individuals at high risk for contracting or transmitting HIV infection. When applied to HIV infection, the term "partner" includes not only sex partners but also intravenous drug users who share needles. Partner notification for HIV infection or acquired immunodeficiency syndrome (AIDS), as for all STDs, is highly confidential and depends upon the voluntary cooperation of the patient. CDC currently recommends the following: "Persons who are HIV-antibody positive should be instructed in how to notify their partners and to refer them for counseling and testing. If they are unwilling to notify their partners or if it cannot be assured that their partners will seek counseling, physicians or health department personnel should use confidential procedures to assure that the partners are notified" (2).

Two complementary notification processes can be used to identify partners, patient referral and provider referral. With patient referral, HIV-infected patients choose to inform their own partners directly of their risk of infection. Trained health department personnel can help instruct patients how to inform sex and needle- sharing partners sensitively about their potential risk for infection. With provider referral, infected patients request assistance in notifying some or all of their partners; they voluntarily provide names, descriptions, and addresses so that the notification process can be carried out by trained health department staff. This process is designed to protect the anonymity of patients; their names are never revealed to sex or needle-sharing partners.

In the AIDS prevention and surveillance projects supported by CDC, states have been required to implement procedures for confidential notification of sex and needle-sharing partners of AIDS patients and HIV-seropositive individuals. All these states currently counsel HIV-infected clients seen in public counseling and testing sites about ways to reduce the risk of transmitting HIV. These states also counsel HIV-infected clients about the need to inform sex and needle-sharing partners of their risk of infection. Forty-eight states, Puerto Rico, the Virgin Islands, and the District of Columbia offer provider referral upon request by clients (Table 1). The other two states authorize notification by health department personnel when female partners may not have known that a risk factor existed and/or in cases of rape or sexual abuse. Fifteen states have partner-notification programs that encourage provider referral for all patients.

Data are available to CDC from partner-notification activities in four states. Colorado emphasizes provider referral as the preferred method for notifying all sex and needle-sharing partners of HIV-infected individuals. From January 1986 through December 1987, 282 index patients were offered partner-notification services. They identified 508 partners, of whom 414 (81%) were located; of these 414, 44 (11%) had previously tested positive for HIV antibody and were not contacted. Of the remaining 370 identified partners, 296 (80%) underwent counseling and testing; 74 (20%) were counseled but refused testing. Forty-five (15%) of those 296 newly tested were positive for HIV antibody. None had previously been reported to the state.

Idaho has instituted a partner-notification program that emphasizes provider referral. Of 120 HIV-positive index patients identified since the program began in 1985, 97 (81%) have received counseling about partner notification. These patients requested assistance to notify 118 partners. Fifty-nine partners (50%) were located, and all accepted counseling and testing; 23 (39%) were found to be infected with HIV.

In 1987, South Carolina initiated partner-notification activities emphasizing provider referral. In one rural county where only one case of HIV infection and no cases of AIDS had been previously reported, 90 sex partners, 69 of whom were county residents, were named by a single HIV-infected homosexual male (3). Of the 68 county residents who consented to testing, 12 partners (18%) were infected with HIV.

Virginia currently provides partner-notification services to HIV-infected patients who request assistance with notifying certain partners. From September 1986 through December 1987, 387 (81%) of the 479 individuals who tested positive for HIV antibody at STD clinics returned for test results and were offered partner-notification services. Of these, 230 patients (59%) chose provider referral to notify their partners. A total of 318 partners were located and accepted counseling and testing; 44 (14%) were found to be positive for HIV infection. In addition to being sex or needle-sharing partners of HIV-infected persons, 38 (87%) of the infected partners belonged to other high-risk groups: 72% were at risk through homosexual/bisexual behavior, and 15% through intravenous drug use. Reported by: TM Vernon Jr, MD, FC Wolf, MPA, NE Spencer, RE Hoffman, MD, MPH, State Epidemiologist, Colorado Dept of Health. JB Perry, CD Brokopp, DrPH, State Epidemiologist, Idaho Dept of Health and Welfare. RF Wykoff, MD, SL Hollis, RN, ST Leonard, RN, CB Quiller, CW Heath Jr, MD, Acting State Epidemiologist, South Carolina Dept of Health and Environmental Control. CW Riley, AM Cader, MD, GB Miller Jr, MD, State Epidemiologist, Virginia State Dept of Health. Div of Sexually Transmitted Diseases, Center for Prevention Svcs, CDC. Editorial Note: Partner notification, with emphasis on provider referral, became an integral strategy for national syphilis control in the mid-1940s after penicillin became widely available. Subsequently, it has been used in STD control programs for gonorrhea and chlamydia (1,4). Provider referral has been shown to be effective, but costly (5), in controlling focal outbreaks of infections due to antibiotic-resistant gonococcal strains (6) and in targeting endemically infected core groups in specific high-risk populations (7,8). Because of resource limitations, patient referral, rather than provider referral, has played an increasingly important role in STD control.

When the partner-notification model is applied to the control of HIV infection, certain differences must be considered. The incubation period for HIV is long; therefore, sex partners or needle-sharing partners from months or years earlier may potentially have been the sources of infection. Partner notification for patients with hepatitis B, which has an epidemiologic pattern similar to that of HIV infection, has proven difficult because of the prolonged period of infectivity, the large number of anonymous sex partners among many homosexual men, and the inaccessibility of the intravenous drug-using population (9).

The assurance of confidentiality and protection against discrimination, which are critical in dealing with any STD, have become legal issues in the case of HIV infection (10,11). These issues may influence the success of programs based on patient referral alone (12). Confidentiality is essential to ensure that individuals at risk continue to seek counseling, testing, or partner-notification services.

Partner-notification data from several states reveal a high seroprevalence rate, ranging from 11% to 39%, among persons identified as sex or needle-sharing partners, many of whom are themselves engaging in high-risk behavior. By identifying such individuals, the partner-notification process can target risk-reduction messages to those at greatest risk of acquiring or transmitting infection. Thus, partner notification provides both primary and secondary prevention of HIV infection.

Notification of unsuspecting partners is especially important because it enables persons who may not have been reached through other AIDS education programs to receive risk-reduction education. For example, the partner-notification process can identify female and male partners of intravenous drug users or female partners of bisexual males who may have been exposed to HIV infection but who may be unaware of their risk. Partner-notification activities targeted toward women of childbearing age contribute additionally by potentially preventing the perinatal transmission of HIV (13).

Homosexual men who voluntarily request counseling and HIV testing may be at lower risk for infection than those who have refused testing (14). Through the partner-notification process, these high-risk partners who otherwise might not request risk-reduction education can receive counseling. Also, counseling of partners provides an opportunity to offer other beneficial services to those at risk, including drug treatment, STD treatment, tuberculosis testing and treatment, adult immunizations, psychosocial support services, and contraceptive counseling.

The type of partner-notification services provided by different health departments will depend on local resources and the number of seropositive persons identified. In San Francisco, which has high rates of infection among homosexual men, provider referral for all partners of homosexual men was not thought to be feasible because of the excessive cost and personnel required. However, the San Francisco Health Department did notify heterosexual sex partners of AIDS patients and received excellent cooperation from both patients and named partners (15). The San Francisco experience demonstrates the feasibility of targeted notification for identifying infected women of childbearing age to prevent perinatal transmission of HIV infection.

State and local health departments are encouraged to develop evaluation programs to identify the most effective partner-notification strategies for different clinical and sociocultural settings in both areas with high and low HIV seroprevalence rates. References

1. Rothenberg RB, Potterat JJ. Strategies for management of sex partners. In: Holmes KK, Mardh P-A, Sparling PF, Wiesner PJ, eds. Sexually transmitted diseases. New York: McGraw-Hill, 1984:965-72.

2. Centers for Disease Control. Public Health Service guidelines for counseling and antibody testing to prevent HIV infection and AIDS. MMWR 1987;36:509-15.

3. Wykoff RF, Heath CW Jr, Hollis SL, et al. Contact tracing to identify human immunodeficiency virus infection in a rural community. JAMA 1988;259:3563-6.

4. Katz BP, Danos CS, Quinn TS, Caine V, Jones RB. Efficiency and cost-effectiveness of field follow-up for patients with Chlamydia trachomatis infection in a sexually transmitted diseases clinic. Sex Transm Dis 1988;15:11-6.

5. Judson FN, Wolf FC. Tracing and treating contacts of gonorrhea patients in a clinic for sexually transmitted diseases. Public Health Rep 1978;93:460-3.

6. Centers for Disease Control. Outbreak of a distinct strain of penicillinase-producing Neisseria gonorrhoeae--King County, Washington. MMWR 1987;36:757-9.

7. Phillips L, Potterat JJ, Rothenberg RB, Pratts C, King RD. Focused interviewing in gonorrhea control. Am J Public Health 1980;70:705-8.

8. Potterat JJ, Rothenberg RB, Woodhouse DE, Muth JB, Pratts CI, Fogle JS II. Gonorrhea as a social disease. Sex Transm Dis 1985;12:25-32.

9. Munday PE, McDonald W, Murray-Sykes KM, Harris JRW. Contact tracing in hepatitis B infection. Br J Vener Dis 1983;59:314-6.

10. Gostin L, Curran WJ. AIDS screening, confidentiality, and the duty to warn. Am J Public Health 1987;77:361-5.

11. Dickens BM. Legal rights and duties in the AIDS epidemic. Science 1988;239:580-6.

12. Kegeles SM, Catania JA, Coates TJ. Intentions to communicate positive HIV-antibody status to sex partners (Letter). JAMA 1988;259:216-7.

13. Centers for Disease Control. Recommendations for assisting in the prevention of perinatal transmission of human T-lymphotropic virus type III/lymphadenopathy-associated virus and acquired immunodeficiency syndrome. MMWR 1985;34:721-6,731-2.

14. Gallagher MM, Bettinger CJ, Keller NM, Wilson J, Hull HF. Voluntary human immunodeficiency virus screening in sexually transmitted disease clinics, New Mexico (Abstract). In: Program of the Epidemic Intelligence Service 88 Conference. Atlanta: US Department of Health and Human Services, Public Health Service, 1988:65.

15. Woo JM, Neal DP, Geoghegan CM, et al. Evaluation of heterosexual contact tracing of partners of AIDS patients (Abstract no. 6002). In: Final program and abstracts of the IV International Conference on AIDS. Book 1. Stockholm, Sweden: Swedish Ministry of Health and Social Affairs, National Bacteriological Laboratory, Karolinska Institute, World Health Organization, 1988:354.

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