About The Toolkit for Technology-Based Partner Services

2 Executive summary

The Toolkit for Technology-based STD and HIV Partner Services serves as a general resource for health departments, community-based organizations (CBOs), and others authorized to provide HIV/STD partner services. It is designed for use with the internet and other digital technologies, such as mobile phones, email, and social networking sites, to trace and contact persons potentially exposed to HIV and other STDs. For the purposes of this toolkit, the term Internet Partner Services (IPS) is used broadly to capture the use of a wide array of technologies for partner services.

This toolkit updates information found in the Centers for Disease Control and Prevention's (CDC) 2015 "Introducing Technology into Partner Services: A Toolkit for Programs,"1 and it is a supplement to the CDC's 2008 Recommendations for Partner Services for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infection.2

As the use of technology for communication has become commonplace, it has become necessary to use popular and emerging technologies to reach at-risk individuals. Individuals for whom there are only virtual identifiers, such as an email address or profile name, may be unreachable without access to the internet, email, text, mobile applications, and other digital tools.

This toolkit provides information, suggestions, and resources about the various components of a program that incorporates the use of technology. It is not intended to be used as a list of "required activities" for Disease Intervention Specialists (DIS).* The information presented in the toolkit is based on published and unpublished evaluations, program experience, expert opinion, and input from several state health departments and community-based nonprofit organizations.

*We use the term DIS broadly to include any staff who interview patients, elicit partner information, and perform partner notification. Other terms for DIS may include Public Health Investigators, Disease Prevention Specialists, Public Health Advisors, etc.

2.1 Introduction

According to the 2008 CDC Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infection,2 partner services and partner notification are defined as "a broad array of services that should be offered to persons with HIV infection, syphilis, gonorrhea, or chlamydial infection and their partners.

A critical function of partner services is partner notification, a process through which infected persons are interviewed to elicit information about their partners, who can then be confidentially notified of their possible exposure or potential risk. Other functions of partner services include prevention counseling, testing for HIV and other types of STDs (not necessarily limited to syphilis, gonorrhea, and chlamydial infection), hepatitis screening and vaccination, treatment or linkage to medical care, linkage or referral to other prevention services, and linkage or referral to other services (e.g., reproductive health services, prenatal care, substance abuse treatment, social support, housing assistance, legal services, and mental health services)."

CDC recommends partner services as an effective public health strategy to reduce STD and HIV transmission and associated morbidity.3 Partner notification is an important component of partner services and is intended to identify, locate, and inform people of their potential exposure to infections, and to refer them into care, thereby breaking the chain of infection and reducing morbidity.

Use of technology for partner services, including partner notification, is also supported by the CDC.45 Technologies include, but are not limited to, the internet, social networking sites, email, instant messaging (IM), mobile devices, mobile applications, and texting. Technology is constantly changing and will need to be continually assessed for its relevance to partner services. We anticipate new technologies will emerge that will be added to future iterations of this toolkit.

Internet partner services (IPS) can be used to identify and collect locating information of partners of STD-positive patients and notify them of a possible exposure or potential risk. Internet partner services can also assist patients who choose to notify partners on their own. Some programs are also using technology for outreach, recruitment, and health communication efforts, but those activities are not addressed in this toolkit.

National guidance exists and applies to the provision of partner services, and these guidelines remain applicable to IPS as well.2 A list of guidelines, relevant resources, and information on technical assistance can be found at the end of this document.

This toolkit was developed to be a flexible resource for use by a variety of stakeholders, from seasoned programs with years of IPS experience to the individual DIS brand new to partner services. This toolkit is not meant to be one size fits all; rather we hope programs can take what they need to adapt or improve their current IPS efforts.

While developing the toolkit, we worked under the following assumptions:

1. You have a solid understanding of the basics of traditional partner services and disease investigation.
2. You understand and are familiar with the ethics of partner services and maintaining patient and partner confidentiality.
3. Your program has assessed or will assess the internal and local/state policies guiding the use of technology for health communication purposes and seek the necessary approvals from various stakeholders, e.g., health department senior staff, information technology staff, and legal departments.
4. This is not a manual or a set of guidelines. Instead, we have curated and developed best practices from studies, evaluations, and those already doing this type of work.
5. Just like technology, the content, examples, and web links currently found in the toolkit may change over time.

Lastly, we welcome your feedback. Hearing what has worked for you and what hasn't and how your program is implementing IPS will allow us to update and improve future iterations of the toolkit.

2.2 Background

Mobile phone ownership and access to the internet has become nearly universal for most Americans. Out of all U.S. adults, 90% use the internet 6and 96% own a cell phone,7 81% of which are smartphones.8 The wide use of the internet and mobile devices for communication makes them ideal settings for meeting prospective sex partners. Research has shown that these venues are being used by a variety of populations to find potential sex partners, and that this behavior can lead to STD acquisition and transmission.9101112131415

Furthermore, mobile phones and mobile phone applications can increase the speed with which a sex partner can be found, further compounding STD risk. As a result of the pseudo-anonymity of the internet and mobile communications, individuals who are newly diagnosed with an STD or HIV may know little more than a profile name or email address of their sex partners. When information for locating partners is limited to such virtual identifiers, the internet and other digital media often become the only means for notifying a partner of their exposure.

These venues can also provide access to valuable information that can then be used for partner notification, such as location information and physical and behavioral characteristics of sexual partners.161718 As such, STD and HIV prevention programs have been encouraged to incorporate the internet and other digital technologies into their prevention efforts.45

2.3 A brief historical context of technology-based partner services

The first documented instance of the internet being used for the purposes of partner notification was in 1999 in response to a syphilis outbreak in San Francisco attributed to sexual encounters facilitated through a chat room.19 In the same year, another study was conducted among an STD clinic population and identified the internet as a possible STD/HIV risk environment.9

As a result of a significant increase in the number of patients reporting sex partners met online through chat rooms, social networking, and "hook-up" sites, public health programs began incorporating the internet and email into their partner services programs.202122 These early efforts showed that internet-based partner services held promise as a legitimate tool when partnered with other traditional methods for disease prevention.

By September of 2005, CDC had responded to the promising outcomes shown in several areas with a "Dear Colleague" letter4 that encouraged program areas to explore the internet as a disease intervention and prevention tool. A second CDC "Dear Colleague" letter supporting the use of the internet for partner services was released in 2010.5

Since the release of the first "Dear Colleague" letter, several studies have been conducted to evaluate IPS outcomes by assessing rates of partner elicitation, notification, and testing and quantifying the number of partners who would not have been contacted without IPS.

In Texas, Vest et al. found that the use of email to reach partners for whom no other contact information was available resulted in 50% of those partners being notified. Of those, 26% were found to be infected with an STD. Additionally, findings showed that sending emails did not require additional staff time and allowed for rapid partner notification communication.23

Ehlman et al. assessed the effectiveness of IPS in Washington, D.C., using STD program disposition codes. They found that internet partner notification (IPN) improved notification and treatment for early syphilis. Using IPN led to a 75% increase in the number of partners investigated and a 26% increase in the number of partners examined and treated, when necessary. At least 285 partners who would not have otherwise been contacted were notified of exposure.24

In addition to emails, social networking sites can also be a venue for partner notification. The Milwaukee Health Department in Wisconsin reported on the use of the social networking site Facebook to augment partner notification efforts involving a syphilis cluster (n=55). Within the cluster, 17 positive cases of syphilis were found, 10 of which were co-infected with HIV. Among the cluster, 2 of the positive cases had been named as Facebook contacts; as a result, they were able to be located by DIS when traditional methods failed. Moreover, these 2 cases were found to be key connectors within the cluster. Facebook was also used to augment traditional partner notification for an additional 5 individuals. Hunter et al. (2014) found that the use of Facebook augmented traditional efforts by allowing DIS to reach partners more quickly, especially among those individuals who may frequently change phone numbers or addresses, while also aiding in the identification of sought-after partners.16

Texting has also been shown to be a very effective way of reaching partners. In a 2011 Letter to the Editor, Kachur et al. described a case in which text messaging was successfully used for partner notification. In this case, DIS in the New York State Department of Health were able to reach and notify a partner of their syphilis exposure through text messages after traditional efforts had failed.25

In 2012, Mendez et al. reported on Multnomah County's texting partner services (PS) program, which consisted of sending a text message for partner notification immediately following an attempt to reach cases by phone, but before mailing letters or conducting a field visit. Text messages were sent to 149 clients immediately following an attempted phone call, and 56% of those texted responded to DIS with a phone call, many within 10 to 15 minutes. They also found texting reduced the need for mailing letters and making field visits.26

Hightow-Weidman et al. evaluated the use of text messaging for partner notification of 29 contacts in North Carolina. Text messaging was used only after traditional or IPN attempts did not elicit a response. Of the 29 contacts, 48% (n=14) responded to the text, all within a median time of 57.5 minutes. Among the 14 responses, 2 new cases of syphilis and 1 new case of HIV were identified.27

Udeagu et al. compared traditional PS, IPS, and text-based (txtPS) PS delivery methods on contact, notification, and HIV testing rates. They found the contact rates for txtPS (77%) to be significantly higher than traditional PS (69%) or IPS (41%; p<0.0001). Both IPS (odds ratio [OR], 2.1; 1.2-3.4) and txtPS (OR, 2.4, 1.7-3.2) resulted in a greater likelihood of notifying partners than traditional PS (p<0.0001), but traditional PS yielded the highest proportion of partners testing for HIV (69% traditional PS versus 34% IPS and 45% txtPS; p<0.0001). They concluded that augmenting their PS program by incorporating the three modes of PS improved their overall PS outcomes, reached partners who were otherwise unreachable, and improved their operational efficiency.28

Pennise et al. reported on the Monroe County Department of Public Health in New York, which has issued smartphones to DIS for use during field investigations since 2012. They reported on a cluster investigation conducted between February and May 2013 through which partner elicitation, notification, and testing were improved through the use of smartphones. Use of smartphones allowed DIS to search online sites and mobile applications with patients in order to elicit partner information in real time. These efforts resulted in seven new cases of disease being diagnosed, including two new cases of HIV.17

Lastly, a structured literature review of published studies about technology for STI and HIV partner services in the United States found that the use of technology resulted in additional partners notified, screened, or tested; the identification of new positive cases; and contact with partners who otherwise would not have been notified of their STI/HIV exposure. Furthermore, the integration of technology provided other programmatic advantages such as improved operational efficiencies, an efficient means of reaching partners, and cost savings.18

In addition to augmenting traditional PS, partner notification through an online community is considered an acceptable tool by members of that community. In a national IPS study performed by The Fenway Institute, Fenway Community Health looked at the acceptability of IPS among men who have sex with men (MSM). A total of 1,848 MSM were recruited online via an internet sex partner-seeking website between October and November 2005. The study concluded that IPS should be considered an acceptable tool for PS, with more than 92% of participants reporting that they would use IPS in some capacity to inform their sexual partners of possible exposure if they were to become infected with an STD in the future.29

Since its inception in 1999, IPS has become a standard practice in many health departments. Internet partner services has been an effective tool for the elicitation, notification, and testing of partners and for reaching those partners who otherwise would not have been notified of their exposure to an STD or HIV.