Gorbach, Pamina M. MHS, DrPH*; Aral, Sevgi O. PhD†; Celum, Connie MD, MPH*; Stoner, Bradley P. MD, PhD‡; Whittington, William L. H. AB§; Galea, Jerome BA*; Coronado, Nora MSW*; Connor, Simon BA*; Holmes, King K. MD, PhD*
PARTNER NOTIFICATION, also known as contact tracing or partner referral, has been a cornerstone of sexually transmitted disease (STD) programs in the United States used to identify, test, and treat persons exposed to syphilis, gonorrhea, chlamydial and HIV infection. The three approaches generally used to inform partners of index patients that they have been exposed to a STD included patient referral, provider referral, and conditional referral. With patient referral, the provider and patient agree that the patient will notify his or her own partners. With provider referral, the patient provides information (e.g., names, addresses, telephone numbers) about the partners with the understanding that health department personnel (e.g., a disease intervention specialist [DIS], nurse, or clinician) will inform the partners without naming the index patient. With conditional referral, a provider obtains the names and locating information of the partners, but allows the patient a specified period in which to notify these partners. If the partners are not notified within that period, the provider notifies these partners without identifying the index patient.1 Studies have addressed the efficiency of provider referral versus patient referral for gonorrhea, chlamydial infection,2,3 and HIV infection.4
Partner notification has both medical and public health objectives. The medical objectives are to ensure that partners infected with STDs, who are often asymptomatic, obtain testing or treatment to avoid complications and the development of long‐term sequelae. The public health objective is to control further transmission of these infections. With a few notable exceptions, such as in Colorado Springs where up to two fifths of eligible partners of patients with chlamydial infection have been located (50% of partners within the last 4 months),5 partner‐notification programs for different STDs have often been plagued by poor success rates. For example, a recent study of partner notification for syphilis reported locating less than 20% of potentially exposed partners, or an average of 1.1 per patient, of the average of 5.7 partners exposed per patient.6 Slightly better notification rates using patient referral for gonorrhea and chlamydial infection were reported in Amsterdam; 40% of partners were confirmed to have been evaluated or treated for STDs, with higher reporting by patients with chlamydial infection and more referrals for partners of female patients.7 In Seattle, a special project to enhance partner‐notification services has improved the program, yet only 50% of partners of heterosexual men and women and 12% of partners of men who have sex with men (MSM) are verified as having been tested or treated for STDs (Whittington WL, personal communication, 1999).8 The inability of partner‐notification programs to contact many potentially exposed persons has sparked debate over the low yield of these programs1 compared with their potential benefits.9
Research on partner‐notification programs has seldom sought the patient's perspective or experience when evaluating program process or program outcomes. A review of partner‐notification research up to 1994 found no studies that attempted to measure the potential psychosocial impacts of partner notification on index patients or on their partners.2 To contribute to the understanding of partner‐notification programs, the University of Washington and King County Department of Public Health initiated a qualitative study of the sexual partnerships of STD patients and the process of partner notification. In particular, an effort was made to understand patterns and reasons for notifying partners exposed to a STD and to elicit patients' perspectives on partner notification and other STD‐control strategies. The objectives of this study were to describe self‐reported patterns of partner notification among STD clients diagnosed with gonorrhea, chlamydial infection, or nongonoccocal urethritis; to identify themes from STD clients' perspectives of why partners are or are not notified; and to determine differences in patterns of partner notification by gender and sexual orientation of STD clients.
From June 1996 through June 1998, 30 heterosexual men and 30 heterosexual women attending the Seattle‐King County Department of Public Health STD Clinic at Harborview Medical Center who had gonorrhea, chlamydial infection, or nongonococcal urethritis were interviewed. In addition, 19 MSM with gonorrhea who obtained care from the Harborview STD Clinic and private providers in Seattle were interviewed. Participants were recruited from persons diagnosed at the clinic or those reported by other healthcare providers. A DIS described the study to eligible persons after completing the standard partner‐notification interview. Identifying information for persons who expressed interest in the study was then provided to study interviewers, who arranged for face‐to‐face interviews. (One woman and one MSM were interviewed over the telephone because of scheduling difficulties.) At the time of the interview, no individual identifying information was collected for participants, and all subjects were assigned a study code that protected their confidentiality. This study was approved by the University of Washington Human Subjects Committee and informed consent was obtained from all participants, all of whom were compensated financially ($40.00) for their time and effort.
The face‐to‐face study interview consisted of a combination of two qualitative data collection techniques: the ethnographic interview and the structured interview. The explicit objective of the ethnographic interview was to understand the informant's experience from his or her point of view. The informant's language thus represents data, “…the words people use provide the structure and categorization of their experience.”10 This type of interview allows respondents the freedom to choose their own words, context, and manner to describe their experiences, thereby permitting cognitive data to emerge.9 The content of the interview is structured according to an interview guide that specifies exact topics to be covered. The structured interview contains specific questions asked of each informant but maintains an open‐ended response, allowing for probing to clarify responses. The study used a semistructured interview that contained specific questions; however, interviewers used ethnographic techniques to allow patients to fully express their interpretations of events and relevant experiences, and to provide a context for the response.
Three interviewers (graduate students in the School of Social Work at the University of Washington) underwent special training in interview techniques, such as probing, framing, summarizing, and checking11 to guide each participant to reflect on experiences with STDs. The interviewers followed a structured set of questions in an interview guide on the following topics: (1) sexual partnerships; (2) history of STDs; (3) sexual history; and (4) experience with last STD, including symptom recognition, STD exam, treatment, and partner notification. The patients were asked specifically about (1) why each partner was or was not told about the STD diagnosis, (2) the process of informing the partner, and (3) the partner's response.
The data‐collection instrument was field tested in a pilot study of 25 patients from the STD clinic. Interviewers were gender matched with participating STD patients. Each interview lasted approximately 1 hour and took place in the study office. Interviews were tape recorded and transcribed verbatim. Data were entered into Ethnograph, a software program for textual and content analysis.
The response text was searched, labeled, extracted, and categorized for each topic of interest (e.g., reasons for partner notification) using content‐analysis methodology. The labels, also known as codes, were derived from the study's research questions. To identify themes, interview segments with the same label were grouped and analyzed for similarities and differences.10 The first set of interviews were independently coded by two persons, and discrepancies were compared and discussed to establish a reliable coding system between coders and to standardize code definitions; however, reliability was not quantitatively assessed. Throughout the study, all coded interview transcripts were reviewed by a coinvestigator to provide oversight to the coding process. The Ethnograph program was used to extract and sort interview text into a single file statements with the same code from all interviews. Matrices were developed for each of the codes to note common threads and contrasts found in the statements.12
A total of 79 patients with STDs were interviewed. Most of the interviews were conducted within 1 week of the DIS referral, which occurred at the time of the partner notification (69% of heterosexual men and 73% of heterosexual women); only a few patients were interviewed 2 weeks or more following the DIS interview (8% of heterosexual men and 15% of heterosexual women).
Table 1 provides basic descriptive information on the study participants. The heterosexual men and women and MSM differed demographically and behaviorally. Women were younger than heterosexual men and MSM, there was more ethnic diversity among the heterosexual men and women, and women were more likely to be unemployed than heterosexual men or MSM.
A range of choices for informing partners of potential exposure to a STD that reflected each patient's partnership patterns was available to each index patient. The index patients who chose each option were grouped together, and themes of reasons for their choices were identified (Table 2). Verbatim quotes representing specific themes found in the content analyses are presented in Tables 3 and 4.
Tell all partners. Index patients expressed a willingness to tell all exposed partners if they were no longer in an ongoing partnership with any of these partners, or if partners were not people who were known socially. One MSM expressed his rationale for choosing to tell all his partners based on the lack of a social relationship with the partners to be notified (Table 3).
Some patients chose to tell all partners in order to stop further transmission of STDs, and understood that they ran the risk of informing persons who may not have been infected. These patients consciously assumed a responsibility for their role in the transmission of STDs to their partners. Other index patients expressed a concern for individual partner's welfare as a reason to notify, given the health risks of STDs. One heterosexual man with chlamydial infection informed his partners because he, “cares about people more than just a roll in the hay,” (i.e., the partners were more than mere sex objects to him).
Most persons who chose to inform all partners had multiple partners with whom they were not engaged in ongoing partnerships. Because many such partners also had multiple partners, and because these partners tended to be disconnected from the partners' social circle, notification did not threaten the status of their partnership or their social standing.
Tell main partners. Patients had both “main partners” who were exclusive partners and “main partners” who were one of multiple partners but identified as the main partner. Almost all patients with main partners informed this partner of potential STD exposure. The rationale, form, and contexts in which these partners were informed, however, greatly varied.
Some persons were engaged in partnerships in which nonmonogamy was accepted and open; therefore, informing the partner that they may have exposed them to a STD was an expression of care for the partner, and the STD infection was conceptualized as an accepted aspect of nonmonogamy. Openness with each other was often described as an important part of these partnerships, which includes openness about the existence of other partners and the potential consequences of nonmonogamy, including STD exposure. Partner notification did not threaten the partnerships with such a mutual understanding; in such partnerships, notification of STD exposure is expected to come directly from the partners and not from a health professional. Persons in these openly nonmonogamous partnerships expect their partners to take responsibility for the infection by informing them, and would be angered by provider referral. Some STD patients reported that they notified their partners, and that a STD was neither a surprise nor an unacceptable event within the context of their open partnership (Table 3). In fact, partner notification can be perceived in such cases as the index partner's expression of trust and caring about their exposed partner.
Although most women informed their main partners of their STD, some did so through the guise of a nonincriminating explanation. Women reported telling their partners that they acquired an “infection,” explicitly not identifying an STD (e.g., a yeast infection or an infection acquired indirectly, e.g., from a toilet seat or dancing platform). Because many women experience reproductive‐tract infections not acquired sexually, their partners may be familiar with the symptoms and not suspect outside sexual activity as the cause. In contrast, none of the men used such explanations for a STD.
Other patients informed main partners when it was not clear who was responsible for acquiring the STD. As with the examples above, these tended to be openly nonmonogamous partnerships in which both partners know that both members of the partnership are at risk for STD and for transmitting an infection. In fact, the responsibility for infection is sometimes shared with the partner, and informing can serve as a reminder that they both have unprotected sex (Table 3).
Finally, there were patients (mostly women) who chose to inform a main partner for the purpose of confronting him or her about nonmonogamy. In many cases, the partner may have not admitted to sexual contact with persons other than the index patient, and continued to have other partners even after the index partner tested positive for STD. In these cases, the STD infection may serve as a catalyst to confronting the issue of nonmonogamy in a partnership in which only one partner has multiple partners without the knowledge or permission of the other partner (Table 3).
Tell main partner, not others. Some patients with a main partner and other partners only notify the main partner of their STD infection, primarily because they only care about their main partners. Not only do STD patients feel unmotivated to notify partners that they have little feeling for, but they perceive that they are putting themselves at risk of gossip if a nonmain partner is informed.
Main partners, but not other partners, are notified because of reported difficulty in locating the latter, and especially because other partners tended to be one‐time partners and were often anonymous. Sexual activity with such partners often occurs without the expectation of further contact, making partner notification a challenge.
Finally, STD patients report notifying main partners and not others to avoid reinfection by the main partner. There may be personal gain for STD patients in notifying a main partner because it ensures treatment of a partner with whom they expect further sexual contact.
Tell others, not main partner. There were no heterosexual men or women who opted for the choice of informing other partners but not a main partner of exposure to STD. In fact, most patients with main partners chose to inform them, as summarized previously. Only one MSM followed this pattern of notification; he believed that he could not have exposed his main partner to an STD because their last sexual encounter preceded his symptoms. Therefore, only the nonmain partners with whom he had sexual contact after symptom onset were notified.
Tell some partners, not others. Patients who had a number of casual contacts and no main partner notified some partners but not others. The principal explanation given for not informing some partners was the inability to locate these persons. Such partners may have been anonymous sex partners with whom neither names nor telephone numbers were exchanged.
Other patients only informed some partners because they perceived no risk of transmission to partners with whom sexual contact was made before the symptom onset. Many patients perceived that an STD can be transmitted only to those sexual partners with whom they have sexual contact while symptomatic; therefore, they did not inform sexual contacts from before time of symptom onset.
MSM also reported a unique reason for only telling some partners; some MSM chose not to inform partners with whom they had only had oral sex because they did not perceive oral sex as a way to transmit STDs.
Tell no partners. Some patients chose to not inform any partners because the partnership had ended (particularly if it was a main partnership). Informing an ex‐partner brings further recrimination to the index patient, and requires further contact with a partner they do not expect to encounter again. Many young female patients chose to not inform ex‐partners, either because they were no longer in contact with these partners or because they had been incarcerated.
Some patients did not inform partners because they assumed the partner already knew that he or she was infected. Patients either presumed the partner was infected first and was aware of this infection, or believed that it was clear to their partner that they had been infected. One man avoided a direct conversation about his infection with a partner. He had sexual contact with her again after he tested positive for an STD, and was treated because he knew that his partner had been treated for a STD (even though he had not discussed this with her). This assumption relieved him of the responsibility of informing her of his infection.
No partners will be informed if all partners are one‐time partners, who are usually anonymous. If the index patient does not know his or her partner's names, he or she can't find and notify these partners. Most patients who chose to not inform any partners were those who only had anonymous or one‐time partners. A few index patients who were able but explicitly unwilling to contact partners stated that they “did not care” about the partner's welfare, or blamed the partners for transmitting the infection. Finally, fear prevented some patients from informing partners.
Reasons Underlying Partner‐Notification Decisions
Perceived transmitters. Patients had a range of responses to those who they perceived as responsible for their infection, with a pattern discerned by gender and sexual orientation of the patient. The majority of heterosexual man and MSM did not inform perceived transmitters. The pattern for women, however, was less consistent. Some women confronted the partners they considered to be responsible for transmitting a STD to them, whereas others chose to not inform such partners. Many patients of both genders and sexual orientation felt angry with the transmitter, as described previously, and assumed that the transmission was deliberate. They effectively retaliated by not returning the courtesy of informing that partner of their exposure to an STD infection. Although a perceived transmitter may have, in fact, been the only possible source of infection (i.e., if he or she was the index patient's only partner), other perceived transmitters may not have been the source. Patients often based their assessments of the source of infection on less‐than‐reliable means, such as the expression on the face of one partner or certain behaviors, yet they had other partners who could have also have been transmitters. A false assessment of the partner as the perceived transmitter suggests that that partner was exposed to STD infection but not informed, and therefore may remain untreated. Of equal or greater concern is that actual transmitters may be correctly assessed but not informed of STD infection. They may have been asymptomatic and unaware of their own infection, yet remain untreated and potentially infectious to other partners when the infected index patient chooses not to inform them.
Fear: a persistent barrier to partner notification. Fear emerged as a strong barrier to partner notification. Men and women confronted a range of different kinds of fears and managed these fears in different ways. Some cited fear as a reason to not notify partners, whereas others chose provider‐assisted partner notification as a way to handle their fear. The first type of fear mentioned was a fear of gossip and stigma expressed by both heterosexual men and women (Table 3). The patients who expressed a fear of gossip tended to be young or adolescent men and women.
Some female patients expressed a fear of partner‐inflicted violence. Younger women were generally more likely to report a fear of violence. Women reported fear that arose from previous threats from a partner as well as from partners who had not threatened them with violence before. Finally, both women in main partnerships and women with little‐known partners expressed fear of violence, indicating fear of partner abuse seems to extend across a range of partnership types. Two women expressed a fear of partner retaliation as a reason to not notify (Table 4).
The final type of fear expressed by patients about partner notification was a fear of rejection, which was only reported by MSM with gonorrhea. One MSM cited a fear of rejection not by a specific partner, but a generic fear of rejection by any person who was aware that he had a STD (Table 4). Although this patient was not in ongoing partnerships with the partners who he needed to notify, he nevertheless was afraid of rejection and stigma that may come from notification. Types of partners least notified are listed by patient gender and sexual orientation in Table 5.
Partner notification is an activity that requires patients with STD infection to tell their sexual partners that they may have exposed them to an infection‐an admission that suggests a lack of exclusivity in the partnership. However, the nature of the nonmonogamy may not be clear. The findings from this study reveal that in the context of some partnerships, exclusivity is neither an expectation nor a requirement. Partner notification in such partnerships does not necessarily threaten the continuation or stability of the partnership, yet may carry expectations about the way notification is accomplished (e.g., by the index patient and not a provider). The nature of other partnerships, such as those that are anonymous or assumed to be monogamous, present different challenges to partner notification. Thus, as providers make recommendations to STD patients about partner notification, they need to ask about the nature of the partnerships in which the sexual contacts occurred, and consider how the dynamics of such partnerships affect the ability of the patient to proceed with notification. Moreover, this study found that most patients with STDs attempted to notify some partners, especially those who were main partners; it was the one‐time or anonymous partners who were often not contacted. Often this was due to an actual inability to recontact these partners because personal information had not been exchanged before or after the sexual encounter. For such partners, focusing on notification by venue rather than focusing on the individual may be a more productive approach in the short run. In the long run, this approach may encourage patients to reduce their anonymous sex contacts, which would reduce the risk of reinfection and further disease transmission.
A surprising finding from this study was how patients identified certain partners as being the transmitters of their STD infection. Patients may not be able to correctly identify the actual source of their infection in all cases, yet those perceived as transmitters often receive special consideration in partner notification. Men, regardless of their sexual orientation, often chose not to notify perceived transmitters. Conversely, many women chose to confront perceived transmitters; however, in most instances, this was when the perceived transmitter was a main partner or a former main partner. Providers must elicit and correct patients' beliefs that perceived transmitters knowingly infected them, and address the possibility that the infection could have come from other partners. Many patients allowed their identification of the perceived transmitter to affect their decision to notify other partners. Such patients did not consider notifying partners with whom they had sexual contact before sexual contact with the perceived transmitter. Therefore, providers must be careful to elicit names of all partners that were within the incubation period of the STD, and explicitly request that those partners who recently preceded the perceived transmitter be notified. Because patients were also found to have similar misconceptions about potential of exposure of partners that preceded the onset of symptoms, providers must make an extra attempt to ask about such partners.
Finally, the study points to other types of partners who are not likely to be notified, such as former partners of women and partners that threaten violence or are otherwise feared. Providers should make special efforts to offer provider‐assisted notification in such cases. The finding that some MSM may not perceive oral sex contacts as partners to be notified also deserves some consideration. Partner notification could be improved if providers carefully ask about types of partners likely to not be notified by index patients, and take care to offer alternative ways to reach those that patients do not intend to notify.
Implications: No One Size Fits All
Men and women face legitimate fears, motivations, and consequences regarding partner notification that must be addressed to increase their participation in such programs. Different types of partners require different strategies for notification. There is a need to further evaluate which strategies work best for which types of partners. The approach to notification should be tailored to the type of patient, their types of partners, and their types of partnerships, where resources allow. Some types of partners react negatively to notification given by providers if it violates an expectation that their partner should conduct such notification themselves. Gender, sexual orientation, and age are all important characteristics that may require different approaches to partner notification. With additional focus on tailored strategies, the effectiveness and cost effectiveness of partner‐notification programs may be improved significantly. These findings point to a need to further develop the training and expertise of those involved in partner notification to include ethnography, although the benefit of such training should be formally evaluated. There is a need to test new strategies for partner notification that provide STD providers guidance when integrating the findings of this research. Finally, future analyses will examine the ethnography of partners‐a contextualized examination of the life patterns of various partnerships from their own perspective, and eliciting the terms of the STD patients themselves.