Thurman, Andrea Ries MD*; Shain, Rochelle N. PhD*; Holden, Alan E.C. PhD*; Champion, Jane Dimmitt PhD*; Perdue, Sondra T. DrPh*; Piper, Jeanna M. MD†
UNTREATED SEXUALLY TRANSMITTED INFECTIONS (STIs) in women lead to the serious sequelae of pelvic inflammatory disease, ectopic pregnancy, tubal factor infertility, and pelvic pain.1 Therefore, notifying sexual partners of STI exposure is important to stop the cycle of reinfection. The increasing demands placed on public health departments have limited comprehensive partner notification (PN) and treatment programs.2 Limited public health resources are mostly dedicated to tracking syphilis and human immunodeficiency virus infections, not Chlamydia trachomatis, Neisseria gonorrheae, or Trichomonas vaginalis, which are more common.3 Increasingly, counseling patients on PN is the obligation of the health care professional who diagnoses the index STI.
PN involves partner elicitation by the index patient, contacting exposed individuals, and providing testing and treatment to partners. This process is complicated by several social, administrative, communication, and psychological issues. PN strategies include patient referral, provider referral, and contract referral.4–6 The first step in PN involves the health care provider understanding the index patient's lifestyle, relationship issues, medical knowledge, self-efficacy, communication ability, and perceived consequences of PN.
The data for this study were obtained from a prospective, randomized controlled trial which was designed to prevent recurrent STIs in low-income Mexican American (MA) and African American (AA) women.7 We obtained detailed patient and partner information for this large cohort of women with nonviral STIs. There have been many studies which examine PN and expedited partner therapy in predominately white5,8–12 and AA populations,13–21 but PN has not been described in a large cohort of MA women. Our goal was to elucidate independent factors that predict PN of STI exposure to male sexual partners. This will assist clinicians who diagnose an STI in low-income MA and AA women to triage those women who are most or least likely to inform their partner(s).
Materials and Methods
The details of Project Sexual Awareness for Everyone 2 have been previously published.7 Institutional review boards at the University of Texas Health Sciences Center San Antonio and the San Antonio Metropolitan Health District approved this study. MA and AA women, aged 15–45 years old, diagnosed with a nonviral STI were referred to our clinic, and enrollment was offered to all English-speaking (to maximize homogeneity across ethnic groups) women, aged 15–45 years old. Patients were enrolled within 1 month of treatment of their baseline infection (mean, 15.6 days; median, 15 days). At enrollment, written informed consent was obtained, and patients participated in a comprehensive intake interview given orally to each participant, by trained research staff. Treatment or retreatment was provided to participants who were untreated, incompletely treated, or possibly re-exposed to an STI. Participants were offered a test of cure following medical therapy.
The primary outcome of the study, termed PN, was determined by asking each woman “Are you going to tell him that you have an STI so that he can get checked?” for each male sexual partner. We considered “Yes,” “He told me,” and “You told him already/he already knows” to indicate “Yes PN.” We categorized “Maybe” and “No” as “No PN.”
We obtained sociodemographic information (ethnicity, age, education, living situation, pregnancy, and employment status, illegal drug use in the last 3 months, index STI(s), and referral clinic) of the index patient and each of her male sexual partner(s). To determine if the woman perceived the relationship(s) as committed, we asked several questions, including “Has your relationship been steady?” “As far as you know, are you going to have sex with him again?” and “Do (did, if pregnant now) you want to get pregnant by this man?” We asked “When did you last have sex with him?” for each partner and analyzed these data as a continuous variable. To determine financial support, we asked, “If you wanted or needed to, could you support yourself and (if applicable) your children without a man's help?”
To determine if a woman had ever experienced physical or sexual violence, we asked the following questions and considered any “yes” answer to indicate a positive screen for physical or sexual abuse: “Has a man/man used a knife, gun, or other weapon against you?” “Forcefully held you down, punched, kicked, or tried to choke you?” “Made you have sex without protection against STIs when you wanted protection?” “Knowingly hurt you physically during sex?” “Made you feel afraid to say no to sex?” “Had sex with you when you didn't know what was happening or were out of control?” or “Made you have sex when you didn't want to?”
To investigate “relationship issues” we asked, “Respond” “A lot” “A little,” or “Not at all” to the following questions: “Besides sex, what do you get from your relationship with him: (a) emotional support, (b) housing/food, (c) other financial help, (d) feelings of warmth and closeness during sex, (e) feelings of warmth and closeness at other times, (f) drugs and/or alcohol, (g) physical protection.” To investigate “communication issues” with each partner, we asked “Tell me if these statements apply a lot, a little, or not at all to your situation with him: (a) You can tell him what you want and he does it, (b) he can tell you what he wants and you do it, (c) he shows you respect, (d) he acts guilty and makes up excuses, (e) he acts abusively toward you, (f) you would be insulted or suspicious if he suggested condom use, (g) you would feel protected if he suggested condom use.” For these questions, we categorized “a lot” and “a little” as “Yes.”
Bivariate relationships between independent variables and PN were first explored using χ2 analysis. We then determined those variables that were independently associated with PN using multivariate logistic regression analysis. SPSS software (Chicago, IL) was used for statistical analysis.
A total of 585 MA and 190 AA women participated in the initial interview and identified 1122 male sexual partners. Table 1 provides women's responses to the primary outcome measure, PN. As shown, most women notified or planned to notify all or some of their male sexual partners. Of the 1122 male partners, 47.7% of women already notified (535 of 1122), 19.5% intended to notify (219 of 1122), 4.5% “maybe” would notify (51 of 1122), 22.1% would not notify (248 of 1122), and 4.5% (50 of 1122) reported “he told me.” Of male partners who either would not or might not be notified (299 of 1122), the primary reason was that the woman did not plan to see him again (48%), did not want to be excused of infidelity (18%), was angry at him (12%), or was concerned he would be angry (18%) or violent (4%).
Table 2 shows individual characteristics of the index women (n = 775) and their male sexual partner(s) (n = 1122) and their relationship to PN. Only 1 variable, living with a partner, was significantly associated with PN; however, this characteristic was highly associated with a “steady” relationship and 1 male sexual partner and was not independent in the final logistic regression analysis. Although index STI (N. gonorrheae, C. trachomatis, T. vaginalis, or syphilis) did not predict PN, multiple index STI(s) were inversely related to PN (P = 0.01, OR: 0.69; 95% CI: 0.53–0.92). Multiple STIs were not significant in the final regression model, as it was related to multiple partners.
We asked the women a series of questions that investigated relationship and communications issues. Table 3 describes PN of all male partners according to whether the woman answered “yes” versus “no” to the relationship and communication questions. Of note, we asked a general abuse question, which, like the more detailed scale of sexual and physical abuse, did not significantly predict PN. Condom use was also not associated with PN. Most of the relationship and communication questions significantly predicted PN on a bivariate basis, but none remained independent in the final logistic regression; being a sole male partner and having a “steady” relationship outweighed all other relationship and communication aspects. The question, “Do you think a long-term relationship with this man is possible?” was predictive of PN (P <0.001) but was associated with a “steady” relationship and was not independent in the final model.
Table 4 reports the 5 variables, all representing aspects of a committed relationship, that independently and significantly predicted those partners who would be told. Table 4 provides the percentage of partners told according to each variable. For example, 84.9% of men were either notified or planned to be notified if they were considered a “steady partner” by the index woman. The model correctly predicted PN status for 73.5% of male partners overall; 73.1% of male partners notified and 74.3% of those not notified were correctly classified by this model.
Results demonstrated the PN rate of various combinations. For example, if a woman considered a male a steady partner, anticipated sexual intercourse with him again, and he was her only partner, the PN rate was 94%. Conversely, if a male was 1 of 3 or more partners and she considered him to be nonsteady and did not anticipate having sex with him again, the likelihood of PN was only 41%.
In this large cohort of low-income MA and AA, the woman's perception that her relationship with individual partner(s) was committed, rather than unique patient or partner characteristics, was most predictive of PN. Even variables that were initially predictive but did not remain independent in the final logistic regression speak to relationship quality. Women who perceived that they were in a committed relationship, namely, a “steady” relationship with only 1 male partner with whom they recently had intercourse, anticipated ongoing sexual activity, and/or with whom they desired pregnancy, were more likely to report PN.
Our study focused on low-income MA and AA women. The United States Census Bureau reports that the fastest growing segment of the US population is of Hispanic origin, mainly from Mexico. These data add to the literature because we report current statistics on PN for MA women in a large border state. In addition, our study is unique, as we report PN rates in pregnant females with an STI. Our population reflected women at high risk for STIs, minority women younger than 25.22 We obtained detailed information on the index women and each male partner(s) and were able to determine key questions that a clinician seeing similar populations (low-income MA and AA) can use to identify partners least or most likely to be notified.
We found that our population, the majority of whom were MA, expressed similar issues and concerns as other low-income minority populations previously studied. Our research is consistent with other studies that found women with 1 steady partner were most likely to notify the men regarding STI exposure.5,8,9,12,14,15,21 Other groups have found that index patients who predict ongoing sexual activity with exposed partners were more likely to disclose their infection.5,8,15,21 The recency of sexual intercourse has also been shown to influence PN in a study of smaller sample size.9 While our study found similar themes, we identified multiple important variables, their associations with one another, and determined the strongest among them by multiple logistic regression. The result was that perception of a “committed” relationship was most important in PN.
The Cochrane database reports that the domestic violence implications of PN are an important research avenue.23 The perceived consequences of abuse and domestic violence of PN has been addressed in previous studies,6,13,15,19 but our study is unique to include a partner specific abuse and violence scale for each patient. This scale has previously been validated in this population, as it pertains to risk of pelvic inflammatory disease and high-risk sexual behaviors associated with acquisition of an STI.24,25 Although physical and sexual abuse were not found to be predictive of PN in our final model, it is likely that our screen appropriately identified so large a subset of women with abuse histories, as to not differentiate PN. We thought the question “Has any man made you have sex without protection against STIs, when you wanted protection?” might be confounded by the fact that all women in the study were recently diagnosed with an STI. However, only 41 of 484 women with positive abuse screens were included solely by this question.
We found that the index patient's race, age, education, perceived financial independence, employment status, referral clinic, and illegal drug use were not predictive of intent to notify partner(s), as has been shown in other studies.8,17 Our findings that partners of patients diagnosed in STI clinics versus other settings had a similar chance of being notified is contrary to findings of other authors,8,12 but is likely because most of our patients were low-income and referred from public clinics. Our PN rate among teens was similar to other smaller cohorts.15–19
The questions that addressed relationship and communication issues were able to predict PN. However, a “steady” relationship and number of partners superseded the individual relationship and communication questions in the final model.
This study is limited by the fact that we addressed the woman's intention to notify a partner and could not confirm if the patient actually notified the partner or if he received testing and treatment. PN is a difficult variable to validate. However, almost half of the men fell into the categories of “I already told him” or “he told me.” The cross-sectional nature of the study, although a limitation, reflects the reality a clinician faces when informing a patient of an STI and counseling her to notify her partner(s).26
Different PN strategies should be considered for each patient.4 Determining an effective PN strategy is a complex process. This large study yielded 5 variables upon which a clinician can focus to determine those partners who are most and least likely to be notified. Thus, clinicians could provide additional counseling and assistance to women who are unlikely to notify their partners and help stop the cycle of reinfection.
1. Thurman AR, Soper DE. Sequelae of pelvic inflammatory disease. In: Sweet RL, Wiesenfeld HC, eds. Pelvic Inflammatory Disease. Hampshire, UK: Taylor and Franics, 2006:69–84.
2. Institute of Medicine. (US) Committee on Prevention and Control of Sexually Transmitted Diseases. In: Eng TR, Butler WT, eds. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press, 1997:432.
3. Golden MR, Hogben M, Handsfield HH, et al. Partner notification for HIV and STD in the United States: Low coverage for gonorrhea, chlamydial infection, and HIV. Sex Transm Dis 2003; 30:490–496.
4. Macke BA, Maher JE. Partner notification in the United States: An evidence-based review. Am J Prev Med 1999; 17:230–234.
5. Gorbach PM, Aral SO, Celum C, et al. To notify or not to notify: STD patients' perspectives of partner notification in Seattle. Sex Transm Dis 2000; 27:193–200.
6. Toomey KE, Latif AS, Steen RC. Partner management. In: Dallabetta G, Laga M, Lamptey P, eds. Control of Sexually Transmitted Diseases. Arlington, VA: AIDSCAP/FHI, 1996.
7. Shain RN, Piper JM, Holden AEC, et al. Prevention of gonorrhea and chlamydia through behavioral intervention: Results of a two-year controlled randomized trial in minority women. Sex Transm Dis 2004; 31:401–408.
8. Golden MR, Whittington WLH, Handsfield HH, et al. Partner management for gonococcal and chlamydial infection: Expansion of public health services to the private sector and expedited sex partner treatment through a partnership with commercial pharmacies. Sex Transm Dis 2001; 28:658–665.
9. Ramstedt K, Forssman L, Johannisson G. Contact tracing in the control of genital Chlamydia trachomatis
infection. Int J STD AIDS 1991; 2:116–118.
10. van Duynhoven YT, Schop WA, van der Meijden WI, et al. Patient referral outcome in gonorrhoea and chlamydial infections. Sex Transm Infect 1998; 74:323–330.
11. van de Laar MJ, Termorshuizen F, van den Hoek A. Partner referral by patients with gonorrhea and chlamydial infection: Case-finding observations. Sex Transm Dis 1997; 24:334–342.
12. Golden MR, Whittington WLH, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352:676–685.
13. Schillinger JA, Kissinger P, Calvet H, et al. Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis
infection among women: A randomized, controlled trial. Sex Transm Dis 2003; 30:49–56.
14. Kissinger P, Brown R, Reed K, et al. Effectiveness of patient delivered partner medication for preventing recurrent Chlamydia trachomatis
. Sex Transm Dis 1998; 74:331–333.
15. Rosenthal SL, Baker JG, Biro FM, et al. Secondary prevention of STD transmission during adolescence: Partner notification. Adolesc Pediatr Gynecol 1995; 8:183–187.
16. Chacko MR, Smith PB, Kozinetz CA. Understanding partner notification (patient self-referral method) by young women. J Pediatr Adolesc Gynecol 2000; 13:27–32.
17. Oh MK, Boker JR, Genuardi FJ, et al. Sexual contact tracing outcomes in adolescent chlamydial and gonococcal cervicitis cases. J Adolesc Health 1996; 18:4–9.
18. Magnus M, Schillinger JA, Fortenberrey JD, et al. Partner age not associated with recurrent Chlamydia trachomatis
infection, condom use or partner treatment and referral among adolescent women. J Adolesc Health 2006; 39:396–403.
19. Fortenberry JD, Brizendine EJ, Katz BP, et al. The role of self-efficacy and relationship quality in partner notification by adolescents with sexually transmitted infections. Arch Pediatr Adolesc Med 2002; 156:1133–1137.
20. Nuwaha F, Faxelid E, Neema S, et al. Psychosocial determinants for sexual partner referral in Uganda: Qualitative results. Int J STD AIDS 2000; 11:156–161.
21. Schwartz RM, Malka ES, Augenbraun M, et al. Predictors of partner notification for C. trachomatis
and N. gonorrhoeae
: An examination of social cognitive and psychological factors. J Urban Health 2006; 83:1094–1104.
22. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55:1–94.
23. Mathews C, Coetzee N, Zwarenstein M, et al. Strategies for partner notification for sexually transmitted diseases. Cochrane Database Syst Rev 2001; 4:CD002843. DOI: 10.1002/14651858.CD002843.
24. Champion JD, Piper J, Holden AEC, et al. Abused women and risk for pelvic inflammatory disease. West J Nurs Res 2004; 26:176–191.
25. Champion JD, Shain RN, Piper J, et al. Sexual abuse and sexual risk behaviors of minority women with sexually transmitted diseases. West J Nurs Res 2001; 23:241–254.
26. Golden MR, Whittington WLH, Gorbach PM, et al. Partner notification for chlamydial infections among private sector clinicians in Seattle-King county: A clinician and patient survery. Sex Transm Dis 1999; 26:543–547.