MacKellar, Duncan A. MA, MPH*; Hou, Su-I DRPH†; Behel, Stephanie MPH*; Boyett, Brian MS*; Miller, David BA*; Sey, Ekow PHD‡; Harawa, Nina PHD§; Prachand, Nik MPH∥; Bingham, Trista PHD‡; Ciesielski, Carol MD∥¶
Hiv partner counseling and referral services (PCRS) include the broad array of prevention counseling, testing, and referral services provided to HIV-infected persons and their sexual and needle-sharing partners.1 In accordance with national PCRS policies, HIV test and medical-care providers should discuss with their HIV-infected clients the need to notify partners of their possible exposure to HIV and help plan how partners might be notified.1,2
Two frequently used partner-notification strategies include client partner notification (CPN), where HIV-infected clients personally notify their partners, and health-department partner notification (HDPN), where clients give sufficient information to health department staff who are then responsible for notifying identified partners.1–4 Provision of PCRS and use of CPN and HDPN are important prevention strategies in the United States because many partners of HIV-infected persons are unaware of their HIV infection, and because most persons who become aware of their infection take steps to prevent transmission to others.3–6
Most research on PCRS, conducted before the dissemination of national policies and the availability of highly active antiretroviral therapy, has focused on the effectiveness of HDPN in identifying and testing HIV-infected, unaware partners.3,4 Provision of PCRS by HIV test and medical-care providers since the dissemination of national polices and the relative use of CPN and HDPN to notify partners have not been reported and are unknown. Use of CPN to notify all locatable partners by client socio-demographic characteristics, time since diagnosis, number and types of partners, and exposure to PCRS is also unknown. Information on these and other potential correlates of CPN might be useful for improving PCRS by identifying potential partner-notification barriers and helping clients choose successful strategies to notify partners.
To evaluate implementation of national PCRS policies and to help meet these information needs, we analyzed data from the client’s perspective on exposure to PCRS from HIV test and medical-care providers, use of CPN and HDPN, and correlates of CPN among persons recently diagnosed with HIV in Chicago and Los Angeles.
Survey Design, Recruitment, and Interview
We conducted a cross-sectional, observational study of persons recently diagnosed with HIV referred from a nonprobability sample of 51 HIV test, medical, and research providers in Chicago and Los Angeles in 2003 and 2004. Providers referred patients who were 18 years of age and older, and who were diagnosed with HIV within the prior 6 months. Other persons who learned of the study could also participate (self referral) provided they had documentation of being at least 18 years of age and having received an HIV diagnosis within the prior six months.
In Los Angeles, eligibility was restricted to residents of Metro and South service planning areas. In Chicago, eligibility was restricted to Chicago residents. Eligible persons who wished to participate provided informed consent, completed a face-to-face interview and a blood test to confirm HIV infection, and were compensated for their time and travel costs. The interview questionnaire collected information on demographics, sexual and drug-use behavior, exposure to PCRS at HIV diagnosis and source of HIV medical care (if applicable), the number of locatable partners notified through CPN and HDPN, and reasons for not notifying locatable partners (if applicable). All sexual behavior (e.g., number of locatable sex partners) was measured in the 6 months before HIV diagnosis.
Exposure to PCRS was measured with 2 questions on whether their provider (1) discussed the need for sex and needle-sharing partners to be HIV tested and (2) offered health department assistance in notifying partner(s) of their possible need for testing. Both questions were asked about providers at HIV diagnosis and at source of HIV medical care (if applicable). Locatable partner was defined as a sexual partner in the 6 months before HIV diagnosis who was not known to be HIV-positive and whom the client could contact directly or indirectly through others. CPN was defined as the participant personally telling locatable partners that they might have been exposed to HIV. HDPN was defined as providing the health department with sufficient information on locatable partners so that they could be notified.
The χ2 statistic for categorical variables and the Wilcoxon rank sum test for continuously scaled variables were used to compare participants from each city and participants who reported having only opposite-sex partners (heterosexual, HET) with men who reported having sex with men (homosexual, MSM). For HET and MSM in each city and for all participants in both cities combined, we report the number and proportion of participants who reported being exposed to PCRS from HIV test and medical-care providers, having ≥1 locatable partners, and using CPN and HDPN to notify locatable partners. We also report the number, median, and interquartile range (Q1–Q3) of all (total), locatable, and notified sex partners.
To estimate the number of partners who might have benefited from notification, we excluded from the count of total partners those who were known to be HIV-positive with whom participants reported having unprotected anal or vaginal sex. Exclusion of HIV-positive partners with whom participants had only oral sex or protected anal or vaginal sex was not possible as these data were not collected. Participants who reported having needle-sharing partners were also excluded from analyses because the types of partners notified (i.e., sex or needle sharing) were not measured and because very few participants reported having needle-sharing partners.
Logistic regression was used to evaluate independent correlates of CPN of all locatable partners. We included in the regression model all variables that were significantly (P <0.05) associated with CPN of all locatable partners in bivariate analyses and other nonsignificant but potentially important confounders (e.g., demographics). We evaluated effect modification by including two-way interaction terms between medical provider and demographic and risk variables. The full logistic regression model was reduced by the stepwise elimination of insignificant interaction terms. One interaction term was found to be significant (race-ethnicity and medical provider) and the model was not reduced any further. All analyses were performed using Statistical Analysis Software (SAS) version 9.1 (SAS Institute, Inc., Cary, NC).
Analytical Restrictions and Socio-Demographic Characteristics
Of 698 participants, analyses excluded 27 participants who reported having needle-sharing partners and 78 who reported having no sexual partners (n = 64) or only HIV-positive partners (n = 14). Analyses excluded an additional 3 participants who were determined by interviewers to report invalid data. The remaining 590 participants (Chicago, 253; Los Angeles, 337) were interviewed a median of 37 days (Q1–Q3: 17–96) after HIV diagnosis. Proportionally more participants from Chicago were referred to the study from a public-health STD clinic, and were younger, of black race, female, and heterosexual (Table 1).
Exposure to PCRS at HIV Diagnosis
Of the 590 participants, 302 (51.2%) reported that their test provider discussed the need to notify partners and 231 (39.2%) reported that their provider offered HDPN at HIV diagnosis. Proportionally more participants from Chicago than Los Angeles reported that their test provider discussed the need to notify partners (60.5% vs. 44.2%; P <0.0001) and offered HDPN (49.8% vs. 31.2%; P <0.0001). Exposure to PCRS at HIV diagnosis did not vary significantly between HET and MSM (Table 2).
Exposure to PCRS at Source of HIV Medical Care
Of the 590 participants, 371 (62.9%) reported having seen an HIV medical-care provider a median of 2 times (Q1–Q3: 1–3). Of the 371 participants, 246 (66.3%) reported having discussed the need to notify partners and 175 (47.2%) reported being offered HDPN at their source of HIV care. Discussing the need to notify partners did not vary significantly by city; however, proportionally more participants from Chicago than Los Angeles reported being offered HDPN at their source of care (53.6% vs. 41.9%; P = 0.02). Controlling for city, proportionally fewer MSM than HET reported being offered HDPN at their source of HIV medical care (42.9% vs. 58.8%; P = 0.01) (Table 2).
Locatable and Notified Partners.
The 590 participants reported a total of 5091 sex partners (median: 3; Q1–Q3: 1–6); 439 (74.4%) participants reported that 1253 (24.6%) of these partners were not known to be HIV-positive and were locatable (2.1 locatable partners per participant). The proportion of participants who reported ≥1 locatable partners did not vary by city or between HET and MSM (Table 2). For both cities combined, MSM on average reported more locatable partners (mean 2.4; median 1; Q1–Q3: 1–3) than HET (mean 1.2; median 1; Q1–Q3: 0–1) (P <0.0001). Of the 439 participants who reported ≥1 locatable partners, 332 (75.6%) reported notifying 696 (55.5%) partners through any method (1.6 partners notified per participant with ≥1 locatable partners). Of the 696 partners, 585 (84.1%) were notified through CPN, and 94 (13.5%) were supposed to be notified through HDPN and 17 (2.4%) through other means (Table 2).
Client Partner Notification.
Of the 439 participants with locatable partners, 305 (69.5%) reported personally notifying at least 1 partner and 208 (47.4%) reported notifying all of their locatable partners (1.3 client-notified partners per participant with ≥1 locatable partners). CPN of ≥1 partners did not vary significantly by city or between HET and MSM (Table 2). Proportionally more participants who reported 1 locatable partner (compared with multiple locatable partners), or who had more time to notify partners since their HIV diagnosis, reported notifying all their locatable partners (Fig. 1).
In logistic regression analyses, having fewer locatable partners, not having any casual sex partners, and having unprotected sex with all partners remained significantly associated with CPN of all locatable partners after adjusting for potential confounders (Table 3). Discussing the need to notify partners with an HIV medical-care provider (but not a test provider) was also significantly associated with CPN; however, this association depended on participant race-ethnicity. Compared with those who did not have a provider, proportionally more participants who discussed notifying partners at their provider reported notifying all locatable partners (black and Hispanic participants only), and proportionally more participants who had a provider who did not discuss notifying partners reported notifying all locatable partners (Hispanic participants only) (Table 4).
Health Department Partner Notification.
Of the 439 participants with ≥1 locatable partners, proportionally more participants from Chicago than Los Angeles reported using HDPN to notify ≥1 partners (20.1% vs. 1.3%, P <0.0001). Among Chicago participants, use of HDPN did not vary significantly between HET and MSM (Table 2). Of 179 participants who did not use HDPN and who reported having ≥1 unnotified locatable partners, 134 (74.9%) were asked the primary reason for not using HDPN. Of those asked, 37 (27.6%) reported they were unaware or had just become aware of HDPN, 28 (20.9%) that it was their responsibility for partner notification, and 11 (8.2%) that they were afraid of loss of anonymity or reprisal from the health department or partners.
Partners Not Notified.
Of the 5091 total sex partners, 4395 (86.3%) had not been notified, 557 (10.9%) of whom were locatable (Table 2). Of the 186 participants who had not notified ≥1 locatable partners, 136 (73.1%) were asked the primary reason for not notifying their partners. Of those asked, 49 (36.0%) reported that ≥1 partners could not be notified at the moment (e.g., partner out of town), that they hadn’t had enough time since their diagnosis, or that they still intended to notify their partners; 17 (12.5%) reported they were fearful of notifying their partners, didn’t know what to say, or needed counseling; and 8 (5.9%) reported that they had used condoms with their partners or that their partners looked healthy.
Despite national policies that all HIV-infected persons be provided PCRS,1,2 we found that many recently HIV-diagnosed persons in Chicago and Los Angeles reported that their HIV test or medical-care provider did not discuss the need to notify partners and did not offer health-department partner-notification services. Although MSM reported more locatable partners than heterosexuals, they were less likely to be offered HDPN at sources of HIV medical care. Not surprisingly, most participants used CPN to notify sexual partners (proportion of CPN-notified partners: Chicago, 76%; Los Angeles 94%).
The low reported exposure to PCRS and use of HDPN is troubling because nearly half (45.5%) of locatable partners had not been notified; that HDPN has been available in Chicago and Los Angeles since the late 1990s and is effective in testing partners of both heterosexuals and MSM,3,4 that few participants reported not using HDPN because they disliked it or lacked trust in the health department, and that many were unaware of its availability. Consistent with low provision and use of HDPN in many states,7 these findings highlight the need to improve PCRS at both HIV diagnostic and medical-care settings to increase use of HDPN so that all locatable partners are notified.
Although proportionally more participants from Chicago reported being offered and using HDPN, these differences were largely driven by Chicago Department of Public Health (CDPH) STD clinics that are funded to provide these specific services. Compared with Chicago participants who used other providers (n = 150), a substantially larger proportion of participants who used CDPH clinics for HIV testing or medical care (n = 103) reported being offered HDPN (80.6% vs. 48.7%; P <0.0001). Only 11 (3.3%) participants from Los Angeles were either HIV-diagnosed or had received HIV care at similar clinics.
Locatable and Notified Partners
Our findings (Chicago, Los Angeles) on the average number of locatable partners per client (2.3, 2.0) are consistent with the average number of partners elicited per client for partner notification in 9 other studies (median of 9 study averages: 2.2, range: 1.1–11.6).4 However, our findings on the proportion of participants who reported personally notifying ≥1 partners (73%, 66%) are considerably larger than the proportion of participants (27%) who reported notifying ≥1 past sexual partners in a study conducted on 111 men (mostly MSM) in the late 1980s in Los Angeles by Marks et al.8 Also, our findings on the proportion of locatable partners notified through CPN (51%, 43%) are similar to 1 study conducted in Colorado in 1993 (57%),9 but is substantially larger than that reported by Marks et al. (6%) and Landis et al. (7%).8,10 The study by Landis et al., conducted in North Carolina in the late 1980s, is the only randomized controlled trial comparing the effectiveness of CPN and HDPN, and is regularly cited as evidence of very low effectiveness of CPN in notifying partners.1,4–7 That study, however, randomized only 35 persons (mostly MSM) into CPN, and health-department staff were able to contact and assess CPN in only 42 (29%) of the 143 partners who were supposed to have been notified by clients.10
Differences in our findings with Marks et al. and Landis et al. can be attributed, at least in part, to our restriction of participants with ≥1 locatable partners (or total locatable partners) in the denominators of our reported proportions. The reported proportions by Marks et al. and Landis et al. were based on total partners identified, which included unlocatable partners.8,10 It is also plausible, however, that real increases have occurred since the late 1980s in both the proportion of HIV-infected persons who notify ≥1 past partners and the proportion of partners notified through CPN. Since these early studies, substantial changes have occurred in the sexual behavior of MSM (e.g., reduction in anonymous unlocatable partners), availability and efficacy of highly active antiretroviral therapy, and beliefs about HIV testing and benefits from knowing one’s HIV status.11–14
Correlates of Client Partner Notification
We found that most participants who reported only 1 locatable partner reported notifying that partner, particularly among those who were interviewed more than 30 days after their HIV diagnosis. Although we did not measure the type of partners notified, many may have been current main partners with whom CPN is known to frequently occur.4,15,16 In contrast, substantially fewer participants with multiple locatable partners notified all their locatable partners, even among those who were interviewed >90 days after their HIV diagnosis.
Several participants decided not to notify some locatable partners out of concern for personal safety, or because they had used condoms, or that their partners looked healthy. Consistent with these reported reasons, we found that participants who had casual partners or who had used condoms with at least some of their partners were significantly less likely to notify all their locatable partners. Lack of knowledge about casual partners may have raised concerns about partner reactions and personal safety when considering CPN. Likewise, participants who had used condoms with partners or who had partners who appeared healthy may have felt that infection risks were low from these partners and that notifying them was unnecessary.
As part of PCRS, HIV-test and medical-care providers should routinely assess potential barriers in notifying partners and help clients choose appropriate strategies so that all locatable partners are notified in a timely manner.1,2 Our findings suggest that PCRS providers should be especially attentive to barriers in notifying multiple locatable partners, locatable casual partners, and locatable partners with whom clients had used condoms or who were perceived to be at low risk. Notification of all locatable partners is critical given reports of high levels of undiagnosed HIV infection among MSM perceived to be at low HIV risk, and that 14% to 26% of notified partners who test are newly HIV diagnosed.4,17–20
Finally, we found that black and Hispanic participants who reported having an HIV medical-care provider who discussed the need to notify partners were significantly more likely to notify all their locatable partners compared with black and Hispanic participants who had not obtained HIV care. The potential influence of medical providers on CPN is plausible given that brief interventions delivered by providers can be effective in influencing patient behavior on other health issues (e.g., smoking cessation, diet, cancer screening).21–24 Underscoring the need to incorporate effective PCRS within the medical-care of persons living with HIV,2 we found that approximately two-thirds of participants with multiple locatable partners interviewed 31 to 180 days after HIV diagnosis had not notified all their locatable partners.
Our findings are subject to several limitations. First, participation bias could not be evaluated because we were unable to obtain the total number of eligible clients or the number of clients referred to the study from all participating providers. Although we had a reasonably large sample, our findings may not generalize to all eligible clients of our provider network, and certainly not to all newly HIV diagnosed persons in Chicago and Los Angeles or elsewhere. Second, because we could not exclude all HIV-positive partners from total partners, our reported number of unlocatable partners, representing partners at risk for HIV, is upwardly biased. However, the relatively small number of reported HIV-positive unprotected-sex partners that were excluded from analysis (n = 241, 4.5% of 5332 total partners) suggests that this upward bias is small. Third, our findings on partners notified may be upwardly biased because of the social incentive to report having notified partners in a face-to-face interview. However, our finding of 1.3 client-notified partners per participant with ≥1 locatable partners is plausible and consistent with 1 other study.9 Moreover, we interviewed nearly 200 participants within 30 days of their HIV diagnosis, and it is plausible that a higher overall CPN rate would have been observed if we interviewed these participants >30 days after their diagnosis. Finally, observed associations with CPN may not be causal. In particular, the association between CPN and provider discussions may reflect the fact that black and Hispanic participants who used CPN to notify all locatable partners were more likely to seek HIV care than those who didn’t notify all their partners.
Given these limitations and the paucity of existing literature, new studies are needed to explain why some public-health systems more fully implement PCRS and HDPN, why CPN is used soon after HIV diagnosis for some locatable partners and delayed or never used for others, the potential race/ethnic-specific influence of medical-care providers on CPN, and the proportions of partners notified through CPN who test and are newly HIV diagnosed.
Our finding that a large majority of partners of recently HIV-diagnosed persons are unlocatable (Chicago, 70%; Los Angeles, 79%) underscores the limitation that PCRS and use of CPN/HDPN cannot reach all HIV-infected, unaware partners. Our findings, however, also suggest that PCRS and HDPN services remain underutilized in both HIV diagnostic and medical-care settings, and that many locatable at-risk partners who might benefit from being notified of their potential exposure to HIV are either not notified or are not notified in a timely manner. HIV test and medical-care providers should routinely provide PCRS, offer HDPN services, and assist HIV-infected clients in implementing plans that ensure that all locatable partners are notified and provided an opportunity to learn their HIV status.
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