Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI) worldwide1 and is responsible for considerable reproductive morbidity. Various methods have been employed aimed at controlling chlamydia on a population level including chlamydia screening. A cornerstone in the control of bacterial STIs, including chlamydia, is partner notification which not only prompts partners who may be unaware of their infection to seek testing and treatment, but can also prevent reinfection of the index person.2,3 Furthermore, studies suggest that expedited partner therapy may be effective in enhancing chlamydia control. Patient delivered partner therapy (PDPT), where infected individuals are given antibiotics to give to their sexual partners, has been shown to reduce reinfection rates of chlamydia in index patients.4 Although it appears to be common practice among Australian general practitioners,5–7 PDPT is not supported by specific legislation in Australia, unlike in some US states.8,9
Previous studies have reported that only about half of all partners with chlamydia or gonococcal infection are treated, or likely to have been treated, using various patient referral methods.10–13 Strategies that help to improve patient referral are therefore required. Although a number of studies have examined the partner notification experiences, practices, and preferences of individuals,10,11,14–16 few have sought to ascertain individuals' views on possible supports to assist them with this process. In this study, we aimed to describe the partner notification experiences of individuals recently diagnosed with chlamydia and determine what specific tools might help to improve partner notification practices.
MATERIALS AND METHODS
Participants were recruited from 3 public sexual health clinics located in Victoria (Melbourne Sexual Health Centre), Queensland (Cairns Sexual Health), and the Australian Capital Territory (Canberra Sexual Health Centre) between August 2007 and January 2008.
During this time eligible individuals recently diagnosed with chlamydia were invited into the study when they were given their test result. Individuals were considered eligible if they were aged 16 years and over, had a reasonable command of English and tested positive for chlamydia. Individuals interested in being contacted about the study were asked to nominate a telephone number and time for a research assistant to contact them for a telephone interview. Up to 3 attempts were made to contact potential participants approximately 1 to 2 weeks post diagnosis. Individuals provided verbal consent for the telephone interview, after being read a plain language statement. The discussion of partner notification with patients diagnosed with chlamydia was routine practice at all study clinics. PDPT was not provided at any of the clinics.
The telephone survey was initially piloted with 10 individuals recently diagnosed with chlamydia. The survey included questions on demographic information, number of recent sexual partners and the proportion contacted, and views on possible supports to assist with partner notification. Closed questions were used to ask individuals reasons for partner notification and a combination of closed and open questioning to ask individuals opinions of various partner notification methods. Survey questions were informed from the findings of an earlier qualitative study with chlamydia infected individuals. Participants indicated that they contacted partners very quickly post diagnosis or not at all.17 Individuals were offered a $15AUD gift voucher for their participation. We asked about sexual partners in the prior 6 months (hereafter referred to as “recent sexual partners”) as the notification of sexual partners in the preceding 6 months is currently recommended in Australia.18
Data were analyzed using SPSS version 17.0. The chi square test was used to analyze categorical data. Answers to open ended answers were analyzed thematically and categorized where applicable by investigators J.B. and M.C.
Ethical approval for this study was granted by the Human Research Ethics Committee of The University of Melbourne.
A total of 494 people were diagnosed with chlamydia across the 3 sexual health clinics during the study period. Of these, 350 were invited to participate across the 3 clinics: 286 were eligible and 64 ineligible. Of the 286 eligible individuals, 239 agreed to be referred to the study and 202 (71%) completed the telephone survey. The remaining 37 either could not be contacted after repeated attempts, were no longer interested in participating, had gone overseas or were deemed ineligible after further questioning. Table 1 outlines the characteristics of participating individuals. Overall, women were significantly more likely to report a lower proportion of casual partners (as opposed to regular) compared to MSM or heterosexual men (55% vs. 88% and 92%, respectively, P <0.001).
Chlamydia Diagnosis and Advice
The 202 participants were interviewed a median of 4 days (range: 0–180) after being informed of their chlamydia diagnosis. Ninety-eight percent of individuals reported being advised by a doctor or nurse to notify their partner(s) about their chlamydia, 18% reported being provided with a brochure about chlamydia and 8% with a letter that their partner could take to a doctor.
Sexual Practices and the Notification of Partners
Individuals reported a total of 1438 sexual partners in the 6-month period preceding the study, of which 217 (15%) were regular partners and 1221 (85%) casual partners. The majority of individuals reported at least 1 recent casual sexual partner (164/202, 81%). Table 2 details the total number of sexual partners and the notification of partners.
The median number of days from an individual's diagnosis to first contact with a partner(s) was zero, that is, on the same day, and the maximum number of days to first contact was 7 days (mean: 0.5, SD = 1.2). Overall, 84% (169/202) of chlamydia infected individuals had contacted at least one of their recent sexual partners. In total, 23% (333/1,458) of all partners were notified: half were regular (164/333, 49%) and half were casual partners (169/333, 51%). Overall, 70% of regular partners (164/233) and 14% (169/1,205) of casual partners were contacted. Individuals reported that they still intended to contact 6% of partners (61/1,105).
MSM contacted a significantly lower proportion of partners than heterosexual men or women (15% vs. 31% and 46%, respectively, P < 0.001). Of the partners contacted, MSM described 54% as casual and 46% as regular, heterosexual men 56% as casual and 44% as regular and women 38% as casual and 62% as regular. Women were more likely to contact a higher proportion of regular partners than MSM or heterosexual men (P = 0.04).
Gender, sexual practice, level of education, employment status, number of recent sexual partners, and number of partners for which contact details were available were not associated with whether at least 1 partner was contacted. There was a difference in the proportion of individuals who notified at least 1 partner, by age: 16 to 24 years (90%), 25 to 34 years (85%), 35 to 44 years (72%), and 45 years and above (67%) (P = 0.05).
Table 3 outlines the main reasons and methods individuals used to tell their partners about their risk for chlamydia infection. Heterosexual men were more likely to inform their partners by telephone than MSM or women (65%, 49%, and 42%, respectively, P = 0.02).
The main reason cited for preferring face-to-face or telephone methods to inform a partner was that individuals felt that information of this nature needed to be relayed personally, particularly with a known or current partner. Informing partners by e-mail, text message (SMS), or letter was generally regarded as inappropriate and an impersonal means of informing a sexual partner unless contact details were not known, it was a casual or anonymous sexual partner, or there was concern or fear about a partner's reaction.
When informing their partners about their risk for chlamydia, only 5% (9/169) of individuals, who contacted at least 1 partner, reported that they experienced verbal (n = 8) or physical abuse (n = 1) as a result of informing their partner(s). Six men (4%) and 3 (2%) women reported abuse. Of the men, 1 (1%) identified as MSM and 5 (3%) as heterosexual. Overall, 50% of individuals described their experience of telling their partners as “better than expected,” 45% as “neither better nor worse” and only 5% as “worse than expected.” The main reasons individuals did not tell some or all of their partners are reported in Table 3. MSM and women were more likely not to have contacted a partner(s) out of embarrassment than heterosexual men (6%, 10%, and 0%, respectively, P = 0.03). MSM and heterosexual men were more likely not to have contacted a partner(s) due to a lack of contact details, than women (54%, 46%, and 15%, respectively, P < 0.001). No other significant associations regarding the notification of partners and methods used were found.
Antibiotics for Partners
Over half of all individuals (56%) indicated that they would have liked to have been given an additional dose of antibiotics (PDPT). The main reasons provided were because: it would have been more convenient for their partner (34%); it is more likely their partner would have been treated (18%); and it is more likely their partner would have been treated earlier (9%).
Partner Notification Resources
Individuals' opinions on the usefulness of resources are shown in Table 4. While only a minority of chlamydia infected individuals contacted partners using SMS or e-mail, half indicated (95/202, 47%) that they would have found a website that allowed them to send anonymous e-mails or SMS useful.
Of those individuals who had not informed all their sexual partners from the prior 6 months with known contact details (n = 94), 34% reported it likely they would have contacted more of their partners if resources such as web-based tools had been available. There was no significant difference between individual's age, gender, educational level, and employment status, and the likelihood that they would have contacted more partners if these resources were available. Heterosexual men were significantly less likely than MSM or women to report it likely they would use these resources if available (4% vs. 16% and 12%, respectively, P = 0.02).
In this survey of people recently diagnosed with chlamydia, most of whom who had just notified sexual partners of their infection, we were able to determine the motivation behind and experiences of partner notification for chlamydia. Overall, this was a group of sexually active men and women, reflecting their recruitment from sexual health services where higher risk clients are seen. Eighty-four percent of individuals contacted at least 1 sexual partner, however, overall less than a quarter of all partners were notified, with MSM or heterosexual men least likely to contact partners. Contact with partners was generally made soon after diagnosis or not at all. Most individuals were driven to notify their partners out of concern for them or because they felt that it was “right thing to do.” Few experienced negative reactions from their partners as a result.
In practice, only a minority used technologies such as e-mail and SMS to inform partners; however, if offered a website with anonymous e-mail and SMS services approximately half indicated they would find such a resource useful and a third reported that they would have contacted more partners had these services been available. Furthermore, over half of participants would like to have been given antibiotics to give to their partner with some indicating that with PDPT it would have been more likely that their partners were treated.
Strengths and Limitations
To our knowledge, this is one of the first studies to examine chlamydia infected individuals' views on possible supports to assist them with partner notification. Past studies have commonly examined patients' partner notification experiences and preferences, either hypothetically,19,20 as a past experience,21,22 or as a future intention,23 rather than as an actual recent experience. Studies have also commonly included patients diagnosed with any STI, centered mainly around adolescents, and/or primarily examined rates of partner notification and treatment, or factors associated with notification.10,16,19,21,24,25 Few studies have sought to obtain the views of individuals who have themselves recently undertaken partner notification for chlamydia about possible supports to assist them.
A limitation of our study is that individuals were only recruited from sexual health services and therefore may not be representative of the experiences or views of individuals diagnosed in other settings. It is possible that partner notification is less likely to be carried out to the same degree in primary care settings. In all of the study clinics, policies were in place where discussion of partner notification was routine for all patients diagnosed with chlamydia and where there was a high awareness of the importance of partner notification among staff. It is possible that in settings where partner notification is not dealt with as thoroughly, resources could be even more useful at enhancing notification of partners. Finally it would have been informative if we had asked individuals who reported it likely they would have contacted more partners if resources such as web-based tools had been available, which type of partners (casual or regular) they would have contacted using these methods.
Some studies suggest that more partners are likely to be treated if contacted by a health professional,26 however, limited resources often preclude provider referral. Past research has found that patient referral, a more realistic alternative, is preferred by both GPs and patients.27 In a survey of the STD practices and partner notification preferences of US physicians, physicians showed a preference for patient referral over provider referral or case reporting, with the majority of physicians indicating that they always asked their patients to contact their partner(s).28,29 Of those individuals who contact partners, contact is often made shortly after diagnosis or treatment.11,17 While index patients are more likely to contact their primary partners24,25 by personal means, that is, by telephone or face-to-face,10 the use of e-mail or SMS is considered acceptable in certain situations. In our study, while individuals reported a preference for contacting their partners personally, one-fifth had actually used their own telephone to SMS, or e-mail address to e-mail a partner. Half indicated that they would have found a website that allowed the sending of anonymous e-mails or SMS useful. Individuals commonly do not contact partners for certain reasons including: because they were a casual or anonymous partner; due to concern about partners reactions including rejection or violence; because of embarrassment; not perceiving a need to; or because they presume a partner is not the source of infection.10,19,23–25 New technologies such as e-mail and SMS, increasingly popular forms of communication, offer a less direct and confrontational means of notifying partners. Although not acceptable to all, past research has found new technologies to be preferred by a significant minority as an alternative means of partner notification.14
Online STI partner notification sites such as inSPOT (available at: http://www.inSPOT.org/) and Let Them Know (available at: http://www.letthemknow.org.au) provide notification advice and services to individuals diagnosed with STIs. InSPOT, the first online STI partner notification system, provides a service to meet the sexual health information and partner notification needs of MSM. A replication of the site is offered across a number of US cities and internationally, providing users with an electronic postcard (e-cards) service to notify partners of their STI risk.30–32 From 2004 to 2008, nearly 50,000 e-cards were sent to people from the site.30 Tailoring resources to anIN audience may be important given that gender, age, sexual orientation, and relationship type can all impact on the way in which, and reasons why, partner notification is undertaken.25 In our study, MSM, heterosexual men and women differed in their experiences of partner notification. Recent examination of online partner notification technologies has found broad acceptance among MSM for e-mail partner notification,33 and initial observations point to it being an effective partner notification tool.31,32
The use of PDPT as a strategy in reducing chlamydia transmission and reinfection in the Australian population also requires consideration. Although currently not supported by legislation, the use of PDPT is a reasonably common practice among Australian general practitioners.5–7 In this study, a considerable number of our individuals supported its use, many of whom felt it more likely their partner would have been treated if it was available. Combined with patient referral, PDPT has shown to be effective in improving the treatment of partners4 and requires further examination as a partner notification strategy in Australia.
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