Sexually Transmitted Diseases:
Notification for Sexually Transmitted Infections and HIV Among Sex Workers in Guatemala: Acceptability, Barriers, and Preferences
Sabidó, Meritxell MD, MPH, PhD*,†,‡; Gregg, Lucile Parker BA§; Vallès, Xavier MD, PhD‡,¶; Nikiforov, Mikhail BStat*,‡; Monzón, Jose Ernesto MD‖; Pedroza, Maria Isabel MD**; Vermund, Sten H. MD, PhD§; Casabona, Jordi MD, MPH, PhD†,‡,¶
From the *Fundació Sida i Societat, Barcelona, Catalonia, Spain; †Department of Paediatrics, Obstetrics and Gynaecology, and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; ‡CIBER Epidemiología y Salud Pública, (CIBERESP), Barcelona, Spain; §Institute for Global Health, Vanderbilt University School of Medicine, Nashville, TN; ¶Centre for Epidemiological Studies on HIV/AIDS and STI of Catalonia (CEEISCAT), Institut Català d'Oncologia/Health Department, Generalitat de Catalunya, Badalona, Catalonia, Spain; ‖Fundació Sida i Societat, Escuintla, Guatemala; and **Health District of Escuintla, Ministry of Health, Escuintla, Guatemala
The authors thank the personnel of the UALE project for their support and assistance throughout the study, as well as the participants for their time. They also thank the following organizations for their cooperation: the Primary Health Care Centers, the District Health Department of Escuintla, and the National Program on Prevention and Control of Sexually Transmitted Infections and HIV/AIDS of Guatemala.
Supported by the Emphasis Program of the Office of the Dean, Vanderbilt University School of Medicine, the Tinker Foundation, and the Catalan Agency of Cooperation for Development.
Correspondence: Meritxell Sabidó, MD, MPH, PhD, Fundació Sida i Societat, Ribes 91, baixos, 08013 Barcelona, Spain. E-mail: email@example.com.
Received for publication May 17, 2011, and accepted February 7, 2012.
Partner notification for HIV and other sexually transmitted infections is acceptable and feasible among female sex workers attending sexually transmitted infection clinics in Guatemala, especially for regular partners. Intention to refer the sexual partner was best predicted by attitude followed by social norms and baby's protection. Women preferred notification via patient-based referral.
Different types of partner notification systems for sexually transmitted infections (STIs) and HIV have been implemented based on available infrastructures and local preferences.1 Although in previous studies, patients have preferred to notify partners themselves (patient referral),2,3 more partners are more likely to be treated if a health professional contacts them (provider referral).4
Evidence from developing countries shows that although most of the index patients (58%–93%) are willing to notify their sexual partners,5,6 more than half fail to refer them.7 Women face many difficulties in notifying partners, including embarrassment, the stigma surrounding HIV/STIs,8,9 denial that “nice” partners are at risk, and expectation of harm from doing so, such as domestic violence or abandonment.7,10,11 Female sex workers (FSWs) might present particular barriers to partner notification such as fear of loss of job or legal consequences. FSWs often lack contact information for clients and might be less motivated to notify them.
In the province of Escuintla, in southern Guatemala, the interplay of high rates of sex work, male migrant workers drawn by the sugarcane harvest, truck drivers traveling on the Pan-American road, and migrants from Central America to Mexico and the United States are likely drivers of one of the highest HIV prevalence rates in the country.12 FSWs in Escuintla present a prevalence of HIV and syphilis as high as 6.3% and 3.9%, respectively.13 Most of them are highly mobile, have low literacy, and have a large number of sexual partners.14 Within this context, we conducted a study with the aim of identifying Guatemalan FSWs' preferences for notification of sexual contacts, their intention to notify, and barriers and facilitators to partner referral.
FSWs attending 3 STI clinics of Escuintla were interviewed if they were at least 18 years old, verbally consented, and presented a clinical diagnoses of genital herpes or warts or a laboratory diagnosis of Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, syphilis, or HIV according to standard microbiologic procedures.14 A regular partner and an occasional partner were defined as a husband/boyfriend/steady partner and as someone with whom she had sporadic sexual intercourse without exchange of money or other form of payment, respectively. A client was defined as someone paying for sex. A regular client was defined as someone who had repeated encounters with a given FSW and might be considered special.
Intentions of partner referral by partner type were collected by asking how likely FSWs were to refer their current regular or occasional partner and their last client to the clinic within the next month. Responses were recorded as very likely, likely, unlikely, and very unlikely and analyzed in terms of very likely/likely or unlikely/very unlikely. Data on intentions to refer a partner were collected following the Attitude-Social Influence-Self Efficacy model.15 According to the Attitude-Social Influence-Self Efficacy model, the referral of one's sexual partner is best predicted by intention, which in turn is influenced by psychological variables, such as one's potential for self-efficacy, perception of local social norms, and beliefs about the benefits and disadvantages of notifying their partners. External variables, such as sociodemographic or sexual behavior, preceded the psychological questions in the interview. Various methods of partner notification were rated, and data were collected on FSWs' ability to receive private mail and on whether they had their own phone.
Data were analyzed using STATA 10.0 (College Station, TX, 2009). To determine factors associated with last client referral intention, we performed univariate analysis and those factors that showed statistical association (P ≤ 0.05) with the outcome were entered in a backward-fitted multivariate regression model. The study was approved by the Vanderbilt University Institutional Review Board and by the directors of the 3 STI clinics in Guatemala.
We approached and interviewed 116 FSWs with a laboratory diagnosis of an STI, including HIV. An additional 465 women were screened and excluded, 460 because they did not have an STI and 5 because they were <18 years of age. Their median age was 24.5 years (interquartile range: 20–30.5), and most (67.2%) came from Guatemala. Illiterate FSWs comprised 19.8%, whereas 50.0% had begun or completed primary school. Only 17.8% were married or cohabitating, and most (93.0%) ethnically self-identified as Ladina (mestizos). Median monthly income was US$400 (interquartile range: 196–555). Overall, 36.2% had a regular partner, 10.4% an occasional partner, and 59.9% a regular client.
The majority of women (81.8%) were asymptomatic, and 7.8% were pregnant. Twenty-one FSWs (18.1%) reported at least 1 lifetime STI episode. Of those, 57.1% received counseling on the importance of referring their partners for treatment, and 33.3% had referred a partner to the clinic. From queries about stigma perception from their current STI, most women believed that people would avoid them (62.1%), would feel uncomfortable with them (58.6%), would think that they were not clean (57.8%), or would think badly of them (67.2%).
Within the next month, almost all of the women (97.6%) had the intention to refer their regular partners to the clinic, 83.3% their occasional partners and 62.6% their last client (Table 1). Intention was slightly higher for regular clients (65.0%) than for new ones (61.3%). In the multivariate model (Table 2), the factors that remained associated with the intention to refer their last client were a positive attitude toward referring them to the clinic within the next month (P < 0.001), perceiving that people the FSWs respected would think it important to convince the last client to attend the clinic (P = 0.02), and believing that partner notification prevents the infection being transmitted to the fetus/baby if the FSWs were pregnant (P = 0.04).
Respondents who could receive private mail (64.7%) or that had their own phones (63.8%) were more likely to consider these methods to be good for partner notification (Table 3). For each partner notification method, the preferred message was to inform the partner(s) that they need to contact the clinic.
We found that a partner notification intervention is acceptable and feasible among FSWs in Guatemala, especially for regular partners. Given that condom use is low with regular partners,14 regular partners are a target group for HIV/STI prevention efforts. A principal strength of our study was the excellent rapport of our research staff with our FSW population, nested within popular STI clinics known for treating FSWs with respect. This likely improved the validity of our data and is essential to investigate sensitive topics such as potential harms derived from notification. Research in other settings has also shown that women are more likely to refer steady partners than occasional partners or clients.16–19 FSWs might acknowledge a sense of responsibility to tell those partners with whom they have stronger emotional ties or have formed long-standing relationships,20 as well as perceive the need to be honest with them.16 Partner notification for clients has some specific challenges, which are contextually different compared with noncommercial partners, including less motivation to refer those clients and limited contact information to allow further communication.21
Intention to refer sexual partners was best predicted by attitude followed by social norms, which agrees with previous studies.22,23 Gender inequity and economic vulnerability of FSWs hinders their ability to take the initiative in sexual matters and to influence their partners' behaviors. Therefore, it is expected that social norms have a strong impact on FSWs.22 An important motivation to notify was the concern about infection risk to their fetus or baby. In a study among women treated for maternal syphilis in urban Bolivia, many participants prioritized preventing reinfection and having a healthy baby over protecting themselves from a negative reaction from their partner.24 The perceived benefit of preserving the health of offspring could be an educational opportunity to improve notification through counseling. Fear of stigma was mentioned by most of the women but was not identified as barrier to intend to refer partners. In other studies, stigma was an important element that influenced partner notification.8,9,19,25 Perceptions of the partners' likely reactions and self-efficacy were not important in deciding whether to notify, contrary to findings from other studies.16–19,23 However, FSWs often experience violence from sexual partners,26 and this potential barrier to self-efficacy should be further investigated before implementing partner referral in this population.
The most favored method of partner referral was self-notification (patient referral), similar to a study in genitourinary clinics in the United Kingdom.2 Patient-based referral systems allow index patients to control the conditions under which they notify their partners.27 Consistent with the same UK study,2 more of our FSW patients thought that self-notification (i.e., asking partners to contact the clinic) was a “good” method of partner referral. However, in a study conducted among patients attending a herpes clinic in London suggested that asking partners to go to the clinic was not the most frequent strategy used in telling partners about infection.16 The content of the counseling or wording of the text/letter of a provider referral system has an influence on the acceptability of the method and may affect the success of the partner notification method. Many, but not all, women could receive private mail and/or had phones, which correlated with the acceptability of that method of communication for partner notification. However, the use of these modes of communication raises issues about confidentiality and anonymity among women who live in brothels.28
The study has several limitations. We regret not having collected data on whether subjects a priori considered their partners to be contactable and on actual partner referral of FSW under this study. We acknowledge, too, that positive intention to refer partner might not be a good proxy for referral behavior.7 We included HIV-positive women, although HIV and STIs substantially differ in disease patterns and availability of treatment.4 In addition, subjects might be more reluctant to disclose their HIV status to sex partner because of fear of harmful effects. Finally, the study size was small thus limiting some statistical inferences to be sufficiently valid.
Considering the high intention to notify partners, in particular regular partners, and the positive attitudes toward notification, STI/HIV prevention programs should integrate partner notification as an essential component, and health staff should consistently assist index patients in notification. However, we lack evidence on partner notification from the partners' perspective. Studies on how partners and regular clients of FSWs feel about being notified and whether it would be acceptable to receive this information from FSWs would help in designing and integrating a partner notification system best suited to this population. Patient-led partner notification might increase the acceptability and use of notification among vulnerable women in Guatemala. However, STI/HIV services can best serve their patients by offering several approaches to inform different kinds of partners.
2. Apoola A, Radcliffe KW, Das S, et al.. Patient preferences for partner notification. Sex Transm Infect 2006; 82:327–329.
3. Sahasrabuddhe VV, Gholap TA, Jethava YS, et al.. Patient-led partner referral in a district hospital based STD clinic. J Postgrad Med 2002; 48:105–108.
4. Mathews C, Coetzee N, Zwarenstein M, et al.. Strategies for partner notification for sexually transmitted diseases. Cochrane Database Syst Rev 2001:CD002843.
5. Nuwaha F, Kambugu F, Nsubuga PS, et al.. Efficacy of patient-delivered partner medication in the treatment of sexual partners in Uganda. Sex Transm Dis 2001; 28:105–110.
6. Steen R, Soliman C, Bucyana S, et al.. Partner referral as a component of integrated sexually transmitted disease services in two Rwandan towns. Genitourin Med 1996; 72:56–59.
7. Alam N, Streatfield PK, Khan SI, et al.. Factors associated with partner referral among patients with sexually transmitted infections in Bangladesh. Soc Sci Med 2010; 71:1921–1926.
8. Cunningham SD, Tschann J, Gurvey JE, et al.. Attitudes about sexual disclosure and perceptions of stigma and shame. Sex Transm Infect 2002; 78:334–338.
9. Fortenberry JD, McFarlane M, Bleakley A, et al.. Relationships of stigma and shame to gonorrhea and HIV screening. Am J Public Health 2002; 92:378–381.
10. Potterat JJ. Partner referral tools and techniques for the clinician diagnosing a sexually transmitted infection. Int J STD AIDS 2007; 18:293–296.
11. Cunningham SD, Meyers T, Kerrigan D, et al.. Psychosocial factors influencing the disclosure of sexually transmissible infection diagnoses among female adolescents. Sex Health 2007; 4:45–50.
13. Lahuerta M, Sabido M, Giardina F, et al.. Comparison of users of an HIV/syphilis screening community-based mobile van and traditional voluntary counselling and testing sites in Guatemala. Sex Transm Infect 2011; 87:136–140.
14. Sabido M, Giardina F, Hernandez G, et al.. The UALE Project: Decline in the incidence of HIV and sexually transmitted infections and increase in the use of condoms among sex workers in Guatemala. J Acquir Immun Defic Syndr 2009; 51(suppl 1):S35–S41.
15. De Vries H, Mudde AN, Dijkstra A, et al.. Differential beliefs, perceived social influences, and self-efficacy expectations among smokers in various motivational phases. Prev Med 1998; 27:681–689.
16. Green J, Ferrier S, Kocsis A, et al.. Determinants of disclosure of genital herpes to partners. Sex Transm Infect 2003; 79:42–44.
17. 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.
18. Passin WF, Kim AS, Hutchinson AB, et al.; Team HAPRSP. A systematic review of HIV partner counseling and referral services: Client and provider attitudes, preferences, practices, and experiences. Sex Transm Dis 2006; 33:320–328.
19. 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.
20. Temple-Smith M, Hopkins C, Fairley C, et al.. The right thing to do: patients' views and experiences of telling partners about chlamydia. Fam Pract 2010; 27:418–423.
21. Macke BA, Maher JE. Partner notification in the United States: An evidence-based review. Am J Prev Med 1999; 17:230–242.
22. Alam N, Chamot E, Vermund SH, et al.. Partner notification for sexually transmitted infections in developing countries: A systematic review. BMC Public Health 2010; 10:19.
23. Nuwaha F, Faxelid E, Wabwire-Mangen F, et al.. Psycho-social determinants for sexual partner referral in Uganda: Quantitative results. Soc Sci Med 2001; 53:1287–1301.
24. Klisch SA, Mamary E, Diaz Olavarrieta C, et al.. Patient-led partner notification for syphilis: Strategies used by women accessing antenatal care in urban Bolivia. Soc Sci Med 2007; 65:1124–1135.
25. Clark JL, Long CM, Giron JM, et al.. Partner notification for sexually transmitted diseases in Peru: Knowledge, attitudes, and practices in a high-risk community. Sex Transm Dis 2007; 34:309–313.
26. Decker MR, Mack KP, Barrows JJ, et al.. Sex trafficking, violence victimization, and condom use among prostituted women in Nicaragua. Int J Gynaecol Obstet 2009; 107:151–152.
27. Hawkes S, Mabey D, Mayaud P. Partner notification for the control of sexually transmitted infections. BMJ 2003; 327:633–634.
28. Tomnay JE, Gebert RL, Fairley CK. A survey of partner notification practices among general practitioners and their use of an internet resource for partner notification for Chlamydia trachomatis
. Sex Health 2006; 3:217–220.
© Copyright 2012 American Sexually Transmitted Diseases Association