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.
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