Large and growing epidemics of syphilis now affect men who have sex with men (MSM) in high-income nations throughout the world, and, in at least some areas, rates of other sexually transmitted infections (STIs) are likewise increasing.1–9 Current approaches to partner notification and treatment among MSM fail to ensure the treatment of many potentially infected partners,10–12 and new and more effective means to increase partner treatment among MSM with STI are needed.
Two relatively new and potentially useful partner notification strategies have received substantial attention in the last decade: patient-delivered partner therapy (PDPT) and electronic postcards (e-cards). Patient-delivered partner therapy is the practice of giving patients diagnosed as having an STI medications or a prescription to deliver to their sex partners. It has been extensively studied and found to be effective among heterosexuals in randomized controlled trials.13–16 However, studies in MSM have been extremely limited. Most have focused on demonstrating that many MSM accept PDPT for their partners.17,18 The evidence related to e-cards is likewise quite limited. E-cards are electronic messages delivered via the Internet. The cards are sent via an Internet site, the best established of which is inSPOT (www.inspot.org). InSPOT was originally developed in 2004 for use by MSM diagnosed as having STI19 and has since expanded to serve heterosexuals.20 Studies evaluating inSPOT have demonstrated that many people visit the Internet site and send e-cards and that many MSM report that they would be willing to send such cards if they were diagnosed as having an STI.11,18,21,22 However, no studies to date have shown that Web-based partner notification increases partner notification or treatment, and in our small randomized controlled trial examining the use of PDPT and inSPOT among MSM with gonorrhea or chlamydia, MSM randomized to be offered inSPOT overwhelmingly chose not to use the site to notify their sex partners.23
To be effective, both PDPT and e-cards rely on sex partners to take action, to take medications provided as PDPT, and/or to seek a medical evaluation. To our knowledge, no studies have examined how sex partners respond to PDPT or e-cards. We carried out the current study to examine the acceptability of PDPT and inSPOT from the perspective of the sex partner and to gauge how receipt of PDPT or an e-card might affect the recipient’s intention to seek a medical evaluation or notify additional partners.
We recruited a convenience sample of MSM from the Public Health–Seattle and King County Sexually Transmitted Disease (STD) Clinic. The STD Clinic is the only STD clinic in King County, Washington and serves approximately 8000 patients per year, roughly a quarter of whom are MSM (Public Health–Seattle and King County. 2010 King County Sexually Transmitted Diseases Epidemiology Report, 2011, unpublished). Participants were recruited between September 21, 2009, and January 5, 2010. The survey instrument was self-administered, and men who could not read and write English were excluded. We were unable to track the number of MSM who refused to participate in the survey.
In the STD Clinic, patients were approached in the waiting room while waiting to be seen by a clinician. Men who have sex with men were identified via information from their medical chart or a registration form. Patients completed the survey in the waiting room and returned it to study staff. Participants received a $5 gift card for completing the survey.
The survey presented respondents with 4 hypothetical scenarios that varied in the type of sexual activity described (oral vs. anal), the HIV status of the partner, and the infection that participants were exposed to. The first 3 scenarios described oral or anal sex with a new partner, followed by notification by the partner that the participant had been exposed to an STI and an offer of PDPT from the partner (Table 1). A fourth scenario described partner notification via an inSPOT e-card and no PDPT; this scenario included a color picture of an inSPOT e-card. The 4 scenarios included the following combination of elements: (1) oral sex, a partner with unknown HIV status, exposure to gonorrhea; (2) unprotected insertive anal intercourse (UIAI), an HIV-negative partner, exposure to chlamydial infection; (3) UIAI, a partner with unknown HIV status, exposure to gonorrhea; and (4) mostly oral sex with 3 partners in the past 2 to 3 months, exposure to gonorrhea.
Questions about each situation were asked in the context both being asymptomatic and experiencing symptoms. For example, after the first scenario (which described an oral sexual encounter), participants were asked, “If you had no symptoms, would you see a doctor?” and “If you had a sore throat, would you see a doctor?” (Table 1). For the 2 scenarios detailing anal exposure, symptoms were described as “discomfort or discharge from your butt.” After each scenario, participants were asked if they would see a doctor, seek testing for HIV and syphilis, and notify their sex partners of exposure to an STD. Scenarios describing an offer of PDPT from a partner also included questions about taking the medication enclosed in a PDPT packet, both in the presence and in the absence of symptoms; the survey included a color picture of a PDPT packet widely used in Washington state. The survey additionally included questions that directly asked respondents if they would seek testing if notified by a partner directly, via a signed e-card or via an anonymous e-card (e.g., “If you received an anonymous email card [like above] saying that you might have been exposed to gonorrhea or Chlamydia by a sex partner, would you go to get tested? The card would have information about STDs and would give you information about where to go for medical care.”), and whether they would be more or less likely to seek testing if they received PDPT, or if receiving PDPT would have no effect on their likelihood of seeking care. Last, the study instrument asked participants about their STD history, their preferred method for partner notification, whether a partner had ever notified them of an STD exposure, whether they sought treatment when notified, and whether they tested for HIV infection when receiving care after being notified.
We carried out descriptive analyses of participants’ intentions to seek medical care and to use the PDPT medications for each scenario. We compared responses across survey questions using the McNemar test. We used χ2 tests and the Fisher exact test to compare responses to the same questions across groups (i.e., men who reported they would use PDPT vs. those who would not). In scenarios that included an offer of PDPT, we specifically examined whether those who said they would take the medication would be more or less likely to seek a medical evaluation. Responses to questions regarding the 2 scenarios, including UIAI and an offer of PDPT from the partner (the second and third scenarios described previously), were virtually identical, and thus, we present results for only the second scenario. In analyses of questions regarding testing for HIV, participants who reported that they were HIV infected were excluded. We stratified results both by having a history of STD and by being a previous contact to an STD. There were no differences by either characteristic, and therefore, we present overall results (data not shown). Study procedures were approved by the University of Washington institutional review board.
Of 185 MSM who completed the survey, we excluded data from 3 (1.6%) because of incomplete data, leaving a total sample of 182 MSM. Of these, 102 (56.0%) had ever been diagnosed as having an STI and 90 (49.0%) had previously been a contact to a bacterial STI (Table 2). Nineteen (10.9%) participants reported being HIV infected, 30 (16.7%) did not know their HIV status, and the remaining 131 (72.8%) reported that they were HIV uninfected.
Intention to Seek Medical Evaluation
When presented with 4 hypothetical situations and asked if they would seek a medical evaluation, participant responses varied based on the method of notification and whether or not participants were told that they had symptoms. In the absence of symptoms, fewer participants indicated that they would seek care if notified via an anonymous e-card than if notified by a partner (64% vs. 84% [scenario 1; P < 0.0001] and 64% vs. 89% [scenario 2; P < 0.0001]; Fig. 1). When questions described rectal symptoms, almost all (scenarios 2 and 4: 98%) participants said that they would seek an evaluation, regardless of the type of notification (Fig. 1); fewer men indicated that they would seek evaluation if their only symptom was a sore throat (82%).
Similarly, when we asked participants if they would seek an HIV test after being notified by a partner (scenarios 1 and 2) and by anonymous e-card (scenario 4), 86% of HIV-uninfected participants said that they would seek HIV testing if notified by a partner, but only 78% said that they would seek testing if notified anonymously via an e-card (P < 0.0001 for direct notification [scenarios 1 and 2] methods vs. anonymous e-card comparisons [scenario 4]). HIV-uninfected men also indicated that they would test for HIV sooner than they would otherwise test if notified directly by a partner than if notified via an anonymous e-mail (90% vs. 70%, P < 0.0001 for direct notification methods [scenarios 1 and 2] vs. anonymous e-card [scenario 4] comparisons).
Study participants’ responses to direct questions related to how they might respond to various approaches to partner notification (i.e., not related to the four scenarios) were largely consistent with their responses to questions that described partner notification scenarios. When asked directly if they would get tested for STDs after notification of a possible exposure, 95% and 94% of participants indicated that they would seek testing if notified via a signed e-mail or e-card, respectively, compared with 77% if the method of notification was an anonymous e-card (P < 0.0001 for both signed e-card and signed e-card vs. anonymous e-card; Fig. 2). In response to a question asking participants if they would be more or less likely to seek care after notification through a signed e-mail compared with an anonymous e-card, 48% responded that they would be more likely to seek care if they received a signed e-mail, 40% reported that the type of communication they received from a partner did not matter, and the remaining 12% responded that they would be more likely to see a clinician if they received an anonymous e-card. When an anonymous e-card was compared with a telephone call from a partner, 56% responded that they would be more likely to see a provider if they received a telephone call, whereas 33% and 11% reported that the type of communication would not affect their decision to seek care and that they would be more likely to seek care if they received an e-card, respectively.
Intention to Notify Sex Partners
For each of the 4 hypothetical situations, participants were asked if they would notify their sex partners after being notified themselves. Study participants more frequently indicated that they would notify additional partners if they were directly notified by a sex partner than if they were notified via an anonymous e-card (85% would notify partners in response to scenarios 1 and 2, vs. scenario 4, vs. 69%; P < 0.0001 both comparisons).
Partner Responses to PDPT
In response to the 3 situations describing a partner offering the participant PDPT, approximately half of participants said that they would take the medication offered to them. The presence of sore throat after an oral sexual exposure was not associated with reporting a higher intention to take medication provided through PDPT (P = 0.48; Fig. 3). However, more men reported that they would take medication provided through PDPT if they had rectal symptoms than if they were asymptomatic after an anal exposure (P = 0.0003). To evaluate whether PDPT use would influence participant intentions to see a medical provider, we stratified intention to seek a medical evaluation by willingness to use the PDPT medications offered by a sex partner. Most men reported that they would seek medical evaluation even if they took medication provided as PDPT. However, except among men with symptoms, virtually all of whom reported that they would seek a medical evaluation, participants who said that they would take the PDPT medications were less likely to say that they would seek a medical evaluation (Fig. 4) than those who would not use PDPT offered by a partner, although for scenario 2, which described UIAI, the association was of borderline statistical significance (Fig. 4).
When asked directly whether participants believed that they would be more or less likely to be treated for an STD if given medication by a partner than if they had to go to a medical provider for treatment, 39% responded that they would be more likely, 13% less likely, and 48% no more or less likely to be treated if given medication by a partner. Similar proportions reported that they would be more (40%), less (11%), or no more or less likely (50%) to be tested for HIV or syphilis after being given medication by a partner.
Preferences for Notifying Partners
The study instrument asked participants how they would prefer to notify partners if they themselves were diagnosed as having an STD. When inSPOT was described and participants asked specifically if they would use it to notify partners, 56% stated that they would. Similarly, when asked whether they would be more or less likely to notify partners if they had a way to e-mail partners anonymously, 45% responded that they would be more likely to notify partners if they had that option; 43% stated that having the option to e-mail partners anonymously would not affect their decision to notify partners. However, when we listed several options for contacting partners and asked participants how they would be most likely to notify partners of an STD exposure (participants could choose multiple options), only 39% reported that they would use an e-card. Participants most frequently said that they would choose to notify partners via a telephone conversation (62%), in person (53%), or through an e-mail (45%). Given recent interest in using text messaging to notify partners, we also asked about notifying partners through a text; 33% responded that they would text a partner to notify him.
Our study findings suggest how anonymous e-cards and PDPT might have both positive and negative effects on HIV/STD transmission. On the positive side, we found that 39% of MSM were interested in using anonymous e-cards to notify partners and that 45% of men felt that the option of using such cards would make them more likely to notify their partners. Approximately half of men indicated that they would take medication given to them by a partner who notified them of an STD exposure, and 39% thought that receiving PDPT would make it more likely that they would be treated. On the other hand, men indicated that they would be less likely to seek care, including HIV/STD testing, and less likely to notify their partners if they received an anonymous e-card than if they were notified via another mechanism. Similarly, men who reported that they would take medication provided to them as PDPT indicated that they would be less likely to seek care and HIV/STD testing.
Previous studies have found that MSM with bacterial STD notify a smaller proportion of their sex partners than do heterosexuals.24 Partners of MSM are also less likely to be tested for STIs to which they are exposed than partners of heterosexuals.12 Men who have sex with men may have more anonymous partners that they are unable to contact25,26 and also be less willing to provide contact information for their contactable sex partners to the health department for purposes of HIV partner notification compared with heterosexuals.27 Internet partner notification web sites were developed under the assumption that providing MSM with a means of anonymously notifying partners would increase partner notification in this population. Our findings agree with those of several prior surveys that have found that many MSM are interested in using e-cards to notify partners.21,28,29 However, the extent to which this hypothetical interest translates into actual use of such sites is uncertain. In a previous study in which we randomized MSM diagnosed as having gonorrhea or chlamydial infection to inSPOT or other partner notification strategies, only 1 of 27 men randomized to inSPOT used it to notify a partner.23 Thus, the actual practice of using an Internet-based partner notification method may vary widely from intentions expressed in surveys. In addition, in the current study, most men reported that they would prefer to notify their partners in person or by telephone, similar to results reported in several other studies among both MSM and heterosexuals.11,21,29–31
We believe that our findings support concerns that PDPT and anonymous e-cards could decrease HIV and syphilis testing among MSM, although the adverse effect associated with the interventions, at least measured in this study using hypothetical scenarios, is only moderate in size. Men who have sex with men who are contacts to STIs have a high prevalence of concurrent HIV infection. Stekler et al.32 found that among MSM attending 4 US STD clinics as contacts to an STI, 6.3% of those tested were newly diagnosed as having HIV; similar findings have been reported by McNulty and colleagues33 in Australia. As such, the cost of missed opportunities for HIV and syphilis testing among MSM contacts to STD may outweigh any benefit associated with the use of PDPT or inSPOT among MSM with STD.
Our study was small, and most of the participants were MSM recruited in the waiting room of our local STD clinic. Although other studies examining the acceptability of inSPOT and PDPT among MSM have used a general sample of MSM, many of whom were recruited online, our study may be more representative of MSM with STD and therefore more appropriate for this topic of study. That being said, our population probably cannot be generalized to all MSM with STD. An additional concern is that our subjects were all seeking care in a clinic, and as such, the results may not reflect the intentions of MSM who are disinclined to seek care from medical providers, a group that may particularly benefit from interventions such as PDPT. A further limitation of the study is that we did not ask participants about their intentions regarding seeking a medical evaluation or using PDPT if they were notified of an STD exposure by a regular partner. Patients may be more likely to accept PDPT or seek a medical evaluation if notified by regular partner; as such, our results regarding the proportion of MSM who would use PDPT or seek a medical evaluation may be somewhat conservative. However, this issue would not affect our findings regarding the limitations of anonymous notifications through e-cards or e-mails.
In conclusion, we believe that our findings support current Centers for Disease Control and Prevention guidelines that recommend against the routine use of PDPT in MSM exposed to gonorrhea or chlamydial infection.34 How e-cards might affect HIV/STD transmission among MSM remains uncertain. Our study suggests that anonymous e-cards may be less effective than other means of notifying partners of an STD exposure. As a result, we believe that such e-cards should be regarded as a last-choice partner notification method. Internet sites that send e-cards should urge users to send cards that identify the sender and that facilitate communication between partners.
1. Branger J, van der Meer JT, van Ketel RJ, et al.. High incidence of asymptomatic syphilis in HIV-infected MSM justifies routine screening. Sex Transm Dis 2009; 36: 84–85.
2. D’Souza G, Lee JH, Paffel JM. Outbreak of syphilis among men who have sex with men in Houston, Texas. Sex Transm Dis 2003; 30: 872–873.
3. Fenton KA, Imrie J. Increasing rates of sexually transmitted diseases in homosexual men in Western Europe and the United States: Why? Infect Dis Clin North Am 2005; 19: 311–331.
4. Kahn RH, Heffelfinger JD, Berman SM. Syphilis outbreaks among men who have sex with men: A public health trend of concern. Sex Transm Dis 2002; 29: 285–287.
5. Kerani RP, Handsfield HH, Stenger MS, et al.. Rising rates of syphilis in the era of syphilis elimination. Sex Transm Dis 2007; 34: 154–161.
6. Lee DM, Chen MY. The re-emergence of syphilis among homosexually active men in Melbourne. Aust N Z J Public Health 2005; 29: 390–391.
7. Muldoon E, Mulcahy F. Syphilis resurgence in Dublin, Ireland. Int J STD AIDS 2011; 22: 493–497.
8. Wang K, Yan H, Liu Y, et al.. Increasing prevalence of HIV and syphilis but decreasing rate of self-reported unprotected anal intercourse among men who had sex with men in Harbin, China: Results of five consecutive surveys from 2006 to 2010. Int J Epidemiol 2012; 41: 423–432.
9. Center for Disease Control and Prevention. Trends in primary and secondary syphilis and HIV infections in men who have sex with men—San Francisco and Los Angeles, California, 1998–2002. MMWR Morb Mortal Wkly Rep 2004; 53: 575–578.
10. Hogben M, Paffel J, Broussard D, et al.. Syphilis partner notification with men who have sex with men: A review and commentary. Sex Transm Dis 2005; 32 (10 suppl): S43–S47.
11. Bilardi JE, Fairley CK, Hopkins CA, et al.. Experiences and outcomes of partner notification among men and women recently diagnosed with chlamydia and their views on innovative resources aimed at improving notification rates. Sex Transm Dis 2010; 37: 253–258.
12. Herzog SA, McClean H, Carne CA, et al.. Variation in partner notification outcomes for chlamydia in UK genitourinary medicine clinics: Multilevel study. Sex Transm Infect 2011; 87: 420–425.
13. Golden MR, Whittington WL, 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.
14. Kissinger P, Mohammed H, Richardson-Alston G, et al.. Patient-delivered partner treatment for male urethritis: A randomized, controlled trial. Clin Infect Dis 2005; 41: 623–629.
15. Kissinger P, Schmidt N, Mohammed H, et al.. Patient-delivered partner treatment for Trichomonas vaginalis infection: A randomized controlled trial. Sex Transm Dis 2006; 33: 445–450.
16. 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.
17. Stephens SC, Bernstein KT, Katz MH, et al.. The effectiveness of patient-delivered partner therapy and chlamydial and gonococcal reinfection in San Francisco. Sex Transm Dis 2010; 37: 525–529.
18. Coyne KM, Cohen CE, Smith NA, et al.. Patient-delivered partner medication in the UK: An unlawful but popular choice. Int J STD AIDS 2007; 18: 829–831.
19. Klausner JD, Kent CK, Wong W, et al.. The public health response to epidemic syphilis, San Francisco, 1999–2004. Sex Transm Dis 2005; 32 (10 suppl): S11–S18.
20. Levine D, Woodruff AJ, Mocello AR, et al.. inSPOT: The first online STD partner notification system using electronic postcards. PLoS Med 2008; 5: e213.
21. Kachur R, McFarlane M, Smith A, et al. Use of electronic partner notification services among online U.S. men who have sex with men. International Society for Sexually Transmitted Diseases; June 28–July 1, 2009; London. 2009.
22. Mimiaga MJ, Tetu AM, Gortmaker S, et al.. HIV and STD status among MSM and attitudes about Internet partner notification for STD exposure. Sex Transm Dis 2008; 35: 111–116.
23. Kerani RP, Fleming M, DeYoung B, et al.. A randomized, controlled trial of inSPOT and patient-delivered partner therapy for gonorrhea and chlamydial infection among men who have sex with men. Sex Transm Dis 2011; 38: 941–946.
24. Bilardi JE, Fairley CK, Hopkins CA, et al.. Experiences and outcomes of partner notification among men and women recently diagnosed with chlamydia and their views on innovative resources aimed at improving notification rates. Sex Transm Dis 2010; 37: 253–258.
25. Menza TW, De Lore JS, Fleming M, et al.. Partner notification for gonococcal and chlamydial infections in men who have sex with men: Success is underestimated by traditional disposition codes. Sex Transm Dis 2008; 35: 84–90.
26. Tomnay JE, Pitts MK, Fairley CK. Partner notification: Preferences of Melbourne clients and the estimated proportion of sexual partners they can contact. Int J STD AIDS 2004; 15: 415–418.
27. Carballo-Dieguez A, Remien R, Benson DA, et al.. Intention to notify sexual partners about potential HIV exposure among New York city STD clinics’ clients. Sex Transm Dis 2002; 29: 465–471.
28. Mimiaga MJ, Fair AD, Tetu AM, et al.. Acceptability of an Internet-based partner notification system for sexually transmitted infection exposure among men who have sex with men. Am J Public Health 2008; 98: 1009–1011.
29. Mimiaga MJ, Reisner SL, Tetu AM, et al.. Partner notification after STD and HIV exposures and infections: Knowledge, attitudes, and experiences of Massachusetts men who have sex with men. Public Health Rep 2009; 124: 111–119.
30. Tomnay JE, Pitts MK, Kuo TC, et al.. Does the Internet assist clients to carry out contact tracing? A randomized controlled trial using Web-based information. Int J STD AIDS 2006; 17: 391–394.
31. Rietmeijer CA, Westergaard B, Mickiewicz TA, et al.. Evaluation of an online partner notification program. Sex Transm Dis 2011; 38: 359–364.
32. Stekler J, Bachmann L, Brotman RM, et al.. Concurrent sexually transmitted infections (STIs) in sex partners of patients with selected STIs: Implications for patient-delivered partner therapy. Clin Infect Dis 2005; 40: 787–793.
33. McNulty A, Teh MF, Freedman E. Patient delivered partner therapy for chlamydial infection—What would be missed? Sex Transm Dis 2008; 35: 834–836.
34. Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases, Atlanta, GA: US Department of Health and Human Services, 2006.