The Real World of STD Prevention
The use of partner services for the control of sexually transmitted infections and HIV has been widespread since 1936, when the Public Health Service first recommended that sex contacts of those infected with syphilis be found, notified, and interviewed for their own protection.1 Since that time, partner services have become the standard of care and primary method of control efforts used by local Public Health Services regarding syphilis and HIV.2,3 Typically, the process of partner services involves disease interventionist specialists who query newly infected clients about their sex or drug using contacts and then locate those contacts in the field to inform them that they have been exposed. In fact, modeling suggests that this approach could be effective in reducing transmission4 and it may be cost-effective compared with other public health department control efforts.5,6 For these reasons, the approach has been adopted in several other international settings.7,8
Digital communication technologies such as cell phones and the Internet have rapidly become ubiquitous. In 2009, nearly 80% of American homes reported having at least 1 cell phone and 74% of Americans reported use of the Internet.9,10 That such technologies have begun to replace traditional communication technologies is evident by the rapidly increasing number of homes with only a cell phone (no landline), which grew from 7.3% in 2005 (January to June) to 20.2% in 2008 (July to December).9 These patterns are also evident in historically technology poor communities such as the south side of Chicago.11 Despite these advances, concomitant innovations in public health that use such technology to curb the spread of disease have traditionally lagged behind. This is even more obvious in the context of partner services where Internet and text approaches to identifying and contacting risk network members would be an obvious strategy to reaching individuals who often use the same digital communication strategies for finding sex partners.12 Using the Internet for partner notification has previously been described,13,14 and the Centers for Disease and Control Prevention issued general recommendations for using the Internet to notify partners in 2009.2 Although text message approaches have been used domestically for several HIV treatment interventions,15,16 to date there has been little in the way of text message engagement around partner notification.17
Hightow-Weidman et al. present data on a North Carolina experience using Internet and text messaging to enhance partner services.18 The team described the addition of a field coordinator at the University of North Carolina in 2011 and the number of contact cases initiated and their outcomes related to Internet partner services (IPN) and text messaging partner services for 12 months. Internet partner service involves the sending of e-mails in contrast to text messaging partner services, which involves the sending of text messages. They compared these results to an equivalent period in 2010. The authors found that the numbers of IPN contacts initiated after 2011 was higher than those in 2010. This is not surprising given that more Internet partner contacts were elicited by disease interventionist specialist officers in 2011 compared with 2010, and the addition of a new staff member at the University of North Carolina represents additional human resources dedicated to partner services. The authors did not present data on how many distinct Web sites and apps were used before and after the change in staffing. Because it is unlikely that increased Internet and app use occurred for 12 months, the tripling of IPN elicitation is notable. The increase is likely due to the new staff at the University of North Carolina, but indirect effects such as public health department staff changing their work practices cannot be excluded. Texting partners was then added to the IPN strategy to reach individuals who did not respond to IPN: nearly 50% responded to this modality. This improvement in case contact is likely due to the differential use of e-mail accounts, many of which are used infrequently, as well as changing aliases and uncertain Internet alias longevity patterns. Future work should examine the longevity of cell phone numbers, and our ability to keep these active may help with future partner notification services. From the data presented, we also do not know how texting fits within the greater partner services strategy for the Department of Public Health and why texting partner was not used for other non–Internet-related cases.
Despite some of the limitations in program evaluation, Hightow-Weidman et al. demonstrated 2 very important public health strategies that, if implemented on a wider scale, could have considerable impact on the HIV epidemic as we move toward HIV elimination. First, they demonstrate the importance of academic and public health partnerships. These academic public health partnerships can potentially streamline procedures of case finding, bring additional human resources to HIV elimination, and develop innovative public health strategies that may not be standard of care. Trust built through such partnerships is required to ensure that the relationship is mutually beneficial and strong enough to withstand some of the bureaucratic and logistical challenges to merging efforts between academic and public health institutions. A second important strategy implemented by the investigative team was to merge clinical data (HIV viral loads) with partner notification data to provide potentially powerful and exciting new avenues for the spectrum of engagement in HIV care implementation. For example, the team was able to reidentify individuals who were known to be previously infected but who were either with a detectable viral load and/or not linked to care. They then demonstrated success in linking/reengaging some of these individuals to/with care, and possibly eliminating the transmission potential these rediscovered individuals have within existing high-risk networks. Such reengagement represents a next-generation spectrum of engagement in HIV care strategy for Public Health Departments that may decrease onward transmission by linking people to care and decreasing the amount of virus circulating within these networks. An extension to partner services could also include periodically engaging virally unsuppressed individuals to assess for onward HIV transmission. Certainly, this approach will require careful review to ensure that accurate clinical data are collected and merged, and most importantly, it will again require partnerships between academic and public health institutions so that the data can be verified with clinical providers and then acted upon to reengage clients into existing clinical care structures. The authors should be commended for this incredibly important work, and it is only with such efforts and collaborations that we will move closer to HIV elimination.
1. Service PH. The Eradication of Syphilis. Washington, DC: U.S. Dept. of Health,Education and Welfare; 1961.
2. Centers for Disease Control and Prevention. Recommendations for partner services programs for HIV infection, syphilis, gonorrhea, and chlamydial infection. MMWR Recomm Rep 2008; 57: 1–83; quiz CE81-84.
3. Samoff E, Koumans EH, Katkowsky S, et al. Contact-tracing outcomes among male syphilis patients in Fulton County, Georgia, 2003. Sex Transm Dis 2007; 34: 456–460.
4. Hyman JM, Li J, Stanley EA. Modeling the impact of random screening and contact tracing in reducing the spread of HIV. Math Biosci 2003; 181: 17–54.
5. Cohen DA, Wu SY, Farley TA. Comparing the cost-effectiveness of HIV prevention interventions. J Acquir Immune Defic Syndr 2004; 37: 1404–1414.
6. Holtgrave DR, Valdiserri RO, Gerber AR, et al. Human immunodeficiency virus counseling, testing, referral, and partner notification services. A cost-benefit analysis. Arch Intern Med 1993; 153: 1225–1230.
7. Hsieh YH, Wang YS, de Arazoza H, et al. Modeling secondary level of HIV contact tracing: Its impact on HIV intervention in Cuba. BMC Infect Dis 2010; 10: 194.
8. Brown LB, Miller WC, Kamanga G, et al. HIV partner notification is effective and feasible in sub-Saharan Africa: Opportunities for HIV treatment and prevention. J Acquir Immune Defic Syndr 2011; 56: 437–442.
11. Schneider J, Makelarski JA, Van Haitsma M, et al. Differential access to digital communication technology: Association with health and health survey recruitment within an African-American underserviced urban population. J Urban Health 2011; 88: 479–492.
12. Klausner JD, Wolf W, Fischer-Ponce L, et al. Tracing a syphilis outbreak through cyberspace. JAMA 2000; 284: 447.
13. CDC. Using the Internet for partner notification of sexually transmitted diseases—Los Angeles County, California, 2003. MMWR Morb Mortal Wkly Rep 2004; 20: 129–131.
14. Ehlman DC, Jackson M, Saenz G, et al. Evaluation of an innovative internet-based partner notification program for early syphilis case management, Washington, DC, January 2007–June 2008. Sex Transm Dis 2010; 37: 478–485.
15. Bouris A, Voisin D, Pilloton M, et al. Project nGage: Network supported HIV care engagement for younger black men who have sex with men and transgender persons. J AIDS Clin Res 2013. In press.
16. Dowshen N, Kuhns LM, Gray C, et al. Feasibility of interactive text message response (ITR) as a novel, real-time measure of adherence to antiretroviral therapy for HIV plus youth. AIDS Behav 2013; 17: 2237–2243.
18. Hightow-Weidman L, Beagle S, Pike E, et al. “No one’s at home and they won’t pick up the phone”: Using the internet and text messaging to enhance partner services in North Carolina. Sex Transm Dis 2014; 41: 143–140.