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EDITORIAL REVIEW

HIV partner notification

taking a new look

Fenton, Kevin A.1,3; Peterman, Thomas A.2

Author Information

1Department of Sexually Transmitted Diseases, University College London Medical School, London, UK

2Division of HIV/AIDS Prevention, National Centre for STD, HIV, TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

3Requests for reprints to: Kevin Fenton, Department of Sexually Transmitted Diseases, Mortimer Market Centre, Off Capper Street, London WC1E 6AU, UK.

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Introduction

Partner notification (or contact tracing) is the process of informing individuals of their potential exposure to an infectious disease and offering counselling and treatment [1]. Over the past 40 years, partner notification has formed a central component in sexually transmitted disease (STD) control programmes [2–7], and there is increasing evidence to support an expanded role for STD partner notification among core groups [1,8–10], and for disease outbreak control in the wider community [11–18]. Partner notification has been recommended as an intervention strategy to prevent HIV transmission [19–21], alongside HIV counselling, testing, sexual health promotion, and the social marketing of condoms [22–24]. National policies and guidance promoting HIV partner notification for persons with newly diagnosed HIV infection have now been developed in many countries [25].

Since the beginning of the AIDS epidemic, the use of partner notification in HIV prevention has been a much debated and often emotive issue [26]. Opponents of the strategy have pointed to the relatively high cost of partner notification, the limited evidence for its effectiveness in preventing HIV transmission, and the unresolved ethical considerations [27,28]. Proponents have focused on the benefits of partner notification as a targeted intervention for identifying infected individuals and preventing disease transmission, on its contribution to the understanding of HIV epidemiology, and on the ethical obligation to inform partners of their risk.

Recent advances in HIV treatment options, diagnostic technology (e.g., oral fluid, urine and home-based testing), and a better understanding of the natural history of HIV infection have shifted the balance of benefit in favour of early diagnosis and treatment [29]. Partner notification should be re-examined in the light of these developments. Currently, several new, effective antiviral drugs are available for people with symptomatic and advanced HIV disease and perhaps during early infection [29,30]. Antiviral therapy has been shown to be effective in reducing maternofetal transmission [31–33] and the HIV RNA levels in semen and cervical secretions [34], which may reduce sexual transmission of the virus. The effect of early therapy on the quality of life, opportunistic infections, and life expectancy is yet to be determined, but initial results are encouraging.

The potential benefits of partner notification are not limited to HIV-seropositive partners. Those who test negative after notification may benefit from quality, client-centred counselling, which has been shown to reduce the risk of acquiring new STD [35,36]. Reviews of the efficacy of AIDS prevention programmes in reducing risk behaviours [37,38] have concluded that HIV counselling and testing are associated with lowering sexual risk behaviour in homosexual men, injecting drug users (IDU), and serodiscordant couples.

In this review, we provide an overview of the rationale for HIV partner notification and summarize the evidence concerning its effectiveness. We examine the practical limitations and explore possible strategies for overcoming these. Finally, we outline some of the remaining research questions on HIV partner notification.

Rationale

The primary objective of partner notification for STD is to notify partners at risk so that uninfected partners might avoid acquiring infection and infected partners might avoid transmitting infection. Other objectives are to identify high-risk sexual or social networks and, ultimately, to reduce the burden of disease in the community [1]. Possible benefits and costs of this strategy to individuals, their contacts, and the community have been proposed (Table 1); however, these benefits and costs are not well quantified [39].

T1-1
Table 1:
. Potential benefits and costs of HIV partner notification.

The early identification and treatment of infected partners may reduce HIV transmission by reducing the number of potentially infectious contacts. This benefit has been clearer for treatable STD than for HIV infection (Table 2). Indeed, it has been argued that in the absence of a cure for HIV, partner notification may prevent infection only if notified contacts modify their behaviour to reduce the risk of further disease transmission. Limited evidence suggests that such behavioural change occurs after notification, although few follow-up studies have been carried out [40,41]. Wykoff et al.[40] evaluated a partner notification programme to identify and educate the sex and needle-sharing partners of individuals with HIV in a rural health district in South Carolina, USA. After notification, the mean number of sex partners per 6-month period decreased from 7.1 to 1.3 (82% reduction) for HIV-positive persons and from 4.1 to 1.9 (54% reduction) for HIV-negative persons. Reports of at least some condom use increased from 0 to 80% in HIV-positive men and from 0 to 69% in HIV-negative men.

T2-1
Table 2:
. Factors influencing the success of partner notification for sexually transmitted diseases (STD) and HIV infection.

Other studies have shown that HIV prevention counselling can be effective in different settings, but whether this can be generalized to persons located via partner notification is uncertain. Kamb et al. [35] evaluated the efficacy of HIV counselling in increasing condom use and reducing STD in a randomized controlled trial in five inner-city STD clinics: 5801 HIV-negative heterosexual patients were randomized to receive educational, prevention, or enhanced counselling and were followed up at 3-month intervals for 1 year. After 6 months, 143 (9.8%) participants in the educational control group had new STD, compared with 107 (7.3%; P < 0.001) in prevention counselling and 98 (6.8%; P < 0.001) in enhanced counselling. Condom use was significantly higher (P < 0.05) and the number of sexual partners fewer in the enhanced and prevention counselling groups, compared with the educational control group.

Results from studies of serodiscordant couples [42–44] indicate that informing partners about their exposure risk may result in reduced transmission by the index case, as both partners negotiate safer sex and modify their sexual behaviour. Couple counselling in combination with social support seems to be an effective means of promoting and sustaining behaviour change by HIV-infected individuals and their heterosexual partners[38]. Higgins et al. [37] reviewed 50 studies that included data on the behavioural effects of HIV counselling and testing. All longitudinal studies of homosexual men reported reductions in risky behaviour by tested and untested men, and a few reported greater decreases by seropositive men, than by seronegative men, and those untested or unaware of their serostatus. For IDU in treatment, reductions in injecting drug use and sexual risk behaviours were found after HIV counselling. Substantial risk reduction by heterosexual couples with one infected partner was noted; however, findings amongst other heterosexuals at increased risk were scarce and mixed. The authors concluded that further studies should specifically address the behavioural consequences of counselling and testing in various settings.

Partner notification can also provide important surveillance information. For many years, disease intervention specialist activities for other STD have been at least informally guided by partner investigations. When patients frequently named partners from a particular area (e.g., bath house, hotel, crack house), investigators would initiate a ‘cluster investigation’ of all persons in that area or would offer targeted screening or treatment to persons from the area where transmission was occurring [45,46]. The chronicity of HIV infection means that finding individual cases does not necessarily equate to identifying an area of ongoing transmission. However, new methods of virus typing may allow investigators to distinguish whether a partner is infected with the same virus as the index patient [47]. New markers are being developed to identify recently infected persons, and these may help to identify the likely interval of exposure of the client and focus partner notification on partners exposed within this period [48].

As a research tool, partner notification programmes can provide valuable information on sexual and drug-injecting networks [49,50] and sexual mixing patterns [51–53]. Partner notification studies can also contribute to a better understanding of HIV transmission dynamics [54–56] and to better estimating the duration of the infectious period [55,57,58].

HIV partner notification, an international perspective

Although partner notification for STD has become accepted clinical practice in many developed countries throughout the world, the use of this strategy for the control of HIV infection has been extremely varied and at best fraught with controversy. In many countries, the continuing debate between the rights of the individual and the responsibilities of the state (public health, communicable disease control) have made the development and delivery of partner notification programmes contentious. In 1991, Blaxter [25] outlined some of these differences and issues.

In many Western industrialized countries, health-care reforms have seen a progressive move towards market-oriented systems which afford greater choice to the individual. Rapid advances in combination drug therapy are placing increased pressure on HIV/AIDS budgetary allocations, with the potential danger that funds will be shifted away from prevention towards treatment. In these settings, government policies and laws regarding HIV partner notification are diverse. In Denmark and Norway, the individual's confidentiality is regarded as absolute, and partner notification led by health-care workers has met opposition. In Iceland and Finland, physicians are legally obliged to inform the partners of an HIV-positive patient. Even in countries that have HIV partner notification policies, the concerns of health-care workers about HIV partner notification at the local level remain largely unaddressed, and the discrepancy between policy and practice remains large [59].

In developing countries, the implementation of HIV partner notification programmes has been particularly challenging. Poor infrastructure for the diagnosis and management of STD including HIV, limited resources to fund proactive provider referral programmes, and social stigmatization have hindered the employment of such programmes [60–62]. In addition, the potential benefits of therapeutic advances and new technologies have yet to be realised in countries where even lowcost medical interventions cannot be offered [63]. Nevertheless, the usefulness of HIV partner notification in resource-poor settings has been described and HIV partner notification has been successfully incorporated into STD services [60,64–66]. HIV counselling and testing in this setting may be effective in allowing discordant couples to be identified and counselled to avoid further transmission [42,44]. A study in the Republic of Congo (formerly ZaĂ¯re) [42] in which discordant couples were offered intensive counselling after they were notified of HIV test results, condom use increased from < 5% at baseline to 71% at 1-month follow-up and 77% at 18-month follow-up.

Provider referral for STD and HIV may be less feasible in developing countries because of its high costs (health-care worker time, financial resources). Strategies to overcome this have been described [67,68]. Njeru et al. [60] in Kenya looked at the rates of partner referral in primary-level health centres in Kenya: 254 STD clinic patients were given 5–10 min of additional counselling on the importance of referring partners for STD treatment. The highest rates of partner notification occurred among women who attended maternal child health or family planning clinics and among married men and women who attended general outpatient clinics. They concluded that strengthening counselling and directing partner notification toward these patients and clinic settings may be an effective and inexpensive way to increase partner notification in this setting.

Ethical dilemmas

Although partner notification for STD is now regarded as ethically acceptable [1], ethical concerns about the role of HIV partner notification as a prevention strategy are longstanding. These concerns include conflicts between the rights of the individual and those of the state, sexual ethics and obligations, and medico-legal implications.

Some of the ethical questions raised by HIV partner notification have included: Do patients or health-care providers have a moral duty to inform sexual or drug injecting contacts of their exposure risk [69–71]? Does the health-care worker's relationship with the index patient take priority over the obligation to protect others from the patient's infection? Just how important is an individual's right to know that he or she may be at risk? Is there a moral obligation to inform partners, even if safer sex is practised or when activities are of low risk? How do these obligations differ with the index patient's gender, sexual orientation, type of sexual encounter, relationship status, and social dynamic (e.g., threat of domestic violence or partnership break-up) [71]?

Some critics have proposed that this ethical debate has ultimately been destructive, and that it has undermined the strategy through confusion and misunderstanding [26]. In many instances, the perception of partner notification has erroneously shifted from the supportive tradition of contact tracing to the more threatening ‘moral or legal duty to inform’. More recently, the ethics of withholding a potentially effective strategy to combat HIV transmission have been questioned. Is it ethical not to provide a well-resourced and supported HIV partner notification programme? Should a public health strategy that may be one of few tools available for HIV prevention among the poor and minorities not be seriously considered [72]?

These ethical concerns are shared by patients, healthcare workers, and policymakers, and they have undoubtedly influenced the degree to which HIV partner notification policies have been developed and implemented internationally. Ultimately, there are no simple answers; at its core, HIV partner notification deals with many difficult and sensitive issues, such as trust between individuals and obligations to partners. Attempts to resolve these ethical dilemmas may well be futile, but at the very least there should be a willingness to critically re-examine these concerns as practitioners gain more experience with partner notification and as more information is obtained on the effectiveness and limitations of the strategy.

Evaluating HIV partner notification

In January 1989, representatives from 20 countries met at the World Health Organization (WHO) headquarters in Geneva to evaluate partner notification for HIV infection. Consultants from public health, epidemiology, law, and social medicine reviewed the resources that would be required and the benefits of such a programme. They concluded that the information was insufficient to assess the effectiveness of partner notification as an HIV prevention strategy; and they suggested controlled intervention trials [73]. To date, very few trials have been carried out [74].

Process

There are three main accepted methods for undertaking HIV partner notification: ‘patient referral’, in which HIV-infected persons are encouraged to notify partners of their possible exposure to HIV without the direct involvement of the health-care worker; ‘provider referral’, in which the health-care worker notifies partners; and ‘contract referral', in which the patient is counselled about notifying their partners with the understanding that the health-care worker will search for any who do not visit the clinic within a contracted time period. These methods are voluntary and confidential, and provided within the context of comprehensive HIV and STD prevention, care, and support programmes [1,75–79].

Provider referral results in the notification of more partners than patient referral [74,80–83]. A randomized controlled trial by Landis and colleagues in North Carolina [84] compared the success of patient referral and provider referral in notifying partners. Most of the subjects were men (69%), black (87%), homo-/bisexual (76% of the men), and had a median age of 30 years. Thirty-nine were assigned to the provider referral group and 35 to the patient referral group. In the provider referral group, 78 (50%) out of 157 partners with locating information were successfully notified; in the patient referral group, only 10 (7%) out of 153 were notified. The investigators concluded that patient referral was quite ineffective, despite the North Carolina law requiring that partners be notified. Provider referral was significantly more effective.

Provider referral for HIV infection requires more staff training and is more labour intensive than patient referral [1]. There is weak evidence to suggest that partner notification for STD is more effective when undertaken by specially trained professionals than routine health-care workers [39,80,85]. In spite of this evidence, the provision of appropriate training for staff who undertake partner notification differs within and between countries. In some settings, specially trained contact tracers, health advisers or disease intervention specialists are employed to undertake HIV partner notification; in others, health professionals (e.g., doctors or nurses) are responsible. In a survey of 59 larger genitourinary medicine clinics in England, Fenton et al.[59] found that fewer than one-half (47%) had provided specific training for their health advisers, who were primarily responsible for HIV partner notification. Only 15% of clinics had provided any training for physicians. In Canada, public health staff carrying out partner notification were trained in 73% of 154 local health units surveyed. Training was given upon employment (13%), during in-service (37%), or informally (50%) [86].

Outcomes

The goals of partner notification are to inform partners and control disease. Most outcome evaluations have assessed the number of partners notified, the number of partners that received HIV counselling and testing, and the number of partners found to be HIV-positive [87]. The outcomes of some of the larger evaluations of partner notification programmes are summarized in Table 3. These indicators are at best a compromised effort to quantify disease prevention activity. They give no indication of the likelihood of interrupting transmission: for example, did risk behaviour change after notification, and were new infections prevented? These indicators also give no information on the likelihood of transmission from different partners since the tracing of a monogamous partner is treated the same as the tracing of a partner who has 20 other partners.

T3-1
Table 3:
. Recruitment and outcomes of selected HIV partner notification evaluations.

The effect of partner notification on disease incidence in the community has not been evaluated. In addition, whether HIV partner notification is more effective in preventing disease when compared with other strategies (e.g., promoting voluntary HIV testing or offering tests to persons considered at high risk) remains uncertain [88]. Nevertheless, findings from descriptive studies of HIV partner notification have provided us with a greater understanding of the feasibility, effectiveness, complications, outcomes, acceptability, and costs of the strategy.

Feasibility

Partner notification for HIV infection is currently undertaken in a wide range of settings by a variety of health-care workers. For a comprehensive HIV partner notification strategy, professionals in other clinical settings (e.g., antenatal clinics, tuberculosis clinics, private practice) would also need to develop the appropriate skills to ensure that HIV partner notification is undertaken [89]. Patient referral has worked in both developed and developing countries. Provider referral is usually more successful than patient referral in reaching partners [74].

There are, however, some unresolved logistical issues. Partners cannot be notified directly if the patient does not know who they are, or where they might be located (e.g., partners who may have been exposed at an earlier stage in the patient's infection). Undertaking HIV partner notification in groups where most sexual encounters are casual can also be problematic [90] and other strategies may be more effective with these individuals [91–93]. The long infectious period of HIV can make it difficult for health-care workers to define the retrospective period for notifying partners. As more people are living longer and healthier lives with HIV, the discussion of partners, safer sex and notification should be ongoing as new relationships develop. Partner notification may also present particular challenges when undertaken with hard-to-reach or vulnerable groups (e.g., IDU, the inner-city poor, and some ethnic minority communities). There are no easy answers to these issues; however, the continued evaluation of partner notification programmes will help determine how they may be best adapted to meet specific needs.

Effectiveness

HIV partner notification is effective in uncovering previously undiagnosed HIV infections. In general, 10–35% of locatable contacts who are HIV tested will be diagnosed seropositive for the first time [94–102] (Table 3). The seroprevalence among all locatable contacts is even higher, as it would include those already known to be HIV-positive who are usually not counselled or retested. In general, current or more recent partners are most likely to be named, located, and counselled through HIV partner notification [94–102]. As mentioned above, the effectiveness of notification is constrained by the limited information provided by index patients and the fact that the identity or where-abouts of many partners are not known. This explains the often large differences between the number of contacts identified, the number for whom adequate locating information is available, and the number eventually notified (Table 3). This limits the potential of partner notification to reduce disease incidence in the wider community.

HIV partner notification may meet with varying success in different risk groups. This could be a reflection of partnership patterns, social prejudices or the biases of health-care workers in how, when, and with whom HIV partner notification is undertaken. Marks et al. [103] studied the self-reported practices of men infected with HIV in Los Angeles concerning notifying past sexual partners of their risk of infection. Overall, 111 subjects reported a total of 926 sexual partners during the preceding 12 months; 51 partners (5.5%) were informed of their risk by the subjects. A multivariate logistic regression analysis indicated that those with the most past sex partners were least likely to attempt to notify any partner. The same inverse relationship was obtained for actual notification and may stem in part from the greater proportion of unidentifiable partners among those reporting many encounters.

The success of a partner notification strategy depends upon the setting in which it is undertaken and the population studied. HIV partner notification may be more cost-effective than other methods (e.g., promoting HIV testing) in low-prevalence settings [94] since high-risk partners may be identified through sexual or drug-injecting networks. In high prevalence populations, HIV partner notification could lead to a lower cost per diagnosed case; however, this would have to be compared with other prevention strategies. In a 1995 study, Hoffman et al. [100], compared health department-initiated partner notification at a single anonymous HIV test site in Denver with 13 confidential HIV test sites throughout Colorado over an 18-month period. The average number of named, notified, and counselled instate partners was 30–50% greater among confidential site index patients than anonymous site index patients.

Complications

HIV partner notification may be associated with adverse outcomes (Table 1). Domestic violence after partner notification, especially among women from lower socioeconomic and ethnic minority backgrounds, has been documented [72,104,105]. Rothenberg et al. [106] found that substantial numbers of health-care providers in Baltimore reported knowledge of their HIV-positive patients’ experiences with domestic violence before and after notification. Although the risk of domestic violence within vulnerable groups has been used as a case against HIV partner notification, some have argued that it is precisely within these groups that targeted interventions are needed and most effective [72]. The likelihood of violence has not been quantified, but health-care workers should be aware of this risk and should take steps to reduce the possibility of violence before and after notification.

Other potential adverse effects of partner notification include stress, stigmatization, and discrimination among notified contacts [107]. Loss of confidentiality through identification of the index patient and emotional trauma experienced by the notified partner have also been described. These suggest a need for caution and emphasise the special nature of the training needed for safe and effective partner notification.

Effect on relationships

The stability of relationships after notification remains uncertain. On the one hand, partner notification could disrupt relationships, resulting in the formation of new partnerships and thus increasing the possibility of transmission in the community. One study gives some insight: Nabais et al. [108] studied the implications that the index patient's disclosure of HIV status had on the sexual partnerships of 50 couples who had been together for over 6 months. They found that HIV status was frequently disclosed to main sexual partners and that disclosure did not result in separation or disruption of the relationship. Results from studies of concordant and discordant couples also indicate that relationship disruption occurs infrequently, and there appears to be important benefits in the adoption of safer sex strategies and counselling to reinforce risk-reducing behaviours [42–44,109]. However, these studies are selective and reflect outcomes for persons who chose to disclose their seropositive status to their partners rather than being led to disclosure by partner notification.

Acceptability

Only a few studies have looked at the acceptability of HIV partner notification to patients, contacts, and health-care workers. The maintenance of confidentiality may be an important determinant in the acceptability of partner notification to index patients. A study of 25 HIV-positive women in New Jersey [110] showed that 68% of them were willing to give the names of their sexual partners to the health department as long as their (i.e., the index patients') confidentiality was maintained. Only 20% of the women would agree to partner notification if their names were disclosed to the partner.

In general, between 50 and 100% of notified partners will accept counselling about their HIV exposure, and will agree to have an HIV test (Table 3). This high degree of compliance suggests that this at-risk group is interested in obtaining information about their exposure and the options available for management. A few studies have confirmed that partners are likely to give positive feedback about their notification experiences. In South Carolina, Jones et al. [83], studied the acceptability of health department notification in an anonymous questionnaire to partners notified of their exposure during the preceding 2 years. Of the 202 partners notified, 132 (65%) were locatable and completed the questionnaire. When asked whether they thought the health department did the right thing in telling them about their exposure, 87% responded, ‘yes'; when asked whether the health department should continue to notify persons exposed to HIV, 92% agreed. Responses were similar for homo-/ bisexual men, heterosexuals, and IDU, men and women, and whites and blacks.

The acceptability of HIV partner notification to health-care workers remains largely unresearched. A few studies have indicated differing beliefs and attitudes towards partner notification for HIV infection [111,112]. These may influence the degree to which HIV partner notification policies are accepted and practised locally.

Costs

Although it is generally held that publicly funded HIV partner notification programmes result in net economic gains to society, only a few studies have specifically looked at the cost-effectiveness of the strategy [113]. These studies have used different methods, so costs cannot be readily compared across sites; however, one finding is consistent: provider referral is more costly to health departments than patient referral. Provider referral has been estimated to cost between US$ 33 and 373 per partner notified, and US$ 810 and 3205 per infected partner identified [94–97,114,115]. It has therefore been argued that when resources are limited, the highest priority for provider referral should be partners who are less likely to be aware of their risk of infection (e.g., male and female sex partners of IDU, or female partners of bisexual men) [116,117].

In summary, HIV partner notification can identify individuals known to the index patient, who are at significantly increased risk of having or acquiring HIV infection. Provider referral is in general more effective in achieving this; however, it is more labour intensive and costly. Partner notification is most effective in identifying current or recent regular partners, for whom adequate locating information is usually available. In general, the effectiveness of the strategy is limited by a number of factors. First, partner notification is not routinely undertaken with all eligible index patients. Secondly, the limited information about past and casual partners results in a reduction in the number of notifiable contacts. Finally, there are some remaining ethical and safety concerns about the strategy.

Strategies for more effective HIV partner notification

Given the current evidence concerning the effectiveness, the outcomes and the limitations of HIV partner notification, what can be done to make it more successful? Although review of the literature has high-lighted a variety of strategies, insufficient evaluation limits confidence in determining which approaches work best. Some points are clear.

Training

Partner notification is unlikely to succeed without adequately training the health-care workers directly involved. This training should include at a minimum, guidance on the codes of good practice, the content and structure of interviews (e.g., pre- and post-test counselling) and the methodology of patient, provider, and contract referral [1]. It is also important that attention be paid to equipping health-care workers with the skills to work with groups in which partner notification may be difficult or particularly sensitive. Whenever possible, training should be guided by evidence of the effectiveness of proposed strategies and combined with rigorous evaluation.

Clinical guidelines

The development and implementation of guidelines on HIV partner notification has increased internationally [118–120]. Guidelines can help to change clinical practice, reduce variability, and influence patient outcomes [121]. Ideally, they should be evidence-based, clear, cost-effective, and applicable. Guidelines are more likely to be successful if local circumstances are taken into account and if they are disseminated by active educational interventions and implemented by using patient specific reminders that relate directly to professional activity [121]. Once established, guidelines should be evaluated for effectiveness in achieving set aims and objectives.

Clinical audit and evaluation

Clinical audit is a systematic method of improving the quality of patient care by critically analysing aspects of medical practice for the use of resources, diagnosis and treatment, outcome and quality of life [122]. Although not strictly seen as research, audit is primarily educational and may be directed towards changing clinical practice, increasing the use of clinical guidelines, and improving the use of effective and appropriate interventions [123,124]. Clinical audits are already being used to monitor the use of treatment protocols for certain STD and AIDS [125]. Audit of HIV partner notification using better guidelines and performance indicators could be developed and implemented locally.

Other types of process evaluation should also be part of the strategy. For example, if one purpose of partner notification is to contribute to surveillance, one should periodically evaluate how partner notification has contributed to knowledge of disease distribution. This information should be more formally recorded and shared with others who are doing partner notification.

Monitoring performance indicators

Performance indicators can influence performance, but only if they are monitored. A survey of Canadian health units found that few could supply process measures of their programmes’ effectiveness [86]. Since performance indicators define priorities, they should be reviewed periodically to ensure that they reflect the goals. Two traditional performance indicators are the contact index and the epidemiological index. The contact index is the number of partners elicited per infected patient interviewed. In practice, this has often been replaced by the number of partners that the patient can remember by name (or with locating information) because contact tracers are evaluated according to the percentage of persons named that are found. The epidemiological index is the number of infected partners per patient interviewed. Neither index gives much information about how much disease may have been prevented.

A ‘weighted disease intervention index', which has been used for syphilis, emphasises the finding of recent partners who may have infectious syphilis more than the finding of partners who have latent syphilis [88]. This approach could be expanded to HIV by giving more weight to finding individuals whose position in the sexual network suggests they would be more important transmitters than others. At present, no published performance indicators reflect a benefit for finding partners who are likely to transmit to many others.

Reviewing the research agenda

HIV partner notification research of the past decade has primarily been aimed at evaluating its feasibility and outcomes. There have been few rigorous evaluations of the behavioural and social impact of partner notification. The opportunities for doing randomized controlled trials are limited; nevertheless, controlled trials will remain the gold standard for assessing the effectiveness of the strategy and comparing outcomes with other prevention activities. Research objectives should increasingly be directed towards (i) determining standards for good practice (what works and at what cost?); (ii) defining and evaluating new process and outcome measures, including behaviour change; and (iii) exploring new strategies (e.g., using new diagnostic technology) to improve the uptake and effectiveness of partner notification.

The following are some key areas that should be of prioritized for research.

Relative cost-effectiveness of different components of STD/HIV prevention programmes: outreach, screening, clinic services, and partner notification

Community trials to test prevention benefits do not seem feasible. What alternative approaches could be taken to guide programmes that consider (at least informally) the balance of these approaches many times a year?

The sequalae of partner notification

How many infected partners receive therapy for their infection? How many infected partners change their behaviour to avoid transmitting to others? How many uninfected partners reduce their risk of infection? How many partnerships end, and how many new ones are established? Should partner notification be repeated for persons who continue to practice unsafe sex? Should investigators recontact partners who are known to be HIV-positive and counsel them about safer sex? All the potential reasons for doing partner notification when a person is first discovered to have HIV apply to partnerships that are formed later. Should partner notification be ongoing and repeated with individuals forming new partnerships? How best is this undertaken?

Determining the notification period. How far back in time should one search for partners to notify?

Current partnerships are clearly a priority because ongoing exposure could be interrupted and infection averted. Past partners who are likely to be infected may also be a priority because they could be exposing others. An analysis of partner notification records can show the likelihood of finding partners from the distant past, which may be useful in determining appropriate notification periods. Such analysis might also reveal important information about the risk of transmission at different stages of infection. Is it possible to find partners of persons who are and persons who are not on treatment to determine whether there is a difference in transmissibility?

The effect of HIV testing technologies on partner notification

Technology now exists to test oral fluid or urine, facilitating the collection of specimens in the field. Rapid field tests could be useful for testing and eliminating the loss-to-follow-up that occurs when persons are referred to clinics or need to return for their results. Tests that reflect the duration of infection in the index patient could help determine how far back in time one should notify partners.

Using partner notification studies to supplement surveillance information

Cluster investigations and other surveillance approaches should be studied for their effects on the behaviour of persons reached directly or through diffusion in the community. If surveillance is information for action, who should get the information learned in partner notification analyses? It seems appropriate to notify persons in an area (crack house, park) if investigations are revealing an increasing number of infections linked to that area. Mapping transmission patterns in a community by using virus typing could show how the virus is evolving and perhaps reveal evolutionary pressures on the virus.

Finally, all partner notification programmes should be performing process research to identify problems with and solutions to partner notification issues in their area. Which partner notification strategies are effective? From the disease prevention perspective, who are the priority partners to be sought? How should a programme balance intervention options?

Conclusions

Recent studies have increased our understanding of the usefulness and limitations of partner notification for identifying partners at risk. However, the evidence remains insufficient to reach conclusions about the effect of partner notification on disease transmission in the community. It is unlikely that the randomized controlled trials called for by WHO will ever be performed, and even with the results of such trials we would be left wondering how to balance the duty-to-warn against the prevention of infection. Of the many areas for future research, the most critical is to learn what happens to partnerships and to the partners in the months following partner notification. Many steps can be taken to improve the quality of partner notification, including a shift away from traditional performance indicators towards indicators that more clearly emphasise prevention.

New developments in therapy, counselling, testing technology, and new trends in the HIV epidemic have increased the value of partner notification. More partners would be reached if all infected persons were routinely referred for partner notification assistance. However, adequate training and support must be provided for those personnel who are directly involved. Finally, in order to further develop and refine the strategy, continuing evaluation of the process and outcomes of partner notification should be encouraged.

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Keywords:

HIV; partner notification; contact tracing evaluation; prevention

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