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Partner Notification for HIV and STD in the United States:: Low Coverage for Gonorrhea, Chlamydial Infection, and HIV

GOLDEN, MATTHEW R. MD, MPH*†; HOGBEN, MATTHEW PhD; HANDSFIELD, H. HUNTER MD*†; ST. LAWRENCE, JANET S. PhD; POTTERAT, JOHN J. BA§; HOLMES, KING K. MD, PhD*

Sexually Transmitted Diseases: June 2003 - Volume 30 - Issue 6 - p 490-496
Article
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Background Little is known about the scope of current public health partner-notification (PN) activities in the United States.

Goal The goal of the study was to define what PN services U.S. health departments provide in areas with high STD/HIV-related morbidity.

Study Design The study involved a survey of STD program staff members in U.S. areas with the highest reported rates of infectious syphilis, gonorrhea, chlamydia, and HIV in 1998.

Results Staff members of 60 (77%) of 78 health departments provided data. PN interviews were conducted with 7583 (89%) of 8492 cases of syphilis, 23,097 (17%) of 139,287 cases of gonorrhea, and 26,487 (12%) of 228,210 cases of chlamydia. In areas with mandatory HIV reporting, 4375 (52%) of 8328 persons infected with HIV were interviewed for PN.

Conclusions Except for patients with syphilis, public health PN services affect only a minority of persons with STD or HIV infection in high-morbidity areas of the United States.

US health departments in areas with high STD- and HIV-related morbidity provide partner notification services to most persons with infectious syphilis, approximately half of persons with newly reported HIV infection, and only small minorities of persons with gonorrhea or chlamydial infection.

*Division of Infectious Diseases and the Center for AIDS & STD, University of Washington, and Public Health–Seattle and King County STD Program, Seattle, Washington; and Division of STD Prevention, Centers for Disease Control and Prevention, and §Independent consultant, Atlanta, Georgia

The authors thank the survey respondents who voluntarily provided information for this study, Tim Tyree for help with data management, and Tamara Battle for assistance contacting survey respondents.

Dr. Golden is supported by NIH K23 AI01846-02.

Reprint requests: Matthew R. Golden, MD, MPH, Harborview Medical Center, Box 359777, 325 9th Avenue, Seattle, WA 98104. E-mail: golden@u.washington.edu

Received September 11, 2002,

revised January 02, 2003, and accepted January 6, 2003.

PARTNER NOTIFICATION (PN) has been a cornerstone of STD control efforts in the United States since the 1940s, when Surgeon General Thomas Parran promoted the practice as a syphilis case-finding tool. 1 Over the course of the subsequent 6 decades, many health departments expanded PN programs to include gonorrhea, 2 chlamydial infection, 3 and HIV infection. 4 These public health programs seek to ensure that the sex partners of persons with diagnosed STD are evaluated and treated, typically by offering patients voluntary assistance in notifying their sex partners. (HIV PN programs also attempt to ensure that the needle-sharing partners of persons infected with HIV are notified and receive HIV testing and counseling.)

Despite their long history, relatively little is known about these basic public health activities. Systematic reviews of the literature have generally emphasized the paucity of data supporting the efficacy of PN, 5–8 and there is considerable dissatisfaction with this basic tool to control bacterial STD. In 1997, the Institute of Medicine report on STD advocated overhauling the PN system in the United States by placing greater emphasis on the role of clinicians in ensuring the treatment of their patients’ sex partners and through the development of new, more cost-effective approaches to health department–mediated PN. 9

Despite prevailing skepticism about the value of PN for preventing bacterial STD, the Centers for Disease Control and Prevention (CDC) has advocated increased emphasis on HIV PN as part of the Serostatus Approach to Fighting the HIV Epidemic (SAFE), a key component of which is decreasing the proportion of persons infected with HIV who are unaware of their HIV status. 10

American STD/HIV control efforts are decentralized, and there are no current national data on PN activities. A 1995 survey of local health departments found that 92% offered at least some PN services to persons with syphilis, while 67% provided PN services to persons diagnosed with gonorrhea and 52% offered such services to persons with chlamydial infection. 11 However, no publication has reported what proportion of persons with HIV or other STDs receive publicly supported PN services, how health departments target these services, or what type of PN assistance patients routinely receive.

To better define the current PN system in the United States, we surveyed health departments in U.S. cities and counties with high rates of STD and HIV infection to determine how they target PN services, what services they provide, and what proportion of persons with reportable STD and HIV infection in their jurisdictions are interviewed for purposes of PN. In addition, we sought to identify barriers to improved PN.

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Methods

We identified the 50 cities in the United States with the highest rates of each of the three commonly reportable bacterial STDs (gonorrhea, chlamydial infection, and syphilis), using the 1998 STD surveillance report of the CDC. 12 Because some cities had among the 50 highest rates of some STDs but not others, this process identified a total of 58 locations. We then identified the 50 Metropolitan Statistical Areas (MSAs) with the highest prevalence of AIDS, using the 1999 HIV/AIDS Surveillance Report from the CDC. 13 This yielded 20 additional areas, for a final sample size of 78 jurisdictions.

Contact persons for each selected area were identified from a list of local health departments published by the National Association of County and City Health Organizations (NACCHO). The survey was mailed to officials at city health departments and to county officials in locations where county departments act as the primary source of public health services. If respondents reported serving several adjacent counties, one of which was identified as having high rates of STD, and the respondent had only aggregated data for the entire jurisdiction, data from more than one county were used.

Each health department originally received a survey in July 2000. Respondents received duplicate copies to allow completion of separate surveys by persons in STD and HIV/AIDS programs in areas where separate programs existed. To encourage completion of the survey, a minimum of two additional copies were subsequently sent to nonresponding health departments during the following year, and contact persons were telephoned. Respondents were also telephoned to obtain missing data and to clarify inconsistent responses.

The survey collected data on three topics: (1) numbers of full-time-equivalent (FTE) personnel assigned to work on STD problems in general and on PN in particular; (2) numbers of cases of each STD reported in 1999, number of cases reported from public health settings, and number of case patients interviewed for PN; and (3) type of PN provided to persons whose STDs were diagnosed in public STD clinics, public health venues other than STD clinics, criminal justice settings, and the private medical sector. Respondents were asked open-ended questions to identify barriers to improving PN and to solicit suggestions on what the CDC could do to improve PN services. Data on syphilis-related morbidity and PN were limited to primary, secondary, and early latent cases.

To describe the type of PN their health departments provided in 1999, we asked respondents to characterize their PN programs by choosing among four described approaches in PN, three of which have been regarded as standard in the public health literature. 5 These approaches included the following options: (1) attempted contact of all or almost all patients and all partners (provider referral); (2) attempted interview of all or almost all patients and contact of only partners who are not examined within a specified period of time (conditional referral); and (3) no routine public health assistance with PN is provided and individual clinicians are responsible for PN. Because clinicians probably infrequently do more than advise patients to refer their partners for treatment, 14 this was assumed to imply PN would be left up to patients themselves (patient referral). In addition, we offered respondents a fourth option: attempted interview of all or almost all patients and contact of only the partners who patients themselves cannot or will not contact (offer assistance). Respondents were invited to clarify how PN is targeted in their jurisdictions if the four choices given did not accurately describe their practice. For gonorrhea and chlamydial infection, respondents were asked to estimate how frequently clinicians in their health department give medication to patients to give to their sex partners (0%, 1–24%, 25–49%, 50–74%, or 75–100%).

To assess the scope of PN programs, we calculated the proportion of persons reported with each STD who were interviewed for purposes of PN. Because PN generally focuses on newly diagnosed STD, whereas AIDS reporting includes newly diagnosed cases and previously reported cases of HIV disease that have progressed to AIDS, we chose to calculate only the proportion of newly reported case patients with HIV infection receiving PN. Jurisdictions in which HIV infection was not reportable during the study period could not supply data on the number of new cases of HIV infection in their area in 1999; as a result, it was not possible to calculate what proportion of persons with newly diagnosed HIV infection in those areas were interviewed for purposes of HIV PN. Consequently, all data presented on the proportion of HIV-infected patients interviewed for PN include only areas in which HIV infection was reportable.

Two health department respondents stated they were unable to determine how many recipients of PN had been reported with HIV infection as opposed to AIDS. In these instances, we used combined data. Four respondents indicated their health departments did not compile data on how many patients with gonorrhea they interviewed for PN, and five reported they did not collect such data for chlamydial infection. One jurisdiction indicated that chlamydial infections were not reportable in their area in 1999. Thus, the proportion of persons interviewed for PN could not be calculated for chlamydial infection in six jurisdictions and for gonorrhea in four jurisdictions.

Five health departments could not provide numbers of persons interviewed for PN for one or more STDs but estimated the proportion of patients in their area who received PN services. These estimates are included in the present analysis. Although the survey asked how many person with each STD were interviewed for PN, six respondents reported interviewing more persons with HIV infection than the total number of cases occurring in their area in 1999, and 9 reported interviewing more persons with syphilis than the total number of syphilis cases in their county. This likely reflected respondents’ interpretation of the question to include contact interviews as well as interviews in known cases. In these instances, the number of case patients interviewed was calculated as the total number of cases reported.

Bivariate analyses of association were performed with the chi-square test. The correlation between the proportion of STD case patients interviewed for PN and the number of reported cases and number of PN staff were calculated with the Pearson correlation coefficient. All statistical procedures were performed with the SAS system (SAS Institute, Cary, NC).

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Results

Of the 78 surveys sent out, 61 were returned to us by the contact person, of which 60 were sufficiently complete to be included in the final analysis, a response rate of 77%. Table 1 presents the regional distribution of participating health departments, the job title of respondents, and the number and types of persons conducting PN in each health department.

TABLE 1

TABLE 1

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Syphilis

Eighty-seven percent of all respondents reported that their department attempts to interview all persons reported to have infectious syphilis, regardless of where the original diagnosis was made (Table 2), and 95% indicated that provider referral was their standard approach. Forty-two respondents (70%) indicated that their department did not require the permission of a patient's clinical provider before contacting the person reported to have syphilis. The majority of health departments (52%) indicated that they interviewed all persons reported to have early syphilis during 1999, and of the total 8492 cases occurring in areas served by participating health departments, respondents reported that 7583 (89%) of the patients were successfully contacted and interviewed.

TABLE 2

TABLE 2

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HIV

Of the 60 health departments who returned a useable survey, 41 (68%) responded that HIV infection was reportable in their jurisdiction in 1999. Of these, 37 (90%) were in the Midwest or South. In large measure this reflected the absence of HIV infection reporting in New York and California, states containing 10 jurisdictions that returned surveys. Most health departments in jurisdictions with reportable HIV infection indicated that their policy was to attempt to provide HIV PN services to all patients, regardless of where it was diagnosed, and as with syphilis, provider referral was the dominant PN strategy.

Thirty-four respondents (83%) stated that their department did not routinely seek the permission of the reporting clinical providers before contacting patients infected with HIV. Thirty-seven health departments with reportable HIV (90%) provided data on the number of persons reported with HIV infection and on the number interviewed for PN in 1999. The median proportion of cases interviewed for PN was 75% (Table 2). Of the total 8328 cases of HIV infection reported from all responding health departments in which HIV was reportable, 4375 (52%) of the case patients were interviewed for PN.

The proportion of reported HIV case patients successfully interviewed for PN in a jurisdiction was inversely proportional to the total number of cases reported (r = −0.55;P = 0.0004) (Figure 1). Eight health departments (24%) with 250 or more cases of HIV infection in 1999 received 59% of the HIV case reports in jurisdictions with reportable HIV that responded to the survey; a median of 27% of persons reported to have HIV infection in these 8 jurisdictions were interviewed for PN. The ratio of the number of PN staff to the number of HIV cases reported varied 20-fold among health departments, from 0.01 to 0.2 (median, 0.05). The proportion of persons infected with HIV who were interviewed was positively associated with the number of staff members available for interviewing (r = 0.48;P = 0.004).

Fig. 1

Fig. 1

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Gonorrhea and Chlamydial Infection

Most health departments reported concentrating PN services for gonorrhea and chlamydial infection on patients seen in STD clinics (Table 2). Although the overwhelming majority of all PN interviews for the four STDs (80%) involved gonorrhea or chlamydial infection, PN was offered to only very small minorities of patients with these infections. Twenty-two health departments (37%) provided no routine PN services for gonorrhea and 27 (45%) provided no such services to patients with chlamydial infections. Among those health departments providing PN services, a median of 43% of patients with gonorrhea and 14% of patients with chlamydial infection were interviewed. Among all persons reported to have these STDs in jurisdictions served by responding health departments, only 17% of persons with gonorrhea and 12% of persons with chlamydial infection were interviewed for PN.

The proportion of persons with gonorrhea interviewed was associated with a higher ratio of PN staff members to cases (r = 0.28;P = 0.03) and was inversely related to the total number of reported cases in the area (r = −0.29;P = 0.03). In addition, there was marked regional variation in how frequently PN was provided for gonorrhea. Compared to health departments in the East or the West, health departments in the South and Midwest more frequently provided PN services in fewer than 20% of gonorrhea cases (68% versus 35%;P = 0.02). No association was observed between the provision of PN for chlamydial infection and (1) the ratio of number of reported cases to PN staff members (r = −0.04;P = 0.77) or (2) the number of cases of infection (r = −15;P = 0.26).

When services were provided outside of STD clinics, health departments generally reported adopting a more tentative and less labor-intensive approach to PN. In contrast to cases of HIV infection and syphilis, 53% of health departments routinely sought the permission of clinical providers before contacting patients with gonorrhea or chlamydial infection. In settings other than public STD clinics, PN most frequently consisted of offering patients assistance with PN rather than conditional or provider referral. Six health departments (10%) in six different states reported ever giving patients medication to treat their sex partners, and of these, only one reported doing so for greater than 25% of cases.

In response to open-ended questions about how PN services were targeted, four health departments indicated that they specifically directed PN services to pregnant women, two stated they target untreated cases, one concentrated efforts on adolescents, and one focused efforts on a geographic area defined as a core. Six respondents stated they routinely gave patients with gonorrhea or chlamydial infection referral cards to give to partners.

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Barriers and Suggestions to Improve PN

Among the 60 respondents, 53 (88%) identified at least one barrier to improved PN or offered at least one suggestion to improve PN in their jurisdiction. The most commonly reported barrier to improved PN was insufficient funding or personnel, a factor identified by 24 respondents (40%). Six (10%) reported the inability to retain staff as a barrier to improved PN. Other factors mentioned as barriers by three or more respondents included noncooperation by private providers and community-based organizations in PN, particularly for HIV infection; political opposition by men who have sex with men and by organizations opposed to condom distribution; and the absence of mandatory HIV infection reporting. Twenty-eight respondents (47%) suggested that increased funding or increased federal disease intervention specialist (DIS) assignees would improve their PN services, and seven suggested that improved wages and DIS career opportunities would help. Beyond increased funding, 23 respondents (40%) suggested that the CDC improve ongoing training opportunities for PN staff. Several articulated a belief that there had been a general erosion in PN practices, such as in ongoing training in interviewing techniques, quality assurance by the CDC, and epidemiologic and data management support.

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Discussion

PN was initiated as a means to control syphilis. Our findings suggest that in much of the United States, it remains little more than that. We found that in areas of the United States where HIV/STD-related morbidity is high, PN services are universally offered to persons with early syphilis, frequently provided to persons with newly diagnosed HIV infection in areas where HIV infection reporting is mandatory, and provided to only a very small minority of persons reported to have gonorrhea and genital chlamydial infections.

In areas of the United States with the highest rates of HIV infection, most HIV-infected persons do not receive public health PN services. At the time of our survey, only 68% of responding health departments in our sample were in states where HIV infection reporting is mandatory, and only 52% of persons reported to have HIV infection in those states were interviewed by public health workers for purposes of PN. Given that HIV infection reporting is incomplete and that it is not required in some states, including New York and California (which together reported 29% of all AIDS cases in the United States in 1999), 13 it seems likely that fewer than one third of people with newly diagnosed HIV infection in the United States received public health PN services in 1999. (New York instituted mandatory HIV infection reporting in 2000.)

The effectiveness of PN for HIV infection is uncertain, and the practice remains controversial. 8,15 Several states have described successful HIV infection PN programs, 16,17 and a small randomized trial showed that providing persons with newly diagnosed HIV infection with voluntary public health PN services increased the number of their sex partners who were notified and the number who had HIV infection diagnosed, in comparison with relying on patients to notify partners themselves. 18 The CDC is currently promoting greater emphasis on HIV infection PN. 10 Our findings demonstrate HIV infection PN was far from universal in 1999.

The fact that areas that reported higher numbers of HIV infection cases provided PN to a smaller proportion of patients suggests that providing PN services to all persons with newly diagnosed HIV infection may require increased funding. In addition, there was a common belief among respondents that DIS personnel require additional training to effectively implement PN. The information we collected does not allow us to assess the effectiveness of HIV infection PN, and the effectiveness of HIV infection PN remains to be established. 15 However, if more widespread HIV infection PN is to be promoted, improved funding for staff, training, and data collection will be needed and will likely require federal leadership and resources.

Our survey findings lend support to the Institute of Medicine's conclusion that the current public health approach to gonorrhea and chlamydia PN needs to be redesigned. Many (perhaps most) persons with gonorrhea or chlamydial infection do not notify all of their sex partners. 14,19–21 While no definitive study data have demonstrated that PN decreases the incidence or prevalence of gonorrhea or chlamydial infection, the institution of more aggressive PN programs has been temporally associated with declines in rates of these infections, 19,22 and mathematical modeling studies have consistently suggested that PN can have a significant prevention impact. 23–26

However, even if PN can affect bacterial STD rates, it appears that the PN programs that exist in most U.S. cities with high rates of STD are much too modest to have a meaningful impact, and the persistence of hyperendemic rates of gonorrhea and chlamydial infection in these cities may in part be attributable to the failure to scale up effective PN. We found that public health PN services for gonorrhea and chlamydial infections affect very small minorities of persons with these infections and that these services are focused almost exclusively on STD clinic patients, accounting for a relatively small percentage of all patients with reportable STD. 27

We recently reported that STD clinic patients were only slightly less likely to notify their partners then were patients treated in the private sector, 21 and the focus on STD clinic patients is more a product of convenience and tradition than one of epidemiologic rationale.

Providing traditional PN services to a majority of persons with gonorrhea and chlamydial infection would require substantially increased funding, substantially more efficient use of existing resources, or both. Providing traditional PN services to all persons with gonorrhea or chlamydial infection would involve hundreds of thousands of additional DIS investigations annually and is probably not feasible from a cost perspective.

Clearly, significant reform of the U.S. PN system for gonorrhea and chlamydial infection will need to involve new, more efficient approaches to partner management. Two observational studies have associated lower rates of recurrent chlamydial infection with the practice of providing antibiotics to infected women to treat their sex partners (i.e., patient-delivered therapy). 28,29 Most private sector clinicians report that they have given patients medication to give to sex partners, although few report doing so for all of their patients with gonorrhea or chlamydial infection. 14,30

A recent report from King County, Washington, demonstrated that a health department can implement such an approach to affect a large segment of the population with gonorrhea and chlamydial infection. 21 Although patient-delivered therapy may prove to be a feasible and relatively cost-effective approach to PN, our survey indicates this practice remains extremely uncommon in U.S. health departments.

Our study has several limitations. First, we surveyed only selected areas with high STD and HIV morbidity. Consequently, we cannot comment on PN practices in areas with lower rates of infection; PN may be more widely offered in such areas. However, our findings apply to a substantial number and proportion of all reported STD and HIV infection cases. The areas that responded to our survey reported 8328 (39%) of the 21,419 cases of HIV infection reported in the United States during 1999, 13 139,287 (39%) of the 360,076 cases of gonorrhea reported in 1999, and 228,210 (35%) of the 659,441 cases of chlamydial infection reported in 1999. 31

Second, our estimates of the proportion of persons interviewed for PN may be imprecise. STDs are underreported, and some respondents reported more interviews of patients with syphilis and HIV infection than the total number of cases in their jurisdiction in 1999, a circumstance suggesting that they may have included in their tabulations interviews conducted with contacts of case patients who never had an STD diagnosed. As a result, the true proportion of persons receiving public health PN services for HIV infection and STD in high-morbidity U.S. counties is probably lower than we found.

In summary, health jurisdictions in the United States with high rates of STD and HIV infection provide PN services to the majority of persons with infectious syphilis, fewer than half of persons with newly diagnosed HIV infection, and fewer than 20% of persons reported to have gonorrhea and genital chlamydial infections. Although additional resources are probably needed to expand and improve HIV infection PN services, the number of cases nationally and the breadth and funding of current prevention and treatment programs suggest universal provision of HIV PN services is probably feasible if PN is prioritized.

Efforts to improve PN for gonorrhea and chlamydial infection may also require additional funds but will need to incorporate new, more efficient approaches to PN that target services to those in greatest need of assistance and persons playing demonstrably key roles in sustaining community transmission of these infections. Developing low-cost mechanisms to assist providers in ensuring that their patients’ sex partners are treated could substantially increase the efficacy of PN efforts.

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