A key factor that may influence respondents' willingness to self-notify is the type of relationship they have with their partners. A study of out-of-treatment drug users4 indicated that participants would be most willing to self-notify their close drug-using friends (72%) and sex partners (71%) and their casual drug-using friends (67%). However, only 55% would be willing to self-notify their casual sex partners. Another study reported that former and current drug users would be more willing to self-notify their main sex and needle-sharing partners than casual partners.8 These results suggest that potential PCRS clients may be more willing to self-notify their main sex and needle-sharing partners and are more reluctant to self-notify casual partners.
Would Potential Clients Be Willing to Have Health Service Providers Notify Their Partners?
It appears that most potential PCRS clients would be willing to participate in provider referral (Table 2B).12,27–29 However, participants' willingness to use provider referral varied according to their sexual orientation and drug use history. One study12 reports that fewer MSM (80%) were willing to provide their partners' contact information to the health department for provider referral than women (89%) or heterosexual men (92%). In a study of HIV-positive patients, most of whom were MSM, approximately 79% of the participants stated they would disclose their partners' names to at least one type of provider.28 More respondents were willing to provide partner information to a doctor (64%) or social worker/case manager (62%) than to health department personnel (48%) or a member from the gay community (45%). These differences may indicate a preference to work with familiar and trusted providers as opposed to seeking “outside” assistance from providers whom many index patients believe will not maintain confidentiality.28
Drug users' willingness to participate in provider referral is more varied. Two studies12,27 reported that the majority (85% and 87%) of substance users would provide partner contact information to the health department, whereas two other studies4,8 indicated that drug users were more reluctant to have a provider notify their partners. In particular, only 2% to 14% of drug users in Hoffman et al's study reported a preference to have an outreach worker notify their partners. These data probably underestimate willingness to use provider referral because the survey questions required participants to select one referral method over the other. In addition, the authors noted that the community outreach workers could have been perceived as a threat to the participants' confidentiality.4
Although people's willingness to participate in provider referral varies, they do generally support PCRS programs. Most respondents (78–92%) from five studies believed that health departments should provide partner notification programs or assist in informing potentially exposed partners (Table 2C).3,27–29,32
Do Actual Clients Choose to Use Provider Referral to Notify Their Partners?
Data from seven studies13,30,31,33,34,36,37 report that the majority of PCRS clients (59–82%) used provider referral to notify one or more of their partners (Table 2D). Data were collected from a variety of HIV-positive clients who actually participated in PCRS, including ethnic minorities, MSM, women, and injection and other drug users. Five of these studies30,31,33,36,37 report that more clients chose to use provider referral instead of self-referral to notify their partners. Furthermore, two studies31,36 report that clients chose to notify the majority (71–75%) of their partners through provider referral. Although most studies report that index patients chose provider referral over client referral, one study35 of MSM in San Francisco reported that fewer index patients agreed to notify partners through provider referral (5%) than self-referral (32%). Such a finding suggests potential regional and cultural differences in partner notification preferences across various communities.
Index patients' choice of referral method may be influenced by other factors, including their relationship with their partners, drug use history, and sexual orientation. In one study, IDUs were significantly more likely to name partners for provider referral than other index patients, including heterosexuals and MSM.13 Levy and Fox note that although most (82%) IDU clients chose provider referral for notifying at least one partner, these clients chose to self-notify 72% of their significant others.31
Are Partners Receptive to Being Contacted Through Provider Referral?
The majority (53–87%) of participants in three studies,12,27,29 which included MSM and former or current IDUs, either wanted to be notified or were comfortable with a healthcare provider notifying them (Table 2E). According to one study,12 partners were more comfortable being notified by the index patient (75%) than a provider (53%). Such data may indicate respondents' desire for their partners to notify them instead of a stranger.
What Types of Perceived Barriers Prevent Potential Clients From Participating in Partner Notification?
Several studies report that clients are often hesitant to participate in partner notification for fear of negative partner reactions (i.e., abuse or abandonment)4,8,32,41 or that their confidentiality will be compromised (Table 2F, G).3,28,32,37 Female clients expressed concern that their partners may react violently on being notified and therefore refused to participate in PCRS.4,8,41 Hoffman et al4 reports that more participants feared being harmed by casual partners as opposed to close partners. In other cases, concerns and misconceptions about confidentiality may potentially prevent potential clients from participating in partner notification services.3,28,32,37 Participants from two studies3,32 believed that they would be forced to disclose partners' names to the health department or providers would reveal their identities to their partners. One study37 reported that index patients provided more partner names for provider referral after they confirmed that the health department would maintain their confidentiality, supporting that concerns about confidentiality played a role in their willingness to participate.
Do Index Patients Experience Negative Effects From Partner Notification?
Seven studies8,29,31,38–41 included in this review explored whether index patients experienced negative effects (e.g., physical, emotional, or sexual abuse; dissolution of relationship with primary partner; emotional trauma) resulting from participation in partner notification (Table 2H). The physicians interviewed in Rothenberg et al's study41 reported that 23% of their patients were emotionally abused, 19% were abandoned, and 8% were physically abused after their partners were notified. However, five studies collecting client data indicate that clients self-reported few negative experiences.29,31,38–40 In fact, two studies38,40 found that relationships did not dissolve as a result of partner notification and one study40 reported that the overall rates of emotional and physical abuse declined.
Are Providers in Favor of Partner Notification?
According to four studies,14,24,25,42 the majority (68–98%) of providers, which include general practitioners and HIV counselors, are in favor of partner notification and have positive attitudes toward specific PCRS programs (Table 3A). Two additional studies examined how the issues of clients' consent and the threat of violence influence providers' attitudes toward partner notification.8,41 Data from these studies indicate that providers are more likely to favor partner notification (92% and 100%) only if their clients are fully willing to participate and are not at risk for abuse.
Do Providers Believe Partner Counseling and Referral Services Is Effective?
It is plausible that providers' approval of PCRS may be influenced by their perceptions of its overall effectiveness. Data from three studies8,14,41 indicate that providers think partner notification is effective (Table 3B). Rothenberg et al41 report that 82% to 97% of physicians believed that HIV partner notification is somewhat or very effective in: 1) reducing the spread of HIV infection, 2) providing testing and counseling to people at risk for infection, and 3) providing treatment to infected people. In New Jersey, 81% of HIV counselors surveyed believed the state's Notification Assistance Program was working.14 STD counselors from Roger's et al's study8 reported having a 50% to 90% success rate of getting partners referred to the clinic. In addition, these counselors believed PCRS was more effective if it was conducted by a provider rather than the index patient.
How Are Providers Conducting Partner Notification and Related Activities?
Data from four studies14,26,41,42 indicate that providers, including physicians, HIV counselors, and other health professionals, are inconsistent in referring HIV-positive patients and clients to PCRS, reporting index cases to the health department, and providing assistance with partner notification (Table 3C). In two studies,26,42 less than half of the physicians surveyed referred their HIV-positive patients to a PCRS program. Similarly, another study14 reported that 57% of HIV counselors routinely recommended the state's Notification Assistance Program to persons newly infected with HIV for PCRS. In general, the majority (82–88%) of health providers encouraged their clients to disclose their serostatus to their partners.26,41,42 However, the degree to which providers assisted clients in notifying partners varied. Rothenberg et al41 reported that only 34% of healthcare providers assisted female index clients with informing their partners. In another study,14 84% of HIV counselors helped prepare their clients for notifying their partners. Although such discrepancies may reflect the different roles of the providers surveyed or training and procedures in a specific site, they still highlight the fact that many HIV-positive clients are not receiving PCRS.
This report provides a comprehensive, systematic review of studies that examined client and provider attitudes, preferences, choices, experiences, and practices regarding HIV partner notification. Overall, it appears that index patients and people seeking HIV testing have favorable attitudes toward partner notification and are generally in favor of using either client or provider referral methods. The majority of notified partners were comfortable being contacted through either referral method, although partners may have preferred the index patient contacting them as opposed to a health provider.
There are several factors that can affect clients' attitudes and choices of partner notification methods. Although potential and actual clients may have similar attitudes toward either notification method, more index patients typically chose provider referral as their preferred notification method. It is possible that more index patients chose provider referral because it shifts the notification burden away from the index patients and allows them to maintain their anonymity from notified partners.31 Clients are, however, more willing to personally notify primary sex and drug partners. One plausible explanation why participants are more willing to self-notify their main partners is the result of sharing a strong emotional connection with these partners and feeling personally responsible for their partners' health. It is also possible that they simply do not know their casual partners' contact information. In addition, clients' attitudes and choices toward a particular notification method vary according to their own risk behaviors. MSM and drug users may have different preferences that PCRS needs to address. MSM may be less willing to provide partner information as a result of a general mistrust of public health authorities.12,13,43 Some drug users may be unwilling to provide partners' names because they are engaging in an illegal activity and fear their partners would face legal ramifications.8,14,31
This review also identified two primary barriers that can deter clients from participating in partner notification. One such barrier is clients' concerns about the PCRS process, particularly regarding client confidentiality. It appears that clients are more willing to participate in PCRS and provide partners' contact information when they believe that their confidentiality will be maintained. The fear of negative effects, including abuse, stigmatization, and abandonment, resulting from PCRS is another major barrier to client participation in PCRS. Although some clients do experience negative effects as a result of PCRS, the studies included in this review suggest these events are rarely reported. However, few studies have specifically examined negative outcomes and assessed levels of abuse before notification. Index patients who are in abusive relationships may very well experience physical violence after notifying their partners, but such abuse could be the result of the relationship itself rather than the partner notification process.31 Further research is needed to assess whether participation in structured PCRS programs increases index patients' risk of experiencing abuse, relationship dissolution, and other psychosocial outcomes. In addition, future studies can explore which HIV partner notification method is more effective in preventing such negative outcomes.
Providers, including physicians and HIV counselors, are in favor of notifying partners potentially exposed to HIV. Although providers perceive PCRS as an effective tool in fighting the HIV epidemic, the literature suggests inconsistencies in how they conduct PCRS, refer clients to PCRS services, and provide other related activities. There are also clear gaps in providers' practice and knowledge of partner notification services and responsibilities. Such gaps can lead to unnecessary delays in the testing, counseling, and timely treatment of high-risk and exposed partners, whereby they continue to practice risky behaviors unaware of their own (as well as their partners) potential risk.
There are several limitations regarding this review's findings. One concern is that many studies collected data from clients who volunteered to receive testing or participate in HIV partner notification. Such sampling bias may provide more favorable response and thus may not be generalizable to a more high-risk population.4 Some studies3,4,8,12,27,28,32 in the review proposed hypothetical questions to participants who never sought HIV testing or had not participated in partner notification. We included such data to help address the external validity concerns given that this population may participate in PCRS in the future. Few studies included in this review provided PCRS process data regarding the content and delivery of PCRS; thus, we cannot provide a more detailed assessment of how the PCRS process itself is related to clients' attitudes and acceptance of partner notification. Finally, this review did not examine newer forms and uses of HIV partner notification, including Internet-based notification and social network identification.19,44–46 Further research is needed to examine clients' and providers' perceptions of these approaches.
This review's findings indicate that HIV partner notification is acceptable to most clients and providers. Considering that index patients want to use both client and provider referral approaches to inform various partners, PCRS programs can best serve their clients by offering both strategies.8,12 In addition, PCRS counselors should provide clients with the education, skills, and assistance necessary to self-notify their partners.4,31 Given that misconceptions remain about PCRS, particularly with regard to confidentiality, providers should educate their clients to clarify any misunderstanding.1 Because there may be regional or cultural differences among PCRS clients, particularly among MSM, women, and IDUs, PCRS programs could greatly benefit from collecting process data regarding these index patients' and their partners' experiences with PCRS. Such data can assist PCRS programs in tailoring their services to specific types of clients to increase participation.3,6
Furthermore, there are inconsistent service practices and clear referral gaps between general physicians and PCRS programs. As such, HIV-positive patients may not be referred to PCRS or counseled about partner notification by health professionals who provide HIV testing. Providers who conduct HIV testing need to collaborate with local and state PCRS programs to ensure that PCRS is offered to all patients diagnosed with HIV. Education and training is also needed to inform both public and private providers to increase their awareness of PCRS programs and related policies and to improve service delivery. Finally, although it appears that few index patients experience negative outcomes resulting from partner notification, providers need adequate training to correctly assess and address their clients' risk for abuse when conducting PCRS procedures.1,4,16,41
As this review has shown, most clients and providers have positive attitudes toward PCRS and are willing to participate in HIV partner notification. Although studies have indicated that partner notification, particularly provider referral, is effective in encouraging at-risk individuals to seek HIV counseling and testing,6,16,17,19 there are still knowledge gaps in understanding how to implement and deliver PCRS. In other words, research needs to focus on improving the operation and delivery of PCRS to increase its acceptability and use among clients and providers. All of the aforementioned actions can enhance both client and provider willingness to participate in HIV partner notification and ultimately increase the overall effectiveness of PCRS to identify, counsel, and test potentially exposed partners.
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