AS WE LOOK AT THE EVER-INCREASING technological innovation in public health, one of the authors recalls the suspicion with which a nameless health department treated e-mail in the late 1990s, something akin to how the Luddites felt about the horseless carriage. Times have changed, however, and innovation in partner management for STD and HIV has expanded to the Internet.1,2 In this issue of Sexually Transmitted Diseases, Mimiaga and colleagues surveyed men who have sex with men (MSM) using an online site to meet sex partners.3 Given the high rates of anonymous and semianonymous sex that results from online-initiated encounters, sometimes the only means of contacting those partners subsequently is through the Internet, assessed in Mimiaga's article via e-mail.
Results from Mimiaga et al.3,4 clarify some basic points about partner notification with MSM. They found high overall acceptability of partner notification via e-mail across respondents: 92%. This is a similar finding to acceptance of partner notification among MSM in surveys of in-person patient referral or health department involvement,5 and reminds us that partner notification is about as widely acceptable as a concept among MSM as among other partitions of society.6 Partner notification effectiveness with MSM is also comparable to that for heterosexual patients, albeit if judged by traditional indices of effectiveness. A review of partner notification efforts among cities with largely MSM-driven syphilis outbreaks in the early 2000s found proportions of partners notified and brought to treatment that were similar to statistics for the population at large.7 A specific comparison of syphilis partner notification with MSM patients compared to heterosexual male patients in Georgia found almost identical yields for partner notification in each group.8 The differences between MSM and heterosexual men lie in the proportion of total partners claimed: MSM claimed more partners overall and more partners for whom no in-person investigation could be started.7,8 For these partners especially, innovations in contact methods such as e-mail are sorely needed.
Roughly two-thirds of respondents in Mimiaga et al. reported that they would use the health department to send notification e-mails to some or all partners, while a little under a quarter reported they would notify all of their partners on their own.3 Substantial preference existed for patient referral of main partners versus health department referral of other partners. HIV-infected men were less enamored of health department-based notification than were uninfected men, with 29% preferring to notify all their partners themselves, versus 21% of uninfected men. Those HIV-infected men and men with other prior STD experience were less inclined to involve health departments in partner notification reminds one of the history of STD/HIV stigma and, as the authors conclude, points to the need for carefully calibrated and marketed partner notification efforts. For that matter, many HIV-infected men are likely comfortable enough with disclosure to view notifying partners as perfectly manageable without health department help. Not that too much should be made of the differences between responses from infected and uninfected men: responses were never more than 8% points apart, so the general portrait holds for each group.
Health departments certainly have an interest in some level of involvement with e-mail notification in particular and Internet-based partner notification (IPN) in general, although the level and nature of that involvement is an evolving story. For HIV infection, this means bringing people to vital long-term care, so the relative efficiency of notification methods in case-finding has serious implications for infected people. How relevant “offline” partner notification evaluations are to online models is hard to say, but one Colorado program evaluation in which patients had a choice of health department or patient-led referral with health department referral as a back-up showed that patient referral yielded only about a fifth of all notifications.9 Interestingly, in the above evaluation, health department investigators were able to find partners who the patient had chosen to notify, but not done so (90% or more of partners were notified eventually, regardless of whether the patient has chosen patient referral or health department referral as the first option). Thus, the health department was able to offer a choice of notification strategies to infected patients without reducing the effectiveness of their infection control efforts. One hopes that this approach can be applied via the Internet; it involves the patient and the health department in a collaborative venture in which each party at least implicitly recognizes the stake the other holds in partner notification and subsequent management. The Colorado data were collected in 1988; if patients and public health could collaborate in that era of the HIV epidemic, they certainly ought to be able to do so now.
Other recent data have shown that electronic partner notification appears to be less efficient in bringing people to care than in-person efforts.10 In a Texas evaluation, partners of persons infected with HIV or early syphilis for whom only an e-mail contact was available were characterized as “pseudonymous.” Health department staff sent e-mail notification to these partners. Specific exposure information was not contained in the e-mail, and the purpose of the e-mail was actually to elicit more detailed contact and identifying information for health department-led partner notification. Just under half of partners (49.7%) to whom staff sent e-mail were confirmed as notified, and 40% of all partners were evaluated. These figures were lower than in-person efforts for controls (70% notified and 66% evaluated). A Chicago-based health center conducted a retrospective case audit of 304 syphilis cases, who named 368 partners.11 Of 190 contacted via e-mail, 121 (64%) responded and 77 (41%) were examined (12 new infections, 32 preventively treated, 33 found to be uninfected). Telephone notification produced statistically equivalent estimates. The proportion evaluated was almost identical to the Texas figure,10 and both estimates serve as reminders for staff to ensure a pseudonymous partner actually is contactable only via e-mail. Thus, all else being equal, a program ought to prefer in-person notification.
However, in programs, all else is hardly ever equal. Any program might welcome the prospects of e-mail bringing contact with 2 in 5 partners before staffs have to leave the office. Moreover, persons with pseudonymous partners were more likely to have multiple partners. As some of those multiple partners were presumably casual partners, who are typically less likely to be notified than main partners, the relative efficacy of e-mail notification in Vest et al. may be underestimated. Patient-led efforts may even be more effective than health department-led efforts for e-mail (or other Internet-based) notification, partly due to restrictions on what content public health staff typically can put in an e-mail. One can easily imagine a patient e-mailing a partner, getting a reply, and then arranging to tell them the news about exposure. One can less easily imagine partners replying by e-mail to an unknown entity warning one about an “urgent health matter.” Anecdotal evidence from some of the early adopters of IPN bears upon this question. Many have found that including specific detail about a possible STD infection, increases the likelihood that partners will respond to the IPN attempt. The conundrum lies in the weighing of improved confidentiality against the likelihood of a message being read and action taken. E-mails citing STD exposure as above are sent only to closed e-mail systems, and the chance of the e-mail being shared is unlikely.
A British clinic-based study compared 2 cohorts receiving contact slips with or without specific infection (in this case, chlamydial exposure) information on the contact slip.12 Of 190 partners for whom contact slips were issued with infection-specific information, 160 (84%) sought evaluation, compared to 48 (33%) of 144 partner for whom a nonspecific contact slip was issued. The population studied was heterosexual, but there is no particular reason to believe MSM would respond differently (and MSM are not the only group of Americans to use the Internet for seeking sex partners, anyway). The results certainly suggest further exploration.
It seems clear that almost every health department should be receptive to using the Internet for partner notification because this method will reach partners who are likely to remain otherwise ignorant of their exposure to STD/HIV. We conclude with a broader point. Internet partner notification is not the answer in toto to timely patient care and infection control efforts, but neither are enhanced counseling, referral cards, or expedited partner therapy. To that list, we can add health department-mediated partner notification—even that method is not suitable for every case, and resources do not even permit the option with sufficient frequency beyond syphilis and HIV.13,14 Each basic method and innovation or enhancement is useful, nevertheless. This is so because they can all help if programs are receptive to innovation (in fact many programs produce the innovation), and patients and partners grasp the patient-level and societal benefits of partner notification for STD.
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