The prevalence and incidence of HIV remains high among men who have sex with men (MSM) in many countries, despite promotion of and improved access to testing for HIV and antiretroviral treatment.1–3 Seroprevalence studies from several countries indicate that between 20% and 31% of MSM with HIV remain unaware of their diagnosis.4–6 Reducing the proportion of people with undiagnosed HIV could help curb HIV transmission because those newly diagnosed with HIV typically change their sexual behavior to reduce the risk of onward transmission.7–9 In addition, earlier diagnosis allows earlier initiation of antiretroviral therapy to optimize the impact of HIV treatment as prevention.
In a systematic review, 20% of the partners of individuals newly diagnosed with HIV tested positive for HIV.10 Given this yield, which is substantially higher than that typically seen from HIV screening, improved partner notification for HIV could help reduce undiagnosed HIV in the population. However, there are limited data to inform what strategies might be effective in improving partner notification among MSM diagnosed with HIV.
This study aimed to determine if the implementation of opt-out referral of MSM newly diagnosed with HIV to partner notification officers (PNO) increased the proportion of sexual partners notified.
Study Population and Intervention
This study was undertaken at the Melbourne Sexual Health Centre, the main public sexually transmitted infections clinic in Victoria, Australia. Men who had sex with men attending the clinic were routinely offered screening for sexually transmitted infections including HIV, in line with Australian guidelines that recommend annual testing for MSM with more frequent testing for men who engage in high-risk behavior. Before April 2013, sexual health nurses and physicians could offer patients newly diagnosed with HIV a referral to the Victorian Department of Health PNO: opt-in referral. In April 2013, the clinic implemented a new policy, whereby all patients newly diagnosed with HIV were referred to the PNO unless they declined the referral: opt-out referral. We compared the outcomes from HIV partner notification for MSM diagnosed with HIV between 2 periods: April 2012 to March 2013 (the opt-in period) and April 2013 to March 2014 (the opt-out period). Women and heterosexual men were excluded.
After referral, the PNO arranged to meet with the newly diagnosed patient face to face, where possible at the clinic, immediately after the consultation where the diagnosis of HIV was given. They interviewed the index patient to ascertain the number of partners at risk of infection since the last negative HIV test, if previously done, and details of sexual practices with each partner. The index patient was asked to provide the names of partners with as many contact details for each partner as possible. The officers usually contacted partners via telephone, but also used any other methods of contact provided by the index patient, such as via internet chat room sites, phone applications used to meet partners, email, letters, and occasionally face-face meetings. If necessary, multiple attempts were made to contact partners. The officers advised partners that they had come into contact with HIV and recommended HIV testing. They did not conduct HIV testing themselves or ascertain the outcome of any HIV tests.
Data Collection and Analysis
The sexual history of men attending the clinic was routinely obtained by computer-assisted self-interview (CASI) prior to HIV testing. Information from CASI was used to determine the total number of sexual partners over the prior 12 months, receptive and insertive anal sex, and condom use with anal sex. These CASI data were imported real time into the electronic clinic record. Men also self-reported the number of partners at risk of HIV to the clinician during the consultation or PNO. As per the Australian Contact Tracing Handbook, we included all partners from the last negative HIV test or from onset of risk behaviour if there was no previous test. The reported number of sexual contacts of men diagnosed with HIV (denominator) and the proportion of contacts successfully notified (numerator) were determined by reviewing the electronic clinic record written by the clinician at the time of the consultation, together with detailed reports provided by the PNO. The latter listed each reported partner in a deidentified manner and whether that partner had been contacted. For consistency, where there was discrepancy in numbers recorded (numerator or denominator) by the clinician in the clinical record and the PNO report, the larger number was used.
Data were analyzed using SPSS version 21. Fisher exact test and χ2 tests were used to compare proportions with 95% confidence intervals (95% CI). The Mann-Whitney U test was used to compare median viral loads, CD4 count, months since last HIV test, and number of partners since last HIV test between the opt-in and opt-out groups.
Ethical approval for the study was granted by the Alfred Hospital Research Ethics Committee (number 525-12). Permission for this study was also obtained from the Victorian Department of Health.
Demographic, Laboratory and Behavioural Characteristics
During the study period, there were 111 new diagnoses of HIV among MSM, with 51 diagnosed during the opt-in period and 60 during the opt-out period. The characteristics of men in each period, and the results of laboratory investigations are shown in Table 1. There were no significant differences in the behavioural and laboratory characteristics between the groups. Of the 85% of men who reported a previously negative HIV test, the median interval between that test and HIV diagnosis was 11 months (interquartile range [IQR], 3–24). Overall, the median number of male sexual partners reported for the preceding 3 and 12 months were 2 (IQR, 1–4) and 3 (IQR, 1–5), respectively. Ninety-three percent of men had engaged in anal sex with a casual partner in the prior 3 months, and most had unprotected anal sex with these partners: 76% reported no or inconsistent condom use with receptive anal sex and 67% reported no or inconsistent condom use with insertive anal sex.
A high proportion of men had a concurrent sexually transmitted infection at the time of their HIV diagnosis, with 36% having Chlamydia trachomatis, Neisseria gonorrhoeae or early syphilis. Overall, 20% of the study population had rectal gonorrhoea or chlamydia at the time of their HIV diagnosis.
Twenty-three percent of men were diagnosed during HIV seroconversion as evidenced by the presence of an indeterminate Western blot result: the median viral load among these men was significantly higher than men with a fully developed Western blot at diagnosis (100,000 copies/mL vs 27,700 copies/mL, P = 0.047). The median CD4 count was significantly higher among seroconverters (650 μ/mL versus 448 μ/mL, P = 0.03). Time since last negative HIV test was significantly lower among seroconverters (4 months vs 15 months, P < 0.001). There was no difference in the median number of partners in the last 3 months between these groups (3, IQR, 2–10 vs 3, IQR, 1–4). Although overall, the proportion of partners of seroconverters who were notified (36/102, 35.3%; 95% CI, 26.0–44.6) was higher compared with those diagnosed with a fully developed Western blot (80/335, 24.8%; 95% CI, 19.3–28.5), this did not reach statistical significance.
Impact of Changing to an Opt-Out Approach
Men diagnosed with HIV were significantly more likely to accept assistance from the PNO during the opt-out period (85%) compared with the opt-in period (24%) (95% CI, 6.9–46.9). The proportion of partners reported by index patients who were notified of their HIV risk was compared between the opt-in and the opt-out periods. A significantly higher proportion of reported partners were notified with opt-out referral (85/185, 46.0%; 95% CI, 38.6–53.4) compared with opt-in referral (31/252, 12.3%; 95% CI, 8.5–17.0) (Fig. 1). The median number of partners notified of their risk was higher in the opt-out period (1 [IQR, 1–2]) than in the in the opt-in period (0 [IQR, 0–1]).
Partner notification was more effective when the PNO were involved in both time periods. During the opt-in period: for those who used the PNO a total of 21 of 98 (21.4%; 95% CI, 13.3–29.5) partners were contacted. Where the PNO did not become involved, 10 of 154 (6.5%; 95% CI, 2.6–10.4) partners were contacted. During the opt-out period, 6 of 25(24.0%; 95% CI, 7.3–40.7) partners were contacted by the index patient without the assistance of the PNO, whereas 78 of 160 (48.8%; 95% CI, 41.2–56.7) partners were contacted when the PNO were involved.
Of those who declined PNO involvement in the opt-out period (n = 9), 2 (3.3%) did not feel comfortable meeting with the PNO, 2 (3.3%) had a regular partner who was already known to be HIV positive and no other partners, 1 (1.7%) had no sexual partners in Australia, and for 2 (3.3%) patients, the treating clinician deemed it inappropriate to discuss partner notification.
The most common reason that partners were not contacted in the opt-out period was that the index case had no contact details available for the partner (77/100; 77%). Other reasons were that the partner did not respond to messages from the PNO to contact them (17/100; 17%) or that the contact details provided by the index partner were incorrect (6/100; 6%).
In this study, opt-out referral of MSM newly diagnosed with HIV to PNO was associated with an increase in uptake of partner notification services and a substantial rise in the proportion of reported partners who were contacted: from 12% to 46%. To our knowledge, this is the first study that compares the outcomes of an opt-out approach for partner notification compared to an opt-in approach among individuals diagnosed with HIV. Given the high proportion of undiagnosed HIV infection in many populations, the potential benefit of treatment as prevention, and current limited success of expanded HIV testing, these results suggest that opt-out referral to PNO should be considered as a strategy to help further reduce the number of HIV-positive MSM who are unaware of their status.
Our study findings are consistent with those from other studies that have shown that provider referral leads to more contacts being notified compared to patient self-referral.11–14 In a randomized study in the United States conducted in 1992, patient referral resulted in only 7% of partners being notified compared with 50% using provider referral.12 Since 2008, the CDC has recommended that partner services should be offered to all patients who test positive for HIV with direct public health program involvement as early as possible after diagnosis.15 Our study took place in a sexual health service with clinicians with a high awareness of the need for partner notification. Routine referral to PNO or similar public health workers may have an even greater effect in primary care or low HIV caseload settings.
Several factors must be taken into account when interpreting the results of this study. Because numbers of partners at risk was based on self-report, it is possible that the number of partners at risk is not accurate in both periods. The numbers may have been overestimated due to social desirability bias or underestimated where the patient had undertaken partner notification themselves and hence not reported them. Also, because this was a before and after study, it is possible other factors contributed to the differences in proportion of partners contacted. The overall ratio of partners to men in the study in the opt-in period was higher than that in the opt-out period which could have meant more casual partners who were more difficult to trace in the before period. Additionally, in the opt-in period, clinicians mainly determined the number of partners at risk because the assistance of PNO was only used in 24% of cases as compared with 85% of the opt-out group. The PNOs took detailed sexual histories and excluded partners where there was low risk of transmission, for example, where no anal sex took place. It is likely that clinicians included partners at low risk, hence the overall number of partners reported in the opt-in period was higher. We were unable to determine if those partners who were contacted went on to have HIV testing or how many tested positive for HIV. However, based on previous studies and the characteristics of men in this study, one might expect that a considerable proportion of partners would be HIV positive.10,16–18 Most men in this study reported recent unprotected insertive and receptive anal sex with sexual partners. Also, a quarter of men in this study were seroconverting at the time of their diagnosis, with a median viral load of 100,000 copies/mL indicating a high degree of infectiousness. Individuals who are seroconverting are overrepresented in HIV transmissions, and early diagnosis may lead to fewer transmissions.9,19
Although opt-out referral to partner notification services increased the proportion of contacts who were informed of their risk, 55% of partners were ultimately unable to be contacted. This likely reflects a high number of anonymous or casual sex partners and is consistent with the findings of a recent study in New York city.20 Ninety-three percent of men in this study reported anal sex with a casual partner in 3 months preceding their diagnosis, and the most common reason that those partners were unable to be contacted was lack of any method of contact. Australian gay men have increasingly adopted newer social media technology, such as smart phone applications like Grindr, to meet sexual partners, with use increasing from 23% to 38% of gay men surveyed between 2011 and 2013. Other methods for seeking partners, such as at gay bars or public places, have meanwhile decreased.21 Finally, 85% of men in this study had a previous HIV test, which allowed a clear period for partner notification in the majority of cases. The findings of this study may not be generalizable to other populations where testing is less frequent or other HIV risk groups where fewer casual sex partners are involved.22,23
Involvement in this process was voluntary, and the majority of men offered referral chose to engage with the PNO. For the 15% who declined involvement, future research into the acceptability of this approach may provide insights into options for improving partner notification in this group.
Although provider referral for HIV is more resource intensive than self-referral, the lifetime cost savings from each additional case of HIV prevented is large.11,12,24 A formal cost-effectiveness study would be useful to quantify this further. Further research is required to identify how more casual partners of MSM diagnosed with HIV can be reached in an era when social media are increasingly used for seeking sexual partners.
1. Wilson DP. HIV treatment as prevention: natural experiments highlight limits of antiretroviral treatment as HIV prevention. PLoS Med 2012; 9: e1001231.
2. Beyrer C, Baral SD, van Griensven F, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet 2012; 380: 367–77.
3. The, Kirby and Institute. HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2013. Sydney: The Kirby Institute, The University of New South Wales; 2013.
4. Chen M, Rhodes P, Hall H, et al. Prevalence of undiagnosed HIV infection among persons aged >13 years—National HIV Surveillance System, United States, 2005–2008 Centers for Disease Control and Prevention. MMWR 2012; 61: 57–64.
5. Nosyk B, Montaner JSG, Colley G, et al. The cascade of HIV care in British Columbia, Canada, 1996–2011: a population-based retrospective cohort study. Lancet Infect Dis 2014; 14: 40–9.
6. Pedrana AE, Hellard ME, Wilson K, et al. High rates of undiagnosed HIV infections in a community sample of gay men in Melbourne, Australia. J Acquir Immune Defic Syndr 2012; 59: 94–9.
7. Gorbach PM, Weiss RE, Jeffries R, et al. Behaviors of recently HIV-infected men who have sex with men in the year postdiagnosis: effects of drug use and partner types. J Acquir Immune Defic Syndr 2011; 56: 176–82.
8. Fox J, White PJ, Macdonald N, et al. Reductions in HIV transmission risk behaviour following diagnosis of primary HIV infection: a cohort of high-risk men who have sex with men. HIV Med 2009; 10: 432–8.
9. Brenner BG, Roger M, Routy JP, et al. High rates of forward transmission events after acute/early HIV-1 infection. J Infect Dis 2007; 195: 951–9.
10. Hogben M, McNally T, McPheeters M, et al. The effectiveness of HIV partner counseling and referral services in increasing identification of HIV-positive individuals a systematic review. Am J Prev Med 2007; 33: S89–100.
11. Landis SE, Schoenbach VJ, Weber DJ, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. N Engl J Med 1992; 326: 101–6.
12. Brown LB, Miller WC, Kamanga G, et al. HIV partner notification is effective and feasible in sub-Saharan Africa: opportunities for HIV treatment and prevention. J Acquir Immune Defic Syndr 2011; 56: 437–42.
13. Recently diagnosed sexually HIV-infected patients: seroconversion interval, partner notification period and a high yield of HIV diagnoses among partners. Qjm 2001; 94: 379–90.
14. Golden MR, Dombrowski JC, Wood RW, et al. A controlled study of the effectiveness of public health HIV partner notification services. Aids 2009; 23: 133–5.
15. Centers for Disease, Control, and Prevention. Recommendations for Partner Services Programs for HIV infection, syphilis, gonorrhoea and chlamydial infections. In: Shaw F, ed. Morbidity and Mortality Weekly Report, 2008.
16. Ahrens K, Kent CK, Kohn RP, et al. HIV partner notification outcomes for HIV-infected patients by duration of infection, San Francisco, 2004 to 2006. J Acquir Immune Defic Syndr 2007; 46: 479–84.
17. van Aar F, Schreuder I, van Weert Y, et al. Current practices of partner notification among MSM with HIV, gonorrhoea and syphilis in the Netherlands: an urgent need for improvement. BMC Infect Dis 2012; 12: 114.
18. Garcia de, Olalla P, Molas E, et al. Effectiveness of a pilot partner notification program for new hiv cases in Barcelona, Spain. PloS One 2015; 10: e0121536.
19. Heijman T, Geskus RB, Davidovich U, et al. Less decrease in risk behaviour from pre-HIV to post-HIV seroconversion among MSM in the combination antiretroviral therapy era compared with the pre-combination antiretroviral therapy era. Aids 2012; 26: 489–95.
20. Udeagu CC, Bocour A, Shah S, et al. Bringing HIV partner services into the age of social media and mobile connectivity. Sex Transm Dis 2014; 41: 631–6.
21. Lee E, Limin M, McKenzie T, et al. Gay Community Periodic Survey: Melbourne 2013 Sydney. National Centre in HIV Social Research: University of New South Wales, 2013.
22. Glick SN, Morris M, Foxman B, et al. A comparison of sexual behavior patterns among men who have sex with men and heterosexual men and women. J Acquir Immune Defic Syndr 2012; 60: 83–90.
23. Golden MR, Stekler J, Kent JB, et al. An evaluation of HIV partner counseling and referral services using new disposition codes. Sex Transm Dis 2009; 36: 95–101.
24. Schackman BR, Gebo KA, Walensky RP, et al. The lifetime cost of current human immunodeficiency virus care in the United States. Med Care 2006; 44: 990–7.