What is partner notification?
The terms ‘partner notification’ and ‘contact tracing’ are often used interchangeably. These terms refer to the process of informing partners of a person with human immunodeficiency virus (HIV) (or other sexually transmissible infections (STIs)) that they are at risk of having an STI such as HIV, and they should seek testing and treatment. Partners sharing injecting equipment may also be at risk of contracting HIV or viral hepatitis. Until the partner is assessed as not having the infection, or until they are adequately treated, they should take precautions not to transmit their possible infection to others. The main purpose of partner notification is to assist partners who may be unaware of their risk, to have testing, and if they have the infection, to have treatment.
Why is partner notification important?
If health professionals are diagnosing and treating a client for HIV, it is extremely important that they discuss the need for partner notification with this client. If a person is diagnosed with HIV, then they have acquired their infection from another person, and possibly transmitted it on to other partners. Consideration of transmission risk in people who have HIV infection should include those that may have acquired the infection through unprotected sexual contact or sharing injecting equipment.
Partner notification is considered a cornerstone strategy in the public health management of HIV, and is undertaken for the following reasons:
- By contacting a partner who may be asymptomatic but have HIV infection, you may provide a reminder to him or her to have a test when he or she would normally not do so.
- Asymptomatic partners with the infection will avoid potentially serious sequelae, as treatment may prevent HIV-related complications which can be serious and costly.
- There is clear evidence that the earlier a person is diagnosed with HIV and commenced on treatment, the better the prognosis will be.
- Finding and arranging testing and treatment for partners exposed to HIV means that, if they have the infection, they will not inadvertently transmit the infection onward to their future partners.
- The more people who are treated for HIV in a community, the smaller the population pool of infection in that community will be. This in turn means that fewer people will be exposed to HIV.
- Making contact with partners provides the health-care worker with the opportunity to deliver personalised education and support to that partner, this will include prevention strategies aimed at reducing exposure to others in the future.
- Partner notification can also provide valuable data that inform policy makers and educators about an outbreak of an infection and consequently will assist them to plan effective preventive and management campaigns and strategies.
What is the index case?
The index case is the initial case of HIV infection in a person newly diagnosed with HIV. The health professional must raise with this person the possibility of notifying his or her partners of the need to test and potentially treat. Partner notification is completely dependent on the index person being prepared to discuss this matter and to identify partners who need follow-up. If the index person chooses not to provide any information or details about the partners at risk, then there is no possibility of any health professional contacting those partners. Therefore, in order to have this discussion with an index person, it is important that the health professional create a non-threatening and non-judgmental environment in which the index person is comfortable to talk. The interview should be confidential and private and the language used must be easily understood by the index person.
It is important to determine with the index person what sexual activities took place and, therefore, which of those activities could potentially transmit HIV. By having this discussion, the health professional can also identify sexual activities that do not need to be followed up, such as those where the risk of transmission was nil. It is also important to have an understanding of infection prodromes and window periods as this will determine how far back in time partners should be contacted. For example, when considering partners of a person diagnosed with HIV, there is no need to contact partners where the sexual activity was protected (such as with a condom) or partners who were identified where the sexual activity took place over 3 months prior to the last negative test result of the index person.
It is important to stress to the index person that if a health professional is to notify partners on his or her behalf, then the identity of the index person will remain strictly confidential and will never be divulged to the partner. If this is not guaranteed, then the index person is often anxious and will not provide the health professional with the contact details of all partners who are at risk.
If the index person does not feel safe enough to provide information, or confident enough to follow up the partners themselves, then partner notification is not possible. The index person is more likely to provide information to a health professional or carry out partner notification themselves if they understand why it is important to notify partners and what the potential outcome for partners will be.
Methods of partner notification
Partner notification can be carried out in three different ways:
- Patient referral: the index patient himself or herself informs the partners that they should seek testing and treatment. This is often referred to as partner notification.
- Provider referral: a health-care professional informs partners of their need for testing and treatment. This is often referred to as contact tracing.
- Conditional referral: a combination of the previous two strategies.
Patient referral: how does this work in the clinical setting?
This strategy is by far the most common form of partner notification carried out in Australia. It is when the index person agrees to undertake the process himself or herself. In this circumstance, it is important that health-care workers discuss with the index person how he or she is going to carry out partner notification and the best time to do it. The index person needs to have a good understanding of the infection so he or she can answer any questions the partner may have. It will also be helpful if the index person is equipped with suggestions and resources; for example, where the partner may go to seek testing and treatment.
It may also be helpful to practise different scenarios with the index person so that he or she can adopt a means of informing the partner that is comfortable for him or her.
If the index person is going to inform their partner/s, then his or her own infection will obviously not be confidential. Fear of others finding out about the infection that the index person has is often the main reason why he or she may prefer health-care workers do this work.
The health professional’s aim during the interview with the index person should be to motivate him or her to inform partners. The question often arises about how the health professional will actually know that the index person completed the task. It is always a good idea for someone to check with the index person that partner notification has actually been completed. It may be reasonable to call the index person a few weeks after this discussion to check with him or her how things are going. He or she may require assistance at that time and the health professional can take over the task if the index person has been unsuccessful in completing it.
Provider referral: how does this work in the clinical setting?
The index person may ask for a health professional to take on the responsibility of informing his or her sexual partners of the need for them to seek HIV testing.
Experienced health-care workers with a good understanding of HIV and who use sensitivity and common-sense in their practice should be able to discuss partner notification with their index clients.
Health professionals who do not have extensive experience in partner notification can request support, advice and information from experts who work in this area. There are health-care workers in each Australian state, as well as other countries, who undertake partner notification work on a full-time basis. Details of these workers can be obtained usually through a local public health unit of a government department or via an internet search of local sexual health services. The health professional does not need to know the full name and contact details of every partner for partner notification to be carried out successfully. Partner notification can be completed with limited information, such as a first name and a mobile phone number of the partner. Sometimes, even just a first name and an address, or work location, or details of where the named person can be found is sufficient.
However, the index person’s health-care provider may not feel comfortable undertaking partner notification on behalf of the index person or may not have enough time available to do the work themselves. In this case partner notification officers or contact tracers may take on the task.
This strategy is used when the health-care worker accepts that index clients will attempt to make contact with their partners but they accept that they may need to pass the task across to the health-care worker after an agreed period of time if they have been unsuccessful.
Partner Notification Officers and Contact Tracers: who are they and what qualifications do they have?
Health professionals who undertake partner notification on a regular basis are often sexual health professionals who work in this specialty area. Having the capacity to offer testing in the community when undertaking provider referral partner notification is beneficial and having the capacity to deliver medication to clients or partners is often valuable, particularly for those partners who may have difficulty accessing clinical services.
Nurses often have additional skills, such as postgraduate training in mental health, psychology or psychiatric nursing, that enable them to make psychological assessment of both index clients and partners being traced during the process to ensure their physical safety and psychological wellbeing. These skills also promote the rapid establishment of a trusting environment in an often stressful situation, especially if a partner is traced for HIV, is asymptomatic and unaware of their risk.
Partner notification is an important part of the public health management of HIV and nurses often play a key role. The topic must be raised with all people who are diagnosed. The aim is to decrease onward HIV transmission and to prevent unwanted sequelae in those who are found to have HIV infection but would not have sought testing without having been informed of the need to do so. (For more information on contact tracing go to http://contacttracing.ashm.org.au)