Public health benefits of partner notification for sexually transmitted infections and HIV: TECHNICAL REPORT
European countries have used partner notification as one of a range of measures to control sexually transmitted infections (STI) since the early 1900s. Besides clinical benefits, public health benefits are also recognised such as controlling the spread of STI, reducing STI-related morbidity and mortality, reaching people with asymptomatic STI and people who do not present for diagnosis, counselling and treatment. Considerable variation in the ways of implementation exists across countries. Differences in laws, policies, regulations and clinical guidelines contribute to this. Health system characteristics, such as governance structures, public-private mix, models of service provision, resource allocation, financing – including payment for care and reimbursement of clinicians, and access to care, also influence practice. Differences in the microbiological and clinical characteristics of STI moreover contribute to variations in partner notification practice. Cultural, social and economic contexts also influence the way in which partner notification is perceived and practised in countries in Europe.
There are different approaches to partner notification, which can be broadly defined as patient referral, provider referral, and contract or conditional referral. Lack of consensus about the most effective methods of partner notification is another reason for the diversity of practice across countries and also represents a challenge to improving partner notification efforts.
Purpose and scope
The overall aim of this project was to provide a better understanding of current policies and practice in Europe and to evaluate the public health benefits of partner notification, particularly its role in STI and HIV prevention. The specific objectives were to:
- review the legal, regulatory and policy context for partner notification, including laws concerning the
criminalisation of STI transmission
- review the availability and content of clinical guidelines for partner notification
- describe the organisation of health services for delivery of partner notification
- review current practices and evidence on the effectiveness of different approaches to partner notification for
- identify factors that facilitate or limit implementation of partner notification.
The project focused on the 27 EU Member States, Iceland, Liechtenstein and Norway. Sexually transmitted
infections covered were HIV, chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae), syphilis
(Treponema pallidum), trichomonas (Trichomonas vaginalis), Mycoplasma genitalium, herpes simplex, genital
warts, hepatitis B and hepatitis C.
Information was obtained through three online questionnaires designed to gather information about the:
- legal and policy framework for partner notification
- availability and content of clinical guidelines for partner notification
- organisation of healthcare services for delivering partner notification.
More in-depth information about issues influencing partner notification practice was collected through interviews with health professionals and policy-makers from Denmark, Estonia, France, Romania and Sweden. Information collected through the questionnaires and in-depth interviews, was triangulated through a review of documents relating to the legal, policy and regulatory context for partner notification in Europe. Two literature reviews were performed; a systematic review of the literature on effectiveness of different methods of partner notification for syphilis, HIV, gonorrhoea, chlamydia, non-specific urethritis, trichomoniasis, hepatitis B and C; and, a literature review of qualitative studies on STI/HIV patients’ views and attitudes about partner notification, their preferred methods, factors limiting partner notification; and on health professionals’ attitudes and perceptions of barriers to partner notification.
The legal context for partner notification varies within Europe. Some countries have wide-ranging legal obligations to enforce partner notification, others have laws that are not enforced, and some have no such laws. Eleven of the 24 countries that responded to the specific questionnaire reported the existence of laws or regulations that make partner notification compulsory for the healthcare provider, the patient or both. These laws most often apply to HIV, syphilis, gonorrhoea, chlamydia, hepatitis B and C.
There is no clear correlation between the existence of laws that make partner notification compulsory and routine partner notification. In 22 of the 24 countries, partner notification was described as routine for at least one STI. Infections for which partner notification is considered routine are often those for which notification is also mandatory.
Compulsory partner notification can have both positive and negative effects. International guidelines recommend voluntary partner notification as an intervention for STI control, with non-voluntary disclosure to partners only when all other avenues have been exhausted. Voluntary partner notification is still the rule in most countries in Europe.
The existence of laws, and attitudes towards compulsory partner notification, are influenced by a country’s social, political and historical context. Laws that criminalise transmission exist, and have been used in nine countries. However, comparison of survey responses with other sources suggested that this may have been underreported, in particular for HIV.
Public sector services for the diagnosis and treatment of STI are provided in all 23 countries that responded to the questionnaire regarding availability and content of clinical guidelines for partner notification. Diagnosis and treatment services were provided in STI or genitourinary medicine (GUM) clinics in 22 countries, in dermato-venereology clinics in 16 countries and in other settings, including general practice, infectious disease units, gynaecology clinics and public health departments, in 13 countries. In most countries in Europe, specialist STI clinics also have the main responsibility for partner notification for syphilis, gonorrhoea, chlamydia and HIV. Few countries have dedicated staff for partner notification or provide training in partner notification: five countries have dedicated staff for partner notification, four countries reported that they provide formal training for doctors specialising in STI, four provide training for other doctors and four provide training for nurses specialising in STI.
Patient referral is the preferred approach to partner notification in most countries in Europe. Questionnaire responses concerning partner notification in specialist STI clinics showed that patient referral is the preferred method for partner notification for all STI. Provider referral was used in some countries, most often for syphilis, gonorrhoea, chlamydia and HIV.
There is insufficient evidence about the most effective methods of partner notification for HIV or syphilis. A summary of systematic reviews concluded that there was insufficient evidence to draw conclusions about the best method of partner notification for syphilis and HIV; other systematic reviews have concluded that provider referral is more effective than patient referral in ensuring notification and treatment for HIV and other STI. For HIV, the one randomised trial identified found that index patients given a choice of method – patient or provider referral – had more partners tested for HIV than those who used patient referral alone. For syphilis, a randomised controlled trial found that there was little difference in the number of partners treated per index patient between contract referral and provider referral. The effectiveness of patient referral for syphilis has not been evaluated, although this is the preferred method in many European countries. Trials comparing different methods of partner notification for syphilis, particularly for men who have sex with men (MSM) amongst whom there have been outbreaks of syphilis in Europe and for pregnant women, would provide valuable and much needed evidence. There is some evidence that enhanced patient referral and expedited partner therapy may be more effective in reducing re-infection for chlamydia, gonorrhoea, non-gonococcal urethritis (NGU) or trichomoniasis, but this is not conclusive. No trials on the effectiveness of partner notification for hepatitis B or C were identified. Few trials have been conducted in Europe.
Lack of resources, provider skills and time are barriers to partner notification. Limited funding, linked to the low political priority given to partner notification, was cited as a barrier by informants in four of the five countries where interviews were conducted. Changes in the organisation of healthcare have also led, in some cases, to increased involvement in STI care of practitioners without specialist training. The literature also suggests that lack of time for partner notification is a concern among general practitioners. Providers considered novel methods to be better than no partner notification at all; novel methods that require minimal time and training of primary care staff may be one way to enhance partner notification at the primary care level.
The majority of healthcare providers see the value of partner notification. There is little support for mandatory partner notification and concern about use of provider referral, in particular for HIV partner notification, because of patient confidentiality issues.
Partner notification is influenced by patients’ knowledge, attitudes and the type of sexual relationship. The qualitative literature review showed that, in general, patients view partner notification as important for public health reasons, in particular with respect to HIV. However, patients perceived partner notification as a difficult task. Concerns about negative reactions from partners, the impact on relationships, stigma and social repercussions were cited as a barrier to partner notification. Lack of knowledge about STI is also a barrier in some contexts. Patient referral methods requiring less interaction, for example, providing pharmacy contact slips to partners, were preferred for notifying ex-partners or casual partners. Given the factors that influence partner notification, methods need to be flexible and tailored to the needs and situation of the index patient.
Conclusions and recommendations
This report shows the wide variety of partner notification practices in Europe, determined by diverse legal and policy frameworks and influenced by cultural and social factors. The following recommendations are formulated to build on growing interest on partner notification in Europe:
- Strengthen the evidence-base with respect to the positive and negative effects of laws that make aspects of partner notification compulsory and laws on criminalisation of transmission; harmonise European-wide
recommendations with respect to the criminalisation of transmission of HIV and STI that conform to international human rights standards and monitor the use of laws to prosecute individuals.
- Address gaps in the evidence and determine the most effective approaches to partner notification in Europe, develop and disseminate evidence-based guidelines on partner notification including a range of approaches
for implementation that can be adapted to different country contexts, population groups and healthcare settings, including primary care settings. Promote the use of clinical audits as a tool for monitoring partner
notification practice against agreed standards and the development of interventions to improve outcomes.
- Improve awareness with respect to the importance of partner notification in STI prevention and control among policy-makers and the need for partner notification interventions to be adequately resourced.
- Facilitate comparison of practices and outcomes across countries in Europe by development of a set of common indicators for monitoring and evaluation of the outcomes of partner notification.