Evidence suggests that most new HIV infections originate from
HIV-infected persons not yet aware of their infection.1 This
emphasizes the need to identify HIV-infected persons and link them to
medical, prevention and other services as soon as possible after they become
infected. One strategy for accomplishing this is voluntary partner
counseling and referral services (PCRS), including partner notification (PN).2,3,4
PCRS assists HIV-infected persons with notifying their partners of their
exposure to HIV. Notified partners, who may not have suspected their risk,
can then choose whether to be tested for HIV, enabling those who test HIV
positive to receive early medical evaluation, treatment, and prevention
services, including risk-reduction counseling. A key element of PCRS is
informing current and past partners that a person who is HIV-infected has
identified them as a sex or injection-drug-paraphernalia-sharing partner and
advising them to have HIV counseling and testing. Among sex partners, close
partners and those with whom contact has been recent, frequent, or of longer
duration are more likely to be notified5,6,7,8; however, PCRS
should include casual partners (or contacts), as well. Informing partners of
their exposure to HIV is confidential, in that partners are not told
who reported their name or when the reported exposure occurred, nor is
information about the partners reported back to the original HIV-infected
person. It is voluntary in that the infected person decides which
names to reveal to the interviewer.
PCRS can be an effective tool for reaching persons at very high risk for HIV
infection: in studies of HIV PCRS, 8%-39 % of partners tested were found to
have previously undiagnosed HIV infection.9 However, a recent
survey of health department staff in U.S. areas with high reported rates of
HIV found that, in areas with mandatory HIV reporting, only 52% of persons
infected with HIV were interviewed for PCRS.10 PCRS has been
found to be cost-effective.11,12,13 Acceptability of PCRS has
been indicated in surveys of individuals seeking HIV testing, HIV-infected
persons, and notified partners, in which the majority of respondents have
indicated support for PN.14,15,16
HIV PCRS includes several elements: identifying, locating, and interviewing
HIV-infected persons (index patients) to offer PCRS and elicit names of
partners; locating partners and notifying them of their exposure to HIV; and
providing HIV counseling, testing, and referral services to the partners.
PCRS is usually done by health departments. In some areas, community-based
organizations (CBOs) or other agencies perform at least some parts of PCRS
(e.g., interviewing index patients to elicit partner names); however, state
or local laws and regulations may limit or prohibit PCRS being done outside
the health department.
There are 3 main strategies for reaching and informing partners of their
exposure. In provider referral, the clinical care provider or health
department staff, with permission from the HIV-infected client, informs the
partner and refers him or her to counseling, testing, and other support
services. Although some clinicians may wish to take on the responsibility
for informing partners, one observational study suggested that health
department specialists were more successful than physicians in interviewing
patients and locating partners.17 In patient or client
referral, the HIV-infected person accepts full responsibility for
informing his or her partners of their possible exposure to HIV and for
referring them to HIV counseling and testing services. Although some persons
initially prefer to inform their partners themselves, many clients often
find this more difficult than anticipated. Furthermore, notification by
health department staff seems to be substantially more effective than
notification by the infected person.18 In contract referral,
the infected person has a few days to notify his or her partners. If, by the
contract date, the partners have not come for counseling and testing, they
are contacted by the health department. In a variation, dual referral,
the HIV-infected client and the provider inform the partner together. Some
reports of partner violence after notification suggest a need for caution,
but violence seems to be rare.19,20
Many states and some cities or localities have laws and regulations about
informing partners of their exposure to HIV. Some health departments require
that even if a patient refuses to report a partner, the clinician must
report to the health department any partner of whom he or she is aware. Some
states also have laws regarding disclosure by clinicians to third parties
known to be at significant risk for future HIV transmission from patients
known to be infected. This is called duty to warn.21 The Ryan
White CARE Reauthorization Act requires that health departments receiving
Ryan White funds show “good faith” efforts to notify marriage partners
of HIV-infected patients.
The purpose of this document is to provide guidance to state and local
health departments to achieve the following:
- Routine provision of PCRS, in public and private settings, to persons
with newly diagnosed HIV
- Ongoing provision of PCRS to HIV-infected persons who remain sexually
active or continue to inject drugs
- Effective linkage of persons diagnosed with HIV through PCRS to
medical evaluation, treatment, prevention, and other appropriate
Other agencies and providers doing PCRS must work closely with their
respective health departments and adhere to all applicable laws and
Steps for health departments
- Develop and implement programs to provide PCRS in public and private
sectors to all persons newly diagnosed with HIV. These programs should
address all steps of PCRS, including
- Contacting persons newly diagnosed with HIV to offer them PCRS
- Interviewing persons who accept PCRS to elicit names of and
locating information for sex and
- Locating, notifying, counseling, testing, and providing test
results to partners
- Linking partners, especially those who test positive, to
appropriate medical evaluation, treatment, prevention, and other
- Ensure that PCRS is
- Confidential in all aspects
- Available with both confidential and anonymous counseling and
- Culturally sensitive and acceptable to the affected population
- Timely (i.e., locating and notifying activities are initiated and
- Ensure that information about how to access PCRS services is easily
accessible by health care providers in the public and private sectors,
CBOs, and other agencies diagnosing or providing services to
- Encourage providers, CBOs, and other agencies providing services to
HIV-infected persons to routinely screen clients for ongoing sexual and
injection-drug-use activities and to provide PCRS, directly or through
referral, for new partners who may have been exposed to HIV.
- Ensure that providers, CBOs, and other agencies diagnosing or
providing services to HIV-infected persons are aware of all laws and
regulations relevant to PCRS in their respective jurisdictions.
- Ensure that all clients receiving PCRS are assessed for the
possibility of partner violence and, when indicated, are referred to
agencies with expertise in this area.
- Ensure that all staff members doing PCRS receive initial and ongoing
training in PCRS methods and receive close supervision and routine,
periodic performance evaluation. Training curricula for PCRS and PN are
available from CDC, and many courses are available from health
departments and the National Network of STD/HIV Prevention Training
- Work with health care providers, CBOs, and other organizations serving
or representing HIV-infected persons to educate them about the potential
benefits of PCRS for HIV-infected persons, their partners, and the
community and to develop community support for these services.
- Work closely with non-health department agencies (e.g., CBOs) that are
considering providing PCRS services to assist in planning their
programs, including identifying which elements of PCRS the agency should
conduct, how the agency’s PCRS activities will be coordinated with
health department PCRS activities, how appropriate reporting to the
health department will be ensured, and what laws and regulations may be
applicable to the program.
Working with Partners and Integration into Existing Services
- PCRS is part of a comprehensive array of services needed by
HIV-infected persons and their partners. It should be fully integrated
with those services, beginning when a client first receives HIV
counseling and testing and continuing after the client enters care and
- PCRS cannot function as an isolated activity in the health department.
Health departments should work closely with private sector and other
providers (including Ryan White Care funded programs) to help them
develop strategies for integrating PCRS into their services (e.g.,
routinely screening HIV-positive clients for behavioral and clinical
risks for HIV transmission to identify those who should be offered PCRS).
- Whether HIV PCRS is conducted by HIV/AIDS program staff or by disease
intervention specialists (DIS) in sexually transmitted disease (STD)
programs, where PN for other STDs is also conducted, HIV/AIDS and STD
programs should collaborate to provide the most effective services and
to use resources effectively.
- Some PCRS programs focus primarily on patients diagnosed in the public
sector, especially STD clinics; however, most persons with HIV are
diagnosed in the private sector. Health departments should work with
private sector health care providers (including programs funded under
the Ryan White Care Act) to help foster understanding of and support for
providing PCRS to HIV-infected persons diagnosed in the private sector.
- PCRS may place a substantial burden on health department resources.
Managers may need to prioritize PCRS activities, such as the order in
which HIV-infected persons are offered PCRS or the order in which
partners are located and offered PCRS.
- Concerns often voiced regarding HIV PCRS include potential violations
of confidentiality, the stigma associated with HIV, and the potential
for partner violence associated with PCRS. It is critical that all PCRS
programs include strict procedures for ensuring privacy,
confidentiality, and security of data, as well as screening for and
addressing potential partner violence.
- Some states have laws and regulations that limit partner notification
activities. Amendment of these laws should be considered, where
appropriate, in order for PCRS to be successfully implemented.
- In some instances, HIV-positive clients may have sex or may share
injection equipment with persons they do not know. In these
circumstances, general information obtained through PCRS can be used to
identify high-risk areas and venues where PCRS programs can provide or
arrange for outreach services. A more recent phenomenon is use of the
Internet for finding sex partners; strategies for PCRS in this situation
need to be explored.
- In some circumstances, ensuring confidentiality may be difficult. For
example, if an HIV-positive client (index patient) has a spouse or other
partner who is known to have had no other partner, the PCRS provider and
index patient should fully discuss all available options for notifying
the partner and together formulate the most appropriate plan. For
example, a dual-referral approach, in which the HIV-infected client
informs the partner of his or her HIV status in the presence of the PCRS
provider, might be appropriate in this situation. By having a
professional counselor present, this approach supports the client and
may reduce other potential risks. If there is any concern about possible
partner violence, assistance should be sought from persons with
expertise in violence prevention.
- Unlike bacterial STDs, HIV is not curable; therefore, PCRS should be
an ongoing process for clients who have new sex or
injection-drug-paraphernalia-sharing partners. Clients who remain
sexually active or continue to use injection drugs should be counseled
regarding self-disclosure of HIV status and provided opportunities to
develop their self-disclosure skills.
- Many questions remain regarding the best approaches for conducting
PCRS (e.g., best methods for interviewing and eliciting partner names,
optimal length of time period used for interviewing, tailoring
elicitation and notification procedures to specific populations,
potential roles of agencies other than health departments). These
questions should be addressed through evaluation of existing programs
and by conducting operational research.
Since 1989, North Carolina has offered HIV PCRS to persons who test positive
for HIV. PCRS is done by DIS. DIS are specially trained health professionals
who attempt to locate HIV-infected patients and their exposed partners and
ensure that both are referred to HIV and syphilis evaluation, treatment, and
prevention services. When a positive HIV test result is reported to the
local health department by a medical care provider or clinical laboratory, a
DIS is assigned to the investigation. After verifying that the person has
not been previously reported as HIV positive, the DIS contacts the
patient’s medical provider to initiate PCRS. The DIS reviews medical
records to obtain demographic and clinical information about the reported
patient (i.e., index patient); attempts to contact the index patient;
conducts a voluntary, confidential, in-depth interview with the index
patient, requesting information on all sex and
injection-drug-paraphernalia-sharing partners within the past year; and
assesses the potential for partner violence. The DIS ensures that all
HIV-infected clients have received HIV prevention counseling, are informed
about measures for reducing or preventing HIV transmission, and, if needed,
receive referrals to HIV care and case management.
After obtaining partner information, the DIS searches regional records to
determine whether named partners have already been reported as HIV infected.
The DIS then offers index patients the options of provider referral or
contract referral to assist in notifying partners, not already known to be
HIV positive, of their possible exposure to HIV. When located, partners are
informed that they may have been exposed to HIV and are either referred to
HIV counseling and testing clinic services or are provided these services
In North Carolina in 2001, there were 1,603 newly diagnosed HIV and AIDS
cases; 166 (10%) were diagnosed because of PCRS. Through PCRS, 1,532 sex or
needle-sharing partners were notified; of those, 404 (26%) had previously
tested HIV positive. Of 1,128 not previously known to be HIV-positive, 610
(64%) were notified, counseled, and tested for HIV; 125 (20%) of these were
newly diagnosed with HIV infection. Of the 1,532 partners interviewed, half
had not been tested previously; 488 (64%) of these were tested through PCRS,
and 108 (22%) were found to be positive for HIV. Of 188 partners who had
previously tested negative, 122 (65%) were retested through PCRS; of those,
17 (14%) were newly diagnosed with HIV infection.
CDC grantees receiving HIV prevention funds will be required to routinely
report the following indicators to monitor their HIV partner counseling and
CDC’s HIV Prevention Program Performance Indicators*:
- Number and percent of contacts with unknown or previously negative HIV
serostatus receiving an HIV test after PCRS notification (C.1)
- Number and percent of contacts with a newly identified, confirmed
positive HIV test among all contacts tested (C.2)
- Number and percent of contacts with a previously known, confirmed
positive HIV test among all contacts (C.3)
Other program measures:
- Number of persons newly diagnosed and reported with HIV (index
- Collection of HIV transmission risk data in accordance with CTR
- Number of index patients located, offered, and who accepted PCRS
- Demographics of index patients and contacts (e.g., race/ethnicity,
gender, socioeconomic status)
- Number of named contacts
- For each index patient accepting PCRS
- Located, offered, and who accepted PCRS
- With a positive test result who are successfully linked to medical
evaluation, treatment, and prevention services
* The CDC Technical Assistance Guidelines for Health Department HIV
Prevention Program Performance Indicators provides information on setting
baseline, target, and indicator specification including appropriate data
sources, calculations and reporting issues. Note: Performance indicators may
have been modified to reflect specific population or setting
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evidence-based review. Am J Prev Med 1999;17:230-242.
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immunodeficiency virus counseling, testing, referral, and partner
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department notification of HIV exposure, South Carolina. JAMA
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Guidelines and Recommendations
CDC. Program operations. Guidelines for STD prevention. Partner services.
Revised Guidelines for HIV
Counseling, Testing, and Referral.
CDC. Recommendations for
Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial
CDC. Technical Assistance Guidelines for CDC’s HIV Prevention Program
National Network of STD/HIV Prevention Training Centers.
State or local health department HIV/AIDS prevention programs. State AIDS
Directors and contact information from the National Alliance of State and
Territorial AIDS Directors (NASTAD).