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Notification of Syringe-Sharing and Sex Partners of HIV-Infected Persons -- Pennsylvania, 1993-1994

In April 1993, a man incarcerated in a prison in Berks County in eastern Pennsylvania voluntarily requested testing for human immunodeficiency virus (HIV) antibody and was diagnosed with HIV infection. Following an interview and counseling by Pennsylvania Department of Health HIV Prevention Program (HIVPP) staff (1), he provided contact information about four persons with whom he had shared syringes to inject drugs before incarceration. As a result of follow-up investigation, HIV infection was diagnosed in two of these four persons. One of these two persons provided contact information about 47 partners, including 41 partners with whom he had shared syringes only and six with whom he had had sex and shared syringes. By May 1994, partner notification follow-up of the four partners of the index patient and all subsequently identified partners of HIV-infected persons identified a social network of 124 persons linked by syringe-sharing and/or sex. This report describes the findings of the investigation of this network during April 1993-May 1994 and limited additional information from June- September 1994.

Of the 124 persons in the network, 113 were residents of a single community or its surrounding county. Of 121 persons contacted by HIVPP staff during the investigation, 68 (56%) were incarcerated in either the same prison as the index patient, a county prison in one of two adjacent counties, or one of two state prisons in other neighboring counties; 53 (44%) were residing in the community. HIVPP staff informed each of the 121 persons of their possible exposure to HIV (without disclosing the name of the HIV-infected person who had named them as a partner), offered HIV-antibody testing, and advised them about HIV-prevention measures (2). During posttest counseling, 21 HIV-infected persons gave information about their partners (range: one to four; 29 total). After those persons verified that their names had not been disclosed to these partners, the HIV-infected persons supplied information about 58 additional partners (3). Although HIVPP staff contacted partners in prisons, bars, and locations where illegal drugs were injected, at no time was staff safety threatened.

Of the 121 persons interviewed, 108 (89%) were injecting-drug users Table_1, and 91 (75%) had a history of previous and/or current incarceration. None of the injecting-drug users in the network reported drug use while in prison. Nearly all of the persons interviewed (118 {98%}) accepted HIV-antibody testing; of these, 44 (36%) were HIV-positive, including 33 (44%) of 75 males and 11 (26%) of 43 females. HIV antibody was detected in 18 (42%) of the 43 men with two or more HIV-infected partners and six (43%) of the 14 women with two or more HIV-infected partners.

Sharing of syringes was the most common connection (98%) HIV-infected persons had with others in the network. A history of syringe-sharing (syringe-sharing only or both sex and syringe-sharing) was reported by 56 (76%) of 74 HIV-negative persons and all 44 HIV-positive persons. Nine (20%) persons chose to personally notify some of their partners and contacted 16 persons, all of whom requested HIV-antibody testing. The initial follow-up of the index patient and his contacts identified 21 persons (19 men and two women) who did not know they were HIV-infected.

Further partner-notification activities during June-September 1994 identified 18 additional persons in the network, six of whom had HIV infection diagnosed; three were previously unaware of their infection. All persons who agreed to be tested for HIV antibody were counseled to adopt and maintain risk-reduction behavioral changes. Persons who tested HIV-positive were referred to medical, psychosocial, and substance-abuse treatment services (4).

Through September 1994, HIVPP staff spent 2 1/2 to 10 hours locating and interviewing each contact. The estimated cost (hourly wage multiplied by staff time plus mileage) for partner notification of this network was $13,969. The average cost was $94 for each contact located and $583 for each of the 24 previously unknown cases of HIV infection identified. Reported by: K Waldron, MA, Pennsylvania AIDS Education and Training Center, Graduate School of Public Health, Univ of Pittsburgh. NC Breisch, HIV Prevention Program; J Hersh, MEd, JT Rankin, Jr, DVM, State Epidemiologist, Bur of Epidemiology, Pennsylvania Dept of Health. Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs; Office of the Associate Director HIV/AIDS, CDC.

Editorial Note

Editorial Note: The partner-notification process identifies persons who are sex and/or syringe-sharing partners of HIV-infected persons, enables those persons to be informed of their possible exposure, and counsels them about the benefits of learning their serostatus. Identification of persons who are unaware of their HIV infection is important for interrupting HIV transmission: HIV-infected partners who previously were unaware of their infection can be counseled to adopt and maintain behavioral changes to prevent further transmission of HIV, and can be referred for psychosocial, substance-abuse, and medical treatment (including prevention of opportunistic infections) (4). Counseling and testing also can assist exposed but uninfected partners to recognize their risks for HIV infection and to initiate and sustain behavioral changes to reduce their risks. The findings in this report indicate that the partner notification method can be successful with persons who are incarcerated and persons who inject drugs.

Other important elements of partner notification reflected in this investigation were that first, HIV-infected persons were counseled on risk reduction and health maintenance and referred to medical and other services; HIV-infected inmates also had access to the prison's drug- and alcohol-treatment program and prerelease planning for continuity of care. Second, health department notification services did not give the name of HIV-infected persons when they informed partners of their possible exposure. Third, a large proportion of the identified partners were located and accepted HIV-antibody testing. Fourth, the cost for locating HIV-infected persons was relatively low (5). Fifth, most HIV-infected persons asked health department staff to notify their partners. Finally, although HIVPP staff located many partners in areas associated with risk to personal safety, they were able to interview and provide HIV-antibody testing without incident.

To ensure the effectiveness of partner notification, health departments should follow four principles. First, health department staff should be nonjudgmental, maintain confidentiality, offer voluntary testing, and reassure incarcerated contacts that those who are HIV-positive will not be housed separately and will be able to decide to whom their HIV test results will be disclosed. Second, the search for partners should be extended to a broad range of settings, including residences, workplaces, bars, settings where illegal drugs are injected, and prisons. Third, health department staff should help persons recognize and accept their HIV risk and explain the public health importance of reducing HIV transmission. Fourth, partners should be visited multiple times to underscore the urgency of the information, counsel them about the benefits of learning their serostatus, and reinforce the commitment of the health department to the process. The care the health department takes in not revealing the name and other information about HIV-infected persons is critical in ensuring that these persons provide reliable information to enable location of their sex and/or syringe-sharing partners.

References

  1. CDC. HIV counseling, testing and referral: standards and guidelines. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1994.

  2. 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.

  3. Cates W, Toomey KE, Havlak GR, Bowen GS, Hinman AR. Partner notification and confidentiality of the index patient: its role in preventing HIV. Sex Transm Dis 1990;17:113-4.

  4. Gallant JE, Moore RD, Chaisson RE. Prophylaxis for opportunistic infections in patients with HIV infection. Ann Intern Med 1994;120:932-44.

  5. Crystal S, Dengelegi L, Beck P, Dejowski E. AIDS contact notification: initial program results in New Jersey. AIDS Educ Prev 1990;2:284-95.



Table_1
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TABLE 1. Characteristics of persons in a syringe- and sex-linked social network * --
Pennsylvania, May 1994
=======================================================================================
                                      Men (n=78)     Women (n=43)       Total (n=121)
                                     --------------  ---------------    -------------
Characteristic                       No.      (%)    No.       (%)      No.     (%)
-------------------------------------------------------------------------------------
Reported sex with partners
  of the same sex                     11     (14.1)    4     (  9.3)     15    (12.4)

Had history of injecting-drug use     76     (97.4)   32     ( 74.4)    108    (89.3)

Had exchanged sex for money            4     ( 5.1)   25     ( 58.1)     29    (24.0)

Had two or more HIV-infected
  partners within the network         43     (55.1)   14     ( 32.6)     57    (47.1)

Had history of incarceration          63     (80.8)   28     ( 65.1)     91    (75.2)

Contacted in prison                   51     (65.4)   17     ( 39.5)     68    (56.2)

Accepted HIV-antibody testing         75     (96.2)   43     (100.0)    118    (97.5)

Had HIV-infection                     33     (42.3)   11     ( 25.6)     44    (36.4)
-------------------------------------------------------------------------------------
* Of 124 persons identified in the network, one man and two women were not located.
=======================================================================================

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