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Sexually
Transmitted Diseases > Program Guidelines > Partner Services
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PARTNER SERVICESPartner services are offered to all patients with STDs whether reported by public or private agencies. Some patients voluntarily seek medical attention, while others are examined as a direct result of outside intervention, such as insurance or job requirements, legal reasons (e.g., premarital, jail sentence), local health departments efforts, or partner request. Ideally, every patient would be offered partner services, but the specific population for partner services may vary by program, as determined by locally established priorities and by available resources. Patients who are being treated for STDs are the best source of information regarding their infections. Every interview must be planned and approached as if it will be the only opportunity to provide and to secure information from the patient. Every effort must be made to interact face-to-face. Interviews should include an effort to identify others at risk within the community who would benefit from an examination. Necessary identifying, descriptive, locating, and exposure information for each partner within the interview period must be exhaustively pursued. Finally, interviews afford an opportunity to identify areas or specific locations within a community where at-risk populations reside or congregate. This information can be used to conduct carefully planned screening efforts for at-risk populations. Such an approach to targeted screening can be particularly effective and is critically important to the efficient use of limited resources. While interviewing the patient, the DIS should make every attempt to enlist the patient as a resource, making it clear that the information the patient provides will be confidential and very helpful to the DIS, the patient, and the patient's partners. The DIS can incorporate elements of client-centered counseling by acknowledging treating the patient as a partner in reducing additional STD in their community. The partnership should be clear to the patient. Recommendation
The person who comes into a clinic for STD services without being referred is known as a volunteer. Generally, people who voluntarily come into the clinic for a STD exam have noticed symptoms of disease on themselves or their partners, have been told that they need an exam, or have been motivated by something they have read, seen, or heard. This reason may be an important clue which can be used later to elicit partners. Index patient is a term often inter-changed with "original" patient and refers to patients newly diagnosed with a STD who are candidates for interview by trained DIS. Included among the services offered during the course of such interviews is assistance with the notification and timely referral of those partners determined to be at risk for infection. Effort also is expended to identify others within the patient's "community or social network" of friends or acquaintances (but not sexual partners) who might benefit from an examination. This is called "clustering". In addition to partners, individuals who are identified as the result of an interview with an infected person but who are not partners of that person are called suspects and are divided into three (3) categories based on likelihood of infection: S-1—People with symptoms suggestive of disease S-2—Partners of other persons known to be infected S-3—Others who might benefit from a STD examination (e.g., pregnant females, roommates) All partners and suspects who are referred for examination as the result of an interview should, at a minimum, be informed as to the reason for the referral; should be provided information about the disease; should be informed of the reasons why they should have a sense of urgency in seeking a timely and appropriate medical evaluation; should be given the opportunity to be examined, should be given the opportunity to ask questions; and should receive client-centered counseling to develop a personalized risk reduction plan. In certain situations it may be appropriate also to interview partners and suspects. Another reason people come to the clinic is that they have been told by a partner or by a DIS that they may have been exposed to a disease. In such cases, the person may not have any signs or symptoms of the disease but still needs to be examined and treated. Anyone reasonably believed to have been exposed to a disease should be prophylatically treated at the time of exam based on CDC treatment guidelines. As an example, any partner thought to have been exposed to primary, secondary, or early latent syphilis within the preceding 90 days may test negative, yet still be infected since the incubation period for syphilis can be up to 90 days. Even though a partner tests negative, he or she should be treated. If test results are not available on a stat basis, the partner should still be treated during the initial visit and the infection status (infected-brought to treat or preventively treated) can be determined when test results return. If the partner is not infected, he or she may be interviewed about recent partners and other persons within the community who might benefit from an examination. Interviews of this type are called cluster interviews and often provide important information. For example, if the individual being cluster interviewed is a partner who provides more recent date(s) of exposure than the date stated by the index patient, the result could be the prophylactic treatment that might otherwise not have been offered. These same individuals may be able to provide target locations for screening and outreach, additional information about partners, or locating information for other partners or cluster suspects already named but for whom there was insufficient information to initiate field investigation. To maintain confidentiality it is important to pursue such cluster information equally among all at-risk persons named by the partner during the interview. This approach provides valuable social network information. This type of interview requires special raining, as the DIS employs specific motivational approaches and because special measures must be taken to preserve the confidentiality of the index patient. Individuals initiated for field investigation from non-infected persons during cluster interviews are called "associates" and also fall into three categories: A-1—People with symptoms suggestive of disease A-2—Partners of other persons known to be infected A-3—Others who might benefit from a STD examination Information obtained from interviewing partners, suspects, and associates should be carefully reviewed in light of information provided by the index patient and through other investigative efforts and used as the basis for any subsequent reinterview of the index patient. Index patients referred by other providers New STD infections diagnosed by non-health department providers come to the attention of program surveillance units in a variety of ways. A health care provider may directly notify the program office of a newly diagnosed case; a provider may send a patient to the health department clinic for clinical management; or positive laboratory results may be reported which prompt follow-up by the surveillance unit. Providers reporting cases of STD to the health department should be contacted for permission before the DIS approaches the patient for partner services. Many providers prefer to treat their patients for STD and leave the responsibility of counseling them to the health department. In many instances, prior agreements or memoranda of agreement are in place, providing routine permission for follow up. In this case, the DIS would contact the patient and perform an original interview. Another type of index patient is the patient who is identified via syphilis screening. In this case, the positive test result is reported to the health department by the laboratory while the result may not be known to the individual who was screened. The DIS in this situation must first perform a record search to determine whether the positive test is related to a previously known infection. If it is a new (and not previously adequately treated) infection, the DIS should notify the index patient of his or her infection and then refer the index patient for the full range of partner services. Patients are sometimes presumptively interviewed on the basis of presenting symptoms or laboratory findings that are suspicious or not yet available or confirmed. This also may be the only opportunity to speak to the patient. The purpose of this type of interview is to afford the staff additional information by assuring the rapid examination and medical evaluation of recent sex partners. This information can help medical practitioners make appropriate diagnostic and treatment decisions. These efforts have the secondary benefit of expediting the disease intervention process for those patients later determined to be infected. Recommendation
Case management efforts entail seven steps: pre-interview analysis, original interview, post-interview analysis, referral of at-risk individuals (sex or needle-sharing partners and clusters), cluster interview(s), reinterview(s), and case closure. Please refer to the STD Employee Development Guide (Centers for Disease Control and Prevention) for additional information. Because the interview process is complex, a recommended "interview format" has been developed and is discussed in the section on types of interviews. Formal training in the application of this format is available and programs are strongly encouraged to require formal training for all new staff performing DIS partner services before they interview patients. Ideally, every patient with a STD should be interviewed and counseled. However, the extent to which all such patients can be interviewed and counseled will be determined by the availability of qualified staff, by funding, and by morbidity levels. If it is not feasible to provide these services to every patient, programs should establish a priority basis for determining which patients with STD will be interviewed and counseled. The extent to which DIS assist patients in notifying their partners should also be determined by local program areas. The following factors should be considered for setting interview priorities: STD specific morbidity, infectiousness of disease (and stage of disease for syphilis), public health cost or burden of infections and their sequellae, amenability of the disease to the intervention, profile of partners (e.g., adolescent or female with a known or suspected pregnancy), and available program resources. Programs should reevaluate priorities for partner notification in light of these factors at regular intervals. Using these principles, some program areas have developed priorities similar to the following:
The interview period covers the time from the earliest date a patient could have been infected to the date of treatment. It is divided into two sections; the source period (which always includes the maximum incubation period) and the spread period. The incubation period begins with the date of infection and ends with the first appearance of signs or symptoms. The source period is the interval during which a patient most likely contracted the disease. The spread period is the time during which a patient is potentially infectious and could have passed the disease on to others. With syphilis, the source period and the incubation period never overlap with the spread period, since the exposure (source) and the development of disease (incubation) precede active infection (spread). It is important that the components of the interview period be thoroughly understood. See Appendix A for disease specific information. Although there are standard interview periods recommended in this guideline (Appendix A), it is suggested that individual programs regularly review local data and social network analysis to determine appropriate interview periods for optimal resource allocation and case-finding. For example, recommendations based on localized data collection have ranged from 15 to 30 days for gonorrhea patients (Starcher, 1983; unpublished data, 1997), from 30 days to as long as six months for female chlamydia patients (Zimmerman-Rogers, 1997; unpublished data, 1997), and 90 to 180 days for early latent syphilis (Gunn, 1998; unpublished data, 1997). Most often, the public health clinic provides a safe and convenient setting in which to interview and counsel patients compared to the field setting. The clinic allows for greater control over the interview process and permits access to additional personnel and materials, including medical records. However, interviews conducted outside the clinic setting afford the opportunity to observe patients in surroundings in which they are more comfortable and more in control. Interviews conducted in the home, for example, will afford the patient ready access to personal address books, pictures, etc., that can be helpful in locating partners, suspects, and associates. Interviews undertaken in other settings (e.g., crack houses, bars, housing projects, cars) also introduce the issue of personal safety for staff. Whatever the setting, DIS must foster a patient's trust and must assure confidentiality if an interview is to be successful, that is, create an opportunity for disease intervention. Interviews should be conducted in person and confidentially. However, in certain situations, it may be necessary to interview and counsel the patient by telephone. When efforts to meet with a patient in person have been unsuccessful or when the patient is not in the same city as the DIS, a telephone interview may be considered, if consistent with local policy. Telephone interviews do not allow patient observation and should be used with discretion and in accordance with local program policy. When interviewing by phone, certain privacy issues must be taken into account (such as making sure that one is speaking to the patient, cellular phones are not being used, no one else is on the line, etc). Telephone interviews may be followed by a face-to- ace reinterview. No studies have been published comparing the effectiveness of telephone interviewing vs. face-to-face interviewing, nor have any studies been published that discuss the ethical implications of telephone interviewing vs. face-to-face interviewing. Pre-interview analysis (patient assessment) DIS should thoroughly review all available materials related to a patient's case before each interview and counseling session. Such a review should include as many of the following as possible:
Verification is particularly important for those patients who "volunteer" at the STD clinic because any discrepancy provides cause for concern that must be addressed in the interview as this may be the only opportunity to speak with the patient. Once pre-interview analysis is completed, the DIS should initiate the session. However, a willingness to speak with a DIS does not mean that the individual is willing to fully disclose everything that is needed to best manage the case, especially partner information. When the patient is resistant to the interview process, the DIS should attempt to determine the reason(s) behind this unwillingness to cooperate and then address each issue, using motivational techniques such as: mode of transmission, confidentiality, asymptomatic nature of disease, reinfection, complications, consequences, social responsibility, and risk of HIV. Sometimes, a change in interviewer will facilitate a more open discussion. An interview should not be conducted with a third party present, even at the patient's request, unless it is for reasons of auditing DIS performance or translation. For those patients that still refuse to go forward with the interview, the DIS must carefully weigh any benefits to be gained by continuing to pursue the issue. Any decision not to interview a patient should be reviewed with the immediate supervisor. Whenever possible, this review should take place before the patient leaves the clinic. Programs are encouraged to require supervisory personnel to follow up with patients refusing an interview to assess whether there are DIS skill deficiencies that need to be addressed, patient dissatisfaction issues or a poor match of patient and interviewer.
Page last modified: August 16, 2007 Page last reviewed: August 16, 2007 Historical Document Content Source: Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention |
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Program Operations Guidelines for STD Prevention
