Sexually Transmitted Diseases  >  Program Guidelines  >  Partner Services

Program Operations Guidelines for STD Prevention
Partner Services

Previous Page

Table of Contents

Next Page

Sections on this page:

• Partner Notification Strategies
• Provider Referral, Self (Patient) Referral
• Contract Referral
• Evidence Supporting Partner Notification
• Other Important Concepts About Partner Notification
• Encouraging the Partner to Seek Medical Treatment
• Follow-up to Ensure Notification Is Received and Understood
• Ensuring That the Partner Has Access to Health Care
• Diagnostic Assessment of Partners in the Field
• Case Closure

Partner Notification Strategies

Three primary strategies can be used to notify partners of possible exposure to STD or HIV infection: Provider, Self, or Contract referral. Often, more than one strategy may be used to notify different partners of the same infected patient. The strategy will depend on the particular patient, the particular STD, and on partner circumstances. For example, a patient with a STD may feel that he or she is in a better position to notify a main partner, but would prefer that the provider (DIS) notify other partners.

Programs must make the decision as to when a particular type of notification will work best in their area. This decision should be based on program priorities, disease morbidity, and program staffing levels. For example, a program may chose to utilize provider referral for patients with infectious syphilis yet utilize patient referral or contract referral for patients with gonorrhea and chlamydia. Others may chose to conduct provider referral for all patients, regardless of disease. In any case, DIS must work under the assumption they may have to locate a partner, even if the patient referral or contract referral option is used. DIS should obtain locating information on all partners and suspects, regardless of the option chosen, so they are prepared to follow up on partner notification activities.

Provider Referral

Provider referral is a notification strategy where, with the consent of the infected patient, the provider takes responsibility for confidentially notifying partners of the possibility of their exposure to a STD. The DIS will search health department open and closed records to determine whether the partner has ever been tested or treated for STD or HIV and to seek additional locating information. If the partner has been previously tested and/or treated, then the DIS determines whether notification is still warranted. Notification may not be needed if the partner has been recently tested, treated, or counseled and is aware that he or she has been exposed to an STD. If notification is needed, the DIS can use the information provided by the original patient or by record search to locate and refer the partner for prevention counseling, testing, and examination (see Appendix F for details of provider notification process). Once the partner has been located, the DIS informs him or her confidentially and privately of the possibility of his or her exposure to STD. Information leading to the identity of the original patient is never revealed to the partner.

Research has shown that provider referral is the most effective method to notify partners (Macke, 1999). When discussing partners, the DIS should elicit names and exposure information with the assumption the health department will perform the notification. Advantages to this method are the ability to:

• verify that partners have been offered and have received evaluation and risk reduction counseling;
• ensure the patient's confidentiality since no information about the patient is disclosed to partners;
• help defuse any partner anger or blame reactions, and respond to the partner's questions or concerns;
• offer field specimen collection (blood, saliva, urine);
• provide on the spot counseling;
• identify opportunities to provide behavior change counseling; and
• provide immediate referrals and offer information.

Disadvantages to this method are:

• the difficulty in readily locating and identifying partners;
• less familiarity with the lifestyle and problems of the partner; and
• it uses more staff members and financial resources as compared with other methods.

Self (Patient) Referral

Self referral (sometimes called patient referral) is the notification strategy whereby the patient with a STD accepts full responsibility for informing partners of their exposure to a STD and for referring them to appropriate services. When self referral is chosen, the interviewer should coach and/or role play the following:

• WHEN to do the notification—encouraging the patient to notify partners promptly.
• WHERE to perform the notification—encouraging a private setting.
• HOW to tell the partner—coaching the patient to avoid blame by stating in simple terms someone has tested positive, and because this person cares about the partner, he/she is encouraging the partner to seek examination and treatment.
• REACTION—asking the patient how they think the partner will react, or has reacted to difficult news in the past. Help the patient anticipate potential problems, especially in regard to loss of anonymity. If a patient has difficulty at this point, the benefits of provider referral should be discussed and promoted.

Advantages to this method are:

• notification may result in a more prompt referral to appropriate services because the patient is usually more familiar with the identity and location of the partner; and
• fewer staff members and financial resources may be used.

The disadvantages of self referral include:

• forfeiting of anonymity, resulting in possible disclosure of the infection to third parties, subsequent discrimination, or a partner's reaction;
• the loss of confidentiality may increase the potential for violence;
• the patient may, intentionally or unintentionally, convey incorrect information, resulting in incomplete or ineffective referrals;
• the patient may not follow through on the notification of the partner, resulting in the increased probability of transmission to others and in additional time for the DIS, who will then have to contact the partner; and
• increased difficulty in evaluating outcomes.

Contract Referral

Contract referral is the notification strategy in which the provider negotiates a time frame (usually 24-48 hours) for the patient to inform his or her partners of their exposure and to refer them to appropriate services. The DIS collects all locating information for all partners, suspects, or associates discussed during the interview. If the patient is unable to inform partners within an agreed-upon time period, the DIS will notify and refer the partners. As in provider and self referral, the interviewer needs to obtain identifying and locating information on partners at the time of the interview. The DIS should also negotiate a confirmation of referral. Similar to provider referral, this option affords the DIS the ability to verify that partners have been notified and referred.

The advantages of this method are:

• it provides professionally trained support for the patient who chooses to notify his or her partners;
• it ensures that referral to appropriate services is provided and that prompt follow-up for the partner is available.

Disadvantages to this method are:

• it may result in lost time and the potential for further transmission of disease if the patient does not notify partners.

The following ideas and recommendations (West, 1997) may serve as guides for developing partner notification approaches:

• Provider referral is more effective than self referral in reaching partners, suspects, and associates.
• Most individuals will cooperate in notifying at least some partners, suspects, and associates.
• Partners are generally receptive to being notified and will seek testing once they have been notified.
• Partners often are unaware of their or their partners' STD risks.
• Partners frequently are found to have a STD.
• It is important for patients to recognize and understand the importance of partner notification.
• Reaching persons in early stages of their infection can enhance disease intervention and prevent disease complications.
• Many legal and ethical concepts pertain directly to partner notification and have important implications (duty to warn, right to know, duty to protect public health, right of confidentiality and privacy, protection against discrimination, need to protect family and personal relationships).

DIS should be prepared to discuss the pros and cons of each notification strategy, including the likelihood of verbal or physical abuse. Programs should have in place a means of assessing the likelihood of violence as a result of partner notification and have a plan for addressing those situations.

Evidence supporting partner notification

While there are unanswered questions about partner notification, a review of the evidence supports several recommendations (Macke, 1999). There is good evidence to show 1) partner notification can be an effective means of finding at-risk and infected persons, 2) provider referral generally ensures that more partners are notified and medically evaluated; and 3) the reputation of partner notification service providers influences the success of partner notification as an intervention. More research is needed on tailoring elicitation and notification procedures to specific populations, the effect of new testing technologies on partner notification, and the consequences of partner notification for infected persons and their partners.

Other important concepts about partner notification

Encouraging the partner to seek medical treatment

The actions that a person takes (or does not take) to address health concerns include appraising the problem and the need for clinical care, reaching a decision to seek care, and acting on that decision. For example, a partner may have symptoms consistent with a STD but "appraise" the situation as a "normal" discharge and, as a result, not seek clinical care independently. People also sometimes treat themselves or consult with alternative practitioners. Partners tested in the field should be encouraged to obtain their test results and an appropriate medical evaluation (including treatment, if needed). Published literature identifies that the following factors contribute to delays in seeking appropriate treatment for an STD: a lack of symptoms (Niemiec, 1978) or the classification of STD symptoms as normal (Harrison, 1982; Fortenberry, 1997); being female (Leenaars, 1993); adolescents' sense of invulnerability and the stigma associated with acquiring a STD (Fortenberry, 1997). It is worth noting that persons with multiple partners and persons with a single partner are equally likely to delay care (Leenaars, 1993). Finally, partners may need other types of referrals as well (i.e., pregnancy, intimate violence) and DIS should be prepared to make these referrals and to support the patient in obtaining other services to the extent possible.

Follow-up to ensure notification is received and understood

When a partner who has been notified of his or her exposure does not seek medical evaluation, the DIS should follow up with that partner to ensure they understand the importance of timely and appropriate medical evaluation. Often, repeated conversations are needed. In these situations, DIS should be persistent and employ appropriate motivational techniques in a manner that conveys a sense of urgency and re-emphasizes the benefits and value of medical evaluation. Stalled investigations should be brought to the attention of a supervisor at the earliest opportunity for discussion and further action. Non-productive routine visits or dropping a referral letter is not an effective use of program resources.

Ensuring that the partner has access to health care

If a partner is evaluated by a provider outside the health department, the DIS should contact the provider to ensure that the partner receives appropriate and timely test(s) and treatment(s). Following the appointment time, the DIS should contact the provider to verify appropriate management of the partner. Self-reporting is not sufficient. The health care provider treating a partner should be personally contacted, or the medical record reviewed to verify that appropriate tests and treatments were administered. Conversely, if the partner was referred from another health care provider and is treated in a health department clinic, the information regarding treatment of the partner should be communicated back to the referring health care provider.

Diagnostic assessment of partners in the field

Venipuncture is a skill required of public health nurses, and of many federal, state, and local DIS and is an especially valuable tool in the disease intervention process. Programs intending to use DIS in this manner need to review all relevant state health and safety codes and local public health protocols to determine required training and certification procedures before performing this activity. DIS must exercise the utmost care and professional judgment when performing field venipuncture procedures and must be certain to have the appropriate equipment and supplies available before undertaking field activities that may include drawing blood. For more detailed information regarding venipuncture, see the chapter titled "Medical and Laboratory Services." It is strongly recommended that part of the training afforded DIS include an orientation to the state or local "Occupational Infections in the Workplace" policy and the supporting procedural manual. This will expose the DIS to precautions and procedural recommendations set forth by NIOSH, CDC, and state OSHA programs. Programs also must have in place an "Occupational Infections in the Workplace" policy that is at least as restrictive as the Occupational Safety and Health Administration policy (see references for complete citation). More current information may be obtained from the OSHA website (www.osha.gov).

More and more disease control programs are exploring opportunities presented by emerging laboratory technology and the resulting testing procedures to identify and control communicable diseases. For example, tests that rely on urine or saliva to detect chlamydia, gonorrhea, or HIV infection have created opportunities for conducting screening activities that target specific high-risk populations at the community level. Some programs have expanded or are in the process of expanding the responsibilities of DIS to include administering these tests in the field and are using DIS to read skin tests for tuberculosis. Any decision to expand the responsibilities of the DIS in this area must be predicated on 1) the additional duties being consistent with DIS position descriptions; 2) DIS ability to legally provide the services outlined; and 3) DIS being afforded the necessary training to properly and safely deliver those services.

Case closure

For some cases of syphilis, diagnosis is not determined until case closure. This is particularly true for those persons with positive bloods, but without a symptom or blood test history. Only through interview and follow up of sex partners can it be determined if such a person should be classified as early latent, late latent, or syphilis of unknown duration.

A case is closed when the DIS and next level supervisor agree that all reasonable steps to intervene in the disease process have been completed. Before such a discussion, the DIS should carefully review the entire case record and those of related infections to ensure that all program required data needs have been met; that information is complete and consistent (e.g., test results documented, reinterview and cluster interview forms present, contacts and  clusters dispositioned, and any necessary source/spread determinations made); and that all supervisory recommendations have been fully addressed. The entire lot or record should be submitted to the supervisor for final review. Interview records indicating that contact was not made or that partners were not medically evaluated must be discussed and signed off with the supervisor before closure. With the concurrence of the supervisor, the case is updated to reflect the closure date. Cases should be closed within locally established time frames.

Previous Page

Table of Contents

Next Page