Strategies for partner notification for sexually transmitted diseases
To prevent further transmission of infection or of re-infection of index patients, sexual partners should be referred for diagnosis and treatment. However, the potential negative effects of partner notification (e.g. domestic violence) raise doubts about its benefits.
RHL Commentary by Volmink J
1. EVIDENCE SUMMARY
This Cochrane review compared the effectiveness of partner notification strategies for the treatment of sexually transmitted infections (STIs). Three main referral strategies were compared: provider referral (partner notification by health care personnel), contract referral (health personnel notifying partners who fail to visit the health clinic by an agreed date) and patient referral (the index patient notifying his/her partner or partners). Educational strategies to improve patient referral were also evaluated.
There is some evidence that provider referral is more effective than patient referral in patients with non-specific urethritis. One trial found provider referral yielded higher rates of receiving treatment and chlamydia detection compared with patient referral. Giving patients a choice between provider and patient referral also appears to be more effective than just assigning the notification task to the patient. In one study in patients with HIV, more partners were notified and more partners tested positive for HIV when patients were offered the choice between provider and patient referral.
Another trial compared the effectiveness of the choice between patient and provider referral plus counseling and contact cards versus patient referral alone in patients with an STI. In the group that was offered the choice between patient and provider referral plus counseling and cards, male index patients reported more partner notifications and more partners came forward for treatment than in the case of those assigned to the patient referral group only; however, in the former group there was also a higher rate of domestic quarrels. No differences were found for women index patients.
There is also some evidence that compared with patient referral alone, contract referral results in more partners of gonorrhoea patients presenting for care. The results of the review did not provide sufficient information for conclusions to be reached about the relative efficacy of contract versus provider referral strategies.
One trial sought to improve patient referral through education (of the index patient) by a nurse plus counseling by lay workers. This intervention resulted in a small increase in the number of partners being treated compared with standard patient referral.
A comprehensive search strategy was used to identify published and unpublished randomized trials. Independent reviewers applied eligibility criteria, extracted data and assessed methodological quality of included studies. None of the trials identified was excluded from the review; however, the reviewers noted that there was a risk of bias in all of them.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
Sexually transmitted infections remain a major public health problem worldwide. They are a leading cause of morbidity with far-reaching health, social and economic consequence (1). Rates of STIs are increasing in some regions, especially in people aged 15–25 years. The best means to deal with the spread of the infections continues to be elusive (2). The HIV/AIDS pandemic, with its devastating effects especially in sub-Saharan Africa, has focused attention on the urgent need to control STIs since the presence of STIs substantially increases the risk of sexually acquired HIV infection (1).
2.2. Feasibility of the intervention
Patients with STIs are likely to have partners who are infected. In order to prevent the further transmission of infection or of re-infection of index patients, sexual partners should be referred for diagnosis and treatment. This is particularly important for female partners of male patients with STIs since the female partners are frequently asymptomatic and thus may not come for treatment. While each of the three available strategies for partner notification should be feasible in under-resourced settings, special challenges exist. Provider referral may be more challenging and costly to implement compared with others. Where health services are overburdened, it may be difficult to ensure adequate privacy for patients to discuss issues of notification of partners. Where health care providers are not adequately trained to be sensitive towards patients’ needs, there is a risk of some of the providers adopting authoritarian and coercive approaches to partner notification, which are likely to render patients even less willing to share information. Cultural factors must always be considered since failure to consider issues such as the imbalance of power between men and women could lead to the abandonment of, and violence against, women. In this regard the importance of confidentiality cannot be emphasized sufficiently. Finally, in under-resourced settings access to adequate diagnostic and treatment facilities can be difficult. This is especially true for women in rural areas whose partners are treated in the cities where they are employed as migrant workers.
2.3. Applicability of the results of the Cochrane Review
The extent to which information from these studies can be generalized is unclear. The trials included in the review assessed the effects of partner notification for only a limited number of STIs and only two of the studies were conducted in developing countries. Furthermore, the paucity of data on the potential negative effects of partner notification, such as domestic conflict and violence, does not permit conclusions about whether the benefits of the interventions outweigh the risks. This issue is particularly important for people with HIV/AIDS living in developing countries, where antiretroviral treatment is generally not available, stigma of the disease is great and early death from the disease is certain.
2.4. Implementation of the intervention
This review provides limited evidence that provider referral or a choice between patient and provider referral is more effective than patient referral in bringing partners to health services for treatment. In view of the limited number of available trials, the poor methodological quality of the trials and limited data from low-income countries, it is not possible to choose between different partner notification strategies.
Trials comparing the effects of various notification strategies in developing countries (especially those with high HIV and STI rates) are needed. These trials should be carefully designed to limit bias (for example, through adequate allocation concealment and blinding of outcome assessments). Studies should assess a broader range of outcomes including re-infection rates, incidence of STIs, costs and harmful effects.
- Guidelines for the management of sexually transmitted infections. Geneva. World Health Organization 2001;(WHO/HIV-AIDS/2001.01).
- Gilson RJC, Mindel A. Sexually transmitted infections. British medical journal 2001;322:1160-1164.
This document should be cited as: Volmink J. Strategies for partner notification for sexually transmitted diseases: RHL commentary (last revised: 11 November 2002). The WHO Reproductive Health Library; Geneva: World Health Organization.