HIV: Interventions to Identify HIV-Positive People Through Partner Notification by Provider Referral Archived Review

The CPSTF finding is based on evidence from a systematic review of 9 studies (search period 1985 – 2004). The review was conducted on behalf of the CPST by a team of specialists in systematic review methods, and in research, practice, and policy related to HIV prevention.

Nine studies assessing provider referral qualified for the review and examined a series of related outcomes.

• Number of partners located and notified: 67% (8 studies)
• Number of notified partners (with unknown HIV status) who were tested: 63% (6 studies)
• Number of tested partners who were HIV-positive: 20% (7 studies)
• There was little difference among the three partner-notification methods evaluated (provider, patient, and contract referral) in terms of the mean number of infected individuals identified (although very few studies tested patient or contract referral).
• Behavioral changes after partner notification:
  • There were changes in the direction of safer sexual behavior with HIV partner notification.
  • Small number of studies and diversity of comparisons and outcomes precludes firm conclusions.
• Data do not suggest substantial harms to the person who is screened and found to be HIV positive resulting from partner notification services (two studies).

An economic review and cost-effectiveness analysis, using the same data set as this review and comparing three methods of referral (provider, patient, and mixed [dual]), found that provider referral is the most cost effective from both provider and societal perspectives.

• Review findings are likely to be applicable across a broad range of settings and populations.
• Included studies were conducted among a variety of populations (black and white men and women; gay, bisexual, and straight; intravenous drug users or not), in a variety of settings in the U.S. (statewide in seven states and locally in several cities), over a 20-year period.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps for partner counseling and referral services through provider, patient, and contract referral.

Results from the Community Guide reviews of the partner counseling and referral services reviews indicate that a number of PCRS-related issues warrant additional study and evaluation, primarily on patient, contract, and dual referral and comparisons of relative effectiveness among these methods and provider referral.

Approaches to partner notification vary; they include non health-department referral assistance, such as outreach-assisted partner notification; incorporation of social, as well as sexual, networks into PCRS and partner notification; and self-testing algorithms. The last unavoidably delays PCRS compared with in-person counseling and testing (followed by PCRS). Research is ongoing into the effectiveness of these approaches and ways to best match approaches to individuals and communities who are most likely to benefit from them. In trying to compare methods, the field would benefit from further comparisons of provider referral with other referral methods. Among the papers included in this review, the Landis randomized control trial demonstrated a large effect size for provider referral versus contract and patient referral. Nevertheless, comparisons with greater numbers of participants and more diverse settings would improve the quality of comparative evidence. Finally, this review did not specifically address the acceptability of PCRS, including partner notification, to patients and their partners, which should be evaluated further as this may affect the success of the process.

More studies are needed of the effects of PCRS on certain outcomes, especially behavior change and possible harms. The reductions in risk behavior found in Hoxworth subsequent to notification echo the conclusions of a recent meta-analysis showing that risk behaviors among those who know they are HIV-positive are, overall, less frequent than risk behaviors among those unaware of their status. Partner violence, although not proven to be a consequence of notification, is still a putative harm, especially in the context of patient referral (e.g., Rothenberg et al.). Moreover, the existence of violence in relationships where HIV/STD transmission occurs is widely supported anecdotally by public health staff. Even though the nature of the violence and the extent to which observed violence is attributable to notification is unclear, the risk should continue to be recognized by researchers and practitioners.

To the best of our knowledge, the effect on sexual behavior and partner notification participation of laws punishing “knowing transmitters” has not been studied. Research suggests that transmission of HIV may increase temporarily and substantially with STD co-infection, which speaks both to the importance of ongoing HIV partner notification and to the legal implications of admitting to having sex while HIV-positive. (Some jurisdictions have laws against HIV-positive individuals engaging in sex without disclosure of their HIV status. Becoming infected with an STD would constitute proof that the HIV-positive person had had sex, at which point disclosure would become an issue.) This critical contextual variable should receive additional study. Finally, although it seems self-evident that information garnered through PCRS, including partner notification, contributes to our epidemiologic understanding of HIV and its spread, it would be worthwhile to evaluate the benefit of PCRS to the research and programmatic efforts of public health agencies in fighting HIV.

The studies in this review were conducted:

• Among a variety of populations (black and white men and women; gay, bisexual, and straight; intravenous drug users or not)
• In a variety of settings in the United States (statewide in seven states and locally in several cities)
• Over a 20-year period

Hogben M, McNally T, McPheeters M, Hutchinson AB, Task Force on Community Services. The effectiveness of HIV partner counseling and referral services in increasing identification of HIV-positive individuals: a systematic review. American Journal of Preventive Medicine 2007;33(2S):S89–100.

Task Force on Community Services. Recommendations to increase testing and identification of HIV-positive individuals through partner counseling and referral services. American Journal of Preventive Medicine 2007;33(2S):S88.

Dooley, Jr. SW, Douglas, Jr. JM, Janssen RS. PCRS for HIV infection: New endorsement of an old approach. American Journal of Preventive Medicine 2007;33(2S):S81-3.

Golden MR. HIV PCRS: Finally getting beyond the name. American Journal of Preventive Medicine 2007;33(2S):S84-5.

Kissinger P, Malebranche D. Partner notification: Promising approach to reducing HIV/AIDS racial disparities in the U.S. American Journal of Preventive Medicine 2007;33(2S):S86-7.

Effectiveness Review

Analytic Framework – See Figure 2 on page S92

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table
Contains evidence from reviews of partner counseling and referral services through provider, patient, and contract referral

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

CDC. Partner counseling and referral services to identify persons with undiagnosed HIV—North Carolina, 2001. MMWR 2003;52:1181 4.

CDC. Partner notification for preventing human immunodeficiency virus (HIV) infection–Colorado, Idaho, South Carolina, Virginia. MMWR 1988;37:393 6.

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

Hoffman RE, Spencer NE, Miller LA. Comparison of partner notification at anonymous and confidential HIV test sites in Colorado. J Acquir Immune Defic Syndr Hum Retrovirol 1995;8:406 10.

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.

Rutherford GW, Woo JM, Neal DP, et al. Partner notification and the control of human immunodeficiency virus infection. Two years of experience in San Francisco. Sex Transm Dis 1991;18:107 10.

Spencer NE, Hoffman RE, Raevsky CA, Wolf FC, Vernon TM. Partner notification for human immunodeficiency virus infection in Colorado: results across index case groups and costs. Int J STD AIDS 1993;4:26 32.

Toomey KE, Cates WJ. Partner notification for the prevention of HIV infection. AIDS 1989;3(Suppl 1):S57 S62.

Wykoff RF, Jones JL, Longshore ST, et al. Notification of the sex and needle-sharing partners of individuals with human immunodeficiency virus in rural South Carolina: 30-month experience. Sex Transm Dis 1991;18:217 22.

Economic Review

Ekwueme D, Hutchinson A, Dean H, Kim A. Estimating the cost and effectiveness of three referral strategies for HIV partner counseling and referral services (Abstract). 2005: E24.

The following outlines the search strategy used for the systematic review of partner counseling and referral services through provider, patient, and contract referral.

A comprehensive search strategy for studies evaluating HIV PCRS, including partner notification, was developed in conjunction with HIV reference librarians from the CDC Information Center. The literature search was initiated in September 2003 and later updated in September 2004 using five database-specific search strategies for AIDSLine, Embase, Medline, PsycInfo, and Sociofile. To reduce publication bias and gaps in the automated search, the Community Guide staff conducted additional searches using the Internet, reference lists, and referrals from HIV specialists at CDC and members of the team that conducted the systematic review. Studies were eligible for inclusion if they:

• Were published in English during 1985-2004
• Were conducted in a country with a high income economy
• Assessed partner notification
• Provided data to calculate the proportion of individuals tested through partner notification who tested positive for HIV

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Although acceptance and support of HIV partner notification is sometimes visible among HIV-affected communities, actual and perceived stigmatization of HIV-positive people still exists, and some individuals and HIV advocacy groups are suspicious of any governmental presence in HIV control efforts.
• Moreover, HIV differs from curable STDs in that people, once infected, are theoretically never free of transmission risk. This condition suggests that partner notification should be an ongoing process in which public health professionals encourage new partners of HIV-positive people to be notified of their exposure and tested. But some jurisdictions have laws designed to punish anyone who knows that he or she is HIV positive and admits to having sex without disclosing his or her HIV status.
• Norms for anonymous sexual encounters may differ among groups who vary in STD and HIV risk. For example, men who have sex with men, among whom HIV is more prevalent than in other groups, appear to also have more anonymous partners, making partner notification much more difficult.
• The long asymptomatic phase of the pathogen can make it difficult to gauge how far back in time to identify partners to be notified.

Healthy People 2020

Healthy People 2020 includes the following objectives related to this CPSTF recommendation.

• HIV, Objective 13 (HIV-13): Increase the proportion of persons living with HIV who know their serostatus
• HIV, Objective 14 (HIV-14): Increase the proportion of adolescents and adults who have been tested for HIV in the past 12 months