A systematic review of HIV partner counseling and referral services: client and provider attitudes, preferences, practices, and experiences

OBJECTIVES: The objectives of this study were to understand client and provider attitudes, experiences, and practices regarding HIV partner notification in the United States and to help identify future research and program needs. GOALS: The goals of this study were to synthesize the literature reporting client and provider attitudes, experiences, and practices and to identify potential negative effects of HIV partner notification. STUDY DESIGN: This study consisted of a systematic qualitative review. RESULTS: Clients were willing to self-notify partners and participate in provider notification, and few reported negative effects. The majority of health care providers were in favor of HIV partner notification; however, they did not consistently refer index clients to HIV partner notification programs. CONCLUSION: Considering that clients have positive attitudes toward self- and provider referral, local HIV prevention programs need to ensure that all HIV-positive clients are offered partner notification services. Additional research is needed to assess the potential risks of notifying partners and to identify effective techniques to improve client and provider participation.     

Partner notification for HIV and syphilis: effects on sexual behaviors and relationship stability

BACKGROUND: Partner notification (PN), originally designed for syphilis control, has been used to control the spread of HIV since 1985. Because HIV infection is noncurable, the benefit of contact tracing and treatment demonstrated for the control of syphilis may not apply to HIV. For HIV, PN must facilitate behavior change that will reduce the spread of the infection. One concern is that HIV PN can promote the breakup of old partnerships and increase the acquisition of new partners, thereby spreading HIV infections. GOAL: The purpose of this study was to determine the effect of partner notification (PN) on sexual behavior and relationship stability among HIV partnerships, with use of syphilis partnerships for comparison. STUDY DESIGN: Partnerships were eligible if the index case was interviewed by a disease intervention specialist (DIS) for PN and named at least one sex partner. Partnership information was reported by index cases interviewed at baseline and 3 and 6 months post-PN. Trends in partnership dissolution and acquisition, sexual abstinence, condom use, emotional abuse, and physical violence reported by HIV infection and syphilis index cases were compared. RESULTS: A total of 157 index cases (76 HIV infection and 81 syphilis) reported 220 partnerships (94 HIV and 126 syphilis). The PN process was completed for 32.7% of partnerships and it was completed more often for partnerships that were classified as main and cohabiting. After PN, 46.8% of partnerships dissolved, 15.9% of cases acquired a new partner, and emotional abuse and physical violence decreased significantly. HIV index cases were somewhat more likely to report using condoms at last sex act and less likely to acquire a new sex partner after PN compared to syphilis index cases. There was no difference post-PN between HIV infection and syphilis partnerships for partnership dissolution, physical violence, emotional abuse and abstention from sex. CONCLUSION: HIV PN did not appear to cause greater partnership dissolution, new partner acquisition, or violence compared with syphilis PN.     

HIV-related risk behaviors and history of sexually transmitted diseases among male migrants who patronize commercial sex in China

BACKGROUND AND OBJECTIVE: Men who pay for sexual services are at increased risk for HIV/sexually transmitted disease. Data on the sociodemographic and behavioral characteristics of such men in China are limited. STUDY DESIGN: Two cross-sectional surveys, using similar instruments, were completed among Chinese migrants in Beijing, Shanghai, and Nanjing in 2002. A total of 1304 rural-to-urban migrant men from community settings ("community sample") and 465 migrant men attending sexually transmitted disease clinics ("STD clinic sample") were included in the current study. RESULTS: Ten percent of men in the community sample and 32.7% of men in the STD clinic sample reported having ever paid for sex. Nearly 20% of clients from the community sample and 60% of clients from the STD clinic sample reported a history of STDs. For both the community and STD clinic samples, working at industrial or construction sectors, multiple sexual partners, regular sex partner having sex with others, and a history of drug use were associated with being a male client. In addition, perceived peer sexual risk and perceived vulnerability to STD were associated with being a male client in the community sample, and a history of STD and being tested for STD/HIV were associated with being a male client in the STD sample. CONCLUSION: Male migrants who paid for sex in China were vulnerable to HIV/STDs. HIV prevention efforts should target young migrant men who work at factory and construction sectors. STD clinics may be important sites for outreach and intervention efforts among male clients.     

Prevalence of syphilis and HIV infections among men who have sex with men from different settings in Shenzhen, China: implications for HIV/STD surveillance

HIV/STD surveillance system data are important for developing prevention and control programmes for men who have sex with men (MSM), now a core group in Chinese HIV/STD surveillance activities. MSM were recruited from different settings in Shenzhen and were tested for HIV and syphilis. A substantial prevalence of HIV and syphilis infections was found in this population. However, risk behaviours and sociodemographic characteristics varied greatly among MSM recruited from the different settings (gay sauna, gay bar and MSM clinic), suggesting that carefully considering and selecting appropriate settings to represent the MSM population is critical for developing HIV and STD surveillance and prevention programmes.     

Intention to notify sexual partners about potential HIV exposure among New York city STD clinics' clients

BACKGROUND: Partner notification legislation has recently been implemented in New York State. GOAL: The goal of the study was to assess willingness of individuals seeking HIV testing to (1) give counselors contact information about partners, if infected, and (2) contact partners on their own. STUDY DESIGN: Before implementation of the legislation, 1372 individuals seeking HIV testing at New York City Department of Health STD clinics completed a brief, anonymous survey. RESULTS: More than 90% of heterosexually active individuals and more than 80% of men who have sex with men (MSM) could contact sex partners with whom they had had unprotected vaginal/anal sex. Were they to test HIV-positive, almost all respondents would have been willing to notify sex partners personally; 90% of heterosexually active individuals and 80% of MSM also expressed willingness to provide contact information to providers. Respondents preferred to be notified by a sex partner rather than by a provider. Patient-referred clients reported being more comfortable with the referral than provider-referred clients. CONCLUSIONS: Voluntary partner notification performed by the index case-with notification by the provider should the former fail to occur-is recommended.     

HIV and STD status among MSM and attitudes about Internet partner notification for STD exposure

OBJECTIVES: This study assessed the acceptability and perceived utility of Internet-based partner notification (PN) of sexually transmitted disease (STD) exposure for men who have sex with men (MSM) by human immunodeficiency virus (HIV) serostatus. STUDY DESIGN: We recruited 1848 US MSM via a banner advertisement posted on an MSM website for meeting sexual partners between October and November 2005. RESULTS: Even though there was broad acceptance of a PN e-mail across HIV serostatus groups, HIV-infected men rated the importance of each component (e.g., information about where to get tested/treated, additional education regarding the STD exposed to, a mechanism for verifying the authenticity of the PN e-mail) lower than HIV-uninfected or status-unknown participants (all P's <0.01). Additionally, HIV-infected participants were less likely to use the services offered within a PN e-mail (if they were to receive an e-mail notifying them of possible STD exposure in the future), and were less likely to inform their partners of possible STD exposure via an Internet notification system in the future (all P's <0.01). A similar trend emerged about men who reported not having a previous STD compared with those who did. Men who reported no previous STD found Internet PN more acceptable. CONCLUSIONS: Overall, this study documents broad acceptance of Internet PN by at-risk MSM, regardless of HIV serostatus, including a willingness to receive or initiate PN-related e-mail. If public health officials consider using Internet notification services, they may need to anticipate and address concerns of HIV-infected MSM, and will need to use a culturally-sensitive, social marketing campaign to ensure that those who may benefit from these services are willing to use this modality for PN. Internet PN should be considered as a tool to decrease rising STD and HIV rates among MSM who use the Internet to meet sexual partners.     

Human immunodeficiency virus and other sexually transmitted infections among female sex workers in two major cities in Papua New Guinea

BACKGROUND: Treatable sexually transmitted infections are very common in developing countries and quite often are inadequately treated or remain untreated despite the fact that they enhance the transmission of human immunodeficiency virus (HIV). GOAL: To estimate the prevalence of HIV, syphilis, chlamydial infection, gonorrhea, and trichomoniasis among female sex workers in Port Moresby and Lae, Papua New Guinea, and to collect data on associated behaviors. STUDY DESIGN: Self-identified female sex workers recruited through our peer-mediated sexually transmitted disease (STD)/HIV risk-reduction community outreach program were invited to participate in the study. Participants underwent pretest counseling, were interviewed, and were asked to self-collect vaginal swab specimens for the detection of STDs and to provide 10 mL of blood for HIV and syphilis testing. RESULTS: A total of 407 female sex workers, 207 in Port Moresby and 200 in Lae, were enrolled in the study. The overall prevalence rates of HIV, syphilis, genital chlamydial infection, gonorrhea, and trichomoniasis among these women were estimated to be 10%, 32%, 31%, 36%, and 33%, respectively. The sex workers in Port Moresby had a significantly higher HIV infection rate (17%) than those in Lae (3%) and a significantly lower trichomoniasis rate (21%) than those in Lae (44%). Mixed infections were common, occurring in 45% of the cases. Despite a high rate of symptoms, the rate of treatment-seeking was low. Condom use among the sex workers was very inconsistent; 85% reported that they did not use condoms at all times when having sex with their clients. Common reasons cited were dislike by clients, unavailability, alcohol use, and familiarity with a client. CONCLUSIONS: STDs are very common among female sex workers in Port Moresby and Lae and very often present as multiple infections. Despite STD/HIV awareness campaigns, unsafe sex-particularly irregular use of condoms-continues among sex workers and their clients. Barriers to safer sexual behavior need to be addressed, as do improvements in provision of STD services.     

Rising rates of syphilis in the era of syphilis elimination

OBJECTIVE: The objective of this study was to assess the impact of syphilis control activities in King County, Washington. STUDY DESIGN: We calculated rates of early syphilis and trends in numbers of persons tested and diagnosed through screening and partner notification from 1998 to 2005. RESULTS: Early syphilis cases increased from 38 in 1998 to 188 in 2005 with 92% occurring among men who have sex with men (MSM). Our health department conducted public awareness campaigns, increased publicly financed syphilis screening among MSM by 179%, and intensified partner notification efforts. Despite these efforts, the prevalence of syphilis among screened populations was only 1.1%, and 71% syphilis cases were diagnosed after seeking care for symptoms. The proportion of cases diagnosed through screening and partner notification did not significantly change during the evaluation period. Early syphilis incidence among MSM more than doubled between 2003 and 2005. CONCLUSIONS: New, innovative approaches to syphilis control are needed.     

HIV prevalence and risk behaviour among prostitutes and clients in Amsterdam: migrants at increased risk for HIV infection.

OBJECTIVES--To study groups of prostitutes and clients of prostitutes in order (i) to determine HIV prevalence and sexual risk behaviour, (ii) to determine differences between samples recruited within and outside a clinic for sexually transmitted diseases (STD) and (iii) to determine correlates of inconsistent condom use (ICU) among both groups. DESIGN--Participants were interviewed and anonymously tested for HIV-antibody; approximately half were recruited at a clinic for sexually transmitted diseases (STD) and half at prostitute working places. SETTING--An STD clinic and prostitute working places in Amsterdam in 1991. SUBJECTS--201 female prostitutes without a history of injecting drugs and 213 male clients of female prostitutes. MAIN OUTCOME MEASURES--antibodies to HIV, consistency of condom use in commercial vaginal contacts in the preceding 6 months. RESULTS--HIV prevalence was low: three prostitutes (1.5%; 95% CI 0.5-4.6%) and one client (0.5%; 95% CI 0.1-3.3%) were infected. All three HIV positive prostitutes originated from AIDS-endemic countries, came to the Netherlands only recently and were recruited outside the STD clinic. Large differences between subgroups resulted from the two recruitment methods: while clients of prostitutes with relatively high risk behaviour were strongly represented among the STD clinic sample, high risk prostitutes were underrepresented in this sample. Consistent condom use (with 100% of contacts) was reported by 66% of prostitutes and 56% of clients of prostitutes. Inconsistent condom use was found to be high among prostitutes who had migrated from Latin America and among migrant clients of prostitutes. CONCLUSIONS--When monitoring HIV infection one must take into account imported cases. HIV prevention efforts should be particularly focused at prostitutes from Latin America and at clients of prostitutes who migrated to the Netherlands.     

Characteristics of female sex workers with US clients in two Mexico-US border cities

BACKGROUND: HIV prevalence is increasing among female sex workers (FSWs) in Tijuana and Ciudad Juarez, 2 Mexican cities on the US border. Quasilegal prostitution in both cities attracts large numbers of sex tourists. We compared FSWs with and without US clients in both cities. METHODS: FSWs aged > or =18 years reporting unprotected sex with > or =1 client within the last 2 months, who were not knowingly HIV-infected, were enrolled in a behavioral intervention study. At baseline, participants underwent interviews, antibody testing for HIV and syphilis, and vaginal swabs for detecting gonorrhea and Chlamydia. Logistic regression identified factors associated with reporting >1 US client. RESULTS: Of 924 FSWs, 69% had US clients. Median age and duration in sex work were 32 and 4 years. Prevalence of HIV, infectious syphilis (titer > or =1:8), gonorrhea, Chlamydia, and any STI was 6%, 14%, 6%, 13%, and 27%, respectively. Compared with other FSWs, FSWs with US clients were more likely to have syphilis titers > or =1:8 (16% vs. 10%, P = 0.01), gonorrhea (8% vs. 2%, P <0.001) or any STI, including HIV (30% vs. 20%, P = 0.002). Factors independently associated with having US clients were: living in Tijuana, being younger, speaking English, being paid more for having sex without a condom, having >250 clients in the last 6 months, having syphilis titers > or =1:8, and injecting drugs. CONCLUSIONS: In these border cities, FSWs reporting US clients were more likely to have current STIs and to engage in higher-risk behaviors. Intensified binational prevention efforts involving both FSWs and their clients are urgently needed.     

Partner notification for sexually transmitted diseases in Peru: knowledge, attitudes, and practices in a high-risk community

OBJECTIVES: Notification and treatment of sex partners after diagnosis of a sexually transmitted disease (STD) is essential to reduce reinfection and further transmission. GOAL: The goal of this study was to determine the prevalence of partner notification and subsequent health-seeking behavior in a high-risk population in Lima, Peru. STUDY DESIGN: STD-infected participants of an HIV/STD prevention trial completed a questionnaire concerning partner notification. RESULTS: Of the 502 STD-positive subjects, 287 completed the survey. Among survey participants, 65% informed their primary partner and 10.5% informed casual or anonymous partners. Reasons for failure to notify varied by partner type and included not understanding the importance of partner notification, embarrassment, fear of rejection, and inability to locate the partner. When notified, approximately one third of all partners sought medical attention. CONCLUSIONS: Partner notification in Peru is limited by relationship dynamics, social stigma, and limited contact information. Interventions could emphasize the importance of notification, improvement of communication skills, and introduce contact tracing programs (including Internet-based systems) and expedited partner therapy.     

Part time female sex workers in a suburban community in Kenya: a vulnerable hidden population

BACKGROUND: In sub-Saharan Africa, female sex workers (FSWs) are a vulnerable high risk group for the acquisition and transmission of sexually transmitted infections (STI) and HIV. OBJECTIVES: To study parameters of sexual behaviour and knowledge of STI and HIV, to describe health seeking behaviour related to STI, and to measure the prevalence of gonorrhoea, chlamydia, syphilis, and HIV-1, to provide baseline data for targeted STI and HIV prevention interventions. METHODS: In a cross sectional survey with snowballing recruitment, between February and March 2000, 503 self identified FSWs in a suburb in Mombasa, Kenya, were interviewed with a structured questionnaire and screened for gonorrhoea, chlamydia, syphilis, and HIV-1. RESULTS: The mean number of sexual partners in the previous week was 2.8 (SD 1.6). The mean number of non-regular clients and regular clients in the previous week was 1.5 (1.0) and 1.0 (0.9) respectively. The median weekly income from sex work was $US15. A total of 337 (67%) women had an alternative income in the informal sector. 146 (29%) and 145 (45%) never used a condom with a client and non-paying partner respectively. The prevalence of gonorrhoea, chlamydia, and syphilis was 1.8%, 4.2%, and 2.0% respectively. The overall HIV-1 seroprevalence was 30.6%. CONCLUSIONS: There is a large need for intensive STI and HIV prevention interventions in part time FSW.     

广州市男男性行为人群STD/HIV相关高危行为特征及就诊延误影响因素调查分析

目的:了解广州市男男性行为(MSM)人群STD/HIV相关高危行为特征和就诊延误影响因素,为制定有针对性的防控措施提供依据。方法:2014年10月至2015年9月期间,对参加STD/HIV自愿咨询检测且已经出现疑似STD/HIV感染相关症状、近2年内发生过同性性行为的MSM进行面对面问卷调查,采集静脉血检测HIV和梅毒。结果:共调查313名MSM,38.02%近2年内与异性发生过性行为,40.89%拥有固定的同性性伴,肛交性行为中每次都使用安全套的比例为47.04%。本次病程中80.51%发生就诊延误,首次就诊间隔时间平均为30天,影响就诊延误的因素主要包括职业、对同性恋的态度、近2年是否发生异性性行为、是否曾患其它非梅毒性病、就诊频次、是否暂停性生活。血清学监测结果 HIV感染率为20.77%,现症梅毒感染率为6.39%,同时感染HIV和梅毒的比例为4.79%,就诊延误发生者的HIV感染率和梅毒感染率均高于未发生就诊延误者,差异有统计学意义(P值均0.05)。结论:广州市MSM人群HIV感染率高,高危行为普遍存在,就诊延误发生率高,防控形势严峻,应加大宣传教育、提高医疗服务可及性和服务质量以减少就诊延误的发生。     

Case-finding effectiveness of partner notification and cluster investigation for sexually transmitted diseases/HIV

OBJECTIVE: To assess the case-finding effectiveness of partner notification(PN) and cluster investigation for sexually transmitted disease (STD)/human immunodeficiency virus (HIV). STUDY: Literature review and quantitative summary. RESULTS: Since 1975, the median case-finding yield for syphilis, gonorrhea, and chlamydia PN reported in the literature is about 1 new case found for every 4 or 5 cases interviewed. The yield from HIV PN is approximately half as large, although there is substantial variability in yield across reports for each disease. Published reports underline the central role provider referral plays in effective PN and case-finding. Successful PN is more likely with index cases who are of majority ethnicity and detected through screening or spontaneous presentation for care with symptoms and with partners with whom index cases have had sexual contact that is recent, frequent, and of long duration. The case-finding yield for HIV PN also is much higher when cases are diagnosed through confidential, rather than anonymous, testing. Cluster investigation and related strategies tend to have lower case-finding yields than PN but can play a very useful case-finding role, especially in settings with high disease incidence. CONCLUSIONS: STD/HIV PN and cluster investigation can contribute meaningfully to case finding. More research is needed to strengthen the empiric foundation of PN and related strategies, including the impact they have on disease transmission.     

Identifying likely syphilis transmitters: implications for control and evaluation

BACKGROUND/OBJECTIVES: Persistence of syphilis in communities may be maintained by relatively small groups of high-risk persons centrally placed among a larger group with low to moderately risky behavior. We sought to determine which control strategies identified particularly high-risk, early-stage syphilis cases considered to have high prevention value. METHODS: In 2 cities with recent heterosexual outbreaks, data were abstracted for early syphilis cases from 1997 through 2002. Disease stage and number of sex partners were used to create an index to estimate the relative likelihood and magnitude of future transmission had the case not been treated. We estimated the relative transmission potential for each stage of syphilis (primary = 4.3, secondary = 2.5, and early-latent = 1.0) and multiplied by the number of reported partners to determine a prevention value score. Cases scoring >10 were considered high prevention value. Cases were stratified by the method used to detect the case. RESULTS: Of 1,700 female early syphilis cases, 174 (10%) were high value. Cases were identified by private physicians (28% of all female cases and 16% of high-value cases), jails (19% of all, 40% of high-value cases), partner notification (16% of all, 10% of high-value cases), sexually transmitted disease (STD) clinic (9% of all, 13% of high-value cases), and the emergency room (8% of all, 4% of high-value cases). Of 1,851 male cases, 228 (12%) were high value. Cases were identified by jails (27% of all male cases and 14% of high-value cases), STD clinic (21% of all, 47% of high-value), private physicians (17% of all, 17% of high-value), partner notification (14% of all, 11% of high-value), and the emergency room (6% of all, 14% of high-value). CONCLUSIONS: Private physicians identified the most female cases; however, jail screening identified the most high-prevention-value female cases. Jail screening identified the most male cases; however, the STD clinic (self-referred) identified the most high-prevention-value cases. Partner notification identified relatively few high-value cases.     

HIV-1 infection-associated risk factors among sexually transmitted disease patients in Athens, Greece: 1990 to 1996

OBJECTIVE: To determine trends in HIV seroprevalence and related risk factors among patients with sexually transmitted diseases (STDs) and to report the respective epidemiologic history characteristics. METHODS: A cross-sectional seroepidemiologic study conducted from 1990 to 1996 among 5,669 symptomatic STD cases was carried out. RESULTS: The overall HIV test acceptance was 98.9%, and 1.2% patients (n = 66) were seropositive. Highest rates were detected among those who were born or resided in Sub-Saharan Africa. Seropositivity fluctuates significantly by age, and is excessive in persons 45 years and older (2.6%). A significant decreasing trend in STD incidence and HIV seroprevalence among patients younger than 25 years was detected. Male homosexuals and bisexuals (MSM) exhibited the highest overall rate of infection (5.8%) followed by intravenous drug users (2%). Highly promiscuous STD patients (ie, those who had more than 10 partners during the past 6 months) presented a significantly increased HIV seroprevalence when compared with patients of the same sexual orientation. STD patients infected with HIV mostly belonged to notable risk categories of AIDS (men who have sex with men, 72.7%). Awareness of serostatus was low (13.6%). In male patients, the HIV seropositivity rate was significantly higher among early syphilis and proctitis cases, whereas in females this higher rate occurred with herpes genitalis. CONCLUSIONS: Promiscuity and sexual orientation significantly influence the seroprevalence rate. Exposure to HIV remained stable despite the above declining time trends, which implies the need for additional preventive interventions targeted to the real health and illness behavior of the partner.     

Physicians' opinions about partner notification methods: case reporting, patient referral, and provider referral

BACKGROUND: The United States has relied upon partner notification strategies to help break the chain of infection and re-infection for sexually transmitted diseases (STD). Physicians are a vital link in the system of STD control, but little is known of physician opinions about partner notification strategies. METHODS: We collected opinions about partner notification from a national probability sample of physicians in specialties diagnosing STDs. Physicians responded to 17 questions about three relevant forms of STD partner notification: patient based referral, provider based referral, and case reporting. RESULTS: Exploratory factor analyses showed that responses for each form of partner notification could be grouped into four categories: perceived practice norms, infection control, patient relationships, and time/money. Multivariate analyses of the factors showed that physicians endorsed patient based referral most favourably and provider based referral least favourably. CONCLUSION: Physicians' opinions about partner notification strategies appear to reflect objective reality in some areas, but not in others. Strategies that improve the fit between physicians' opinions and effective notification are needed: some are discussed here.     

A case control study of HIV seroconversion in gay men, 1988-1993: what are the current risk factors?

OBJECTIVE: To investigate current risk factors for HIV seroconversion among homo/bisexual men. DESIGN: Matched case control study in a large STD clinic in central London. Data on risk factors were obtained by case note review. METHODS: Fifty-six cases who had at least one negative HIV test followed by a positive test between June 1988 and July 1993, and two homo/bisexual controls (having two or more negative HIV tests) matched to each case on age, total number of HIV tests and test interval period were identified. Univariate and multivariate odds ratio were calculated for acute STD, ano-genital intercourse, condom use and HIV status of sexual partners. RESULTS: Adjusted odds ratios (95% confidence intervals) for HIV seroconversion were 4.1 (1.3-13.3) for having an acute interval STD and 4.6 (1.4-15.4) for having a known HIV infected sexual partner. Compared with men who always used condoms, odds ratios for men who sometimes or never used condoms were 7.9 (2.2-28.9) and 16.2 (3.0-86.0) respectively. Unprotected ano-genital intercourse was commonly reported by both cases and controls, and reported condom use was no greater with a known HIV infected partner than with a partner of unknown HIV status. CONCLUSION: HIV seroconversion among homo/bisexual men attending STD clinics is strongly related to having an acute STD, a known HIV infected partner and not using condoms. Although consistent use of condoms is highly protective, knowing that a partner is HIV infected does not ensure condom use between serodiscordant men. More effective, well-evaluated interventions are needed to reduce sexual risk-taking in this population.