April 2003

Current Knowledge

Evidence suggests that most new HIV infections originate from HIV-infected persons not yet aware of their infection.¹ This emphasizes the need to identify HIV-infected persons and link them to medical, prevention and other services as soon as possible after they become infected. One strategy for accomplishing this is voluntary partner counseling and referral services (PCRS), including partner notification (PN).^2,3,4

PCRS assists HIV-infected persons with notifying their partners of their exposure to HIV. Notified partners, who may not have suspected their risk, can then choose whether to be tested for HIV, enabling those who test HIV positive to receive early medical evaluation, treatment, and prevention services, including risk-reduction counseling. A key element of PCRS is informing current and past partners that a person who is HIV-infected has identified them as a sex or injection-drug-paraphernalia-sharing partner and advising them to have HIV counseling and testing. Among sex partners, close partners and those with whom contact has been recent, frequent, or of longer duration are more likely to be notified^5,6,7,8; however, PCRS should include casual partners (or contacts), as well. Informing partners of their exposure to HIV is confidential, in that partners are not told who reported their name or when the reported exposure occurred, nor is information about the partners reported back to the original HIV-infected person. It is voluntary in that the infected person decides which names to reveal to the interviewer.

PCRS can be an effective tool for reaching persons at very high risk for HIV infection: in studies of HIV PCRS, 8%-39 % of partners tested were found to have previously undiagnosed HIV infection.⁹ However, a recent survey of health department staff in U.S. areas with high reported rates of HIV found that, in areas with mandatory HIV reporting, only 52% of persons infected with HIV were interviewed for PCRS.¹⁰ PCRS has been found to be cost-effective.^11,12,13 Acceptability of PCRS has been indicated in surveys of individuals seeking HIV testing, HIV-infected persons, and notified partners, in which the majority of respondents have indicated support for PN.^14,15,16

HIV PCRS includes several elements: identifying, locating, and interviewing HIV-infected persons (index patients) to offer PCRS and elicit names of partners; locating partners and notifying them of their exposure to HIV; and providing HIV counseling, testing, and referral services to the partners. PCRS is usually done by health departments. In some areas, community-based organizations (CBOs) or other agencies perform at least some parts of PCRS (e.g., interviewing index patients to elicit partner names); however, state or local laws and regulations may limit or prohibit PCRS being done outside the health department.

There are 3 main strategies for reaching and informing partners of their exposure. In provider referral, the clinical care provider or health department staff, with permission from the HIV-infected client, informs the partner and refers him or her to counseling, testing, and other support services. Although some clinicians may wish to take on the responsibility for informing partners, one observational study suggested that health department specialists were more successful than physicians in interviewing patients and locating partners.¹⁷ In patient or client referral, the HIV-infected person accepts full responsibility for informing his or her partners of their possible exposure to HIV and for referring them to HIV counseling and testing services. Although some persons initially prefer to inform their partners themselves, many clients often find this more difficult than anticipated. Furthermore, notification by health department staff seems to be substantially more effective than notification by the infected person.¹⁸ In contract referral, the infected person has a few days to notify his or her partners. If, by the contract date, the partners have not come for counseling and testing, they are contacted by the health department. In a variation, dual referral, the HIV-infected client and the provider inform the partner together. Some reports of partner violence after notification suggest a need for caution, but violence seems to be rare.^19,20

Many states and some cities or localities have laws and regulations about informing partners of their exposure to HIV. Some health departments require that even if a patient refuses to report a partner, the clinician must report to the health department any partner of whom he or she is aware. Some states also have laws regarding disclosure by clinicians to third parties known to be at significant risk for future HIV transmission from patients known to be infected. This is called duty to warn.²¹ The Ryan White CARE Reauthorization Act requires that health departments receiving Ryan White funds show “good faith” efforts to notify marriage partners of HIV-infected patients.

Objectives
The purpose of this document is to provide guidance to state and local health departments to achieve the following:

• Routine provision of PCRS, in public and private settings, to persons with newly diagnosed HIV
• Ongoing provision of PCRS to HIV-infected persons who remain sexually active or continue to inject drugs
• Effective linkage of persons diagnosed with HIV through PCRS to medical evaluation, treatment, prevention, and other appropriate services

Other agencies and providers doing PCRS must work closely with their respective health departments and adhere to all applicable laws and regulations.

Procedures
Steps for health departments

1. Develop and implement programs to provide PCRS in public and private sectors to all persons newly diagnosed with HIV. These programs should address all steps of PCRS, including
   1. Contacting persons newly diagnosed with HIV to offer them PCRS
   2. Interviewing persons who accept PCRS to elicit names of and locating information for sex and injection-drug-paraphernalia-sharing partners
   3. Locating, notifying, counseling, testing, and providing test results to partners
   4. Linking partners, especially those who test positive, to appropriate medical evaluation, treatment, prevention, and other services
2. Ensure that PCRS is
   1. Confidential in all aspects
   2. Available with both confidential and anonymous counseling and testing
   3. Culturally sensitive and acceptable to the affected population
   4. Timely (i.e., locating and notifying activities are initiated and completed promptly)
3. Ensure that information about how to access PCRS services is easily accessible by health care providers in the public and private sectors, CBOs, and other agencies diagnosing or providing services to HIV-infected persons.
4. Encourage providers, CBOs, and other agencies providing services to HIV-infected persons to routinely screen clients for ongoing sexual and injection-drug-use activities and to provide PCRS, directly or through referral, for new partners who may have been exposed to HIV.
5. Ensure that providers, CBOs, and other agencies diagnosing or providing services to HIV-infected persons are aware of all laws and regulations relevant to PCRS in their respective jurisdictions.
6. Ensure that all clients receiving PCRS are assessed for the possibility of partner violence and, when indicated, are referred to agencies with expertise in this area.
7. Ensure that all staff members doing PCRS receive initial and ongoing training in PCRS methods and receive close supervision and routine, periodic performance evaluation. Training curricula for PCRS and PN are available from CDC, and many courses are available from health departments and the National Network of STD/HIV Prevention Training Centers.
8. Work with health care providers, CBOs, and other organizations serving or representing HIV-infected persons to educate them about the potential benefits of PCRS for HIV-infected persons, their partners, and the community and to develop community support for these services.
9. Work closely with non-health department agencies (e.g., CBOs) that are considering providing PCRS services to assist in planning their programs, including identifying which elements of PCRS the agency should conduct, how the agency’s PCRS activities will be coordinated with health department PCRS activities, how appropriate reporting to the health department will be ensured, and what laws and regulations may be applicable to the program.

Working with Partners and Integration into Existing Services

1. PCRS is part of a comprehensive array of services needed by HIV-infected persons and their partners. It should be fully integrated with those services, beginning when a client first receives HIV counseling and testing and continuing after the client enters care and treatment services.
2. PCRS cannot function as an isolated activity in the health department. Health departments should work closely with private sector and other providers (including Ryan White Care funded programs) to help them develop strategies for integrating PCRS into their services (e.g., routinely screening HIV-positive clients for behavioral and clinical risks for HIV transmission to identify those who should be offered PCRS).
3. Whether HIV PCRS is conducted by HIV/AIDS program staff or by disease intervention specialists (DIS) in sexually transmitted disease (STD) programs, where PN for other STDs is also conducted, HIV/AIDS and STD programs should collaborate to provide the most effective services and to use resources effectively.

Programmatic Considerations

1. Some PCRS programs focus primarily on patients diagnosed in the public sector, especially STD clinics; however, most persons with HIV are diagnosed in the private sector. Health departments should work with private sector health care providers (including programs funded under the Ryan White Care Act) to help foster understanding of and support for providing PCRS to HIV-infected persons diagnosed in the private sector.
2. PCRS may place a substantial burden on health department resources. Managers may need to prioritize PCRS activities, such as the order in which HIV-infected persons are offered PCRS or the order in which partners are located and offered PCRS.
3. Concerns often voiced regarding HIV PCRS include potential violations of confidentiality, the stigma associated with HIV, and the potential for partner violence associated with PCRS. It is critical that all PCRS programs include strict procedures for ensuring privacy, confidentiality, and security of data, as well as screening for and addressing potential partner violence.
4. Some states have laws and regulations that limit partner notification activities. Amendment of these laws should be considered, where appropriate, in order for PCRS to be successfully implemented.
5. In some instances, HIV-positive clients may have sex or may share injection equipment with persons they do not know. In these circumstances, general information obtained through PCRS can be used to identify high-risk areas and venues where PCRS programs can provide or arrange for outreach services. A more recent phenomenon is use of the Internet for finding sex partners; strategies for PCRS in this situation need to be explored.
6. In some circumstances, ensuring confidentiality may be difficult. For example, if an HIV-positive client (index patient) has a spouse or other partner who is known to have had no other partner, the PCRS provider and index patient should fully discuss all available options for notifying the partner and together formulate the most appropriate plan. For example, a dual-referral approach, in which the HIV-infected client informs the partner of his or her HIV status in the presence of the PCRS provider, might be appropriate in this situation. By having a professional counselor present, this approach supports the client and may reduce other potential risks. If there is any concern about possible partner violence, assistance should be sought from persons with expertise in violence prevention.
7. Unlike bacterial STDs, HIV is not curable; therefore, PCRS should be an ongoing process for clients who have new sex or injection-drug-paraphernalia-sharing partners. Clients who remain sexually active or continue to use injection drugs should be counseled regarding self-disclosure of HIV status and provided opportunities to develop their self-disclosure skills.
8. Many questions remain regarding the best approaches for conducting PCRS (e.g., best methods for interviewing and eliciting partner names, optimal length of time period used for interviewing, tailoring elicitation and notification procedures to specific populations, potential roles of agencies other than health departments). These questions should be addressed through evaluation of existing programs and by conducting operational research.

Vignette
Since 1989, North Carolina has offered HIV PCRS to persons who test positive for HIV. PCRS is done by DIS. DIS are specially trained health professionals who attempt to locate HIV-infected patients and their exposed partners and ensure that both are referred to HIV and syphilis evaluation, treatment, and prevention services. When a positive HIV test result is reported to the local health department by a medical care provider or clinical laboratory, a DIS is assigned to the investigation. After verifying that the person has not been previously reported as HIV positive, the DIS contacts the patient’s medical provider to initiate PCRS. The DIS reviews medical records to obtain demographic and clinical information about the reported patient (i.e., index patient); attempts to contact the index patient; conducts a voluntary, confidential, in-depth interview with the index patient, requesting information on all sex and injection-drug-paraphernalia-sharing partners within the past year; and assesses the potential for partner violence. The DIS ensures that all HIV-infected clients have received HIV prevention counseling, are informed about measures for reducing or preventing HIV transmission, and, if needed, receive referrals to HIV care and case management.

After obtaining partner information, the DIS searches regional records to determine whether named partners have already been reported as HIV infected. The DIS then offers index patients the options of provider referral or contract referral to assist in notifying partners, not already known to be HIV positive, of their possible exposure to HIV. When located, partners are informed that they may have been exposed to HIV and are either referred to HIV counseling and testing clinic services or are provided these services on-site.

In North Carolina in 2001, there were 1,603 newly diagnosed HIV and AIDS cases; 166 (10%) were diagnosed because of PCRS. Through PCRS, 1,532 sex or needle-sharing partners were notified; of those, 404 (26%) had previously tested HIV positive. Of 1,128 not previously known to be HIV-positive, 610 (64%) were notified, counseled, and tested for HIV; 125 (20%) of these were newly diagnosed with HIV infection. Of the 1,532 partners interviewed, half had not been tested previously; 488 (64%) of these were tested through PCRS, and 108 (22%) were found to be positive for HIV. Of 188 partners who had previously tested negative, 122 (65%) were retested through PCRS; of those, 17 (14%) were newly diagnosed with HIV infection.

Monitoring Implementation
CDC grantees receiving HIV prevention funds will be required to routinely report the following indicators to monitor their HIV partner counseling and referral services.

CDC’s HIV Prevention Program Performance Indicators*:

1. Number and percent of contacts with unknown or previously negative HIV serostatus receiving an HIV test after PCRS notification (C.1)
2. Number and percent of contacts with a newly identified, confirmed positive HIV test among all contacts tested (C.2)
3. Number and percent of contacts with a previously known, confirmed positive HIV test among all contacts (C.3)

Other program measures:

4. Number of persons newly diagnosed and reported with HIV (index patients)
5. Collection of HIV transmission risk data in accordance with CTR Guidelines
6. Number of index patients located, offered, and who accepted PCRS
7. Demographics of index patients and contacts (e.g., race/ethnicity, gender, socioeconomic status)
8. Number of named contacts
   1. For each index patient accepting PCRS
   2. Located, offered, and who accepted PCRS
   3. With a positive test result who are successfully linked to medical evaluation, treatment, and prevention services

* The CDC Technical Assistance Guidelines for Health Department HIV Prevention Program Performance Indicators provides information on setting baseline, target, and indicator specification including appropriate data sources, calculations and reporting issues. Note: Performance indicators may have been modified to reflect specific population or setting characteristics.

References

1. Marks GS, Senterfitt W, Crepaz N. Relative contribution of HIV-positive persons aware and unaware of their serostatus to sexual HIV exposure in the United States: Findings from a meta-analytic review. In press.
2. Macke BA, Maher JE. Partner notification in the United States: An evidence-based review. Am J Prev Med 1999;17:230-242.
3. West GR, Stark KA. Partner notification for HIV prevention: A critical reexamination. AIDS Education and Prevention: HIV Counseling and Testing. 1997;9(Suppl. B):68-78.
4. Fenton K, Peterman TA. HIV partner notification: Taking a new look. AIDS 1997;11:1535-1546.
5. Perry SW, Card CA, Moffatt M, et al. Self-disclosure of HIV infection to sexual partners after repeated counseling. AIDS Educ Prev 1994;6:403-11.
6. van Duynhoven YT, Schop WA, van der Meijden WI, van de Laar MJ. Patient referral outcome in gonorrhea and chlamydial infections. Sex Transm Infect 1998;74:323-330.
7. Kissinger PJ, Niccolai LM, Mangus M, et al. Partner notification for HIV and syphilis: effects on sexual behaviors and relationship stability. Sex Transm Dis 2003; 30(1):75-82.
8. Hoxworth T, Spencer N, Peterman TA, Craig T, Johnson S, Maher JE. Changes in partnerships and HIV risk behavior after partner notification. Sex Transm Dis 2003;30(1):83-8.
9. Golden MR. HIV partner notification: A neglected prevention intervention [editorial]. Sex Transm Dis 2002;29:472-475.
10. Golden MR, Hogben M, Handsfield HH, et al. Partner notification for HIV and STD in the United States: low coverage for gonorrhea, chlamydial infection, and HIV. Sex Transm Dis 2003;30:490-496.
11. Holtgrave DR, Valdiserri RO, Gerber AR, Hinman AR. Human immunodeficiency virus counseling, testing, referral, and partner notification services. A cost-benefit analysis. Arch Intern Med 1993;153:1225-1230.
12. Toomey KE, Peterman TA, Dicker LW, et al. Human immunodeficiency virus partner notification: cost and effectiveness data from an attempted randomized controlled trial. Sex Transm Dis 1998;25:310-316.
13. Varghese B, Peterman TA, Holtgrave DR. Cost-effectiveness of counseling and testing and partner notification: a decision analysis. AIDS 1999;13:1745-1751.
14. Jones JL, Wykoff RF, Hollis SL, et al. Partner acceptance of health department notification of HIV exposure, South Carolina. JAMA 1990;264:1284-1286.
15. Carballo-Diéguez A, Remien RH, Benson DA, et al. Intention to notify sexual partners about HIV exposure among New York City STD clinics’ clients. Sex Transm Dis 2002;29:465-471.
16. Golden MR, Hopkins SG, Morris M, Holmes KK, Handsfield HH. Support among persons infected with HIV for routine health department contact for HIV partner notification. J Acquir Immune Defic Syndr 2003;32:196-202.
17. Giesecke J, Ramstedt K, Granath F, Ripa T, Rado G, Westrell M. Efficacy of partner notification for HIV infection. Lancet 1991;338:1096-100.
18. Landis SE, Schoenbach VJ, Weber DJ, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. New Engl J Med 1992;326:101-106.
19. Rothenberg KH, Paskey SJ. The risk of domestic violence and women with HIV infection: implications for partner notification, public policy, and the law. Am J Public Health 1995; 85:1569-76.
20. Maher JE, Peterson J, Hastings K, et al. Partner violence, partner notification, and women’s decisions to have an HIV test. J Acquir Immune Defic Syndr 2000;25:276-82.
21. Gostin LO, Webber DW. HIV infection and AIDS in the public health and health care systems: the role of law and litigation. JAMA 1998;279:1108-13.

Resources
Guidelines and Recommendations
CDC. Program operations. Guidelines for STD prevention. Partner services.

CDC. Revised Guidelines for HIV Counseling, Testing, and Referral.

CDC. Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infection.

CDC. Technical Assistance Guidelines for CDC’s HIV Prevention Program Performance Indicators.

Training
National Network of STD/HIV Prevention Training Centers.

State or local health department HIV/AIDS prevention programs. State AIDS Directors and contact information from the National Alliance of State and Territorial AIDS Directors (NASTAD).