Tracing the sexual contacts of an infected person is an essential element in controlling the spread of sexually transmitted infections through a population. Unlike most conditions, where, once definitively treated the job is done, when you have treated someone for an sexually transmitted infection, you are only part way through the management process. Your patient caught the infection from someone and may have passed it on to others. It is your duty to make an attempt to get these people tested and, if necessary, treated. Since many sexually transmitted infections cause symptoms in only a small proportion of infected people, you can not rely on these partners developing symptoms and getting themselves checked up.
Formerly the term ‘contact tracing’ was used for this process. This term has fallen out of favour because it implies that most sexual contacts have to be tracked down and that the index case (the person with the infection) has no role in the process. For this reason, the term ‘partner notification’ has become more popular.
The World Health Organisation (1999) describes partner notification as:
.. .the process of contacting the sexual partners of an individual with a sexually transmitted infection including HIV, and advising them that they have been exposed to infection. By this means, people who are at high risk of sexually transmitted infections/HIV, many of whom are unaware that they have been exposed, are contacted and encouraged to attend for counselling, testing and other prevention and treatment services.
The infections for which partner notification is required include: chlamydia, gonorrhoea, syphilis, trichomoniasis, non-specific urethritis, pelvic inflammatory disease, HIV, hepatitis B, hepatitis C, epididymitis and chancroid.
Partner notification is not required for some sexually transmitted infections, e.g. anogenital warts, molluscum contagiosum and genital herpes. This might seem odd when many of those sexual contacts will be infected with the causative viruses. The problem is that in most cases they will show no signs of the condition and there are no useful diagnostic tests which can detect asymptomatic infection.
Not all of a person’s previous sexual contacts need to be notified. The time frame depends on the condition and the mode of presentation. For example, in someone with asymptomatic chlamydia, sexual contacts over the previous 6 months should be notified. In a man with symptomatic urethral gonorrhoea, the time frame is 2 weeks prior to the onset of symptoms. In latent syphilis of unknown duration, partner notification could extend to several years. As you can see, partner notification can vary from a simple matter of a man telling his ex-girlfriend to go and get a check-up to an investigation which attempts to find a dozen people, some of whom may be barely known to the index patient.
When seeing a sexual contact it is important to consider the ‘window period’ of the infection in question. An HIV test might be negative 2 weeks after a sexual contact with an infected person, but this does not mean that it will still be negative after 3 months.
There are three approaches to partner notification:
- 1. Partner/client referral. The index patient informs contacts that they need to attend a clinic or their general practitioner (GP) to be screened and possibly undergo treatment.
- 2. Provider referral. A health care worker informs the patient’s contacts that they need to attend a clinic or their GP to be screened and possibly undergo treatment. The contacts are not told the name of the person who gave their details, nor are they told what the infection is.
- 3. Conditional referral. This is a verbal agreement between the patient and the health care worker that the healthcare worker will inform the contacts if the index has not done so after an agreed number of days.
Resistance to partner notification can be overcome by clarifying the level of confidentiality, e.g. contact data only available to staff involved in care, contacts will not know who gave their details, and contacts will not find out about each other. In order to achieve this, contacts may need to be given appointments at different times.
In the UK, partner notification is usually performed or coordinated by sexual health advisers. These are often people with a background in nursing or a related profession. Health advisers are usually based in genitourinary medicine clinics. Because of the move toward managing more sexually transmitted infections in primary care and family planning clinics, health advisers are supporting partner notification within these environments.
Another development is centralized partner notification, a system in which details of all relevant sexually transmitted infections diagnosed by a laboratory are forwarded to health advisers. This will include people diagnosed by their GP, those in other community settings and hospital inpatients. Clearly there are issues of consent here — the index patient needs to be aware that their details will be passed on.
As well as detecting previously undiagnosed infection, partner notification is an ideal opportunity to help patients reduce future risk of acquiring an STL Issues to cover include:
- • transmission routes for the various infections
- • risk reduction
- • factors that may encourage risk taking, e.g. drugs/alcohol, and how to tackle them.
Sexually transmitted infections and blood-borne viruses will never be eradicated from a population, but with good partner notification the spread can be limited.