Sexual Behavior – Partner Counseling & Referral Services (PCRS)

Research Gaps

What are Research Gaps?

Prior to and during the literature review and data analysis, the review team and the Community Preventive Services Task Force attempt to address the key questions of what interventions work, for whom, under what conditions, and at what cost. Lack of sufficient information often leaves one or more of these questions unanswered. The Community Guide refers to these as "research gaps." Research gaps can be pulled together in the form of a basic set of questions to inform a research agenda for those in the field.

Identified Research Gaps

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.

Evidence Review

Hogben M, McNally T, McPheeters M, et al. The effectiveness of HIV partner counseling and referral services in increasing identification of HIV positive individuals: A systematic review. Am J Prev Med 2007;33(2S):S89–S100.