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

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 CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to HIV/AIDS prevention.

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Detailed results from the systematic review are available in the CPSTF finding [PDF - 126 kB].

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).

Detailed results from the systematic review are available in the CPSTF finding [PDF - 126 kB].

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.

Each Community Preventive Services Task Force (CPSTF) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the CPSTF finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the CPSTF recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the CPSTF recommendation is based.

Identified 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