HIV Prevention: Partner Services Interventions to Increase HIV Testing

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends partner services interventions to increase HIV testing. Systematic review evidence shows interventions are effective at identifying and testing sexual and needle-sharing partners of persons newly diagnosed with HIV infection, which improves health for population groups disproportionately affected by HIV. Economic evidence indicates partner services interventions to increase HIV testing are cost-effective.

The full CPSTF Finding and Rationale Statement and supporting documents for HIV Prevention: Partner Services Interventions to Increase HIV Testing are available in The Community Guide Collection on CDC Stacks.

Intervention

HIV partner services are offered to people with a diagnosis of HIV infection (index patient) and their sexual or needle-sharing partners. Interventions include notification of possible exposure, HIV testing, and related services. In the United States, HIV partner services are most often delivered by trained health department personnel (CDC 2008).

Partner notification is an essential component of partner services (CDC 2008). Trained personnel interview patients diagnosed with HIV infection to learn about their sexual or needle-sharing partners and make plans to confidentially notify partners of their potential exposure to HIV.

Patients may choose to notify partners either in person or remotely (e.g., telephone, email, text), through one or more of the following approaches:

  • Provider referral trained health department personnel notify partners
  • Self-referral (also known as client or patient referral) patients accept full responsibility for notifying partners and refer them to appropriate services
  • Third-party referral professionals other than health department staff (e.g., HIV counselors or clinicians) notify partners

Programs offer additional services to patients diagnosed with HIV and their partners, including prevention counseling, HIV testing, linkage to medical care, and referral or linkage to other services (e.g., preventive services, reproductive healthcare, prenatal care, substance abuse treatment, social support, housing assistance, legal services, and mental health services).

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 27 studies. Studies were identified from a previous Community Guide review (search period 1985 to 2004, Hogben et al., 2007), and an update search (search period 2004 to April 2020). The systematic 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 prevention, treatment, and care.

This recommendation updates and replaces the 2005 findings for interventions to identify people with HIV infection through partner notification by provider referral (recommended), patient referral (insufficient evidence), or contract referral (insufficient evidence).

Study Characteristics

  • Included studies were conducted in the United States (22 studies), Canada (1 study), Taiwan, China (1 study), Spain (1 study), Sweden (1 study), and the United Kingdom (1 study).
  • Studies evaluated state-wide interventions (5 studies) or programs that were implemented in urban (21 studies) or rural (1 study) areas.
  • Index patients were interviewed to identify sexual partners only (7 studies), sexual or needle-sharing partners (18 studies), or sexual, needle-sharing, or social network partners (2 studies).
  • Index patients were offered provider referral (19 studies), self and provider referral (7 studies), or a mix of self, third party, and provider referral (1 study).

Summary of Results

The systematic review included 27 studies.

  • Fourteen included studies reported intervention effectiveness for the following outcomes:
    • Identifying partners the median partner index ratio was 2.4, meaning 2.4 index patients were interviewed to identify one sexual or needle-sharing partner (12 studies).
    • Notifying partners a median of 59.8% percent of identified partners were notified 59.8% (10 studies).
    • Getting partners tested a median of 55.1% of notified partners were tested for HIV (11 studies).
    • Diagnosing partners with HIV infections a median of 14.6% of tested partners were diagnosed with HIV infection (14 studies).
      • A median of 9.4 index patients were interviewed to find one partner newly diagnosed with HIV infection (13 studies).
      • A median of 1.7 index patients were interviewed to identify one partner with HIV infection (newly or previously diagnosed (8 studies).
    • Linking index patients and partners with HIV infection to care index patients and partners who received partner services were more likely to be linked to care within 90 days of diagnosis when compared with persons not receiving these services (2 studies).
  • Sixteen studies examined whether intervention effectiveness varied with intervention or population characteristics.
    • Context for the initial interview
      • In person interviews were more effective at getting partners tested for HIV (1 study) and finding partners newly diagnosed with HIV infection (1 study) when compared with initial interviews done remotely.
      • Multiple interview sessions with the index patient were more effective at identifying partners newly diagnosed with HIV infection (1 study) when compared with one interview session.
    • Partner notification process
      • Referral approaches provider referral was more effective at notifying, testing, and finding partners newly diagnosed with HIV infection (5 studies) when compared with self or third-party referral.
      • Notification context internet or text notifications were more effective at notifying partners (2 studies) when compared with traditional notification methods such as in-person or over the phone. In-person notifications were more effective at identifying partners newly diagnosed with HIV infection (3 studies) when compared with notification through internet or text.
    • Partner testing site offering point-of-care testing was more effective at getting partners tested than referring partners to clinics for testing (1 study).
    • Index patient, acute or non-acute infection index patients with acute HIV infection identified more partners newly tested positive for HIV infection than did index patients with non-acute or long-standing HIV infection (1 study).
    • Index patient, pregnancy index patients who were pregnant identified more partners newly tested positive for HIV infection than did index patients who were not pregnant (1 study).
    • Partner mode of transmission the number of index patients interviewed to find one partner newly diagnosed with HIV infection was over 10 times lower for index patients’ male-to-male sexual or intravenous drug use contacts than it was for index patients’ heterosexual contacts (1 study).

Summary of Economic Evidence

Economic evidence shows HIV partner services to increase HIV testing are cost-effective, based on cost per quality-adjusted life year (QALY) estimates that were either cost-saving or below a conservative benchmark of $50,000 per QALY gained. The systematic economic review included six studies (search period January 2000 through July 2021). Monetary values are reported in 2020 U.S. dollars.

  • The mean intervention cost per person tested was $1,761 (2 studies) and the median intervention cost per person newly diagnosed with HIV was $22,144 (4 studies).
  • The mean net cost per QALY gained was $25,526 (2 studies), and two studies reported net cost less than zero indicating cost-savings.

Applicability

Based on results from the systematic review, the CPSTF finding should be applicable to all urban settings in the United States and all types of index patients and partners, independent of age, sex, race, ethnicity, or HIV transmission category.

Evidence Gaps

  • How effective are partner services interventions at reconnecting persons out-of-care to HIV medical care? Partners identified by index patients may know their HIV status but out-of-care. Partner services interventions may help link these people with medical care. None of the included studies reported on this outcome.
  • How effective are partner services interventions at increasing partners’ access to PrEP or repeat testing? Partners who test negative for HIV and remain at high risk for exposure may be offered HIV prevention services such as PrEP or repeat HIV testing.
  • How effective are partner services interventions in rural areas? Is the intervention cost-effective when used in rural settings?
  • Does intervention effectiveness differ by racial and ethnic group? How effective are partner services interventions for American Indian and Alaska Native communities?
  • Does intervention effectiveness differ by the socioeconomic status (SES) of index patients and partners?
  • What are the economic effects of using enhanced technologies such as internet, e-mail, texts, and social media for HIV partner services?
  • What are the effects of adding self-testing kits for index patients to distribute to their partners on both the effectiveness and economics of the intervention?

Implementation Considerations and Resources

  • Digital interventions to improve adherence to daily-use HIV PrEP were highly accepted among study participants. Of the services offered, participants were most likely to use daily pill reminders and weekly check-ins.
  • Although three studies included participants over 40 years of age, included studies recruited relatively young participants who were more likely to be comfortable with digital communication, and few reported difficulties sending and receiving messages.
  • Interventions may need to be compliant with the Health Insurance Portability and Accountability Act (HIPAA). There are concerns around confidentiality when sending HIV-related text messages, and some interventions use innocuous language such as “time to take vitamin pills” to replace HIV-specific language. One study reported that their intervention was HIPAA compliant.
  • Digital health interventions have technology and equipment requirements. In 2021, 85% of U.S. adults used a smartphone (Statista), 77% had high-speed broadband service at home (Pew Research Center), and 93% used the Internet (Pew Research Center), suggesting digital interventions could be widely implemented. The digital divide for smartphone ownership has diminished by race or ethnicity, but still exists for Americans with lower incomes, older adults, and people living in rural areas. It is important to consider participants’ income, age, and geographic location when implementing these interventions.
  • Structural and financial barriers exist for PrEP access, including patients’ ability to get prescriptions and attend required clinic visits and testing appointments. These disparities in access lead to disparities in HIV care, morbidity, and mortality. Implementers may want to consider available ways to address some of these barriers. For example, most insurance plans and state Medicaid programs cover the cost of PrEP. The Ready, Set, PrEP program provides PrEP for free or at a reduced cost to those who qualify. Other programs include co-pay assistance programs that lower costs of PrEP medications and state PrEP assistance programs that cover costs for medication, clinical visits, and lab testing.

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.