Partner notification (PN) is the process whereby sexual partners of an index patient are informed of their exposure to a sexually transmitted infection (STI) and the need to obtain treatment. For the person (index patient) with a curable STI, PN aims to eradicate infection and prevent re‐infection. For sexual partners, PN aims to identify and treat undiagnosed STIs. At the level of sexual networks and populations, the aim of PN is to interrupt chains of STI transmission. For people with viral STI, PN aims to identify undiagnosed infections, which can facilitate access for their sexual partners to treatment and help prevent transmission.
To assess the effects of different PN strategies in people with STI, including human immunodeficiency virus (HIV) infection.
We searched electronic databases (the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE) without language restrictions. We scanned reference lists of potential studies and previous reviews and contacted experts in the field. We searched three trial registries. We conducted the most recent search on 31 August 2012.
Published or unpublished randomised controlled trials (RCTs) or quasi‐RCTs comparing two or more PN strategies. Four main PN strategies were included: patient referral, expedited partner therapy, provider referral and contract referral. Patient referral means that the patient notifies their sexual partners, either with (enhanced patient referral) or without (simple patient referral) additional verbal or written support. In expedited partner therapy, the patient delivers medication or a prescription for medication to their partner(s) without the need for a medical examination of the partner. In provider referral, health service personnel notify the partners. In contract referral, the index patient is encouraged to notify partner, with the understanding that the partners will be contacted if they do not visit the health service by a certain date.
We analysed data according to paired partner referral strategies. We organised the comparisons first according to four main PN strategies (1. enhanced patient referral, 2. expedited partner therapy, 3. contract referral, 4. provider referral). We compared each main strategy with simple patient referral and then with each other, if trials were available. For continuous outcome measures, we calculated the mean difference (MD) with 95% confidence intervals (CI). For dichotomous variables, we calculated the risk ratio (RR) with 95% CI. We performed meta‐analyses where appropriate. We performed a sensitivity analysis for the primary outcome re‐infection rate of the index patient by excluding studies with attrition of greater than 20%. Two review authors independently assessed the risk of bias and extracted data. We contacted study authors for additional information.
We included 26 trials (17,578 participants, 9015 women and 8563 men). Five trials were conducted in developing countries. Only two trials were conducted among HIV‐positive patients. There was potential for selection bias, owing to the methods of allocation used and of performance bias, owing to the lack of blinding in most included studies. Seven trials had attrition of greater than 20%, increasing the risk of bias.
The review found moderate‐quality evidence that expedited partner therapy is better than simple patient referral for preventing re‐infection of index patients when combining trials of STIs that caused urethritis or cervicitis (6 trials; RR 0.71, 95% CI 0.56 to 0.89, I 2 = 39%). When studies with attrition greater than 20% were excluded, the effect of expedited partner therapy was attenuated (2 trials; RR 0.8, 95% CI 0.62 to 1.04, I 2 = 0%). In trials restricted to index patients with chlamydia, the effect was attenuated (2 trials; RR 0.90, 95% CI 0.60 to 1.35, I 2 = 22%). Expedited partner therapy also increased the number of partners treated per index patient (three trials) when compared with simple patient referral in people with chlamydia or gonorrhoea (MD 0.43, 95% CI 0.28 to 0.58) or trichomonas (MD 0.51, 95% CI 0.35 to 0.67), and people with any STI syndrome (MD 0.5, 95% CI 0.34 to 0.67). Expedited partner therapy was not superior to enhanced patient referral in preventing re‐infection (3 trials; RR 0.96, 95% CI 0.60 to 1.53, I 2 = 33%, low‐quality evidence). Home sampling kits for partners (four trials) did not result in lower rates of re‐infection in the index case (measured in one trial), or higher numbers of partners elicited (three trials), notified (two trials) or treated (one trial) when compared with simple patient referral. There was no consistent evidence for the relative effects of provider, contract or other patient referral methods. In one trial among men with non‐gonococcal urethritis, more partners were treated with provider referral than with simple patient referral (MD 0.5, 95% CI 0.37 to 0.63). In one study among people with syphilis, contract referral elicited treatment of more partners than provider referral (MD 2.2, 95% CI 1.95 to 2.45), but the number of partners receiving treatment was the same in both groups. Where measured, there was no statistical evidence of differences in the incidence of adverse effects between PN strategies.
The evidence assessed in this review does not identify a single optimal strategy for PN for any particular STI. When combining trials of STI causing urethritis or cervicitis, expedited partner therapy was more successful than simple patient referral for preventing re‐infection of the index patient but was not superior to enhanced patient referral. Expedited partner therapy interventions should include all components that were part of the trial intervention package. There was insufficient evidence to determine the most effective components of an enhanced patient referral strategy. There are too few trials to allow consistent conclusions about the relative effects of provider, contract or other patient referral methods for different STIs. More high‐quality RCTs of PN strategies for HIV and syphilis, using biological outcomes, are needed.
Strategies for partner notification for sexually transmitted infections, including HIV.
Sexually transmitted infections (STI) are a major global cause of acute illness, infertility and death. Every year there are an estimated 499 million new cases of the most common curable STIs (trichomoniasis, chlamydia, syphilis and gonorrhoea), and between two and three million new cases of HIV. The presence of several STIs, including syphilis and herpes can increase the risk of acquiring or transmitting HIV.
Partner notification (PN) is a process whereby sexual partners of patients given a diagnosis of STI are informed of their exposure to infection and the need to receive treatment. PN for curable STI may prevent re‐infection of the patient and reduce the risk of complications and further spread.
A review update of the research of the strategies of partner notification in people with STI, including human immunodeficiency virus (HIV) infection was conducted by researchers in the Cochrane Collaboration. After searching for all relevant studies, they found 26 studies. This review covers four main PN strategies: 1) Patient referral means that the patient tells their sexual partners that they need to be treated, either with (enhanced) or without (simple) additional support to enhance outcomes. 2) Expedited partner therapy means that the patient delivers medication or a prescription for medication to their partner(s) without the need for a medical examination of the partner. 3) Provider referral means that health service personnel notify the partners. 4) Contract referral means that the patient is encouraged to notify partners but health service personnel will contact them if they do not visit the health service by a certain date.
The 26 trials in this review included 17,578 participants. Five trials were conducted in developing countries and only two trials were performed among HIV‐positive patients. Expedited partner therapy was more successful than simple patient referral in reducing repeat infection in patients with gonorrhoea, chlamydia or non‐gonococcal urethritis (six trials). Expedited partner therapy and enhanced patient referral resulted in similar levels of repeat infection (three trials). Evidence about the effects of home sampling, where patients with chlamydia received a sample kit for the partner, was inconsistent (three trials). There were too few trials to allow consistent conclusions about the relative effects of provider, contract or other patient referral methods for different STIs. More studies need to be performed on HIV and syphilis and harms need to be measured and reported.
Sexually transmitted infections (STI) have a negative impact on the social, health and economic well‐being of a country. Every year an estimated 499 million new cases of the four most common curable STI, trichomoniasis, chlamydia, syphilis and gonorrhoea, are acquired (WHO 2012). Furthermore, two to three million new cases of human immunodeficiency virus (HIV) occur per year (UNAIDS 2010). Up to 4000 infants become blind annually due to eye infections attributable to underlying gonococcal and chlamydial infections in the mother (WHO 2007).
The term STI includes both infections that remain latent or asymptomatic and those that progress to a clinical manifestation (disease). In this update, we used the term STI instead of sexually transmitted diseases (STD), which was used in the original review. STI are more prevalent in countries and communities where socio‐economic conditions are poor (Glasier 2006; Low 2006a). Curable STIs are often overshadowed by the burden of HIV, but are important causes of morbidity in their own right ( Table 15 ).
| Disease | DALYs |
| HIV | 58.5 million |
| Chlamydia trachomatis | 3.7 million |
| Gonorrhoea | 3.5 million |
| Other | 280,000 |
DALY: disability adjusted life years.
Clinical symptoms of STIs can be non‐specific and, where possible, the diagnosis needs to be confirmed by laboratory testing. In lower‐income countries, laboratory testing is not always available and women and men reporting symptoms suggestive of an STI are often treated according to algorithms without confirmatory tests. For male urethritis and genital ulcers, this approach is effective but with vaginal discharge the risk of misdiagnosis is high. Syndromic management of STI can therefore lead to over‐treatment and adverse social consequences such as stigma and intimate partner violence (Trollope‐Kumar 2006). Women are more likely than men to suffer from reproductive tract complications of STIs such as chlamydia and gonorrhoea if the infection ascends to the upper genital tract; pelvic inflammatory disease (PID), ectopic pregnancies and infertility are the most commonly documented complications (Gerbase 1998). STIs are, however, often asymptomatic in both women and men (WHO 2007). As a result, disclosing a diagnosis of an STI to sexual partners and partner treatment play a critical part in the comprehensive management of STI. Willingness to disclose varies according to the STI and gender (Alam 2010). In one study among people with a diagnosis of HIV, 85% of people living with HIV were sexually active, but only 58% revealed their HIV status to recent sexual partners (Simbayi 2007). In a study in Connecticut, US, 25% of females with chlamydia intended not to notify their partners (Niccolai 2007) as most (46%) thought it unimportant and 43% were not willing to discuss the condition. In a study in India, the patient characteristics most likely to increase the odds of referring a partner were having a diagnosis of genital ulcer disease (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.08 to 7.13, P value = 0.033) and having the intention to inform the regular partners (OR 16.9, 95% CI 3.29 to 86.70, P value = 0.001) (Sahasrabuddhe 2002).
"Partner notification is a process that includes informing sexual partners of infected people of their exposure, administering presumptive treatment, and providing advice about the prevention of future infection" (UNAIDS 1999). Partner notification (PN) is also known as contact tracing, partner management or partner information. A person with a newly diagnosed STI is often referred to as an 'index case' or 'index patient'. The index patient has one or more sexual partners. The sexual partners of the index patient might have been the source of the infection in the index patient or they might have acquired the infection from the index patient.
A variety of approaches has been used to notify sexual partners and to ensure that they receive treatment. In principle, managing infection in people with more than one current sexual partner should have the greatest impact on the spread of STI (Fenton 1997). The use of different approaches depends partly on the STI for which they were originally intended. There are other influences at the country level, including cultural factors, the structure and financing of health systems, and clinical consensus. At the individual level, factors such as patient choice influence choice of PN strategies. Traditionally, three main approaches have been defined: patient referral, provider referral and contract (or conditional) referral. Definitions and explanations of these PN methods are given below.
Patient referral (patient‐led referral) refers to an approach in which health service personnel encourage index patients to notify their own partners. In this review, we used the term simple patient referral to refer to spoken advice from health service personnel about the need for sexual partners to receive treatment. This can be seen as a minimum standard for a PN intervention. There is, however, no agreement about the content of a consultation for simple patient referral. Patient referral was developed in the 1970s when rates of gonorrhoea in the US were very high and the capacity of specialist PN personnel was exceeded. Patient referral has since become the preferred method of PN for gonorrhoea and subsequently chlamydia in many countries. There has been great interest in developing methods to support index patients so that the outcomes of patient referral can be improved or enhanced (Trelle 2007). Patient referral can, therefore, be split into two categories (simple and enhanced), according to the level of support given to the patient. Expedited partner therapy (EPT) has developed in the US since the late 1990s as a new patient‐led strategy to help index patients to get their partners treated more quickly.
Enhanced patient referral refers to a group of strategies that supplement the spoken advice with the aim of improving patient referral success, including educational material such as videos viewed in waiting rooms, written disease‐specific information for index patients to give to their partners, home sampling kits for partners, disease‐specific websites, theory‐based counselling and reminders by telephone or other means (Trelle 2007).
EPT is a group of strategies to enhance the success of patient referral by increasing the numbers of partners treated and speeding up the time to treatment (CDC 2006). The EPT strategies include: patient‐delivered partner medication (PDPM) or patient‐delivered partner therapy (PDPT), where the index patient receives antibiotics (often in a package with condoms and written information) to give to their partner without the need for a medical examination of the partner (Golden 2005); or additional prescriptions given to index patients for their partner(s). EPT can reduce loss to follow‐up of index cases (Young 2007), and reduce the risk of repeated infection in the index case (Golden 2005). There are, however, disadvantages, including the risk of adverse drug reactions, other underlying disease remaining undetected and a missed opportunity for counselling and testing for other STIs including HIV (Golden 2005). In some countries, such as the UK, EPT is not legal unless the partner is assessed before receiving antibiotic treatment (ECDC 2013).
Provider referral (provider‐led referral) uses third parties (usually specialist health service personnel) to notify partners. The name of these health professionals differs between countries, for example; 'disease intervention specialists' (DIS) in the US; 'health advisers' in the UK and 'Kurators' in Sweden. Provider referral originated in Scandinavia and the UK as a method to trace and refer the sexual partners of people with syphilis when treatment first became available. More recently, it has been used for other clinically severe STIs such as HIV infection and hepatitis B. It can also be used for other STIs such as gonorrhoea and chlamydia when the index patient is unable to notify partners by themselves. Provider referral should only be done with the explicit consent of the index patient. In some countries, for example France, provider referral does not occur because it is seen as an invasion of privacy (ECDC 2013).
Contract referral (conditional referral) refers to an approach in which there is an agreement (contract) between the patient and the health professional. Health service personnel encourage index patients to notify their partners, with the understanding that health service personnel will notify those partners who do not visit the health service by an agreed date. Contract referral is, in practice, difficult to define as a separate PN approach. It can be difficult to distinguish from provider referral if the time window for patient referral is very short (two or three days) (Peterman 1997). In contrast, contract referral is often used as an extension to simple patient referral, rather than a separate strategy, if the index patient has not been able to inform their partner(s) when they are followed up.
There are different aims of PN, depending on the level at which it is targeted and the infection (Low 2006a). At the level of the index patient with a curable STI the aim is to provide concurrent antibiotic treatment to the sexual partner(s) so that infection can be eradicated in both people and re‐infection prevented in the index patient, which is a clinical goal. For the sexual partner(s) the aim is to identify and treat infection that might have been the source of infection in the index patient, or might have been acquired from the index patient. At the level of sexual networks and populations, the aim is to interrupt chains of transmission and reduce the spread of STIs, which is a public health goal. For viral STIs, the aim is to identify previously undiagnosed infections, which can provide early access for sexual partners to treatment and prevent onward transmission through behavioural change by the infected person.
To succeed, PN strategies need to first elicit from the index patient details of all sexual partners from whom he/she may have acquired the infection, or whom he/she might have subsequently infected. Identifying partners in the latent period of infection (usually three months for primary syphilis and one month for acute urethritis) (Toomey 1996), should identify those from whom infection was acquired, while identifying partners after the onset of symptoms will identify those who were likely to have been infected by the index case. The time period for identifying partners differs between countries for different STIs.
For most PN strategies, eliciting partner information from infected people is a prerequisite to notifying sexual partners. For example, when health service personnel notify partners, they rely on the index patient to count, name and provide details to enable all his/her partners to be traced. Once partners have been elicited, PN strategies need to provide either the index patient or the health service personnel with the necessary knowledge, skills or resources to enable them to locate, notify, medically evaluate and test or treat these partners.
Communication between partners, during which the index patient encourages them to consider screening or treatment, has been identified as a critical point in effective PN strategies (Young 2007). The communication usually requires the index patient to disclose their STI diagnosis. Disclosure can lead to benefits other than successful partner treatment, such as emotional support and protecting the health of others. Disclosure can also lead to stigma, rejection, physical abuse and discrimination (Arnold 2008).
PN has been practised as a measure to control STIs since the early 1900s (ECDC 2013), but there is limited evidence of its public health impact. Many evaluations have not been conducted as randomised controlled trials (RCTs) and many were conducted in developed countries before the HIV/acquired immunodeficiency syndrome (AIDS) pandemic. It is not known whether interventions developed for high‐income countries are applicable to resource‐limited settings.
There are several published systematic reviews of PN. The first included only studies conducted in developed countries (Oxman 1994). Another included only published studies conducted in the US after 1980 (Macke 1999). The original Cochrane Review by Mathews et al. was assessed as up to date in July 2001 (Mathews 2001). Trelle et al. systematically reviewed studies of enhanced methods of patient referral, including EPT, to improve the effectiveness of simple patient referral (Trelle 2007). The latest systematic review only studied curable STIs in developing countries (Alam 2010). Considering the ongoing developments in this field, the Cochrane Review was updated in line with recommendations of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).
To assess the effects of alternative PN strategies.