HIV/STI partner notification by providers
Partner notification by providers, also known as provider referral, contact tracing, or partner counseling and referral services, encourages patients who test positive for sexually transmitted infections (STIs) to voluntarily share information about current or past sex and needle-sharing partners with a health care provider. Providers notify partners who have been exposed to a STI of their potential risk and help them seek counseling, testing, and prevention and care as appropriate1, 2, 3. Partner notification is part of broader partner services1. Provider referral is most often used for patients with HIV and syphilis4. Notification is often completed by disease information specialists at public health departments or similar public health personnel5.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Increased STI testing
What does the research say about effectiveness?
There is strong evidence that partner notification by provider referral increases testing for HIV among partners of newly diagnosed patients6, 7 and increases identification of HIV in undiagnosed individuals5, 6, 7.
Based on effectiveness among HIV patients, the Centers for Disease Control and Prevention (CDC) also recommends patient notification by provider referral for syphilis and, in high priority cases, gonorrhea and chlamydia4. When resources do not allow provider referral, CDC recommends that patients infected with chlamydia and gonorrhea be counseled to inform their partners independently4. Additional research is needed to confirm the most effective type of referral for STIs other than HIV5.
Barriers to successful partner notification include anonymous partners, individuals not feeling comfortable sharing partner contact information, insufficient contact information when partners primarily communicate through apps, declining partner notification services, and staffing issues among partner notification programs8.
Experts suggest that the current partner notification system is outdated, as it primarily relies on mail and phone contact in a world where digital communication such as in smart phone apps or text messaging is increasingly the norm1. Electronic communication methods may be especially helpful to contact partners that met through dating apps and social media platforms9. Use of electronic notification options such as text messaging, email, social networking, and other websites and apps appear to be acceptable, particularly when partners might not have been notified9 or been unreachable without electronic notification10, such as those met through dating apps11.
Experts suggest partner notification expansion into routine care should be considered instead of only being offered upon a new diagnosis12; being offered partner notification options in various settings may improve participation13.
How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.
It is unclear what impact HIV/STI partner notification by providers may have on disparities in HIV and STI incidence, especially among vulnerable populations including people of color, young people, and LGBTQ populations.
Inequalities by sexuality, gender, race, geographical location, and economic status persist in HIV diagnosis and care16. In 2021, 70% of new HIV infections where among men who have sex with men (MSM)17 and in 2019, 29% of new HIV infections were among Hispanic individuals18, most of them among MSM19, and 41% were in Black individuals20. New HIV infections disproportionately affect Black MSM (who account for 26% of new HIV cases)21, Black heterosexual women, and Black transgender women22. Chlamydia, gonorrhea, and syphilis also disproportionally affect racial and sexual minority groups. In 2021, almost a third of new infections were in Black individuals, MSM were diagnosed with around a third of gonorrhea cases and almost half of syphilis infections, and among women STI rates were highest for Black, American Indian/Alaskan Native, and Native Hawaiian/Pacific Islander individuals23.
Traditionally, partner notification is to be provided to those with a new diagnosis, but a Chicago-based study of young Black MSM suggests not all individuals are being offered this service13.
What is the relevant historical background?
Sexually transmitted infections (STIs) have carried stigma for centuries, shaped by negative views of poverty, women, and sex24. STIs are associated with promiscuity and deviant behavior for women, while STIs in men are treated merely as a medical condition25. Stigma has continued to shape how STIs are studied, diagnosed, and treated. The racist and unethical Tuskegee Syphilis Study, administered by the federal government, intentionally withheld syphilis treatment from Black men for decades without their knowledge, to study the natural course of the disease, ultimately sowing widespread mistrust of health systems and medical research26.
When the AIDS epidemic began, federal response was slow to acknowledge and respond to it, in part because it primarily affected gay men in a time when many states still criminalized homosexuality. While the first case of HIV/AIDS in the U.S. was reported in 198127, 28, major federal funding wasn’t allocated until 198528. HIV criminalization laws were passed in many states criminalizing behavior such as non-disclosure, exposure, and/or transmission of HIV, or increasing sentence length for crimes based on someone’s HIV status29, long before pharmaceuticals were available to treat or prevent transmission30. Today, HIV criminalization unjustly applies criminal law to nonmalicious behavior by people living with HIV and the laws are disproportionately applied to people from groups who have been marginalized31, While 13 states have repealed or modernized their HIV criminalization laws, 34 states still have HIV/STI/communicable disease criminalization laws in place in 2023. Such laws can carry penalties up to life in prison29.
Partner notification has been a public health tool since the 18th century, when Danish priests participated in contract tracing efforts to notify sexual partners of individuals with syphilis. In 2016, the WHO recommended partner notification services be a part of the standard care provided to an individual with HIV32. Today, in an effort to keep up with modern technology, electronic notification options are being considered in order to notify partners via email, text messaging, social networking, and apps9, 11. State and federal funding are important to address the rising incidence of STIs, however, historical trends show that funding has stagnated33.
Equity Considerations
- What clinics or organizations in your community provide partner notification? What method(s) do they use?
- Who is offered partner notification services? Are notification services provided to everyone? How can services be expanded to ensure all individuals with a positive diagnosis are offered partner notification services?
- How does stigma, and other barriers, prevent people from accessing sexual health care and HIV/STI testing services in your community? What additional strategies can be implemented to overcome those barriers?
Implementation Examples
Partner notification services appear to be used widely; in 2016, most surveyed STI testing sites reported providing some form of partner notification services14. Partner services offer free services to newly diagnosed individuals and their partners; services include HIV and STI testing, referrals to support services, counseling, and connecting individuals to the necessary care they need. Partner services vary by state, based on state-level policies15.
Implementation Resources
‡ Resources with a focus on equity.
CDC-Partner services for HIV and STDs - Centers for Disease Control and Prevention (CDC). Partner services for HIV and STDs. 2021.
CDC-Partner services - Centers for Disease Control and Prevention (CDC). Partner services.
CDC-Partner notification services - Centers for Disease Control and Prevention (CDC). How can partner notification services help me and my patients?
Footnotes
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1 Golden 2022 - Golden MR, Gibbs J, Woodward C, Estcourt CS. Priorities in the implementation of partner services for HIV/STIs in high-income nations: A narrative review of evidence and recommendations. Sexual Health. 2022;19(4):309-318.
2 CG-HIV-positive partner notification - The Guide to Community Preventive Services (The Community Guide). HIV: Interventions to identify HIV-positive people through partner notification by provider referral (2005 archived review).
3 Hogben 2007 - Hogben M, McNally T, McPheeters M, Hutchinson AB. The effectiveness of HIV partner counseling and referral services in increasing identification of HIV-positive individuals a systematic review. American Journal of Preventive Medicine. 2007;33(2 Suppl):S89-S100.
4 CDC MMWR-Partner services 2008 - Centers for Disease Control and Prevention (CDC). Recommendations for partner services programs for HIV infection, syphilis, gonorrhea, and chlamydial infection. Mortality Weekly Report (MMWR). 2008;57(RR-09):1-83.
5 Cochrane-Ferreira 2013 - Ferreira A, Young T, Mathews C, Zunza M, Low N. Strategies for partner notification for sexually transmitted infections, including HIV. Cochrane Database of Systematic Reviews. 2013;(10):CD002843.
6 CG-HIV/AIDS and pregnancy - The Guide to Community Preventive Services (The Community Guide). HIV/AIDS, STIs, and pregnancy.
7 Hogben 2016 - Hogben M, Collins D, Hoots B, O'Connor K. Partner services in STD prevention programs: A review. Sexually Transmitted Diseases. 2016;43(Suppl 1):S53-S62.
8 Magaziner 2018 - Magaziner S, Montgomery MC, Bertrand T, et al. Public health opportunities and challenges in the provision of partner notification services: The New England experience. BMC Health Services Research. 2018;18:75.
9 Pellowski 2016 - Pellowski J, Mathews C, Kalichman MO, et al. Advancing partner notification through electronic communication technology: A review of acceptability and utilization research. Journal of Health Communication. 2016;21(6):629-637.
10 Hochberg 2015 - Hochberg CH, Berringer K, Schneider JA. Next-generation methods for HIV partner services: A systematic review. Sexually Transmitted Diseases. 2015;42(9):533-539.
11 Contesse 2019 - Contesse MG, Fredericksen RJ, Wohlfeiler D, et al. Attitudes about the use of geosocial networking applications for HIV/STD partner notification: A qualitative study. AIDS Education and Prevention. 2019;31(3):273-285.
12 Oehler 2021 - Oehler C, Rajagopal A, Songster T, et al. Partner notification services for patients with established and new HIV infection leads to diagnosis and linkage of HIV-positive partners. AIDS and Behavior. 2021;25:809-813.
13 Gore 2018 - Gore D, Ferreira M, Khanna AS, Schneider J. Human immunodeficiency virus partner notification services among a representative sample of young Black men who have sex with men demonstrates limited service offering and potential benefits of clinic involvement. Sexually Transmitted Diseases. 2018;45(9):636-641.
14 Desir 2016 - Desir FA, Ladd JH, Gaydos CA. Survey of partner notification practices for sexually transmissible infections in the United States. Sexual Health. 2016;13(2):162.
15 CDC-States’ partner services policies and laws - Centers for Disease Control and Prevention (CDC). How can partner notification services help me and my patient? Know your state’s partner services policies and laws.
16 Taggart 2021 - Taggart T, Ritchwood TD, Nyhan K, Ransome Y. Messaging matters: Achieving equity in the HIV response through public health communication. Lancet HIV. 2021;8(6):e376-e386.
17 CDC-HIV incidence - Centers for Disease Control and Prevention (CDC). HIV Incidence.
18 CDC-Hispanic/Latino HIV Incidence - Centers for Disease Control and Prevention (CDC). HIV: HIV by group. HIV and Hispanic/Latino People: HIV Incidence.
19 CDC-Hispanic/Latino MSM HIV incidence - Centers for Disease Control and Prevention (CDC). HIV: HIV by group. HIV and Hispanic/ Latino Gay and Bisexual Men: HIV Incidence.
20 CDC-African American HIV Incidence - Centers for Disease Control and Prevention (CDC). HIV: HIV by group. HIV and African American People: HIV Incidence.
21 CDC-African American MSM HIV Incidence - Centers for Disease Control and Prevention (CDC). HIV: HIV by group. HIV and African American Gay and Bisexual Men: HIV Incidence.
22 CDC-HIV and black discrimination - Centers for Disease Control and Prevention (CDC). HIV and Black/African American people in the U.S.
23 CDC-STI Surveillance - Centers for Disease Control and Prevention (CDC). Sexually Transmitted Infections Surveillance.
24 McGough 2005 - McGough LG. HIV/AIDS stigma: Historical perspectives on sexually transmitted diseases. Virtual Mentor: Ethics Journal of the American Medical Association. 2005;7(10):710-715.
25 East 2012 - East L, Jackson D, O’Brien L, Peters K. Stigma and stereotypes: Women and sexually transmitted infections. Collegian. 2012;19(1):15-21.
26 Tobin 2022 - Tobin MJ. Fiftieth anniversary of uncovering the Tuskegee syphilis study: The story and timeless lessons. American Journal of Respiratory and Critical Care Medicine. 2022;205(10):1145-1158.
27 HIV.gov - HIV.gov. HIV and AIDS timeline.
28 Bennington-Castro 2020 - Bennington-Castro J. How AIDS remained an unspoken—but deadly—epidemic for years. History. 2020.
29 CDC HIV-Exposure - Centers for Disease Control and Prevention (CDC). (2023, December 19). HIV and STD criminalization laws. Retrieved October 17, 2024.
30 CDC HIV-Criminalization - Centers for Disease Control and Prevention (CDC). (2023, December 18). HIV criminalization and ending the HIV epidemic. Retrieved September 18, 2024.
31 Bernard 2022 - Bernard, E. J., Symington, A., & Beaumont, S. (2022). Punishing vulnerability through HIV criminalization. American Journal of Public Health, 112(S4), S395–S397.
32 Golden 2017 - Golden MR. Assisted partner services for HIV: Ready to go global. AIDS. 2017;31(13):1891-1893.
33 NCSD-STD Funding - National Coalition of STD Directors (NCSD). As STD funding stagnates, rates rise to all-time highs.
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