Review of Recommendations for Partner Services Matthew Hogben Centers for Disease Control and Prevention March 13, 2008 The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention

Overview Common goals and strategies: Treating disease and interrupting transmission Working on different STD from a common framework Tailored tactics: Different infections require different emphases on aspects of the partner services chain and sometimes different approaches Specific changes in new recommendations Overall public health involvement – the “umbrella” change Identifying candidates for services Linkage to care QA and evaluation Collaboration Innovation

PS Elements Identify PS candidates (index patients) Contact index patients, Interview, counsel and refer Notify partners of their exposure Provide appropriate services to partners

Common goals For infected persons: Maximize access to partner services by providing all infected persons with support to ensure that their partners are confidentially informed of their exposure; Maximize effective linkage to medical care, treatment, and prevention interventions to reduce the risk for transmission to others, and other services. For partners of infected persons: Maximize the proportion of partners who are notified of their exposure; Maximize early linkage of partners to testing, medical care, prevention interventions, and other services. For the community: Reduce future rates of transmission by aiding in early diagnosis, treatment – or, in the case of HIV, linkage to treatment – and provision of prevention services to infected persons.

Identifying candidates Identify PS candidates (index patients) Use all your resources to find candidates: Partner services programs should use surveillance and disease reporting systems to assist with identifying persons who are potential candidates for partner services. Strongly consider using individual-level data, if appropriate security and confidentiality procedures are in place.

Increased involvement Contact index patients → Interview, counsel and refer Notify partners of their exposure Take responsibility for finding infection: All persons with newly diagnosed or reported early syphilis infection or HIV should be offered partner services. Resources permitting, all persons with newly diagnosed or reported gonorrhea should be offered partner services. Persons with newly diagnosed or reported chlamydial infection should either be offered partner services as with gonorrhea, or programs should plan alternative strategies to enable partners to be notified. Know where you stand: Conduct a thorough review of all laws relevant to their provision of those services

Tailored tactics for different diseases New HIV (contract) Early Syphilis (provider) All Follow-up Interview Repeat cases GC (FDT) All FDT Subset It’s one example for one part of the process. Just note you’ve said something about dealing with each of the STD in the recommendations. Other GC, All CT (EPT) Re-interview subset One of multiple possible program approaches to PN

Provide appropriate services to partners Linkage to care Provide appropriate services to partners Treatment STD treatment guidelines Entry into long-term care for HIV Patients and partners may benefit from a range of services: Referral resources for psychosocial and other support services. DIS should be provided updated information about referral resources on a routine basis. DIS should screen for immediate needs and make appropriate referrals. Many referral needs can be addressed through linkage to medical care and HIV case management

QA and evaluation Can programs answer these questions? How completely is the program covering newly reported cases with partner services? How effectively is the program identifying partners, notifying them of their risk, and examining or testing them for infection? How effectively is the program identifying and treating new cases (syphilis and gonorrhea), or identifying new positives and linking them to care services (HIV).

Sources CDC offers: Program consultants and project officers www.cdc.gov/std/program Program Operations Guidelines chapter on evaluation Practical Use of Program Evaluation Guidance in specific announcements (DSTDP and DHAP)

Collaboration Partner services program managers should ensure, to the extent possible: Persons receive HIV and STD prevention and related social services in a coordinated manner with the goal that services are well integrated at the client (service delivery) level. That shared protocols and policies are developed to help coordinate partner services for persons identified through HIV, STD or other health department clinics. Partner services program managers should encourage private medical providers to support partner services. Ensure widespread distribution of these recommendations to health department partners, medical providers, CBOs and HIV prevention CPGs. A NCHHSTP priority: Program Collaboration and Service Integration Within organizations STD and HIV programs in health departments Patient overlap, therefore record overlap Services should not oppose one another, especially in the face of co-infection Related health services (TB, Hepatitis, social services)

Innovation Examples: Interviewing Interview techniques for increasing recall RCT in Colorado Springs, 2000 – 2001 Recall cues (Group 1) Locations, relationship roles, alphabet, social networks vs. (Group 2) First names vs. (Group 3) Individual characteristics Group 1 improved numbers of partners elicited by 21% Group 1 improved numbers of partners notified by 11% (per index case) Brewer et al. STD 2005;32: 189-93.

Medication in the field (EPT) Field-delivered therapy San Francisco, 1999-2000 Public health staff carried medications for partners in the field Treatment rates rose from 62% to 81% Patient-delivered partner therapy 3 trials covering gonorrhea or chlamydial infection Meta-analysis revealed significant reductions in reinfection, improved treatment and improved notification for both STD Make a note for the internet, too. Steiner et al. AJPH 2003;93:882-4. Trelle et al. BMJ 2007;334: 354.

Not all innovation is new… Milwaukee, WI: 1977-1978 Women with repeat gonococcal infection received PN services Repeat infection indicates high transmission rates and incidence Purpose of PN here is to reach “core transmitters” and therefore reduce incidence

April-June 1977 Oct-Dec 1978 N cases = 114 N cases = 28 N partners = 126 (Contact index = 1.11) N partners = 23 (Contact index = 0.82) N notified = 100 (79%) N notified = 15 (65%) N previously treated = 53 N previously treated = 5 N treated = 14 N treated = 9 NNTI = 8.1 NNTI = 3.1

Neolithic era PN… I’m from the health department about an important health concern. It’s not fair. Latex and TV won’t be invented for 10,000 years.