Incorporating HIV Prevention into the Medical Care of Persons Living with HIV Ask ∙ Screen ∙ Intervene Developed by: The National Network of STD/HIV Prevention Training Centers, in conjunction with the AIDS Education Training Centers Module 3: Partner Services & Referrals

Learning Objectives: Module 3 Upon completion of training, providers who care for HIV-infected persons will be able to: Realize the concerns and considerations about local partner notification law Outline the partner referral options and process Utilize health department support Give key messages about PCRS to patients

Breaking the Chain of Infection Make no assumptions Maintain tact and respect Use open-ended questions Ask specific questions Identify and correct misconceptions Tailor the intervention Clinical Management Partner Services Behavioral Counseling Routinely integrate into clinical encounters

Clinical Management & Partner Services Ask Builds on common questions Screen Identifies need Intervene Stops the spread of disease at multiple points

Behavioral Counseling & Partner Services Ask Utilizes patterns identified Screen Determining the patient’s mental readiness Intervene Development of referral plans

Strengthening Referrals Case Management Behavioral Intervention Partner Services

Partner Notification Laws Vary by state and region Consult with state HIV/AIDS Program and Policy Offices Consider visiting

What are HIV Partner Counseling and Referral Services (PCRS)? Voluntary and confidential services Voluntary and confidential services Available to persons living with HIV and their potentially exposed sex and/or needle – sharing partner(s) Available to persons living with HIV and their potentially exposed sex and/or needle – sharing partner(s) Assists HIV infected persons to tell their partner(s) about possible exposure Assists HIV infected persons to tell their partner(s) about possible exposure Facilitates linkages to services Facilitates linkages to services

“The Big Picture” Transition Investigative Activities Partner Referral Options Elicitation Partner Referral Plan + Coaching Summary Follow Up Links to Other Services Test Decision Prevention Counseling Partner Notification Phase 1 Phase 2 Phase 3

Key Benefits to Patients and Partners Common Concerns Patient doesn’t have to reveal HIV/STD status Fulfills ethical desires for patient Partner learns information about real risk Opens access to wide range of prevention and care services to partner Intervenes in spread to other partner(s) or unborn children Threat to confidentiality Potential for violence, especially against women, when HIV+ serostatus is revealed Stigma-related discrimination

Key Benefits to Clinicians Common Concerns Fulfills public health and ethical concerns Improves patient outcomes Provides ongoing health department support to meet legal obligations Can be performed by non-clinical staff Threat to confidentiality and patient/provider relationship Increased work load in a time-limited environment Unclear legal expectations

Objectives of Partner Management Facilitate a patient’s decision to notify an exposed partner Address patient concerns related to partner notification Coach a patient to self-disclose status to exposed partner, if it can be done safely Identify circumstances when partner notification may be difficult or dangerous, and make appropriate referrals, if available Provide ongoing support to clinical providers

What is your role? Support for patients who want to disclose HIV status and need help Support for patients who have exposed someone to HIV and want the individual(s) notified Information gatherer for other care providers/health department staff to assist with partner notification

When To Bring Up The Subject Anytime patient mentions a partner(s) or a new partner When pregnancy is involved When you have given a positive test result and have managed all other patient medical concerns and issues When patient asks for help with informing partner(s) about possible exposure to HIV At any medical, social or behavioral follow-up appointment

Step 1: Transition Goal: Use a phrase that takes patient to the topic of exposed partner(s) Sample transition statements: “We’ve talked quite a bit about services available to you, but one we haven’t yet discussed involves helping you tell your partner(s) they may have been exposed to HIV. How do you feel about that?” or “Now that we’ve talked about ways to keep you healthy, let’s talk about ways to keep your partner(s) healthy. How do you feel about telling your partner(s) they’ve been exposed to HIV?

Situations That Ease The Transition Part of routine care for all patients Patient brings up topic of partner(s) or disclosure of status to partner Patient suspected test results would be positive

Step 2: Referral Options Goal: Provide patient with partner referral options Patient Referral Provider Referral Dual Referral Contract Referral

Step 3: Partner Elicitation Goal: Gather partner information Identifying Information Locating Information Exposure Information

Time Frame Guidelines for deciding how far back to consider informing partner(s): 1 year Best chance for prevention Allows for early intervention (for infected partner(s)) Best chance for finding a partner 3 months before last negative HIV test As far back as client requests As state guidelines dictate Guidelines for deciding how far back to consider informing partner(s): 1 year Best chance for prevention Allows for early intervention (for infected partner(s)) Best chance for finding a partner 3 months before last negative HIV test As far back as client requests As state guidelines dictate

Using Health Department Staff Contact the local health department STD control program manager Notification requires the following partner information: First and last name is ideal; however, a nickname/street name is acceptable Two pieces of locating information A detailed description of the partner Type and dates of exposure Be prepared to give the infected patient’s HIV test date, where testing occurred and the date you were asked for assistance in locating the partner(s)

Why Utilize Health Department Staff? Trained and experienced staff provide PCRS and other STD related counseling services in both field and clinic settings Provide ready linkages to other services Can immediately notify partner(s), usually between hours after becoming aware of the need to reach a partner(s) Relieves you and your staff from those duties

Notification by Health Department Health Department Staff will: Ensure they are talking to the right person Identify self Secure private area to talk Deliver message Answer questions/provide business card

Step 4: Referral Plan and Coaching Goal: To assist patient with determining how each partner will be managed Help patient assess own willingness or ability to: Disclose own HIV status Accept that partner is not bound to protect confidentiality Contact partner promptly Find a private place for discussion Help partner understand seriousness of HIV Refer the partner for services Anticipate and handle partner’s reactions

Step 5: Summary Goal: To wrap-up session Review referral plans Re-emphasize confidentiality Ask if there are any other questions Review personal prevention plan Goal: To wrap-up session Review referral plans Re-emphasize confidentiality Ask if there are any other questions Review personal prevention plan

Case Study Remember Tony. He is married to a woman who recently had a yeast infection. He engaged in anal and oral sex with 5 male partners over the last 3 months. He “hooks up” with men via the internet. He has mentioned that his wife is also HIV infected. He uses condoms during anal sex only.

Case Study - continued Would you introduce option of PCRS program? What transitional phrase can we use to initiate a conversation with our patient about PCRS? What supports and benefits can PCRS offer: PatientPartner What are your ethical and legal concerns regarding your patient?

Co-Infection Case Study

Charting Considerations Do Document That PCRS was explained and offered The number of partners the patient will contact and the number he/she wants assistance with, including type of exposure information Whose partner information was forwarded for partner notification (e.g. health department staff) If coaching was provided to patient

Charting Considerations Do Not Document Names of partner(s) in patient’s medical record Specifics of conversation that could potentially compromise the partner(s) anonymity

“Take Home” Messages for Patients Assistance is available to inform your partner(s) of possible exposure to HIV HIV PCRS is a confidential service that you elect to use These services can help you tell your partner(s) about possible exposure or provide you with a trained staff person who can notify your partner(s) for you without ever mentioning your name or anything about you If you want a staff person to notify your partner(s), they will never be told any information that could identify you This is a free and ongoing service that you can access at any time

PCRS In Action “Real Life” 22 year-old, heterosexual male tests HIV positive in a correctional setting PCRS is offered and he names three women- a 19 year-old and a 20 year-old. Information about the third woman is unknown. The names of both women are forwarded to the appropriate health jurisdiction and they are found in the same city Both women initially did not believe they were at risk, but elected to test for HIV and both were infected

PCRS was offered and each accepted the service The 19 year old named the original patient as her only lifetime partner and the 20 year old named a female partner who tested negative A year after the initial PCRS session with the original male patient, a discussion around new partners surfaced at an EIP session At the EIP session, he discussed 3 additional partners. One of those partners was 16 years old and she had recently given birth to his child. She was unlocatable. PCRS In Action “Real Life”

Additional Resources Local Health Department HIV/AIDS Programs – National Alliance of State and Territorial AIDS Directors (NASTAD) – Centers for Disease Control-Division of HIV – State STD Program Managers – see handout National Coalition of STD Directors – HIV Criminal Law and Policy Project STD HIV Prevention Training Center – Partner Management and Program Support Services Quadrant Coordinator –