• • Partner notification is an important component of treating patients for most sexually transmitted diseases (STDs).
  
• • Partner notification for syphilis, HIV, and possibly hepatitis B is usually best done by collaborating with experts from the local health department.
  
• • Partner notification is also a priority for gonorrhea, chlamydia, trichomoniasis, nongonococcal urethritis, and pelvic inflammatory disease, although patients will usually need to notify partners themselves after appropriate coaching.
  
• • Some patients resist notification out of fear of losing a relationship or because a relationship has already ended.
  
• • Emphasizing the health benefits helps patients initiate and successfully complete notification, thereby improving their own health, the health of partners, and the health of the community.

Tracing partners of patients with STDs has been done for centuries but was first introduced on a national scale by Surgeon General Thomas Parran as part of his five-point plan to control syphilis in 1937. At the time, syphilis was killing about 20,000 people per year in the United States. Parran’s campaign, and the subsequent discovery of penicillin, led to a nadir in syphilis rates in 1956. As rates dropped, health department efforts expanded beyond partners to test other people in the patient’s social network, but decreases in funding were followed by increasing rates of syphilis and periodic epidemics. Meanwhile a gonorrhea control campaign began in the 1970s, a chlamydia campaign began in the 1990s, genital herpes was increasingly diagnosed, human papillomavirus was linked to cervical cancer, and HIV infection appeared.

With an estimated 19 million new STDs each year in the United States, the most common approach to partner notification has become denial. Patients and clinicians who know the importance of treating partners may ignore it because they are uncomfortable or unfamiliar with the process. Becoming familiar with the partner notification process can help overcome this denial and improve the patient’s health.

Partner notification involves talking to patients with STDs about approaches to testing and treating their partners. Ideally, exposed partners can be cured before they develop complications or become infectious and transmit disease to others. Health department assistance with notification is not available for all STDs. Health departments seek active involvement in addressing syphilis and, to a slightly lesser extent, HIV. Some health departments will try to notify some partners of people with hepatitis B, gonorrhea, or chlamydia. For many STDs, however, patients are responsible for notifying their own partners. Most patients wonder what to do about their partners and appreciate advice from their physicians.

Patients benefit when their partners are notified. Patients who have been cured are susceptible to reinfection; untreated partners pose a risk to patients who have been treated for syphilis, gonorrhea, chlamydia, or trichomoniasis. Patients with chronic infections such as HIV can obtain social support from partners who become aware of their infection. Finally, most infected persons want what is best for their partners, and thus want them to be aware of their exposure because it is important for the partner’s health.

Partners benefit if notification occurs early enough to prevent or cure an infection that would otherwise have caused illness. Infections that lead to serious illness (eg, HIV) are more important than infections that less often cause disease (eg, herpes simplex virus or human papillomavirus). Partners benefit more when notified about bacterial infections, which usually are curable, in contrast to viral infections, which usually are not. However, treatment of HIV infection, while not curative, provides significant benefits to partners who might otherwise remain untreated. Partners who have acquired incurable infections also benefit from knowing about their infection because they can avoid transmitting it to other partners. Uninfected partners who are notified can take steps to avoid infection. Vaccination can prevent acquisition of infection by partners of hepatitis B carriers. Uninfected partners of HIV-infected patients can question their contacts about the infection or will need to change sex practices with all of their partners to reduce risk of infection, because health departments do not disclose the identity of the infected person. Changing high-risk behavior could reduce risk of infection for all persons notified about an STD.

Communities benefit when partner notification reduces the likelihood of infection in the community. Health department personnel can identify potential avenues for intervention in a community by interviewing patients and their partners about how and where they met, and what their sexual practices were. This information can lead to screening programs at high-risk venues, focused prevention campaigns (eg, posters showing syphilis ulcers), or informing persons in high-risk areas that syphilis is being transmitted via oral sex.

Yet another benefit of partner notification is that it fulfills the ethical obligation to share with individuals information that may be important to their health. This obligation extends to both the patient, who has a duty to disclose, and the health care provider, who has a duty to warn. This obligation is most compelling for serious curable infections or in situations where exposure is likely to be ongoing. However, even when there is not much to be done about it, partners have a right to know important information about their health.

The potential benefits of notification for the patient, partners, and community depend on the particular infection and what can be done following notification. The greatest benefits are for serious but easily curable infections that have a long incubation period (see Table 28–1). The potential to interrupt transmission is greater for syphilis and hepatitis B, in which there is a relatively long time between infection and infectiousness (3–4 weeks), compared with other infections (several days or less). The cost of finding new infections via partner notification compares favorably with screening campaigns when the infection is rare.

Currently, in the United States, partner notification offers the greatest benefit for syphilis. Syphilis can progress to fatal disease or result in stillbirth, it is easily cured, it is not transmissible until about 3 weeks after infection, and many infected persons are otherwise unaware of their infection. Other infections are good candidates for partner notification in some respects, but not in others. For example, HIV is a serious infection, but treatment does not eliminate infection, and preventing transmission depends primarily on behavior change. Thus, for HIV, partner notification, counseling, testing, and early treatment of infected partners may produce substantial prevention and clinical benefits for a very serious condition, but these benefits require additional interventions beyond notification and may not be realized in all cases. For human papillomavirus infection, there is no evidence that treatment affects elimination of infection, and infection is very common, often transient, less serious, and difficult to diagnose, so partners are not usually rigorously sought for notification.

Rapid notification of partners increases the chance of preventing further transmission and decreases the risk of serious complications among persons who are already infected. Usually partner notification is discussed when patients are told about their diagnosis and treatment. When HIV is diagnosed, patients may need time to react to their diagnosis, and it may be better to discuss the details of partner notification at a second visit a few days later. Because HIV is a chronic infection, patients may need to be reinterviewed for HIV partner notification if they acquire a new STD or if they have new partners who were not informed about the patient’s infection.

Partner notification aims to reach the partner who transmitted infection to the infected patient (the source) as well as any subsequent partners who may have acquired infection from the patient (“spread contacts”). The infecting organism and clinical findings provide clues about when the patient acquired the infection.

For syphilis, the interval for notifying partners varies by stage of disease: for primary syphilis, 3 months prior to the onset of symptoms; for secondary syphilis, 6 months prior to the onset of symptoms; for early latent syphilis, 1 year prior to the time of diagnosis.

For HIV infection, partners to be notified include all partners since 3 months before the last negative serologic test or 3 months before presentation with acute retroviral syndrome. When there is no previous HIV test, or when infection could have been acquired several years before the diagnosis, health departments often limit searches to partners from the year prior to the positive test because of difficulties in locating earlier partners. The US Congress has mandated that, for HIV infections, STD control programs notify all marital partners from the preceding 10 years.

Hepatitis B notification intervals have not been established. The greatest benefits from hepatitis B notification would be from vaccinating partners who may be exposed again, and from administering hepatitis B immune globulin to partners exposed in the preceding 14 days.

Gonorrhea, chlamydia, and trichomoniasis partner investigations generally go back 60 days prior to the onset of symptoms or the date of the positive test.

There are two basic approaches to notifying partners. In provider notification, trained health department employees (often called disease intervention specialists) gather information about partners from the patient and then notify the partners without revealing the identity of the patient. In patient notification, patients notify their partners after coaching by their physician.

Advantages of provider referral include verification that notification took place; protection of the patient’s confidentiality because no information about the patient is disclosed to partners; help with diffusion of any partner anger or blame; on-the-spot information about the disease and appropriate counseling; and possible collection of specimens for testing. Advantages of patient referral include lower cost and the potential for more rapid referral because the patient is more familiar with the identity and location of the partner.

Provider Referral

This method of notification is usually used for syphilis, HIV, and, sometimes, hepatitis B. The provider, usually a health department employee but sometimes a physician, performs partner notification.