Partner Notification: A potted history
It is now widely acknowledged that a key component in controlling the spread of sexually transmitted infections is actively contacting partners who may be infected and encouraging them to attend a G.U.M. Clinic. To merely treat someone with an infection without addressing the issue of where they got it from or whom they might have passed it on to will have little impact on the levels of infection in any given community.
In the past punitive and compulsory methods were used to get contacts seen whereas today in this country we rely on more persuasive approaches. This demands a high degree of skill and tact by the health adviser.
In the Victorian era women suspected of having a venereal disease (V.D.) could be sent to the workhouse and forced to wear yellow dresses for easy identification. The Contagious Diseases Act of 1864 sought to protect soldiers and sailors in military and naval towns by compelling women suspected of spreading venereal disease to be examined before a magistrate and detained in a designated hospital for treatment. This act was repealed in 1886 after many years of campaigning by Mrs Josephine Butler, a prominent social reformer of the day.
In 1913 a Royal Commission was set up to look at the problem of venereal diseases in the UK that eventually reported in 1916. This led to the 1917 Venereal Diseases Regulations that named syphilis, chancroid and gonorrhoea as V.D.s. Local authorities were given powers to provide free, confidential services for the diagnosis and treatment of V.D.s.
The Great War saw a mammoth rise in V.D.s and posed a real threat to the defence of the nation. For example in Newcastle upon Tyne 100 beds at the workhouse infirmary were offered to the War Office in September 1914 for wounded soldiers and sailors but in a matter of months 1000 beds were occupied by servicemen for little other than the treatment of syphilis. This was mirrored around the country with 23,000 servicemen in 1917 hospitalised for anything up to 7 weeks with V.D. Evidence was emerging of people using matchsticks to deliberately expose themselves to the disease to avoid the greater scourges of life (and death) in the trenches.
Health education work was conducted nationally by printing and widely distributing pamphlets on V.D. The Lord Chamberlain lifted his ban on Eugene Brieuxs play about syphilis, Damaged Goods, and it toured the country.
In the inter-war years treatment for V.D. required repeated attendance at clinics and involved painful procedures such as urethral irrigation. Defaulting for treatment was high and attempts to recall such patients was hampered by the use of false names and addresses and concerns over confidentiality breaches.
The social upheaval generated by the 2nd World War once again sent V.D. rates soaring. The position on Tyneside appeared to be much worse than other parts of the country with the particular worry that troops were rendered unable to fight being incapacitated by disease. Defence regulations 33B came into force in 1942 requiring doctors question patients and record the names of their consorts. Should someone be named more than once powers were enacted to compel them to be examined and treated. Failure to comply could lead to prosecution and potentially imprisonment. Civilian clinics were less vigorous in this activity than military ones but the concept was introduced of contact tracing by authorities (known as provider referral) when previously it had been left to the patient (known as patient referral).
Public Health nurses working on American bases in the UK began to trace British contacts of their infected personnel. This had become a national policy in the USA in 1937. Influenced by our allies' activity an initial 6 month experiment known as the Tyneside Scheme for the Reduction of Venereal Disease got off the ground in 1943. It proved successful in that further funding was secured and the results published after the war influenced other centres (such as Wakefield) to set up their own schemes. Contact Tracers gradually emerged as a distinctive group of clinic personnel. They were largely drawn from medical social work (almoners) and health visiting.
By the 1950s syphilis was well down from the recorded immediate post war peak incidence. Gonorrhoea however was seen as the main venereal enemy. Contact slips were widely used but only appeared effective with regular partners. Two London clinics at St. Thomas Hospital and Whitechapel appointed 3 social workers to focus on this problem. Their published work further refined the process of provider referral.
The 1968 and 1974 National Health Service (Venereal Diseases) regulations set out to remove certain difficulties in communicating confidential information to those concerned with contact tracing and still inform working practices to the present day.
" Every Regional Health Authority and every Area Health Authority shall take all necessary steps to secure that any information capable of identifying an individual obtained by officers of the Authority with respect to persons examined or treated for any sexually transmitted disease shall not be disclosed except-
(a) for the purpose of communicating that information to a medical practitioner, or to a person employed under the direction of a medical practitioner in connection with the treatment of persons suffering from such disease or the prevention of the spread thereof, and
(b) for the purpose of such treatment or prevention.
Increasing rates of V.D.s saw more contact tracers employed nationally and in 1969 The Society of Social Workers for the study of Venereal Diseases was established. It proved to be a useful vehicle for exchanging information and airing problems. It eventually became known as The Society of Health Advisers in Sexually Transmitted Diseases (SHASTD) with a written constitution.
By the mid 1980s the threat of HIV to the British populace significantly increased funding to GUM Clinics and elevated their status. Research activity flourished within the discipline at an unprecedented rate. The role of the Contact Tracer was expanded to embrace the challenge of educating the public about HIV and deal with vast numbers of people presenting for testing. The label Contact Tracer became less fashionable and was eventually replaced by that of Health Adviser. The traditional contact tracing activities had to compete with a growing HIV workload particularly in large urban clinics with a resultant much reduced profile in some centres.
In 1992 the Department of Health funded a project on Partner Notification in HIV which proved politically sensitive and extremely controversial. It provoked much debate within the profession about issues of human rights such as the right to (or not to) know ones sero-status. The public health responsibilities of the health adviser to prevent further spread of infection and the duty of care to individual clients with the virus created a role conflict for some that was not easily resolved.
By the mid 90s it was clear that HIV was infecting relatively few people (approximately 1500 per year in the UK) in contrast to early predictions yet it continued to affect many and large numbers still presented to their GUM Clinic for testing. Combination drug therapies greatly improved survival rates when complied with.
The influential Health of the Nation document (Department of Health, 1992) set targets of achievement in sexual health. Gonorrhoea was selected as a Key Area in particular and a marker of sexual health, partner change and behaviour likely to influence HIV transmission. For some time prevalence had been falling with the possibility of eradicating it discussed optimistically. However 4 years later annual statistical returns from clinics to the Department of Health began to record a worrying reversal in what had been a steady decline in gonorrhoea for nearly two decades. The trend was now in an upward direction and this was also noted in other transmissible infections such as chlamydia which can cause long term serious complications. A national audit on the clinical management of gonnorhoea recommended that partner notification should be examined having identified problems in co-ordination between clinics, particularly in large metropolitan areas. An national audit on genital chlamydia followed and drew similar conclusions on notifying and treating partners. Both audits issued standards for partner notification which were initially developed by SHASTD in 1995. Developing guidelines for good practice in health advising are soon to be produced by SHASTD as well as offering a tool to the profession for auditing partner notification activity.
Partner notification in conclusion forms a cornerstone in the control of sexually transmitted infections with the health adviser occupying a central and crucial role. In North America it is increasingly known as partner management which seems to reflect the fact that securing the attendance of a sexual contact is a more complex activity than merely tracing and notifying an individual. It demands a high degree of skill to be caried off sensitively and can be extremely time consuming. When carried out to an elevated standard it holds economic benefit to the Health Service by preventing costly damage to health from sexually transmitted infections. More importantly it can limit the physical damage and resultant pyschological trauma often encountered by someone with an infection by ensuring a shallower pool of infection in the community.
The Government is currently reviewing the outdated 1861 Offences against the Person Act with proposals that HIV transmission be potentially deemed a criminal act. History has shown that punitive methods rarely achieve the desired effect of disease reduction. Conversely it can be argued that it may exacerbate the problem by inhibiting people coming forward to be tested. Resource constraints in the Health Service have encouraged some clinics to make cost savings by cutting back on health advisers. The fear is that the short term financial gain will not benefit the sexual health of the public if the focus on partners becomes blurred. The past 50 years has seen an enormous refinement in dealing with sexually transmitted infections within the social context of peoples lives. We would do well not to throw away the history books!
Chris Faldon: Newcastle GUM Clinic