These guidelines have been produced as a working document for all Health Advisers based in Departments of Genito-Urinary Medicine.   It is anticipated that they will also be of benefit to those interested in the issues of partner notification in sexually transmitted diseases.

PARTNER NOTIFICATION GUIDELINES

 Contents

INTRODUCTION 

In 1993 the Society of Health Advisers in Sexually Transmitted Diseases (SHASTD) established a working group to produce guidelines on partner notification.  This working group consisted of health advisers from Departments of Genito-Urinary Medicine (GUM) from within the United Kingdom, representing both urban and rural areas.  Through this initiative these guidelines have been produced.  For the purposes of these guidelines the term partner notification will be synonymous with contact tracing.

 The United Kingdom saw the establishment of the first contact tracing projects for sexually transmitted diseases (STDs) over forty years ago.  Initially these projects were developed to identify, diagnose and treat the contacts of persons with venereal diseases, essentially gonorrhoea and syphilis.  It was during this period that the availability of treatment for all STDs highlighted the public health issues and identified contact tracing as an important part of control.  Although these early initiatives were only a part of the wider public health approach, it is recognised that contact tracing has played and continues to play a fundamental role in the control of STDs in the UK.   These continue to be the basis of the management of partner notification as we know it today, which has developed over the years to become a complex and challenging component of the role of the health adviser.

 Aims of Partner Notification

 The aim of partner notification is to break the chain of transmission of STDs and reduce the national rates of infections through:-

 Partner notification should be available for all those patients/clients with a diagnosis of an STD.

Definitions of Partner Notification

'Partner notification'

 “The spectrum of public health activities in which sexual partners of individuals with STD or HIV infection are notified, counselled on their exposure and offered services".

The partner should be given information on:

 'Patient referral'

“The approach whereby an infected patient is encouraged to notify partner(s) of their possible infection without the direct involvement of health care providers.  The patient may: (i) provide the partner with information; (ii) accompany the partner to the clinic; or (iii) simply hand over a contact slip.  The health care provider may counsel patients about the information to be passed on to their partners and the methods of providing it.”

'Provider referral'

“The approach whereby health care providers or other health care workers notify a patient’s partner(s).  The infected patient provides information on partner(s) to a health care worker, who then confidentially traces and notifies the partner(s) directly.”

(World Health Organisation Management of Patients with STDs)

Principles of Partner Notification

“Partner notification should be voluntary and not punitive in any way.  Index patients should have full access to available services whether or not they are willing to co-operate in notification activities.”

 (Department of Health Guidance on partner notification for HIV infection) PLCO(92)5

Confidentiality

Confidentiality is of paramount importance in the area of GUM.  All health professionals are bound by a common law duty of confidentiality.  In addition to this the NHS (Venereal Diseases) Regulations 1974 and the National Health Service Trust (VD) Directive 1991 offer additional protection to patients rights of confidentiality.  The records of all patients attending a GUM must remain confidential to that department.

Health Adviser Code of Ethics

The agreement and co-operation of the index patient must be established before partner notification can be undertaken.  It is important that the index patient understands the need to inform partner(s)/contacts who have possibly been exposed to an STD.  To enable this to happen clear, detailed and relevant information about the nature of the infection needs to be obtained and its modes of transmission clarified.  The Society believes that all health advisers should work to the SHASTD Code of Ethics in order to provide a professional and ethical health advising service.  Partner notification should be undertaken within the context of a full GUM service.  This includes a full screening, diagnostic and treatment service to include not only partner notification but also health education/promotion and counselling.  It is important that all patients have the opportunity to explore factors which affect the individual risk to their own sexual health.

Issues for Consideration in the Practice of Partner Notification

Partner notification should be non-coercive, confidential

and should not be seen as punitive 

 With HIV the issues of partner notification are complex.  In addition to the basic principles of good practice the issue of partner notification should be raised at the pre-test discussion.

Methodology of Partner Notification

1.      Patient referral

The majority of partner notification in the UK is patient referral based.  The preferred method of patient referral is through the use of contact slips.  These enable reliable and efficient cross-referencing and ensure appropriate screening and treatment of the contact.  The use of Department of Health diagnostic codes for STDs on contact slips provides an anonymity and confidentiality for the index patient.   All health advisers should be conversant with Department of Health diagnostic codes for STDs.  Health advisers are the key health care professionals involved in patient referral partner notification – other health care workers, e.g. doctors, may instigate patient referral partner notification with the issue of contact slips.

 All patients with an STD should have partner notification issues raised with them.  Patient referrals relies on the use of contact slips and the co-operation of the patient/client.   Contact slips are issued in order to:-

 a)      enable sexual contacts to seek medical advice and treatment

b)     to inform the contacts clinic of index patients diagnosis, reference number and date of diagnosis.

c)     to cross reference and enable evaluation of partner notification action.

The issue of contact slips should include the following considerations:

 i)      One contact slip for each contact

ii)     Each contact slip with contain the following information relating to the index patient; date of diagnosis, reference number; Department of Health diagnostic code; name and address of issuing clinic.  The reverse of the contact slip ship should be completed with the contacts information, reference number; date of attendance, Department of Health diagnostic code and name and address of issuing clinic.  If contacts attend other GUM, completed contact slips should be returned to the issuing clinic as soon as possible.

iii)    All information from contact slips should be cross-referenced.

Patient referral partner notification may take place without the issuing of contact slips, for example, when the contact is only accessible by telephone or lives abroad (Department of Health diagnostic codes are not applicable outside the UK).  World Health Organisation codes are available but, as these may not be widely used, naming the infection may be preferable.

Patients should be encouraged to use contact slips as this helps facilitate the management of partner notification.

2.      Provider referral

This is where the index patient decides that they wish the health adviser to manage partner notification on their behalf.

To enable the health adviser to carry out provider referral the index patient must give full and accurate information regarding contact(s) sought.  Provider referral should be offered by health advisers to those patients where other methods of partner notification are inappropriate.

As with all forms of partner notification the confidentiality of the index case must be protected, although it is important that possible loss of confidentiality is discussed with the index patient before any provider referral is commenced.  Identification of the index patient must never be confirmed by a health adviser.  However, if the contact has only one sexual partner, confidentiality may be compromised.

It may be necessary for the health adviser to seek the assistance of colleagues in other clinics in order to carry out provider referral.

Provider referral may take place by letter, telephone call or domiciliary visit.

Methods

There should be nothing specific in the letter to suggest STDs.  The envelope should be marked “Private and Confidential – Addressee Only” and the envelope should not be identifiable as being sent from a hospital.  The full name and address provided the index patient should be used.  It is sometimes possible to check addresses through the telephone directory, FHSA and electoral roles.  A telephone number for easy access to a health adviser needs to be included in the letter in order to encourage swift resolution of partner notification.

The correct identify of the patient contact needs to be established by the health adviser.  Issues to be taken into account include: convenient time for discussion of a personal nature and possible need for verification of the authenticity of the call.  Checking correct identity over the phone is difficult, therefore one should disclose as little as possible and encourage a face to face interview.

The advantages and disadvantages of each individual domiciliary visit need to be carefully considered prior to undertaking this method of partner notification.  Visits risk causing domestic upset to the partner/contact if other family members/friends or partners are present, but allow for the contact to be informed of their potential exposure and to be reassured.   As with all domiciliary visits the safety of staff is of paramount importance.

 3.       Contract Referral

This is a method where the patient and health adviser negotiate and agree with an acceptable time span in which the index patient will attempt patient referral.  If this is not successful then re-negotiation takes place and provide referral may be agreed.

The preferred method for patient referrals is through the use of contact slips.  They enable reliable and efficient cross referencing and ensure appropriate screening and treatment of the contact.

4.      No Referral

There will be situations when no method of partner notification is appropriate.  This may be where there is a threat of physical violence, either to the patient or to the health advisers; or where there is a history of sexual assault; or if the partner notification has to take place abroad; or if there is insufficient information.

Issues for Consideration in the Management of Partner Notification

It is hoped that these guidelines will facilitate partner notification and encourage good practice and management.  In addition it is hoped that those clinics that do not have a written policy for partner notification will use these guidelines as a basis from which to work.