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We assessed Boston-area men who have sex with men (MSM) in terms of their knowledge of partner notification (PN)/partner counseling and referral services (PCRS) and intentions to use such services if exposed to/infected with a sexually transmitted disease (STD) or human immunodeficiency virus (HIV) in the future.
The study used a convenience sample of STD clinic patients (n=48) and a modified respondent-driven sampling method (n=70) to reach a diverse sample of MSM (total sample n=118) in Massachusetts. Participants completed a one-on-one, open-ended, semistructured qualitative interview and quantitative survey.
Overall, white, HIV-infected MSM had the highest level of knowledge about PN activities. MSM who were unfamiliar with PN were disproportionately nonwhite and HIV-uninfected. Participants were more likely to notify past partners of HIV exposure than STD exposure. The preferred method of PN for the majority of MSM was direct person-to-person notification. Notably, nonwhite participants were more likely to endorse Massachusetts Department of Public Health PN services than white MSM, who preferred involvement of primary care providers.
PN is an important public health strategy for treating and preventing STDs and HIV among at-risk populations, especially MSM who engage in sexual behavior with anonymous or otherwise non-notifiable sexual partners. Although many MSM had an understanding of the ethical desirability of informing exposed partners and recognized the value of preventative behaviors, they require further education to overcome barriers to PN as well as to gain knowledge of the various methods of both traditional and nontraditional notification, such as Internet PN.
Of the more than 40,000 new infections identified annually in the U.S., more than half are among men who have sex with men (MSM),1 men who are also at increased risk for sexually transmitted disease (STD) infections,2–6 thereby amplifying transmission of human immunodeficiency virus (HIV) in this population.7 These syndemics underscore the need to develop and expand culturally appropriate and innovative STD and HIV prevention programs for MSM.
Partner notification (PN) has become a mainstay of local and state-level STD and HIV prevention and control programs. PN includes four different approaches for notifying the sexual partners of clients infected with an STD or HIV: (1) provider referral (notification of sexual partners via a third party, such as an individual's medical provider), (2) partner referral (notification of sexual partners via the index client), (3) contract referral (an agreement between the client and provider, where the client is given the opportunity to notify his sexual partners independently, with the understanding that the partners will be notified by a third party if they have not been notified by a predetermined date), and (4) dual referral (both the client and provider notify the client's sexual partners together).8–14 Laws regarding PN/partner counseling and referral services (PCRS) for STDs and HIV infection differ from state to state, and PN/PCRS is usually a voluntary process in that client confidentiality is protected by law. In Massachusetts, PN/PCRS is not legally constrained or required, but is a matter of policy and practice.
Evidence of the effectiveness of PN as a useful strategy to reduce the spread of STDs and HIV is mounting. PCRS has been shown to increase identification of a high-prevalence target population for HIV testing and early intervention services, as well as reduce subsequent risk behaviors.15–20 Moreover, prior research on PN has documented broad acceptance of PN by at-risk U.S. MSM, regardless of HIV serostatus.10,11,21 Although several barriers to PN have been identified in previous work with MSM, notably the frequency of anonymous partners, concerns about protecting confidentiality, mistrust with respect to public health professionals and providers, and fear of rejection,22–24 additional research is needed to more thoroughly understand MSM attitudes and experiences with PN/PCRS and why PN programs have a lower level of participation among MSM.12
The current study is the first of its kind to our knowledge that used a mixed-methods approach (qualitative interview with a quantitative assessment) to assess attitudes and experiences with PN/PCRS for both STD and HIV exposure and infection with an exclusively MSM sample. The goal of the study was to assess participants' knowledge of PN/PCRS, intentions to use such services if exposed to/infected with an STD or HIV in the future, and features of an ideal PN/PCRS system, including the acceptability of Internet PN, to ultimately design more effective PN programs and services targeting MSM.
Between March 2006 and May 2007, 118 individuals participated in a one-on-one, open-ended, semistructured interview and quantitative survey with a trained interviewer. Participants were eligible if they were 18 years of age or older, a Massachusetts resident, and identified as MSM. Two groups of participants were identified for the study. Participants in Group 1, a convenience sample (n=48), recently presented at Fenway Community Health (FCH) for STD testing because they were concerned about high-risk sexual behavior (defined as unprotected oral receptive sex or protected/unprotected anal sex), were experiencing genitourinary symptoms, or had been diagnosed as HIV infected within the last six months. Group 2 participants were recruited using a modified respondent-driven sampling (RDS) method (n=70) and were identified via the social networks of selected individuals in the convenience sample who reported male-to-male sexual behavior in the last 12 months.
The qualitative interview consisted of questions related to participants' experience with and knowledge of PN for STDs and HIV. Each interview was digitally recorded and then transcribed verbatim by a professional transcription company. After completing the qualitative interview, each participant was given an interviewer-administered quantitative survey on demographics, HIV and STD testing, sexual behavior, and drug and alcohol use. All study activities took place at FCH, a freestanding health-care and research facility specializing in HIV/acquired immunodeficiency syndrome care and serving the needs of the lesbian, gay, bisexual, and transgender community in the greater Boston area.25 The FCH Institutional Review Board approved the study, and each study participant completed an informed consent process.
Participants in Group 1 were recruited via advertisements in the clinical and medical areas at FCH. To reach a diverse variety of social networks of MSM in Boston, the study utilized a modified RDS method.26,27 Six MSM from Group 1 were selected to act as study “seeds.” Seeds were evaluated for their commitment to the goals of the study and motivation to recruit three eligible peers within their social network. To meet the sample size within the study period, four additional seeds were selected after one year. Seeds were asked to recruit up to a maximum of three participants (acquaintances, friends, or sexual partners), who in turn were asked to recruit a subsequent wave of up to three participants, and so on, until the sample size of 118 had been reached. Each participant was given five cards with study information to hand to potential recruits. To keep track of social networks, each card had a number code that connected participants back to the initial seeds. Participants were compensated $40 for their participation in the study, as well as $20 for each eligible participant they recruited who subsequently completed a study interview.
The qualitative interview guide was developed by conducting a thorough literature review and gathering input from MSM health specialists at FCH and the Massachusetts Department of Public Health (MDPH) to ensure the survey instruments were appropriate to the study population.
Demographic, sexual behavior, and drug use questions were adapted from the Centers for Disease Control and Prevention's (CDC's) National Behavioral Surveillance Survey, MSM cycle28 and from a previous FCH study focusing on patient/provider communication and perceptions of risk for STDs and HIV.29 Questions were developed to assess barriers to contacting sexual partners if given a positive STD/HIV test diagnosis, including venues and methods for meeting sexual partners; partner relationships; total number of sexual partners within the time frame presently utilized by the Massachusetts state PN/PCRS system (for 12 months); ability to contact sexual partners by phone, e-mail, or other source(s); and information about frequency of anonymous encounters. The survey included the CAGE questionnaire,30–32 a clinical screening instrument for alcoholism.
The qualitative data from this study were analyzed using content analysis.33 After transcripts were reviewed for errors and omissions, study staff used NVIVO® software34 to thematically organize transcripts. Research staff then reviewed the coded transcripts and agreed on the final themes. Data were reexamined and ongoing discussions between coders and study investigators allowed for further theorizing and making interconnections between research questions and data. Interview data were stratified by HIV and STD history, as well as by white/nonwhite to examine group differences. Demographic survey data were entered into a Microsoft® Excel® database and analyzed with SPSS® software.35 Chi-square global tests of independence were used to test independent associations between variables. Odds ratios were calculated to assess the risk of particular outcomes. Correlations were used to assess the extent to which scores on two variables occupied the same relative position. Demographic data were also examined for differences between recruitment method types (STD clinic patients vs. RDS sample).
Table 1 outlines demographic characteristics of the sample. There were no statistically significant differences with respect to demographics and other behaviors between the FCH clinic sample and the RDS sample. As such, all data were analyzed in aggregate.
In the past 12 months, participants reported having had oral or anal (insertive or receptive) sex with a mean of 41.7 (standard deviation [SD] = 29.1) male sexual partners. Participants reported a mean of 8.9 (SD=21.2) anonymous male sexual partners they could not contact by telephone, e-mail, or some other means (Table 2). Unprotected insertive (56%) and anal receptive (48%) sex with at least one non-monogamous male partner was commonly reported in the past 12 months.
All but one participant had previously been tested for HIV and 81% of MSM (n=95) had previously been screened for STDs. The most frequently reported sites for HIV and STD screening were community clinics (72%), private physician's offices (42%), STD clinics (20%), or emergency rooms/urgent care clinics (17%).
In total, 66% of participants (n=78) reported a positive test result on their last HIV test and 57% (n=67) had been previously diagnosed with an STD. White MSM were more likely to have a history of STDs as compared with nonwhite MSM (odds ratio [OR] = 2.30, p<0.03), with 36% reporting prior syphilis, 61% gonorrhea, and 21% chlamydia. Overall, 40% of the HIV-infected MSM had previously been diagnosed with an STD.
Only 9% (n=7) of HIV-infected MSM reported having been previously contacted by MDPH offering PN services following their HIV diagnosis. Of MSM testing positive for an STD, 15% (n=10) reported having been contacted by MDPH offering PN services. Only 7% reported having been contacted previously by MDPH requesting that they get tested for HIV and 14% had previously been contacted by MDPH requesting they get screened for STDs.
Of the men in the sample who reported having heard about PN/PCRS (n=41), the information was obtained from a variety of sources: 48% from other homosexual friends, 45% from health-care providers, 27% from other friends, 18% from MDPH staff, 9% from media sources, and 8% from family members.
The majority of participants (65%) had not previously heard of PN activities prior to study involvement. Only 25% of MSM provided a correct description of PN. Common incorrect definitions included informing current sexual partners of STD/HIV status prior to engaging in sexual contact and maintaining open communication with sexual partners.
Overall, 81% of nonwhite MSM and 72% of HIV-uninfected MSM were unfamiliar with PN. Moreover, 69% of nonwhite, HIV-uninfected participants provided incorrect definitions of PN, the highest percentage of incorrect PN definitions by demographic and serostatus group. In contrast, 50% of white, HIV-infected participants provided correct PN definitions, demonstrating the highest PN knowledge by demographic and serostatus group.
HIV-uninfected MSM (75%) reported being contacted after an STD diagnosis more often than HIV-infected participants (54%). Nonwhite MSM were the least likely to report PN for STDs (31%). Nonwhite, HIV-uninfected MSM reported notifying partners of STD exposure least often and were less likely to have been notified by partners of previous STD exposures compared with white MSM (19% vs. 83%, p<0.05). The most common explanation for failure to notify past sexual partners after STD diagnosis was engagement with anonymous sexual partners (89%). Additional barriers to PN for STDs included embarrassment, shame/guilt, fear of rejection or loss of partner, and fear of partner discovering their infidelity. Some participants (20%) expressed a “not my concern” mentality, articulating a belief that choosing to engage in risky sexual behavior involves an inherent risk of spreading infection, suggesting minimal responsibility or obligation to notify.
Of the total 78 HIV-infected participants, 68% discussed their experiences notifying past partners of potential HIV exposure. HIV-infected MSM frequently described the anticipation and task of notifying partners of potential HIV exposure as “very difficult.” Significantly, 29% of nonwhite, HIV-infected participants reported not engaging in PN activities ever, which was the greatest percentage by demographic and serostatus group. Across the entire sample, common barriers to notifying sexual partners of potential HIV exposure were fear of rejection, fear of losing a partner, and the involvement of drugs or alcohol. The inability to contact past partners due to anonymous sexual encounters, such as men met on the Internet, also figured prominently (89%). Furthermore, several HIV-infected participants described their own shock and denial as debilitating, and felt too consumed by their own thoughts and fears to consider engaging in PN activities.
MSM experienced a higher frequency of negative reactions from past sexual partners when notifying of potential exposure to STDs (36%) as compared with HIV (21%). Interestingly, a large proportion of HIV-infected MSM (42%) were in a committed relationship at the time of their diagnosis and 45% specified that their committed partner was also HIV infected prior to learning of their own status. This contributed to less surprise at diagnosis and more awareness of the virus and treatment options, and may account for why HIV-infected MSM encountered a higher frequency of non-pejorative reactions (partner expressed appreciation, acted indifferent to the news, or offered support to the diagnosed individual).
With respect to being contacted by past sexual partners for potential STD/HIV exposure, 42% had been previously notified of possible exposure to an STD and 19% to HIV. White MSM reported being notified about exposure of an STD more frequently than nonwhite participants (83% vs. 19%). When asked what the experience of being contacted was like, responses fell into two major classifications. Some participants were unaffected by notification due to cognizance of their risk-taking behavior. Others described the experience as “very scary” and felt especially concerned about their own health.
Direct partner-to-partner notification was the most frequently preferred PN method, espoused by 53% of the sample. Participants expressed a belief that a major drawback of third-party involvement was the invasion of a contacted partner's privacy.
One-third of the sample indicated that they preferred assistance from a third party (i.e., a medical provider, MDPH, or a community agency) in notifying partners. Participants felt that obtaining assistance from agencies that possessed specialized expertise and knowledge in STD/HIV and PN was indispensable. Overall, 81% of nonwhite, HIV-uninfected participants expressed approval of MDPH PN services and 75% of HIV-uninfected participants endorsed the service highly. Several participants also noted that MDPH was an essential resource in the event that there was a history of domestic violence between partners.
With regard to being contacted by partners of a potential STD or HIV exposure, most participants (57%) were not concerned with how a partner chose to contact them, but rather with whether or not they were notified of exposure. “Just as long as I find out” was a very common statement. In terms of preferred method of notification, the majority of participants (62%) expressed an inclination toward being notified directly by their partner; only 8% indicated preference for involvement of a third party, whether a medical provider, MDPH, or a community agency. Nearly one-quarter (24%) of MSM showed no partiality toward a particular method of notification.
The majority of participants (52%) described their motivation to notify partners as a moral obligation. “It's the right thing to do” was a widespread response. Caring for a partner and his health was the second most common source of motivation, while preventing spread of disease universally was also fairly common. Motivating factors also included the extent of sexual intimacy with specific partners. Only HIV-infected participants listed guilt as a source of motivation.
The most frequently cited barrier to motivation for PN reported by 47% of MSM was fear of negative reactions from sexual partners. A significant number of participants also indicated that the greatest obstacle to notification was difficulty in contacting partners, typically due to anonymous encounters. Additional deterrents mentioned were fear of rejection or loss of partners, embarrassment or trepidation, fear of negative stigma attached to infection, and dislike of a sexual partner.
Participants were presented with hypothetical situations of STD and HIV infection to evaluate what actions they would take regarding PN. MSM in the sample were less likely to personally notify exposed partners for HIV diagnosis (59%) as compared with exposure to a curable STD (including chlamydia, gonorrhea, or syphilis) (75%). Participants were also more likely to get help for PN from a third party for HIV exposure (37%) as compared with STD exposure (19%). For both STDs and HIV, participants indicated that if the partner was casual or an anonymous sexual encounter, they would be more likely to utilize MDPH services for PN.
Overall, participants were less likely to inform partners of potential exposure to STDs than to HIV. Of the eight participants reporting no intentions for notification, seven mentioned that practicing safe sexual behaviors and maintaining personal health was an individual responsibility. Importantly, five mentioned that STDs would present with physical symptoms and, therefore, partners would be capable of seeking treatment without being informed of actual exposure.
One-quarter of the participants noted the greater severity of HIV to explain why they would notify partners about that exposure compared with an STD. Factors that differentiated HIV and STD notification were the perceptions that HIV has no known cure, HIV is life-threatening and life-changing, and HIV is not as easily detectable as many STD symptoms. Moreover, 10% reported that notification was imperative with respect to HIV transmission, because individuals need to know as soon as possible to seek out immediate testing and treatment.
When asked to provide a description of what an ideal PN system would look like, 37% explained that it would be similar to the existing MDPH system. Several MSM suggested that MDPH PN services should be more widely advertised. Many participants, especially HIV-infected MSM, felt that PN should be encouraged or that both partners should be present during notification. Many participants emphasized the need for comfort and convenience, including counseling throughout the entire PN process. Additional features discussed were the need to employ knowledgeable and supportive individuals to provide PN services, the involvement of a physician, and the importance of providing ample information throughout the process. Several participants suggested that anonymous services be available through community health agencies due to stigma attached to government-run programs. Moreover, several participants recommended a telephone hotline providing PN options and assistance. Finally, for a number of participants, an ideal PN system would involve an Internet-based service on a sexual partner meeting website.10,11
This study found that a sexually risky cohort of Boston-area MSM demonstrated a dearth of knowledge about PN. MSM who were unfamiliar with PN were more likely to be nonwhite and HIV-uninfected, suggesting that MSM education will need to be sensitive to minority community concerns. Overall, white, HIV-infected MSM had the highest level of knowledge about PN activities. Although many participants had an understanding of the ethical desirability of informing exposed partners and appeared to recognize the value of preventative behaviors, they require further education to overcome barriers to PN as well as to gain knowledge of the various methods of notification.
Participants were twice as likely to indicate that they would inform partners of exposure to HIV infections compared with STDs. The perceived severity of HIV compared with STDs may have accounted for the greater willingness to use PN activities after HIV exposure. Several participants incorrectly mentioned that PN for STDs was unnecessary because symptoms would ultimately alert a partner of infection. This finding is consistent with previous research documenting a lack of STD awareness and knowledge among MSM in the Boston area19 and suggests a need to educate MSM about asymptomatic STDs. Moreover, participants indicated that the most common motivator to getting screened for STDs was the appearance of symptoms, explaining why many at-risk MSM do not get screened at least annually for HIV, syphilis, and gonorrhea, despite CDC recommendations to do so.36
Many participants discussed the contextual and relational factors that affect a chosen PN method, emphasizing that if and how one notifies a partner depends heavily on the nature and closeness of the relationship. This is consistent with previous research, which has shown that a key factor that may influence willingness to notify past sexual partners is the type of relationship between the individuals.14 However, because some MSM in this study specified that partner factors were insignificant in their decisions about notification, other variables will need to be considered in educating MSM about PN services.
A predominant barrier to notification was engagement with anonymous sexual partners. Overall, 89% of participants reported having not notified some partners of exposure due to anonymous sexual encounters. Many MSM in the sample met anonymous partners through the Internet, which is similar to previous studies documenting that risky sexual behaviors were common among MSM who use the Internet.37–40 Several participants indicated that Internet-based PN would be part of their ideal PN system, supporting recent research demonstrating broad support for Internet PN services among MSM who seek partners on the Internet, including a willingness to receive or initiate PN-related e-mail for STD exposure.10,11
Being notified, seeking testing, notifying others, and coping with diagnosis and treatment all were mentioned as being more comfortable experiences if accompanied by a partner in a committed relationship, especially for HIV-infected participants. In particular, HIV-infected MSM in a committed relationship with partners who were HIV infected prior to learning of their own status provided an important source of support to newly diagnosed MSM. Future research will benefit from assessing more of the types of relationships MSM have and how these impact notification practices.
Consistent with findings from previous PN studies with women and injection drug users,41–44 another major barrier to STD and HIV notification for MSM was fear of negative reactions from partners. Significantly, MSM experienced a greater proportion of negative reactions from past sexual partners when notifying of potential exposure to STDs (36%) as compared with HIV (21%). Fear of verbal and physical attacks, loss of relationships, and general anger made respondents wary of engaging in PN activities and should be addressed in educating MSM about PN. Public health officials will need to develop means of assisting MSM in notifying their partners of exposures in ways that facilitate their safety.
The most commonly preferred PN method for MSM in the sample was direct partner-to-partner notification. Participants expressed concerns with confidentiality issues with regard to third-party involvement when explaining this preference. This is consistent with other PN research suggesting that MSM may be less willing to provide partner information for PN activities as a result of general mistrust of public health officials and concerns about confidentiality.21–24,45,46 Significantly, participants were more likely to get help for PN from a third party for HIV exposure as compared with STD exposure.
Findings from previous studies suggest regional and cultural differences may influence PN preferences.14 In the present study, nonwhite respondents endorsed the use of MDPH PN services more than white participants. White respondents preferred involvement of a primary care provider more than nonwhite respondents, and white respondents often cited their primary care providers as the most knowledgeable and trustworthy sources of health information. The respect and appreciation for physicians expressed by participants suggests that educating clinicians about PN services may enhance future efforts at STD and HIV control.
When describing aspects of an ideal system, many respondents referenced the need for counseling as part of the notification process. Some respondents who had engaged in previous discussion surrounding PN and some who had previous knowledge of PN prior to the study reported such discussion took place in counseling or support groups. Counselors and similar providers may represent important sources of information about PN and can assist with overcoming barriers to notification, including risk behavior associated with drug and alcohol use and embarrassment, shame, or guilt. Counselors and mental health providers should be well-versed in best notification practices, and PN trainings for providers working with MSM should be made widely available.
Some participants who utilized the MDPH PN system reported being confused or alarmed, particularly when being notified about an HIV or STD exposure. The main problem seemed to be that notified individuals were not presented with enough information regarding the purpose of the service and recommendations for subsequent preventative measures. PN systems should strive to provide contacted individuals with as much information as possible regarding the role of the service, testing, and counseling options, and be available and receptive to any questions. Cultural sensitivity training of health officials, and education of at-risk MSM about PN may help to mitigate the problems noted by the participants in this study.
While both the relatively small sample size (n=118) and the utilization of mixed recruitment methods (convenience sample and modified RDS sample) limited the generalizability of findings, the current study demonstrates that although many MSM had an understanding of the ethical desirability of informing exposed partners and recognized the value of preventative behaviors, they require further education to overcome barriers to PN as well as to gain knowledge of the various methods of both traditional and nontraditional notification, such as Internet PN.
PN is an important public health strategy for treating and preventing STDs and HIV among at-risk populations. A variety of PN efforts have been successful, but to optimize PN program efficacy, evaluation of PN programs should be conducted and refined. The use of nontraditional PN methods, such as the Internet, might help to reach MSM who engage in sexual behavior with anonymous or otherwise non-notifiable sexual partners.