Results from this article demonstrate that persons who were older than 25 years, male, or reported male-male sex and/or injection drug use in the previous year or since their last negative HIV test were more likely to refuse to provide partner information. Among those who provided partner information, those who reported being single or having male-male sex, injection drug use, or both in the past year were less likely to provide the names or contact information for their partners. Almost three-quarters of named partners who were referred by index clients were located and offered PCRS. The dual referral approach for notifying partners yielded the highest proportion and the contract referral approach yielded the lowest proportion of referred partners who were subsequently located and offered PCRS.
The percentages of index clients who refused to provide information about their partners varied by the PCRS approach used. The lowest refusal rates were observed at sites that used the traditional referral approach, whereas the highest refusal rate occurred at the site using the CBO referral approach. This may be explained in part by the possibility that the health departments have the most experience using the traditional approach for PCRS, whereas CBOs may not have comparable experience with and also may not prioritize PCRS. Although the Los Angeles site had the highest percentage of index clients who refused to provide partner information, this site recruited more than half of all of the index clients who participated in this project, it recruited the second highest number of index clients who provided partner information among participating sites, and tested more named partners than any other participating site [9
]. These findings indicate that a CBO referral approach to PCRS may be able to offer PCRS to large numbers of partners of index clients even if refusal rates using this approach are high. However, these conclusions should be interpreted with caution because it is not clear whether they are due to the approach, site characteristics, or a combination of the two. It is also possible that these findings were due in part to the ability of the CBO to reach a large number of index clients in an area with a high prevalence of HIV infection.
Index clients who were married were more likely to provide information about and names of partners than single index clients, whereas persons who reported male-male sex and/or injection drug use in the past year were less likely to provide information about and names of partners. In addition to the finding that people who engaged in male-male sex and/or injection drug use may have been more likely to have anonymous partners, our findings might indicate that MSM and IDUs may be more reluctant to share personal information, possibly due to social stigma, negative feelings toward being HIV-positive [18
], or misconception about named-based partner notification, as reported previously [19
]. Therefore, additional effort will likely be needed to encourage MSM and IDUs to participate fully in PCRS.
The importance of timely interviewing is highlighted by our finding that persons interviewed within 3 month of diagnosis were two and half times as likely to provide partner information as those interviewed later. This likely reflects the fact that persons who have been living with HIV infection for some time may feel that they know how to disclose their HIV status and have had some experience disclosing their status with others. Additionally, some people may have already received PCRS at the time of their diagnosis, and therefore might have been less receptive to participating in PCRS at this time. However, this may also indicate that index clients interviewed more than 3 months after diagnosis may have trouble recalling identifying and locating information for their partners. Although health departments may face challenges with timely reporting of HIV diagnoses, CDC recommends that all persons with newly diagnosed or reported HIV infection should be offered PCRS at diagnosis or as soon after diagnosis as possible [3
]. Thus, interviews should be conducted with index patients as early as possible following diagnosis in order to achieve the full public health benefits of PCRS.
To measure the effectiveness of PCRS, it is important to examine not only how many partners are referred by index clients, but also how many referred partners are actually located and offered PCRS. During this project, the dual referral approach resulted in the highest proportion of named partners being located and offered PCRS. This is not surprising since most of the partners referred by this approach were recruited in Los Angeles, where index clients brought their partners to the CBOs for notification using the dual referral method. At the other participating sites, however, fewer people selected the dual referral approach. Therefore, it is unclear whether this referral approach would be as effective in other jurisdictions.
Provider referral and self-referral are two widely used approaches for partner notification [20
]. During this project, almost equal numbers of index clients selected each method of referral for partner notification and both approaches had similar success in reaching partners. In comparison, the contract referral approach was the least effective method used in this project, resulting in only 38% of partners being located and offered PCRS. However, it is important to note that the relative effectiveness of this method may have been related to the characteristics of the sites rather than the approaches themselves. Our findings do suggest that the effectiveness of PCRS may vary by the type of referral approach that is offered. Thus, the choice of referral method for partner notification needs to be taken into consideration for the implementation of future PCRS programs. Further examination of different approaches of PCRS and operational research evaluating the use of different referral approaches by approach should be conducted to identify the best ways to reach and test partners.
Data cited in the CDC partner services recommendations suggest that provider referral is the most effective method for notifying partners [3
]. We found that the dual referral method was the most effective method used in our analysis. Because data comparing the effectiveness of various PCRS approaches are limited, this is the first report of the effectiveness of the dual referral method. The provider and dual referral methods both draw on the skills of the DIS to provide information about the process of PCRS, information about HIV as a disease, assistance obtaining HIV testing, and, if needed, linkage to care. Further studies should examine the dual referral method more closely and determine when this method can be best utilized.
Our findings are subject to several limitations. First, convenience sampling was used to recruit index clients to participate in this project, a relatively small number of sites were included in this project, and the selection of participating sites was not systematic, therefore our results may not be representative of all HIV-infected persons. Second, these data were largely based on self-report from index clients and may therefore be subject to desirability and recall biases. Third, our assessment on the effectiveness of different referral approaches for reaching partners was based on a demonstration project rather than a study designed to compare those referral approaches, and so caution should be used when interpreting some of our conclusions. A systematic evaluation of PCRS including qualitative examination of acceptance and refusal of services would be needed to obtain generalizable findings about which PCRS approaches are most effective.
In this project, we found that various PCRS approaches by participating sites were effective in identifying and reaching partners for notification. Using PCRS approaches that rely on collaboration between health department and CBO staff, or those that are conducted solely by CBO staff may succeed in identifying partners exposed to HIV infection, obtaining partner locating and identifying information and offering PCRS, and sometimes such approaches may be more effective than traditional PCRS approaches. Our data showed that the dual referral method may be the most successful referral method for non-traditional approaches of PCRS, however this finding should be interpreted with caution, as this project was not designed to make direct comparisons between the approaches. This demonstration project sheds light on ways to enhance the implementation of HIV partner services. However, further studies will be needed to evaluate combinations of PCRS approaches and referral approaches and identify the most effective methods to reach partners and prevent HIV transmission. Health departments should implement PCRS approaches that integrate the strengths of traditional approaches with the reach of non-traditional approaches, such as the placement of DIS at CBOs in order to maximize the success of this public health intervention.