Intimate partner violence, partner notification, and expedited partner therapy: a qualitative study

"It's not safe for me and what would it achieve?" Acceptability of patient-referral partner notification for sexually transmitted infections to young people, a mixed methods study from Zimbabwe

Partner notification (PN) is considered integral to the management of sexually transmitted infections (STI). Patient-referral is a common PN strategy and relies on index cases notifying and encouraging their partners to access treatment; however, it has shown limited efficacy. We conducted a mixed methods study to understand young people's experiences of PN, particularly the risks and challenges encountered during patient-referral. All young people (16-24 years) attending a community-based sexual and reproductive health service in Zimbabwe who were diagnosed with an STI were counselled and offered PN slips, which enabled their partners to access free treatment at the service. PN slip uptake and partner treatment were recorded. Among 1807 young people (85.0% female) offered PN slips, 745 (41.2%) took up ≥1 PN slip and 103 partners (5.7%) returned for treatment. Most participants described feeling ill-equipped to counsel and persuade their partners to seek treatment. Between June and August 2021, youth researchers conducted in-depth interviews with 41 purposively selected young people diagnosed with an STI to explore their experiences of PN. PN posed considerable social risks, threatening their emotional and physical safety. Except for a minority in long-term, publicly acknowledged relationships, participants did not expect PN would achieve successful outcomes. Public health discourse, which constructs PN as "the right thing to do", influenced participants to adopt narratives that concealed the difficulties of PN and their unmet needs. Urgent interrogation is needed of whether PN is a suitable or constructive strategy to continue pursuing with young people. To improve the outcomes of preventing reinfection and onward transmission of STIs, we must consider developing alternative strategies that better align with young people's lived experiences.Plain language summary Partner notification is a public health strategy used to trace the sexual partners of people who have received a sexually transmitted infection (STI) diagnosis. It aims to interrupt the chains of STI transmission and prevent reinfection by treating both the person diagnosed and their sexual partners. The least effective but most common partner notification strategy used in many resource-limited settings is called "patient referral". This involves a sexual healthcare provider encouraging the person diagnosed to give a "partner notification slip" to their potentially exposed sexual partner/s and persuading them to access treatment. This research sought to better understand young people's experiences of partner notification, particularly the risks and challenges they faced during patient-referral.All young people (16-24 years) attending a community-based sexual and reproductive health service in Zimbabwe who were diagnosed with an STI were counselled and offered PN slips, which enabled their partners to access free treatment at the service. Young people trained as researchers interviewed 41 young people who had received a STI diagnosis to explore their experiences of partner notification.Only a small number (5.7%) of the partners of those who took a slip attended the service for treatment. Most participants felt they did not have the preparation, skills, or resources to persuade their partners to seek treatment. Many described negative experiences during and after partner notification, including relationship breakdown, reputation damage, and physical violence.These findings suggest that we should reconsider if partner notification is suitable or effective for use with young people. We should explore alternative approaches that do not present risks to young people's social, emotional, and physical safety and well-being.

Approach to Managing Sex Partners of People with Sexually Transmitted Infections

Partner management of sexually transmitted infection (STIs) is essential to identify and treat new cases, prevent reinfection in the index case, interrupt chains of transmission, reduce STI-related morbidity, and target STI screening and treatment interventions. The responsibility for partner notification and treatment falls on the health care provider. Approaches to partner management include patient referral, provider referral, contractual referral, and expedited partner therapy (EPT), with EPT and enhanced partner referral outperforming other methods. This article provides an overview of clinical recommendations regarding partner management, with particular emphasis on EPT, and an update on new and emerging evidence in the field.

Controversies and evidence on Chlamydia testing and treatment in asymptomatic women and men who have sex with men: a narrative review

Background

Chlamydia trachomatis (CT) is the most common bacterial sexually transmitted infection (STI) worldwide. CT is mainly asymptomatic. Test-and-treat strategies are widely implemented to prevent transmission and complications. Strategies are not without controversy in asymptomatic women and men who have sex with men (MSM). Concerns are emerging to test and treat asymptomatic persons for urogenital CT (‘Controversy 1’) and pharyngeal or rectal CT (‘Controversy 2’), whereby testing symptomatic persons is not under debate. Opposed views in CT treatment involve using azithromycin versus doxycycline (‘Controversy 3’). The objective of this review is to provide coverage of these public health and clinical controversies by reviewing the current scientific evidence.

Methods

A literature search was performed using PubMed for relevant publications between 2018 and September 2021, and iterative retrieval of additional relevant publications.

Results

Controversy 1. In women, the majority of asymptomatic CT are at the urogenital site, and detections mostly include viable CT. CT easily transmits to a partner and potentially also between the vaginal and rectal areas; the clinical impact of urogenital CT is established, although risks for adverse outcomes are uncertain. Wide-scale testing in asymptomatic women has not resulted in reduced prevalence. In MSM, evidence for the clinical impact of asymptomatic urogenital CT is lacking. Controversy 2. Rectal CT is common in women diagnosed with urogenital CT, but the clinical impact of asymptomatic rectal CT is uncertain. In MSM, rectal CT is common, and most CT infections are at the rectal site, yet the risk of longer term complications is unknown. In both sexes, pharyngeal CT is uncommon and has no documented clinical impact. Controversy 3. In the treatment of rectal CT, doxycycline has superior effectiveness to azithromycin. Evidence has also accumulated on the harms of test-and-treat strategies.

Conclusions

Current practices vary widely, from widescale test-and-treat approaches to more individual patient- and partner-level case management. Choosing which asymptomatic people to test at what anatomic site, and whether to test or not, requires an urgent (re-)definition of the goals of testing and treating asymptomatic persons. Treatment guidelines are shifting toward universal doxycycline use, and clinical practice now faces the challenge of implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07171-2.

Test-and-treat is a key strategy in the control of Chlamydia trachomatis (CT). We discuss recent controversies and present scientific evidence regarding urogenital, rectal, and pharyngeal CT test-and-treat strategies in women and in men who have sex with men (MSM). This should inform best practices for the prevention and management of the most common bacterial sexually transmitted infection (STI) worldwide.

Improving Women's Health and Combatting Sexually Transmitted Infections Through Expedited Partner Therapy

Sexually transmitted infections (STI), including Chlamydia trachomatis and Neisseria gonorrhoeae, have reached record high rates in the United States. Sexually transmitted infections disproportionately affect reproductive-aged females aged 15-44 years, who account for 65% and 42% of the total reported C trachomatis and N gonorrhoeae cases, respectively. Undiagnosed STIs can result in serious health complications that put women at an increased risk for pelvic inflammatory disease, ectopic pregnancy, and tubal factor infertility. Many of these women are seen by physicians (eg, obstetrician-gynecologists, family medicine doctors, pediatricians) or other clinicians (eg, nurse practitioners, midwives, physician assistants) who care for women. These clinicians have the opportunity to help curb the continued increase in STI incidence rates with the implementation and use of expedited partner therapy. Expedited partner therapy is a proven effective health care practice that allows clinicians to give patients medications or prescriptions to distribute to their partners. Despite expedited partner therapy's proven effectiveness, there are barriers to its implementation that must be understood to enhance STI treatment and prevention efforts. In this commentary, we discuss these barriers, and appeal to women's health clinicians to implement or increase use of expedited partner therapy for the treatment of women with STIs and their sexual partners.

A pill for the partner via the chlamydia patient? Results from a mixed method study among sexual health care providers in the Netherlands

Background

Chlamydia prevalence in the Netherlands remains high despite targeted efforts. Effective Partner Notification (PN) and Partner Treatment (PT) can interrupt transmission and prevent re-infections. Patient Initiated Partner Treatment (PIPT) may strengthen chlamydia control. This study explores the current practice of PN and PT, and benefits of, and barriers and facilitators for PIPT among professionals in sexual health care in the Netherlands.

Methods

A qualitative study was performed among GPs, GP-assistants (GPAs), physicians and nurses working at Sexual Health Clinics (SHC) and key-informants on ethnical diversity using topic lists in focus groups (N = 40) and semi-structured questionnaires in individual interviews (N = 9). Topics included current practices regarding PN and PT, attitude regarding PIPT, and perceived barriers and facilitators for PIPT. Interviews were taped, transcribed verbatim, and coded using ATLAS.ti. A quantitative online questionnaire on the same topics was sent to all physicians and nurses employed at Dutch SHC (complete response rate 26% (84/321)).

Results

The qualitative study showed that all professionals support the need for more attention to PN, and that they saw advantages in PIPT. Mentioned barriers included unwilling PN-behaviour, Dutch legislation, several medical considerations and inadequate skills of GPs. Also, concerns about limited knowledge of cultural sensitivity around PN and PT were raised. Mentioned facilitators of PIPT were reliable home based test-kits, phone-contact between professionals and notified partners, more consultation time for GPs or GPAs and additional training. The online questionnaire showed that SHC employees agreed that partners should be treated as soon as possible, but also that they were reluctant towards PIPT without counselling and testing.

Conclusions

Professionals saw advantages in PIPT, but they also identified barriers hampering the potential introduction of PIPT. Improving PN and counselling skills with specific focus on cultural sensitivity is needed. PIPT could be considered for specific partners. PIPT in combination with home based testing and using e-healthcare should be further explored and developed.

Perceived Risk of Intimate Partner Violence Among STI Clinic Patients: Implications for Partner Notification and Patient-Delivered Partner Therapy

Patient-delivered partner therapy (PDPT) is the practice of providing patients diagnosed with a bacterial sexually transmitted infection (STI) medication to give directly to their partner for treatment without requiring the partner to participate in diagnostic testing and counseling. Despite a growing body of evidence in support of PDPT, literature is limited to date on the influence of perceived risk of intimate partner violence (IPV) on PDPT use. We analyzed mixed-method data from 196 quantitative surveys (61% male, M age = 31.2, 92% Black or African-American) and 25 qualitative interviews to better understand the barriers and facilitators associated with PDPT delivery for patients attending a Midwestern, publicly funded STI clinic in the U.S. Nearly a third of surveyed patients (29; 34% of women, 26% of men) expressed worry about IPV when delivering PDPT. Patients had concerns about infidelity worry, embarrassment, and anxiety (referred to as IWEA hereafter) associated with partner notification and PDPT delivery. We found IWEA was highly correlated with IPV concerns in a fully adjusted logistic regression model. Women had 2.43 (95% CI = 1.09-5.42) times greater odds of worrying about IPV than men; other significant factors associated with IPV worry included higher condom use, no prior STI diagnosis, and being uninsured (as compared to having Medicare/Medicaid insurance). Encouraging communication between healthcare providers and their patients about the potential for IPV could facilitate patient triaging that results in the consideration of alternative partner referral mechanisms for patients or partners at risk of harm and better outcomes for patients and their partners.

Anticipated Notification of Sexual Partners following STD Diagnosis among Men Who Have Sex with Men and Transgender Women in Lima, Peru: A Mixed Methods Analysis

BACKGROUND

New strategies to support partner notification (PN) are critical for STD control and require detailed understanding of how specific individual and partnership characteristics guide notification decisions.

METHODS

From 2011 to 2012, 397 MSM and TW recently diagnosed with HIV, syphilis, or another STD completed a survey on anticipated notification of recent sexual partners and associated factors. Qualitative interviews were conducted with a subset of participants to provide further depth to quantitative findings. Prevalence ratios and generalized estimating equation (GEE) models were used to analyze participant- and partner-level factors associated with anticipated PN.

RESULTS

Among all partners reported, 52.5% were described as "Very Likely" or "Somewhat Likely" to be notified. Anticipated notification was more likely for main partners than casual (adjusted Prevalence Ratio [aPR], 95% CI: 0.63, 0.54-0.75) or commercial (aPR, 95% CI: 0.44, 0.31-0.62) partners. Other factors associated with likely notification included perception of the partner as an STD source (aPR, 95% CI: 1.27, 1.10-1.48) and anticipated future sexual contact with the partner (aPR, 95% CI: 1.30, 1.11-1.52). An HIV diagnosis was associated with a lower likelihood of notification than non-HIV STDs (aPR: 0.68, 0.55-0.86). Qualitative discussion of the barriers and incentives to PN reflected a similar differentiation of anticipated notification according to partnership type and type of HIV/STD diagnosis.

DISCUSSION

Detailed attention to how partnership characteristics guide notification outcomes is essential to the development of new PN strategies. By accurately and thoroughly assessing the diversity of partnership interactions among individuals with HIV/STD, new notification techniques can be tailored to partner-specific circumstances.