4.1 Preparing the PCRS Provider

In large part, the manner in which PCRS is provided to and perceived by the affected communities determines how successful HIV prevention programs will be (see Section 4.5). Therefore, program managers and supervisors should ensure that PCRS staff -

• are skilled and competent in providing PCRS;
• are culturally competent and demonstrate respect for the community to be served;
• are knowledgeable about HIV infection, transmission, and treatment;
• are knowledgeable in local, state, and federal laws regarding HIV and other relevant issues of providing health care, especially the right to privacy and confidentiality;
• receive updated information and periodic retraining as appropriate;
• have standards, objectives, and specific guidelines for performance;
• are appropriately supervised and given written and oral feedback about their performance on a regular basis; and
• have appropriate problem-solving skills to deal with situations that might be encountered in a field setting, e.g., personal safety, violence to others.

In addition to receiving formal training, such as CDC’s training course on PCRS, an inexperienced PCRS provider should complete an internship by being teamed with a more experienced provider for a period of time before conducting PCRS alone (see Section 6.1). Another way to enhance a provider's performance is through routine peer review of selected cases.

Providers of successful PCRS programs regularly go outside the clinic or office setting to reach partners. The inexperienced provider will need training in deciding when to deliver PCRS outside the office or clinic and when to postpone PCRS. Benefits of delivering PCRS in a partner's home might include providing the partner with a familiar environment and helping the provider better understand the personal circumstances of that partner. Whether or not to do PCRS outside the clinic or office, or whether it is best postponed until an adverse situation can be resolved, must be decided on a case-by-case basis. In addition, training in avoiding confrontations, diffusing anger, and mediating disputes will better prepare any provider for handling potentially violent situations.

4.2 Setting Activities in Motion

For those partners the provider will be contacting, the first step the provider should take is to verify the identifying and locating information given by the HIV-infected client. Locating and notifying partners should begin as soon as possible after the provider and HIV-infected client have decided on the best approach to use for each partner and priorities have been set for reaching partners. If the client will be informing partners, the client should be well-coached on how to do so and should be provided opportunities to obtain additional counseling, assistance, or other support during the process.

4.3 Maintaining Confidentiality

Confidentiality for all persons involved in PCRS must continue to be maintained. All attempts to make contact with a sex or needlesharing partner should be confidential. This is often difficult because other community members might ask the purpose of the provider's visit and why he or she is attempting to make contact. Nevertheless, providers should not, for example, reveal to others why they are trying to find a particular person. Likewise, providers should never leave a note or message that mentions HIV exposure as the reason for attempting to make contact. In addition, no other information should be revealed that might lead to others learning the reason for the contact or that might otherwise lead to disclosure of sensitive information or to a breach of confidentiality. As each partner is located, he or she should be informed privately and face-to-face, if at all possible. However, if the person refuses to meet with the provider, informing a partner by telephone might become necessary. In such situations, only limited information should be provided to the partner, and the goal still should be to arrange a face-to-face meeting if at all possible. Informing a partner by telephone should only be done as determined by state and local jurisdictions and after every step has been taken to ensure that the correct person has been located, is on the telephone, and others are not listening. Further attempts should be made to arrange a meeting in person.

The original HIV-infected client will sometimes inquire about the results of the PCRS provider's activities regarding his or her partners. The provider, when requested, can reveal whether a particular partner has been informed of his or her exposure to HIV, but must not reveal any confidential information about that partner, including whether the partner decided to be tested or whether he or she is HIV-infected.

Of equal importance is not revealing any identifying information about the original client to the partner, including the person's sex, name or physical description, or time, type, or frequency of exposure. Although the PCRS provider will need to document the results of his or her activities in a thorough, concise, and timely manner, confidentiality must still be maintained for all persons involved. Information that identifies partners should be kept locked in a secure location. Client and partner information, other than the official record (as determined by state practice), should be destroyed when current PCRS activities are concluded.

State or local areas should establish PCRS record-keeping policies and procedures, and client and partner information should be maintained in accordance with these policies. Many public health programs have developed policies and procedures to safeguard sensitive client or partner information. One example can be found in CDC’s Guidelines for HIV/AIDS Surveillance, Appendix C, Security and Confidentiality (as revised October 1998). In developing their policies, PCRS managers can choose to review and adapt the policies and procedures in this document or those of other public health programs.

4.4 Helping Partners Access Services

The PCRS provider must be well prepared to handle the initial reactions of the person who is being informed of possible exposure to HIV. That person will undoubtedly need immediate counseling, followed by referral to additional HIV prevention counseling. The provider must be prepared to answer the questions and concerns of each partner without revealing any identifying information about the original HIV-infected client.

As described earlier, referring partners to needed prevention, treatment, and other relevant services is a goal of PCRS. Testing is a very important issue to persons who have just learned of possible exposure. The provider must be prepared to, at a minimum, refer them to counseling and testing services. For many years, providers have taken blood specimens of those who consent at the time of notification, which requires specialized training. With the current availability of oral fluid and urine collection kits, and rapid testing systems, program managers are encouraged to consider providing on-the-spot collection of specimens for HIV testing as each partner is informed. If the partner has previously been tested, and those results were negative, the PCRS provider should stress the need to follow up with another test if exposure history indicates it is warranted.

However, many partners will need referrals for other kinds of social and medical support services beyond counseling and testing. The PCRS provider should already have agreements in place and an up-to-date resource guide so that immediate referrals can be made to services such as substance abuse treatment, family planning assistance, other STD treatment, domestic violence prevention, mental health counseling, or housing assistance (CDC, 1993). Having agreements in place for collaboration between PCRS providers and referral sources will help ensure that those services can be successfully accessed. PCRS providers should then follow up with each partner contacted to ensure that test results and other referral services have in fact been received. If providers in another health jurisdiction have been asked to contact a partner, health departments should follow up with that provider to determine that services have been received.

4.5 Addressing Community Concerns

The potential exists for PCRS to have a negative impact on HIV-infected individuals, their partners, or affected communities (Rothenberg and Paskey, 1995; West and Stark, 1997). Some community leaders view these kinds of activities with suspicion and are apprehensive about such issues as -

• whether disclosure of partner names is done voluntarily;
• possible denial of health care or other services if the HIV-infected client refuses to reveal partner names or otherwise refuses to cooperate with the provider;
• unintended effects on personal relationships, such as partnership breakup or violence;
• potential for invasion of privacy or loss of confidentiality for HIV-infected clients and their partners; and
• possible discrimination if confidential information held by government agencies is ever released, either accidentally or by law.

Although PCRS providers cannot always resolve these issues, they can strive to build relationships of trust between themselves and those they serve, including the leaders of affected communities. Working with HIV prevention community planning groups and others when determining and evaluating priorities, policies, and procedures for PCRS will help increase community support and acceptance. PCRS providers should be prepared, whenever an opportunity arises, to address legitimate concerns and dispel misconceptions about policies and practices (West and Stark, 1997).

Go to Section 5.0