3.1 Encouraging Client Participation

3.1.1 Fully Informing and Reassuring Clients

The PCRS provider should explain the purpose and process of PCRS before PCRS activities can begin. The HIV-infected person serves as the "gate-keeper" to his or her partners. Program experience indicates that once a person understands the benefits both to themselves and their partners, they willingly participate in PCRS. Therefore, ensuring that the HIV-infected person fully understands the PCRS process and its benefits is important.

Providers should create an environment that is private, confidential, and comfortable enough so that clients are encouraged to participate in PCRS without feeling fearful or coerced. Reminders of the voluntary nature of PCRS and explanations of how privacy will be maintained for clients and partners alike will be necessary before some individuals feel secure enough to participate.

Each interaction a counseling and testing or health care provider has with an HIV-infected client is a potential opportunity to discuss the importance of informing that person's sex or needle-sharing partners of their possible exposure to HIV. Prevention counseling, prevention case management, and medical follow-up sessions while clients are in treatment, all provide opportunities to stress the importance of getting partners involved in PCRS. Community-level interventions provide other opportunities to reach out to partners.

3.1.2 Developing an Atmosphere of Trust

The success of the PCRS process hinges on the trust and cooperation of the persons infected with HIV and their partners. How well the provider fosters an atmosphere of trust, respect, and rapport with the HIV-infected individual will have a significant impact on PCRS. Client-centered counseling techniques (CDC, 1994) are highly recommended for developing this relationship, not only with original clients but also with their partners. The ability to develop trust and rapport will also enhance the PCRS provider's effectiveness when working in the community.

3.1.3 Introducing PCRS

During the first visit, the health care provider, using a client-centered approach (CDC, 1994), should begin discussions with the client on the risks to his or her partners. This visit would typically be for HIV counseling and testing. When clients choose to be tested and the results are positive, then the provider must offer, at the earliest appropriate opportunity, to assist in formulating an individualized PCRS plan. That plan is always based on the personal circumstances of the HIV-infected client and each of his or her partners.

When the provider demonstrates genuine concern for the overall well-being of clients and their partners during discussions about PCRS, the provider encourages greater client participation. Clients' reactions vary significantly to learning that their HIV test results are positive; therefore, the provider must gauge the appropriate point at which to initiate the discussion about the PCRS plan. In fact, other critical issues might need to be resolved first. For example, the client might express suicidal ideation or a fear of a violent reaction from a partner. Because potentially violent situations might be encountered, collaboration between the PCRS program and the appropriate state or local violence prevention programs is important. Such collaboration will help in developing plans and protocols for such situations and provide opportunities for the PCRS provider to learn about relevant services.

3.2 Formulating a PCRS Plan

HIV prevention programs use two basic approaches for reaching partners (West and Stark, 1997). In this document, the term client referral is used when HIV-infected individuals choose to inform their partners themselves and refer those partners to counseling and testing (see Section 3.2.1). (NOTE: The terms patient referral and self-referral are sometimes used instead of client referral.) The term provider referral is used in this document when the PCRS provider, with the consent of the HIV-infected client, takes the responsibility for contacting the partners and referring them to counseling, testing, and other support services (see Section 3.2.2).

Sometimes a combination of the two approaches is used. With the dual-referral approach, the HIV-infected client informs the partner of his/her serostatus in the presence of the PCRS provider. By having a professional counselor present, this approach supports the client and reduces other potential risks. In such situations the PCRS provider must not reveal the client's serostatus to the partners without prior informed consent. With the contract-referral approach, the PCRS provider does the informing only if the client does not notify the partner within a negotiated time period (see Section 3.2.3).

The PCRS provider should explain to clients all available options for reaching their partners, including the advantages and disadvantages of each approach. Then, together they can formulate a plan that can result in each partner being confidentially informed and encouraged to access counseling and testing or other social or medical services. Some HIV-infected individuals will be reluctant to participate in PCRS. Client-centered counseling techniques and reassurances of confidentiality can encourage better participation. Resolving problems through role-playing, for example, might help clients overcome barriers to participating in PCRS and help them better prepare for their part in those activities. No matter which approach is chosen, the PCRS provider should ensure the partners are actually informed of the exposure.

3.2.1 Taking a Closer Look at Client Referral

When HIV-infected clients choose to inform their partners themselves, they usually need some assistance to succeed. Although the majority of clients do not experience negative consequences when notifying partners, the PCRS provider can help the client minimize any potentially negative consequences. The provider should, therefore, be prepared to assess the situation and ability of the HIV-infected client to make successful notification and referrals. Based on this information, clients might need to be coached on:

1. the best ways to inform each partner;
2. how to deal with the psychological and social impact of disclosing one's HIV status to others;
3. how to respond to a partner's reactions, including the possibility of personal violence directed toward the client or others; and
4. how and where each partner can access HIV prevention counseling and testing.

Despite the provider's coaching, however, the client's lack of counseling skills and experience might result in unsuccessful or ineffective PCRS. Another disadvantage of the client-referral approach is that the client might unintentionally convey incorrect information about HIV transmission, available support services, confidentiality protections, or other issues. The client also forfeits anonymity to partners, increasing the potential for disclosure of serostatus to third parties, subsequent discrimination, or partner repercussion. The findings of Landis et al. (1992) clearly indicate that fewer partners are actually informed of their possible exposure to HIV when the client-referral approach is used. However, because PCRS is a voluntary process, clients should be able to choose this approach. The PCRS program needs reasonable systems for monitoring whether partners are actually reached (see "Contract Referral" in Section 3.2.3). Also, more support to the client in notifying their partners will enhance the effectiveness of notifying partners.

For anonymous test sites, the client-referral approach poses a slightly different problem because some clients might be less likely to give the provider information about partners. Under these circumstances the provider will be less likely to determine whether PCRS has been successful. Although PCRS can be provided to anonymous clients, CDC currently recommends providers encourage the client to voluntarily enter a confidential setting for PCRS and additional medical follow-up. Here again, an appropriately detailed discussion with anonymous clients of how confidentiality will be maintained for themselves and their partners can ease the transition of anonymous clients to a confidential setting. That transition will also be eased if clients are not required to take another HIV test. If the anonymous and confidential test sites are at separate facilities, reciprocal agreements between the two might be necessary so that the client's confirmed positive test result can easily be transferred to the confidential setting.

At confidential test sites, PCRS providers should make every reasonable effort to follow up with each HIV-infected client to assess how well he or she has progressed with PCRS. Whenever feasible, careful and confidential monitoring of which of the client's partners actually do access counseling and testing services can greatly enhance quality assurance and program evaluation. This also will help ensure that partners have actually been reached.

Despite its drawbacks, client referral is the approach frequently chosen, and it can have some advantages. Because the client is usually more familiar with the identity and location of the partner, this approach can allow some partners to be referred for counseling and testing more promptly. Also, some clients choose this approach because they feel the best way to preserve a current relationship is by informing the partner themselves rather than having a third party - the provider - do it. Finally, when client referral is conducted successfully, fewer staff are used and fewer resources are consumed than with the provider-referral approach, so the financial burden for HIV prevention programs is reduced.

3.2.2 Taking a Closer Look at Provider Referral

When the client chooses provider referral, the provider will also need to assess the situation regarding each partner, including the best ways to inform them, how to locate and contact them, suggestions on how to approach them, how to predict the psychosocial impact of their learning their HIV serostatus, and how to respond to partners’ reactions. Research indicates that provider referral is more effective in serving partners than client referral (Landis et al., 1992). The following are some of the advantages of using the provider-referral approach:

1. The PCRS provider is able to readily verify that partners have been confidentially informed and have received client-centered counseling and testing services.
2. The PCRS provider can better ensure the HIV-infected client's anonymity since no information about the client is disclosed to his or her partners.
3. A well-trained PCRS provider is better able to defuse the partner's potential anger and blame reactions as well as accurately and more comprehensively respond to the partner's questions and concerns.
4. Provider referral better facilitates learning about sexual and drug-injection networks, thus potentially enhancing overall HIV prevention efforts in affected communities.
5. In many cases, the PCRS provider can deliver on-site HIV testing to the partner.

Among the disadvantages of the provider-referral approach is the fact that PCRS providers are not always able to readily locate and identify the partners. Because the provider is less familiar with how to reach the partners, actually locating them to discuss their possible exposure to HIV can be more difficult. The provider-referral approach also entails substantial financial costs and causes some ethical concerns among leaders of affected communities (Fenton and Peterman, 1997; West and Stark, 1997). For example, Fenton and Peterman (1997) found that financial costs for provider referral are between $33 and $373 per partner notified and between $810 and $3,205 per infected partner notified. This program expense, however, is greatly offset in the long run because PCRS frequently reaches persons who do not suspect they have been exposed to HIV and is likely cost-effective (see Section 1.3). Once informed, they can access prevention counseling and testing, and if HIV-infected, they can enter treatment earlier. It is important to note that some infected people who choose provider referral might still notify some partners about their serostatus and will thus need relevant counseling.

3.2.3 Taking a Closer Look at Combined Referral Approaches

Two variations on provider and client referral are the dual- and contract-referral approaches. Potentially, combinations of these approaches can enhance the advantages of both approaches for the client while reducing the disadvantages.

Dual Referral. Some HIV-infected clients feel that they and their partners would be best served by having both the client and the provider present when the partner is informed. The dual-referral approach can work well for these clients. The dual approach allows the client to receive direct support in the notification process. The PCRS provider is available to render immediate counseling, answer questions, address concerns, provide referrals to other services, and in some cases potentially minimize partner repercussions. Being present also enables the provider to know which partners have in fact been served, and to some extent, learn about sexual and drug-injecting networks. Whether the client or provider will take the lead in informing the partner should be worked out in advance of the notification.

The provider still needs to coach and support the client as with the client-referral approach. The provider and the HIV-infected client need to consider, in particular, the partner's possible concerns about having his or her relationship with the client revealed to the provider. By considering this issue in advance, the client and the provider can anticipate the partner's possible reactions and discuss how to respond appropriately.

Contract Referral. The other variation on provider and client referral, the contract-referral approach, might require more negotiation skill on the PCRS provider's part. In the contract-referral approach, the provider and client decide on a time frame during which the client will contact and refer the partners. If the client is unable to complete the task within that agreed-upon time period, the PCRS provider then has the permission and information necessary to serve the partner. The provider must also have agreement with the client about how to confirm that partners were notified and what follow-up is required for situations where the client does not make the notification. Negotiation skill and a relationship of trust are needed so that the provider will have the identifying and locating information immediately available if the client does not inform the partner before the time limit expires.

When the contract-referral approach is used, the PCRS provider should also negotiate a provision with the client whereby the partner confirms in some way (e.g., telephone call, appointment for services) to the provider that he or she has been informed of being at risk. Otherwise, the provider may have difficulty knowing which partners have been informed and whether or not provider referral or some other assistance is now needed.

3.3 Setting Priorities for Reaching Partners

The PCRS plan must include prioritizing which sex or needle-sharing partners need to be reached first, based on each client's and partner's circumstances. Ideally, all partners should be reached, but limited program resources usually dictate that priorities have to be set. Priorities are determined by deciding (1) which partners are most likely to be already infected and to transmit infection to others; (2) which partners are most likely to become infected; and (3) which partners can be located. Priority is also affected by federal and state laws. For example, federal legislation requires that a good-faith effort be made to notify "any individual who is the marriage partner of an HIV-infected patient, or who has been the marriage partner of that patient at any time within the 10-year period prior to the diagnosis of HIV infection." (Public Law 104-146, Section 8[a] of the Ryan White CARE Reauthorization Act of 1996.)

A number of factors influence how the PCRS provider and client decide which partners need to be reached first. Obviously, if the client has had only one partner during his or her life-time, that partner is likely to be infected. When the client has had more than one partner, other factors then have to be considered, such as the following:

• Possible Transmission of HIV to Others. The partner who is most likely to transmit HIV to others must receive highest priority. A partner who is a pregnant woman should be reached as soon as possible for counseling, testing, and referral to medical treatment if infected, to avoid perinatal transmission. Likewise, the partner who the client knows has multiple other sex and needle-sharing partners needs to be reached as soon as possible to reduce the potential for transmission of HIV to others.
• Partners of a Recently Infected Client. If, for example, the client had a negative HIV test result 6 months ago, but now the test result is positive, partners within that 6-month time period or in the potential "window period" that preceded the negative test would receive priority. These partners are more likely to have acquired or been exposed to HIV than any of the client's partners during the period before the client's HIV negative test. Other evidence of a recently infected person might be indicated by the exposure history of the client, e.g., client with a history of negative test results, findings from less sensitive EIA or serologic testing algorithm for recent HIV seroconversion, or other evidence of recent infection.
• Likelihood of the Partner Being Unaware of Exposure to HIV. Some individuals are less likely than others to suspect a risk for HIV infection or to understand what being "at risk" means. For example, many heterosexual women might be less aware of their HIV risk and therefore less likely to access counseling, testing, or other prevention services without PCRS.
• Partners at Continued Risk. Reaching the client's current, recurring, or recent partners is a high priority because those partners might be at continued risk of becoming infected with HIV, if not already infected.
• History of Other STDs. Either the client's or partner's history of other STD infections is an important factor in setting priorities. For example, if a partner was treated for another STD, that partner is more likely to also be infected with HIV and, additionally, more likely to transmit HIV to others. If the HIV-infected client has a recent history of other STD infection, then his or her sex partners are more likely to have been HIV-infected, especially those exposed during the STD infection (Wasserheit, 1992).
• Transmission of Strains of HIV That Are Resistant to Antiretroviral Therapies. If information or evidence exists that the client is infected with a strain of HIV resistant to antiretroviral therapies, partners of this client would have high priority for PCRS services.

The PCRS provider and client should begin by noting current or recent partners and the details of their exposure. Next, working back in time, they should consider any other partners who need to be contacted. By briefly noting the circumstances for each partner and then moving quickly on to the next one, the provider will be better able to stimulate the client's memory. Then, together, they can determine the priorities for reaching as many partners as program resources might permit. Because determining when a client was actually infected or the circumstances associated with individual partners is often difficult or impossible, some HIV prevention programs routinely attempt to locate and counsel all partners from a defined time period. This time period, often 1-2 years, frequently is based on availability of resources for PCRS. Programs with greater amounts of resources, those with lower morbidity, or those that give higher priority to PCRS frequently attempt to reach and counsel partners exposed over a longer time period.

Once the provider and client have established which partners are to be reached, they can begin discussing a plan for reaching these partners. For those partners the provider will be contacting, exact locating information, plus the dates, types, and frequency of exposure should be noted (See Section 4.2). During this phase, new information about partners might come to light that necessitates adjustments in the priorities previously established.

In addition to the factors listed previously, the PCRS provider must also consider federal legislation and relevant state laws that require a good-faith effort be made in notifying current spouses or persons who have been spouses of a known HIV-infected person during the 10 years prior to the client's diagnosis of HIV infection. Both the program policies of PCRS and the efforts of individual providers contribute to the required good-faith effort.

PCRS providers can satisfy the requirement of a good-faith effort by (1) asking all HIV-infected clients if they have a current or past marriage partner(s), (2) notifying these partners of their possible exposure to HIV, except in situations when, in the judgment of public health officials, there has been no sexual exposure of a spouse to the known HIV-infected individual during the relevant time frame; (3) referring them to appropriate prevention services; and (4) documenting these efforts. Programs need to have or develop policies to guide providers in situations in which the HIV-infected client does not give consent and will not allow the provider to notify his or her current or past marriage partner(s).

3.4 Considering Other Options and Special Circumstances

3.4.1 Other Persons Who Might Need To Be Contacted

While the PCRS plan is being developed and priorities are being set for reaching partners, the provider should take special note of any other persons being mentioned who might be at risk. For example, during interviews or counseling sessions, the HIV-infected client might discuss other persons who are not sex partners but are involved in a sexual or drug-injection network with high risks of HIV transmission. Another example is children or newborns who might have been exposed perinatally or through breast-feeding. Although not direct sex or needle-sharing partners of the HIV-infected client, these other persons should be offered HIV prevention counseling and testing, if resources and program policies permit. General information obtained through PCRS, not just a person's name, can be used to identify high-risk places and venues where PCRS programs can provide outreach services. CDC encourages such efforts to identify and lower risks of HIV and other STDs within sexual or drug-injection networks and is interested in working with state and local health authorities to develop methods and more detailed guidance on network identification, analysis, and intervention.

3.4.2 "But, I Do Not Want My Partner To Be Contacted!"

Unfortunately, in some cases HIV-infected clients initially will simply not want their partners notified. For example, they might fear loss of anonymity, the breakup of a relationship, or other adverse consequences. Clients might say that partners have already been informed about their risks or that partners would not be interested in counseling, testing, or other support services. Providers can encourage a client's participation by explaining that the partner benefits by knowing his or her HIV status and being able to seek immediate treatment if infected. Also, if infected, the partner can avoid transmitting the virus to others. However, when a client is determined not to disclose partner names, the PCRS provider should counsel the client as if he or she has chosen the client-referral approach.

Sometimes a client might not want his or her partner notified because of fear of a violent reaction from the partner. It is not uncommon for persons receiving public health services to report having experienced violence in their lives (Maher, 1998). Therefore, providers should be aware of the potential for partner violence and should be prepared to make appropriate referrals. If the provider has indication of a potentially violent situation for the client or others, the provider must make an assessment prior to notifying the partner and seek expert consultation before proceeding. States have varying legal requirements about reporting situations such as those involving violence or child abuse. The PCRS program must comply with relevant state laws and local regulations.

In some cases, the provider knows of a partner at risk even though the client has not identified that partner. Whether or not a legal "duty to warn" such partners (or identified partners that the client did not want notified [see Appendix B]) exists is best determined by reviewing applicable state laws or regulations, especially regarding spousal notification. All states must have a policy established to guide health department staff in situations in which an HIV-infected client indicates he or she does not plan to notify known partners and will not provide the information necessary for the health department staff to make the notification.

The Association of State and Territorial Health Officials recommends in its 1988 Guide to Public Health Practice: HIV Partner Notification Strategies that a health care provider may invoke his or her "privilege to disclose" (see Appendix B) when that provider knows of an identifiable at-risk partner who has not been named by the HIV-infected person. State and local HIV prevention program managers should consider the ASTHO recommendations and their own relevant laws when developing policies and procedures.

3.4.3 PCRS for Needle-sharing Partners

Sharing of needles, syringes, and other paraphernalia used for injection drug use (e.g., illicit drugs, steroids) carries high risk for transmission of HIV. Throughout this document, the importance of providing partner counseling and referral services to HIV-infected clients with needle-sharing partners is emphasized. CDC recognizes that some HIV prevention programs have relatively limited experience in working with needle-sharing partners and that special issues exist relating to clients disclosing information about such partners, reaching such partners, deciding which prevention interventions should be provided, and referring them for needed services.

Some state and local HIV prevention programs have already gained considerable experience in reaching and serving needle-sharing partners and report that such services are feasible and likely to be effective. For example, Levy and Fox (1998) reported that injection drug users infected with HIV want to notify their sex and needle-sharing partners and are willing to participate in the PCRS process. Information provided by HIV-infected clients who are injection drug users may help HIV prevention program managers gain insight into the extent and types of prevention service needs of injection drug users and how best to deliver and target such services.

CDC will provide expanded guidance on PCRS for needle-sharing partners in future versions of this guidance.

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