1.1. How HIV PCRS Has Evolved
Once known as "contact tracing,"
outreach activities for finding, diagnosing, and
treating partners of persons infected with
sexually transmitted diseases (STDs) have long
been used by public health workers as a prevention
activity. In the 1930s, U.S. Surgeon
General Thomas Parran advocated the use of
contact tracing to help "prevent new chains of
[syphilis] infection" (Parran, 1937). Contact
tracing was later expanded to include partners
of persons infected with gonorrhea and other
STDs, including the human immunodeficiency
virus (HIV), and came to be known in the
1980s as "partner notification" (West and
Stark, 1997).
In the 1980s, when public health workers were
first being confronted with the rapid spread of
HIV, the virus that causes acquired immunodeficiency
syndrome (AIDS), informing persons
of their possible exposure to HIV and offering
counseling, testing, and referral services were
already recognized as an important disease
prevention effort that could help stem the tide
of HIV infection. As HIV prevention activities
have evolved, so has the terminology for
informing the HIV-infected person’s sex and
needle-sharing partners of their possible exposure
to the virus. Today, the term HIV partner
counseling and referral services (PCRS) more
accurately reflects the range of services available
to HIV-infected persons, their partners,
and affected communities through this public
health activity.
Of necessity, PCRS for HIV differs from
partner services for other STDs because the
"epidemiological, biological, and clinical
characteristics of HIV are different" (West and
Stark, 1997). Despite recent advances in treatment,
we do not yet have a cure for AIDS, so
HIV remains a lifelong issue for those infected.
Furthermore, because society frequently
stigmatizes and sometimes discriminates
against HIV-infected persons and their families
and friends, the affected communities may be
concerned about the potential negative impact
of PCRS. HIV prevention programs need
affected communities to be involved in and
understand PCRS for the overall prevention
efforts to be accepted and effective.
Federal and state legislative mandates in the
1990s have underscored the importance of
notifying sex and needle-sharing partners of
their possible exposure to HIV. Recent examples
include the federal requirement to
notify spouses of HIV-infected persons (Public
Law 104-146, Section 8[a] of the Ryan White
CARE Reauthorization Act of 1996) and state
legislation to require health departments to
offer HIV partner notification services to
newly reported HIV-infected persons (National
Council of State Legislators, 1998). Legal
and ethical concepts such as the rights of
individuals to know their risk of infection, to
learn their HIV status anonymously or confidentially,
and to be protected against discrimination
if HIV-infected, will continue to drive
public health policies and legislative action on
HIV PCRS (West and Stark, 1997). Public
health policies and legislative actions related to
the above concepts will determine, at least in
part, how PCRS is conducted.
1.2 What Are the Goals of PCRS?
PCRS is a prevention activity with the following goals:
- Providing services to HIV-infected persons
and their sex and needle-sharing
partners so they can avoid infection or, if
already infected, can prevent transmission
to others.
- Helping partners gain earlier access to
individualized counseling, HIV testing medical evaluation, treatment, and other
prevention services.
Through PCRS, persons - many of whom are
unsuspecting of their risk - are informed of
their exposure or possible exposure to HIV.
Notified partners can choose whether to be
tested, and if not tested or if found to be
uninfected, can receive counseling about
practicing safer behaviors to avoid future
exposure to HIV. If, however, they are found
to be infected, they can seek early medical
treatment and practice behaviors that help
prevent transmission of HIV to others and
reduce the risk of becoming infected with
other STDs.
PCRS can be instrumental in identifying
sexual and drug-injecting networks at high risk
for transmission of HIV or other sexually
transmitted diseases (Fenton and Peterman,
1997; West and Stark, 1997). These networks
are made up of individuals who share social
relationships involving sex or drug use. Such
networks can be identified and described at
least partly through information obtained by
PCRS activities (West and Stark, 1997). Future
prevention interventions can then be more
effectively directed, and the HIV risks within
the network(s) potentially reduced. Network
research, combined with new methods of virus
typing and identification of recently infected
persons (Janssen, et al., 1998), will contribute
to a greater understanding of HIV transmission
(Fenton and Peterman, 1997).
1.3 Is PCRS Cost-effective?
Some have raised concerns about the
high potential cost of PCRS and have questioned
on these grounds whether or not it
should be supported. In fact, although the
relative investment per person reached might
be greater than other public health activities,
PCRS is likely to be highly cost-effective. A
simple threshold analysis illustrates the probable
cost-effectiveness of PCRS to society.
Assuming an estimated current $154,402
lifetime cost in the United States of a person
acquiring HIV infection and eventually dying
from HIV-related illness (Holtgrave and
Pinkerton, 1997) and a conservatively estimated
average $3,205 cost of PCRS to reach
one infected person (Toomey et al., 1998),
PCRS must prevent 1 infection out of every
51 HIV-infected partners reached through
PCRS to be cost-effective. As PCRS links
HIV-infected partners to client-centered counseling
and other interventions proven or likely
to be effective, this appears to be a threshold
relatively easy to achieve by programs.
Greater effectiveness, such as preventing only
2-3 infections for every 51 HIV-infected
partners reached through PCRS, would convey
substantial cost savings to society.
1.4 Who Benefits from PCRS?
Clearly, three distinct beneficiaries of
PCRS are (1) persons with HIV infection;
(2) their spouses and other sex and/or needle-sharing
partners; and (3) affected communities
(Fenton and Peterman, 1997). Through a
client-centered approach, HIV-infected persons
can receive counseling about their risk behavior
and be offered a range of choices and
support in informing their partners of the
possibilities of exposure to HIV (CDC, 1994).
Studies have shown that a client-centered
counseling approach can result in behavior
change, thereby decreasing the likelihood of
HIV transmission to others (Kamb et al., 1998
and Fenton and Peterman, 1997). HIV-infected
persons can also benefit from referrals to other
social and medical services, such as couples
counseling, prevention case management, and
antiretroviral therapy.
For the partners of HIV-infected persons, one
basic benefit comes from being informed that
they are at risk. This will be particularly
helpful information for those who do not even
suspect that they might have been exposed.
Once informed, the partner can decide to
access available HIV prevention counseling
and testing services. If not infected with HIV,
partners can be assisted in changing their risk
behavior, thus reducing the likelihood of
acquiring the virus. Or, if already HIV-infected,
the partner’ s prognosis can be improved
through earlier diagnosis and treatment.
The role of PCRS, earlier diagnosis, and
prevention and treatment services might have
prevention benefits at the community level in
reducing future rates of HIV transmission.
Evidence is accumulating that antiretroviral
therapy reduces the amount of HIV in genital
secretions and fluids and thus might reduce the
infectivity of HIV (Gupta P, et al., 1997;
Vernazza PL, et al., 1997; Vernazza PL, et al.,
1997; Musicco M, et al., 1994). However,
concern may be well justified that some might
misinterpret antiretroviral therapy as a cure
for HIV and thus be less concerned about
adopting safe behaviors or exposing others
(Kalichman SC, et al., 1998; Kelly JA, et al.,
1998; Remien RH, et al., 1998; Remien RH, et al., 1998). Efforts to link HIV-infected persons
to treatment must also continue to emphasize
safe behavior during the course of treatment.
Effective PCRS also can improve disease
surveillance, identify social sexual networks at
high risk that can then be targeted for prevention
(Fenton and Peterman, 1997), and potentially
assist a comprehensive program in lowering
the transmission rate of HIV. In addition,
PCRS can benefit service providers in the community
by increasing their access to individuals
in need of their services, especially people
who would not come to them on their own.
1.5 What Activities Are Involved in PCRS?
PCRS should be introduced at the
point an individual seeks HIV prevention
counseling and testing. A brief overview of the
activities associated with PCRS is included in
this section, but more detailed discussions are
provided throughout the remainder of
this document.
- Person Seeks HIV Prevention Counseling
and Testing. PCRS begins when
persons seek, either through private care
providers or publicly funded programs,
HIV prevention counseling and testing.
As they enter services, they should be
assisted first, ideally through client-centered
counseling techniques, in -
- assessing their risks of acquiring or
transmitting HIV, and
- negotiating a realistic and incremental
plan for reducing risk.
During the initial counseling and testing
session, the provider should also explain
(1) how HIV testing will be conducted if
the client does choose to be tested, and
(2) all the available options for PCRS.
The provider must assist clients in understanding
their responsibility, if their HIV
test results are positive, for ensuring that
their partners are informed of their
possible exposure, and referring those
partners to HIV prevention counseling,
testing, and other support services
(CDC, 1994).
- Client Tests Positive and Chooses To
Participate in PCRS. Once a client’ s test
results are confirmed positive, that person
should be provided the earliest appropriate
opportunity to receive partner counseling
and referral services. Reactions to
learning one is infected with HIV vary,
and personal circumstances differ among
individuals. PCRS providers need to
recognize and accommodate those clients
who need other issues resolved before
being ready to participate in PCRS. This
might mean, for some individuals, scheduling
a follow-up appointment to discuss
PCRS issues more thoroughly.
- PCRS Provider and Client Together
Formulate a Plan and Set Priorities.
The PCRS provider (who might not be
the counseling and testing provider)
counsels the client on if, how, and when
specific partners should be informed of
their risk of exposure. The provider
should present partner referral options
(Section 3.2). Then, the client and PCRS
provider together can develop a plan for
reaching partners that uses one or more of
the referral options. The plan should be
one that will result in each partner being
(1) informed of possible exposure to HIV;
(2) provided with accurate information
about HIV transmission and prevention;
(3) informed of benefits of knowing one's serostatus; (4) assisted in
accessing counseling, testing, and other support services; and (5) cautioned
about the possible negative consequences of revealing their own or others' serostatus to anyone else.
As the individualized plan is developed,
the PCRS provider and client prioritize
which partners should be reached first
(Section 3.0 provides a discussion of how
priorities are set).
- HIV-Infected Client Voluntarily Discloses
Information About Partners. The
HIV-infected client is encouraged to
voluntarily and confidentially disclose the
identifying, locating, and exposure information
for each sex or needle-sharing
partner that the PCRS provider or the
client will attempt to inform.
- Client and/or Provider Informs Each
Partner of Possible Exposure to HIV.
The client and/or the PCRS provider
informs each sex or needle-sharing
partner who can be located of his or her
possible exposure to HIV. Ideally, the
partner is always informed confidentially
face-to-face, but this cannot necessarily
be ensured when the client chooses
to inform the partner without the
provider’s assistance.
- Client and/or Provider Assists Partner
in Accessing Counseling, Testing, and
Other Support Services. At the core of
PCRS is referring the now-informed
partner to counseling, testing, and needed
social and medical services. If on-the-spot
counseling and/or testing for HIV and
other STDs is not practical or not desired
at this time, each partner should receive,
immediately upon being informed of
possible exposure to HIV, a specific
referral for obtaining client-centered
counseling and testing. Some partners
will also need immediate referrals for
medical evaluation, substance abuse
treatment, mental health, or other support
services to enhance or sustain risk-reducing
behaviors.
How each PCRS activity is conducted might
have a direct impact on how communities
perceive the value of such efforts to themselves
and to public health. Quality assurance for
services provided, routine staff and program
evaluations, and network analysis are, therefore,
necessary components of PCRS. For
example, ensuring that strict confidentiality is
maintained for all persons involved in PCRS
will encourage community support and involvement.
(See Sections 4.3,
4.5, and
6.2)
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