Q. Why has the Centers for Disease Control and Prevention (CDC) issued new recommendations for partner services?

A. Until now, CDC has published two separate guidelines for HIV/AIDS and STD partner services—the 1998 HIV Partner Counseling and Referral Services (PCRS) Guidance and the partner services module of the 2001 Program Operations Guidelines for STD Prevention. Inconsistencies and differences in degree of detail between these two documents have led to confusion at the service delivery level, where often the same program—even the same person—provides partner services for HIV and other STDs. In addition, because of changing epidemiological patterns of HIV and other STDs, persons co-infected with HIV and syphilis constitute an increasingly significant proportion of all syphilis cases. This further highlights existing discrepancies and the urgent need for a single set of recommendations. Furthermore, program staff regularly noted that different approaches to partner services for HIV and other STDs were a barrier to effective, efficient program management and led to the fragmentation of services for individual clients. This fragmentation has resulted in wasteful duplication or missed opportunities to address either an STD or HIV.

By integrating the guidance for HIV and STD partner services into a single document, the new CDC recommendations will reduce existing duplication and discrepancies; address emerging issues and technologies; and improve the fit between recommended practices, evidence, and programmatic experience. The updated, integrated document provides one unified set of recommendations to serve as a basis for delivery of partner services and related training and capacity-building assistance.

Q. What are the key differences between the new recommendations and the old guidance for HIV (1998 PCRS Guidance) and STD (2001 Program Operations Guidelines)?

A. The most important distinction between the new recommendations for HIV and STD partner services and older guidance documents is that the new recommendations are integrated, while previous sets of guidelines addressed HIV and STD separately. In addition, the new recommendations place increased emphasis on the following:

• Integration of services at the client level.
• Programs should use surveillance and disease reporting systems to assist with identifying persons with newly diagnosed or reported STDs, including HIV, who are potential candidates for partner services.
• Direct public health program involvement in partner services as close as possible to the time of diagnosis.
• The rationale underlying selection of a preferred notification strategy for each disease named in this document.
• Active linkage to care for HIV-infected persons.
• Collaboration with internal and external partners involved in all aspects of partner services, including assuring that for HIV, partner services is accessible to all infected persons throughout the prevention and care continuum.
• Program monitoring and evaluation and quality assurance.
• What HIV and STD programs should do rather than how they should do it.

Q. Who is the intended audience for the new partner services recommendations? 

A. The audience for the new recommendations for HIV/STD partner services is health department program managers responsible for overseeing partner services programs for HIV and other STDs at the state and local levels. While CDC anticipates that various service organizations and providers will have some interest in the content of the new, integrated recommendations for HIV and STD partner services, recommendations in this document are intended primarily to help program managers plan, implement, and evaluate partner services provided to persons with HIV and other STDs and their partners. For example, program managers can use the document to help plan and manage prevention efforts, target resources, establish program priorities, and develop program policies. In addition, the recommendations should influence the design of training curricula for future partner service programs and activities.

Q. How were the new recommendations developed? 

A. The new recommendations are the product of a highly collaborative and open process that began in 2005. The two existing guidance documents were reviewed and compared to identify areas of commonality and difference. Numerous organizations and individuals with potential interest or expertise in partner services were notified that the recommendations were being revised and were invited to provide input; over 70 stakeholder groups were included in this process. CDC conducted an extensive literature review and convened listening groups at several national conferences held in 2005, including the HIV Prevention Conference, the HIV Prevention Leadership Summit, the United States Conference on AIDS, and the National STD Prevention Conference. CDC also held focus groups with members of affected communities, program managers, frontline health department and community-based organization (CBO) staff, and private sector clinicians. Finally, CDC funded a review of state laws related to partner services. Based on the information gained through these activities, CDC developed draft recommendations, which it presented to approximately 70 participants from 23 states and the District of Columbia at a consultation convened in Atlanta in November 2006. Following the consultation, CDC formed a steering committee and seven workgroups to revise the draft recommendations. The steering committee and all workgroups included both CDC staff members and non-CDC members recruited from the consultation attendees. In January 2008, CDC disseminated the newly revised document for review and comment to a wide range of persons representing federal agencies, health departments, academic and research centers, professional organizations, CBOs, and community advocacy groups. Based on comments it received from these reviewers, CDC then revised the final recommendations.

Q. Why do the new recommendations advocate the sharing of data between surveillance units and partner service programs?

A. Data collected through HIV/AIDS and STD surveillance systems are used for many complementary public health purposes at the national, state, and local levels. For example, data are used to monitor disease, estimate incidence of infection, identify changing trends in transmission, target and evaluate prevention interventions, and allocate funds for care and prevention services. Some states and territories also use case reports to initiate partner services for infected individuals and offer referrals for prevention, medical care, and supportive services.

Sharing information between HIV/AIDS and STD surveillance programs and partner services programs is important for comprehensive disease intervention and potentially offers many mutual benefits, including:

• Surveillance data can provide a more complete understanding of the population of persons newly diagnosed in the public and private sectors who are in need of partner services.
• Using surveillance data to initiate partner services can help ensure that partner services are offered to every newly-identified or reported person for whom public sector-mediated services are appropriate, thereby supporting our public health goal of maximizing access to partner services.
• Linking surveillance and partner services can help ensure that patients testing positive receive and understand their test results, access treatment or are linked to medical care services, and receive appropriate prevention counseling.
• Surveillance data can supplement client-level program information, such as demographic, risk characteristics and testing history, and inform partner service providers before initial contact with clients.
• Partner services programs can supplement surveillance data by providing surveillance programs with more complete and accurate demographic and risk information and helping to identify duplicate reporting.
• Sharing information may help streamline surveillance and partner services activities and may add efficiency. For example, sharing information may limit the number of times the same medical record is reviewed or a medical provider is contacted about the same individual.
• Surveillance data can help partner services programs identify and develop relationships with health care providers who diagnose and treat persons with HIV and other STDs, allowing partner services programs to better target their education and outreach efforts to key service providers.
• As a result of the collaborative relationships they have established with health care providers, partner services programs can also improve surveillance data by encouraging complete and timely reporting of HIV/AIDS and other STDs.

Q. If surveillance data are shared with partner services programs, what protections does CDC recommend those programs implement to ensure that confidentiality and data security are maintained?

A. Partner services data for STDs/HIV, with or without data obtained from disease reporting systems, are among the most sensitive public health data routinely collected and merit careful protection. For this reason, the new Recommendations encourage all partner services programs—whether they share data with surveillance programs or not—to establish and follow strict, jurisdiction-specific guidelines, policies, and procedures for information security and confidentiality. An appendix to the Recommendations outlines a set of guiding principles and standards which should be in place before partner services and surveillance programs share individual-level data. Guiding principles include maintaining data in a physically and technically secure environment, outlining procedures for authorized role-based access, establishing procedures for thorough investigation of security breaches, and ongoing review of policies and procedures to continually improve data protections. The standards, which were drafted in close collaboration with representatives from the Council of State and Territorial Epidemiologists (CSTE), closely adhere to previously published technical guidance from CDC and CSTE describing minimum data security and confidentiality standards that should be met by HIV/AIDS surveillance programs. As such, the standards included in the Recommendations reflect both best principles and practices for protecting HIV/AIDS and STD data.

Some states and territories use case reports to initiate partner services for infected persons and offer referrals for prevention, medical care, and supportive services. Partner services programs in these jurisdictions have an excellent record of protecting confidentiality and data security, and continued vigilance is critical to future success. However, certain surveillance programs have imposed limits on sharing of HIV/AIDS surveillance data with partner services programs, citing differences in security and confidentiality protections between the two. In some cases, programs imposed these limits after collaboration with communities and medical providers on implementation of named-based HIV reporting, which resulted in use of reporting methods that separate surveillance and partner services.

Ideally, every program should engage key stakeholders, such as medical providers, community advocates, and community planning groups, in the design and implementation of surveillance and partner services data linkage processes, as such collaboration may improve support for, and the success of, these measures. Such community involvement will be particularly important in jurisdictions which imposed limits on data sharing between partner services and surveillance programs on the basis of community input. Failure to engage in the same careful collaboration and deliberative processes with medical providers and affected communities could otherwise lead to erosion of the public trust and of the integrity of the systems already established in those jurisdictions.

Q. Does the model of partner services outlined in the new recommendations represent the only way to do partner services? 

A. No, CDC encourages tailoring partner services methods to local needs. CDC’s newly-issued recommendations for HIV and STD partner services emphasize health department-led partner notification models because these are widely practiced and well documented. These recommendations, however, also speak to patient-mediated referral and to several innovations that can be practiced with either patients or health department staff as the medium for referral (e.g., Internet partner notification).

Q. When should partner services be offered?  

A. CDC suggests offering partner services as soon as possible after diagnosis, regardless of the infection. Urgency and promptness are essential elements of effective partner services.

Q. Do the recommendations suggest different notification strategies for various HIV/STDs? 

A. The decision as to which strategy is used for notifying each potentially exposed partner should be made collaboratively by the patient and the Disease Intervention Specialist (DIS). Programs must be able to accommodate a range of strategies for notifying partners exposed to various STDs and HIV. Programs should regularly review the effectiveness of their partner services activities for each disease and incorporate these findings into their alignment of strategies for partner services. Programs should consider patient needs, program capacity, and the nature of the infection. However, the recommendations stress the importance of involving health-care providers or health department personnel (that is, a DIS), regardless of the notification strategy selected. Even if the patient chooses to notify one or more of his or her partners, the DIS should be actively involved by coaching the patient on how to accomplish the notification safely and successfully and should follow up with the patient to verify that the notification occurred.

Q. How did CDC determine which populations to designate as “special populations?”

A. CDC’s new recommendations for HIV/STD partner services designate three groups as “special populations”—youth, immigrants and migrants, and incarcerated persons. CDC selected these populations because of the important legal, social, developmental, and ethical issues that may impact whether and how partner services are provided to the three groups.

Q. How will CDC support the implementation of the HIV/STD partner services recommendations?

A. CDC is currently developing a number of new products and strategies to assist jurisdictions with implementing the recommendations. Training is a key element of the implementation strategy. CDC is working with the HIV/STD Prevention Training Centers to revise the current STD and HIV partner services training materials to create integrated training for partner services. CDC anticipates incorporating a variety of teaching methodologies into the materials:  some materials may involve computer technology, such as e-learning, while other materials may involve instructor-led sessions. CDC also plans to offer a series of train-the-trainer sessions in addition to other technical assistance to local instructors. Finally, CDC intends to cross-train DSTDP and DHAP instructors in the materials so that both Divisions can work effectively with local programs. CDC may also develop or revise other training products based on grantee needs.

Q. Will CDC provide technical assistance to programs implementing the new partner services recommendations? 

A. CDC recognizes that jurisdictions may require technical assistance when implementing the recommendations. Currently, CDC grantees can access individual and programmatic technical assistance through the following means or individuals:

• HIV Project Officers, STD Program Consultants, and/or Surveillance Project Officers assigned to each jurisdiction.
• CDC staff with technical expertise in partner services.
• HIV/STD Prevention Training Centers.
• Other national partners such as the National Alliance of State and Territorial AIDS Directors (NASTAD) and the National Coalition of STD Directors (NCSD).

In addition to the above, CDC is working with national partners to develop a comprehensive technical assistance system for partner services that will focus on providing technical assistance to individuals and organizations that will implement the recommendations.

Q. Will CDC offer additional funding to programs charged with implementing the recommendations?

A. No. At this time, CDC does not anticipate providing additional funds to support programs with implementing the new recommendations for HIV/STD partner services; however, it does plan to offer material and technical assistance throughout the implementation process. Programs can identify resources to support the implementation of partner services through activities such as forming strategic partnerships with other service providers, diverting funds from less effective or lower priority programs, or examining current operations to ensure that existing resources are being used efficiently.

Q. How will CDC monitor the provision of partner services by grantees?

A. HIV/STD partner services will be monitored by collecting program performance indicators, information provided by grantees in their interim and annual progress reports, information obtained through site visits by project officers and program consultants, and for HIV, data collected through the Program Evaluation and Monitoring System (PEMS). CDC will give site-specific feedback based on data and also will provide periodic regional or national summaries of the data.

Q. How does the cost-effectiveness of partner services compare with the cost-effectiveness of other case-finding strategies for HIV and STDs?

A. Published estimates have placed the cost of newly identifying one HIV-infected person through partner services between $3900 and $6600 (2006 US dollars). These estimates compare favorably to HIV counseling and testing programs as well as other interventions designed to identify HIV-infected persons. The estimated costs of identifying one HIV-infected person in health care settings have ranged from $5300 to $7900 (seropositivity rate of 2% to 0.6%), while the cost of identifying one HIV-infected person in jails is approximately $4800 (seropositivity rate of 0.6% to 1.3%). 

Given the high lifetime cost of HIV treatment, HIV prevention interventions such as partner services may be cost-effective if the cost of lifetime care (which a recent estimate placed at $385,200 when discounted at a rate of 3%) exceeds that of preventing one infection. Over the years, a small number of researchers have evaluated the cost-effectiveness of HIV partner services, and each study found that partner services is not only cost-effective, but from the societal perspective, also cost-saving.

Partner services is also cost-effective for other STDs; according to an analysis of partner notification for chlamydial infection, field follow-up was cost-effective, compared to screening. A more recent analysis of patient referral costs for curable STD diagnosed at a single visit yielded estimates of $25 to $83 per partner treated, depending on the patient referral strategy used.  Lastly, collateral benefits from efforts to control STDs through partner notification are important and frequently underestimated. For example, whether monetized or not, visible public health efforts to eliminate syphilis confer social benefits as CDC attacks a disease that has historical elements of injustice.

Q. Will implementing the HIV/STD partner services recommendations require that current partner services providers, such as Disease Intervention Specialists, be retrained?

A. No. While there may be a need for local staff updates or “booster” training sessions on the focus of the partner services recommendations and possible changes in program direction, the skills required to conduct effective partner services in the past are the same skill sets required in the new recommendations. Health department personnel previously trained to conduct partner services will not need retraining unless the supervisor believes there is a current skill deficit.

Q. How do the new recommendations fit in with other CDC initiatives?

A. The Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infection advance a number of CDC initiatives, some of which are HIV or STD specific, while others transcend the artificial boundary between HIV and other STDs. With respect to HIV initiatives, the new recommendations will further CDC’s efforts, as part of the Advancing HIV Prevention (AHP) initiative, to reduce barriers to early diagnosis of HIV infection and increase access to quality medical care, treatment, and prevention services for those living with HIV. Like CDC’s 2006 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings, which they both complement and amplify, the new partner services recommendations will increase the number of infections detected and decrease the time between infection and diagnosis. An estimated one quarter of infected individuals are unaware of their infection, and these individuals are believed to disproportionately contribute to ongoing transmission (accounting for an estimated 50-75% of all new cases). Individuals who become aware of their infections are apt to reduce risky behaviors that could lead to transmission of the virus; if they begin highly active antiretroviral therapy (HAART), which substantially lowers viral load, the potential for ongoing transmission may be further suppressed. Early diagnosis and consequent initiation of medical treatment (specifically, HAART) also improve an individual’s long-term chances for survival.  By extending the case-finding reach of the testing recommendations to current and former sexual and needle-sharing partners of newly diagnosed individuals, the Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infection will augment CDC’s efforts to shrink the pool of infected but unaware persons, potentially decreasing HIV transmission rates and HIV-associated morbidity and mortality.

The new recommendations also complement a number of initiatives that the Division of STD Prevention and it partners have undertaken to prevent STDs and their complications.  Specific examples include: 

• Improve prevention and control of Chlamydia (CT):  Annual CT screening for sexually-active women age 25 and younger is recommended by CDC, U.S. Preventive Services Task Force (USPSTF) and other professional medical organizations. Increased prevention screening efforts are critical to preventing the serious health consequences of this infection, particularly infertility.  Because early re-infection of both women and men treated for CT is common because of incomplete treatment of partners, innovative partner services approaches such as expedited partner therapy (EPT), wherein patients provide prescriptions or medications directly to their partners, can enhance prevention efforts.
• Enhance progress in eliminating syphilis:  Many STD project areas are experiencing dual epidemics of infectious syphilis: one in MSM, and another re-emerging in heterosexual populations with potential for subsequent increases in congenital syphilis.  In 2008, CDC introduced guidance for Evidence-based Action Planning for Syphilis Elimination (SE) to facilitate program assessment, improve effectiveness, and inform decisions about future program development for syphilis control.  Evidence-based action plans guide the collection of information on target populations and subsequent interventions provided, including partner services.
• Use of technological innovation:  Several programs have already undertaken efforts to notify partners via email or similar avenues (e.g., instant messaging, chat room dialogue), and their experiences have demonstrated that staff are able to locate, notify, test and treat some partners.  Consequently, CDC, National Coalition of STD Directors and their partners collaborated on "The National Guidelines for Internet-based STD and HIV Prevention:  Accessing the Power of the Internet for Public Health”, a user-friendly document that provides guidance on how to use the Internet to provide STD prevention services, including partner notification.  By highlighting this important guidance document and, more broadly, the potential of the Internet as a medium for reaching and notifying exposed partners, the Recommendations will reinforce CDC efforts to encourage the wider adoption of new technologies by STD prevention programs.

Finally, the Recommendations both exemplify and further the aims of CDC’s Program Collaboration and Service Integration (PCSI) initiative. PCSI is a mechanism of organizing and blending interrelated health issues, separate activities, and services in order to maximize public health impact through new and established linkages between programs to facilitate the delivery of services. The integrated nature of the Recommendations document alone contributes to progress on these goals, as it replaces separate and occasionally contradictory sets of HIV and STD-specific partner services guidelines with a single, cohesive set of recommendations for a number of STDs including HIV. Moreover, the new partner services recommendations consistently emphasize the necessity of integration at the client services level and collaboration (where integration is not feasible) at the programmatic level. Adoption and implementation of the Recommendations by health departments will be tantamount to the adoption and implementation of PCSI principles and practices.

Q. How does CDC intend for these recommendations to be used by health departments?

A. The Recommendations were developed to assist jurisdictions with planning, implementing and evaluating partner services for persons with HIV or other STDs and their partners. Toward that end, the Recommendations provide policy suggestions and key contextual information intended to indicate what partner services programs should do and why. They are not, however, meant to serve either as an instruction manual for day-to-day operations or as a detailed training curriculum for partner services. How recommended partner services practices are implemented in a particular jurisdiction is left to local discretion.  However, CDC does plan to provide programs with technical assistance and supporting materials.

CDC expects jurisdictions which receive CDC funding for partner services to have programs that are consistent with the Recommendations. HIV and STD program managers should look to the program requirements listed in their cooperative agreements and to their Project Officers and Program Consultants for specific technical direction and assistance.

Q. How does CDC advise programs to handle partner services for persons with known HIV-infection?

A. Certain persons who received a previous diagnosis of HIV might have declined partner services at the time of diagnosis, might have partially participated but subsequently become interested in participating fully, or might have new partners.
These persons can be reached through outreach to HIV care providers or case managers. Accordingly, program managers responsible for HIV partner services should work actively with HIV clinical care providers and case managers to engage them in identifying patients who need partner services, offering them these services, and linking them to health department Disease Intervention Specialist (DIS) when indicated.

Acquisition of new STDs by persons with known HIV infection indicates ongoing sexual risk behaviors. This is of particular importance because infection with other STDs facilitates transmission and acquisition of HIV. HIV-infected persons with recurrent STDs might be identified in STD clinics, other care or service venues, or via STD reporting systems, so it is important for partner services programs to have systems in place to identify these persons. Similarly, persons who previously received a diagnosis of HIV infection are sometimes named as partners in the course of conducting partner services with other index patients, which also might indicate ongoing sexual risk behaviors. In either case, these persons are likely in need of additional education, prevention counseling, other prevention interventions, such as Comprehensive Risk Counseling and Services (CRCS), and additional partner services. Also, any number of underlying psychosocial problems may impede an HIV-infected person in reducing his or her risky sexual or drug-using behaviors. Partner services programs must be prepared to make referrals to address these needs and increase the likelihood of successful behavior change.

Depending on the unique circumstances of each case, options available to partner services program managers in cases involving persons who persistently engage in behaviors that put themselves and others at risk might include 1) mobilizing increasingly intensive prevention interventions; 2) facilitating access to HIV primary care and case management; 3) arranging linkage to substance abuse treatment, mental health services, or other relevant psychosocial services; 4) conducting epidemiologic investigation of situations involving possible exposure of persons to infection; and 5) seeking state and local legal consultation when public health interventions are not sufficient or appropriate. Determining the most appropriate course of action requires consideration of the details of the specific situation; every case must be managed carefully and confidentially.

Q. How do HIV criminal transmission and exposure laws—or other criminal laws that can be applied to HIV-infected persons—affect programs providing on-going partner services to persons with known HIV-infection?

A. Criminal laws of general application, such as assault, battery, or reckless endangerment laws, might be used to prosecute a person who intentionally exposes another person to infection. However, many states have gone a step further and enacted criminal laws focusing either specifically on HIV transmission or generally on transmission of sexually transmitted infections. These laws vary according to several factors, including 1) which types of conduct are considered criminal; 2) the specificity with which the proscribed conduct is described; 3) the knowledge required; and 4) whether disclosure of HIV infection before engaging in the conduct mitigates legal liability. Because these laws and their application to HIV-infected persons vary widely among states, their implications for program policies and practices will be determined at the state and local level. CDC thus recommends that program managers be aware of the applicable laws regarding criminal transmission and exposure in their jurisdictions and coordinate with legal counsel regarding specific cases in which allegations of criminal transmission or exposure are made.

Q. What is CDC doing to minimize data entry burden and avoid duplicate entry into STD*MIS and PEMS?

A. CDC’s Divisions of HIV/AIDS Prevention (DHAP) and STD Prevention (DSTDP) are working together to ensure that the required variables for HIV Partner Services are identical in DHAP's National HIV Monitoring and Evaluation (NHM&E) data entry and reporting system (PEMS) and DSTDP's STD surveillance and case management software (STD*MIS ). Grantees will be able to enter HIV Partner Services data into the system that best meets their needs. If grantees use STD*MIS, a data extract file will be created to extract the HIV partner services data from STD*MIS. Those data may then be submitted to state HIV prevention programs, and subsequently to CDC, via the secure data network (SDN). If grantees use PEMS, data will be submitted through that system to CDC. Data need only be entered into one system at the local level and will be integrated into the national database at CDC.